Project Name: Spinney Hill Medical Centre (MC) ASCVD Primary Care Lipid Management Collaborative Working Project

Project Summary:

The Collaborative Working Project (CWP) is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Networks (PCNs) 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 Spinney Hill Medical Centre (MC).

The CWP will be led by a Clinical Pharmacist alongside a multi-disciplinary team; including Pharmacy Technician, Healthcare Assistant, Administrative Support, General Practitioner providing clinical oversight aiming to achieve:

1.    Identification of sub-optimally treated ASCVD patients who are not achieving recommended targets for lipid management   
2.    Identification of patients who have previously not tolerated or refused alternative lipid modification therapies  
3.    Review of treatment options and decision on next steps in collaboration with patients   
4.    Counsel and optimise patients where appropriate  
5.    Early identification of at-risk patients who have not had intervention in their health and wellbeing  
6.    Identification of patients, following risk assessment review, of patients who are sub-optimally treated

Planned Milestones:

  • Kick-off Meeting with Project Leads
  • PCN Level Lipid Management pathway/protocol development
  • Collection of baseline data, in line with the measures of success contained within the Data Collection table above
  • Clinical Audit and Clinical Audit Discussion with Member Practices
  • Collection & submission of 3 months clinical activity data.
  • Project Review meeting to discuss project progress. 125 patients to have been reviewed within milestone 4
  • Collection & submission of 6 months clinical activity data
  • Project Review meeting to discuss project progress.
  • 125 patients to have been reviewed within milestone 5
  • Development of Business Case
  • Analysis of CWP data, submission of Final CWP 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 the practice HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up.

Anticipated Benefits to the Organisation:

  • 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

Anticipated Benefit to 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 healthcare organisations

Start Date & Duration: May 2023 for 10 Months including 6 months of clinical activity

UK | May 2023 | UK2305318355

Project Name: Spinney Hill Medical Centre (MC) ASCVD Primary Care Lipid Management Collaborative Working Project

Completion Date: April 2024

Outcome Summary:

This collaborative working project has led to a change in clinical practice at Spinney Hill Practice with regards to optimising Lipid management for patients, with improvements seen the way in which clinicians file lipid profile blood tests and being vigilant with patients with ASCVD who are at increased risk and appropriately optimising treatment.

Key Project Outcomes Data:

  • An additional 142 patients requiring lipid management were seen in clinics throughout the duration of the project.
  • Backlog of patients awaiting review has been reduced from 387 to 113.
  • The time taken from identification of patient requiring support to being seen in clinic has reduced from 12 weeks to 8 weeks.


The number of patients with ASCVD waiting to be reviewed has been reduced by approximately 60% with patients now waiting on average 8 weeks to be seen in clinic compared to a twelve week wait prior to this project. This ensures patients are being treated appropriately within a shorter time frame, therefore reducing the risks associated with sub-optimal management of ASCVD.

A business case with regards to Lipid Management has been presented to the GP Partnership who have fully embraced this novel method to helping our patients and will continue to do so in the future to help manage our patients moving forward.


The patients identified as part of this project will continue to be followed up and managed using our new lipid management pathway whilst newly eligible patients will be captured and treated accordingly.