Finding the missing millions: Driving improvements in cardiovascular disease prevention

2 Oct 2026

In light of World Heart Day on 29 September 2026, we revisit the CVD Modern Service Framework, together with CVDPREVENT (National Audit of Cardiovascular Disease Prevention in Primary Care)

Following the publication of the Government’s Cardiovascular Disease (CVD) Modern Service Framework (MSF) in July 2026, CVDPREVENT (commissioned in part by HQIP*), reflects on how it supports the audit’s core aim of “finding the missing millions who don’t yet know they are at risk” (as their Clinical Lead, Dr Peter Green, puts it). In other words, how will the CVD Framework work in tandem with programmes like audits and the wider sector to prevent ‘heart disease’, and reduce related complications and deaths over the next decade? 

A single national ambition 

The Modern Service Framework has one main clear and measurable ambition: to reduce premature deaths from heart disease and stroke among people under 75 by 25% within ten years. To achieve this, it sets out a goal of reaching people who are most likely to experience heart attacks and strokes before these events occur. The Framework adopts a cardiovascular-kidney-metabolic (CVKM) approach, which recognises the close connection between cardiovascular disease, kidney disease and metabolic conditions such as diabetes. Rather than addressing these conditions separately, it seeks to improve prevention, diagnosis and treatment across the whole pathway. 

Aligning CVDPREVENT with the Framework’s priorities 

The MSF’s initial focus is on driving improvements in twelve priority areas over the next three years. Each priority has a baseline, a three-year target and a ten-year target. Such clear goals support clear metrics for CVDPREVENT, and so they are aligning their work to relevant priorities in the Framework. To enable ICBs and other healthcare planners to work toward one consistent set of national ambitions, CVDPREVENT is adopting the MSF’s ambitions where they supersede the audit’s previous targets. In the case of some priorities, their work is able to already evidence progress: 

Framework priority	CVDPREVENT indicator
Priority 3: SGLT2 inhibitors	The new CVDP001VCVKM indicator supports monitoring of appropriate SGLT2 inhibitor use as part of a broader CVKM approach
Priority 4: Hypertension treatment to target	CVDP007HYP measures treatment to target among people with hypertension who do not have established cardiovascular disease
Priority 5: Lipid optimisation	CVDP008CHOL supports the assessment of lipid management among people without established CVD
Priority 7: Blood pressure and cholesterol optimisation	For people who already have cardiovascular disease, the framework will use: CVDP010HYP, a new hypertension indicator CVDP012CHOL, which measures cholesterol treatment to target
Priority 8: Four-pillar therapy for heart failure	The new CVDP004HF indicator supports monitoring of four-pillar therapy for people with heart failure with reduced ejection fraction, commonly known as HFrEF

Case finding – identifying the missing millions 

The audit’s indicators also support the measurement of two further CVD MSF priority areas: smoking cessation (priority 1) and CVRM case-finding (priority 2). In relation to the latter, the scale of case-finding required is significant. CVDPREVENT’s data indicate that more than one million people across England have a recorded marker that may suggest undiagnosed hypertension, chronic kidney disease (CKD) or diabetes. In March 2026, 1.86% of the registered population (942,504 people) had a single blood pressure reading of 140/90mmHg or above but no GP-recorded hypertension. A further 0.39% had their last two eGFRs (measure of kidney function) below 60ml/min/1.73m², meeting the diagnostic criteria, but no GP record of CKD. Finally, 0.044% had their last two HbA1c records at 48mmol/mol or above, meeting the diagnostic criteria, but no GP record of diabetes. Over 1.1 million people remain in these potential missed diagnosis groups. Identifying these people is central to the ambition of “finding the missing millions”. Earlier diagnosis provides opportunities to manage risk factors before someone experiences a heart attack, stroke or other serious complication. Case-finding is therefore not simply about adding diagnoses to patient records. It is about connecting people to appropriate services, and saving and improving lives. Millions of lives, in fact. 

