As a ‘worrying picture’ of heart health emerges, Kathy Oxtoby looks at what ICBs and PCNs are doing to support their populations – from blood pressure testing in the heart of communities, to bringing cardiology to primary care.
There are around 6.4 million people living with cardiovascular disease (CVD) in England (7.6 million in the UK), according to the British Heart Foundation (BHF). And an ageing and growing population could see these numbers rise still further.
Since the BHF was established in 1961, the annual number of deaths from heart and circulatory diseases, including coronary heart disease, stroke, heart failure and vascular dementia, has fallen by nearly half. ‘This has been one of the UK’s major health success stories,’ says Jennie Barr, healthcare lead at the British Heart Foundation.
‘A lost decade of progress’
Look at more recent years, however, and ‘we see a worrying picture’, says Ms Barr. As of 2022, more people in the UK are dying under the age of 75 from heart and circulatory diseases than at any time in the last 14 years. ‘We are calling this a lost decade of progress,’ says Ms Barr.
While the reasons for this ‘lost decade of progress’ are complex, the charity says there are some key factors at play.
There is an ageing population, along with the increasingly complex nature of cardiovascular diseases and people living with more than one long-term condition.
There is also an increasingly unhealthy population, with people living with conditions that put them at heightened risk of developing a heart or circulatory disease, such as obesity, excess weight, or high blood pressure.
Then there are growing inequalities, with those in the most deprived parts of England twice as likely to die early from a heart or circulatory disease than those in the least deprived.
And the shock of the pandemic, and the lost opportunities to access care at its height, have contributed to record long waits for care.
Issues and challenges for health and care services
Health and care services supporting and treating people with these conditions face challenges.
Healthcare costs relating to heart and circulatory diseases in England are estimated at £10 billion each year. CVD’s cost to the wider economy in England (including premature death, long-term care, disability and informal costs) is estimated to be £24 billion each year.
There are record waiting times for heart tests and treatment. Cardiac elective waiting lists in England are at their highest total on record, standing at 428,067 in August 2024. The number of people waiting over 18 weeks rose to 175,322 in the same month. A record 41% of the cardiac waiting list in England are waiting longer than the maximum target treatment time of 18 weeks.
There is also immense pressure in urgent and emergency care, staff shortages, and evolving patient demand exacerbated by the pandemic.
And ICS leaders are ‘still having to prioritise short-term funding and performance over the long-term changes they know are necessary to put the NHS on a sustainable footing’, says Ms Barr.
Ways challenges are being addressed
As to some of the ways these challenges are being addressed, she says there are ‘several good programmes and best practice initiatives happening around the country’. However, these approaches are often short-term due to limited funding, and key learnings are not always shared or scaled more widely’.
The BHF says some good examples of CVD approaches include:
- NHS England’s Core20PLUS5 approach to inequalities, which includes hypertension and cholesterol as clinical priorities.
Hypertension case finding is one of the Core20PLUS5 aims. ‘We know the prevalence of risk factors for CVD tend to be higher in more deprived areas. The Core20PLUS5 programme is an important approach to tackling risk factors, and we would welcome publicly accessible data, case studies and any learnings and best practice around its progress from a regional perspective,’ says Ms Barr.
- The BP@Home remote management programme has shown promising improvements for some patients.
- The CVDPREVENT audit of primary care is supporting local systems to deliver targeted support to areas of unmet need.
- The Community Pharmacy Blood Pressure Checks service is enabling hypertension case-finding in community pharmacies, closer to the patients who need it.
- Community Diagnostic Centres aim to boost diagnostic capacity by shortening waits for common tests that are provided closer to home. Healthwatch recently published an evaluation of CDCs, finding that patients are having positive experiences and accessing timely, more personal and convenient care.
‘Overall, these programmes are steps in the right direction,’ says Ms Barr. ‘To help ensure these and similar programmes succeed, we would like to see them have long term funding, the right infrastructure and workforce and be complemented by public awareness approaches.’
Hearts Need More report
This September, the BHF published its Hearts Need More report, outlining the ‘bold and co-ordinated action we need to see across CVD prevention, healthcare and research’, says Ms Barr.
‘In the report, we are calling for a Heart Disease Action Plan as the vehicle we need to drive this change, providing a practical framework to address the challenge of cardiovascular disease and achieving the change that will help transform outcomes for people across the country.’
Such a plan must: prioritise prevention, tackle long waits for cardiac care, embrace and facilitate a revolution in technology and data, eradicate growing inequalities and invest in research, the BHF says.
