Cardiovascular Disease Directed Enhanced Service: views and experiences of General Practices

Executive summary

Background

A key objective of the Scottish Government’s Cardiovascular Risk Factors Programme is to find those living with modifiable risk factors that they are currently unaware of, and to optimise early intervention and care to reduce patients’ risk of developing Cardiovascular Disease (CVD).

The CVD Directed Enhanced Service (DES) formed part of the NHS operational improvement plan, announced in April 2025, and contributes to the Scottish Government’s Cardiovascular Risk Factors Programme. The Scottish Government has allocated £10 million to General Practices in Scotland to find those patients aged 35 to 60 who have not had a full suite of CVD risk factor checks in the last three years. General Practices are particularly encouraged to reach out to patients facing higher levels of deprivation and those who may traditionally under-utilise healthcare services (sometimes referred to as the ‘missing’).

Each practice that signed up to participate in the CVD DES was offered a capped amount of funding, based on the number of patients expected to be identified and offered checks. This was based on the number of patients in each practice weighted by Standardised Mortality Ratio for Coronary Heart Disease Death and by Scottish Index of Multiple Deprivation (SIMD).

Research projects

This summary presents key findings from two separate research projects that explored General Practices’ experiences of, and views on, the CVD DES:

• an online survey conducted and analysed by the Scottish Government, which received 164 responses
• qualitative research conducted by an independent research company (Craigforth), with 31 practices taking part

The primary focus of both the survey and interviews was on year 1 of the CVD DES (2025 to 26), although year 2 was underway at the point at which the research was conducted.

Analysis of, and reporting on, the online survey returns were undertaken by the Scottish Government Health and Social Care Analysis Strategic Insights Unit. Craigforth undertook, analysed and reported on the interviews and have worked with the Scottish Government to produce a combined research findings report. While the main report distinguishes between the findings from the online survey and the interviews, this summary presents an overview from across the combined body of evidence.

Reasons for participating

The main reasons given by practices for signing up to the CVD DES were the availability of funding, the focus on prevention, the age and health profile of the patients on their list and having an opportunity to try and engage with patients with whom they have had no recent contact.

The focus on preventative work was particularly welcomed; this was connected to experience that the general pressure on practice services, along with current funding arrangements, have left little room for practices to be proactive and focus on delivering preventative healthcare.

Set up and training

General Practices were more likely to have attended CVD DES implementation training than not, albeit there was some variation based on health board area. They were most likely to have participated in national online training.

The relatively rapid roll out of the CVD DES has caused some frustrations; this was associated with limited time to prepare, delays in being able to access the information they needed and some initial confusion around eligibility criteria. There was a connected suggestion that project planning might have benefitted from earlier engagement with Practice Managers and Other Healthcare Professionals, rather than primarily GPs.

Identifying and selecting patients

Most General Practices had looked to prioritise inviting patients living in the most socio-economically deprived areas covered by their practice for a CVD DES check.

The ESCRO tool (the sole integrated solution for the requirements for Enhanced Services reporting within NHS Scotland) was most likely to have been used to identify those living in the most deprived areas and patients who had not had recent contact with the practice. Experience of using the ESCRO tool was mixed: while some found it easy, it was also described as challenging or time consuming to use.

Those practices which reported not using ESCRO to select patients to be invited to participate in the CVD DES had tended to use opportunistic approaches, usually inviting patients who were already attending the practice for another health reason to also have the CVD DES checks. Some practices had combined the two approaches and had both identified some patients to be invited to participate whilst also picking up some patients through opportunistic routes.

Approaches to patient engagement

General Practices that were inviting patients to participate in the CVD DES were most likely to have done so by text message, followed by over the phone. While an entirely text-based approach worked well for some practices, others reported that a very low rate of response to texts had led them to switch to making phone calls, even though this was more time-consuming.

There were various options used for patients to register their interest and book a CVD-DES appointment, including using a dedicated number to avoid patients needing to wait in a queue.

While drop-in sessions had worked well for some practices, others found them much less effective and did not see them as offering a worthwhile return on the resources needing to be invested.

Although practices were aware of the Scottish Government provided information pack on innovative engagement methods, most had not tried any of the community-based approaches referenced, typically because they were not thought necessary, because of lack of time and/or resources, or because of practical issues.

Take up and the profile of those engaging

General Practices reported mixed experience around the proportion of patients invited for CVD DES checks who took up the offer. Higher participation rates tended to be linked to either the opportunistic approach or to very specific targeting of those contacted, including by phone.

