Project Name: Central Halifax PCN Lipid and Cardiovascular Disease (CVD) Audit and Medicines Optimisation Collaborative Working

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 optimization of patients with Heart Failure reduced Ejection Fraction (HFrEF), Left Ventricular Systolic Dysfunction (LVSD), or atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner. Pennine GP Alliance Limited, is the legal entity for the PCN. Novartis will contract with Pennine GP Alliance Limited as they are the legal entity contracting on behalf of the PCN.

The CWP will be led by a Clinical Pharmacist (Band 8d), alongside a multi-disciplinary team; including an Advanced Practitioner (Band 8d), and a Technician (Band 7), aiming to achieve:

  • Early identification of at-risk patients who have not had intervention in their health and wellbeing
  • Review of treatment options and decision on next steps in collaboration with HFrEF, LVSD, and ASCVD patients
  • Counsel and optimize HFrEF, LVSD, and ASCVD patients where appropriate 
  • Identification of HFrEF, LVSD, and ASCVD patients, following risk assessment review, of HFrEF, LVSD, and ASCVD patients who are sub-optimally treated 
  • Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies
  • On-going HFrEF, LVSD, and ASCVD patient’s support and annual review to ensure CVD outcomes improve equitably

Planned Milestones:

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 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 from PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, leveling health inequalities within the PCN
  • PCN Improved access to diagnosis and treatment for HF patients
  • More equitable and consistent care and access to care for HF patients; and 
  • Enhanced experience for patients and their carers who live with HF  

Anticipated benefits for 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
  • Increase the overall quality of care and improve equity of access to specialist care for patients with HF;
  • Improve patient flow and increase levels of accurate diagnosis on non-cardiology wards; 
  • Potential less unscheduled re-admissions through faster escalation to current treatments recommended by ESC-HF guidelines, and 
  • Insight into benefits of increased in-patient long-term therapy initiation/optimisation, which may inform ongoing redesign and workforce planning 

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
  • Further opportunities for the appropriate use of heart failure licensed medicines, including Novartis’ medicine, given the current low uptake of contemporary and evidence-based therapies   
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: December 2022 for 14 months.

UK | December 2022 | 577813