Project Name: Stowhealth: Proactive Primary Care Cardiovascular Risk Management Hub
Project Summary:
The primary objective of this CWP is to improve the quality and equity of care for patients by improving early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (“ASCVD”). A dedicated pharmacist will plan and deliver a series of virtual screening clinics and subsequent face to face treatment clinics with a focus on proactive ASCVD risk management at Stowhealth General Practice, Suffolk.
Project Aims:
- Systematically identify and validate, engage, and proactively manage patients at risk of ASCVD across Stowhealth practice, reducing their risk through structured interventions. All clinical decisions will remain the sole responsibility of the treating HCP.
- Embed medicines optimisation and robust lifestyle interventions into patient interactions across the practice, optimising CV (cardiovascular) risk reduction management in line with NICE guidance.
- Increase access for eligible patients to all NICE approved therapies in line with national/local guidelines.
There is an aspiration that the model set out in this project, which is to create efficient, sustainable ASCVD prevention in the patient population of Stowhealth, be shared and potentially diffused across the East Suffolk PCN in the future.
Expected Outcomes
- Increase in the number of patients receiving a comprehensive lipid optimisation and lifestyle intervention and education.
- Increase in number of eligible patients appropriately reviewed and managed in line with NICE guidance including consideration of all suitable treatment options.
- Collection of patient-reported experience measures (“PREMs”) related to the project, with the goal of increasing positive responses regarding patient understanding, confidence and satisfaction with CVD (cardiovascular disease) care.
- Increase in the proportion of patients achieving cholesterol targets per QOF(Quality Outcomes Framework) CHOL004, specifically:
- % of patients on the QOF CHD (Congenital Heart Disease), PAD (peripheral arterial disease) or Stroke/TIA register with an LDL-C (Low-Density Lipoprotein Cholesterol) in the last 12 months of ≤2.0 mmol/L, or where LDL-C not recorded, a non-HDL of ≤2.6 mmol/L.
- Ongoing lipid management for patients via training on ‘NICE NG238 and national recommendations’; provided by the pharmacist to the relevant members of the practice team
- Establishment of a sustainable model of care that could be diffused across the wider locality in Suffolk.
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.
- Enhanced experience around ASCVD with ongoing management of the condition.
ANTICIPATED BENEFITS FOR STOWHEALTH:
- Higher proportion of ASCVD patients proactively identified and reviewed within primary care, improving local population health management.
- Potential reduction in referrals to secondary care for uncontrolled lipids or ASCVD risk, by managing these patients effectively in the community.
- Raised awareness and confidence of ASCVD management within the team
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: March 2026 for 6 months
FA-11632923 | March 2026
Project Name: Stowhealth: Proactive Primary Care Cardiovascular Risk Management Hub
Organisation(s): Stowhealth Violet Hill House, Violet Hill Road, Stowmarket, Suffolk, IP14 1N (the “CW Partner”)
Completion Date: September 2026
Outcome Summary:
This Collaborative Working Project was established to improve the quality and equity of care for patients with atherosclerotic cardiovascular disease through patient identification, clinical review and medicines optimisation within primary care.
A pharmacist-led approach was used to identify and validate patients, undertake clinical review, support patient engagement and facilitate medicines optimisation in line with NICE guidance and local clinical pathways. All clinical and treatment decisions remained the sole responsibility of the treating healthcare professional.
The project completed in September 2026 following delivery of the patient-review, medicines-optimisation and follow-up activity.
Key Project Outcomes Data:
The project delivered:
- Clinical review and validation of a final cohort of 255 patients.
29 recorded medicines optimisation interventions, comprising statin optimisations, ezetimibe initiations and injectable therapy initiations. - Re-review of 84 existing patients, with 61 identified for follow-up.
- Pharmacist-led identification, validation, medicines optimisation and follow-up activity in line with the agreed Collaborative Working Agreement and Project Initiation Document.
- Completion of follow-up activity and transfer of ongoing patient management into routine practice arrangements.
- Practical learning regarding patient eligibility, local demographics, current clinical information, patient engagement and practice readiness that may inform future ASCVD service development.
Outcomes:
The project identified a patient cohort broadly consistent with the original estimate. Patient-level clinical validation established that the number requiring active medicines optimisation was lower than originally anticipated.
Factors influencing the final patient pathway included age and clinical eligibility, current lipid results, existing treatment activity, the need for further blood tests and individual patient choice.
The project demonstrated the importance of distinguishing between a search-derived cohort, a clinically validated cohort and the number of patients requiring or accepting further intervention when planning future ASCVD services.
Benefits for Patients:
- Easier access to personalised, proactive and preventative ASCVD care.
- Improved understanding and ownership of individual health risks.
- An enhanced patient experience through a combined lifestyle and medicines optimisation approach and enhanced experience of ongoing ASCVD management.
- At closure, the practice confirmed that follow-up arrangements were in place for patients requiring blood tests, ongoing clinical review or future treatment decisions.
Benefits for the Partner:
- A higher proportion of patients with ASCVD being proactively identified and reviewed within primary care, supporting local population-health management.
- The potential to reduce referrals to secondary care for uncontrolled lipids or ASCVD risk by supporting appropriate management in the community.
- Increased awareness and confidence in ASCVD management within the practice team.
Benefits for Novartis:
- Insight into the appropriate use of licensed ASCVD medicines, including Novartis medicines, in line with NICE guidance.
- Support for Novartis’ purpose through high-quality Collaborative Working that seeks to address health inequalities.
- An ethical, professional and transparent relationship between Novartis and healthcare organisations.
Conclusion:
The project delivered systematic identification and clinical review of patients with ASCVD, together with pharmacist-led medicines optimisation and follow-up within primary care.
Clinical validation established that the actionable patient cohort was lower than originally anticipated, with ongoing patient care transferred into routine practice arrangements.
The project also generated learning on cohort validation, patient eligibility, local demographics and practice readiness that may inform the design of future ASCVD Collaborative Working Projects.
FA-11815719 | October 2026