Project Name: Royal Free London NHS Foundation Trust Lipid Optimisation

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 optimization of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.  This will be done with the hiring of a Physician’s Associate and Clinical Nurse Specialist who will assist the Health Care Professional to optimise lipid therapy for patients in the 7 Camden PCNs (Central Camden PCN, Central Hampstead PCN, Kentish Town Central PCN, Kentish Town South PCN, North Camden PCN, South Camden PCN, West Camden PCN) (see appendix 1 for list of PCN’s and practices) 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.  

Planned Milestones:

  • Milestone 1: Project kick-off meeting.  Collection of baseline data
  • Milestone 2: Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
  • Milestone 3: Confirmation of recruitment of Physician’s Associate and Clinical Nurse Specialist
  • Milestones 4 through 11: at three monthly intervals:
  • Collection & submission of clinical activity data.
  • Project review meeting.
  • Milestone 12: Development of business case
  • Milestone 13: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary.  Project wrap up meeting.

Expected Benefits:

Patient: 

  • 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.  

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. 

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: March-2023 for 29 months

FA-11449880 | June 2025

Project Name: Royal Free London NHS Foundation Trust Lipid Optimisation

Organisation(s): Royal Free London NHS Foundation Trust, Royal Free Hospital, Pond Street, London NW3 2QG

Completion Date: 02-October-2025

Outcome Summary: 

This CWP has improved the quality of care for patients diagnosed with atherosclerotic cardiovascular disease (ASCVD), who accessed the service. This was achieved by the introduction of a clinical fellow to the CW Partner’s Lipid Clinic for review and optimisation of patients from both primary and secondary care referral, and a clinical nurse specialist (CNS) to the CW Partner’s cardiology department to support the proactive identification, review and treatment optimization. Up to 30 patients per week, a total of circa 1,980 for the duration of the 66 clinic weeks of the project. Of which, 

  • 425 outpatients identified with uncontrolled lipid levels received a reactive treatment review by Clinical Fellow in the lipid clinic (via secondary care and primary care referral), and,
  • 93 inpatients identified with uncontrolled lipid levels received a proactive review by the CNS in the cardiology clinic. 

Therefore, a total of 518 patients were identified and reviewed: of which:

  • 300 patients received medicines optimisation. Remaining patients requiring initiation, continuation or up titration of their statin were referred back to primary care general practitioner for their lipid management. 

Please note. The CWP was amended from the original scope which included the primary care networks (PCNs). The PCNs were removed due to lack of engagement for lipid optimisation in primary care and the project roles worked within secondary care only. The amendment to the CWP also changed the CWP Role from physician’s associate to clinical fellow as the latter has a broad range of clinical duties and is on the doctor’s training pathway.

Key Project Outcomes Data: 

The CWP collaboration resulted in:

  • The creation of a new clinic protocol and process for lipid management.
  • The writing of new standard operating procedures (SOPs).
  • The service team being trained in lipid management which enables the discharge of patients to a general practitioner (GP) with lipid management guidance.
  • The creation of a business case for sustainability of the new clinic within cardiology and the new models of lipid management, post project.

Outcomes: 

  • An average of up to 30 patients with ASCVD and uncontrolled lipids levels accessed the service each week as part of this CWP.
  • A total of 518 patients with ASCVD and uncontrolled lipid levels being identified compared to a baseline of 35.
  • Of which, 300 patients were identified as requiring medical optimisation which was carried out using all NICE approved lipid lowering therapies for the treatment of ASCVD.

Conclusion: 

The CWP has made a positive difference to the service, the CW Partner is looking to continue the work, post project. A business case has been developed for future funding of the CWP Roles post CWP.

FA-11552445 | November 2025