Project Name: Healthier South Wirral Lipid Optimisation Project

Project Summary:

The CWP is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Network (PCN) Contract Direct Enhanced Service) DES and the Locally defined Cardiovascular plans.

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.

The CWP will be led by a lead GP in each practice alongside a multi-disciplinary team; including Administrator, Clinical Director, Clinical Lead, Executive Lead/Sponsor, General Practitioner (GP), Healthcare Assistant (HCA), Pharmacy Technician and Service Manager, aiming to achieve:

  • Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines
  • Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies 
  • Review of treatment options and decision on next steps in collaboration with ASCVD patients
  • Counsel and optimise ASCVD patients where appropriate, who are at the highest risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance.   
  • Early identification of at-risk patients who have not had intervention in their health and wellbeing
  • Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated 
  • On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably

Planned Milestones:

  1. Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
  2. Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity (CW Partner shall ensure that the clinical staff covered by the Novartis Financial Contribution are in place, trained and ready to begin clinical activity).
  3. Collection & submission of 3 months clinical activity data.
    Project Review meeting to discuss project progress.
  4. Collection & submission of 6 months clinical activity data.
    Project Review meeting to discuss project progress.
  5. Collection & submission of 9 months clinical activity data.
    Project Review meeting to discuss project progress.
  6. Collection & submission of 12 months clinical activity data.
    Project Review meeting to discuss project progress.
  7. Development of business case
  8. Analysis of CWP data, 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, leveling health inequalities within the PCN.

Anticipated benefits 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 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: May 2023 for 13 months

UK | May 2023 | UK2305266162

Project Name: Healthier South Wirral Lipid Optimisation Project

Partner Organisation(s): One Wirral CIC, 2 Oxton Road, Birkenhead, Wirral, CH41 2QJ 

Completion Date: 5th Feb 2025

Outcome Summary: 

This project improved the quality of care for patients with atherosclerotic cardiovascular disease (ASCVD) through various strategies. These strategies included early identification, thorough reviews, and medical optimization of patients with ASCVD. By implementing these measures, the project enhanced the overall care provided to patients and ensured timely interventions were administered.

Key Project Outcomes Data:

The collaborative working project led to lipid reviews of 40,000 patient records, resulting in various interventions to manage lipid levels as detailed in outcomes below.

Outcomes:

During the project a total of 40,000 patient recored, those aged 18 and above, were reviewed. Among them, more than 3,000 had a history of a previous cardiovascular event.

Additionally, at the start of the project, there were 913 patients who had already achieved target lipid levels in the previous 12 months. After 12 months of the project's implementation, this number increased to 1,351. This suggests that the project's interventions and strategies have resulted in a significant improvement in lipid control for these patients.

These findings highlight the effectiveness of the project in optimizing lipid management and achieving target lipid levels in ASCVD patients. The project's efforts have positively impacted a substantial number of patients, indicating improvements in the quality of care provided to individuals with ASCVD.

Quote from Partner:

“The lipid optimisation project has given us the opportunity to focus our efforts on CVD prevention and build momentum in proactively identifying patients and optimising their lipid management whilst increasing awareness and upskilling our clinicians to be able to offer the entire range of treatment options now available for the patient.”

Dr Syed-Mohammed (Clinical Director for Healthier South Wirral, Clinical Lead for CVD across HSW PCN)

Conclusion:

These findings underscore the project's success in optimizing lipid management and achieving target lipid levels in ASCVD patients. The efforts have benefited many patients, reflecting improvements in the quality of care for individuals with ASCVD, including those who are sub-optimally treated, allowing for targeted interventions to optimize their care and potentially improve outcomes.

This project also highlights the significant efforts of the team over the past year, complementing the ongoing work of practice staff across the PCN.  Patient management related to lipids has become more efficient, and the teams are committed to maintaining this high standard of care across all practices even after the project concludes.

FA-11445920 | June 2025