A Pharmacy Lens on Cardiovascular-Renal-Metabolic & Obesity- Integrated Neighbourhood Care

In November 2025, the Global Policy Network brought together healthcare leaders from pharmacy, primary care, policy, and digital health to ask a timely question: could neighbourhood care models be the key to stronger primary care and better population health outcomes? The discussion explored key challenges, including fragmented patient records, workforce pressures, and the practical realities of implementing integrated care.

In the UK, cardiovascular disease, kidney disease, metabolic conditions, and obesity are often treated separately. However, many patients live with several of these conditions at the same time. Shared risk factors, including elevated blood pressure, dysglycaemia, dyslipidaemia, and obesity, drive the interconnected progression of these conditions, meaning that treating them in isolation fails to reflect the biological reality of how they interact. As multimorbidity becomes more common, neighbourhood-based care models may offer a more coordinated and effective approach. The roundtable explored how pharmacy could play a stronger role in neighbourhood teams to support prevention, early intervention, and long-term care.

Why Was This Report Needed and Timely?

Cardiovascular disease remains one of the leading causes of illness and death in the UK. National policy increasingly recognises the need for stronger prevention and community-based care. Recent NHS policy, including the emerging NHS 10 Year Health Plan and neighbourhood health initiatives, emphasises integrated multidisciplinary teams working closer to communities. The Neighbourhood Health Framework, published by the Department of Health and Social Care in 2026, marks a significant step forward in translating this ambition into action, setting out how neighbourhood teams should be structured, funded, and held accountable, with community pharmacy explicitly recognised as a key partner in delivering care closer to communities. However, practical mechanisms for shared decision-making, data sharing, and workforce support are still developing, and the pharmacy's potential in cardiovascular prevention remains largely untapped. Community pharmacists are among the most accessible healthcare professionals and interact with patients regularly. Their reach into deprived and underserved communities makes them a particularly vital asset in tackling health inequalities, a priority underscored by the NHS Core20PLUS5 framework. This is especially significant for Black and South Asian communities, who face disproportionately higher rates of hypertension and chronic kidney disease, and for whom proactive, community-based outreach is essential to reducing longstanding health inequalities. This roundtable was convened to explore how pharmacy could help bridge the gap between national policy ambitions and the operational realities of delivering neighbourhood care.

Key Themes

When the Records Don't Follow the Patient

Delegates emphasised that neighbourhood care cannot work successfully without consistent data sharing. Currently, no patient records are available across all care settings. Diagnoses made at hospitals may not appear in general practice systems, and pharmacy-generated data, such as blood pressure measurements, are rarely integrated into shared records. Early indications of cardiovascular disease and chronic kidney disease, such as albuminuria or hypertension, are critical for prevention. When this data is not shared throughout the system, chances for early intervention are lost.

Treating the Whole Person, Not Just One Condition

Delegates discussed the limitations of single-disease care pathways. Many patients live with overlapping conditions: cardiovascular disease, diabetes, kidney disease, and obesity, yet are still moved between specialists without a single, joined-up plan. This leads to duplication, missed prevention opportunities, and the frustration of having to repeat the same story at every appointment. A related structural problem is how patient episodes are recorded: when a hospital visit is coded against just one primary diagnosis, co-occurring conditions may not be captured at all, leaving patients with multiple conditions under-recognised in the system and at risk of receiving fragmented care.

Building a Workforce Ready for the Complexity Ahead

Pharmacists are increasingly involved in clinical practice, including independent prescribing. However, delegates underlined that workforce development must keep up with these changes.  Pharmacists require protected study time, structured supervision, and real-world clinical experience to effectively manage complex cases safely. Delegates also identified a gap in formalised clinical education on cardiovascular, renal, and metabolic conditions as an integrated area. Unlike diabetes or asthma, where accredited university modules, diplomas, and postgraduate courses already exist, no equivalent structured pathway currently exists for CVRM. Creating these programmes would give healthcare professionals formal recognition of their learning, build clinical confidence, and support more consistent practice. Delegates also highlighted the emotional burden of communicating serious diagnoses, such as chronic kidney disease, to patients who have never been told before, pointing to a wider gap in how complex clinical information is shared across the system.

Policy on Paper vs. Reality on the Ground

A common argument was that national policy should be more closely aligned with frontline delivery. Recent service rollouts have occasionally encountered unclear referral routes, poor governance, and insufficient operational readiness. The NHS Blood Pressure Check Service, a commissioned, funded community pharmacy service, has seen lower-than-expected uptake, increasing the risk that people with undiagnosed hypertension go on to develop serious complications. This is a clear example of how service design must account for operational capacity alongside clinical ambition. Delegates were firm: stop short-term, siloed commissioning of pharmacy services and start embedding pharmacists in integrated teams with proper governance, shared records, and long-term funding.

Reaching Patients Before They Reach Crisis Point

Participants pointed to a significant gap in patient awareness: many people with chronic kidney disease or elevated cardiovascular risk do not know they have these conditions. Improving communication standards, shared decision-making tools, and community-level education is essential. Culturally tailored outreach, rather than waiting for patients to present with established conditions, is key to reaching higher-risk communities and enabling earlier, self-directed action. Where pharmacy is often the first and sometimes only point of contact with the health system, this role becomes even more critical.

Building Effective Neighbourhood Teams

Successful neighbourhood models were often described as those built on strong relationships between professionals. Multidisciplinary learning, trust, and regular communication were key factors in improving outcomes. Delegates underlined that neighbourhood teams require dedicated time for collaboration as well as defined governance mechanisms to work effectively.

What Needs to Change?

1.     NHSE and DHSC should fast-track the creation of a single, shared patient record accessible to pharmacy teams.

2.     Integrated Care Boards should run readiness checks before launching new services and embed pharmacists in neighbourhood teams.

3.     Pharmacy leadership bodies should fund protected learning time and structured training for independent prescribing. Universities and professional bodies should develop accredited CVRM education pathways, drawing on established models in diabetes and respiratory care.

4.     Healthcare organisations should improve how diagnoses are communicated to patients, especially for long-term conditions.

5.     Pharmacy must be recognised as a frontline partner in addressing health inequalities, with its presence in deprived communities reflected in commissioning decisions and neighbourhood team design.

6.     Prevention investment must come with dedicated funding, not simply by reallocating budgets from hospitals, but by treating neighbourhood care as a system-wide priority in its own right.

7.     Hospital coding practices must be reviewed to ensure that patients with multiple conditions are fully recognised in clinical records, supporting better risk stratification and more equitable access to integrated care.

The Opportunity Is There, If We Take It

The roundtable made one thing clear: the NHS cannot afford to keep treating interconnected conditions in isolation. Fragmented records, uneven workforce support, and operational gaps are not inevitable; they are solvable, with the right investment and political will. Community pharmacy is already embedded in communities, trusted by patients, and increasingly clinically capable. The question is no longer whether pharmacy should be at the heart of neighbourhood care. It is how quickly we can make that a reality.

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