Managing cardiovascular disease (CVD) for high-risk patients
GP practices are working to reduce the risk of CVD within Cornwall’s most deprived areas.
Impact
- Nine practices actively participating aiming to support over 1,800 at-risk patients.
- Early detection and intervention: Patients will be identified sooner through the proactive care frameworks, and high-risk patients will be treated before they become emergent.
- Proactive case management: This approach will help manage patient workload by ensuring GPs see the highest risk patients first.
- Reduced demand on acute care: Proactive care will help prevent heart attacks and strokes, reducing emergency admissions and hospital visits.
Project summary
GP practices are working to reduce the risk of CVD by optimising blood pressure and lipid management within Cornwall’s most deprived areas.
With an emphasis on proactive care rather than reactive treatment, clinicians are being encouraged to use population health data and innovative risk stratification tools to prioritise high-risk individuals, building on the successful approach developed during the 2023/24 Innovation for Healthcare Inequalities Programme (InHIP) project. The project specifically targets Cornwall’s Deep End practices (practices with the highest level of deprivation), ensuring interventions reach underserved populations.
Nine practices are actively participating, covering a patient population of over 1,800, with potential expansion based on evaluation outcomes. This approach helps to identify patients, particularly those at risk, sooner.
Rationale
High blood pressure and high cholesterol are major contributors to heart attacks and strokes, and are responsible for a quarter of premature deaths. CVD also plays a key role in health disparities, accounting for approximately 20% of the difference in life expectancy between the wealthiest and most disadvantaged communities.
Interventions to reduce blood pressure and cholesterol are highly effective in preventing these serious health events, which have a profound impact on individuals and their families, and are costly for the NHS, social care, and the broader economy.
Key stakeholders
- Health Innovation South West are leading the project and stakeholder engagement. Our role has been critical in implementing the proactive approach in GP practices. We are also leading on the design and facilitation of the evaluation to measure project impact in order to ensure sustained benefits.
- Cornwall Council are supporting stakeholder engagement with GP practices, working with Health Innovation South West to ensure smooth implementation of the project.
- NHS Cornwall and Isles of Scilly are providing clinical leadership and funding for the practices.
Next steps
The project evaluation will be completed by October 2025 to inform ICB decision-making for 2026/27. The ICB will then explore scaling the project to additional practices if successful. Insights from the project may inform future CVD prevention strategies in the South West and nationally.
Public Health is pleased to be collaborating on this pilot project with Health Innovation South West, Cornwall’s Integrated Care Board and primary care to reduce the risk of cardiovascular disease among some of the most vulnerable people in Cornwall. Health Innovation South West have been instrumental in leading this work and engaging stakeholders to deliver the project.
Gareth Walsh, PFPH - Public Health Practitioner, Konsel Kernow / Cornwall Council - Wellbeing & Public Health
