Equality impact assessment: cardiovascular disease modern service framework

Question 1

Introduction

Accepted Answer

The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard in the need to:

eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act
advance equality of opportunity between people who share a protected characteristic and those who do not
foster good relations between people who share a protected characteristic and those who do not

The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality. However, doing so is an important part of complying with the general equality duty.

Question 2

Summary of the cardiovascular disease modern service framework

Accepted Answer

As set out in the government’s 10 Year Health Plan, modern service frameworks (MSFs) are designed to set out:

the evidence-based actions that the health and care system must take now to improve outcomes in the areas that matter most
clear priorities for innovation to address the most complex and persistent challenges

MSFs bring together existing policy intent, evidence and best practice into a single, coherent framework. They encourage integrated care boards (ICBs), local authorities, providers and clinicians to embed MSF priorities within system planning and strategic commissioning, and during consultations. Strategic commissioning involves planning, purchasing and evaluating health and care services to meet local needs.

This will support more consistent delivery and reduce unwarranted variation across the system. Unwarranted variation is differences in care, access or outcomes that cannot be explained by patients’ needs or preferences.

Cardiovascular disease (CVD) remains one of the leading causes of premature mortality in England. Premature mortality is the number of deaths that happen before the age of 75 years. Heart disease and stroke cause more than 33,000 premature deaths each year. It is a major cause of health inequalities, avoidable pressure on the NHS and significant economic loss. After decades of improvement, progress has stalled in recent years.

Poor cardiovascular health contributes significantly to reduced healthy life expectancy and limits participation in work and the wider economy. Improving cardiovascular health is central to the government’s health mission, with an ambition to reduce premature deaths from heart disease and stroke by 25% within a decade.

The cardiovascular disease modern service framework (CVD MSF) was co‑designed with clinicians, people with lived experience and system partners. It sets out the strategic vision and national framework for how the health and care system should work towards the government’s CVD ambition over the next decade. It establishes ‘what good looks like’ across the CVD pathway by setting national priorities, quality standards and service expectations for:

prevention
early diagnosis
treatment
rehabilitation
long‑term management of CVD

Its objectives are to, across England:

improve outcomes
reduce premature mortality
decrease health inequalities
reduce unwanted variation
support more consistent, evidence-based care

It also sets out the challenge areas where innovation, new approaches and new evidence is needed. This will need to involve the whole of the health and care system, local government, academia, industry and charities working alongside central government.

At the heart of the CVD MSF is a shift away from reactive hospital‑based care towards proactive, holistic cardiovascular-kidney-metabolic (CVKM) prevention and management. This reflects the strong interconnection between cardiovascular, kidney and metabolic diseases, including diabetes and their shared risk factors. Together, they cause avoidable ill health, health inequalities and acute system pressure, requiring a shift to delivery closer to home, particularly through neighbourhood health services.

Scope of the CVD MSF

The CVD MSF is a strategic framework, not a detailed delivery plan. It focuses on areas where:

the health and care system has the strongest evidence of impact on premature mortality
improvement is likely to have the greatest impact

It primarily addresses secondary prevention^{[footnote 1]}, early detection, treatment optimisation, acute care, rehabilitation and longer-term management of CVD and related CVKM conditions.

The CVD MSF does not seek to duplicate or replace wider primary prevention or population‑wide policy interventions addressing broader determinants of health. This is because these sit outside the health and care system and are covered by other government strategies. Nor does the CVD MSF prescribe detailed local delivery models. Instead, it sets national direction and expectations, with implementation locally led by ICBs, local authorities and delivery partners, tailored to population needs.

While the CVD MSF takes a holistic CVKM approach, initial focus for the first 3 years is on implementing 12 priority actions where:

evidence is strongest
there is greatest scope for improvement

It places a strong emphasis on reducing inequalities and tackling unwarranted variation, ensuring that improvements are delivered equitably across the country.

This equality impact assessment (EqIA) supports the development and implementation of the CVD MSF by assessing how the framework may affect people with different protected characteristics. It is an important part of the evidence demonstrating compliance with the Public Sector Equality Duty under the Equality Act 2010. Importantly, it also aims to show how the CVD MSF can contribute to improving outcomes, reducing inequalities and reducing unwanted variation for people across all communities.

Delivering the CVD MSF will be an iterative process, adapting over time as delivery models develop and new evidence and innovation emerges. No single organisation can achieve this ambition alone. Progress depends on co-ordinated action across local health and care systems and communities, with delivery tailored to local circumstances. As a result, the specific equality impacts will depend on how priorities are implemented locally.

The forthcoming delivery plan will include consideration of the specific equality impacts associated with implementation. This includes how different groups may experience and benefit from the CVD MSF priorities, and any additional actions required to support equitable outcomes. This EqIA will be reviewed and updated as delivery plans and implementation arrangements are further developed.

The CVD MSF sets out 7 evidence-based principles of equitable implementation to guide systems in reducing health inequalities. These principles should inform strategic commissioning and service delivery at national, system and neighbourhood^{[footnote 2]} levels to:

allocate resources proportionate to need and roll out services first in areas of greatest need
build long‑term, trusted partnerships with local organisations including local authorities, health and social care teams and voluntary, community and social enterprise (VCSE)^{[footnote 3]} partners at the neighbourhood level
co‑design and culturally adapt services with communities
deliver care through accessible, flexible and trusted routes
provide additional support for underserved communities to access services
use proactive and targeted approaches to reach those missing from services
embed equity‑focused monitoring, evaluation and adoption

Question 3

Intended aims

Accepted Answer

As set out in the health mission, the government has established a clear ambition to reduce premature deaths (under the age of 75) from heart disease and stroke by 25% within a decade. Achieving this aim is central to improving population health, narrowing health inequalities related to ethnicity and age and reducing unwarranted variation across geographies. Given that inequalities are strongly associated with premature cardiovascular mortality, embedding equity throughout policy design and delivery is essential to success.

Consistent with the 10 Year Health Plan, MSFs will identify and prioritise the best‑evidenced interventions that will support progress towards this goal. They focus on those with the greatest opportunity to deliver improvements in value, outcomes and equity. The CVD MSF reflects this approach by concentrating system effort on a defined set of high‑impact actions, where evidence of benefit is strongest, and all of which are associated with significant unwarranted variation.

There remain unacceptable and persistent inequalities across the CVD pathway, including:

risk factor detection and treatment
acute care
long‑term management
rehabilitation

These are compounded by unwarranted clinical variation and differences in access, quality and outcomes between communities. Addressing these issues is fundamental to delivering the government’s ambition and reducing avoidable premature mortality.

In working towards this ambition, the CVD MSF aims to raise overall performance and narrow unwarranted variation, ensuring that system-level action does not inadvertently widen inequalities. Instead, it supports delivery of interventions that reach those at highest risk of premature CVD and those who are currently underserved or disproportionately affected.