The role ICBs and PCNs in improving heart health
Integrated Care Boards (ICBs) can play a ‘vital role in improving heart health in England by coordinating health services and driving strategic planning at a regional level’, says Ms Barr.
‘ICBs with a focus on prevention and early detection of cardiovascular disease can work towards reducing inequalities by identifying and targeting high-risk communities to reduce CVD risk factors. and deliver tailored interventions. They can support innovation by facilitating the use of digital health technologies for remote monitoring and self-management of heart conditions.’
Ms Barr says each ICS has ‘thousands of people who have hypertension, a condition that is often preventable’. ‘If these individuals are treated efficiently, there is huge potential to reduce future capacity pressures on the local health and care system.’
CVD leadership within ICBs and primary care networks (PCNs) in England is ‘crucial for driving coordinated efforts to tackle cardiovascular disease’, says Ms Barr. ‘Strong leadership ensures that heart health is prioritised in strategic planning, resource allocation, and service integration across all levels of care.’
Recent analysis shows that ICS leaders are making ‘positive progress in their local systems’, says Ms Barr. This highlighted that CVD is a priority in almost two-thirds of ICS plans, second only to cancer, and every ICS has identified it as one of their top priority clinical areas.
‘This is something the BHF is glad to see’, says Ms Barr, ‘and we are keen to see support for ICSs to facilitate ongoing prioritisation of CVD.’
The BHF emphasises the need for investing in CVD leadership and prioritising CVD prevention and management across all levels of care. ‘We support ICS leaders taking a population management approach targeting high-risk groups and reducing health inequalities,’ says Ms Barr.
‘Being driven by data and fostering collaborations between primary care, secondary care, and community services are critical to optimise patient outcomes. Leaders must actively engage and listen to their communities’ ensuring services reflect local needs and empower patients in their own care.’
The BHF has developed a resource to help ICBs understand high blood pressure.
Warrington Innovation Network (WIN) PCN: Using an app to monitor blood pressure remotely
Warrington Innovation Network (WIN) PCN, with Cheshire and Merseyside ICB, has been focussed on treating the patients which it knows have high blood pressure, rather than case finding.
‘The rationale is that we actively target patients who we know are at risk, and support them to better manage their blood pressure,’ says Dr Dan Bunstone, clinical director, Warrington Innovation Network (WIN), and executive GP, Chapelford Medical Centre.
The PCN uses remote monitoring with the HealthyYou app that enables patients to manage their blood pressure at home, and signals to a remote team of clinicians when they are ready for review.
The app also has features that enable patients to screen for an irregular heartbeat, and get an indicative blood pressure using only the camera on their smart phone. ‘That’s enabled us to screen thousands of patients for irregular heartbeats and diagnose 20 new cases of atrial fibrillation,’ says Dr Bunstone.
With the blood pressure initiative, patients use the HealthyYou app to monitor their blood pressure with readings being reviewed by a remote clinician. ‘Our focus is on lifestyle advice and lifestyle changes, which enables us to treat around 75% of patients successfully without the addition of medication,’ says Dr Bunstone.
‘We run the initiative through one PCN, but it’s taken collaboration between all of the PCNs to achieve.’
The PCN has a team of HCAs and prescribing advanced nurse practitioners (ANPs). This means the team is enabled to manage patients all the way through admission and ultimately to discharge without the need to refer back to primary care.
All the surgeries within Warrington have enabled access to the remote care team, and they run searches through the GP records to create lists of patients who are at greatest risk.
Patients are onboarded onto the HealthyYou app, which is usually done remotely, and are guided through the process. Patients will then upload reading to the app, which guides them through how to achieve an average home blood pressure, and then flags for the clinical team when patients are ready for review.
Along the way, HealthyYou gives them “nudges” about adding more readings, so momentum is maintained. There is also a health score as part of HealthyYou, which effectively takes patients through lifestyle questionnaires and advice so they can start making positive lifestyle changes as soon as they download the app.
When patients are ready for review they are booked into clinics with the ANP team, and they will then go through the next stages of treatment, or lifestyle changes that will have the most impact. ‘This part of the process is really efficient, as the lifestyle data and interventions have already been collected in HealthyYou before the appointment,’ says Dr Bunstone.
Patients can download HealthyYou from app stores free of charge, and can benefit from the lifestyle advice it creates.
An AF screening initiative also ran across WIN PCN. ‘We texted our patients at increased risk and they completed screening using the technology in HealthyYou. We screened thousands of patients very efficiently, and across a two-month period, finding an additional 20 cases of atrial fibrillation (AF) that had previously gone undiagnosed.
‘The AF screening wasn’t funded, but because we already had the technology to use with the app, it made sense to do, and reaped significant benefits,’ says Dr Bunstone.
