Embedded Bulletin | Edition 26 – CVD is back, but delivery is still the test
The new CVD Modern Service Framework is probably one of the most important NHS policy publications for some time. Not because it says cardiovascular disease matters. We knew that. Not because prevention is suddenly a good idea. It always was. It matters because it pulls cardiovascular, kidney and metabolic disease into one national frame and makes prevention, earlier diagnosis and neighbourhood delivery central to the next phase.
The problem is the operating model.
The NHS can now describe the population it needs to find, the risks it needs to manage and the outcomes it wants to improve. What is much less clear is who will do the work, how it will be funded, where it will happen and how much more General Practice is expected to absorb.
The lead issue – the CVD framework is strong, but funding will decide whether it happens
The Government's new Cardiovascular Disease Modern Service Framework sets a clear ambition to reduce premature mortality from heart disease and stroke by 25% within ten years. It also says the system needs to find the “missing millions” who do not yet know they are at risk, shift care closer to home, prioritise prevention and early diagnosis, and deliver joined-up cardiovascular, kidney and metabolic care.
That is the right ambition.
CVD is one of the few areas where the NHS can make a serious argument that better prevention, diagnosis and optimisation could reduce future acute demand. Blood pressure, cholesterol, diabetes, chronic kidney disease, obesity, atrial fibrillation and smoking do not sit neatly in separate boxes in real life. They cluster in the same patients, in the same communities and often in the same practices.
The framework recognises that. It moves away from a narrow cardiac view and toward a broader cardiovascular kidney metabolic model. The old single condition way of working does not match how risk actually behaves in patients.
The strongest part of the framework is that it does not stop at general prevention language. It identifies a more practical set of priorities – finding undiagnosed or unmanaged risk, starting and optimising treatment, improving acute care for stroke and STEMI and expanding rehabilitation. It also names the ABCDE risks: atrial fibrillation, albuminuria, blood pressure, cholesterol, diabetes, excess weight and kidney function.
That gives local systems a much clearer starting point, but this is where the hard bit begins.
Finding the missing millions is politically attractive. It sounds proactive, modern and population health led. The danger is systems become very good at creating new registers of risk and less good at funding the work that follows.
Diagnosis is not the outcome. A patient with newly identified hypertension still needs treatment initiation, monitoring, titration, adherence support and follow-up. A patient with raised cholesterol still needs a conversation, prescribing, optimisation and review. A patient with albuminuria or CKD risk still needs coding, medicines optimisation, renal aware monitoring and escalation rules. A patient with suspected heart failure still needs access to diagnostics, interpretation, treatment and ongoing support.
None of that happens by magic.
Most of it lands in or around primary care, community pharmacy, community diagnostics, specialist advice, neighbourhood teams and acute networks. That means the delivery model matters just as much as the framework.
The framework says further implementation information will be published later this year to help local systems prioritise existing resource. That phrase is doing a lot of work.
If “existing resource” means genuinely redesigning pathways, reducing duplication, using pharmacy properly, building diagnostic capacity and supporting primary care with funded models, then there is a real opportunity, but if it means asking practices to find, code, recall, monitor and optimise more patients without additional capacity, then we know how this ends.
The practical test is simple. If a GP practice is being asked to do more cardiovascular prevention work, where is the funded service specification? Where is the pharmacist support? Where is the diagnostic route? Where is the community pathway? Where is the data support? Where is the accountability when a patient needs escalation? Where is the time?
That is the bit I would watch most closely.
The framework is a strong case for change, but the NHS is not short of cases for change. It is short of delivery models that survive contact with workload, workforce and finance.
For pharma, medtech and diagnostics companies, this is highly significant. It creates a national policy basis for hypertension, hypercholesterolaemia, diabetes, CKD, heart failure, atrial fibrillation, remote monitoring, ambulatory diagnostics, stroke prevention and rehabilitation, but nobody should assume this means easy adoption.
The companies that make progress will be the ones that help systems answer the practical questions; which population, which pathway, which provider, which funding route, which workforce, which metric and which implementation support?
A product aligned to one of the framework priorities is not enough. The real opportunity is to help local systems make the framework deliverable.