Access, experience and outcomes of CVD‑related care are influenced by a range of intersecting factors, including:

age
sex
ethnicity
geography
deprivation
wider social determinants of health

This EqIA considers the potential impact of the CVD MSF. It reflects the 3 Equality Act 2010 duties:

eliminating discrimination
advancing equality of opportunity
fostering good relations between people with and without protected characteristics

Improvements in cardiovascular health are expected to deliver wider societal and economic benefits, including:

reduced sickness absence
improved productivity
increased participation in work

This assessment focuses primarily on the anticipated impacts of the CVD MSF for people with protected characteristics.

The CVD MSF sets out 12 evidence-based priorities that the health and care system should deliver now to accelerate progress towards the ambition to reduce premature mortality by 25% within a decade. These actions are prioritised because:

current performance is inconsistent
too many people are not being reached
evidence shows they offer the greatest opportunity to improve outcomes alongside tackling inequalities

Together, they form the core of system improvement, oversight and accountability.

For each priority, the CVD MSF defines:

clear quality standards
how progress will be measured
expected 3‑year and 10‑year performance ambitions

This provides a consistent national framework for improvement while allowing flexibility for local delivery.

It also sets out a long-term vision for how innovation will transform prevention, diagnosis and treatment. The CVD MSF highlights the critical role of neighbourhood health services in delivering more proactive, population-based care. The government is committed to working with the health and care system, local government, academia, industry and charities to develop new approaches and evidence to address the challenges identified and maximise impact.

The CVD MSF is a national strategic framework, enabled nationally but delivered locally. Its impact will depend on how health and care system partners, predominantly ICBs and local authorities, implement the priorities in ways that reflect local population needs. As a result, this EqIA provides a general assessment of anticipated impacts on equality, recognising that specific effects will depend on local implementation choices, delivery models and population context.

Question 4

Evidence

Accepted Answer

This EqIA is informed by a broad and well‑established evidence base on CVD, its unequal distribution across the population and the interventions most likely to reduce premature mortality, which is a strong indicator of health inequalities. By improving cardiovascular outcomes, we would expect to reduce unwarranted variation.

The main sources of evidence used to develop this assessment include:

national data sources describing inequalities in access, experience and outcomes for CVD in England. These sources provide insight into variation across the CVD pathway by age, sex, ethnicity, deprivation and geography. This includes data from:
relevant national reports and reviews, including the British Heart Foundation’s Bridging Hearts report, the Chief Medical Officer’s annual reports, and findings from the Learning from Lives and Deaths - people with a learning disability and autistic people (LeDeR) programme, which highlight persistent and long‑standing inequalities in cardiovascular risk, care and outcomes
peer‑reviewed academic literature, prioritising high‑quality systematic reviews, meta‑analyses and robust population‑based studies, with a focus on evidence relevant to the English health and care system

In addition to published data and literature, this assessment draws on extensive stakeholder engagement undertaken as part of the development of the CVD MSF. This includes engagement with national clinical experts, professional societies, public health specialists and academics. It also includes charity partners, voluntary and community sector organisations, healthcare commissioners and senior system leaders, alongside patient and public representatives.

Meaningful patient and public voice (PPV) engagement was embedded throughout the development of the framework with a programme of structured face‑to‑face and virtual workshops and discussion sessions. This included dedicated workshops with:

NHS England cardiac and stroke PPV members
PPV representatives from national charity partners within the Health and Wellbeing Alliance (Stroke Association, Kidney Research UK, British Heart Foundation, Heart UK, Diabetes UK)

This enabled individuals with lived experience of CVD and health inequalities to directly contribute.

This engagement contextualised quantitative evidence, surfaced practical barriers and enablers to equitable care, and strengthened understanding of how inequalities in cardiovascular prevention, diagnosis and treatment are experienced in practice. Themes arising from this engagement, and how they have informed the framework, are set out later in this document.

Evidence, prioritisation and equity

Inequalities in CVD outcomes are well researched, long standing and consistently demonstrated in the evidence. Premature mortality and poorer outcomes are strongly associated with factors such as deprivation, geography, ethnicity, sex and multimorbidity (when someone has 2 or more long-term health conditions at the same time).

In line with the 10 Year Health Plan, the CVD MSF adopted a prioritisation‑led approach. It focuses on identifying a defined set of actions where accelerated improvement would have the greatest potential to:

reduce premature mortality
tackle unwarranted variation
improve outcomes
increase equity

The 12 priorities were identified through a combination of:

epidemiological data
modelling
clinical evidence
expert judgement
stakeholder insight

They focus on areas where national and system‑level effort would deliver the greatest benefit for populations at highest risk.

In addition to these priorities, the CVD MSF roadmap includes a wider set of well established, evidence-based interventions that systems are expected to deliver as part of standard practice. These interventions are known to improve cardiovascular outcomes and reduce mortality and inequalities, and their consistent and equitable delivery remains essential to achieving overall impact. The prioritisation process was therefore intended to support acceleration and focus, rather than to imply that non‑prioritised interventions are of lesser value or impact.

This approach focuses the framework on a limited number of actions where there is the strongest evidence of impact on premature mortality and the potential to reduce health inequalities.

Current modelling and evidence support the overall direction of the priorities. However, evidence is not consistently available to quantify the impact of specific interventions by protected characteristic or predicting how local delivery approaches will affect inequalities. This reflects both the limitations in routinely collected data and the fact that delivery decisions are taken locally.

Evidence gaps and ongoing development

There remain known evidence gaps, particularly in relation to:

the differential impact of specific interventions by protected characteristic
the most effective delivery models for reducing inequalities across different local contexts
the interaction between digital, service and workforce innovations and equity

Addressing these gaps will require continued evaluation, improved data collection and disaggregation of data. Disaggregation is reporting by groups such as age, sex, ethnicity or deprivation and area to understand differences. The CVD MSF emphasises equity‑focused monitoring, learning and iteration over time. Ongoing collaboration with organisations such as the National Institute for Health and Care Excellence (NICE), the National Institute for Health and Care Research (NIHR) and academic partners will support the strengthening of the evidence base. This will inform future updates to both the CVD MSF and this EqIA.

Question 5

Analysis of impacts

Accepted Answer

The CVD MSF intends to improve cardiovascular healthcare access, experience and outcomes for all people, regardless of social, demographic or economic characteristics. The following section briefly outlines existing inequalities in CVD for each protected characteristic and assesses the anticipated impact of the CVD MSF on these inequalities. This analysis considers existing evidence of inequalities alongside the CVD MSF’s priorities and standards.

The impacts described below are anticipated at a national level and will depend on how effectively the CVD MSF is implemented locally. This includes the extent to which systems tailor delivery to address known inequalities.

We acknowledge that there is significant interaction between different personal characteristics, which can compound the risk of inequalities (often termed ‘intersectionality’). This includes the characteristics protected under the Equality Act 2010 and analysed below, alongside factors such as deprivation and geography, which are not considered as protected characteristics in the Equality Act 2010.

