Project Name: Primary Care Lipid Management – Collaborative Working Project

Project Summary:

The key aim of the project is to improve lipid management at speed and scale at the PCN level and improve the quality of care for patients with Atherosclerotic Cardiovascular Disease (ASCVD) and uncontrolled lipid levels.
 
The CWP aims to address critical limitations within the system to the identification and treatment of eligible primary hypercholesterolemia (heterozygous familial and non-familial) or mixed dyslipidemia patients/ ASCVD and uncontrolled lipid levels to ensure that appropriately treated patients benefit from all available and appropriate therapies without unnecessary delay.

The service will aim to achieve:

  1. Identification of sub-optimally treated patients who are not achieving NICE recommended reductions in non-HDL lipid levels.
  2. Identification of patients who have previously not tolerated or refused alternative lipid modification therapies.
  3. Review treatment options in a consultative way with patients.
  4. Counsel and optimize patients where appropriate.

Planned Milestones:

  1. PCN Level Lipid Management pathway/protocol development.
  2. Collection of baseline data, in line with the measure of success.
  3. Clinical Audit and Clinical Audit Discussion with Member Practices.
  4. Collection of 3 months clinical activity data & Project Review meeting to discuss project progress.
  5. Collection of 6 months clinical activity data & Project Review meeting to discuss project progress.
  6. Collection of 9 months clinical activity data & Project Review meeting to discuss project progress.
  7. Development of business case.
  8. Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary.

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.
  • 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 appointments or been lost to follow-up. Thus, leveling health inequalities within the PCN.

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 primary care pharmacist led lipid management clinics in primary care.
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES.

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 the NHS which addresses the problem of health inequalities.
  • Ethical, professional, and transparent relationship between Novartis and the NHS.

Start Date & Duration: August 2022 – 11 months

UK2208125080

Project Name: Primary Care Lipid Management – Collaborative Working Project

Partner Organisation(s): Little Horton Lane, for and on behalf of the Horton Primary Care Network

Completion Date: June 2023

Outcome Summary:

The project resulted in improvement lipid management for a limited cohort of patients but unfortunately the ambition to improve at speed and scale was not to fully achieved due to recruitment and capacity challenges experienced by our partner. As a result they were not able to dedicate time to the project as intended.

The CWP was ended early by mutual agreement of both parties. 

Key Project Outcomes Data:

Outcome data for milestones 1 to 5 – Baseline, 3 and 6 months data:

  • Baseline: Accessing service: 0, LDL >2.6 in last year:550, statin not tolerated or declined:86, accessing NICE approved treatments: 152. 
  • 3 months data: Accessing service: 86, LDL >2.6 in last year:559, statin not tolerated or declined:86, accessing NICE approved treatments:221. Time from identification to accessing service: 3 weeks
  • 6 months data: Accessing service: 63, LDL >2.6 in last year:587, statin not tolerated or declined:93, accessing NICE approved treatments:157. Time from identification to accessing service: 3 weeks

Milestone 5 was the final data point before the CWP closed. 

Outcomes:

  • The ASCVD project allowed 149 patients within the PCN access to lipid optimisation over 6 months. 
  • Time taken between identification and patient being seen was 3 weeks 
  • Originally set for 11 months clinical activity, the Project was stopped by mutual consent after collection of 6 months clinical activity due to a change in workforce within the practice-based pharmacist team across the PCN.

Conclusion: 

Whilst it is disappointing that the CWP was unable to achieve its full objectives, the activities completed piloted a new model of care for lipid management within primary care.  It allows for the proof of concept to be shared as an education model, future scalability potential and can support potential future business case development for future funding.

FA-11377288 | March 2025