This page details the high level findings and outcomes for service users, staff and the wider south east London system from the implementation of a targeted prevention, detection and early disease optimisation programme within the multi-morbidity model of care (MMMoC). This element of the programme helps to find chronic kidney disease earlier and optimise care closer to home.
To see our complete findings on the impact of targeted prevention, detection and early disease optimisation on people living with chronic kidney disease and other long-term conditions, click here to see our report.
Our challenge
- Chronic kidney disease is common, but many people do not know they have it
- Kidney disease significantly increases the risk of heart attacks, strokes and kidney failure
- In south east London, kidney disease registers were about half their expected size
- Many people with kidney disease had not had a urine test in the last year
- People in undeserved communities are more likely to be diagnosed late and have worse outcomes
Our ambition
The targeted prevention, detection and early disease optimisation initiatives aimed to:
- Find kidney disease earlier, especially in underserved groups.
- Make testing easier through community and home-based options.
- Optimise medicines earlier to reduce future heart and kidney complications.
- Build neighbourhood models that bring specialist support into primary and community care.
MMMoC: The wider programme of work
- Offered a comprehensive, holistic approach to LTC care across the whole pathway
- Enabled integrated, multidisciplinary working at scale
- Improved outcomes and experience for service users and staff
- Supported system sustainability and preventative transformation
Targeted prevention, detection and disease optimisation work: the approach
What we did
Between 2023 and 2025, six sites across 12 primary care networks delivered or worked with four linked programmes.
The four programmes were
- HIDDEN CKD: community kidney screening with trained peer educators.
- HIDDEN BP (blood pressure): digital home urine testing for people with hypertension who had not had recent testing.
- Long list work: proactive reviews for people with coded or likely uncoded kidney disease.
- PROTECT KIDNEY: point-of-care clinics to rapidly optimise kidney medicines.
How we evaluated the work
- We used routine NHS data to compare trends before and after the work started.
- We used interrupted time series analysis at service user and population level.
- We also used activity data and qualitative feedback from staff and service users.
Involvement
South East London system
- Delivery took place across six sites and 12 primary care networks
- Teams included primary care, secondary care, community pharmacy, academic, voluntary sector and community partners.
- Integrated neighbourhood teams were developed through co-design workshops from October 2023 to January 2024.
- Sites finalised operating procedures and risk stratified cohorts from January to April 2024.
Scale of delivery
- 964 residents received community kidney screening through HIDDEN CKD.
- 5,208 service users received a digital remote testing kit
- 3,222 people were seen as part of the long list proactive review work
- 296 people were seen in kidney point-of-care clinics
Value: Service user
What this means for people:
- People could get kidney checks in trusted community spaces
- People could complete urine testing at home using a digital kit
- People with kidney disease could get faster medicines optimisation closer to home
- Point-of-care testing meant some people could get results and medicine changes in one appointment
Loved the immediacy. It was reassuring and efficient.
Outcomes: Population impact
- Community kidney screening: 964 residents were tested in community settings. 373 (38.7%) had abnormal initial albuminuria results and CKD was confirmed in 231 (23.9%).
- Digital home testing: 3,283 people with hypertension completed a home urine test. 1,304 people had abnormal or high abnormal results requiring follow-up.
- Sodium-glucose cotransporter 2 inhibitor (SGLT2i) prescribing: Prescribing rose by 15.48 percentage points in the short list at the start of the intervention. This is about 51 more people prescribed an SGLT2 inhibitor.
- Urine albumin-to-creatinine ratio (uACR) testing: Urine testing rose by 19.54 percentage points in the short list at the start of the intervention.
- Blood pressure control: Blood pressure control rose by 5.62 percentage points in the short list at the start of the intervention.
Value: Workforce
- Staff valued being able to test, explain results and optimise medicines in one pathway.
- Point-of-care clinics helped staff make fast clinical decisions
- Staff worked across primary care, hospital care, community pharmacy, academic and the voluntary sector.
- The model built learning across neighbourhood teams and specialist services.
This cuts all of that out. We can adjust medication immediately.
Outcomes: System
- Case closer to home: Specialist kidney expertise was brought into primary care, community settings and community pharmacy
- Better use of medicines: Point-of-care clinics reviewed 296 people, with 190 people fully medically optimised in clinic.
- Fewer hospital visits: Outpatient attendances fell by 38.13 per 1,000 people per month in the short list after the intervention
- Less pressure on primary care: GP appointments fell in MMMoC sites, with an immediate drop of 195.96 per 1,000 people after the intervention.
- Impacts are still emerging: It may be too early to see clear changes in emergency admissions and A&E attendances.
What next?
The MMMoC has become the blueprint for integrated neighbourhoodworking in south east London.
The targeted prevention, detection and early disease optimisation workstream will continue to:
- Scale learning through the Healthy Hearts Pathway across South East London
- Complete economic evaluation for the kidney POC by the end of 2026
- Complete service user-level analysis for digital remote testing with Healthy.io
- Continue scaling HIDDEN CKD in other parts of London and support return on investment work
- Publish learning from the individual programmes for peer review
What are we most proud of?
The targeted detection, prevention and early disease optimisation has:
- Found people at risk of kidney disease through trusted community and home-based testing.
- Moved beyond detection by rapidly optimising medicines closer to home.
- Showed that neighbourhood teams can improve clinical care and reduce outpatient use at scale.