The ICB received £250k funding for the Cardiovascular Health scheme after an application process through Cheshire and Merseyside ICB, 12 months ago. ‘We’d already run the project within WIN PCN with the support of Etc.Health, and so had both a proof of concept and a team, which meant we could hit the ground running,’ says Dr Bunstone.
‘The patients we chose to engage with were, by definition, our harder to reach cohorts,’ he says. ‘Supporting them to reach their blood pressure target was always going to be more challenging, but that’s what we set out to do.’
‘Our patients love the service,’ he says. ‘We’re re-imagining our patients’ relationship with health as we now contact them when we expect them to be “unwell” and to prevent illness. This flip in the relationship has proved game changing.’
One notable benefit is around lifestyle advice and managing patients’ care holistically. ‘They aren’t simply prescribed more medication, and indeed this is actively avoided. We wanted to leave a legacy, and by losing weight, getting more active and eating more healthily, we don’t just treat blood pressure, but improve all-cause mortality risks, including cancer,’ he says.
Around 700 patients have been treated to date, with an average reduction in blood pressure across that group of 14 points. ‘To put that in perspective, that reduces the group’s incidence of heart attack and stroke by around 3%, which means we’ve already prevented around 20 heart attacks and strokes,’ he says.
‘We’ve only utilised £150k of funding to date, which effectively means a five times return on investment. We’re actively and demonstrably saving lives.’
‘We are at a critical point of the project,’ says Dr Bunstone. ‘The £250k funding runs out at the end of March 2025, but even if we do no more work, we’ve already saved the system around £750k. Our anticipation is that we will have saved at least 50 cardiovascular events by the end of the project, which extrapolates to a system saving of almost £2 million.’
With the need to move to digital, and to preventative care, ‘we have a proven piece of work that is scalable, and delivered remotely, so could be delivered in any region within the country with the current team’.
To ICB and ICS leaders looking at improving heart health he says: ‘Prevention has to be the focus, and it cannot wait for “next year”.
‘We have to change the narrative and move towards a health system that not only treats disease, but directly supports improving health, and empowering patients.
‘By investing in projects like the one we have in Warrington, you will realise a significant return on investments through reductions in cardiovascular events.’
Bath and North East Somerset, Swindon and Wiltshire ICB: free blood pressure checks at local events
People living in Bath and North East Somerset, Swindon and Wiltshire had free blood pressure checks this September, as part of Know Your Numbers week at a series of local events. Pop-up events were held at Somerset and Dorset Railway, a music festival, and rugby and football matches.
Visitors were able to see if they had high blood pressure – which usually has no symptoms – by getting a simple check from a clinician at these events.
The initiative, led by Bath and North East Somerset, Swindon and Wiltshire ICB ‘brings together local health and care organisations to help prevent ill-health and make it easier for people to take control of their own health and wellbeing’, the ICB says.
‘The only way for people to find out if their blood pressure is high is to have it checked. Getting this done is easy and can save lives.’
The pop-up events will ‘help to reach people who are unaware that they have high blood pressure and guide them towards the treatment and support they need to bring it under control’, the ICB says.
Gill May, chief nurse at Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board says: ‘Many adults living with high blood pressure remain undiagnosed. Without detection and appropriate intervention, it can increase the risk of having a stroke, heart attack or heart failure.
‘Getting out and about in our local community will allow us to raise awareness of this hidden killer, help to prevent heart attacks and strokes and, ultimately, improve the health of our local population.’
Leicester, Leicestershire and Rutland (LLR) ICB and Fosseway PCN: bringing cardiology to primary care
Dr Arshad Khalid is clinical director, Fosseway PCN – which has four practices serving 46,000 patients – and transformation lead in cardiology for Leicester, Leicestershire and Rutland (LLR) ICB, which has a population of 1.1 million. Dr Khalid is a GP partner at Orchard Medical Practice, Broughton Astley, and for 24 years has also worked in cardiology outpatients.
He says one of the challenges for both the PCN, the ICB, and nationally, are lifestyle factors, such as weight gain and lack of exercise, which are having an adverse effect on heart health, ‘and we need to communicate that to our population’.
To support heart health, the ICB has funded and led in commissioning 12-lead ECG, 24-hour Holter and 24-hour ambulatory blood pressure monitoring, throughout LLR. And it has established a revenue stream whereby practices are remunerated for providing those services. All the equipment for these tests has been funded by the ICB, and services are provided over a PCN footprint.
The initiative – which began in 2022 as a pilot run by Dr Khalid and an ICB manager – has increased atrial fibrillation and hypertension case finding. The scheme is ‘proving such a success we’re trying to establish long term service provision’, says Dr Khalid.
