Posted on: 27 November 2025
By Dr. Sunil Daga, MBBS MRCP (Nephrology) PhD FRCP Edin. Clinical Associate Professor (FMH – University of Leeds); Honorary Consultant Renal Transplant Physicians (Leeds Teaching Hospital); West Yorkshire’s kidney health lead.
Chronic Kidney Disease (CKD) is a significant but often under-recognised health challenge. In the UK, one in ten individuals over the age of 35 years already has moderate kidney damage, yet awareness remains low. The burden of kidney disease is rising rapidly: dialysis prevalence is predicted to increase by over 400% by 2033 and poor kidney health is projected to become the fifth leading cause of premature death. Bringing this condition into the limelight and embedding kidney health as a system priority has been a central focus of my tenure as West Yorkshire (WY) CKD Lead.
It has been a privilege to support this work during a period of significant system transformation for integrated care systems nationally, and to contribute to improving outcomes for patients living with, or at risk of, CKD. Following my time as a West Yorkshire Health Equity fellows, I share many highlights of the journey towards improved kidney health outcomes with several equally passionate colleagues across West Yorkshire ICB and within the Yorkshire and Humber Kidney Clinical Network.
Driving System-Level Improvement in CKD Care
From the outset, a focus of the WY kidney health strategic thinking has been promoting a consistent, evidence-based, population health approach to CKD. This required and continues to require close collaboration across primary care, secondary care, public health, commissioning, digital teams, and industry partners. Our shared aim is to reduce unwarranted variation, support earlier diagnosis, and ensure that kidney health is understood to be and becomes a core element of long-term condition management.
One element of the WY CKD role which I enjoyed most was bridging silos of excellence—bringing together pockets of outstanding practice, sharing knowledge, and creating systems where innovation and expertise can be applied across the region rather than remaining isolated.
Partnership Working towards system wide impact
Our partnership-led approach has delivered real change across the North. Through the industry-supported Care4Me project—run across three PCNs in Leeds, Affinity CKD project at Bradford and one in Wakefield—we demonstrated how targeted support can accelerate proactive, personalised care, while also highlighting the persistent North/South investment divide.
These pilots have now shaped mainstream practice, with proactive care models like GPOP becoming business as usual across Leeds Place. This is a significant system-wide win, enabling earlier identification and better management of patients at scale.
We also strengthened the wider innovation ecosystem by connecting diverse partners—including the clinical laboratory network, West Yorkshire Health Innovation Network, Kidney Research Yorkshire, Kidney Research UK, and academic teams at the University of Leeds and Leeds Beckett University—showing how industry, charities, academia, and local systems can work together for greater impact.
Developing a Unified CKD Guideline for West Yorkshire
Recognising the importance of consistency in clinical practice across our five Places, working with the West Yorkshire CaReMe group, we successfully developed a single CKD guideline for West Yorkshire. Development of the guideline involved aligning local renal expertise with national evidence and local care pathways. The WY CKD guideline provides:
• A shared reference point for all primary care teams
• Streamlined referral processes
• Clear, harmonised guidance on staging, monitoring, and management
• Greater clarity for clinicians navigating multiple long-term conditions
This unified guideline represents a meaningful step towards reducing variation and supporting system-wide quality improvement.
Minuteful Kidney: Scaling Innovation through Partnership
A significant achievement has been the implementation and evaluation of the Minuteful Kidney project, delivered in partnership with Healthy.io and supported through NHSE Health Technologies Adoption and Acceleration Fund (HTAAF). Over 22,000 patients across a third of the GP practices in the system were reached.
This initiative brought clinically validated home albuminuria testing directly into patient pathways, enabling:
• Earlier detection of kidney damage in high-risk groups
• Reduced barriers to testing
• Improved follow-up and risk stratification in primary care
• Better utilisation of digital and remote tools within integrated care
The initiative demonstrated how targeted innovation, aligned with population needs and supported through industry collaboration, can strengthen CKD detection at scale. Lessons from this programme will inform future digital adoption and data-driven secondary prevention approaches across West Yorkshire.