Although some practices had found it relatively easy to find a sufficient number of patients who were willing to have the CVD DES checks, others had found it harder than they expected. This was particularly the case among patients living in more deprived areas.

Even if the profile of patients going through the CVD DES may tend towards those living in areas of higher deprivation, many practices questioned whether the CVD DES, in its current form, is an effective mechanism for engaging with the ‘missing’ population of patients.

Clinical assessment and outcomes

The 2025 to 2026 CVD DES circular (sent to health boards by the Scottish Government) set out what was to be included in the CVD Risk Factors bundle check, and that a toolkit was available to guide clinicians on pathways. The Right Decision Service CVD prevention and risk factors toolkit lays out CVD pathways for blood pressure, lipids, glycaemia, obesity and smoking. The circular also noted that practices should use the results to create an ASSIGN score for each patient; ASSIGN is a cardiovascular risk score, which estimates the 10-year percentage risk of developing CVD for individuals who do not currently have a diagnosis of CVD.

Most practices had used the Right Decision Service CVD pathways, and they tended to report their use as straightforward, albeit there had been some early issues. The most commonly reported reason for not using the Right Decision Service CVD pathways was lack of awareness among responding practices.

The vast majority of responding practices also reported using the ASSIGN score, and again most had found it straightforward to use. However, some raised concerns around low-risk scores given by ASSIGN v2.0 which, it was argued, may undermine progress in treatment of CVD risks by reducing prescription of statins. It is important to note, however, that this research was not designed to evaluate the validity or performance of ASSIGN v2.0.

Although the research did not gather any formal outcome related information, many new diagnoses of hypertension, high cholesterol and pre-diabetes/diabetes were reported, as well as a smaller number of serious but unrelated health conditions having been diagnosed as a result of a patient coming in for a CVD check.

Delivery, workload and resources

As well as having a role in identifying patients who might participate in the CVD DES, the ESCRO was also the standard route through which practices reported on the CVD DES checks they had completed. Although its use was generally seen as relatively straightforward, some practices referenced the administrative and IT burden associated with delivering and implementing the programme. This included finding use of the ESCRO tool to be both challenging and time-consuming.

Most practices reported that CVD DES implementation and delivery had resulted in an increased workload, although most commonly a small increase. These increases related to both administrative and clinical time, albeit the balance depended on the specific approaches being used. Both the set up phase, including getting to grips with ESCRO, and inviting patients to participate were reported as resource heavy, especially when the latter included phone-based invitations.

General Practices had delivered the CVD DES using their existing staff team, generally by staging appointments over a number of months, with use of overtime tending to be associated with out of hours work, such as extended appointment hours or running evening or weekend clinics.

Although interviewees were not generally able to identify specific services or workstreams that had been curtailed as a result of the CVD DES, some reflected that delivering the programme required staff time and appointment capacity which might otherwise have been available for routine activity.

In terms of resource level per patient, practices were most likely to report that funding levels had been adequate, although there were also references to it being the bare minimum required and not being viable were per patient funding rates to be reduced.

Emerging impact and next steps

All of the 31 practices that took part in an interview had decided to take part in year 2 of the CVD DES, and all reported that they had made the right decision to sign up to participate in the first place. Setting aside the availability of resources, practices’ initial and ongoing support for a focus on prevention was clear.

However, ongoing operational challenges relating to workload, funding, administrative burden and patient engagement were also highlighted. That said, most were tending to use similar approaches in year 2 as those they had employed in year 1.

Although most practices were supportive of the focus on CVD, particularly given its prevalence in Scotland, there were references to the overall impact on longer-term health outcomes being limited by the scale of the CVD DES. Connected to reflections on the potentially limited impact of the CVD DES was an appetite from many practices to potentially deliver a higher number of interventions, especially among practices who had been funded to see fewer patients because of the age and/or socio-economic profile of their list.

However, for others the current number of places for which they have funding was seen as a more workable option going forward. This view tended to be linked to resourcing within the practice but also, on occasion, to a continued focus on those living in more deprived areas and the ‘missing’. With a continued focus on this patient group, some practices thought they would find it difficult to find higher numbers of patients who were interested in taking part.

Although there tended to be support for an ongoing focus on patients living in areas of higher deprivation, there was less of consensus around the focus on ‘missingness’. This was in no way to suggest that practices did not see value in looking to engage with this group of patients, but they were not always convinced that the CVD DES is an appropriate or effective vehicle for doing so. Instead, it was suggested, the Scottish Government may wish to consider an additional and focused piece of work that looks at innovative practice around engaging with this patient cohort.