A heart health screening initiative has been supported by £100,000 of NHS England funding, which Dr Khalid and an ICB manager successfully applied for in 2022. ‘We then met with clinical directors of five PCNs where hypertension was most underdiagnosed, and said: “let’s screen large numbers of people”,’ he says. The screening found 545 new hypertensives, ‘and showed that if you give the power and the funding to the right people you can achieve something solid, fast’.
On the service provision front, across LLR, ‘we have excellent echocardiography available direct to practices and PCNs, which is an established service provision that continues to be funded by the ICB’, he says. Dr Khalid and an ICB manager recently revamped the request process to make ‘access to echocardiography equal across the whole of LLR’. ‘Most patients can have an echocardiogram less than three weeks after their GP has requested it, which is tremendous.’
Recently, Dr Khalid and a pharmacy manager from the medicines optimisation team at the ICB launched the Atrial Fibrillation Detect pilot. Funded by a pharmaceutical company, the scheme involves a simple diagnostic stick that an individual holds for thirty seconds, which tells them whether their pulse is regular or irregular. Those whose pulse is irregular then have a 12 Lead ECG. ‘The aim is to increase diagnosis of atrial fibrillation,’ says Dr Khalid.
Discussions are underway about involving community pharmacists in taking blood pressures, and then doing the 24-hour ambulatory blood pressure, as well, he says.
The ICB also has NHS England funding for ‘heart failure champions’ – doctors or specialist nurses who target the identification of heart failure patients and then establish appropriate treatment.
Asked why, with so many competing health priorities, heart health is so important, Dr Khalid says it is a ‘growing problem’, exacerbated by the Covid pandemic. A ‘significant catch up’ is required to identify the patients who were missed by the healthcare system during that time, he says. ‘And we’re trying.’
Derby and Derbyshire ICB and Derby City Place Partnership: ‘Going Further Faster’ with a place based approach
Deprivation goes ‘hand in hand with heart health outcomes’, says Allan Reid, consultant in public health at Derby City Council and co-chair of Derby City Place Partnership Board. ‘The ICB and the wider system face a challenge in addressing the inequalities in CVD, and cardiovascular health outcomes. It’s important we work to ensure equitable access to heart health services across the whole clinical pathway, which includes action on the wider social determinants of CVD.’
In Derby, in October 2023, the Going Further Faster hypertension case-finding pilot initiative was carried out in the community, as well as in primary care settings.
One of the drivers for this approach was the Derby Health Inequalities Partnership, which is a key partner within Derby City Place, and has been developed as a vehicle to get health interventions out into communities and tackle health inequalities.Through Community ActionDerby – the umbrella organisation for voluntary and community groups in Derby – micro-grants were given to communities from the Derby Health Inequalities Partnership to deliver blood pressure testing within communities, with Community Connectors trained in using blood pressure machines and checking blood pressures.
The ICS had commissioned GP practices with NHS England funding, which was weighted towards deprivation – those that served more deprived communities were given a bigger share of the funding. ‘If practices are working in a deprived area, generally they are funded less than other areas and have less staff. With projects like this, weighting towards deprivation really helps to increase uptake,’ says Dr Komal Raj, a GP at Wilson Street Surgery, Derby and GP place representative at Derby City Place Partnership.
At the end of the programme, in general practice an extra 3,500 blood pressure checks were done within a month.
‘Across Derby city, general practice held extra clinics during weekdays, and weekends. Patients could also text their blood pressure in for GPs to read and manage further care,’ says Dr Raj.
‘Across Derby city, general practice held extra clinics during weekdays, and weekends. Patients could also text their blood pressure in for GPs to read and manage further care,’ says Dr Raj.
Funding from NHS England was used to free up some clinical time to go through the blood pressure results.
‘If you want big population health management changes and benefits across the system, you’ve got to fund the extra capacity to take the work on,’ says Dr Raj.
Individuals identified with high blood pressure then had this managed by their general practice.
The initiative ‘demonstrated the impact that can be made at place level, taking into account that population, and also what makes things happen at place – with combined local authority, health service, voluntary sector and community input’, says Mr Reid.
‘Going forward with this piece of work, we can think about upscaling to include atrial fibrillation, and cholesterol.’
He says it is important to make sure these kinds of initiatives are developed in co-production with communities and the voluntary sector – ‘they are more likely to get buy-in and be effective’.
‘A place based approach really does seem to work,’ says Dr Raj. ‘It’s about that early engagement with all the stakeholders and the relationships we’ve built up. It means when initiatives like this come up, we’re in a much better place to make them a success.