What to watch
- Whether the delivery plan brings new money or mainly asks systems to reprioritise existing resource.
- Whether ICBs commission CVD prevention as a proper neighbourhood service or leave it as extra practice workload.
- Whether local metrics focus on treatment completion and optimisation, not just case finding.
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The new GPC Chair is signalling a harder but more practical GP stance
The other story that matters is the arrival of the new GPC England Chair, Dr Clare Bannon.
The headline is Plan B staying on the table, but I don’t think that is the whole story. The more important signal is that GP leaders appear to be framing the next stage around funding, sustainability and the value of the partnership model.
Pulse reported that the new GPC England leadership will prioritise a GP funding uplift ahead of wider GMS reform. That is a sensible order of events. Reform without stabilisation is just another ask.
The NHS often talks about changing the GP contract as if the contract is the main obstacle. Sometimes it may be, but if the underlying problem is that practices are underfunded, short of workforce, short of space and carrying more unfunded risk, changing the contract does not solve the problem. It can simply create a more sophisticated way of overloading the same delivery platform.
There is a tendency in some NHS conversations to treat the partnership model as old fashioned. I think that is lazy. GP partnerships are imperfect but they are also one of the few parts of the NHS where local clinical ownership, long term population knowledge, business discipline and patient continuity still sit together.
The question is not whether partnerships should be preserved as a sentimental attachment to the past. The question is whether the NHS understands what it loses if it weakens them.
The partnership model carries risk that the wider NHS often does not see. Premises risk. Staffing risk. Employer risk. Cashflow risk. Local service risk. Access pressure. Patient expectation. Contractual responsibility. That risk is precisely why practices are becoming more selective about what they take on.
This links directly to the CVD framework.
If the NHS wants General Practice to lead more prevention, diagnosis and optimisation, then it needs to recognise the business model underneath. Practices cannot be asked to carry an expanded national prevention agenda while simultaneously facing list cleansing, estate assumptions, A&G workload, shared care pressure, access targets and uncertain local funding.
The new GPC stance looks less like simple resistance and more like a demand for a clearer deal, and that is not unreasonable.
General Practice may still be willing to innovate, but it wants the terms of the innovation properly described. Funding first. Workload counted. Risk shared. Core practice protected. Neighbourhood services built around, not instead of, general practice.
That is not anti-reform. It is probably the only way reform becomes credible.
For ICBs, the lesson is straightforward. If local plans depend on primary care, engage early and be honest about the money. Do not build a neighbourhood model or CVD pathway on the assumption that practices will absorb the consequences because the policy is worthy.
For industry, the lesson is equally direct. Primary care adoption now needs a provider model, not just a clinical rationale.
Neighbourhood health is becoming real where the deal is real
Kent and Medway continues to be the neighbourhood example worth watching.
Every GP practice in Kent and Medway has reportedly signed up to the local PCN DES variation. That suggests practices will engage when the model feels negotiated, funded, locally owned and built through existing primary care infrastructure.
The detail that caught my eye is the upfront use of ARRS funding. Cashflow and confidence are not side issues in General Practice. They are often the difference between a model being deliverable and a model being another committee diagram.
The wider neighbourhood debate is now moving into exactly the right place; resources, contracts, accountability and the relationship with core general practice.
RCGP warnings that neighbourhood services should never replace core General Practice are important.
The same applies to GP leader warnings that neighbourhood working must be backed by resources. These are not objections to neighbourhood care. They are objections to vague models that shift work without strengthening the platform.
The NHS should be careful here.
Neighbourhood health has the potential to improve care for people with complex needs, frailty, multimorbidity and avoidable hospital use but it will fail if it becomes another layer above practices, another set of meetings, or another route for moving work out of hospital without the funding and workforce moving with it.
The Kent and Medway model is interesting because it does not appear to start by inventing an entirely new structure. It works through a local contract variation, uses PCN infrastructure and gives practices a reason to participate.
That may not be the only model, but it is a useful test.
The questions for every neighbourhood model should be:
- What is the deal?
- Which patients are in scope?
