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