Suffolk & North East Essex Integrated Care System

Cardiovascular disease

WHY this is important for people in Suffolk & North East Essex

The best care and quality of life for people with cardiovascular disease are essential if everyone in Suffolk and North East Essex is to live well.


As an Integrated Care System we will ensure that:
  • People have the information and support they need to reduce the risk of developing cardiovascular disease
  • People with cardiovascular disease have the right treatment and support to manage their condition
  • People have the best treatment and care for survival and recovery from cardiovascular disease.

What do we know about people’s local experiences?

  • “The cardiac service and intervention is excellent giving me complete peace of mind when I was dealt with immediately”
  • “This year was 2 years post heart attack.    I received a letter from my surgery inviting me to see the Practice Nurse for Coronary Heart Disease Annual Check.      I think it is an excellent idea for reassurance to have an annual check in the surgery, it was worthwhile having a BP, urine and weight check.”

For further information see and

Public Health England’s ‘Health Matters’ highlights:

  • Cardiovascular disease (CVD) is the leading cause of death worldwide, accounting for 31% of all global deaths.
  • 6.8 million people are living with cardiovascular conditions. Poor cardiovascular health can cause heart attacks, strokes, heart failure, chronic kidney disease, peripheral arterial disease, and the onset of vascular dementia.
  • Rates of mortality from heart disease fell between 2001 and 2016 in England, but since 2011 improvements have slowed, and plateaued.
  • CVD accounts for one in four of all deaths in England; the equivalent to one death every four minutes.
  • CVD is one of the conditions most strongly associated with health inequalities. If you live in England’s most deprived areas, you are almost four times as likely to die prematurely than those in the least deprived.
  • CVD is one of the conditions most strongly associated with health inequalities. If you live in England’s most deprived areas, you are almost four times as likely to die prematurely than those in the least deprived.
  • For further information see
HOW we plan to make a difference 

    1.1 More people will routinely know their ABC (Atrial Fibrillation, blood pressure and cholesterol)

  • Improving the effectiveness of physical Health Checks. People will know their level of risk of developing cardio-vascular disease (CVD) and if necessary, can access early treatment to prevent developing CVD. A range of checks are available for people with specific needs such as mental health or learning disabilities. The ICS has been an early adopter of mobile Electrocardiogram (ECG) devices provided by the Eastern Academic Health Science Network (EAHSN). These small devices have been used by health professionals to detect Atrial Fibrillation and ensure patients access onward care.
  • Opportunities for people to check their health provided by voluntary sector, community pharmacists and GPs. Widening access will help improve uptake of checks including the greater use of health kiosks across our are

    1.2 More people will know if they have a genetic risk of sudden cardiac death.

  • Expanding access to genetic testing for Familial Hypercholesterolaemia (FH). FH causes early heart attack and affects at least 150,000 people in England; so far only 7% have been identified. Knowing the risk of FH enables early treatment.

    1.3 More people will know if they have a high-risk condition that could lead to CVD. Atrial Fibrillation and hypertension are often under-diagnosed.

  • Primary care pharmacists and nurses will case find and treat people with high-risk conditions. Where 100 people with Atrial Fibrillation are identified and receive anticoagulation medication, an average of 4 strokes are averted. (NHS Long Term Plan).

    1.4 People will receive prevention services that are based on best clinical practice.

  • The National CVD prevention audit for primary care will support continuous clinical improvement in prevention

    2.1 People experiencing breathlessness will have better access to tests for heart failure and heart valve disease

  • Improved access to echocardiography in primary care. 80% of heart failure is diagnosed in hospital, despite 40% of people having symptoms that should have triggered an earlier assessment. Greater access to testing will improve the early detection of heart failure and heart valve disease.
  • Exploring access to wearable technology to test and monitor conditions

