Project Name: Proactive Primary Care Cardiovascular Risk Management Hub

Project Summary: 

The primary objective of this Collaborative Working Project (“CWP”) is to is to improve the quality and equity of care for patients and support the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (“ASCVD”) who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance, in response to the needs of the CW Partner.  This will be achieved by creating an innovative HUB Long Term Condition (“LTC”) team model, focussing on proactive ASCVD risk management for primary care patients.

The CWP will be led by an executive team including the CW Partners Chief Executive Officer, Managing Director and Clinically by the Clinical Director and Nursing Director alongside a multi-disciplinary team including General Practitioners, Clinical Pharmacists and practice nurses aiming to achieve: 

  • Development of a dedicated HUB LTC team, working across Primary Care Networks (“PCNs”) to systematically identify, engage, and proactively manage patients at risk of ASCVD.
  • Early identification of patients in primary care at increased risk of ASCVD, with the aim of collaborating with them to reduce their risk through structured interventions.
  • Implementation of Clinitouch remote patient monitoring (“RPM”) digital technology:
    • Puts a powerful monitoring and education tool directly into the hands of patients and HUB clinicians.
    • Delivers personalised risk scores, tailored educational content, and specific clinical and treatment recommendations.
  • Embed medicines optimisation in every pathway alongside robust lifestyle interventions, maximising overall cardiovascular risk reduction.
  • Increase access for eligible patients to all NICE approved therapies in line with national/local guidelines
  • Establish a model that creates efficient, sustainable ASCVD prevention, serving as a template for expansion into other LTC areas as the NHS pursues its long-term strategic priorities.
  • Conduct an evaluation of patient outcomes and healthcare resource utilisation, with an expectation of improved patient health and reduced total costs over an appropriate time horizon

Expected Benefits: 

Anticipated Benefits for Patients:

  • Easier access to personalised, proactive and preventative ASCVD care.
  • Improved understanding and ownership of their health risks.
  • Enhanced experience with a combined lifestyle and medication approach.
  • Access to structured education content to support lifestyle improvements and reduction in ASCVD risk.
  • Improved access to lipid management care through a dedicated HUB team 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.
  • Reduced health inequalities, including support for digitally excluded patients with technology and training provided as required.

Anticipated Benefits for CW Partner:

  • Higher proportion of ASCVD patients proactively identified and reviewed within primary care, improving local population health management.
  • More patients receiving expert, personalised cardiovascular risk assessment and optimisation closer to home, led by the HUB LTC nurse, reducing the need for hospital-based interventions.
  • Potential reduction in referrals to secondary care for uncontrolled lipids or ASCVD risk, by managing these patients effectively in the community.
  • Increased proportion of patients receiving guideline-directed pharmacotherapy, supporting improved achievement of QOF CHOL004 and NHS targets.
  • Real-world operational insights into the effectiveness of a HUB LTC nurse-led lipid and ASCVD risk management model, supported by Clinitouch digital engagement and risk monitoring.
  • Direct alignment with NHS Long Term Plan priorities and the objectives of the national CVDPREVENT programme, positioning Spirit Primary Care as a leader in proactive, digitally enabled cardiovascular prevention.
  • Enhanced reputation and future business case evidence for sustainable primary care service models, enabling future commissioning for similar pathways across other LTCs.

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 healthcare organisations. 

Start Date & Duration: August 2025 for 15 months

FA-11481792 | July 2025