Data indicate that more than one million people across England have a recorded marker that may suggest undiagnosed hypertension, chronic kidney disease or diabetes 

Liz Corteville, Quality Improvement Lead at CVDPREVENT, adds: “What this scale tells us is that the opportunity to save lives is already sitting in GP records, right now. Our job at CVDPREVENT is to make that visible and actionable, through the Quality Improvement Data Packs, the Data & Improvement Tool and targeted educational outreach, so finding these million-plus people isn’t an abstract national ambition but something a practice or PCN can genuinely work through, quarter by quarter.” 

Making variation visible 

One of CVDPREVENT’s greatest strengths lies in making variation visible. As of March 2026, cholesterol treatment of patients with identified CVD target stood at 52.96% nationally, however achievement varied significantly by ethnicity (ranging from 40.8% in the Black ethnic group to 56.9% in the Asian ethnic group¹). Insights like this enable ICBs, GP practices and other healthcare providers to target support, rather than treat CVD prevention uniformly.  

The audit’s insights are also extremely valuable in aligning resources with local need. For example, in Hampshire and the Isle of Wight, where CVDPREVENT data have been used to compare local performance with other areas of England, and target support accordingly. As a result, between March 2022 to September 2025, the ICB reported considerable improvements: 

• Additional 55,000 people without established CVD being identified as being at high risk of developing it.
• Additional 62,500 people being diagnosed with hypertension
• Additional 70,000 people having their blood pressure treated to target
• Additional 47,000 people at high risk of CVD starting lipid-lowering treatment 

Also, between June 2024 and September 2025, a further 5,000 people with known CVD had their cholesterol treated to target.

Looking forward  

The Modern Service Framework signals that further indicators aligned to CVDPREVENT’S work are likely to follow. As outlined above, the audit has already introduced new baseline indicators in the current reporting round, including measures relating to CVKM risk and heart failure. Over time, this should expand the programme’s treatment-to-target role from the priorities it already covers to fuller CVKM reporting.  

While CVDPREVENT will be the principal source of information on the Framework’s primary care priorities, it will not cover every aspect. Priorities concerned with acute hospital care and rehabilitation are likely to remain within the remit of other national audits, such as stroke. This reflects the broader value of the MSF: bringing together information from different parts of the health system around a shared set of outcomes and ambitions. This vision is consistent with the aspirations of wider national healthcare strategy. As the first Modern Service Framework to be published following the NHS 10 Year Health Plan, the CVD MSF’s importance extends beyond preventing, and improving care for, cardiovascular disease (acutely important though that is). Its publication, and subsequent delivery, offers a blueprint for improving treatment, and reducing premature deaths from, a spectrum of conditions, by aligning national strategy and targets with improvement initiatives, including national clinical audits. CVDPREVENT, whose reporting now feeds into the NHS Oversight Framework, is a forerunner of this approach. 

And, as for the “missing millions” living with undiagnosed hypertension, chronic kidney disease, diabetes or other cardiovascular risk factors? By combining clear strategic ambitions with robust national and local intelligence, we stand a much better chance of identifying who they are – and, importantly, saving and improving their lives. If the ambition of the Modern Service Framework is realised, they will no longer be missing; they will be found, supported and given the opportunity to live long and healthy lives. 

¹ CVDPREVENT Data & Improvement Tool 

*About CVDPREVENT 

CVDPREVENT is commissioned by HQIP as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), and delivered by NHS England, NHS Arden and Greater East Midlands Commissioning Support Unit (AGEM CSU) and the NHS Benchmarking Network (NHSBN), which leads the audit’s reporting and quality improvement workstream. It aims to support professionally-led quality improvement in primary care for the prevention of cardiovascular disease (CVD) in England, and has reported on a quarterly basis since data collection began in 2019/20.  

Further information 

• Cardiovascular Disease (CVD) Modern Service Framework (MSF)
• CVDPREVENT Annual Report 2025
• CVDPREVENT Quality Improvement Data Packs
• CVDPREVENT Data & Improvement Tool
• More about CVDPREVENT: www.hqip.org.uk/our-programmes/cvdprevent and www.cvdprevent.nhs.uk
• Cardiovascular reports and updates from HQIP: www.hqip.org.uk/care-area/cardiovascular