Barts Health NHS Trust

Project Name: Pharmacist led Lipid management model of care in North East London (NEL) Collaborative Working

Project Summary:

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) in response to the needs of the CW Partner. This will be done with the hiring of Specialist Pharmacist who will optimise lipid therapy for patients in North East London (NEL) and will support local PCN pharmacists across the 7 boroughs of NEL (see appendix 1 for list of PCN’s in NEL) in their efforts to optimise therapy for patients in Borough by Borough approach. Complex patients will be escalated to a newly created MDT for review.

The CWP will be led by a Consultant Pharmacist & Head of Pharmacy alongside a multi-disciplinary team; including Clinical Pharmacist, aiming to achieve:

1. Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines
2. Identification of ASCVD patients 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 with Patients at the highest risk to be prioritised for review (defined by the NHS partner as  Adult patients who have had an IHD,PAD or Stroke/TIA and are not on a statin therapy and  adult patients with a  sub-optimal non-HDL > 2.5mmol/L despite maximal statin therapy. Cohorts defined by using the UCLP measures.)
4. Counsel and optimise 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

Planned Milestones:

Milestone Delivery Date

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.

Anticipated benefits for the NHS

• 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 healthcare organisations which addresses the problem of health inequalities    
• Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: October 2022 – December 2024 (2 years 2 months)

UK2209291228

Project Name: Pharmacist led Lipid management model of care in North East London (NEL) Collaborative Working

Partner Organisation(s): Barts Health NHS Trust

Completion Date: December 2024

Outcome Summary:

The North East London (NEL) CWP has transformed lipid management for patients with atherosclerotic cardiovascular disease (ASCVD). The 2022–2024 initiative, led by a Consultant Pharmacist in collaboration with primary care teams, aimed to align clinical practice with NHS Accelerated Access Collaborative guidelines, address health inequalities, and support the NHS Long Term Plan’s ambition of reducing premature cardiovascular disease (CVD) mortality.

By implementing a newly integrated pathway that fostered collaboration between specialists and primary care teams, the programme significantly enhanced access to lipid-lowering therapies (LLTs) such as, statins, ezetimibe, bempedoic acid, PCSK9 inhibitors and injectable lipid lowering therapies (IT’s). This partnership led to an increase in the proportion of ASCVD patients meeting lipid targets across NEL, rising from 27% to approximately 45% and contributed to over 1,531 new LLT prescriptions. Additionally, the percentage of patients on combination therapies rose from 3% to 10%, with an estimated 127 major cardiovascular events projected to be prevented over five years, contributing significantly to the NHS Long Term Plan ambition of preventing 150,000 CVD deaths by 2029.

Key achievements include:

• Targeted Clinical Reviews by specialist pharmacist: 5604 patients identified for reviews, with 62% not on LLT and 38% not meeting national lipid targets.
• Collaborative Care: 720 joint GP-specialist pharmacist reviews, addressing coding and personalising treatment plans.
• Therapeutic Advances: A significant increase in LLT prescriptions; 1081 statin, 353 ezetimibe,16 Bempedoic acid and 2 icosapent ethyl. 158 people were identified and consented for LLT optimisation with IT’s: 25 were initiated in PCSK9 inhibitors and 124 were initiated on IT’s.
• Equity and Inclusivity: Multilingual educational support and cultural competence training addressed barriers among diverse patient groups. Observational data highlighted higher LLT decline rates in a small cohort of women, necessitating further exploration of cultural and gender-specific health beliefs.
• Population Impact: ASCVD patients not on LLT decreased from 62% to 32%, and those meeting lipid targets increased to 45% as shown in the latest national audit data from CVDPREVENT.
• Holistic, patient-centred approach: This included personalised care plans, cultural sensitivity and referral to lifestyle and health services, addressing both clinical and social determinants of health.
• Sustainability and Workforce Empowerment: The programme prioritised long-term impact by training 56 pharmacists and primary care clinicians across NEL, focusing on LLT optimisation and treat-to-target approaches for LDL/non-HDL cholesterol. NEL-wide webinars and training sessions were conducted to improve clinician confidence in prescribing newer treatments and delivering appropriate LLT care. Additionally, protected learning time sessions and the development of standardized clinical templates supported sustainable improvements, ensuring effective and equitable LLT optimisation in primary care settings.

This approach has improved clinical outcomes, increased patient access to therapies and contributed to reducing health inequalities across NEL. Advanced injectable therapies, and Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, were introduced to expand treatment options, with a notable increase in patients receiving multiple LLTs (rising from 3% to 10%).

