Atrial fibrillation (AF) is one of the most common forms of abnormal heart rhythm (arrhythmia) and a major cause of stroke. Around 1.5 million people in the UK have been diagnosed with AF. It is estimated that there are significant numbers of people (at least 270,000) over 65 with undiagnosed (or silent) AF in the UK and around 1 in 8 people are not treated effectively (1).  Once diagnosed, most people will be treated with blood-thinning medication to prevent clots (anticoagulants), which reduces the risk of stroke by two thirds (2) and avoid other health care complications. This stroke risk is why it is so important that AF is detected as early as possible. Suffolk and North East Essex ICB and Hertfordshire and West Essex ICB focussed on AF detection in our Core20PLUS 5 populations. 

Suffolk and North East Essex  

In partnership with Suffolk GP Federation, Suffolk and North East Essex ICB targeted a small number of practices to further refine the process of identifying, effectively engaging with and optimising treatment for people who had already been diagnosed with AF.  The focus was on clinically reviewing and supporting those with a diagnosis who were not currently receiving optimised treatment, alongside further understanding the reasons why patients where not accessing appropriate care.   

Hertfordshire and West Essex 

Hertfordshire and West Essex ICS worked with primary care networks (PCNs) located in areas defined by the Index of Multiple Deprivation (IMD) as deprived. They engaged with local voluntary, community, faith and social enterprise organisations (VCFSE’s) to co-develop a community outreach approach to raise awareness of AF in black, Asian and other ethnic groups through in primary care settings to improve detection and subsequent management with direct oral anticoagulants (DOAC’s) where appropriate. 

Lipid managment refers to the management of fats in the blood (cholesterol and triglycerides) (3,4).  A high level of cholesterol is one of the most significant risk factors for cardiovascular disease (CVD). Around 43% of adults have raised cholesterol in the UK which can be reduced with appropriate management, saving lives (5). 

Cambridgeshire and Peterborough 

Cambridgeshire and Peterborough ICS  worked with practices in some of their most deprived areas (see IMD above) to identify and optimise patients with poorly managed lipids, enabling access to novel treatments in line with the NICE AAC lipid management pathway. 

Nearly 43,000 people are diagnosed with bowel cancer every year in the UK (6). Screening aims to find cancer, or changes in the bowel that could lead to cancer, early when treatment is more likely to work. A FIT (faecal immunochemical test) is used to screen for tiny traces of blood in poo that may be an early indication of cancer.

Norfolk and Waveney 

Norfolk and Waveney ICS focused on improving bowel cancer screening. They worked with community champions and connectors in voluntary, community, faith, and social enterprise groups to screen for bowel cancer in higher risk people within Core20Plus groups.  A targeted community outreach programme took place to engage people who have not responded to the national screening programme and looked to provide advice about accessing healthcare and cancer screening tests, specifically the FIT, as appropriate.

Norfolk and Waveney 

Building on the success of the Wave 1 project, this initiative aimed to improve access to health information and services for women who experience additional barriers and inequalities. Delivered in partnership with the Mary Magdalene Group, the WOWBus provided trusted, face-to-face outreach across Norfolk and Waveney, bringing support directly into communities where women are less likely to engage with traditional health services.

The project focused on raising awareness and providing tailored information and signposting on key women’s health priorities, including breast, bowel and cervical cancer screening, sexual and reproductive health, and menopause. The outreach was designed to be culturally appropriate and responsive to local needs, helping to overcome barriers such as stigma, transport, language, low confidence and previous negative experiences of healthcare services.

Particular emphasis was placed on reaching women at greater risk of poor health outcomes, including sex workers, women who use drugs, migrants, Black African women, younger women at risk of sexually transmitted infections, and women experiencing reproductive health challenges.

A total of 766 women engaged with the project. In total, 362 conversations were recorded, including 293 one-to-one and 69 group discussions. This flexible approach enabled women to participate in ways that reflected their individual circumstances, preferences and cultural norms.

Read the report here

Bedfordshire, Luton, and Milton Keynes 

Bedford, Luton, and Milton Keynes (BLMK) ICS  worked with practices in their most deprived areas (see IMD above) to address healthcare inequalities. The initiative focused on underserved populations by improving care and treatment for patients with heart failure with preserved ejection fraction (HFpEF) in five key GP practices.

The project emphasises clinician education, patient engagement and comprehensive monitoring to enhance care delivery. Using NICE guidance TA929 and TA902, the goal was to identify all patients with a confirmed HFpEF diagnosis and optimise their treatment using oral antidiabetic medications, Dapagliflozin or Empagliflozin, to ensure better health outcomes for these vulnerable groups.

