A more joined-up approach to prevention

Written and funded by Novo Nordisk

For people living with long-term health conditions, the NHS is not experienced as a collection of policies, pathways or organisational structures. It is experienced through appointments, conversations, diagnoses and the support available when their health begins to change.

That is why the government’s focus on prevention is so important. The NHS is under sustained pressure, while more people are living with chronic disease for longer.⁽¹⁾ Earlier intervention offers an opportunity not only to reduce future demand, but to help people avoid complications, maintain their independence and enjoy a better quality of life.

This matters particularly in cardiovascular, kidney and metabolic health. Cardiovascular disease, chronic kidney disease, obesity and type 2 diabetes affect millions of people across the UK^{(2) (3) (4)} .These conditions are closely connected, and many people live with more than one of them⁽⁵⁾.

Yet patients can still find themselves moving between separate services, attending multiple appointments and repeating their story to different teams. Each professional may be providing excellent care, but the overall journey can feel fragmented(6). For someone balancing work, family responsibilities, transport difficulties or other pressures, this can make an already complex health situation even harder to manage. It may also mean that opportunities to identify risk earlier or provide more coordinated support are missed.

The government’s cardiovascular-kidney-metabolic (CVKM) approach is therefore a welcome development. It reflects how people actually experience ill health: not always as separate conditions, but as interconnected risks that can develop and progress over time. The opportunity now is to build on that direction together.

Care that reflects people’s lives

The NHS has strong specialist expertise across cardiovascular, kidney and metabolic care. That expertise will remain essential.

At the same time, there is an opportunity to make it easier for professionals across primary, community and specialist services to work around the needs of the whole person. This could mean strengthening shared understanding of how CVKM conditions interact, creating more opportunities for multidisciplinary learning and supporting clearer coordination across services. It could also mean designing pathways that feel simpler from the patient’s perspective.

Neighbourhood health services offer an encouraging route forward. By bringing primary care, community teams and specialists closer together, they could support earlier identification of risk, clearer referrals and more coordinated follow-up. There are already teams across the NHS working across traditional clinical and organisational boundaries to provide more joined-up care. Learning from these approaches, and supporting them to spread, could help more patients benefit regardless of where they live.

The aim should not be to replace specialist care or impose a single model everywhere. It should be to make the system easier to navigate and more responsive to the realities of people’s lives.

Helping prevention to flourish

Delivering prevention consistently also depends on creating the right environment for local NHS teams.

The health service must continue to respond to urgent operational pressures. Access to healthcare services, including GP appointments, urgent and emergency care, and waiting times, remain central concerns for patients and policymakers.Alongside these immediate priorities, there is an opportunity to give greater visibility to the work that prevents ill health from worsening. In CVKM care, that might include understanding whether people at increased risk are being identified and supported, whether treatment is being optimised and whether inequalities in outcomes are narrowing.

Primary care frameworks have made an important contribution to the management of long-term conditions. As they continue to evolve, there may be scope to support a more integrated view of patients living with several connected conditions.

Funding is part of this conversation too. The benefits of prevention often emerge over time and may be felt in a different part of the NHS from where the original investment was made. A community-based intervention today could help prevent a hospital admission in future. Greater flexibility to invest across services and over longer timeframes could make it easier for local systems to pursue these opportunities.

The objective is not simply to create new targets or processes. It is to help teams provide the care they believe will make the greatest difference to patients over the long term.

Data supporting better care

Digital transformation also offers significant potential. The planned Single Patient Record could help reduce fragmentation by making relevant information more accessible across care settings⁽⁷⁾. But its greatest value will come from helping professionals turn information into timely action.

Changes in kidney function, blood pressure or metabolic health may provide an early warning of wider risk. With the right digital support, clinicians could be helped to identify people who may benefit from review, treatment optimisation or additional follow-up. Used appropriately, explainable automation could support this work without replacing clinical judgement or the relationship between a patient and their healthcare professional.

Data could also help local teams understand where disease is undiagnosed or undertreated, and where communities may need more targeted support. For this to succeed, investment in technology must be matched by investment in people. Staff need time, training and confidence to use digital tools safely and effectively. The goal should be to reduce administrative burden, support better decisions and create more time for meaningful conversations with patients.

A shared endeavour

The government has set a positive direction for a more preventive and community-focused NHS.

The CVKM approach provides an opportunity to translate that ambition into care that feels more joined-up, proactive and personal.

Realising that opportunity will require partnership across government, the NHS, local authorities, academia, industry, charities and patient organisations.

At Novo Nordisk, we recognise that no organisation has all the answers. Our role is to listen, contribute evidence and expertise, and work with others who share the goal of improving the lives of people living with chronic disease.

Ultimately, prevention is about more than reducing pressure on services. It is about helping people stay well for longer, avoiding complications where possible and ensuring that care reflects the whole person. That is an ambition worth working towards together.

UK26PA00047 | August 2026 

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