Kingswinford and Wordsley Primary Care Network (“PCN”)

Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project

Organisation(s): Kingswinford and Wordsley Primary Care Network (“PCN”)

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 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.

1. Identification of sub-optimally treated ASCVD patients who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidelines
2. Identification of ASCVD patients who are at higher risk of cardiovascular events and who have previously not tolerated or refused alternative lipid modification therapies
3. Review of treatment options and decision on next steps in collaboration with ASCVD patients
4. Counsel and optimize ASCVD patients where appropriate
5. Early identification of at-risk patients who have not had intervention in their health and wellbeing
6. Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated
7. On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably
8. Education, support, and standardisation of Healthcare Professional (“HCPs”) with regards to ASCVD

Planned Milestones:

Expected Benefits:

Anticipated benefits for patients:

• Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.
• Enhanced experience and counselling 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
• The additional capacity will provide additional time and support for lipid management, focusing of patients who may have previously not attended GP appointments or been lost to follow-up. This help to level health inequalities within the practice and, ultimately, in a wider setting. 

Anticipated benefits for partner 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 novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
• Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
• Opportunity to show the impact of the CWP to create lasting change in lipid management within the Kingswinford and Wordsley PCN 

Anticipated benefits for Novartis:

• 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 novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
• Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
• Opportunity to show the impact of the CWP to create lasting change in lipid management within the Kingswinford and Wordsley PCN

Start Date & Duration: June 2024 – 12 months

UK2406181359

Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project

Partner Organisation(s): Kingswinford & Wordsley PCN, Wordsley Green Surgery, Wordsley Green, Stourbridge, DY8 5PD registered as KW PCN LTD (“CW Partner”)

Completion Date: July 2025

Outcome Summary:

Improved low-density lipoprotein cholesterol (“LDL-C”) to target for eligible PCN Population.

Key Project Outcomes Data:

Our collaboration created capacity for the review of 25% (676) of the identified eligible PCN population of which 27% (184) received a pharmacological intervention resulting in an improved LDL-C to target and alignment to NICE guidelines for the PCN population. 

Outcomes:

This collaborative lipid management project delivered strong clinical and operational outcomes across the NHS, patients, and Novartis, highlighting the benefits of a focused, data-driven approach to cardiovascular disease (“CVD”) risk reduction.

The project supported primary care teams in identifying and reviewing patients with uncontrolled lipid profiles, particularly those not on therapy, on suboptimal treatment, or with persistent elevated LDL cholesterol. In total, 754 patient cases were identified, resulting in 676 structured clinical reviews across the project period.  This approach led to at least 184 pharmacological interventions, including:

• Statins
• Ezetimibe
• Bempedoic acid
• PCSK9 inhibitors (secondary care)
• siRNA
• As well as appropriate decisions where no pharmacological intervention was needed

This structured approach helped embed NICE aligned lipid management pathways into routine primary care, reducing unwarranted variation and supporting earlier intervention in high-risk individuals. The project also demonstrated how external collaboration can help reduce clinical workload while improving care quality and consistency.

Patients directly benefited from timely identification, review, and treatment adjustments. Many had not previously received optimal lipid-lowering therapy or had persistent LDL cholesterol elevation despite existing treatment.

Patients received personalised care, improved access to NICE approved therapies, and support in managing their cardiovascular risk. This proactive approach not only enhanced clinical outcomes but also promoted patient engagement and treatment adherence.

The initiative delivered measurable benefits across system, patient, and industry levels, offering a model for scalable lipid management across other regions and Integrated Care Systems (ICSs).

Conclusion: 

This project has successfully demonstrated the value of a structured, collaborative approach to lipid management across primary care. By identifying at-risk patients, facilitating timely reviews, and supporting the appropriate use of lipid-lowering therapies, it delivered measurable clinical outcomes and supported national CVD prevention goals.

The involvement of pharmacy teams and the integration of innovative therapies highlighted the potential for wider multidisciplinary working and more efficient use of resources. In addition, the partnership model between the PCN, practices and Novartis showcased how industry collaboration can support service delivery without compromising clinical independence.

To ensure sustainability of the project outcomes the CW Partner aims to:

• Explore further integration of digital tools and decision support to streamline future reviews.
• Continue capacity building within pharmacy and clinical teams to sustain lipid optimisation as part of routine care.
• Evaluate longer-term outcomes, including lipid profiles and cardiovascular events, to assess the ongoing impact of interventions.

FA-11488585 | August 2025