Ten general practices across BLMK participated in the project. A total of 180 patient records were reviewed to identify individuals with HFpEF who may benefit from SGLT2 inhibitor therapy. From this cohort, 60 patients were invited for clinical review, resulting in 52 completed appointments, the majority conducted via telephone.

Following clinical assessment and shared decision-making, 35 patients agreed to initiate SGLT2 inhibitor therapy. On further clinical review, the vast majority have continued a SGLT2 inhibitor 6 months later.

Read the report here

Hertfordshire and West Essex

With funding from Health Innovation East, Hertfordshire based charity, One Vision, delivered a cardiovascular health improvement project running from March 2025 – September 2025 and was focused on identifying undiagnosed hypertension and atrial fibrillation (AF) including optimising the management of existing cardiovascular conditions.

Bespoke community engagement events were hosted in trusted community and faith settings to help overcome barriers to access experienced by populations less likely to engage with traditional healthcare services.

The project primarily targeted Black British, Black Other, Asian British and Asian Other communities, which are known to experience higher rates of hypertension and poorer cardiovascular outcomes. By improving access to screening, health education and GP follow-up, the project directly addressed health inequalities and supported both Core20PLUS5 objectives and local Integrated Care System (ICS) prevention priorities.

A total of 15 community engagement events were delivered across Hertfordshire, reaching 803 individuals who received blood pressure checks and cardiovascular risk assessments.

Participants identified with elevated blood pressure, possible AF, or existing cardiovascular conditions were advised to seek follow-up care from their GP.

Read the report here

Mid and South Essex

This project introduced fractional exhaled nitric oxide (FeNO) testing in primary care to support objective asthma diagnosis for children and young people from Core20PLUS5 practices in the most deprived areas of Mid and South Essex. Delivered through a partnership between Health Innovation East and Mid and South Essex ICB, funding enabled the installation of 16 FeNO devices, supported by a community of practice to ensure consistent and effective adoption.

FeNO testing is recommended by NICE (DG12, 2014) for children aged 5–16 when asthma diagnosis remains uncertain following initial assessment if there is diagnostic uncertainty after an initial assessment and they have either normal spirometry or obstructive spirometry with a negative bronchodilator reversibility test.

During the pilot, 368 tests were completed, including 132 (36%) for children and young people. Of these, 48 resulted in an asthma diagnosis, 33 supported ongoing monitoring, and 51 provided reassurance that asthma was not present.

The increased availability of FeNO testing also benefited adults, who received 236 tests. These led to 47 diagnoses and supported monitoring for 92 patients, improving diagnostic certainty and timely access to treatment.

Read the report here

Suffolk and North East Essex 

Respiratory disease is a strategic priority for the Suffolk and North East Essex Integrated Care System (SNEE ICS), reflecting the high prevalence of asthma across the region and variation in existing diagnostic pathways. This project aimed to expand access to fractional exhaled nitric oxide (FeNO) testing within primary care to improve the diagnosis and management of asthma, particularly among populations in coastal and rural communities where access to diagnostic services has historically been limited and levels of deprivation are above the national average.

By increasing the availability of FeNO testing and other diagnostic tools, the project sought to support earlier and more accurate asthma diagnosis, enable appropriate treatment and management, and improve patient outcomes and experiences. A key objective was to reduce asthma exacerbations and avoidable hospital admissions, with a particular focus on children and young people (CYP) living in neighbourhoods ranked within the most deprived 20% nationally according to the Index of Multiple Deprivation (IMD). Through earlier identification and intervention, the initiative aimed to reduce health inequalities and improve respiratory outcomes for these communities.

The project has delivered a significant increase in FeNO testing activity across the system. The number of tests undertaken increased from 134 in 2024/25 to 833 by January 2026, demonstrating a substantial expansion in access to diagnostic services and supporting more timely asthma diagnosis and management.

Read the report here

NHS England- East of England 

The project aimed to reduce inequalities in access to specialist care for people with suspected or confirmed interstitial lung disease (ILD) by establishing a regional virtual multidisciplinary team (MDT). Led by Royal Papworth Hospital NHS Foundation Trust and supported by the East of England Respiratory Clinical Network’s ILD Steering Group, the initiative piloted monthly virtual MDT meetings over 12 months, enabling local clinicians to discuss complex cases with regional specialists.

Health Innovation East funded and supported the implementation of the pilot, working with regional partners to build the evidence base for sustainable, long-term funding.

The pilot concluded in October 2025 and exceeded expectations, with 157 patients discussed compared with an original target of 96. Patients benefited from more coordinated care, improved treatment pathways and, in many cases, reduced travel time.

Clinical outcomes were significant. Following specialist radiology review, 73% of patients received a new or confirmed diagnosis. This led to changes in treatment for 74% of patients, while 41% were identified as suitable for antifibrotic therapies, demonstrating the value of specialist MDT review in improving patient outcomes.

Read the report here