Background and Context

Health Insights is the rail industry’s platform for recording and analysing health data, and the Health Insights Benchmarking workshops bring together representatives from GB rail (train operating companies, infrastructure and supply chain organisations, and freight operators), to discuss health data trends and share best practice. The discussion on CVD referrals emerged due to recent increases in referral rates and concerns about under‑recognised cardiovascular risk in rail.

CVD covers a wide spectrum of conditions—including coronary heart disease, atrial fibrillation, heart failure, congenital heart disease, stroke, and heart attacks—many of which have subtle or asymptomatic onset, making early detection challenging.

The economic and societal consequences are significant:

• Healthcare costs associated with CVD are estimated at £12 billion annually.
• The total economic impact—including premature death, disability, and informal care—is around £28 billion.
• Individuals with heart disease are more likely to leave the workforce, with a 22% exit rate, higher than for those with cancer or mental health conditions.

These trends reinforce the importance of proactive CVD management within safety critical‑critical industries like rail.

Key Insights from Benchmarking Discussions

1. Rising referral rates and affected groups
   An uptick in CVD referrals was noted in this round of reporting where several patterns emerged:

• Ethnic minority employees: one organisation observed increased CVD referrals among Black, Asian, and Minority Ethnic (BAME) workers. This aligns with national evidence that some ethnic groups experience higher rates of hypertension, diabetes, and associated CVD risk.
• Younger employees: one organisation reported an increase in stroke cases among younger employees, highlighting growing concerns about shifting epidemiological patterns. National data verifies this trend, with stroke rates among adults under 55 rising by 67% between 2002 and 2018, while rates among older adults declined.The patterns emerging from the Health Insights platform suggest a need for targeted health interventions and enhanced health monitoring for specific groups within the workforce.

2. Potential contributory factors
   Several factors may be contributing to the observed increase in CVD referrals within rail. Risk factors for CVD can be prevalent among rail employees, where sedentary work, poor dietary habits, insufficient physical activity, chronic stress, and inadequate sleep collectively elevate the risk of hypertension, metabolic syndrome, and, ultimately, cardiovascular events. These modifiable risk factors are well-established contributors to CVD and are often exacerbated by the structure and demands of contemporary work routines.Stress, which was mentioned during benchmarking discussions can also play a role in cardiovascular health outcomes. Prolonged stress has been linked to increased blood pressure, elevated cortisol levels, and adverse cardiac outcomes. A 2024 study published by Harvard Health further confirmed that individuals reporting work-related stress had significantly poorer cardiovascular health metrics.These interrelated factors highlight the need for the industry to consider a more holistic and preventative approach to workplace cardiovascular health.

3. Surveillance and data challenges
   Barriers to accessing and collecting appropriate health data appear to be hindering the effectiveness of CVD prevention and management strategies in rail workplace settings. These barriers include:

• Insufficient investigation into this issue.
• limited proactive or preventative health monitoring.
• Inadequate data capture.This lack of integration makes it difficult to report in clear and consistent ways and could limit the ability to identify emerging CVD risks at a population level. It could also undermine efforts to implement targeted interventions.

4. Variability in preventative and investigative practice
   Approaches to CVD screening varied widely across rail companies and include:

• Service biometric screening (e.g., proactive health screening which enables employees to voluntarily monitor biometric indicators such as body mass index, blood pressure, and QRisk scores)
• Intensive screening models which incorporate routine electrocardiograms (ECGs) and cardiology referrals
• Minimal referral activity where most cases are managed through temporary workplace adjustments.

5. Emerging debates
   This benchmarking group discussion highlighted increasing interest in GLP‑1 receptor agonists such as semaglutide (Ozempic, Wegovy, Mounjaro), widely publicised for their effectiveness in treating obesity and type 2 diabetes (both linked to CVD).Clinical trials show these drugs:

1. 1. • Reduce cardiovascular events.
      • Produce significant weight loss.
      • Improve metabolic health.

