Project Name: High Risk Acute Coronary Syndrome (ACS) Secondary prevention Clinic – South Tyneside and Sunderland Hospitals NHS Foundation Trust

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 optimization of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner with the intention of increasing secondary care initiation of medicines with the repatriation of relevant patients back to primary care for continued care.

The CWP will be led by one clinical pharmacist band 8a (0.2 FTE) working as part of a multi-disciplinary team; including a Consultant Endocrinologist and Healthcare Assistant with Secretarial support. Aiming to achieve the following:

  • Increase in the number of patients with ASCVD and uncontrolled lipid levels accessing the service. 
  • Improve speed of patient access - achieve reduction in the amount of time taken between patient identification and the patient being seen in clinic from baseline. 
  • Achieve reduction in the overall backlog of existing patients with ASCVD waiting to be seen by a pharmacist for follow-up, review, and medicines optimization from baseline (start date of clinical activity). 
  • Increase in the number of patients being able to access all NICE approved medicines for the treatment of ASCVD.
  • Increase in Secondary Care initiation of CVD medicines and repatriation to primary care for continuation of review and follow up.
  • Improve pathway for lipid service referral for other CVD secondary care specialties
  • Improved confidence in Primary care in initiating and managing patients on NICE approved treatments.
  • Identification of ongoing sustainable resource requirement for maintenance long term lipid management pathway 

Planned Milestones:

1Kick Off Meeting
2Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
3Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity 

Collection & submission of 3 months clinical activity data.

Project Review meeting to discuss project progress.


Collection & submission of 6 months clinical activity data.

Project Review meeting to discuss project progress.


Collection & submission of 9 months clinical activity data.

Project Review meeting to discuss project progress.


Collection and submission of 12 months clinical activity data..

Project Review meeting to discuss project progress.

8Development of business case.
9Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary.

Expected Benefits:

Anticipated benefits for patients;

  • 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  
  • 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, leveling health inequalities within the PCN. 

Anticipated benefits for the organisation:

  • Increased proportion of secondary care ASCVD patients undergoing lipid optimisation    
  • Increased proportion of ASCVD patients receiving expert and timely review  
  • Reduction in ASCVD events in patients who have received a review and medicines optimization, and   leading to fewer admissions to secondary care 
  • Increased proportion of patients receiving guideline-directed pharmacotherapy    
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES 

Anticipated benefits for Novartis;

  • 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: November 2023 with 12 Months of clinical activity