Dear Editor

This large-scale study provides critical insights into shifts in cardiovascular disease (CVD) patterns, highlighting both progress in prevention and emerging public health challenges.

The study’s findings on the 19% overall decline in CVD incidence, particularly the 30% reduction in coronary heart disease (CHD) and stroke, are promising. However, the simultaneous increase in arrhythmias, valvular diseases, and thromboembolic disorders is concerning, suggesting a shifting burden of cardiovascular conditions rather than an absolute decline. Furthermore, the plateau in CHD reductions among younger individuals raises concerns about the impact of rising obesity and type 2 diabetes rates in this population.

Despite its strengths, the study has several limitations:
1. Reliance on Electronic Health Records (EHRs): While the dataset is large, coding inaccuracies and underdiagnosis may impact the precision of trends, especially for conditions like heart failure and peripheral artery disease.
2. Lack of Granular Risk Factor Data: The study does not fully account for changes in lifestyle factors (e.g., diet, physical activity, smoking), making it difficult to attribute trends to specific preventive measures.
3. Limited Consideration of Ethnic and Regional Variations: Given the diverse UK population, regional and ethnic subgroup analyses could have provided valuable insights into health disparities.
4. Shorter Follow-Up for Recent Years: Incidence estimates from more recent years (2018–2019) may be less reliable due to incomplete data capture.

To build on these findings, future research should:
• Enhance data linkage by integrating EHRs with lifestyle surveys and biomarker data to better assess risk factor contributions.
• Perform stratified analyses to evaluate how CVD trends vary by ethnicity, geography, and socioeconomic status.
• Examine long-term outcomes by linking incidence data to hospital admissions and mortality records, ensuring a more comprehensive assessment of disease burden.
• Assess the impact of healthcare policies to identify interventions that have contributed to observed trends, such as statin use, hypertension control, and smoking cessation efforts.

This study underscores the evolving nature of CVD in the UK, highlighting both progress and ongoing challenges. While atherosclerotic disease incidence has declined, rising rates of non-ischemic conditions and persistent health disparities require urgent attention. Future research should adopt a more holistic approach, integrating lifestyle, socioeconomic, and healthcare policy factors to inform more targeted prevention strategies.

Dear Editor

Higginson & Ramjeeawon’s commentary rightly raises concerns around the likely outcomes of current debates and challenges of palliative and end of life care provision in the UK. A key, but rarely acknowledge or supported, element of that provision are unpaid/family carers who provide the majority of support to those with palliative and end of life care needs at home. These carers often do this with negative effects on their own health and wellbeing that also threaten their ability to continue caring, potentially increasing health service use for both the person they support and for themselves. There are multiple reasons for these negative effects on carers, including limits on their ability to gain or access support for both their caring role and for their own health and wellbeing.

We need to radically reframe our thinking around unpaid/family carers. We need to think of unpaid/family carers as marginalised patients. We also need to think of unpaid/family carers as part of the workforce. Better identification of, engagement with, and support for unpaid/family carers is needed in relation to both of these reframes. There are evidence-based interventions that could enable this if systematically adopted by those local health strategies that lack concrete plans [1] e.g., the internationally recognised Carer Support Needs Assessment Tool Intervention (CSNAT-I [2-8]). There is also robust evidence that bespoke carer support roles [9] (e.g., the Carer Support Nurse [10]) and systemic change, including making carers more financially secure, are also required [9].

We need to urge these current debates to think of patients and carers as the unit of care (think dyadically) and to think big and consider the potential impacts of improving palliative and end of life care provision beyond palliative and end of life care itself e.g., improving the identification and support of unpaid/family carers could have ripple effects on wider health service use for both patients and carers.

