Project Name: Lime Tree Surgery ASCVD Primary Care Lipid Management Collaborative Working Project
Project Summary:
The Cardiovascular Wellness Program (CWP) aims to enhance patient care and improve outcomes for individuals with atherosclerotic cardiovascular disease (ASCVD). It follows the guidelines set by the Primary Care Network (PCN) Contract Direct Enhanced Service (DES) and the local cardiovascular plans.
A previous collaboration focused on specific cohorts of patients and was completed over 12 months before the start of this project. This collaboration is different as it aims to expand the cohorts to optimise treatment for patients who are not at target cholesterol levels despite being on a lipid lowering therapy (some of which were identified during our previous collaboration).
The CWP is designed to be a multidisciplinary effort, led by a Pharmacy Technician, and supported by a team consisting of a Clinical Pharmacist, Nurse (Band 7), General Practitioner, Healthcare Assistant, and Nurse Associate.
The program aims to achieve the following objectives:
- Identify ASCVD patients who are at high risk of cardiovascular events and are not achieving recommended lipid levels according to national and/or local guidelines.
- Identify ASCVD patients who are at higher risk of cardiovascular events and have previously not tolerated or refused alternative lipid modification therapies.
- Review treatment options for ASCVD patients and make collaborative decisions on the next steps.
- Provide counselling and optimize management for ASCVD patients when appropriate.
- Early identification of at-risk patients who have not received appropriate health interventions.
- Identify ASCVD patients who are not optimally treated after conducting a risk assessment review.
- Provide ongoing support and conduct annual reviews for ASCVD patients to ensure equitable improvement in cardiovascular outcomes.
Planned Milestones:
| Milestone description | Milestone delivery date | |
|---|---|---|
| 1 | CW Partner: Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table. | Within 1 month of execution of the CWA |
| 2 | CW Partner: Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin | Within 1 month of execution of the CWA |
| 3 | CW Partner: Confirmation that the clinical activity has started. | Within 1 month of execution of the CWA |
| 4 | CW Partner: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary CW Partner & Novartis: Project Review meeting to discuss project progress. | Within 3 months of execution of the CWA |
| 5 | CW Partner: Development of business case to continue the service offered by this project. | Within 7 months of execution of the CWA |
| 6 | CW Partner: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary . | Within 9 months of execution of the CWA |
Expected Benefits:
Benefits for Patients
- Improved access to optimal ASCVD diagnosis and management through enhanced lipid management care.
- Enhanced patient experience with ongoing management of ASCVD. Increased access to appropriate medication for eligible patients, promoting health preservation and preventing long-term events. Convenient access to lipid management care in the Primary Care setting, closer to home.
- Additional capacity allowing for more time and support from Surgery HCP for lipid management.
Benefits for patients
- Higher proportion of ASCVD patients receiving primary care reviews.
- Reduction in health inequalities within the surgery as the project targets patients who may not have previously attended GP appointments or who have been lost to follow up.
- Improved access to expert and timely reviews for ASCVD patients closer to home.
- Reduction in referrals of ASCVD patients to secondary care.
- Increased proportion of patients receiving guideline-directed pharmacotherapy. Enhanced understanding of the benefits of primary care pharmacist-led lipid management clinics. Support that aligns with the NHS Long Term Plan, CVDPREVENT, and Network Contract DES.
Benefits for Novartis
- 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:
Proposed start date: 1st March 2025
Total Project: Nine Months
Clinical Activity: Six Months commencing after one month.
FA-11375438
Project Name: Lime Tree Surgery ASCVD Primary Care Lipid Management Collaborative Working Project
Organisation(s): Lime Tree Surgery
Completion Date: 24th September 2025
Outcome Summary:
This CWP delivered proactive lipid management to prevent cardiovascular events and reduce the health burden in the local area, following a structured model where health professionals worked across the Surgery Primary Care Network (PCN) to provide tailored care for patients in alignment with the Network Contract Directed Enhanced Service (DES).
Key Project Outcomes Data:
From approximately 220 patients reviewed, the following lipid management activity was carried out:
Current statin dose optimised: 34
Optimised onto selective cholesterol-absorption inhibitors: 29
Optimised onto adenosine triphosphate-citrate lyase (ACL) inhibitors: 6
Optimised onto RNA interference (RNAi) therapeutics: 19
Outcomes:
Project Aims
To deliver the benefits of improved outcomes for patients with atherosclerotic cardiovascular disease (ASCVD) by delivering proactive lipid management to reduce the risk of a further cardiovascular event.
Method
The project aimed to review and where appropriate escalate the lipid management of patients who are not at target cholesterol levels of 2.6 mml/l or below despite being on LLT (this included patients who were not captured in the previous collaborative working project completed in 2024 between Lime Tree Surgery and Novartis). The practice utilised the Greater Manchester CVD Prevention lipid search tool which stratifies the secondary prevention CVD population of the practice into some clear actionable cohorts. Around 220 patients were found within the 4a cohort (described below) at project initiation 04.04.25
Discussion
The 4a cohort includes
- Patient previously not reviewed
- New Patients to cohort 4a since the previous review
- Patients not achieving target despite previous escalation and therefore appropriate for further escalation
- Patients who previously declined optimisation but will now appear in the search due to expiry of previous codes
- Patients previously excluded from escalation due to medical reasons (frailty, end of life, etc.) but will now appear in the search due to expiry of previous codes
At the project initiation there were 220 patients in the Cohort 4a search. However, this would have included up to 100 patients, reviewed in the previous project, and either deemed inappropriate for, or declined, escalation of lipid management. No patients in the current search were excluded, and all patients were reviewed on an individual basis. The cohort of secondary prevention patients with an LDL >2.6mmol/L and aged over 90 years was 32. 70 patients were over 85.
Results
In addition to the results shared in the Outcomes Data above, the remaining 132 patients either declined escalation, or it was determined that treatment was inappropriate for example, where searches returned very frail and elderly patients, or those situated in care homes etc.
Conclusion:
A successful project, continuing on from the previous collaboration between Lime Tree Surgery and Novartis, with patients therapy escalated where appropriate and the risk of further cardiovascular events reduced. The numbers treated were restricted by the success of the previous project and the frailty of many of the patients in this cohort.
FA-11551590 | November 2025