A real-world preventive primary care model for cardiorenal metabolic disease: clinical impact of a personalised care approach in Harrow, North West London.

backgroundCardiorenal metabolic (CRM) disease, is identified by the co-location of multiple disorders including obesity, diabetes, hypertension, cardiovascular disease and chronic kidney disease (CKD). Early intervention is essential to slow CKD progression, reduce cardiovascular risk, and improve quality of life. The Harrow CRM Hub project established a personalised, multidisciplinary pathway to identify high-risk patients, optimise clinical management, and provide access to lifestyle and psychosocial support. This paper reports on the clinical outcomes achieved within the first year of implementation.

methodsA comprehensive logic model was co-developed to guide the design, delivery, and evaluation of the Harrow CRM programme. Two EHR-identified cohorts were invited: (1) adults aged 20-80 years with BMI >27.5-30 kg/m² (ethnicity-dependent) and non-diabetic hyperglycaemia ± hypertension (CRM Stage 2); and (2) adults with diabetes ± CKD or CVD (CRM Stage 4). Pre visit health questionnaire - using digital tools enabled detailed pre visit updates and tests. Protected consultations (lasting 30 to 45 minutes) followed a structured EHR template incorporating guideline-based optimisation of pharmacotherapy, risk calculators, and co-created lifestyle care plans. Data were extracted for paired analysis of systolic BP, HbA1c, and weight. A qualitative evaluation was undertaken to explore patient and staff experiences of the CRM pathway.

resultsThus far, between November 2024 and September 2025, 2,641 patients were reviewed, with 2,300 included in paired analysis. Across the full cohort, mean changes were -3.65 mmHg in systolic BP (median -2.0 mmHg), -1.03 mmol/mol in HbA1c (median 0.0 mmol/mol), and -0.46 kg in weight (median 0.0 kg) (all p<0.001). For those with an improvement only - an average improvement of -14.12 mmHg (n=1,279) and an average deterioration of +10.61 mmHg among those whose readings worsened (n=895). HbA1c values showed a mean cohort wide reduction of -1.03 mmol/mol (median 0.0 mmol/mol), with mean changes of -8.08 mmol/mol among improvers (n=785) and +5.22 mmol/mol among those with deterioration (n=762). Weight trends showed a mean overall reduction of -0.46 kg (median 0.0 kg), comprising an average improvement of -3.63 kg among improvers (n=1,124) and deterioration of +3.93 kg among those with deterioration (n=761). Among those with paired readings, 33.4% achieved ≥5% BP reduction and 19.7% achieved ≥10%; 19.8% achieved ≥5% HbA1c improvement and 12.7% ≥10%; and 9.6% achieved ≥5% weight loss and 2.7% ≥10%. Overall, 73.9% improved in ≥1 parameter, while 10.4% improved across BP, HbA1c, and weight simultaneously. This real world review identified patients with improvements and deterioration in their health parameters. Qualitative findings showed patients valued extended consultations and holistic discussions, with vast majority of patients reporting greater understanding of their health and feeling more confident to manage it. A staff survey (n=14) provided supportive but preliminary quantitative evidence of having greater confidence in delivering CRM clinics and increased ability to access multidisciplinary expertise.

conclusionA personalised, multidisciplinary CRM model embedded within primary care was associated with statistically and clinically significant improvements in blood pressure, glycaemic control, and weight in a large, ethnically diverse population. Patients and clinicians both reported greater engagement, confidence, and satisfaction. The approach combining structured identification, extended consultations, co-produced care plans, and workforce education demonstrates a scalable, sustainable pathway to slow CKD progression, reduce CVD risk, and enhance patient wellbeing across diverse communities.