The Buckinghamshire Lipid Optimisation Programme is a transformative cholesterol management programme, leveraging advanced data-driven tools to redefine patient care. The programme is a collaborative working programme between Buckinghamshire Healthcare NHS Trust and Novartis Pharmaceuticals UK Ltd.
This initiative represents a bold step in tackling cardiovascular risk through collaboration and cutting-edge technology. The programme, spearheaded by Dr Mark Johnson, Associate Medical Director, has used the Graphnet CIPHA population health platform to identify over 2,800 high-risk patients. The initiative provides personalised interventions, including increased doses of oral lipid lowering therapies (such as statins) and access to injectable lipid-lowering therapies.
Over 1,400 patients have been reviewed within just nine months, with 79% of these patients offered up-titration of their cholesterol lowering medications.
“The scale of this programme and its early successes are a testament to the power of data integration,” said Dr Johnson.
“We’re not only addressing long-standing challenges like medication adherence but also reaching patients who might otherwise slip through the cracks. This is about delivering proactive, patient-centred care that significantly reduces cardiovascular risk.”
Dr Johnson added, “One of the most rewarding aspects of this programme has been the overwhelmingly positive feedback from patients. A 98% satisfaction rate speaks to the dedication of our multidisciplinary team and the clear benefits of this tailored approach.”
Ian Denley, CEO of Graphnet, praised the initiative’s impact: “This is exactly the kind of innovation the NHS needs. By harnessing the full potential of population health tools, Buckinghamshire has demonstrated how data can drive earlier, targeted interventions. These efforts not only save lives but also reduce long-term healthcare costs. We’re thrilled to support this groundbreaking work.”
The programme’s scalable model has been key to its success. Virtual clinics, staffed by bank medical professionals, enabled the team to operate up to 10 sessions simultaneously. Standardised protocols ensured consistent care delivery, while patient engagement strategies, such as tailored communication and pre-appointment information, streamlined processes and reduced no-show rates.
Addressing challenges like medication adherence has been a focal point of the initiative.
“Statin compliance is a well-known issue,” Dr Johnson explained. “Our data tools allow us to identify patterns of non-adherence and open conversations with patients about their challenges. Sometimes, even small interventions, like discussing side effects, can lead to dramatic improvements.”
“This programme is just the beginning,” said Dr Johnson. “We’re already seeing the ripple effects of this work in terms of improved patient identification and system efficiencies. It’s a model that other regions can adopt to make a tangible difference in cardiovascular health.”
The CIPHA population health platform used by Buckinghamshire combines advanced analytics and robust data integration to support individual patient care and broader community health initiatives. By uniting data from hospitals, GP practices, social care, and other sources, the platform provides a comprehensive view of health trends, enabling healthcare providers to collaborate in identifying at-risk individuals, monitoring chronic conditions, and proactively intervening to prevent ill health.
As a member of the CIPHA consortium, Buckinghamshire Healthcare NHS Trust benefits from being part of an 11 Integrated Care System (ICS) network spanning 17 million patients. This partnership fosters the development, trial, and deployment of transformative initiatives using data insights from digital health records.
