Improving outcomes for people living with CVRM conditions

By March 2029, we will have prevented 25% of heart attacks and strokes in North West London, while actively addressing health inequalities. 

North West London’s cardiovascular, renal and metabolic (CVRM) mission brings partners together so that people at risk of, or living with, these connected conditions are identified sooner and cared for as a whole. 

Why this matters 

Around 580,000 people in North West London, about 20% of the population, live with CVRM conditions. Together these conditions account for around 70% of all hospital admissions, and cardiovascular disease remains the largest single cause of premature death in the area. 

These conditions are closely connected. High blood pressure, raised cholesterol, type 2 diabetes and chronic kidney disease often occur together, and each one raises the risk of the others. Treating them one at a time misses the fuller picture of a person’s health and leads to missed chances to act early. 

The burden is not shared evenly. CVRM conditions are strongly linked to deprivation and to ethnicity, with South Asian communities in North West London at particularly high risk. Narrowing that gap is the point of the mission, not an addition to it. 

Our mission 

North West London has adopted a mission-based approach to tackle the health challenges that matter most to local people. Instead of running isolated projects, partners agree a small number of shared priorities and work on them together over several years. 

The North West London Research and Innovation Board established the mission to optimise care for people with long-term conditions, starting with cardiovascular disease. It has since broadened to cover CVRM conditions as a whole. 

The mission’s partners come from the NHS, industry, local authorities, communities and academia. As the health innovation network for North West London, we convene and coordinate that work. Through innovation, collaboration and system transformation, we turn shared priorities into practical change. 

What we do 

Our work is organised around two themes. 

Identifying people at risk earlier 

Many people live with undiagnosed CVRM conditions, or with risk factors that have not been picked up. Finding them sooner means treatment can start sooner, especially for people who are less likely to come forward through the usual routes. 

This year we are: 

1. completing and sharing our evaluation of PocDoc community detection 
2. appraising detection models for commissioners across the Integrated Care Board (ICB), public health and community teams, so the system can decide what to spread
3. implementing health kiosks at three sites in one borough, and evaluating their impact on risk detection and self-management across two boroughs
4. exploring a predictive risk stratification tool with an industry partner
5. scoping and beginning delivery of the national chronic kidney disease detection programme 

Supporting more joined-up holistic CVRM management & care 

When conditions overlap, care works better if it is planned around the person rather than around a single diagnosis. Our second theme is about making that the normal way of working across North West London. 

This year we are: 

1. spreading the holistic CVRM model across North West London, starting with six primary care networks using Clinically-Led workforce and Activity Redesign (CLEAR) methodology, and supporting early implementation through shared learning, guides and toolkits 
2. extending implementation across the sector through a long-term industry partnership 
3. scoping delivery of CVDACTION, a national programme to find and optimise care for people with CVRM conditions 
4. supporting the national chronic kidney disease programme, aligned to system priorities in CVRM 
5. developing and running a pan-London CVRM Academy with the other London health innovation networks and Million Hearts and Minds (a London-wide initiative aimed at improving cardiovascular health and preventing cardiovascular disease)

Innovation and research 

Innovation earns its place in the mission when it improves outcomes for people. That is the test we apply. 

1. We create the conditions to test new approaches in real-world settings across North West London. 
2. We evaluate what we test and publish what we learn, including where things do not work. 
3. We connect innovators with the parts of the system that need them, through our Innovation Forum, roundtables and links with the Office for Life Sciences. 
4. We support the spread of approaches that prove their value, so they become business as usual rather than a pilot that ends. 

The mission is supported by patient partners, an innovation adviser and partners including the North London Cardiac Operational Delivery Network, London Million Hearts and Minds and the other London Health Innovation Networks.

Reducing health inequalities 

This is a condition of the work rather than a separate workstream. Every programme in the mission has to show how it reaches the people at greatest risk. 

1. We use population data to direct effort to the places and groups where need is highest. 
2. We have tested detection innovation in community settings, so people who do not routinely attend appointments still get the offer in a trusted environment. 
3. We design with patient partners and with communities affected by these conditions. 
4. We build equity into evaluation, so we can see whether changes are reducing inequalities or leaving gaps behind.