Cardiovascular Disease Prevention

HI NENC is delivering a Cardiovascular Disease (CVD) Prevention programme, nationally mandated by NHS England. The programme supports CVD Prevention across the North East and North Cumbria with a particular focus on chronic kidney disease (CKD), disordered lipids, familial hypercholesterolaemia (FH) and hypertension. The other clinical area includes atrial fibrillation (AF) which is legacy work from a previous national programme.

Aims of the CVD Prevention Programme

By collaboratively working with partners, we aim to reduce cardiovascular events for patients as a result of their CVD risk factors, closing health inequality gaps, and improving their health by reducing morbidity and mortality.

Our mission is to support the early detection and treatment of patients with CVD risk factors, and to help sustain the legacy of recent national CVD programmes.

HI NENC will work collaboratively with the regional health and social care system, to reduce inequalities within our population, providing capability and capacity to meet our objectives.

Benefits

  • Prevention of future cardiovascular events, increasing years of wellness.
  • Supporting PCNs to achieve their QOF 2024/25.
  • Supporting ambitions laid out in the NHS Long Term Plan.
  • Increase awareness of patients & clinicians of CKD as a risk factor for CVD.
  • Increase awareness of patients & clinicians around the common genetic condition, FH.

Programme Delivery

HI NENC will deliver the programme in its constituent parts. However, where possible, we will take a multi-morbid approach, guided by a cardio-renal-metabolic (CaReMe) ethos. To learn more about the different elements, please see individual project pages

The programme has a strategy group consisting of key stakeholders from across NENC, who provide support, insight and challenge to enable the programme to be responsive and accountable.

Metrics

We have developed programme metrics for CKD, lipids, FH and hypertension. However, the success of the programme will depend on opportunistic and systematic case finding of eligible patients. This will involve using innovative and validated CVD search tools such as CDRC, cascade testing, and robust primary and secondary CVD prevention pathways, to optimise the management of lipids, hypertension and CKD for patients, regardless of their care setting.

NEQOS lead on measurement support for HI NENC Population Health Improvement Programmes. This involves presenting data to the HI NENC strategy group. The latest presentation can be seen on the link below.

Download Metrics Presentation

 

Feedback from local partners

Barry Todd is a North East Pharmacist Practitioner and the Pharmacy Lead at Wallsend Primary Care Network, who has working in partnership with HI NENC to deliver the programme. He said:

“In the 42 years I’ve been a Pharmacist, I’ve never been so excited at the opportunity of breaking down barriers and being able to work collaboratively across all sectors.

“Together we are making a real difference in tackling health care inequalities and driving down cardiovascular morbidity and mortality.”

See details of our partnership working in our case studies and joint working agreements below.

Reducing cholesterol using Inclisiran

HI NENC led the rollout of Inclisiran, a Novartis therapy that lowers cholesterol by up to 50%. This first-of-its-kind initiative involved a novel tripartite agreement between Health Innovation Networks, Novartis, and the NHS, using a population health management approach to target primary care for maximum impact.

Unlike traditional drug rollouts, this collaboration enabled simultaneous adoption in both primary and secondary care, ensuring equitable access. Despite early and ongoing challenges, HI NENC successfully secured regional adoption, demonstrating a new model for introducing innovative therapies into the healthcare system while addressing cardiovascular disease risks more effectively.

In this case study, find out how some patients in the region achieved cholesterol reductions of up to 77%.

CVD healthy heart check pathway using PocDoc® rapid lipid testing

PocDoc® is an innovative point-of-care device delivering a 5-marker lipid panel result in just eight minutes via a smartphone or tablet app. This innovation enables faster detection of cardiovascular disease (CVD) markers, such as those linked to heart attacks and strokes, in non-clinical settings.

HI NENC collaborated with PocDoc to evaluate the device in a real-world setting. This included cholesterol testing at home and in community venues, targeting deprived communities and removing barriers to traditional health checks. 10,000 tests were available during the pilot phase to dramatically expand access to testing, with an aim to identify at-risk individuals early and prevent more cases of CVD.

Read the case study

Lipid-lowering Therapy – A Pharmacist-led Clinic for Secondary Prevention Vascular and Diabetic Foot Patients 

Newcastle Hospitals NHS Foundation Trust and HI NENC have setup a new clinic to provide targeted treatment and support to vascular and diabetic foot patients, who have had a cardiovascular event such as a heart attack or stroke.

The pharmacist-led clinic, set up by Matthew Hart, Specialist Clinical Pharmacist, is thought to be the first of its kind in the UK.

HI NENC has funded Matthew to run the clinic two days a week and provided support with statistical analysis.

