Shifting to prevention: how integrated care systems can tackle cardiovascular disease

Why cardiovascular disease prevention should be prioritised

The NHS is facing significant pressures that are driving an unprecedented decline in public satisfaction with services. At the same time, healthy life expectancy is falling for people in England. Reducing the prevalence of cardiovascular disease (CVD) represents an opportunity to address both of these challenges.

The government has signalled through its health mission that CVD prevention should be a major priority. The case for this is clear:

• CVD is among the leading causes of disability and mortality – more than 7.6 million people in the UK live with CVD, which causes around a quarter of all premature deaths (under 75 years) each year.

• Most CVD is preventable – up to 80% of premature deaths from CVD are caused by modifiable risk factors and are preventable.

• Some of the benefits of CVD prevention are quick to achieve – for example, controlling high blood pressure and high cholesterol can avert heart attacks and strokes in a short period of time.

• The overall burden of CVD to the UK as a whole is estimated at £29 billion annually, including through reduced economic activity and long-term care costs. Almost a third (30%) of people who are economically inactive in the UK have CVD, with analysis suggesting that the onset of CVD increases the risk of leaving the workplace more so than other health conditions.

• Significant progress on CVD prevention has been made over past decades, but in recent years this progress has stalled, in part because of the impact of the Covid-19 pandemic.

• CVD is a leading cause of health inequalities, and is responsible for around a fifth of the gap in life expectancy between the most and least deprived areas of England according to national data.

• Preventing CVD would also help to prevent other conditions such as cancer, diabetes and dementia, because risks factors such as smoking and obesity are common across multiple diseases. CVD also exacerbates the risk of dying from respiratory diseases such as Covid-19 and influenza.

A concerted national drive on CVD prevention would significantly reduce the number of heart attacks, strokes and premature deaths that occur every year, easing pressures on the NHS and delivering wider benefits to the economy. In contrast, without significant improvement in CVD prevention, the UK risks worsening health inequalities, increased economic burden, and continued underperformance relative to other G7 nations.

In this long read, we explore the role that integrated care systems (ICSs) can play in driving this shift. Based on interviews with professionals and an expert roundtable (see ‘About this project’), we first detail what is already happening in systems across England, before explaining what would be needed to go further and to realise the significant benefits that could be achieved through a more systematic approach to CVD prevention.

What are ICSs currently doing to prevent CVD?

As partnerships bringing together the NHS, local authorities and voluntary sector organisations, ICSs are potentially a powerful vehicle for developing a whole-system approach to CVD prevention, drawing on the strengths of all partners and co-ordinating the work done by each organisation. To make the most of this opportunity, the approach to CVD prevention in ICSs needs to bring together at least two core components:

• action on health behaviours and wider determinants known to increase CVD risk, often led by public health teams and local authorities

• scaling up CVD prevention in primary care, with a focus on people with high blood pressure, high cholesterol and atrial fibrillation (irregular heart rhythms).

In our research we found examples of both of these activities taking place in ICSs. However, our overall assessment is that neither is taking place to the extent that is needed, given the scale of the challenge and the potential opportunities.

In relation to the first of these components, public health teams (which are partners within ICSs) play an important role in tackling risk factors such as smoking and obesity. Integrated care boards (ICBs) have also received ring-fenced funding from NHS England for tobacco cessation initiatives. Despite this, we found that action of this kind does not appear to be central to strategic thinking about CVD prevention within ICSs. This lack of focus on tackling risk factors for CVD must be addressed if the impact of CVD on population health is to be reduced, as discussed further in the next section.

In contrast, there has been much more attention on expanding the role of primary care in CVD prevention, with this being the main focus of CVD prevention initiatives led by ICBs in the sites involved in our research. This involved a combination of the following activities:

• Case finding: identifying people with risk factors for CVD (high blood pressure, high cholesterol or atrial fibrillation) or with undiagnosed CVD, and referring them to primary care. This can include working with voluntary sector and community organisations to make testing more accessible, particularly for people from marginalised communities or areas with high levels of deprivation (see Box 1).

• Optimisation: ensuring that people who have risk factors such as high blood pressure or cholesterol, or those with established CVD, are managed optimally in primary care to reduce the likelihood of experiencing a ‘CVD event’ such as a heart attack or stroke. This involves providing appropriate medication, regular monitoring and lifestyle support (see Box 2).

