The challenge

Almost 2m people in the UK have been diagnosed with moderate-severe chronic kidney disease (CKD) by their GP. A further 1 million people may remain undiagnosed (AstraZeneca, 2024).  

Diabetes is the leading cause of CKD (AstraZeneca, 2024). CKD with diabetes is associated with substantial morbidity and higher risk of severe complications and death, as well as being an economic burden.  

In Cornwall and the Isles of Scilly, there are 9,222 people with Type 2 Diabetes and CKD. Within two years of treatment with Dapagliflozin, this could save £1.7m and would be cost-saving after 14 months (AstraZeneca, 2025).  

The solution

As part of our Cardiovascular Disease portfolio of work and our Long Term Conditions and Frailty mission to address multi-morbidity within a rural and coastal context, we are initiating a programme of work targeting chronic kidney disease detection and management in Cornwall and the Isles of Scilly.  

Through partnerships with the Cornwall and Isles of Scilly Integrated Care Board, industry, primary and secondary care, and the third sector in the county, we aim to improve patient outcomes through timely detection and management of heart failure and CKD.  

The programme has been designed to deliver significant patient and system benefits across primary and secondary care, serving as a model for large-scale, collaborative partnership working. 

Our impact so far

Our groundwork in 2025-26 included:  

• Multi-organisational steering group and associated task and finish groups providing leadership, governance and co-ordination of the programme to manage delivery and mitigate risks. 

• Developing a primary care support delivery model definition process, which is near completion. 

• Putting in place a programme evaluation and measurement framework.  

• Supporting Cornwall Integrated Care Board to put in place a CKD Medicine Optimisation Incentive Scheme and associated support which began in Spring 2026, to complement on-going work and support primary care to prioritise CKD patient care. 

• Planning a CKD training programme and undertaking a resource review with all key stakeholders, to enable the provision of comprehensive progressive CKD training to primary care and other healthcare practitioners across the county.  

What’s next?

Our quarterly steering group will continue to provide assurance and governance to the programme through 2026-27.  

We are progressing planning for the CKD training programme and associated resources, as well as finalising a delivery model for primary care.   

Please revisit this page through 2026-27 for the latest updates on our work in heart failure and CKD in the South West. You can also follow us on LinkedIn to stay up to date with our latest news and work in heart failure and CKD across the region.