- What work is being done differently?
- Who is paid to do it?
- What happens in the practice?
- What happens at PCN scale?
- What happens through community services?
- What stays in hospital?
- What is the escalation route?
- What outcomes are being measured?
- What is being stopped to make space?
If those questions cannot be answered, the model is not yet operational. It is still a concept.
The CVD framework points toward neighbourhood delivery, but it cannot rely on neighbourhoods that do not yet have a stable operating model. If CVD prevention is going to sit in neighbourhood teams, then those teams need to exist as funded, staffed, accountable delivery units. Otherwise the work will default back to practices, and practices are already making clear they will ask who is paying.
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Worth watching
- List cleansing reinvestment. NHS England has said funding released through patient list validation will remain within general practice services and be reinvested accordingly. It has also said it is working with ICBs to identify practices that may experience disproportionate effects. Practices will judge it by what happens locally, not by the wording of the national letter.
- QOF and ICB performance management. ICBs being asked to performance manage GP practice QOF achievement fits the wider pattern. Prevention priorities are becoming more measurable, but measurement without support risks becoming another pressure point.
- Workforce plan delay. This remains the hole underneath almost everything. The NHS can publish excellent frameworks, strategies and pathways, but if the workforce plan is delayed and local teams do not have the staff, implementation will be slow, uneven and frustrating.
- Medicines access pilots. Government pilots to speed access to innovative medicines could become important, especially if they address adoption as well as approval. Faster regulatory or NICE access is only useful if local systems can then identify patients, commission pathways and deliver treatment.
What this means in practice
The CVD framework creates a strong national mandate but local adoption will depend on funded pathway redesign, not policy alignment alone.
ICBs need to decide whether CVD prevention will be commissioned as a real neighbourhood service, a primary care enhanced service, a pharmacy-led model, a diagnostic pathway or some combination of all four.
General Practice will not quietly absorb unlimited prevention, monitoring and optimisation work without funding, workforce and accountability.
Industry should treat the framework as an implementation opportunity, not a sales trigger. The question is how to help systems deliver the work.
The new GPC leadership is likely to make funding, sustainability and the partnership model central to the next phase of negotiation.
Closing
The CVD framework is a good thing. It gives the NHS a clear prevention agenda and a more joined-up way of thinking about cardiovascular, kidney and metabolic risk, but the real test is now local.
Finding patients is only the start. Treating, optimising, monitoring and supporting them is the work. That work needs people, time, rooms, data, diagnostics, prescribing support, money and accountability.
The NHS has described the destination. The next question is whether it is prepared to build the route.
As ever, I would be interested in different local views, especially from practices, ICBs, cardiovascular teams and partners trying to turn this into something deliverable.
Sources
CVD Modern Service Framework
- Department of Health and Social Care: Cardiovascular disease modern service framework
- Pulse: GPs to be monitored by ICBs on meeting priorities for cardiovascular disease prevention
- GPonline: ICBs identify practices that need to improve CVD prevention
General Practice leadership and funding
- HSJ: New GP leader seeks collaborative approach
- Pulse: New GPC England Chair to keep Plan B on the table
- Pulse: Plan B will give GPs different options if the NHS fails, says new GPC Chair
- Pulse: Dr Clare Bannon - GP partnerships are the most effective part of NHS
- Pulse: New England GP leaders to prioritise GP funding uplift ahead of GMS reform
Neighbourhood health and local delivery
- GPonline: Every GP practice in Kent and Medway signed up to contract DES variation
- Pulse PCN: Neighbourhood model based on first local DES variation backed by GPs
- GPonline: Kent DES variation hands GPs ARRS cash upfront
- Pulse PCN: Neighbourhood working needs to be backed by resources, GP leaders say
- Pulse: Neighbourhood services should never replace core General Practice, says RCGP
Wider delivery signals
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Scott McKenzie helps pharmaceutical, medtech and device companies cut through NHS complexity and get their offers in front of the right decision-makers. In 2023, he helped launch 53 new NHS projects – and added another 28 in 2024. Behind those numbers is a system-level understanding of what actually gets approved, funded and sustained.
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