South East London Healthy Hearts
Background
Cardiovascular disease (CVD) remains a leading cause of premature mortality and the impact of it is especially felt in deprived communities, where people are 4 times more likely to die.
Data from CVDPREVENT shows that South East London is below the England average for indicators relating to cardiovascular risk.
Preventing CVD depends on identifying and managing the key cardiovascular, kidney and metabolic conditions that drive risk: hypertension, atrial fibrillation, chronic kidney disease, and raised cholesterol/lipids. These are often not identified and managed quickly enough, leading to poorer outcomes for patients and increased pressure on health services.
This cardiorenal-metabolic (CRM) approach is reflected in the national cardiovascular disease modern service framework, which sets out ambitions to improve detection, treatment and cardiovascular outcomes. Many people live with more than one CRM condition, yet care is often delivered through separate, single-condition pathways. As a result, it can take up to two years for treatment to be fully optimised.
South East London has opportunities to improve outcomes across all four priority conditions compared with the best-performing areas in England.
Project overview
The Health Innovation Network South London is working with South East London Integrated Care Board, Clinical Effectiveness South East London, King’s Health Partners and primary care teams across south east London to develop, test, and evaluate the Healthy Hearts model.
The Healthy Hearts project has been developed to provide a more integrated and proactive approach to cardiovascular disease prevention. The project:
- Rapidly identifies and optimises patients with multiple CRM conditions.
- Delivers joined-up care for multiple long-term conditions, rather than separate disease-specific pathways.
- Uses point-of-care testing where appropriate, improving convenience for patients and clinical teams.
- Applies lean service design principles to improve patient experience, outcomes and value.
- Builds capability and skills across primary care teams.
Healthy Hearts aims to:
- Optimise cardiovascular risk factors within a 10-to-12-week period.
- Reduce the number of appointments needed to achieve effective management.
- Improve cardiovascular outcomes and reduce future demand on healthcare services.
- Support the development of a skilled primary care workforce able to deliver multiple long-term condition care and point-of-care testing.
- Develop and evaluate a scalable, evidence-based model for wider adoption across South East London.
Project outputs
A range of resources are being produced to support implementation and future scale-up, including:
- A Healthy Hearts clinical pathway.
- Digital tools for patient identification, clinical review and reporting.
- Education, training and implementation resources for primary care teams.
- Testing of innovative approaches, including point-of-care testing and digital solutions.
- An evaluation programme to assess clinical, operational and economic impact.
As of August 2026, six Wave 1 sites serving a population of more than 250,000 people had been onboarded across south east London. Evaluation is underway to assess whether the model can deliver faster, more proactive, and more complete management of cardiovascular risk factors, with learning informing future rollout.
Resources
Healthy Hearts implementation resources: Education, training and implementation resources for primary care teams
Find out more
To find out more about our work piloting the South East London Health Hearts project and our aim to reduce cardiovascular related events, please get in touch.