We recognise that inequalities exist throughout current CVD healthcare, and no single group bears the full weight of these inequalities. The CVD MSF aims to reflect this by presenting overarching standards that clarify ‘what good looks like’ for all people alongside high-impact areas and their current inequalities where the system can improve care delivery and reduce variation. We also present principles of equitable implementation that should be used to guide health systems to tailor implementation to reduce unwarranted variation locally. We underscore the importance of shifting our approach towards ensuring that those experiencing greater inequality receive proportionally more support (‘proportionate universalism’).

We acknowledge that CVD data is not routinely broken down by all protected characteristics, making it challenging to assess the extent of inequalities that are seen in research. In some cases, care is informed by research evidence or demographic data that may lack representativeness or granularity. This can limit how well services consistently reflect the needs of all population groups.

This emphasis on improved data quality and disaggregation is intended to support local systems to identify inequities in delivery and outcomes and to act through local improvement and implementation approaches.

The CVD MSF will call on the health and care system to routinely disaggregate health data to better identify areas of unwarranted clinical variation. This health data will align to the 12 priorities, comparing expected prevalence with actual numbers and those treated to target across protected characteristics and the overall population.

In the sections below, we have noted research detailing cardiovascular inequalities for these characteristics. Data sources such as the CVDPREVENT Audit already provide valuable insight into inequalities across several protected characteristics and geographies, supporting ongoing monitoring of variation in cardiovascular care and outcomes.

However, evidence and data sources are not available consistently across all characteristics and outcome measures, meaning the impact of some CVD MSF priorities may be less certain for particular groups. Through its focus on ambition metrics and reducing unwarranted variation, the CVD MSF aims to improve overall performance while supporting more equitable outcomes across the population.

Scope of assessment and priorities

The EqIA focuses on the priorities in the CVD MSF which are identified for accelerated delivery because of their strong evidence base. These priorities have the greatest potential to:

reduce premature mortality
tackle unwarranted variation
improve equity of outcomes

These priorities also sit alongside a wider roadmap of evidence-based interventions that systems are expected to deliver as standard, as described elsewhere in the CVD MSF.

The priorities assessed in this EqIA reflect the CVD MSF’s emphasis on:

prevention
early detection
optimal management of long‑term conditions
delivery of care closer to home

They encompass action across the CVD pathway, including:

finding the missing millions with undiagnosed or unmanaged CVKM risk factors. This includes behavioural risk factors like smoking, and the ‘ABCDE’ risks: atrial fibrillation, albuminuria, blood pressure, cholesterol, diabetes, excess weight and reduced kidney function (eGFR). Population health tools, neighbourhood outreach and digital case-finding will support earlier detection of risk and diagnose people earlier
driving treatment to target and accelerating optimisation. This includes supporting adherence for high blood pressure, cholesterol, chronic kidney disease, diabetes and heart failure. It targets people at risk of or living with CVD, especially in underserved groups and those at higher risk of premature mortality from heart disease and stroke
ensuring timely, equitable, high quality acute care for stroke and ST-segment elevation myocardial infarction (STEMI), reducing unwarranted variation and delays across pathways
expanding access to rehabilitation, with hybrid and digital models that increase uptake and treatment, adherence and reduce inequalities

The analysis that follows considers the anticipated impact of these priorities on existing inequalities across protected characteristics, recognising the interaction between individual characteristics, deprivation and geography.

The priorities against the CVD pathway are to:

Proactively and systematically identify people who smoke and offer evidence-based smoking cessation and tobacco dependency services for all smokers in your local population.
Systematically identify and stratify individuals with established or emerging CVKM risk factors, using a holistic assessment of atrial fibrillation (AF), albuminuria, blood pressure, cholesterol, diabetes, excess weight (overweight or obesity) and eGFR (ABCDE) approach, and ensure timely linkage into appropriate prevention and treatment pathways.
Improve uptake of sodium-glucose cotransporter 2 (SGLT2) inhibitors for eligible people with heart failure, chronic kidney disease and type 2 diabetes and consider scope to secure financial savings by switching patients to lower cost therapies.
Ensure people with hypertension are treated to evidence-based targets.
Optimise lipid management for people at risk of CVD.
Deliver all of the 9 diabetes care processes (blood glucose, cholesterol and kidney function, blood pressure, urine ACR, feet examination, weight and eyes) to prevent complications and identify deterioration early.
Ensure people living with CVD have their cholesterol and blood pressure (BP) optimally managed to evidence-based targets, with proactive monitoring and escalation where control is not achieved.
Rapidly increase uptake of 4 pillar therapy for eligible people with heart failure with reduced ejection fraction (HFrEF), with early initiation and timely optimisation.
Increase access to specialist and organised stroke care.
Standardising use of multiple therapies for intracerebral haemorrhage (ICH).
Ensure timely access is available to primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI).
Focus on strengthening and scaling cardiovascular rehabilitation to maximise its contribution to reducing premature CVD mortality, improving outcomes and tackling inequalities.

A summary of the full set of priorities and the wider roadmap interventions is provided in the main CVD MSF publication and is not repeated in detail here.

Disability

Disability is a broad term encompassing a wide range of long‑term physical, mental, sensory and cognitive impairments that interact with social and environmental factors. Cardiovascular disease can also be a cause of disability, particularly through conditions such as stroke, which may result in long-term physical, cognitive, communication and psychological impairments (see reference 1).

Because the underlying causes of disability are highly variable, grouping all people with disability to assess CVD inequalities is challenging. This variation reinforces the importance of the CVD MSF’s focus on system‑wide improvement, consistent standards and reduction of unwarranted variation across the CVD pathway, rather than condition‑specific approaches.

High‑quality international evidence indicates that people with disabilities experience substantially higher all‑cause and CVD‑specific mortality than people without disability (see reference 2). However, the extent to which this excess mortality is preventable through specific cardiovascular interventions remains uncertain. These findings underscore the relevance of the CVD MSF’s priorities to raise overall performance. They aim to improve early detection and optimise treatment for cardiovascular risk factors across the population (priorities 2, 4 to 7), while recognising the role of wider determinants of health.

Learning disability, as a specific form of disability, has clearer evidence of cardiovascular inequality. CVD is the leading cause of death among people with a learning disability, accounting for around one‑fifth of deaths each year. This reflects a combination of higher prevalence of modifiable cardiovascular risk factors, including diabetes, obesity and physical inactivity, and increased genetic risk associated with certain conditions, such as Down syndrome.

Available data also indicates variation within cardiovascular risk management for people with a learning disability. People with a learning disability are more likely to have blood pressure managed to target, suggesting uneven application of evidence-based care across different risk factors. These patterns are directly relevant to the CVD MSF’s priorities on:

systematic CVKM risk identification (priority 2)
diabetes care processes (priority 6)
the treatment of blood pressure and cholesterol to target (priority 7)

Although some treatment indicators compare favourably with the general population, people with a learning disability continue to experience poor cardiovascular outcomes. The CVD MSF therefore seeks to promote equitable, evidence-based management across the full cardiovascular risk profile and pathway of care.

In addition, people with learning disabilities may experience barriers to accessing timely diagnosis, consistent monitoring and long‑term management of cardiovascular conditions. Improving equity of access to evidence-based treatment, proactive follow‑up and co-ordinated care aligns with the CVD MSF’s focus on reducing unwarranted clinical variation and improving continuity across primary, community and specialist services (cutting across priorities 2, 6 and 7).