References
1) Chambers RL, Pask S, Higginson IJ, Barclay S, Murtagh FEM, Sleeman KE. Inclusion of palliative and end of life care in health strategies aimed at integrated care: a documentary analysis [version 2; peer review: 2 approved] [version 2; peer review: 2 approved] [published Online First: 2023/03/30]. AMRC Open Res 2023;4:19. doi:10.12688/amrcopenres.13079.2. pmid:36987529
2) https://csnat.org/ [accessed 31/03/2025)
3) Ewing G, Austin L, Diffin J, Grande G (2015). Developing a person-centred approach to carer assessment and support. British Journal of Community Nursing; 20(12): 580-584.
4) Grande G, Austin L, Ewing G, O’Leary N, Roberts C (2017). Assessing the impact of a Carer Support Needs Assessment (CSNAT) intervention in palliative home care: a stepped wedge cluster trial. BMJ Supportive & Palliative Care; 7: 326-334.
doi:10.1136/bmjspcare-2014-000829 (Online first 2015).
5) Lund L, Ross L, Petersen MA, Blach A, Rosted E, Bollig G, Juhl GI, Farholt HB, Winther H, Laursen L, Hasse M, Weensgaard S, Guldin M-B, Ewing G, Grande G, Groenvold M (2024). Effect of the Carer Support Needs Assessment Tool intervention (CSNAT-I) in the Danish specialised palliative care setting: a stepped-wedge cluster randomised controlled trial. BMJ Supportive & Palliative Care 2024;14:e772-e783. doi:10.1136/bmjspcare-2020-002467
6) Toye C. Parsons R, Slatyer S, Aoun SM, Mooring R, Osseiran-Moisson R, Kill KD (2016). Outcomes for family carers of a nurse-delivered hospital discharge intervention for older people (the Further Enabling Care at Home Program): Single blind randomised controlled trial. Int J Nurs Stud; 64: 32-61. http://dx.doi.org/10.1016/j.ijnurstu.2016.09.012
7) Aoun SM, Grande G, Howting D, Deas K, Toye C, Troeung L, et al. (2015) The Impact of the Carer Support Needs Assessment Tool (CSNAT) in Community Palliative Care Using a Stepped Wedge Cluster Trial. PLoS ONE 10(4): e0123012. doi:10.1371/journal.pone.0123012 (rated RRE grade 3)
8) Aoun S, Deas K, Toye C, Ewing E, Grande G, Stajduhar K (2015). Supporting family caregivers to identify their own needs in end-of-life care: qualitative findings from a stepped wedge cluster trial. Palliative Medicine; 29(6): 508-517.
doi: 10.1177/0269216314566061
9) Grande G, Rowland C, Shield T, Bayliss K, Flynn J, Harris D, Wearden A, Farquhar M, Panagioti M, Hodkinson A, Booth M, Cotterill D, Goodburn L, Knipe C, Bee P. Understanding and addressing factors affecting carers’ mental health during end-of-life caregiving: synopsis of meta synthesis of literature and stakeholder collaboration. Health Soc Care Deliv Res 2025; Feb 19:1-27. https://doi.org/10.3310/RTHW8493
10) https://arc-eoe.nihr.ac.uk/research-implementation/research-themes/palli... (accessed 31/03/2025)

Dear Editor,

Goodyear et al accept that 'increased time spent on phones and social media is generally linked with worse physical, mental, and educational outcomes', but argue that 'simply restricting access to devices can undermine children’s rights to technology design and education that will help them thrive as adults in today’s world'. In the article they argue this from a children's rights perspective, which appears valid.

I would offer an alternative view from the perspective of an occupational physician, an area of medicine that specialises in risk assessment and protecting people (usually employees) from hazards. I would ask if the authors are familiar with the concept of the 'hierarchy of controls', which is a well understood model within the health and safety industry for risk mitigation. The hierarchy (in order of effectiveness from most to least) is:

1) Eliminate the hazard
2) Substitute (replace the hazard)
3) Engineering controls (isolate people from the hazard)
4) Administrative controls (change the way people work with the hazard, for example through education or reducing time each person spends on hazardous task)
5) Personal protective equipment (individual protections)

Under the Health and Safety at Work etc. Act 1974, and subsequent Management of Health and Safety at Work Regulations 1999, employers are expected to undertake adequate risk assessments to identify potential hazards and to mitigate risk where possible by applying the hierarchy of controls. It's worth also noting that the law sets out duties employers have, not just to their employees but also to members of the public (including children at school).