    2.2 People with heart failure and heart valve disease will be supported by integrated community services.

  • Multi-disciplinary community-based teams which bring together acute and community clinicians will work with working with primary care networks. Integrated working will provide more co-ordinated services, improving diagnosis and treatment.
  • People have equality of access to cardiac care services, in locations that are accessible to all our communities. People living in deprivation or marginalised communities should have equal access to high quality cardiac care.
  • Improved access to Improving Access to Psychological Therapies (IAPT) for people with long term conditions. Integrating mental and physical health support for long term conditions supports self-care and improved quality of life.
  • Carers of people with CVD have support to stay well. Supporting carers helps them in their role and also helps them maintain their own good health and wellbeing.
  • Support for patients through our ICS End of Life Strategy will be provided for patients at the end stage of their treatment and care.

    2.3 People with CVD will receive the best hospital based specialist care and advice.

  • Rapid access to heart failure nurses for patients not staying on a cardiology ward. People will receive the support they need regardless of the function of the ward they are admitted to.
  • People with CVD have personalised support, receiving the right treatments and leaving hospital as soon as possible. Better personalised planning will reduce nights spent in hospital and reduce drug spend.

    People who have a cardiac arrest have access to urgent treatment in their community. We will enable this by

  • A network of community first responders and defibrillators. The chances of survival from a cardiac arrest happening outside hospital doubles if the person receives immediate CPR or defibrillation.
  • Educating the public including young people about how to recognise and respond to out-of hospital cardiac arrest
  • Working with partners to harness new technology and ensure the public and emergency services can rapidly locate defibrillators in an emergency.
  • Mapping data on incidence of out-of-hospital cardiac arrests, and map data on survival using the British Heart Foundation’s national Outcomes Registry data. Mapping incidence will enable community services to be directed to where need is greatest. Using the Outcomes Registry will enable tracking of survival rates and targeting of unwarranted variation.
  • Developing improved and enhanced cardiac catheterisation and pacing suites including a new cardiology laboratory at West Suffolk Hospital. This will relieve strain on specialist services at Royal Papworth Hospital NHS Trust and reduce stressful and lengthy journeys to Cambridgeshire and elsewhere for patients.

3.2 People have the best chance of recovery from heart attack, surgery or procedure.

  • We will scale up and improve marketing of NICErecommended cardiac rehabilitation intervention. Cardiac rehabilitation can help prevent up to 23,000 premature deaths and 50,000 acute hospital admissions over 10 years, and improves quality of life.
  • People will have choice of community-based services to rehabilitate and recover. Local community assets such as leisure centres can provide a range of services to suit people’s preferences.

    3.3 People receive high quality cardiac and vascular care based on best practice. We will:

  • Develop and use guidance and tools to support commissioning of cardiac services, by April 2020
  • Develop and use specifications and clinical policies to improve the quality of cardiac and vascular services, by May 2020.
  • Work with royal colleges, GMC and HEE to increase access to interventional radiology training, by March 2021.
  • Implement the recommendations of the Congenital Heart Disease review, by April 2022.
  • High quality services and care pathways enable good recovery and help improve people’s quality of life
  • We will know we are making a difference because we will see:

    Brian had a long history of heart problems, but had recently become significantly frailer, had lost weight and had fallen multiple times. Brian was very low in mood and frustrated that he was not improving, and had stopped engaging in social activities.

    The Market Cross Frailty Project – a proactive approach to frail patients living in their own home – carried out a Comprehensive Geriatric Assessment, a falls assessment and a medication review completed with Brian and his wife at home. As a result they changed his medications (which helped reduce his weight loss and helped his balance), obtained specialist advice from the local Bladder and Bowel service (which saved Brian an unnecessary visit), provided nutritional advice and information on domiciliary dentistry, arranged a personal alarm, helped Brian with welfare benefits and gave his wife information on Suffolk Family Carers.

    Brian’s appetite is improved, he is walking more steadily and has had no further falls and has restarted physiotherapy. He has support from Heart Failure nurses and his mood is monitored through ongoing reviews.

    Last Updated on December 10, 2020

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