Beyond supporting an overall reduction in unwarranted variation, the CVD MSF is not expected to have a differential impact by disability status through condition‑specific pathways. Rather, the CVD MSF sets clear national standards for prevention, treatment optimisation, acute care and rehabilitation. It also embeds principles of equitable implementation (see the ‘Delivery model’ section in the CVD MSF), supporting systems to design and deliver accessible, flexible and responsive services for people with disabilities, including learning disabilities.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities. There will be a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Sex

The Supreme Court has clarified that the term ‘sex’ in the Equality Act 2010 refers to biological sex, that is, the sex registered at birth.

Men and women experience different and distinct inequalities across the CVD pathway. Although premature mortality rates have declined for both sexes, men continue to experience more than twice the risk of premature CVD mortality compared with women. This disparity is driven in part by higher prevalence of significant risk factors among men, including:

These patterns are directly relevant to the CVD MSF’s priorities on:

smoking cessation (priority 1)
systematic CVKM risk identification (priority 2)
hypertension treatment to target (priority 4)

Evidence suggests men are less likely to engage with primary care services or attend NHS Health Checks, reducing opportunities for early identification and management of cardiovascular risk factors (see reference 3). Addressing this gap aligns with the CVD MSF’s focus on proactive, population‑based and neighbourhood‑level case finding to ‘find the missing millions’ (priority 2).

Women, by contrast, experience different forms of inequality across prevention, treatment and recovery. Compared with men, women are less likely to:

have cholesterol levels optimally reduced (priority 7)
receive certain life‑saving interventions such as cardiac surgery (see reference 4) or coronary stenting following myocardial infarction (see reference 5) (priority 11)
be referred to or take up cardiac rehabilitation following a cardiovascular event (see reference 6) (priority 12)

There are also important sex‑specific risk factors affecting women that are relevant to the CVD MSF’s holistic CVKM approach, including hypertension during pregnancy and increased cardiovascular risk following menopause (see reference 7). These factors reinforce the importance of early and systematic risk identification across the life course (priority 2).

Evidence suggests that bias in clinical decision‑making and differences in symptom presentation may result in women’s cardiovascular risk being underestimated. This can contribute to delays in diagnosis and treatment, particularly in acute settings (see reference 3). This underlines the importance of the CVD MSF’s emphasis on timely, equitable, high quality acute care pathways and consistent access to evidence-based interventions (priorities 9 to 11).

The CVD MSF seeks to address these sex‑based inequalities by raising overall performance while narrowing unwarranted variation. For men, this includes strengthening proactive identification and management of CVKM risk factors through population‑based and neighbourhood delivery models (priorities 1, 2 and 4). For women, it includes improving equitable access to effective treatments and follow‑up care, for example:

addressing lower prescribing rates of evidence-based therapies, including SGLT2 inhibitors for eligible women with diabetes (priority 3)
improving access and uptake of cardiac rehabilitation (priority 12)

The CVD MSF sets clear national standards for prevention, treatment optimisation, acute care and rehabilitation and embeds principles of equitable implementation. This aims to support systems to better understand and address sex-based differences in cardiovascular risk, access and outcomes, and reduce premature mortality for men and women.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Sexual orientation

There is evidence that people from sexual minority groups (including lesbian, gay, bisexual (LGB) and other sexual orientations) experience an increased risk of CVD (see reference 8). This increased risk appears to be driven by higher prevalence of certain modifiable risk factors - particularly smoking (see reference 9) - as well as the cumulative effects of prolonged psychological stress and poorer mental health (see reference 10). These factors are relevant to the CVD MSF’s priorities on smoking cessation (priority 1) and systematic CVKM risk identification and prevention (priority 2).

Data between 2011 and 2018 from the 2021 Health Survey for England indicates that rates of high blood pressure, raised cholesterol, diabetes and obesity among LGB men and women are similar or lower to those observed in heterosexual populations. However, smoking prevalence is notably higher among LGB women (see reference 11), reinforcing the importance of targeted and accessible smoking cessation support as part of the CVD MSF’s population‑wide prevention approach (priority 1).

Beyond these risk factor differences, the relationship between sexual orientation and cardiovascular outcomes is less well understood, and routinely collected cardiovascular data is not consistently disaggregated (separated out) by sexual orientation. As a result, evidence on differences in access to, experience of, or outcomes from CVD care by sexual orientation remains limited.

The CVD MSF is therefore not anticipated to differentially impact people based on sexual orientation through distinct condition‑specific pathways. Rather, it seeks to reduce unwarranted clinical variation and improve equity overall by raising performance across prevention, early detection and treatment for all populations.

The CVD MSF emphasises proactive case finding, equitable access to prevention and treatment, and delivery through accessible, trusted routes. This supports improved engagement for groups facing barriers to care or higher exposure to risk factors, including sexual minority populations. Trusted routes may include primary care and community pharmacy, neighbourhood health and integrated neighbourhood teams. They also include VCSE and community‑based organisations, social prescribing services, and partnerships with charities and community groups with established relationships with local populations (priorities 1 and 2, supported by the principles of equitable implementation).

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Race

The relationship between ethnicity and CVD is complex and closely linked to deprivation. Socioeconomic deprivation is a strong determinant of CVD risk and outcomes, and it disproportionately affects people from ethnic minority backgrounds. For example, a substantially higher proportion of Pakistani, Bangladeshi and Black African people live in the most deprived areas compared with White British people. This reinforces the importance of the CVD MSF’s focus on proportionate universalism, proactive case finding and prioritising action in areas of greatest need through population‑based and neighbourhood delivery models (priority 2, supported by the principles of equitable implementation).

Regardless of these data challenges, mortality from CVD conditions varies by ethnicity. Bangladeshi, Pakistani and Indian populations experience higher mortality from ischaemic heart disease and hypertensive disorders, which together account for a substantial proportion of premature CVD deaths. By contrast, White British and White Other populations have the highest mortality rates related to atrial fibrillation, while Bangladeshi populations experience particularly high mortality from stroke. These patterns span prevention, acute care and recovery pathways, underscoring the relevance of CVD MSF priorities across risk factor management, acute care standardisation and rehabilitation (priorities 2, 4 to 7 and 9 to 11).

Differences in CVD outcomes by ethnicity are likely to reflect a combination of factors, including variation in risk factor prevalence such as smoking, obesity, physical activity and the age profile of sub-groups. They also reflect differences in:

effectiveness of risk factor management, including cholesterol and blood pressure control
variation in how risk factors affect different ethnic groups, for example, obesity (see reference 12)
differences in access to or experience of acute and long‑term CVD care (see reference 3)

Wider influences - including culture, health literacy, language barriers, local access to services and racial bias (see reference 3) - also contribute to inequitable outcomes. Addressing these factors aligns with the CVD MSF’s treatment‑to‑target priorities and its commitment to reducing unwarranted variation (priorities 4 to 7).