‘You can bring initiatives to place meetings and can move really quickly. With the blood pressure project it was organised within a few weeks, because everyone was around the table. And the results speak for themselves.’
Dr Chris Weiner, chief medical officer for NHS Derby and Derbyshire Integrated Care Board, says: ‘We are absolutely focused on cardiovascular disease as the key area to focus on in improving the health of local people.
‘It remains our biggest single killer, yet we know it is possible to prevent people from dying or become disabled through events such as having a stroke. The cost to people’s personal health and wellbeing of having a heart attack or stroke is devastating. It is also very expensive financially to our system to provide treatment, rehabilitation and ongoing care.’
He says the ICB wants to proactively identify people who are at risk by encouraging them to take up simple tests, for example for hypertension and atrial fibrillation.
‘We know we need to make it easier for people to come forward for testing, particularly from communities who are at greatest risk.
‘That is why we are working closely with community groups, GP practices, and primary care networks at a local level to make use of their insight and reach into their local populations.
‘ We will then take action at a local level, in the way we have done recently in Derby’s more deprived neighbourhoods, to support people in identifying where their health may be at risk and helping them to manage or reduce that risk where they can.’
North East and North Cumbria ICB: targeted education and preventative care initiatives
With high rates of smoking and alcohol use, poor diet and physical inactivity, there are high levels of cardiovascular disease (CVD) in the region.
The ICB is working with partners across the ICS, including public health, research bodies, and the voluntary sector, to deliver targeted education and preventive care initiatives.
Focused on high-risk groups, such as women, ethnic minorities, and individuals with pre-existing conditions like diabetes and hypertension, ‘this collaborative approach is building a sustainable, continuity of care model which helps support patients through every stage of their health journey’, the ICB says.
The ICB’s clinical conditions strategy focuses on targeted interventions, to enhance patient education and promote healthier lifestyle choices.
Through various initiatives, the ICB is working to support early detection and treatment of CVD risk factors across the region.
This includes a blood pressure kiosks project, which places self-service blood pressure kiosks in community centres to reach deprived and ethnic minority communities who may not typically access blood pressure checks through their GP practice. Trained community champions are on hand to promote and encourage blood pressure checking, ‘making this vital preventive measure as accessible as possible’, the ICB says.
The ICB is also using data-driven insights for targeted improvement work with primary care to improve management of A-B-C (atrial fibrillation, blood pressure, and cholesterol) conditions, supported by the ICB’s CVD prevention clinical leadership team. This data-led approach allows the ICB to identify and address disparities in how these conditions are managed across different communities, encouraging consistency in care delivery.
Dr Saira Malik, the ICB’s clinical lead for cardiovascular disease, says: ‘By focusing on prevention and education, we can prevent one in four people with CVD and its risk factors from dying early. These initiatives are all about making it easier for people in our communities to take that crucial step towards better heart health.’
NHS Cornwall and the Isles of Scilly ICB: promoting simple steps to improving long term health
NHS Cornwall and the Isles of Scilly ICB has promoted Know your Number campaigns during September each year, and also throughout the year, such as at Summer Health and Wellbeing Festivals.
The festivals are part of ‘Healthier Together’ campaign with Healthy Cornwall, working together with local voluntary and community partners and promote five simple steps people can take to improving long term health and wellbeing: getting checked, eating well, moving more, trying new things and being kind.
Similar events are planned over the winter period.
Working together with Cornwall Council, the ICB has provided blood pressure monitors for people to borrow set up BP check facilities at from 24 libraries to help improve access to identifying and monitoring of blood pressures. More than 200 of these devices were loaned out in August to October. Any abnormal results are flagged up for further review at GP surgeries or community pharmacies.
Free blood pressure checks are provided to local employers for their staff, offered free at many local pharmacies, and at GP surgeries as part of the NHS Health Check and working with the public health team, a self-serve wellbeing kiosk is popping up in public places across Cornwall to provide people with information on their blood pressure, as well as other health statistics including heart rate and cardiovascular risk.
The ICB is currently in the pilot stages of adopting digital offers for community cardiac rehab and heart failure management optimisation working together with community providers and acute trust using virtual wards.
Dr Amit Dhulkotia, GP and CVD lead for NHS Cornwall and Isles of Scilly says: ‘High blood pressure is one of the biggest causes of premature death in the South West and it is often called the ‘silent killer’ as it rarely has symptoms. But if untreated, it increases your risk of serious problems such as heart attacks and strokes. Providing simple and free blood pressure checks to people across Cornwall is part of our commitment to preventing ill health in the future.’
