Project Name: Lipid Hub for Community CVD Hub Model of Care – Collaborative Working 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) 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. 

Planned Milestones:

  • Lipid Management pathway/protocol development.
  • Collection of baseline data, in line with the expected project outcome measurements
  • Confirmation that recruitment in process
  • Collection & submission of 3 months clinical activity data.
  • Confirmation that recruitment is complete and all recruited project staff are fully trained.
  • Collection & submission of 6 months clinical activity data.
  • Collection & submission of 9 months clinical activity data.
  • Collection & submission of 12 months clinical activity data.
  • Development of business case to ongoing utilisation of CVD Hubs piloted in this project.
  • Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary.

Expected Benefits:

For the Patient:

  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.
  • Enhanced experience and counselling 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 for lipid management, focusing of patients who may have previously not attended GP appointments or been lost to follow-up. This help to level health inequalities within the practice and, ultimately, in a wider setting.

For the CW Partner:

  • 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 novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
  • Support aligned to NHS Long Term Plan, CDVPREVENT, and Network Contract DES
  • Opportunity to show the impact of the CWP to create lasting change in lipid management within Nimbuscare

For Novartis: 

  • Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines
  • 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: November 2023 for 14 months

FA-11465961

Project Name: ASCVD and Lipid Primary Care Model of Care – Collaborative Working Project

Partner Organisation(s): NIMBUSCARE, 2 Oak Rise, Acomb, York YO24 4LJ

Completion Date: 7th July 2025

Outcome Summary: 

The NimbusCare lipid optimisation initiative was designed to identify and treat patients with atherosclerotic cardiovascular disease (ASCVD) whose lipid levels were not adequately managed under existing systems. The project targeted patients across a selection of engaged practices within the Nimbus group, aiming to reduce cardiovascular (CV) risk at a population level.

Key Project Outcomes Data: 

2300 patients at high risk of ASCVD were identified as eligible for lipid optimisation from 6 practices from the Nimbus group. 

617 consultations conducted and 587 patients improved their lipid control

Outcomes: 

The project created additional capacity to assess lipid control in patients with established cardiovascular disease. Across all six sites, data analysis revealed that 207 high-risk patients commenced statin therapy for the first time, 123 patients were switched to higher intensity statins, and lipid management was successfully optimised for 244 individuals.

Quote from Partner: 

“We have been able to reach patients at high risk of cardiovascular events and optimise their lipid control, right across the city. This will undoubtedly reduce the incidence of heart attacks and strokes, as well as other atherosclerosis drive processes, at a population level in years to come. It helped to establish better care as a norm across the city, and improved access to new NICE recommended treatment”.
Dr Jim Read, Clinical Lead, Cardiovascular Disease Prevention, Nimbuscare Ltd.

Conclusion: 

The project achieved its aims of optimising lipid control for patients at high risk of cardiovascular events. 

FA-11559379 | November 2025