For many people, living with diabetes, heart disease or kidney disease means facing the challenges of multiple long-term conditions; conditions that too often are treated in isolation.

We spoke with Swati Bhagat-Jones, Multiple Long-Term Conditions Lead at Kidney Research UK, about her upcoming talk at Diabetes Professional Care in October. Her talk will explore how healthcare professionals, patients, and the voluntary sector can work together to break down these silos and deliver more holistic, person-centred care.

This conversation promises to inspire fresh thinking about how joined-up care, and stronger partnerships with the charity sector, can better support those living with CVRM conditions.

What are the biggest challenges in coordinating care between diabetes, cardiovascular and renal pathways? How can HCPs practically overcome these silos in everyday practice?

One of the greatest challenges is that our healthcare system still largely operates in disease-specific silos, this also includes the third sector. Diabetes, cardiovascular disease, and kidney disease are deeply interconnected, yet services are often structured around individual conditions. In primary care, frameworks such as QOF and enhanced services reinforce this fragmented approach by rewarding single-disease management rather than incentivising joined-up care. This not only makes it harder for healthcare professionals to coordinate across pathways, but also means patients typically experience fragmented, repetitive, and sometimes conflicting care, which can lead to poorer health outcomes.

To overcome this, we need to move towards integrated models such as CVRM reviews that bring together diabetes, cardiovascular and kidney checks into one holistic consultation. Education and support for primary care teams are critical, along with system-level incentives that promote collaboration. Embedding multidisciplinary working and using shared resources from the voluntary sector can also help break down barriers and ensure that care is organised around the patient, not the condition.

Given the overlap between diabetes and CKD, what strategies or innovations are proving most effective in identifying kidney disease earlier and how can frontline teams be empowered to implement them?

Early detection is essential if we are to prevent CKD progression in people with diabetes. Simple measures, such as routine urine ACR testing in primary care for at-risk patients, remains one of the most effective strategies. However, innovations are urgently needed to improve accuracy and accessibility for point-of-care urine testing, which would transform early detection.

AI-driven risk stratification of primary care records also shows promise, enabling clinicians to identify patients at higher risk of progression. However, this relies on robust early coding, which remains a challenge. Greater awareness and use of tools like the Kidney Failure Risk Equation (KFRE) can also improve decision-making, but only if supported by consistent urine ACR testing. Finally, adapting existing diabetes reviews into broader CVRM reviews could create a practical way for frontline teams to embed kidney checks into everyday care, supported by targeted education and resources.

How can clinicians balance clinical priorities with the patient’s lived experience when managing multiple long-term conditions?

Balancing clinical priorities with the lived experience of patients requires moving beyond a checklist approach. It’s not enough to tick boxes for QOF. True patient-centred care means setting realistic goals that reflect the individual’s circumstances, priorities, and wellbeing. This includes considering mental health, quality of life, and the treatment burden alongside biomedical outcomes.

Using tools such as patient-reported outcome measures (PROMs) and engaging in open conversations about what matters most to patients can help clinicians tailor care in a meaningful way. Empowering patients through education and self-management support is key, as is working in partnership rather than adopting a top-down approach. The third sector also plays a crucial role here, offering trusted information, peer support, and resources that can complement and extend what is possible in the consultation room.

What role do you see the charity and voluntary sector playing in supporting HCPs and people living with CVRM conditions, and how can clinicians build stronger partnerships with these organisations?

The charity and voluntary sector provide a trusted, independent voice for patients and a vital partner for healthcare professionals. Charities can deliver tailored education and patient information that meets people where they are, rather than relying on broad, diagnosis-driven advice. Resources such as Kidney Research UK’s patient leaflets or HCP toolkits can enhance understanding and support conversations in primary care.

Beyond information, charities play an important role in collaborative initiatives. Joint projects like SPOT CKD (Trailblazing new programme to SPOT kidney disease early | North East and North Cumbria NHS) developed in partnership with industry and the NHS, demonstrate the potential for real-world impact. For clinicians, building effective partnerships with the third sector requires authentic engagement and recognition of the challenges faced in primary care. By fostering genuine relationships and embedding voluntary sector support into everyday practice, we can create a more joined-up system that benefits both patients and professionals.

What future models of care or service innovations do you believe hold the most promise for improving outcomes in people living with diabetes and CKD?

Future models of care must focus on integration, accessibility, and patient empowerment. Accurate at-home testing could make a huge difference in identifying problems earlier while reducing the burden of frequent clinic visits. Joint primary and secondary care clinics, such as the LUCID model, also show great potential for delivering coordinated and efficient care.

Digital platforms, like My Renal Care, offer another promising route- providing patients with easy access to their health information, reducing unnecessary travel, and supporting better self-management. In addition, wider adoption of tools like KFRE can guide earlier interventions and personalised care planning. Crucially, raising awareness of CKD across the whole primary care workforce, including HCAs, pharmacists, and social prescribers, ensures early recognition and intervention are part of routine practice, not just specialist care.

You’ll be speaking at DPC this year, could you give our delegates a preview of the key takeaways they can expect to learn from your session?

Delegates can expect to gain a deeper understanding of what it really means to live with multiple long-term conditions and the ways in which siloed care pathways can hinder patient outcomes. The session will highlight how the charity sector can work hand-in-hand with healthcare professionals to deliver more holistic, joined-up care.

Attendees will leave with practical tools, patient and HCP resources, and fresh insights into the CVRM space that can be applied directly in clinical practice. Most importantly, the session will encourage a shift in perspective, by placing the patient’s lived experience at the centre and exploring how collaborative models of care can drive better outcomes for those living with diabetes, CKD and related conditions.

 

Join Swati at Diabetes Professional Care on 22 October in Theatre A to hear more.