Read the case study

Improving access to FH Genetic Testing: GENinCode

Familial hypercholesterolaemia (FH) is a preventable genetic disease which causes high levels of cholesterol in the blood. Yet, the condition remains underdiagnosed in England, with only 5.8% of cases identified. The NHS Long Term Plan set a goal to identify 25% of FH patients and introduced measures like a national cardiovascular disease audit and a Primary Care Network (PCN) directive for systematic case finding. However, genetic testing, the gold standard for FH diagnosis, faces capacity constraints within England’s Genomic Laboratory Hubs, leading to long waiting lists in lipid clinics.

To address this, Health Innovation North East and North Cumbria (HI NENC), in partnership with GENinCode, piloted an alternative genetic testing approach. This programme demonstrated cost-effective, efficient testing with faster reporting times, potentially enhancing identification rates and supporting the NHS goal of improved FH management and prevention.

Read the case study

Educating healthcare professionals about familial hypercholesterolaemia: from a local University to a national Massive Open Online Course (MOOC)

The NHS long term plan highlighted the need to improve the identification and management of with familial hypercholesterolaemia, driving a need for further training for healthcare professionals.

Health Innovation Network funded a  five week course for healthcare professionals, led by Health Innovation North East and North Cumbria. The course was developed and delivered to 118 delegates by Northumbria University and a panel of experts in FH.

Due to high demand for the course, a Massive Open Online Course (MOOC) has been developed. The course equips healthcare professionals across the country to better identify and support people with FH. The course is free and can be accessed here.

Read more in the case study

 

 

HI NENC works collaboratively with a number of partners to enhance local services, please see details of our joint working agreements below.

  • Sanofi and HI NENC are working in partnership under a joint working agreement to facilitate better identification of patients within primary care who may be at risk of having Familial Hypercholesterolaemia (FH) or high cardiovascular risk. Read in full in this joint working agreement.
  • HI NENC, NHS North East and North Cumbria Integrated Care Board and Boehringer Ingelheim are working together in a collaborative working partnership to improve early detection, diagnosis and management of chronic kidney disease (CKD), through the SPOT (Screening, Prevention, Outreach and Treatment for Health Equity) CKD programme. This project aims to operationalise in March 2025 and is anticipated to run for 24 months. Read in full in this collaborative working executive summary.

Healthy Hearts Checks

As part of the wider Cardiovascular Disease Prevention Programme, HI NENC is leading a Healthy Heart Checks programme to support underserved communities across the region. Funded by the North East and North Cumbria Integrated Care Board’s Healthier & Fairer Programme,…

Optimising Lipid Management

The HI NENC Cardiovascular Disease Prevention Programme has a focus on optimising lipid management, to give patients with disordered lipids the best chance of avoiding cardiac events. Disordered Lipids Disordered lipids impact peoples’ health over time causing heart attack and…

CVD resources for healthcare professionals

Cardiovascular disease (CVD) prevention resources for healthcare professionals in the North East and North Cumbria

CVD events and latest news

The Cardiovascular Disease Prevention Team send out a regular newsletter and hold a number of events and training opportunities for healthcare professionals working in the North East and North Cumbria. Find out more about the latest news and upcoming events…

Familial Hypercholesterolaemia

The HI NENC Cardiovascular Disease Prevention Programme includes a focus on Familial Hypercholesterolaemia (FH). The programme supports healthcare staff to identify people with the genetic condition and optimise their treatment, helping to reduce their risk of cardiac events. HI NENC…

Lipid Management Pathway

HI NENC is supporting primary care teams to reduce cardiovascular risk by improving the management of lipids, through the Cardiovascular Disease Prevention Programme. We created this page to provide healthcare professionals with information about treatment options for cardiovascular risk reduction…

Blood Pressure Optimisation

The management of hypertension is a key element of HI NENC’s CVD Prevention Programme. HI NENC, working with NENC ICB, is delivering a ‘back to basics’ blood pressure optimisation education programme to healthcare professionals working in and supporting primary care…

Chronic Kidney Disease

HI NENC is delivering a Chronic Kidney Disease (CKD) programme as part of the Cardiovascular Disease Prevention Programme. The programme focuses on earlier diagnosis and medical treatment to slow CKD progression and reduce cardiovascular complications. The programme will be delivered…

Cholesterol testing pilot

As part of a wider Cardiovascular Disease Prevention Programme, HI NENC delivered a pilot cholesterol testing programme trialling innovative cholesterol test, PocDoc. The pilot came to an end in June 2024 and is currently undergoing an evaluation. Aim The aim…

Atrial Fibrillation

The Atrial Fibrillation (AF) programme, which ran as a national programme from 2018-2020, led to the development of several valuable resources. In addition, one key project from this work continues to operate as a legacy project. Legacy project HI NENC…

Innovation for Healthcare Inequalities Programme (InHIP)

The Innovation for Healthcare Inequalities Programme (InHIP) was a national programme. The programme officially ended in April 2024 however HI NENC is continuing this work through a Healthy Heart Checks programme. HI NENC led on the programme within the North…