Key Project Outcomes Data:

The CWP achieved transformative results in improving the management of ASCVD across NEL:

• Patient Identification and Review: 5,604 ASCVD patients were identified, with 62% initially not on LLT and 38% not meeting LDL/non-HDL targets. After clinical reviews, the percentage of patients on LLT increased from 38% to 68%, with 45% achieving lipid targets. The programme delivered 1,531 new LLT prescriptions, including 1,081 statins, 353 ezetimibe, and 158 IT’s and PCSK9 inhibitors. Combination LLT use increased from 3% to 10%.
• Injectable Therapy (IT) Access and Challenges: A total of 146 patients were referred for IT’s, with 7 not on any LLT due to intolerance and 139 on LLT requiring further optimisation. Primary care teams were reluctant to initiate IT’s due to capacity and experience concerns, with only 3 practices initiating 5 patients locally. Specialist lipid clinics have wait times of 6 months. Based on programme data, and CVDPREVENT audit data, an estimated 327 patients out of 16,175 not on a statin and 2,197 patients out of 33,865 not achieving lipid targets would be eligible for IT’s, totaling approximately 2,524 eligible patients in NEL.
• LLT Decline Challenges: 10% (359/3,462) of patients declined statin rechallenge or non- statin alternatives. Discrepancies in documentation between practice teams and specialist pharmacists highlighted the need for better training. Reasons for decline included perceived good health, prior reassurance, preference for lifestyle changes, and concerns about side effects. Women showed a higher rate of decline.
• Non-Adherence and Re-engagement: 6% (128/2,142) of patients on LLT confirmed non- adherence. Following detailed consultations, these patients were re-engaged with treatment in line with national guidelines.
• Pending Lipid Tests: 30% (641/2,142) of patients had pending lipid tests. Over half of these patients attended consultations to address secondary causes for raised triglycerides like uncontrolled HbA1c, BMI, and lifestyle factors. Blood test reminders were sent, and practice teams received progress summaries to ensure follow-up.
• Unreachable Patients: 12% (679/5,604) of patients did not respond to telephone consultations. Strategies such as offering out-of-hours consultations and face-to-face appointments helped improve accessibility.
• Enhanced Diagnosis and Management: Joint GP-pharmacist reviews corrected 720 coding errors, risk-stratified 310 patients using the QRisk tool for 10-year cardiovascular risk, and based on this, statin therapy was initiated for primary prevention of CVD. Furthermore, 83 individuals were referred for familial hypercholesterolemia (FH) assessment, leading to seven confirmed diagnoses and 8 have no variant detected.
• Multidisciplinary Care: Over 140 complex cases were discussed in virtual MDT meetings, streamlining advanced treatment access and improving patient outcomes.
• Building Primary Care Capacity: Protected Learning Time sessions, peer reviews, and training empowered 56 PCN pharmacists to optimise LLT confidently, enhancing sustainability in lipid management.

The programme exemplifies a collaborative, patient-centered model of care, delivering significant improvements in lipid management, CVD prevention, and health equity across NEL.

Lessons Learned:

The CWP has yielded several key insights into optimizing LLT and improving cardiovascular outcomes across primary and specialist care. These insights highlight the importance of collaboration, addressing training gaps, and overcoming barriers to therapy initiation. Key insights include:

• Sustained Collaboration: Strengthened relationships between primary and specialist care enabled equitable patient access to advanced LLT options, improving treatment outcomes and reducing health inequalities.
• Diverse Approaches to LLT Optimisation: Differences in confidence and approaches to LLT between primary and specialist care teams were observed. Primary care pharmacists often took a cautious approach to statin rechallenges and initiating non- statin therapies. Training on diagnosis coding, LLT management, and integrating new therapies into routine practice remains essential.
• Access Challenges for IT Initiation in Primary Care: Initial hesitancy to initiate IT’s at the practice level was noted due to limited familiarity, capacity challenges, and perceived need for specialist guidance. Despite the development of tailored guidance, training sessions, and the creation of the NEL IT’s Primary Care Guideline, challenges with primary care initiation remain unresolved.
• Medication List Updates: Primary care teams did not consistently update the patient medication list to include IT LLTs that are prescribed by hospital specialist clinics.
• Engagement and Accessibility: Innovative outreach strategies, such as out-of-hours consultations and flexible appointment scheduling, effectively reduced missed patient engagements.
• Addressing Disparities: Cultural sensitivity and patient-centered approaches were key to overcoming misconceptions and increasing LLT uptake
• Holistic Management: Integrating lifestyle modification services and social prescribing enhanced patient outcomes by addressing social determinants of health.
• Sustainability Planning: Structured training and peer reviews equipped primary care teams to sustain high-quality lipid management.

Conclusion:

The CWP has delivered transformative results across NEL, significantly enhancing the management of CVD. This collaborative initiative between specialist pharmacists and primary care teams has enhanced access to LLTs, optimised patient care, and contributed to reducing health inequalities.

The programmes comprehensive is projected to prevent at least 127 major cardiovascular events over five years, directly supporting the NHS Long Term Plan’s prevention goals. The programme has also played a key role in elevating NEL ICB’s performance from the lowest rate of lipid target achievement across London ICBs to the second highest (see Appendix 5). This achievement highlights the value of a collaborative, integrated care model, where specialist pharmacist and teams work together with primary care teams to drive better patient outcomes.

To build on these achievements and ensure lasting, sustainable improvements, securing funding for long-term, permanent specialist pharmacist roles is essential. This will ensure the continued success of integrated pathways, helping to close the health inequalities gap and significantly improving CVD prevention across NEL. With ongoing support and collaboration, this initiative has the potential to make a substantial, long-term impact on population health, contributing to a healthier, more resilient future for all patients.

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