Cardiovascular Disease Directed Enhanced Service: views and experiences of General Practices
Presents the results of an online survey and qualitative interviews conducted with General Practices across Scotland. These explored the views and experiences of practices in implementing and providing the first year of the CVD DES programme, to contribute to its ongoing evaluation.
Footnotes
1 A Scottish Government literature review on Socio-economic inequality and barriers to primary care in Scotland notes that, despite making contact or being eligible for healthcare services, some patients with experience of deprivation may find it difficult to engage with care. It goes on to note that “Missingness is complex, encompassing social, structural and health-related causes…”.
2 The research findings set out within this report focus on the first year of the CVD DES i.e. the period covered by the 2025/26 circular. However, 2026/27 CVD DES, covered by the 2026/27 circular was underway by the point at which the interviews were carried out.
3 The Keep Well health service in Scotland offered community-based health assessments and support to improve health and wellbeing. It includes health checks that assess blood pressure, cholesterol, and blood sugar levels, and provides opportunities to discuss health concerns. It also runs programs like THRIVE, which helps adults with mild to moderate mental health challenges. As an example, information on how one health board (Forth Valley) continues to deliver the THRIVE to Keep Well approach is available from their website.
4 Health boards were required to complete training on the use of the ESCRO tool portal. The training was tailored to local requirements and implemented across Scotland in a phased approach. As a result, boards completed the training at different times, reflecting variations in staff capacity and availability.
5 Information about the ESCRO tool is presented in Chapter 4.
6 Lindsay et al, 2023 define missingness as “The repeated tendency not to take up opportunities for care, such that it has a negative impact on the person and their life chances”.
7 Links Workers (sometimes known as Community Links Workers) provide support to individuals facing various social issues that impact their health and well-being. They work alongside GP practices, making referrals for patients and connecting them with local support services.
8 The target population of this enhanced service are characterised by “missingness”. Therefore patients with known CVD-related conditions were not the target population.
9 EMIS is an electronic patient’s record system. CHI (Community Health Index) is a national is a register of all patients in NHS Scotland. Each patient has a unique 10-digit CHI number.
10 Accurx is a communication platform designed specifically for the NHS. It was launched in Scotland in early 2025, with 3 pilot sites in Lothian, and is now used by over 130 practices in Scotland.
11 Medlink is an automated recall and monitoring system.
12 The information pack has been updated since the interviews were conducted to include examples of good practice from the 2025-26 CVD Directed Enhanced Service (DES). This is the only update.
13 ASSIGN is a cardiovascular risk score, which estimates the 10-year percentage risk of developing cardiovascular disease (coronary heart disease, stroke, and transient ischaemic attack) for individuals in Scotland, who do not currently have a diagnosis of cardiovascular disease. The ASSIGN score has been used across NHS Scotland since its launch in 2006. An updated version - ASSIGN (v2.0) which uses a lower risk threshold – was introduced in January 2025.
14 There is clinical advice (NICE NG238) to recheck lipids and blood tests after starting statins to assess response and tolerability. This could potentially allow dose adjustment. A 6-month check was adopted by the CVD DES to ensure follow up and enable evaluation. However, the Scottish Government also notes that the timing of that test is something it would be appropriate to review for future iterations of the CVD DES.
15 Repeating tests at six months was a pragmatic decision for the first iteration of the CVD DES.
16 Patients were eligible for checks if they had not received the full suite of CVD checks (a blood pressure check, a lipid profile, a weight/BMI, an assessment of glycaemic level and a smoking status asked) in the last three years (noting that the target population was characterised by missingness).
17 Vision software is a clinical system used by NHS Scotland, primarily for GP practices. It provides electronic patient records, prescribing, appointment scheduling and patient services, including online booking and record access. The wider rollout of the Vision IT system began in 2026 and is ongoing.
18 In Scotland, DES (Directed Enhanced Services) are nationally mandated services that Health Boards must offer to GP practices, while LES (Local Enhanced Services) are locally commissioned, optional services that vary by Health Board or Integrated Care Board.
19 A Community Treatment and Care team provides routine healthcare services such as wound care, injections, blood tests, and long-term condition monitoring, delivered in community settings or GP practices.
20 The 6-month re-check appointment was included within the funding calculation for the CVD DES. A claim can be submitted once a patient has completed both the CVD risk factor bundle check and the review appointment. The 6-month review was not linked to the claims process, as doing so would have delayed practices’ ability to submit claims and receive payment.
21 Information about ASSIGN is set out in Chapter 7.
Contact
Email: socialresearch@gov.scot