An integrated primary care model for cardiorenal-metabolic disease

Cardiorenal-metabolic (CRM) disease describes the interconnected burden of obesity, type 2 diabetes, hypertension, cardiovascular disease (CVD) and chronic kidney disease (CKD). These conditions share common drivers, including insulin resistance, inflammation, endothelial dysfunction and neurohormonal activation. Individually, each condition reduces survival; when they cluster, morbidity and mortality increase, placing a considerable burden on healthcare services.

Despite clear guidance on prioritising optimisation of blood pressure (BP), glycaemic control and lipid management, disease management is often organised around separate specialties. This fragmentation can lead to delayed recognition, duplicated appointments, conflicting advice and missed opportunities for prevention, highlighting the need for a more integrated, person-centred approach to CRM care.

To address poor CRM health in Harrow, the CRM Hub project established a personalised, multidisciplinary pathway across five primary care networks. It aimed to identify high-risk patients, optimise clinical management, and improve access to lifestyle and psychosocial support.

To guide the design, delivery and evaluation of the programme, a comprehensive logic model was developed. It linked programme activities to measurable outcomes, including improved health metrics, greater staff confidence, increased patient activation, reduced CRM risk, slower CKD progression and an integrated model of care. The framework also clarified how the Harrow model differed from conventional care, while supporting implementation.

Electronic health records were used to identify two cohorts: 1) adults with BMI >27.5–30 kg/m² and non-diabetic hyperglycaemia, with or without hypertension (Stage 2 CRM); and 2) adults with diabetes, with or without CKD or CVD (Stage 4 CRM). Participants received a pre-clinic health questionnaire to encourage engagement before attending a dedicated CRM appointment. 

Initial protected consultations lasting 30–45 minutes followed a template that incorporated guideline-based pharmacotherapy optimisation, risk assessment and co-created lifestyle care plans. Follow-up included care coordinator check-in calls, repeat measurements at 3–6-month intervals and a further CRM clinic appointment. 

In parallel, a bespoke training package was developed to support delivery of care. It covered the rationale for integrated CRM care, delivery of the primary care pathway, and personalised communication skills and health coaching. A qualitative evaluation was undertaken to explore patient and staff experiences of the CRM pathway. 

Between November 2024 and September 2025, 2641 patients were reviewed; 2300 had follow-up data and were included in paired analysis. Across the whole cohort, statistically significant improvements were observed in all major parameters (P<0.001).

Mean change in systolic BP was −3.65 mmHg (median −2.0 mmHg). Among those with an improvement, the average was −14.12 mmHg; among those with a deterioration, the average was +10.61 mmHg. HbA_1c showed a mean reduction of −1.03 mmol/mol in HbA_1c (median 0.0 mmol/mol), with average changes of −8.08 mmol/mol among improvers and +5.22 mmol/mol among those with deterioration. Weight fell by a mean of −0.46 kg (median 0.0 kg), with mean changes of −3.63 kg among improvers and +3.93 kg among those with deterioration. 

In the paired analysis, 33.4% achieved a ≥5% BP reduction and 19.7% achieved ≥10%; 19.8% achieved a ≥5% HbA_1c improvement and 12.7% ≥10%; and 9.6% achieved a ≥5% weight loss and 2.7% ≥10%. Overall, 73.9% improved in one or more parameter, while 10.4% improved across BP, HbA_1c and weight.

Qualitative findings suggest that patients felt more informed, listened to and confident in managing their health, while the staff described greater confidence in delivering CRM care, increased role satisfaction and easier access to team members inside and outside their practice.

While the findings in this large, ethnically diverse cohort are promising, practical challenges remain around data completeness, variable practice-level engagement and funding uncertainty. The model’s future value will depend on whether the gains can be sustained, cost-effectiveness can be proven and if it can be embedded into routine quality frameworks and scaled across wider primary care networks.

The full article can be read here.