A glimpse of the future: a joined-up approach to cardiovascular, renal and metabolic care

"In July, I had the opportunity to attend a CVRM Community Assessment Day at King’s Park Community Hospital in Bournemouth, in my role as Innovation Adoption Programme Manager at Health Innovation Wessex (HIW).  

The event brought together clinical assessment, personalised care planning and community support in a single setting, offering a glimpse of how a more integrated approach to long-term condition management could improve both patient experience and outcomes. 

During the day, patients received a comprehensive assessment including blood pressure, pulse and BMI measurements, alongside a review of their most recent blood test results. The team also aims to introduce more point of care testing in future, enabling immediate results for areas such as cholesterol, diabetes, and chronic kidney disease to support more timely treatment decisions. 

Patients were provided with a physical health passport to record their results and, while waiting for their clinical review, were able to access advice and support from a range of local organisations. These included Live Well Dorset, the Stroke Association, bhliveactive, alcohol management and smoking cessation services and Help & Care. This created great opportunities to speak to people face to face, learn more about services and support available in their community and pick up tips and practical ways to improve their health and fitness. A key feature of the day was the holistic clinical review. Rather than focusing on individual conditions in isolation, clinicians considered each patient as a whole, helping to ensure treatment decisions reflected their wider health needs and personal circumstances. 

This initiative was developed by Anthony Young (Cardiac Advanced Nurse Practitioner, University Hospitals Dorset) and it was made possible through strong collaboration across organisations who all share the goal of improving services and experience for patients. Anthony currently leads a British Heart Foundation-funded secondary prevention lipid management service, which as well as operating secondary care clinics, works directly with four primary care networks (PCNs) across Dorset. This involves identifying secondary prevention patients, i.e. patients who have had a primary event such as a heart attack or stroke and are not currently treated to NICE’s target set out in the lipid management pathway (March 2024) - meaning they are not achieving a cholesterol reduction in line with the pathway. It also involves supporting workforce development in the primary care teams and operating specialist satellite clinics from within the PCNs' local areas.  

Health Innovation Wessex has supported the programme through engagement with the British Heart Foundation, bid development, ongoing PCN engagement and coordination of the programme's steering group meetings. The longer-term ambition is to introduce a holistic approach into the service with a broader cardiovascular renal/kidney metabolic (CVRM) model. This would be in line with national priorities, and the NHS focus on prevention and community care as well as its focus on integrated care. Health Innovation Wessex will continue to support this ongoing process incorporating the recently published CVD Modern Services Framework (MSF). 

The assessment day demonstrated the potential of this approach with 31 patients attending and the feedback was overwhelmingly positive, with more than 90% of respondents rating their overall satisfaction with the experience 5/5. 

While it is early days with further evaluation and analysis of the data still to come, early signs are encouraging. The event showcased how partnership working, proactive care and a whole-person approach can help deliver a better experience for patients while supporting more effective management of long-term conditions. I’m very much onboard and looking forward to the next day in October!"