Assessment of ethnic inequalities is further constrained by incomplete and inconsistent ethnicity recording in routine data, which limits understanding of variation in access, experience and outcomes. Improving identification of unmet need through systematic risk assessment and better use of routinely collected data aligns with the CVD MSF to strengthen population health intelligence and comprehensive CVKM risk identification (priority 2).

The CVD MSF highlights ethnic inequalities in access to and uptake of evidence-based interventions, including lower uptake of cardiac rehabilitation (priority 12). It also identified variation in prescribing of heart failure and other cardiovascular-kidney-metabolic therapies (priorities 3, 7 and 8).

To support progress, the CVD MSF emphasises the importance of disaggregating local data by ethnicity where possible and applying the principles of equitable implementation (see the ‘Delivery model’ section in the CVD MSF) to tailor delivery. This includes culturally adapting services, widening health communications and using trusted and accessible routes to care to minimise language barriers, strengthen trust and improve engagement across diverse communities.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Age

The primary outcome of the CVD MSF is to reduce premature mortality (deaths under 75 years) from heart disease and stroke by 25% over 10 years. However, the CVD MSF is not focused solely on people aged under 75. Its priorities and delivery expectations apply across the CVD pathway for all age groups, recognising the substantial proportion of CVD burden, including morbidity, mortality and disability, occurs in older adults. Although premature mortality is the headline outcome measure, the framework aims to improve prevention, diagnosis, treatment, rehabilitation and quality of care across the whole population. The performance metrics set out in the CVD MSF are therefore largely age-agnostic, reflecting an expectation that benefits will be realised across all age groups.

Older age is the strongest risk factor for developing CVD, and prevalence increases markedly from midlife onwards. A 2024 UK study showed the median age of CVD incidence diagnosis generally between 65 and 80 years (see reference 13). This reflects both the accumulation of cardiovascular risk factors over time including higher blood pressure, raised cholesterol and increasing prevalence of atrial fibrillation. It also reflects age‑related biological changes such as arterial stiffening and atherosclerosis. These patterns underscore the importance of the CVD MSF’s focus on systematic CVKM risk identification (priority 2) and treatment optimisation across the life course, including blood pressure and lipid management to target (priorities 4, 5 and 7).

At the same time, important age‑related inequalities affect younger adults. Evidence shows that younger age groups are:

Eligible younger adults are also less likely to attend NHS Health Checks (see reference 14), reducing opportunities for early detection and prevention of long‑term cardiovascular risk. Addressing these patterns aligns strongly with the CVD MSF’s priorities to find the missing millions through preventive action, smoking cessation and proactive risk factor identification (priorities 1, 2, 4 and 5).

For younger adults, the CVD MSF seeks to improve outcomes by increasing rates of cardiovascular risk case finding and ensuring timely, evidence-based treatment once risk factors are identified (priorities 1, 2, 4 and 5). For older adults, improving outcomes depends on reducing unwarranted variation in acute clinical management. It also requires ensuring equitable access to effective rehabilitation and recovery support, particularly following heart attack or stroke (priorities 9 to 11 and 12).

The CVD MSF applies clear national standards across prevention, treatment optimisation, acute care and rehabilitation. It supports delivery of age‑appropriate, equitable care throughout the life course, contributing to reduced premature mortality while improving quality of life and outcomes for people of all ages.

We will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Gender reassignment (including transgender)

Research suggests that transgender people may face an increased risk of CVD, including heart attack and stroke. Transgender men are reported to have a higher risk of both stroke and myocardial infarction (heart attack) compared with cisgender women. Transgender women are reported to have a higher risk of stroke compared with cisgender men (see reference 15), with similar rates of myocardial infarction. The reasons for these observed differences are not fully understood but are likely to reflect a complex interaction of biological, behavioural and social factors.

Potential contributors include the cardiovascular effects of hormone therapy, particularly oestrogen therapy in transgender women (see reference 16). They also include higher exposure to psychosocial stress, stigma (see reference 17) and discrimination, and increased prevalence of certain health behaviours such as smoking, alcohol use and substance misuse (see reference 18). These factors align with the CVD MSF’s priorities on smoking cessation (priority 1) and systematic CVKM risk identification and management (priority 2), which are designed to identify and address cardiovascular risk factors across the population.

Wider social and economic factors, including higher rates of unemployment, housing insecurity and barriers to accessing health services, may also influence cardiovascular risk and engagement with care among transgender people (see references 19 and 20). The CVD MSF’s emphasis on delivering care through accessible, flexible and trusted routes, supported by the principles of equitable implementation (see the ‘Delivery model’ section in the CVD MSF) will help to address health access barriers for all population groups.

Beyond these considerations, the relationship between gender reassignment and cardiovascular outcomes remains uncertain, and routine data on CVD access, experience and outcomes are rarely disaggregated by gender identity. Consequently, evidence on variation in cardiovascular care pathways for transgender people is limited.

The CVD MSF is therefore not anticipated to have a differential impact based on gender reassignment through distinct or separate clinical pathways. The CVD MSF sets clear national standards, improving proactive identification and management of modifiable risk factors. It also reduces unwarranted clinical variation across prevention, treatment, acute care and rehabilitation. This supports more equitable cardiovascular care for all populations, including transgender people (priorities 1, 2 and cross‑cutting system improvement).

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Religion or belief

Routine data on access to CVD services, experience and outcomes in England is not consistently collected or reported by religion or belief, limiting the ability to assess variation across the CVD pathway on this basis.

Available evidence suggests some differences in the prevalence of cardiovascular risk factors by religion or belief. In particular, smoking prevalence is higher among people who identify with no religion compared with several religious groups. Addressing smoking as a modifiable risk factor is central to the CVD MSF’s priorities on smoking cessation (priority 1). It also underpins systematic CVKM risk identification and prevention (priority 2), reducing population‑level cardiovascular risk and narrow unwarranted variation.

Beyond differences in individual risk factors, the relationship between religion or belief and cardiovascular outcomes remains uncertain. There is limited evidence to indicate consistent differences in access to, experience of, or outcomes from CVD care attributable specifically to religion or belief.

The CVD MSF is therefore not anticipated to have a differential impact based on religion or belief through distinct clinical pathways. Rather, the CVD MSF supports:

improving overall performance
reducing unwarranted clinical variation
ensuring equitable access to prevention, treatment, acute care and rehabilitation

This supports more consistent cardiovascular care for all populations. Its emphasis on delivery through accessible, flexible and trusted routes is supported by the principles of equitable implementation (see the ‘Delivery model’ section in the CVD MSF). It also enables local systems to respond to the needs of different communities where religion or belief may influence engagement with health services.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Pregnancy and maternity

CVD generally affects women later in life, typically after reproductive age. However, cardiac disease remains an important, though rare, cause of maternal mortality and is currently the second most common cause of maternal death in the UK, following thromboembolic disease (see reference 21). While the absolute number of cardiac deaths during pregnancy is low, these events are of high clinical significance because they reflect severe cardiovascular pathology and important implications for cardiovascular risk across the wider population of women.