• Data analytics: including using population health management tools to segment the population and identify groups at raised risk, and developing local dashboards that allow GPs and other clinicians to look at data on their patients and population in a more granular way (supporting improved case finding, as described above).

• Clinician education and guidance: particularly to improve the support provided in primary care to people at risk of CVD, including those with comorbidities such as diabetes or renal disease (for example, see Box 3).

• Workforce redesign: for example, supporting community pharmacists to offer a broader range of services such as blood pressure checks, cholesterol checks and diabetes tests.

Although the results of some of this work have been promising, we found that the people involved have faced significant challenges in moving from relatively small-scale pilot projects in a defined geography to a system-wide shift that would benefit the entire local population covered by an ICS. We discuss this challenge further in the section on ‘Scaling up CVD prevention in primary care’.

Addressing health inequalities has been a particular focus for the ICSs involved in our research. This often involved targeting prevention initiatives at communities where CVD is highly prevalent, including ethnic minority communities and areas with high levels of deprivation (see Box 1 and Box 2). Some of this work has been funded on a one-off basis using national health inequalities funding, and one of the challenges has been to secure sustainable funding for the longer term. Without this, the impact is likely to be small compared with the scale of inequalities that exist.

It should be acknowledged that significant changes to ICBs (and, by extension, ICSs) are currently under way. As discussed later, this creates both risks and opportunities for their work on CVD prevention.

Action on health behaviours and wider determinants

An effective approach to CVD prevention will require lowering CVD risk throughout the population through action on health behaviours such as smoking and obesity, as well as on the wider socio-economic factors that influence health. However, a consistent feature in our interviews was that when we discussed the work ICSs are doing on CVD prevention, these kinds of public health approaches rarely seemed front of mind.

This is not to say that such work is not taking place. Public health teams in local government typically commission services on weight management and smoking cessation, and the national NHS Health Check programme – also overseen by public health teams – directs people to these and other health and wellbeing services. However, interviewees highlighted several reasons why this existing work is not sufficient.

First, work led by local government public health teams on common risk factors for CVD does not appear to have a high profile in all ICSs or to be explicitly connected or aligned with work happening in the NHS on CVD prevention. The risk here is that the overall impact is less than it could be if public health efforts operated largely in parallel to NHS-led prevention initiatives.

Second, cuts to public health funding over the past 15 years have led to services like these being scaled back considerably. Although ring-fenced funding from NHS England for smoking cessation services may have mitigated some of the impact of this, it has not been enough to fill all of the gaps.

Third, although public health teams do have some degree of involvement in ICSs, other parts of local government that could influence the wider determinants of health remain a largely untapped asset, according to some interviewees.

A general theme then from our interviews was that ‘working much more closely with public health’ and creating an ethos of ‘genuinely doing this together’ will be necessary if systems are going to maximise their potential contribution to CVD prevention. This is a message that has also been reinforced recently by a report from the Association of Directors of Public Health, which argued for the importance of integrated working across the NHS and local government on CVD prevention.

Interviewees also highlighted that the NHS has considerable powers and resources that can contribute towards efforts to address health behaviours and wider determinants. NHS organisations have a significant impact on CVD risk in their local population as major employers and purchasers of goods and services, and as contributors to environmental determinants such as air pollution. By acting as anchor institutions in their local areas, NHS organisations can have a positive impact on CVD prevalence at population level, and ICSs are uniquely positioned to be able to amplify this impact by supporting NHS organisations to embed this way of working.

Scaling up CVD prevention in primary care

Consistently taking a preventive approach to CVD in primary care could help to reduce the prevalence of CVD significantly. At the core of this is proactive monitoring of people with risk factors such as high blood pressure, high cholesterol or atrial fibrillation, as well as people with established CVD or related diseases, and ensuring that they receive appropriate medications and other forms of support that reduce the risk of disease onset, progression or recurrence.

The scale of the opportunity is indicated by the Size of the Prize analysis by UCLPartners, which found that if 80% of people with diagnosed hypertension had their blood pressure reduced to optimal levels using antihypertensive medication (up from around two-thirds currently), the NHS could prevent 7,000 heart attacks, 10,400 strokes and 5,600 deaths in England over three years. Their modelling suggested that this could save the NHS almost £200 million over the same period. The full potential is larger still, as these numbers do not include people with undiagnosed hypertension or with other modifiable risk factors (the same analysis suggests that thousands of heart attacks could also be prevented through more consistent use of cholesterol lowering medication). Previous work highlights the widespread variations that exist in terms of how CVD and its risk factors are managed in primary care.

