Project Name: An enhanced approach to faster diagnosis and earlier intervention for those population groups covered by Our Healthier South East London Integrated Care System who are at greatest risk of cardiovascular disease ill health and poor health outcomes.

Project Summary:

Nationally, cardiovascular disease (CVD) claims 160,000 lives a year and is the largest cause of life expectancy gap (13 years in South East London (SEL)) which differentially affects Black, Asian, and Minority Ethnic (BAME) and deprived communities. CVD is often preventable and is the reason it features so prominently in the NHS Long Term Plan. 

Our aim is to enable solutions that provide faster diagnosis and earlier intervention for underserved communities who are at greatest risk of cardiovascular (CV) ill health and poor health outcomes. The project aims to:

  • Identify the undiagnosed and the undertreated population groups who are at greatest risk of CV ill health
  • Understand what factors drive the current behaviours in these population groups 
  • Co-create solutions with these population groups to provide faster diagnosis and earlier CV intervention
  • Implement and measure the outcomes of a scalable solution
  • Develop a how-to guide for the implementation of solutions aimed at improving access to healthcare for underserved communities across England

Planned Milestones:

  1. Kick-off meeting to pull together key stakeholders to discuss and agree an agile project plan, sub project ownership and deliverables.
  2. Identify the underserved communities at greatest risk of CVD ill Health based on analysis of agreed data sets.
  3. Use a community engagement partner to work with local leaders within the identified community to understand local needs and obtain qualitative data to support the identification of a population health management intervention.
  4. Intervention development and implementation. Use the qualitative and quantitative findings to develop a targeted intervention for the identified community (Amendment 1).
  5. Deployment of CVD bus to take CVD initiatives into the community (Amendment 1).
  6. Evaluation of intervention and recommendations on system scalability, funding recommendations and sharing of best practice via a how to guide. Outcomes Summary Completed.

Expected Benefits:

Anticipated benefits for patients:

  • Faster diagnosis and earlier intervention for their CV health
  • Care closer to home
  • More equitable access to care
  • Tailored CV health information to improve health literacy 

Anticipated benefits for the NHS:

  • Understanding of the underlying reasons for health inequalities amongst groups within our population in the greatest risk of poor CV health
  • More at risk patients treated in timely manner by the NHS
  • Supports one of the key priorities set out in the Long Term Plan regarding cardiovascular disease
  • Development of a how-to guide that can be replicated in other long-term conditions and supporting the first deployment of such a guide in the second phase solution implementation
  • Help to ensure NHS resources can be deployed with maximum efficiency for the underserved communities

Anticipated benefits for Novartis:

  • Understanding of the underlying reasons for health inequalities amongst groups within our population in the greatest risk of poor CV health
  • Aligns with Novartis’ Health Inequality Pledge
  • Publication of the how-to guide and outcomes of the implementation of the Solutions, which Novartis can freely use and share with permission of the CW Partner.

Start Date and Duration: Duration of CWA 24 months from signing of CWA

UK2310104600