Raising the Profile of Kidney Health Across the Region
Throughout my tenure, it was important that I prioritised strengthening awareness of CKD—particularly its role as both a long-term condition and a risk multiplier for cardiovascular disease. Key CKD awareness raising initiatives which I contributed to included:
- World Kidney Day activities with renal services, community groups, charities and primary care networks
- Education events and professional development sessions for clinicians across primary and secondary care
- Supporting wider public-facing campaigns to improve understanding of kidney health and the importance of early detection
Initiatives such as these ensure CKD remains recognised as a priority within broader integrated care board strategic plans. Integral to this was strong inclusive patient voice shaping the conversations.
Kidneys and the Wider Long-Term Conditions Agenda
If I said it once, I would have said it many many times - CKD does not exist in isolation. As such, through my CKD leadership role, I have been pleased to support the inclusion of kidney health in the development and delivery of broader long-term conditions (LTC) programmes across WYICB. Drawing on house of care and intervention decay frameworks, as a member of the WY whole system LTC Oversight group, i feel I have been instrumental in embedding person-centred approaches and enabling a coordinated system response to improve kidney health.
By bridging silos across multi-LTC programmes and sharing best practice, I feel I have meaningfully supported and promoted integrated, high-quality care that places patients at the centre.
Learning, Leadership, and Lasting Relationships
My journey as WY CKD clinical lead has been an incredible learning experience, enriched by working alongside amazing leaders across health and care. Through collaboration, insight sharing, and exposure to innovative practice, I have gained a deeper understanding of system transformation, integrated care, and the potential of digital and community-based solutions.
Of equal significance, through this role I developed lasting friendships and professional networks that will continue to inspire and support me long into the future.
The West Yorkshire Kidney Health Strategic Commissioning Plan
One of the most forward-looking aspects of our work has been contributing to the early development of the West Yorkshire Renal Priority Pathway and subsequently to the co-production of the West Yorkshire Kidney Health Strategic Commissioning Plan. The overarching aims of the WY Kidney Health commissioning plan are to:
• Strengthen prevention and early intervention
• Improve community-to-specialist pathways
• Ensure equitable access to renal services
• Embed patient voice and co-production
• Enhance data capability for population management
The groundwork laid during my time as CKD lead leaves a legacy and provides a strong platform for the next phase of kidney health transformation in the region.
Closing Reflections
As I reflect on my time as CKD lead for WY, it is so encouraging to now see CKD being recognised as a global health priority by the World Health Organisation, reflecting the scale and urgency of the challenge we have been addressing locally. Equally encouraging is the West Yorkshire ICB’s commitment to a kidney health strategic commissioning plan which will bring together those committed to optimising kidney health outcomes across the system. A strategic commissioning plan for kidney health will provide all stakeholders across WY with a clear strategic framework to support prevention, early detection, and integrated care pathways.
I am a health equity fellow and champion. The M62 road divides our region into areas – there are more innovations and changes happening in the north of our patch with greater inequity in the south – this is something all those who continue to be involved in the development and delivery of the WY kidney health strategic plan must work to address moving forward.
I am deeply grateful for the collaboration, professionalism, and commitment shown by colleagues across West Yorkshire, as well as the constructive engagement of industry partners in supporting innovation. The progress we have achieved reflects collective effort, shared ambition, bridging silos of excellence, and a commitment to improving outcomes for people living in our communities through more joined up patient-centred care.
Although my formal role as CKD clinical lead in WY has concluded, I remain committed to supporting kidney health improvement and long-term condition management across the region. It has been an honour to serve in this capacity, and I look forward to seeing the continued development of kidney care within West Yorkshire’s integrated care framework.
System working is like a relay race and not a sprint, I am pleased to pass the baton to Dr Nick Bird as the incoming West Yorkshire ICB CKD Lead. Nick is a GP Partner in Bradford Place and will be continuing the next segment for improving kidney health of West Yorkshire.
A note of thanks on behalf of West Yorkshire Health and Care Partnership:
On behalf of the West Yorkshire Health and Care Partnership, we would like to thank Sunil for his outstanding clinical leadership, his enthusiasm and unwavering commitment to advancing high-quality and equitable kidney health for all. Sunil’s leadership and passion have been truly inspiring, and it is a privilege to work alongside someone who consistently drives positive change in such an important area of care.