South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP

Project Name: High Risk Acute Coronary Syndrome (ACS) Secondary prevention Clinic – South Tyneside and Sunderland Hospitals NHS Foundation Trust

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 with the intention of increasing secondary care initiation of medicines with the repatriation of relevant patients back to primary care for continued care.

The CWP will be led by one clinical pharmacist band 8a (0.2 FTE) working as part of a multi-disciplinary team; including a Consultant Endocrinologist and Healthcare Assistant with Secretarial support. Aiming to achieve the following:

• Increase in the number of patients with ASCVD and uncontrolled lipid levels accessing the service. 
• Improve speed of patient access - achieve reduction in the amount of time taken between patient identification and the patient being seen in clinic from baseline. 
• Achieve reduction in the overall backlog of existing patients with ASCVD waiting to be seen by a pharmacist for follow-up, review, and medicines optimization from baseline (start date of clinical activity). 
• Increase in the number of patients being able to access all NICE approved medicines for the treatment of ASCVD.
• Increase in Secondary Care initiation of CVD medicines and repatriation to primary care for continuation of review and follow up.
• Improve pathway for lipid service referral for other CVD secondary care specialties
• Improved confidence in Primary care in initiating and managing patients on NICE approved treatments.
• Identification of ongoing sustainable resource requirement for maintenance long term lipid management pathway 

This Executive Summary has been amended due to The South Tyneside and Sunderland Hospitals endocrinology department currently having one hundred and fourteen patients (114) that still require lipid lowering therapy (LLT), with an additional one hundred and forty one (141) patients to be added to the waiting list for LLT,  as a result of this project, giving a  total of 255 patients requiring lipid management. To enable these patients to be treated, an extension of nine (9) months is needed, plus funding for a Health Care Assistant (Band 2) for four (4) hours a week and funding for a Clinical Pharmacist (Band 8a) for 0.2 FTE.

Planned Milestones:

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  
• 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 organisation:

• Increased proportion of secondary care ASCVD patients undergoing lipid optimisation    
• Increased proportion of ASCVD patients receiving expert and timely review  
• Reduction in ASCVD events in patients who have received a review and medicines optimization, and   leading to fewer admissions to secondary care 
• Increased proportion of patients receiving guideline-directed pharmacotherapy    
• 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: The project commenced in November 2023 and has been extended to October 2025, which now includes 18 months of clinical activity.

FA-11445929 | June 2025

Project Name: High Risk Acute Coronary Syndrome (ACS) Secondary prevention Clinic – South Tyneside and Sunderland Hospitals NHS Foundation Trust 

Organisation(s): South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP   

Completion Date: December 2025

Outcome Summary: 

This project implemented a band 8a clinical pharmacist (0.2 FTE) as part of a multi-disciplinary team; including a consultant endocrinologist and Healthcare Assistant.

The service supported earlier identification, structured review, and medicine optimisation of patients at high cardiovascular risk. 

Key Project Outcomes Data: 

The collaboration supported service delivery intended to optimise lipid management in high-risk patients over a period of 21 months.

Outcomes: 

Over the course of this project, the service supported evaluation of the role of integrating a specialist pharmacist within the multidisciplinary team (MDT) for management of patients at high cardiovascular risk and optimisation of lipid management pathways. A total of 816 patients were reviewed by the multidisciplinary team between December 2024 and December 2025. The inclusion of a specialist pharmacist allowed for comprehensive medication reviews and treatment optimisation according to local pathway/NICE eligibility criteria¹.

Referral to the pharmacist led lipid optimisation clinic supported escalation of therapy in patients who had not yet achieved their target non-HDL cholesterol. The pharmacist led clinic not only enabled patients to be referred directly following the MDT meeting but also allowed for patients reviewed in the consultant led lipid clinic, primary care and other secondary care specialities to be referred for lipid optimisation which provided an additional referral route for specialist lipid optimisation optimisation. Between December 2024 and December 2025, 235 patients were reviewed in the pharmacist led clinic.

Patients had access to pharmacist led consultations for medication review, counselling and follow-up. Pharmacist led consultations allowed dedicated time for medication reviews, patient counselling and shared decision-making regarding lipid lowering therapy intended to support patient understanding and adherence. In addition to lipid optimisation, 34 patients were referred following MDT review to the lipid clinic for assessment of suspected familial hypercholesterolaemia (FH). 

Overall, the project demonstrated that integrating a specialist pharmacist within a multidisciplinary lipid management pathway can enhance service capacity, support timely optimisation of lipid lowering therapy and improve identification of patients requiring specialist care. The pharmacist led clinic provided a pathway for assessment of eligibility for specialist lipid-lowering therapies. Collectively, these improvements support better management of cardiovascular risk, enhance patient access and provide a sustainable approach to high quality lipid management within secondary care.

Conclusion: 

This Collaborative Working Project demonstrated that embedding a specialist pharmacist within the multidisciplinary lipid management pathway can strengthen service capacity, improve access to specialist lipid optimisation, and support more timely escalation of treatment for patients at high cardiovascular risk. By providing dedicated pharmacist-led review, counselling and follow-up, the service created a structured and sustainable model for identifying patients requiring specialist lipid-lowering therapy, supporting adherence, and enhancing overall cardiovascular risk management within secondary care.

References: 

1. NICE Guidelines and Overview. Available at: Recommendations | Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE (Last accessed 17th June 2026)

FA-11716707 | June 2026