The Health and Safety Executive provide specific advice for schools on applying the law (see https://www.gov.uk/government/publications/health-and-safety-advice-for-...) which states clearly 'Pupils should be safe in school'.

It does appear that in the case of smartphone use by children (and particularly in the school environment) there is increasing evidence of hazard and potential harm, yet the appropriate approach to risk mitigation (i.e. to eliminate the hazard where possible) has been set aside for a preference to place administrative controls (such as education and recommendations of individual behaviour change). In the longer term, I am sure that improved product design (i.e. engineering controls as per the hierarchy) will be possible but for the time being it appears that duties under the health and safety legislation are not being adequately balanced against the rights of the child identified in the article.

In workplace settings, we often have to balance safety against individual rights (for example the rights of a disabled employee to work in safety critical role, where their safety and that of others may be affected by their disability) and it is almost always the health and safety legislation that takes precedence.

I completely agree that the rights of the child must be considered in this complex area of policy, but we must not forget that most rights are relative and need to be held in balance with others.

We cannot rely on some future protections to keep safe the children of today, and if elimination (i.e. banning social media or devices below a certain age) is the best mitigation available currently then I would congratulate the jurisdictions who have been early adopters of such measures. We won't get a second chance to protect the youth of today.

Kind regards,

Dr Chris Edmond

Dear Editor,

Majeed and Abassi call to replace the term “Non-Pharmaceutical Interventions” (NPIs) with “Public Health and Social Measures” (PHSMs), aiming to shift from terminology which may diminish the significance of these interventions1. Whereas “NPIs” may not accurately convey the full scope and complexity of non-pharmaceuticals, “PHSMs” presents a clearer and more comprehensive framework for understanding these interventions. PHSMs are recognized by the World Health Organisation (WHO) as critical measures that "act in concert with medical countermeasures"2, highlighting their equally integral role alongside pharmaceutical interventions in health emergency management, rather than being solely provisional measures.
The COVID-19 pandemic demonstrated that PHSMs were not just temporary measures until vaccines arrived, instead proving instrumental in facilitating reduced transmission rates and the protection of health systems. However, their perceived inferiority led to inconsistent implementation, underfunding, and reduced public adherence. This pattern was exacerbated by findings that trust in authorities ‘strongly influenced’ compliance with PHSMs (public adherence to these measures dropped significantly when trust in governing institutions decreased3). By adopting PHSMs, we acknowledge their scientific rigor, social complexity, and critical role in health security.
Furthermore, using “NPIs” in public health crises ultimately neglects the behavioural, societal and environmental aspects of these measures. Unlike pharmaceuticals, which function at an individual level, PHSMs rely on collective action, making factors such as public trust, community co-operation, and economic conditions pivotal in their success. A more precise term not only overcomes terminological and perceptual barriers, but it also encourages engagement through a shared collective responsibility.
Clear communication is essential in public health. While “NPIs” has helped distinguish these measures from medical treatments, it fails to capture their full impact in pandemics and beyond. For example, lifestyle changes like weight loss for hypertension are not just secondary to medication but are often frontline strategies. Majeed and Abassi rightly highlighted the need for precise language in public health, and adopting PHSMs is a crucial step toward ensuring these interventions are valued, understood, and effectively implemented.

References
1- Majeed A, Abbasi K. Medical journals should use the term “public health and social measures” BMJ 2025; 388 :r409 doi:10.1136/bmj.r409. Available from: https://www.bmj.com/content/388/bmj.r409
2- World Health Organization. WHO Public Health and Social Measures (PHSM) Initiative [Internet]. 2023 [cited 2025 Mar 30]. Available from: https://www.who.int/initiatives/who-public-health-and-social-measures-in...
3- Xu Y, Bayham J, Darzi A, Murray CJL, Halloran ME, Klein EY, et al. The effectiveness of public health measures in reducing the transmission of SARS-CoV-2: A systematic review and meta-analysis. PLoS Med [Internet]. 2022;19(7):e1004037. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9213762/