Project Name: SDS MyHealthcare Limited – Enhanced Lipid Specialist Review 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) in response to the needs of the CW Partner. The project is aiming to achieve:-

  • Identification of sub-optimally treated ASCVD patients at the highest risk of cardiovascular events in primary care, who are not achieving lipid targets as specified in national guidance and/or local guidelines
  • Identification of ASCVD patients at the highest risk of cardiovascular events in primary care, 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  
  • 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. Project Kick Off meeting, Collection of baseline data, in line with the measure of success, confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
  2. Collection of 3 months clinical activity data
  3. Collection of 6 months clinical activity data
  4. Collection of 9 months clinical activity data
  5. Collection of 12 months clinical activity data
  6. Collection of 15 months clinical activity data
  7. Collection of 18 months clinical activity data
  8. Development of business case
  9. Analysis of project data, and submission of Final Project Report

Expected Benefits:

Anticipated benefits for patients:

  • 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 PCN 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 partner 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 and demonstration of benefit via development of business case for substantive funding 
  • Support aligned to NHS Long Term Plan, CDVPREVENT, 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 the NHS which addresses the problem of health inequalities 
  • Ethical, professional, and transparent relationship between Novartis and the NHS

Start Date & Duration: 

Start Date: Dec 2022

Duration: 22 month project (18 months of clinical activity)

UK2212024648

Project Name: SDS MyHealthcare Limited – Enhanced Lipid Specialist Review Project

Partner Organisation(s): SOUTH DOC SERVICES MYHEALTHCARE LIMITED, a company registered in England under company number 10210054, of West Heath Medical Centre, 194-196 West Heath Road, Northfield, Birmingham, West Midlands, England, B31 3HB (“Collaborator” or the “CW Partner”)

Completion Date: 5th July 2024

Outcome Summary:

Improved quality of care for patients and supported the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD).

Improved knowledge/confidence of Lipid management with multiple Primary Care Clinicians within over 60 practices in Birmingham.

Key Project Outcomes Data:

  • Increased the number of patients with ASCVD and uncontrolled lipid levels accessing the service. 
  • Improved the speed of patient access – patients were identified and invited to a Specialist Lipids Clinics, resulting in a reduction in the overall backlog of existing patients with ASCVD waiting to be seen by a pharmacist for a structured medications review. 
  • Increased the number of patients being able to access NICE approved medicines for the treatment of ASCVD. 
  • Sustainability for the resource required for maintenance long term lipid management pathway agreed through the Long Term Condition MDT service.
  • Improved patient reported experience measures linked to the introduction of CWP. 
  • Significant collaboration with key partners to enhance the education offer has taken place for Primary Care Health Professionals, working alongside Novartis, AHSN and the BSOL Training Hub.

Please see key data matrix in outcomes below. 

Outcomes:

Key points:

Dedicated review clinics were held to enable a review of patients within the ASCVD pathway, offering Lipids Optimisation where appropriate. A total of 2,012 patients have received a review, 46% completing a medication optimisation.

Dedicated Complex review clinics were held for patients who required more specialist review (98).

Appropriate patients have been discussed at LTC MDTs (109).

Appropriate patients have been referred to other internal lifestyle services - SDS Dietician (48) and SDS Social Prescriber (36).

Collaboration with key partners to enhance the education offer has taken place for Primary Care Health Professionals, working alongside Novartis, AHSN and the BSOL Training Hub.

Learning:

This project has been the catalyst for a number of transformational improvements across the organisation which ultimately benefits the 9 PCNs, 60+ Practices across a patient population of 430,000. SOUTH DOC SERVICES’ experience of engaging with patients has improved significantly through continuous iterative review of the operational booking and patient pathway processes. 

Through the collaborative efforts of the project partners (Novartis, AHSN, BSOL Training Hub) SOUTH DOC SERVICES has improved the knowledge and confidence of Primary Care Clinicians.

Challenges:

With the organisational support invested in the delivery of this project, whilst facing many challenges along the journey, SOUTH DOC SERVICES was able to overcome a lot of barriers.

There were some that were persistent blocks on optimal delivery including:

The patient demographics range across SOUTH DOC SERVICES’ 9 PCNs meant there were communities within the cohort who were resistant to medication changes. This variation led to some patient communities who were not engaged in addressing their health needs. Some patients were already on sub-optimal therapies and not open to up-titration, whilst others were very resistant to injectable therapies being initiated. Any future project would benefit from suitable patient education tools (face to face and materials) that can be understood by the varied population SDS serve. SOUTH DOC SERVICES already had clinicians delivering who were able to communicate in multiple languages to address this, but alone did not prove to be enough.

Despite a lot of support and education from SOUTH DOC SERVICES’ clinicians when delivering clinics, there were cohorts of patients who refused any injectable therapies due to incomplete understanding of the risks of their lipid profiles and underlying health status.

SOUTH DOC SERVICES’ model was delivery of this project centrally by a team of clinicians, and a common theme noted was that patients did not want to start injectable therapy unless their own GP was going to be recommending the changes. This was communicated to SOUTH DOC SERVICES but in many cases, it was found that their own GPs also face the same challenge when implementing therapy changes.

Identification of the higher risk patients through the searches provided initially was a challenge as it was not targeting the higher risk patients, but this was soon resolved using the Manchester tool. In future, SOUTH DOC SERVICES’ would look to break the search criteria down to ensure our clinicians who are delivering projects are confident all the targeted patients would be captured by the searches.

Quote from Partner:

“An integral project supported by Novartis allowing primary care to invest resource in addressing the national agenda of health inequalities in preventative medicine,  to those who would benefit most by reducing their risk."

Ramandeep Kaur Sandhu, MRPharmS

Conclusion:

This project has achieved the above milestones, including the submission of a business case which has been approved for continuous funding of the service.

FA-11391259 | March 2025