Project Name: Surrey Primary Care GP Federation Lipid Optimisation 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 Integrated Care Board (“ICB”), General practitioner (“GP”) Federation, Primary Care Network (“PCN”) and the Locally defined Cardiovascular plans.
The main objective of the CWP is to improve the quality and equity 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.
The CWP will be led by a full time CVD Specialist Pharmacist alongside a multi-disciplinary team, including PCN Clinical Pharmacists and/or technicians. aiming to achieve:
- 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
- Identification of ASCVD patients who are at higher risk of cardiovascular events and who have previously not tolerated or refused alternative lipid modification therapies
- Review of treatment options and decision on next steps in collaboration with ASCVD patients
- Counsel and optimise ASCVD patients where appropriate
- Early identification of at-risk patients who have not had intervention in their health and wellbeing
- Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated
- On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably
- Communication and engagement plan to onboard PCNs to the project
- Co creation and implementation of a communication plan to upskill existing staff in primary care, maximising long term impact and sustainability of the project
- Prioritisation of PCNs in alignment with the Core20PLUS5 approach to reducing healthcare inequalities and/or PCNs under achieving in CVDPrevent CVDP012CHOL
- Patient education, awareness and empowerment
Expected Benefits:
Anticipated patient benefits:
- 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 Federation with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, levelling health inequalities within the Federation.
Anticipated organisation benefits:
- 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 and CVDPREVENT
Anticipated Novartis Benefit
- Insight on the use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicines, where appropriate
- 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 the Healthcare Organisation
Start Date & Duration: February 2025 for 18 months
FA-11375446 | March 2025