South Lincolnshire Rural PCN

FH Programme

In partnership with South Lincolnshire Rural PCN and
ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement)

Practice Pro Forma

Project overview

Familial Hypercholesterolaemia (FH) is an inherited condition that causes very high cholesterol from birth and significantly raises the risk of premature cardiovascular disease. Early identification and treatment with lipid-lowering therapy reduces this risk substantially. The NHS provides a genetic screening process for those affected, but there is currently no targeted system-wide approach to identifying, contacting, referring and testing at-risk individuals within the area.

The incidence of FH within a Western population is approximately 1 in every 250 patients. Across South Lincolnshire Rural PCN, this translates to a significant cohort of patients with undiagnosed FH and a smaller group already on the practice FH register.

The South Lincolnshire Rural PCN FH Programme uses the FAMCAT2 risk algorithm to identify undiagnosed FH cases and optimise management of patients already on the practice FH register. The programme is supported by a consultant lipidologist from United Lincolnshire Hospitals NHS Trust (ULHT) and delivered in partnership with Eclipse.

The programme operates two streams:

  1. Stream 1 — Case finding. Patients with a history of Total Cholesterol greater than 7.5 mmol/L and/or LDL-C greater than 4.9 mmol/L who do not have an FH diagnosis. Patients are stratified into MDT, Advice & Guidance (A&G), or Monitored routes based on lipid value and FAMCAT2 score. Patients meeting Total Cholesterol greater than 9.0 mmol/L or LDL-C greater than 6.5 mmol/L are routed to the per-PCN FH MDT for further assessment.

  2. Stream 2 — Confirmed FH monitoring. The practice's existing FH register patients. Focus is on therapy adherence, recent lipid monitoring, and identifying patients who would benefit from MDT review.

Eclipse provides the patient identification, patient engagement, dashboards, and clinical decision support. The PCN MDT, supported by the ULHT consultant lipidologist, makes clinical decisions on individual cases. Patient reviews and outcomes are returned to your practice.

If your practice would like to take part: please complete the pro forma below to register your participation and confirm permissions for patient engagement. Practices will be notified prior to any active patient engagement, and will receive a guide on how to view patient lists and document patient reviews.