Certain pregnancy‑related complications are associated with a substantially increased risk of CVD later in life. Evidence shows that women who experience pre‑eclampsia have a significantly higher risk of subsequent cardiovascular events and a markedly increased likelihood of developing hypertension in the years following pregnancy (see reference 22). Similarly, gestational hypertension and gestational diabetes are associated with elevated long‑term cardiovascular risk (see reference 23 and 24). These findings highlight pregnancy as an important period when risks are revealed, rather than a direct focus of CVD MSF delivery.

Although maternity services and acute obstetric care sit outside the direct scope of the CVD MSF, these life‑course risks reinforce the importance of the CVD MSF’s priorities on systematic CVKM risk identification (priority 2). They also highlight the need for long‑term management of blood pressure, lipids and diabetes to evidence-based targets (priorities 4, 5 and 6). Ensuring that a history of pregnancy‑related complications is recognised, coded and acted upon in primary and community care supports earlier identification of women at increased cardiovascular risk.

The CVD MSF strengthens proactive case finding, recall and follow‑up, and optimises treatment once risk factors are identified. This supports improved cardiovascular prevention and management for women with pregnancy‑related risk factors across the life course. In this way, while the CVD MSF does not directly target maternity care, it contributes to reducing later cardiovascular morbidity and premature mortality through earlier detection, prevention and treatment optimisation.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Marriage and civil partnership

Routine data on CVD access, experience and outcomes in England is not consistently collected or reported by marital or civil partnership status. This limits the ability to assess variation across the CVD pathway on this basis.

However, evidence from a large systematic review and meta‑analysis indicates that people who are unmarried - including those who have never married, are divorced or are widowed - have higher odds of developing CVD or dying from coronary heart disease or stroke compared with married individuals. The analysis did not identify substantial differences in this association between men and women. The mechanisms underlying this relationship are not fully understood, but may include the following (see reference 25):

earlier presentation to health services
greater household resources
healthier behaviours
improved adherence to prescribed medications among married individuals

However, the findings reinforce the CVD MSF’s emphasis on proactive identification and management of cardiovascular risk factors through population‑based approaches, regardless of social circumstance, in particular the CVD MSF’s priorities on:

systematic CVKM risk identification (priority 2)
smoking cessation (priority 1)
treatment to target for modifiable risk factors such as blood pressure, cholesterol and diabetes (priorities 4 to 7)

These aim to ensure consistent, equitable access to prevention and treatment across the population.

Beyond differences in overall risk, the relationship between marital or civil partnership status and access to, experience of or outcomes from CVD care remains uncertain. Consequently, the CVD MSF is not anticipated to have a differential impact based on marital or civil partnership status through distinct clinical pathways. Rather, the CVD MSF supports improved cardiovascular outcomes for all individuals, regardless of marital or partnership status, by:

reducing unwarranted clinical variation
strengthening prevention and early diagnosis
improving consistency of treatment and follow‑up

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Geography

There is substantial geographic variation in premature mortality due to CVD in England. A long‑standing north-south gradient exists, with higher premature mortality rates in northern regions compared with southern regions. For example, premature deaths from stroke and ischaemic heart disease are considerably higher in the North East, Yorkshire and the North West than in the South East. This geographic pattern is strongly associated with differences in socioeconomic deprivation and a higher prevalence of major cardiovascular risk factors, including smoking, hypertension and obesity (see reference 26).

These patterns underline the importance of the CVD MSF’s focus on proportionate universalism and prioritising action in areas of greatest need, in particular the CVD MSF’s priorities on:

smoking cessation (priority 1)
systematic CVKM risk identification (priority 2)
treatment of blood pressure, cholesterol and diabetes to evidence-based targets (priorities 4 to 7)

These are central to addressing the drivers of geographic inequalities in premature CVD mortality.

While the north-south gradient remains an important feature of cardiovascular inequality, significant variation also exists at more granular geographic levels. Within regions, integrated care systems, places and neighbourhoods across the country, there are marked differences in CVD outcomes, access to services and quality of care. This reinforces the need for local systems to identify and tackle unwarranted variation within their own footprints, consistent with the CVD MSF’s nationally enabled but locally led approach.

The CVD MSF supports reduction of geographic inequalities through its performance and accountability framework, including embedding equity measures alongside the metrics for each priority. These measures are intended to support health systems to understand geographic variation, identify outliers and monitor differences in performance across local providers and places. Alongside an expected overall improvement in performance, the CVD MSF signals the importance of narrowing the variation gap between the highest and lowest performing services within an area.

An improving average level of performance accompanied by a widening variation gap may indicate that resources and interventions are not being deployed equitably. In such circumstances, the CVD MSF supports systems to review how preventive, diagnostic, treatment and rehabilitation activity can be more effectively targeted to reduce geographic inequalities. This includes priorities across prevention, acute care and rehabilitation (priorities 1 to 12). This approach aligns with the CVD MSF’s principles of equitable implementation (see the ‘Delivery model’ section in the CVD MSF) and its emphasis on using data to guide proportionate action at system, place and neighbourhood level.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Deprivation

Deprivation refers to unmet needs and reduced access to opportunities and resources that are necessary for good health and wellbeing. While often conflated with poverty, deprivation is broader and encompasses multiple dimensions that influence health. In England, deprivation is commonly measured using the Index of Multiple Deprivation (IMD), which incorporates 7 domains:

income
employment
education, skills and training
health and disability
crime
barriers to housing and services
the living environment

CVD outcomes are frequently analysed by IMD, enabling robust assessment of the relationship between deprivation and cardiovascular health.

Deprivation is one of the strongest predictors of poor cardiovascular outcomes. People living in the most deprived areas experience substantially higher rates of heart and circulatory conditions, more complications, poorer survival (see reference 3), and markedly higher premature mortality. The rate of premature CVD deaths in the most deprived decile is more than double that observed in the least deprived areas. This gradient is largely driven by higher prevalence of modifiable risk factors such as:

Addressing these factors is central to the CVD MSF’s priorities on:

smoking cessation (priority 1)
systematic CVKM risk identification (priority 2)
treatment of blood pressure, cholesterol and diabetes to evidence-based targets (priorities 4 to 7)

Deprivation also amplifies cardiovascular risk through additional compounding factors. These include lower health literacy, language barriers, reduced access to services and higher prevalence of multiple long‑term conditions (see references 27 and 3). These factors can affect engagement with prevention programmes, continuity of care and adherence to treatment, reinforcing the need for proactive, population‑based approaches and consistent follow‑up. This aligns with the CVD MSF’s emphasis on ‘finding the missing millions’, improving treatment optimisation and reducing unwarranted variation through systematic approaches (priorities 2, 4, 5, 6 and 7).

People from ethnic minority backgrounds are disproportionately likely to live in more deprived areas, meaning that deprivation further compounds existing inequalities in cardiovascular risk and outcomes. While deprivation and ethnicity are distinct determinants, their interaction reinforces the importance of targeting resources and interventions to areas of greatest need using a proportionate universalist approach.