This opportunity has not gone unrecognised in the NHS. In 2025/26, incentive payments available to GP practices through the Quality and Outcomes Framework were strengthened in relation to CVD prevention, increasing the amount of funding available for controlling blood pressure and cholesterol in specified patient groups. Local initiatives such as those described in Boxes 1–3 above also reflect a recognition of the potential for prevention in primary care to have a significant and rapid impact on health outcomes.

More recently, the government’s 10 Year Health Plan announced that selected ICBs will become ‘prevention accelerators’, testing community-led methods to tackle variation in the uptake of CVD and diabetes prevention interventions in primary care. The risk is that this approach, based on pilot initiatives in selected areas, will not bring about change at the scale or pace needed. To have a bigger impact the government needs to address the barriers that are preventing interventions that are already well-evidenced from being applied consistently across all parts of England. In our interviews, we found that successful local projects are encountering a number of barriers when it comes to being scaled up to cover a wider geography. These include:

• insufficient operational management support – interviewees described there being a lack of capacity in ICBs to support GP practices with the ‘nuts and bolts’ of implementing CVD prevention at scale

• lack of sustainable funding streams – in particular, difficulties at ICB level protecting funding for prevention in the context of immediate operational pressures

• challenges working across ‘system’ and ‘place’ levels – including examples of misalignment between strategic thinking on prevention developed at ICS level and the practical work being delivered more locally

• variable clinical engagement – with some describing weak links between GPs and ICBs and calling for stronger clinical leadership at system level.

To bring about change at scale despite these challenges, local systems will need to do a number of things differently. We identified four key enablers in our research.

First, ICBs and GP practices need to make better use of the available data to target resources effectively, drawing on data sources such as the Cardiovascular Disease Prevention Audit (CVDPREVENT), which provides practice-level data on CVD indicators to support quality improvement in general practice, and tools such as CVDACTION, which has been developed to make it easier to identify which patients to target and to optimise treatment within available capacity.

Second, local systems need to ensure that responsibility for CVD prevention is shared across the wider primary care workforce, with pharmacists, nurses, physician associates, social prescribers and administrative staff all playing important roles. The neighbourhood health teams being developed as part of the government’s 10 Year Health Plan are based on this multi-professional approach and could be a vehicle for taking this work forward. The CVDACTION toolkit can also be used to understand how to make better use of the full primary care workforce, with guidance on how to bring about the pathway and workforce transformation needed to prevent CVD more systematically.

Third, ICBs need to ensure that there is sufficient clinical and professional leadership at system level. These leaders play a vital role in engaging their peers and securing support for the work being conducted across the local system. For example, in Coventry and Warwickshire, a trio consisting of a GP lead, a public health consultant and a cardiologist have been the driving force for much of the system’s work on CVD prevention. Given the widespread changes to ways of working that are required for services to become more systematic about CVD prevention, this leadership is indispensable, and part of the role of ICBs should be to cultivate and support it. Cardiac networks can also play a role in this, supporting ICSs with clinical engagement and workforce development.

Fourth, to have the greatest possible impact at population level, efforts to scale up CVD prevention in primary care need to focus resources on high-risk communities, including Black and Asian communities and areas with high levels of deprivation. To do this, ICBs need to use risk stratification tools to identify target groups, and should strengthen links with voluntary and community sector organisations that can engage with local communities effectively. They also need to work with and through place-based partnerships that are able to understand and respond to local needs, with these partnerships leading on the delivery of many CVD prevention activities.

As ICBs undergo significant changes over the coming months, national bodies need to ensure that systems retain the kinds of capabilities and leadership outlined here – including operational management capacity, analytic expertise, place-based leadership, and clinical and professional leadership. We expand on this theme in the section on ‘Building prevention-focused ICSs’.

Action needed at national level

As set out above, there are both health and economic reasons for the government to prioritise CVD prevention. ICSs can play a significant part in this, but to do so they will need support from national bodies. Interviewees described changes that are needed at national level in terms of leadership, accountability and funding to allow ICSs to bring about a strategic shift to prevention and maximise their impact on CVD outcomes.

Leadership and strategy

CVD has been identified as a national priority, with the government’s ‘health mission’ featuring a commitment to reduce premature deaths from heart disease and strokes by 25% within a decade. To achieve this, local action on CVD needs to be backed up by stronger national initiatives on risk factors such as smoking, alcohol and obesity, using fiscal and other levers at the government’s disposal. The 10 Year Health Plan includes some welcome action on obesity and other issues, but overall the package of proposals does not go far enough in meeting the challenge posed by CVD and creating a sense of urgency around the shift to prevention.

