Project Name: Royal Free London NHS Foundation Trust Lipid Optimisation

Project Summary:
The CWP is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Network (PCN) Contract Direct Enhanced Service (DES) and the Locally defined Cardiovascular plans.

The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.  This will be done with the hiring of a Physician’s Associate and Clinical Nurse Specialist who will assist the Health Care Professional to optimise lipid therapy for patients in the 7 Camden PCNs (Central Camden PCN, Central Hampstead PCN, Kentish Town Central PCN, Kentish Town South PCN, North Camden PCN, South Camden PCN, West Camden PCN) (see appendix 1 for list of PCN’s and practices) in their efforts to optimise therapy for patients in Borough by Borough approach.  Complex patients will be escalated to a newly created MDT for review.  

Planned Milestones:

  • Milestone 1: Project kick-off meeting.  Collection of baseline data
  • Milestone 2: Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
  • Milestone 3: Confirmation of recruitment of Physician’s Associate and Clinical Nurse Specialist
  • Milestones 4 through 11: at three monthly intervals:
    1. Collection & submission of clinical activity data. 
    2. Project review meeting.
  • Milestone 12: Development of business case
  • Milestone 13: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary.  Project wrap up meeting.

Expected Benefits:


  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.   
  • Enhanced experience around ASCVD with ongoing management of the condition.   
  • Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events.  
  • Easier access to lipid management care closer to home in the Primary Care setting.
  • The additional capacity will provide additional time and support from PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, levelling health inequalities within the PCN. 

CW Partner:

  • Increased proportion of ASCVD patients reviewed by primary care.   
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home.  
  • Reduction in ASCVD referral rates to secondary care.  
  • Increased proportion of patients receiving guideline-directed pharmacotherapy.  
  • Insight into benefits of primary care pharmacist led lipid management clinics in primary care.   
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES. 


  • Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicine.  
  • Enhanced reputation and supporting Novartis’ vision that no patient should have to wait for an extraordinary life, by supporting high quality Collaborative Working with healthcare organisations which addresses the problem of health inequalities.    
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation.  

Start Date & Duration: March-2023 for 29 months