The CVD MSF addresses deprivation‑related inequalities through its focus on population‑level prevention, neighbourhood‑based delivery, and equitable allocation of effort across systems. The CVD MSF includes equity metrics designed to expose and reduce unwarranted geographical variation for each priority action. These metrics, applied with the 7 principles for equitable implementation, aim to reduce inequalities when designing and delivering local care (see the ‘Delivery model’ section in the CVD MSF). This supports systems to direct resources where need is greatest and narrow unjustified gaps in outcomes between the most and least deprived communities.

As part of the CVD MSF and implementation of the delivery plan, we will continue to monitor the variation gap in implementation and outcomes across different populations and communities, with a particular focus on narrowing unjustified gaps and reducing cardiovascular health inequalities over time.

Other identified groups

We know that a number of population groups experience particularly severe inequalities in CVD access, experience and outcomes. These groups often face multiple, overlapping risk factors, barriers to care and wider social disadvantage. While not exhaustive, they include the following groups.

People with serious mental illness (SMI)

People living with SMI experience higher premature mortality from CVD compared with the general population. This disparity reflects higher prevalence of modifiable risk factors such as smoking, obesity, diabetes, physical inactivity, substance misuse and poor diet. It also reflects wider determinants such as the effects of deprivation, chronic stress, unemployment, poor housing and reduced social networks.

Addressing these factors aligns with the CVD MSF’s priorities on smoking cessation (priority 1) and systematic CVKM risk identification (priority 2). It also includes treatment of blood pressure, cholesterol and diabetes to evidence-based targets (priorities 4 to 7), and improving continuity and co-ordination of care for people with multimorbidity.

People in prison or on probation

CVD is among the leading causes of death in people in contact with the criminal justice system. Evidence suggests that individuals in prison experience cardiovascular risk substantially earlier than the general population (see reference 28). This reflects a high prevalence of risk factors combined with deprivation, unstable access to care and disrupted continuity of treatment.

These patterns reinforce the importance of proactive case finding (priority 2) and early risk factor management (priorities 4 to 7). It also highlights the need for effective follow‑up and continuity across settings, reducing unwarranted variation for people who move between services.

People who are homeless or rough sleeping

People experiencing homelessness have higher CVD morbidity and mortality compared with the general population (see reference 29), experience cardiovascular events at younger ages, and have poorer outcomes following acute events (see reference 30). Barriers include poor access to preventive services, late presentation, multimorbidity and challenges with follow‑up and adherence to treatment.

These inequalities are directly relevant to the CVD MSF’s focus on ‘finding the missing millions’ (priority 2) and addressing modifiable risk factors (priorities 1 and 4 to 7) through flexible, outreach‑based and trusted delivery models.

People living in coastal communities

People living in coastal areas experience higher rates of coronary heart disease, stroke and transient ischaemic attack than would be expected for populations of similar age and deprivation. This suggests that geographic isolation, access to services, workforce challenges and socioeconomic factors may compound cardiovascular risk.

Addressing these patterns aligns with the CVD MSF’s priorities on population‑based prevention (priorities 1 and 2), treatment optimisation (priorities 4 to 7) and reducing geographic variation in acute care and rehabilitation access (priorities 9 to 12).

Summary of CVD MSF’s anticipated impacts across protected characteristics

The CVD MSF encourages local health systems to robustly and inclusively consider the needs of these and other populations, in line with the CORE20PLUS5 approach and the principles of equitable implementation. The degree to which systems focus on any one group should be guided by local levels of unmet need, risk and inequity, using data to support, rather than one‑size‑fits‑all delivery.

Table 1 summarises the anticipated impacts of the CVD MSF across protected characteristics, structured around the 12 priorities that form the core of the framework’s delivery and accountability model.

Impacts may be direct (direct), indirect through system-wide improvement (indirect), or where no differential impact is anticipated (no differential impact).

Table 1: anticipated impact of the CVD MSF’s 12 priorities across protected characteristics

Protected characteristic and subgroup	1: smoking	2: CVKM risk ID	3: SGLT2i	4: hypertension	5: lipids	6: diabetes processes	7: secondary prevention	8: HF therapy	9: stroke care	10: ICH	11: pPCI	12: rehabilitation
Age (children and young people)	direct	direct	indirect	direct	direct	direct	direct	indirect	indirect	indirect	indirect	direct
Age (working-age adults)	direct	direct	direct	direct	direct	direct	direct	direct	indirect	indirect	indirect	direct
Age (older people)	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct
Sex (female)	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct
Sex (male)	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct
Disability - learning disability	direct	direct	indirect	direct	direct	direct	direct	direct	indirect	indirect	indirect	direct
Disability - physical and/or sensory	direct	direct	indirect	direct	direct	direct	direct	direct	indirect	indirect	indirect	direct
Ethnicity (minoritised ethnic groups)	direct	direct	direct	direct	direct	direct	direct	direct	direct	indirect	indirect	direct
Religion or belief	indirect	direct	indirect	direct	direct	direct	direct	indirect	indirect	indirect	indirect	indirect
Sexual orientation	indirect	direct	indirect	direct	direct	direct	direct	indirect	indirect	indirect	indirect	indirect
Gender reassignment	indirect	direct	indirect	direct	direct	direct	direct	indirect	indirect	indirect	indirect	indirect
Pregnancy and maternity	direct	direct	indirect	direct	direct	direct	direct	indirect	indirect	indirect	indirect	direct
Marriage or civil partnership	no differential impact	no differential impact	no differential impact	no differential impact	no differential impact	no differential impact	no differential impact	no differential impact	- no differential impact	no differential impact	no differential impact	no differential impact
Socioeconomic deprivation (see note)	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct
Geography (coastal, rural, urban)(see note)	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct	direct

Note: deprivation and geography are not protected characteristics under the Equality Act 2010 but are included due to their strong interaction with protected characteristics (intersectionality) and CVD inequality.

Question 6

Engagement and involvement

Accepted Answer

This section summarises how stakeholders, including people with lived experience, clinicians and system partners, were engaged in the development of the CVD MSF. It explains how their insights informed the strategic direction, priorities and principles set out in the framework.

Development of the CVD MSF was underpinned by extensive and structured engagement, led by national clinical leadership through the CVD MSF task and finish group. This group was chaired by the CVD MSF co-chairs Dr Jessica Randall-Carrick and Sir Andrew F Goddard. It brought together a broad range of expertise, including representatives from:

national cardiovascular, diabetes and renal charities
academia
think tanks
public health
local government
relevant royal colleges and professional bodies

The task and finish group provided oversight of the evidence base and tested emerging proposals. The group also helped prioritise interventions with the greatest potential to reduce premature mortality, improve value and narrow inequalities.

Engagement also extended beyond national clinical leadership to include system‑level perspectives, with input from ICB strategy leaders through the NHS Confederation. This helped test the feasibility, relevance and implementation implications of emerging priorities within different health and care system contexts.

