Our team at Health Innovation West of England have been working with One Care (the GP federation for the wider Bristol area) and five primary care networks (PCNs) to deliver an innovative project supported by the Collaborative Lipid Fund. This has focused on supporting clinicians to target patients who have had a cardiac event and require cholesterol review.
Through this project we helped the five PCNs and associated GP practices to identify high risk patients using UCLP Proactive Care Frameworks, and categorise them into four priority groups:
- 1.Patients not currently taking statins to manage high cholesterol
- 2a. Patients taking a statin, but not the best one for their needs
- 2b. Patients taking a statin, but not on the right dose for full effectiveness
- 3. Patients with a non-high-density lipoprotein blood test of higher than 2.5, even whilst on the strongest statin dose they can tolerate.
For the purposes of this project only patients identified as falling within priority groups 1 and 3 were targeted; over 4,600 patients.
In addition to implementing the UCLP Proactive Care Framework tools within primary care, our team at Health Innovation West of England also provided targeted educational training to each PCN to support the management of these patients in line with the NICE lipid management pathway.
The Collaborative Lipid Fund project increased the number of patients who were reviewed and improved the awareness of cholesterol management of both clinicians and patients, and we are confident this work will lead to better cholesterol management overall moving forwards.
We gained some useful insights and key learnings as we delivered this project, which would be helpful to consider when embarking on similar projects with primary care in the future.
Our four key insights are:
- Right team, right approach
It is key to involve all primary care stakeholders in the project design right from the start. This should include agreeing key performance indicators (KPIs) tailored to primary care settings, and data codes employed within primary care practices.
While we ran a project design workshop with PCN colleagues before starting the project, we did not discuss these points. KPIs, and the data codes to measure against these, were determined and agreed by Health Innovation West of England and One Care without practice involvement. We therefore later discovered there were too many KPIs for the project, some of which were unobtainable. In addition, the project data codes differed to those routinely used in GP practices.
Our key learning is that if practice colleagues had been involved in all elements of project design, we could have agreed achievable KPIs that could be measured using routine data codes that did not put extra burden on clinicians.
- Governance and processes
We would recommend involving Information Governance (IG) experts as early as possible in project design to identify what IG requirements are needed to support data collection and sharing of information across organisations.
We were lucky enough to be working with One Care on this project and their Data Protection Officer (DPO). They coordinated the completion of the data protection impact assessment (DPIA), data sharing and processing agreements (DSPAs) with each of the practices in addition to dealing with any specific IG concerns the practices had. Being the GP Federation for the wider Bristol area, they had to the contacts and connections to ensure a smooth process for data collection and extraction.
- Data collection
Implementing a systematic and consistent approach to data collection across the project is important. One Care coordinated data collection for the majority of the PCNs involved but, as one had their own business intelligence (BI) team, they were keen to provide us with their anonymised data direct. It was recognised that PCNs could conduct deep-dives into patient records and ensure they were coded correctly, before re-running data collection searches, thereby acting as a feedback loop. Although within the restraints of the DSPAs One Care were unable to conduct such thorough searches and could only search against specific codes. This meant that one PCN’s performance was showing as a lot higher than the others against KPIs. We are unable to determine whether this is a true reflection of performance or different approaches to data collection.
- Mode of delivery for educational webinars
We started off by inviting primary care colleagues to existing educational webinars that were open to all the integrated care systems we work with.
Due to low numbers of attendance, we pivoted and decided to run PCN-specific sessions delivered during pre-scheduled PCN meetings. This increased the number of clinicians attending the sessions dramatically, as clinicians have protected time to attend their internal PCN meetings.
The key tip here is to use that tried-and-tested quality improvement (QI) approach of adapting when things are not working as planned.
Feedback from PCN colleagues has been extremely positive and it’s been a fantastic project to work on with lots of learning. I’m excited to see what opportunities come up in the future for us to continue working with and supporting primary care colleagues across our local systems.
View the ‘Managing high cholesterol in patients who have had a cardiac event’ case study.
To find out more, contact Amy Bowden, Senior Project Manager on Amy.bowden4@nhs.net or view our Cardiovascular Disease webpage.
Posted on February 11, 2025 by Amy Bowden, Senior Project Manager, Health Innovation West of England
