A quality improvement project optimising management of cardio-renal-metabolic (CRM) patients in primary care and supporting education of staff who are involved in the disease management of these patients in Harrow and Hillingdon, North West London

A collaborative working project between Boehringer Ingelheim Ltd (BIL) and Enderley Road Medical Practice, alongside three additional GP practices (The Pinn Medical Centre, Bacon Lane GP Surgery and Southcote Clinic) operating under separate collaborative working agreements aimed to enhance the delivery of high quality, evidence-based, clinically effective cardio-renal-metabolic (CRM) disease management for adults aged 18 years and over, and upskill primary care teams who routinely care for patients with diabetes and/or patients with raised urine Albumin-to-Creatinine Ratio (uACR).

The project had two primary objectives:

1. Improvement in the holistic management (including primary/secondary prevention measures, physical, lifestyle, nutritional and emotional aspects) of CRM patients in Harrow and Hillingdon.

2. Improvement of staff confidence and proactive case management of CRM patients in Harrow and Hillingdon through training and shadowing opportunities.

This was achieved by:​

• Optimisation of treatment in line with NICE Key Care Processes, NICE guidance NG28 (Type 2 diabetes in adults: management), NICE guidance NG106 (Chronic heart failure in adults: diagnosis and management), NICE guidance NG203 (Chronic kidney disease: assessment and management) and respective local CRM guidelines​.

• Engaging patients in education and enabling them to better understand how to manage their disease. ​

• Collecting data across a number of clinical and service improvement outcomes pre and post patient review​.

• Connecting skills and capabilities across NWL to use system expertise to provide additional capacity. ​

• Providing training and shadowing opportunities to support practice teams to increase confidence and upskilling in CRM patient management and review (expanding their current role).​

The project operationalised in September 2024 for a duration of 18 months.

Key outcomes from data collected across all four GP practices are summarised below:

• A total of 1,364 patients were reviewed across four GP practices, demonstrating both the need for and feasibility of systematic CRM care delivery in primary care settings.

• The programme achieved numerical improvements in key clinical parameters, including:

• Reduction in mean HbA1c (−1.11 mmol/mol)

• Reduction in mean systolic blood pressure (−2.84 mmHg)

• Reduction in mean total cholesterol (−0.2 mmol/L)

• There were 808 instances of medication initiation or optimisation, supporting alignment with NICE guidance and best practice CRM management, including:

• The project enabled a shift from a diabetes-centric model to a holistic CRM approach, improving identification and management of cardiovascular and renal risk alongside glycaemic control.

• Onward referrals strengthened integrated care pathways, with 318 referrals made to additional services, including 193 to dietetic support, supporting lifestyle and preventative interventions.

• High levels of patient engagement were observed, with 89.7% attendance at 3-week follow-up among those requiring review, indicating strong uptake of structured CRM care.

• Patient experience was highly positive, based on 589 survey responses, with patients reporting improved understanding of their conditions, increased confidence in self-management, and high satisfaction with care received.

• The programme delivered meaningful workforce development, with mentorship and shadowing resulting in increased clinical knowledge, confidence, and capability in CRM management across participating practices.

• Sustainable changes were embedded within practices, including standardised EMIS templates, search tools, and structured clinic models, enabling continuation of CRM care delivery beyond the project period.

• The collaborative working model demonstrated a replicable and scalable approach, combining NHS clinical leadership with industry support to improve outcomes for patients with complex long-term conditions.

Boehringer Ingelheim Ltd is pleased to have collaborated with Enderley Road Medical Practice to implement a quality improvement project supported by the upskilling of the current primary care workforce, to improve patient outcomes in CRM.