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What is the challenge your project is going to address and how does it connect to your chosen theme?

Moderate to severe chronic kidney disease (CKD) affects approximately 1 in 16 adults, leads to thousands of premature deaths, affects quality of life and presents a growing burden in terms of both patient numbers and costs of care. The number of people receiving renal replacement therapy increased by 29% between 2002 and 2008, with the annual cost for a patient on dialysis estimated at £27,000.

Identifying earlier stages of CKD and improving their management across the primary / secondary care interface has the potential to improve health outcomes. We have developed an integrated IT system which has demonstrably improved outcomes for patients with CKD in the early adopter CCGs. The rate of patients requiring dialysis in Camden and Barnet has plateau’d, in contrast to most of London and the UK where it has risen substantially in the last decade.

The challenge is to identify the 30% of patients who have undiagnosed CKD, and ensure appropriate treatment plans, with referral if needed.

What does your project aim to achieve?

Identify patients not previously known to have CKD (reduce the ‘prevalence gap’) to provide opportunities for earlier intervention. Inequity of access, social factors and psychological as well as physical factors (e.g. frailty) contribute to patients not being identified or referred.

Diagnosis, appropriate monitoring and treatment with an integrated approach will help ensure patients with CKD are cared for in the most appropriate healthcare environment, addressing risk factors for cardiovascular disease, stroke and progressive CKD. Up skilling and education of primary care clinicians will ensure patients can be safely managed in the community, reducing unnecessary outpatient attendances and creating capacity for secondary care to focus on more complex patients.

Individual patients should benefit by having better health outcomes. There should also be improvements seen in staff experience, patient flow, and financial costs (e.g. appointments, admissions, dialysis).

How will the project be delivered?

A proforma IT template has been established to enable GPs to provide patients with individually tailored CKD care plans and community based renal specialist nurses enable quick access to specialist advice.

We already have a core team including doctors, nurses, patients, administrative staff, commissioners who have been instrumental in delivering the pathways of care.

The plan is to perform an analysis of referral patterns of GP practices to reveal unwanted variation in CKD registers. Using this data, we will identify patients with undiagnosed CKD and then plan better care. For example, patients in care homes who may not be suitable for hospital visits but need supportive care, optimisation of medicines and advanced care planning. We will work with the integrated community ageing team (ICAT) – a consultant led multi-disciplinary team who support care homes. We will also engage the local community to support patients who face barriers to good care, due to social isolation or poverty.

What and how is your project going to share learning throughout?

There are several aspects to the potential for learning.

Clinical management: our integrated CKD template which is already approved for use across the whole of the NCL STP is already a valuable learning resource, and the method by which it is used by GPs is already spreading learning across into primary care, enabling them to provide better care for their patients.

Public health: this approach which encourages us to identify patients whose needs are not being identified or met, perhaps due to inequalities in access, and at an earlier stage of long term health conditions. The approach to management has a focus on early diagnosis, early intervention and patient support to improve quality and length of life.

This approach is widely applicable  beyond CKD, as it could be used for many other long-term conditions.

The knowledge gained will be disseminated through publications as well as sharing with our local commissioners, GP publications and websites, UCL Partners, and on this platform.

How you can contribute

  • Link us up to other groups who have already done something similar
  • We would like to consider doing a public engagement workshop - can you suggest a location (free!)
  • Public health expert to provide input to help understand and identify areas / groups with high unmet needs
  • Health economic evaluation expertise to help support our analyst in determining the potential cost savings

Plan timeline

24 Oct 2019 Publically launch NCL CKD template on GP websites
24 Oct 2019 Re-launch unified EMIS template across NCL
13 Nov 2019 Analyse referral pattern for Islington GP practices (start)
4 Dec 2019 Community engagement event with stakeholders
1 Jan 2020 PDSA 1 - Social prescriber to start work with patient groups
3 Feb 2020 PDSA 2 - Visit Islington localities with high prevalence gap
2 Mar 2020 Launch IT template in Haringey
9 Mar 2020 Start reviewing referral patterns from Haringey CCG
4 May 2020 Depending on results of pilot, start process in other CCGs
1 Sep 2020 Economic analysis of costs and potential savings


  1. Hi I've certainly got an interest in CKD and my department has just embarked on an overhaul of the way we run our clinics (which are overwhelmed). We've spent some time doing primary care training and have provided links for management guidelines, but without much effect. I'd certainly be interested in learning how this goes and whether its something that can be used in our area. Barts and the London have had a big project on something similar, so it might be worth contacting them. Please let me know how you do.

    1. Thank you Aroon. Please see our project here from Barts

      - we would welcome comments or suggestions from you.

  2. A similar project has been running in East London (part funded by the HF), so good idea to make contact with us so we can share learning

  3. Dear team,

    what a great idea! Have you connected with other fellow Qs with an interest in CKD?

    best wishes


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