Project Name: Aegis PCN ASCVD Primary Care Lipid Management Collaborative Working Project
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 Networks (PCNs) 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 atherosclerotic cardiovascular disease (ASCVD) in response to the needs of Aegis Healthcare PCN. Willows Health is the Lead Practice for Aegis Healthcare PCN. Novartis will contract with Willows Health as they are the legal entity contracting on behalf of Aegis Healthcare PCN.
The CWP will be led by a Clinical Pharmacist alongside a multi-disciplinary team; including Pharmacy Technician, Healthcare Assistant, Administrative Support, General Practitioner providing clinical oversight aiming to achieve:
- Identification of sub-optimally treated patients who are not achieving recommended targets for lipid management.
- Identification of patients who have previously not tolerated or refused alternative lipid modification therapies.
- Review of treatment options and decision on next steps in collaboration with patients
- Counsel and optimize patients where appropriate.
- Early identification of at-risk patients who have not had intervention in their health and wellbeing.
- Identification of patients, following risk assessment review, of patients who are sub-optimally treated.
Due to the additional of a practice to the PCN, this project has been updated to reflect this change.
Planned Milestones:
| Milestone Description | Milestone Evidence | |
| 1 | Kick-off Meeting with Project Leads | Kick-off Meeting Minutes Achieved as of April 2024 |
| 1 | PCN Level Lipid Management pathway/protocol development | Confirmation of development & finalisation of PCN Level Lipid Management pathway/protocol Achieved as of May 2024 |
| 2 | Collection of baseline data, in line with the measures of success contained within the Data Collection table above | Anonymised & aggregated baseline data report Achieved as of May 2024 |
| 3 | Clinical Audit and Clinical Audit Discussion with Member Practices | Confirmation of completion of Clinical Audit and Clinical Audit Discussion with Member Practices Achieved as of May 2024 |
| 4 | Collection & submission of 3 months clinical activity data. Project Review meeting to discuss project progress | Anonymised & aggregated 3 months data report. Submission of Project Review meeting minutes. Achieved as of May 2024 |
| 5 | Collection & submission of 6 months clinical activity data Project Review meeting to discuss project progress. | Anonymised & aggregated 6 months data report. Submission of Project Review meeting minutes. Achieved as of May 2024 |
| 6 | Collection & submission of 9 months clinical activity data Project Review meeting to discuss project progress. | Anonymised & aggregated 9 months data report. Submission of Project Review meeting minutes. Achieved as of May 2024 |
| 7 | Collection & submission of 12 months clinical activity data Project Review meeting to discuss project progress. | Anonymised & aggregated 12 months data report. Submission of Project Review meeting minutes. Achieved as of May 2024 |
| 8 | Development of Business Case | Confirmation of development of business case |
| 9 | Collection & Submission of baseline data for additional practice | Anonymised & aggregated baseline data report for additional practice Submission of Project Review meeting minutes. |
| 10 | Collection & submission of 15 months clinical activity data Project Review meeting to discuss project progress. | Anonymised & aggregated 15 months data report. Submission of Project Review meeting minutes. |
| 11 | Collection & submission of 18 months clinical activity data Project Review meeting to discuss project progress. | Anonymised & aggregated 18 months data report. Submission of Project Review meeting minutes. |
| 12 | Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary | Submission of Final CWP Report & Outcomes Summary |
Expected Benefits:
Anticipated Benefits to 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
- 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.
Anticipated Benefits to the 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
Anticipated Benefit to 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: February 2023 for 22 Months with 18 months clinical activity
UK2405161255