ICS leaders also told us they still need a clearer strategic framework to work within, setting out specific expectations and timeframes, and providing a blueprint that can be adapted to local circumstances. The 10 Year Health Plan includes a commitment to produce ‘modern service frameworks’ from 2026 onwards, with CVD being identified as an early priority. This is needed now more than ever to mitigate the dual risks of there being weaker national leadership on CVD during the process of merging NHS England into the Department of Health and Social Care, combined with reduced capacity in local systems to push forward with CVD prevention while ICBs are in flux.

Accountability

In contrast with the strong top-down pressure from national bodies on issues such as waiting times or finances, accountability mechanisms for prevention are relatively weak. Many of those we spoke to said that in the absence of robust accountability for their work on CVD prevention, ICSs were pushed to prioritise other things, and that there is no strong sense of mission or energy in this space. The NHS Performance Assessment Framework for 2025/26 does include some relevant metrics for ICBs – on the provision of lipid-lowering medicines, smoking cessation services and obesity. However, set against this is the fact that many of the prevention metrics included in previous iterations have been removed as part of efforts to reduce the overall number of national targets. The risk is that this sends the wrong signal to people working in the system.

Moreover, the experience of past years is that when local systems are held to account by regional and national teams, some metrics matter more than others. The strong focus from government on recovering waiting times for elective care risks pushing ICSs to see the shift to prevention as a second order priority, and without broader change to the culture and focus of performance management in the NHS, a small number of metrics will not be enough to drive the improvements needed.

Funding

Almost everyone we interviewed for this project spoke about challenges with resources and funding. Part of what people wanted was simply more money to enable them to scale up existing good practice and provide preventive interventions more consistently. Yet people also felt that more could be done with the existing resources if funding flows were rationalised and redesigned. Many of the examples of CVD prevention we encountered were reliant on relatively small non-recurrent funding pots that systems had to bid for (often at short notice) – making long-term planning challenging. This fits with findings of the Hewitt Review, and of other research projects, which have called for flexible long-term funding streams that can be used to improve local population health.

Financial and capacity issues in primary care also need to be addressed. The much-needed expansion of CVD prevention in primary care creates additional work for staff, and if the workforce is going to take this on, it will need resources that match the ask, as well as practical support for developing new ways of working. In the absence of this, there is a risk that attempts to strengthen CVD prevention in primary care have the perverse effect of increasing inequalities, with the capacity to bring about the necessary changes being varied across the country.

Building prevention-focused ICSs

Integrated care systems are one of the primary vehicles for delivering the government’s shift to prevention, but ICSs are themselves going through a period of profound change, triggered in part by the requirement to reduce ICB running costs by 50% by the end of 2025. The model ICB blueprint offers a vision of ICBs becoming ‘strategic commissioners’ in future, with some of their functions being strengthened while others are transferred to other bodies.

These changes mean significant upheaval, but they also create an opportunity to reset the role of ICBs and ensure that, in future, ICSs are better placed to focus on prevention in the way national policy envisages. Our research on CVD prevention offers important insights on this broader question.

First, a prevention-focused ICS needs to have the right capabilities and leadership to implement change at scale. Significantly expanding preventive activities will require practical support, including operational management capacity, analytic expertise, and clinical and professional leadership. In the context of the current changes, national leaders must be careful to ensure that reforms to ICBs do not deplete local systems of the very capabilities needed to achieve the shift to prevention.

Second, there needs to be a continued role for place-based leadership. Partnership working in these smaller geographies within ICSs plays a critical role in delivering the shift to prevention for CVD and other conditions – not least because this is often the level at which links with local authorities and the voluntary sector are strongest. As ICBs merge to cover larger populations, the role of place will be more important than ever and needs to be supported by national policy.

Finally, ICSs will only be able to deliver a meaningful shift to prevention if national policy wholeheartedly and consistently backs this up. The case of CVD illustrates broader tensions in the national approach: although CVD prevention has been identified as a national priority, the pressure for systems to focus on immediate operational pressures has ratcheted up considerably over recent months. Unless accountability and funding mechanisms are redesigned to enable ICSs to give prevention the focus it deserves, and unless the work of local systems is supported by concerted national action, the shift will remain an ambition rather than a reality.