Implementation is only the beginning: lessons from evaluating North West London’s digital tools for chronic kidney disease care. In this blog Margaret Steward, Senior Innovation Advisor at Imperial College Health Partners, reflects on what a recent evaluation of the North West London NIPP Chronic Kidney Disease (CKD) utilities tells us about improving CKD care and why these lessons matter as we move towards more integrated cardiovascular, renal and metabolic (CVRM) services.
North West (NW) London is making strides towards more integrated cardiovascular, renal and metabolic (CVRM) care. As new models and pathways take shape, it is important to look back at earlier innovation, understand where adoption worked in practice and use that learning to shape what comes next.
Chronic kidney disease (CKD) care is an important part of that conversation. Closely linked to cardiovascular disease, diabetes and health inequalities, CKD is a sizeable population health challenge affecting residents across NW London, yet it has historically been underdiagnosed and inconsistently managed.
Over recent years, there has been significant activity across NW London to address this, focused on improving CKD identification and management. One part of this effort was the development of the NIPP CKD utilities – a set of digital tools embedded within EMIS and SystmOne designed to support CKD identification, coding, monitoring and structured reviews in primary care. These utilities emerged from the NHS Insights Prioritisation Programme (NIPP), which brought together clinicians, patients, industry and system partners to better understand local barriers to optimal CKD care and co-design practical solutions.
Three years on from that work, NW London Integrated Care Board (ICB) commissioned Imperial College Health Partners (ICHP) to take a closer look at the impact of the utilities and how they have been adopted in practice. We wanted to understand how routine CKD management has changed since their introduction, what value clinicians felt they added, and what they could teach us about implementation and adoption in a complex primary care landscape.
A positive story for CKD care – what we found
The evaluation found encouraging signs of progress across NW London. The proportion of patients meeting CKD criteria who remained uncoded fell from over 36% in 2023 to 8.5% in 2025. Over the same period, the age-standardised prevalence of coded CKD increased by 28%, while coded CKD incidence more than doubled, reflecting a marked improvement in people being identified and recorded.
While these notable improvements cannot be attributed solely to the introduction of the CKD utilities, they reflect the collective efforts of the system to improve CKD care. Crucially, more people are now being identified and coded appropriately, creating greater opportunities for monitoring, treatment and earlier intervention. Alongside the quantitative findings, clinicians consistently told us that the utilities have supported more structured and manageable CKD processes, playing an important role in helping them translate information into action.
Beyond the tool itself
As someone who works in innovation and implementation, one of the things that strikes me most is how much depends on what happens after launch. On paper, the intervention here was straightforward: a suite of CKD tools embedded within existing clinical systems. But what clinicians described was that the effectiveness of the tools largely stemmed from how those tools were introduced, supported and incorporated into day-to-day practice.
The utilities were most effective where they became part of established ways of working. We heard the strongest examples from practices where CKD reviews were already a defined part of someone’s role, where clinicians used the tools regularly, and where support, learning and reinforcement continued well beyond the initial rollout.
The lesson here is a familiar but important one. Successful adoption of an innovation depends just as much on the conditions around it – ownership, workflow integration, training, incentives, local leadership and opportunities to build confidence through repeated use – as it does on the tool itself.
Looking ahead: CKD in a CVRM future
The evaluation findings are particularly relevant as NW London continues to develop integrated cardiovascular, renal and metabolic (CVRM) services.
The original aims of the CKD utilities align closely with the ambitions of a recent CVRM enhanced service specification for primary care, which seeks to bring together prevention, proactive risk management, personalised care and better support for people living with interconnected long-term conditions.
Perhaps the most interesting question raised by the evaluation is not whether the utilities should continue unchanged, but how the features clinicians value most can be carried forward into future CVRM pathways.
Clinicians consistently told us they valued the CKD-specific functions within the utilities – particularly staging, coding, monitoring and structured review processes. As integrated CVRM models continue to evolve, preserving those functions will be just as important as designing new pathways.
The value of this evaluation goes beyond CKD. It offers practical insight into how we carry forward what works as services evolve, and makes sure innovation keeps supporting clinicians and patients in meaningful ways.
What’s next?
This evaluation forms part of a broader programme of work supporting NW London’s system-wide ambitions for CVRM health. Over the coming months, ICHP will also be sharing findings from our evaluation of the Harrow CVRM Clinic Model, providing further insight into how integrated approaches are being experienced by clinicians and the impact they are having on care and outcomes.
For me, the central lesson from this work is simple – designing an intervention is only the start. Some of the most valuable learning comes later when we take the time to understand how that innovation is used in practice, how it evolves alongside the system around it and what it can teach us about the next stage of improvement.
