Reaching people most at risk of cardiovascular disease

We worked with local NHS teams to reach people most at risk of cardiovascular disease, bringing support closer to communities and helping tackle health inequalities.

Challenge

The NHS Long Term Plan puts health inequalities at the centre of healthcare improvement. Through Core20PLUS5, the NHS is focusing on better outcomes for the most deprived 20% of the population, underserved groups, and five clinical priorities, including cardiovascular disease.

Across our region, teams wanted to reach people who were least likely to access NHS support, but who were more likely to be living with undiagnosed or untreated cardiovascular risk. To do this well, they needed to build trust locally, use data intelligently and design support around people’s lives.

What we did

Through NHS England’s Innovation for Healthcare Inequalities Programme, we supported three local projects focused on cardiovascular disease in Mid and South Essex, North Central London and North East London.

We helped teams turn national ambition into practical, place-based action. This included supporting data collection to shape public engagement, bringing project teams together to share learning, and contributing to evaluation so that insights could be captured and used beyond the programme.

Each project worked with communities in different ways. In Mid and South Essex, a community outreach van helped identify people living with undiagnosed heart failure in deprived and ethnically diverse communities. In North Central London, nurses delivered health checks and lifestyle advice in two of the most deprived wards, while exploring why some people do not take cholesterol medication consistently. In North East London, teams worked through faith settings, libraries and GP records to identify people with high cholesterol and support them to optimise treatment.

The impact

The projects helped teams build stronger connections with underserved communities and offer support in places that felt more familiar and accessible. They created new opportunities to identify people who may otherwise have remained undiagnosed or untreated, including those at risk of heart failure or cardiovascular disease.

By combining local insight, community voices and targeted outreach, the programme showed how health innovations can work in practice for the people who stand to benefit most. The learning is helping teams design services that are more proactive, accessible and responsive to local need, supporting better health for all.