The number of people dying prematurely from Cardiovascular Disease (CVD) is on the rise. There is clear evidence that the management of cholesterol can reduce the risk of cardiovascular events. To address this challenge equitably, a more targeted and proactive approach to managing CVD is required.

We used a population health management approach to implement an innovative lipid management pathway which enables early diagnosis and prevention and helps to address diagnostic and treatment gaps.


The team implemented case-finding systems and helped embed the new lipid management pathway through ongoing engagement and educational sessions for clinicians. They have been instrumental in encouraging dialogue and new ways of working between primary and secondary care teams.


Dr Jai Cegla, Consultant in Metabolic Medicine, Imperial College Healthcare Trust, NHS England Clinical Advisor

What the project involved

Using population health management approaches, ICHP is supporting primary care teams in North West London (NWL) to embed a lipid management pathway that enables early diagnosis and prevention. An important treatment option in this pathway for patients identified at risk of CVD, is Inclisiran – a novel anti-cholesterol drug approved by the National Institute for Health and Care Excellence (NICE) used for secondary prevention. In addition, to facilitate this pathway and appropriate management for patients on the lipid management pathway, ICHP has supported a pilot which enables multi-disciplinary team (MDT) working amongst primary and secondary care teams.

ICHP facilitated the set-up of a Clinician Working Group, which has provided NWL clinical leadership groups with assurance of safe introduction of this new pathway. This group comprises secondary care clinicians and the GP Co-Chair of the Integrated Care System CVD Executive Leadership Group. One clinician in this working group has also become the AHSN clinical champion for this lipid pathway approach. The development of clinician and patient resource packs has also helped us to deliver a clear, standardised approach across NWL. To help empower clinicians to tackle lipid management, we worked collaboratively across the local healthcare system to host webinars which provided a forum for conversation and questions from primary care staff.


  • More than 50 patients initiated with treatment of Inclisiran across two NWL Trusts (as of April 22)
  • 103 doses of Inclisiran ordered in NWL across 23 Primary Care Networks (as of May 22)
  • 362 NWL attendees to three online training sessions
  • Excellent support from Trusts, Trust-PCN Lipid pilot sites and CVD Executive Lipid Subgroup to support Inclisiran uptake/issue resolution (1 September 217 doses in Primary Care and 291 doses in Secondary Care, across 34 PCNs
  • Lipid Management webinar 6 September (166 attendees) – highly rated webinar, previous webinars have been well attended with up to 248 attendees.

Next steps

Data is being used to understand the impact of the current approach and identify target populations and areas in NWL that would benefit from this approach. Work is being undertaken to spread the innovation beyond pilot site. We are also continuing to develop CVD Clinical champions or fellows.

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