Alongside clinical and system engagement, there was extensive patient and public involvement (PPI) throughout development of the framework. This included engagement through NHS England patient panels, dedicated PPV workshops. It also included structured input from major and smaller voluntary and community sector organisations, including through NHS England’s Health and Wellbeing Alliance. These forums provided insight into lived experience across the CVD pathway, including barriers to prevention, diagnosis, treatment, rehabilitation and long‑term support, particularly for groups experiencing poorer outcomes.

Taken together, this engagement generated a strong and diverse body of qualitative insight, reflecting a wide range of communities, protected characteristics and intersecting needs. Engagement insights were fed directly into the policy development process, supporting prioritisation decisions and shaping the CVD MSF’s focus on prevention and early detection and treatment optimisation. They also informed the CVD MSF’s focus on improving timely, equitable, high quality acute care, expanded access to rehabilitation and the principles of equitable implementation set out in the strategy (including proportionate universalism and CORE20PLUS5).

Evidence and testing

Insights from engagement with clinicians, people with lived experience, voluntary and community sector partners, and system leaders were used to test evidence, challenge assumptions and inform prioritisation of the interventions considered in the CVD MSF. Consistent themes emerged across engagement activity, reflecting shared priorities for how the health and care system should address CVD, reduce inequalities and improve outcomes. These themes, and how they are reflected in the CVD MSF, are summarised below.

Addressing inequalities is central to improvement

Stakeholders consistently highlighted persistent geographic, socioeconomic, cultural and system‑generated inequalities across the CVD pathway. These included:

postcode variation
the north-south gradient
rural-urban differences
barriers faced by inclusion health groups

There was strong consensus that these inequalities must be addressed explicitly across prevention, diagnosis, treatment, rehabilitation and follow‑up.

Engagement emphasised the importance of proportionate universalism, equity‑sensitive metrics and data‑driven targeting of effort toward populations at highest risk. This is reflected in the CVD MSF’s focus on narrowing unwarranted variation, prioritising action in areas of greatest need and embedding the principles of equitable implementation and CORE20PLUS5 throughout the framework.

Whole‑pathway, life‑course, person‑centred care

There was strong support for a joined‑up, whole‑pathway approach spanning prevention, early detection, treatment optimisation, rehabilitation and long‑term follow‑up, aligned with NICE guidance and national priorities. Stakeholders emphasised the need for holistic, person‑centred care, positive post‑event messaging and the consistent use of clear, inclusive language.

These views are reflected in the CVD MSF’s adoption of a CVKM, life‑course approach, integrating prevention, early diagnosis, treatment to target and rehabilitation. The framework places emphasis on shared decision‑making, recognition of social risk, lived experience and consistent post‑event support, aligned with national clinical guidance and best evidence.

Prevention and early detection as system priorities

Engagement demonstrated strong support for proactive and early prevention across the life course. Stakeholders highlighted the importance of:

improved recall systems
consistent cardiovascular risk assessment
appropriate use of cascade and genetic testing where evidence supports the benefit

Current arrangements were widely viewed as fragmented, variable and insufficiently systematic.

The CVD MSF reflects this feedback by prioritising population‑based case finding and proactive risk identification. It sets clearer expectations around minimum standards for detection, follow‑up and treatment optimisation, particularly for groups at highest risk of premature disease.

Consistency, minimum standards and joined‑up care

A recurring concern across engagement was variation in access to diagnostics, medicines, rehabilitation, psychological support and follow‑up care. Fragmented pathways, weak information sharing and unclear accountability were seen as undermining outcomes and widening inequalities.

These insights informed the CVD MSF’s emphasis on clear quality standards, simplified and more consistent pathways. They also support improved continuity across primary, community and specialist care, and stronger use of national audits and performance metrics to reduce unwarranted variation.

Digital, data and innovation as enablers - by design, not default

Stakeholders identified the following as critical enablers of improved consistency and productivity:

digital tools
interoperable patient records
data‑driven risk stratification
innovation (including genomics and new therapeutics)

However, there was strong agreement that digital approaches must be inclusive, with appropriate safeguards and non‑digital alternatives to avoid widening inequalities.

This is reflected in the CVD MSF’s digital vision, which positions technology, data and innovation as enablers of better care. The CVD MSF also recognises the need for inclusive design and supporting access through trusted, flexible routes.

Culture, communication and trust

Clear, plain‑English communication, culturally competent and tailored support, and trust‑building approaches were consistently highlighted as essential. Patients emphasised the value of:

written summaries
reliable follow‑up
respectful interactions
meaningful involvement in service design, particularly where past experiences had led to mistrust or disengagement

These themes reinforce the CVD MSF’s focus on person‑centred care, culturally adapted services and delivery through accessible and trusted routes, as set out in the principles of equitable implementation.

Rehabilitation, mental health and recovery

Engagement highlighted rehabilitation as a high‑value but uneven component of care, with variation in eligibility, duration and access, particularly following stroke. Psychological impacts such as anxiety, depression and fatigue were commonly reported, alongside gaps in mental health and vocational support following discharge.

These insights informed the CVD MSF’s prioritisation of expanded and more equitable access to rehabilitation. It emphasises consistency, flexible delivery models and stronger links between acute care, rehabilitation and longer‑term support.

System enablers for delivery at scale

Stakeholders consistently identified enabling factors for delivery at scale, including:

workforce capacity
clinical networks
interoperable data
implementation support

Flexible, regionally responsive delivery models, co‑designed with patients and communities, were seen as essential to translating national ambition into local, equitable impact.

This feedback aligns with the CVD MSF’s recognition that delivery is nationally enabled but locally led, requiring co-ordinated system action rather than prescriptive local models.

Innovation with safeguards

There was strong support for innovation across digital tools, diagnostics, genomics, medicines and redesigned care models. Stakeholders expected innovation should be evidence-based, equity‑assessed and introduced with safeguards to avoid widening disparities.

The CVD MSF reflects this by signalling priority challenge areas for innovation while emphasising the role of evaluation, regulation and partnership to ensure benefits are realised equitably.

Workforce, system capability and implementation

Engagement reinforced the central role of workforce capacity, clinical leadership, consistent implementation and, where relevant, 24/7 service availability in improving cardiovascular outcomes. ICBs highlighted the importance of flexible, locally tailored approaches informed by regional inequalities and service constraints.

These insights underpin the CVD MSF’s emphasis on system capability, clinical networks and shared accountability for improvement.

Across all engagement activity, there was a strong commitment to embedding lived experience, recognition of social context and culturally competent approaches throughout design and delivery. Stakeholders consistently emphasised that ‘one‑size‑fits‑all’ models are unlikely to address entrenched inequalities.

This perspective is reflected throughout the CVD MSF’s design, including its CVKM approach, equity principles and emphasis on co‑design and proportionate universalism.

See the technical annex for stakeholder‑specific engagement insights.

Shaping policy or proposal

We undertook extensive, structured stakeholder engagement throughout development of the CVD MSF. This ensured patient voice, lived experience, system insight and charity expertise shaped the emerging proposals. Engagement took place through:

national patient forums
dedicated PPV workshops
ICB engagement leads
Health and Wellbeing Alliance
major cardiovascular charities

Alignment of the priorities with the engagement findings to shape the CVD MSF is detailed below.