   However, there are wider concerns with these drugs including:

1. 1. • Lack of clarity around long-term safety remains remains uncertain.
      • Effects may diminish when treatment stops.
      • Access and cost are variable.
      • They should supplement — not replace — lifestyle interventions.

   NICE guidance echoes these concerns, emphasising that medication should be paired with long-term diet and physical activity programmes.

   Beyond medication, organisations reported modest gains from internal health promotion initiatives and cardiovascular risk scoring through tools like QRisk and SCORE2. However, it was acknowledged during benchmarking that measurable outcomes in relation to CVD may take years to materialise, underscoring the need for early, long-term data collection and evaluation frameworks.

Implications and Challenges

The rail industry appears to face several challenges in managing CVD risk through OH pathways.

1. Current lack of integrated data systems
   Poor integration across healthcare and OH limits the ability to track individual cases or identify emerging population level ‑level risk patterns.
2. Variation in OH practices across rail
   Differences in referral criteria and the consistency of health promotion efforts create an uneven landscape for managing CVD risk. 
3. Complex diagnosis pathways
   Establishing a direct link between CVD, or indeed other health conditions, and occupational exposures is often difficult. This challenge can delay appropriate interventions and complicate decisions about fitness for duty in relation to CVD risk.
4. Socioeconomic factors
   Employees may enter the industry with existing CVD risk factors, such as hypertension or poor diet, or develop these during employment, which may not be identified or addressed through standard health screening assessments.

   Together, these challenges highlight the opportunity for a more coordinated, standardised approach across the sector.

Step approach to tackling CVD risk in rail.

Four practical steps are proposed below that could be used to tackle CVD risk more effectively across the rail industry:

1. Improve health screening and promote healthy habits
   Introduce consistent checks for blood pressure, heart health, and QRisk scores across the industry. Data sharing across system health providers (i.e. NHS, consultants, and OH) would support earlier detection and suitable follow-up. Portable health kiosks (e.g., SiSu) can be used to facilitate regular health checks.

   These measures should be complemented by targeted interventions focusing on diet, physical activity, smoking cessation, and stress management to support uptake. These measures should be complemented by targeted interventions focusing on diet, physical activity, smoking cessation, and stress management to support long‑term cardiovascular health.

2. Support high risk ‑risk groups
   Prioritise support for high-risk groups, including senior managers experiencing high levels of stress, BAME employees, and newly appointed shift-based staff, as evidenced in international research. Use demographic segments from RSSB’s Health Insights platform to support categorisation.
3. Review medication use
   Monitor the use of drugs like Ozempic for obesity and diabetes through trusted self-report systems. Combine medication advice with lifestyle advice to support longer term and sustainable impact to avoid over-reliance on these interventions.
4. Collaborate across the industry
   Share data and best practice across the industry. Attend industry discussion forums to explore implications and challenges and share best practice with sector peers and other rail organisations. Additionally, insights and best practice from other sectors and OH can be brought into rail through these forums.

Conclusion

CVD presents a growing challenge for the rail industry, reflecting both broader public health trends and sector-specific risk factors. The benchmarking insights gathered through the RSSB Health Insights platform underscore the opportunity to address CVD through a coordinated, evidence-based workplace health strategy.

Rising referral rates—particularly among senior managers, ethnic minority workers, and younger employees— highlight the complex interplay between lifestyle, psychosocial stressors, and workplace conditions.

Despite the availability of screening tools and emerging pharmacological interventions, the effectiveness of current practices is limited by fragmented data systems, inconsistent referral protocols, and a current lack of long-term outcome tracking.

To respond effectively, the industry could look to strengthen screening frameworks, target high-risk groups with tailored interventions, and promote preventative interventions through integrated behavioural and clinical approaches.

This industry discussion highlighted that a shift in the management of such health conditions from reactive case management to proactive, system-wide prevention and early intervention may be needed. This would help ensure that cardiovascular health along with other common chronic health conditions that affect rail employees become a core component of occupational wellbeing screening, promotion, and interventions in the rail industry.

Read the complete paper here

Niamh McMahon is a Senior Health and Wellbeing Specialist at RSSB. Follow Niamh on  LinkedIn