A healthy approach

A dedicated joint strategy to tackle heart and circulatory conditions, kidney disease and diabetes – a group of illnesses which share common risk factors – could cut avoidable deaths and reduce health inequalities, says BHF Scotland

Kevin Haggerty was diagnosed with type 1 diabetes as a child, but didn’t realise he had also developed heart problems until he had a heart attack aged 43. 

“I’d been at work – I was a security guard – and thought I had indigestion,” he explains. 

“It was a Sunday, I always remember that, and I felt really ill, so my partner rang an ambulance. The paramedics rushed me to hospital and into theatre, and I had stents fitted then and there, during the night.” 

Kevin, 52, from near Glasgow, has had three further heart attacks since and 11 stents fitted in total. He is currently awaiting the results of tests to determine the cause of a recent fall. As well as having coronary heart disease, he gets angina, which is chest pain caused by a lack of oxygen-rich blood reaching the heart muscle. Kevin struggles to walk far because of breathlessness. Dependent on a wheelchair and walker, sometimes he feels as if he “exists” rather than lives his life.

There is no doubt at all in Kevin’s mind that his cardiovascular problems are linked to his diabetes and he believes a more joined-up approach would have benefited his health and perhaps prevented some of the problems he’s had.

There are many thousands of patients in Scotland in Kevin’s position, living with heart disease alongside diabetes. Some patients have cardiac problems alongside chronic kidney disease, or diabetes and kidney problems together. Sometimes patients have all three. 

Collectively, these conditions are known as CVRM – cardiovascular (heart and circulatory conditions, including heart attack and stroke), renal (kidneys) and metabolic (including diabetes). They often occur in the same patients because as diseases they often share major risk factors such as high blood pressure, high cholesterol, smoking and obesity. 

Having one of these conditions tends to increase the chances of developing another. For instance, having diabetes can damage blood vessels, leading to coronary heart disease and stroke. Having kidney disease puts you at two to four times higher risk of cardiovascular illness, while cardiovascular disease can worsen chronic kidney disease. 

There’s growing awareness in the UK, Europe and beyond of how valuable it is to take a strategic CVRM approach to policy, planning and delivering care. Recognising where shared risk factors, data, prevention efforts and care pathways can be better joined up can make for more effective patient care. 

In England, for instance, a new 10-year plan for reducing premature deaths from cardiovascular disease and stroke takes a cardiovascular-kidney-metabolic approach. 

Collaborative working across these specialisms is starting to develop in Scotland. The Scottish Government has set up a CVRM advisory group, chaired by BHF Scotland, bringing together doctors, nurses and organisations like Chest Heart & Stroke Scotland, Diabetes Scotland, Kidney Care UK, Kidney Research UK, Stroke Association and the Health and Social Care Alliance Scotland. 

But BHF Scotland recognises that there is a need in Scotland for taking a CVRM approach, as hundreds of thousands of people are affected by one or more of these conditions. This stands in stark contrast to cancer, another major cause of death and ill-health which has a 10-year Scottish Government strategy, with governance structures and financial resource for delivery.

With this in mind, BHF Scotland are turning their attention to the Scottish Government’s planned new Long Term Conditions Framework, due to be published next March. The Framework will cover not only heart disease, stroke, kidney disease and diabetes, but many other illnesses including neurological conditions, chronic pain and long Covid.

BHF Scotland warn that without a strategic focus on CVRM, and sitting alongside such a wide range of other conditions, opportunities for joint work to save lives and improve patient care within this important, interlinked group of illnesses could be missed.

At the same time, BHF Scotland want to ensure that speciality-specific services like heart disease care are maintained and improved since they are currently beset by waiting lists and delays. 

With the right joint approach to prevention, early detection and timely, appropriate treatment, the impact could be huge

Variation or delays in access can have significant health consequences, something that campaigners say any strategic approach to CVRM conditions from the Scottish Government must recognise. Throughout the last decade, the Scottish Government, and the stroke, cardiac and diabetes clinical communities, have worked together to deliver action and improvement plans in these specialist areas. BHF Scotland and its partner organisations want to ensure that work is not lost but built upon. 

Kira McDiarmid, policy and public affairs manager at BHF Scotland, says: “There’s growing understanding that CVRM conditions are linked and that together they account for a very significant proportion of cases the NHS in Scotland deals with, placing growing pressure on services and staff. 

“In fact, put together, heart disease, stroke, diabetes and chronic kidney disease accounted for the largest burden of disease in Scotland in 2024, and caused 31 per cent of all deaths. 

“With the right joint approach to prevention, early detection and timely, appropriate treatment of these illnesses, the impact could be huge. We’re talking about saving lives, reducing inequalities and helping people live healthier, happier, more active lives.”

BHF Scotland would like a CVRM strategy that comes with appropriate governance, resource and accountability that’s comparable to other major conditions such as cancer. It stresses the strategy should aim to ensure equitable access to speciality-specific services and build on Scotland’s cardiovascular (CVD) Risk Factors programme, which seeks to reduce avoidable CVD deaths by 20 per cent over 20 years by improving the detection and management of the shared risk factors that sit behind many cardiovascular, kidney and metabolic conditions by providing sustained programme investment and staffing. The CVRM advisory group also want to see better integration of primary and secondary care data and the continuation of national audit programmes for CVRM conditions to monitor variation and hold the system accountable for improvement.

But McDiarmid stresses that dedicated speciality services for cardiac disease, and also for stroke, kidney disease and diabetes, crucially continue to be needed.

She says: “These remain an important part of the journey for many people. Delays in access to diagnosis and treatment are having significant health consequences for some patients.”

The Framework is being developed just as Scotland loses its strategy for tackling heart disease. The Scottish Government’s Heart Disease Action Plan recently came to an end, with no plans to replace it. 

BHF Scotland is keen to ensure that the focus is not taken away from current problems within cardiology that are greatly impacting on patients, such as waiting times for echocardiograms (key diagnostic tests for heart failure). Nearly two-thirds of patients are waiting for up to 12 weeks for an echocardiogram when urgent referrals are meant to take two weeks and all other referrals, six weeks.

Kevin is all too familiar with long waits in cardiology. He has been waiting nearly three years to see a cardiologist, in spite of having two balloon procedures and three stents fitted last November. 

McDiarmid says: “We are at a critical crossroads for cardiovascular care in Scotland. Eight hundred thousand people in Scotland are living with cardiovascular disease – one in seven of us – and too many are waiting too long for diagnosis and treatment. But we’ve gone from having a dedicated heart disease action plan to a new approach that puts heart disease alongside lots of other conditions, some of which are unrelated.

“It’s right to look at new ways to improve the care of patients with long-term conditions, but a careful balance must be struck.

“We must avoid a situation developing where efforts to tackle damaging cardiology waiting times are weakened because there is no longer a spotlight on cardiovascular disease – especially when we know coronary heart disease is Scotland’s single biggest killer.

“We need a strategy dedicated to the CVRM group of diseases and continued efforts to improve speciality-specific services.”

It could be transformative, McDiarmid says. “If we strike a balance by supporting joined-up working on areas of common ground while at the same time improving services specific to cardiovascular disease, diabetes and kidney disease, we will be doing right by patients. 

“We can reduce avoidable deaths and help many more people to live well with long-term CVRM conditions. We just have to get this right.”

This article is sponsored by British Heart Foundation Scotland