Project Name: Forest Heath PCN Lipid Clinic support project

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).

Planned Milestones:

  • Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
  • Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity; Confirmation of recruitment of  Clinical pharmacist
  • Collection & submission of 3 months clinical activity data. Project Review meeting to discuss project progress.
  • Collection & submission of 6 months clinical activity data. Project Review meeting to discuss project progress.
  • Collection & submission of 9 months clinical activity data.Project Review meeting to discuss project progress.
  • Collection & submission of 12 months clinical activity data.Project Review meeting to discuss project progress. Development of business case for the sustainability of the service and submission to the Trust and /or ICS.
  • Analysis of CWP data from all sites, submission of Final Project 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 
  • 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, levelling health inequalities within the PCN. 

Anticipated benefits for 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 benefits for Novartis:

  • 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: March 2023 for 24 months

UK2303093117

Project Name: Forest Heath PCN Lipid Clinic support project

Organisation(s): (OHS Health, trading as) Forest Heath Primary Care Network

Completion Date: 20th May 2025

Outcome Summary:

A total of 1589 patients with ASCVD successfully achieved their cholesterol targets, as defined by local and national clinical protocols. This outcome underscores the broader impact of intensified lipid management strategies within the PC 

Key Project Outcomes Data:

The 18-month clinical activity within the Forest Heath PCN yielded several significant outcomes: 

  • Target Population Identification: Initial comprehensive searches identified 2436 patients within the broader target population for lipid management across the PCN. 
  • Patient Cohort Selection: 606 patients as having both ASCVD and uncontrolled lipid levels. 
  • ASCVD Cohort for Lipid Management: A larger cohort of 1347 patients, spanning cohorts 1, 2, 3, and 4, were identified as having ASCVD and uncontrolled lipids, indicating the broader need for intensified lipid management strategies. 
  • Significant LDL-C Reduction: Treatment optimisation led to substantial reductions in LDL-C levels. Baseline LDL-C levels among patients receiving treatment were between 2.61 mmol/L to 5.44 mmol/L. Following optimisation, LDL-C levels were significantly lowered, ranging from 0.2 mmol/L to 2.15 mmol/L. 
  • Achievement of Cholesterol Targets: A total of 1589  patients with ASCVD successfully achieved their cholesterol targets, as defined by local and national clinical protocols. This outcome underscores the broader impact of intensified lipid management strategies. 

Outcomes:

The sustained achievement of cholesterol targets in a significant cohort of ASCVD patients reflects a broader improvement in lipid management strategies within the PCN. The ability to provide access to all NICE-approved medicines underscores a commitment to delivering high-quality, guideline-driven care

  • Successful Integration into Primary Care: Treatments were effectively and seamlessly integrated into the existing primary care setting. This successful integration was largely facilitated by the established working system and the efficient utilisation of POCT. 
  • Impact of Clinical Leadership: The PCN's Clinical Pharmacist demonstrated exceptional clinical leadership, playing a pivotal role in spearheading the implementation, monitoring, and ongoing optimisation. This leadership was crucial for the project's success. 
  • Enhanced Access to Medicines: The project ensured that patients had improved access to all NICE-approved medicines for the treatment of ASCVD, thereby expanding the therapeutic options available.
  • Service Development and Workflow: A robust working system was meticulously implemented, incorporating Point-of-Care Testing (POCT). This crucial development facilitated on-the-day blood tests and rapid LDL-C results, streamlining the patient pathway and enabling timely clinical decisions. 
  • Inter-organisational Collaboration: Close and continuous collaboration was fostered with the local heart team. This partnership was instrumental in optimising patient selection, ensuring adherence to clinical guidelines, and facilitating comprehensive patient manage 

Conclusion:

The 18-month project within the Forest Heath PCN unequivocally demonstrates sustained achievement of cholesterol targets in a significant cohort of ASCVD patients. The project serves as a model for successful integration of novel therapies into primary care, underpinned by efficient systems and strong clinical leaders. 

Based on the successful outcomes and learnings from this 18-month evaluation, the following recommendations are put forth: 

  • Sustain and Optimise Current Systems: Maintain and continuously optimise the established working system, particularly the Point-of-Care Testing (POCT) infrastructure, to ensure ongoing efficiency and patient benefit. 
  • Invest in Professional Development: Support ongoing professional development and training for primary care staff regarding treatment administration, monitoring, and patient counselling to maintain high standards of care. 
  • Strengthen Collaborative Partnerships: Foster continued and enhanced collaboration with the local heart team to ensure seamless patient transitions, shared learning, and optimised patient care pathways. 
  • Longitudinal Outcome Monitoring: Implement a robust plan for long-term monitoring of patient outcomes including sustained LDL-C reduction and cardiovascular event rates. 

FA-11463514 | June 2025