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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 affects 2.6 million adults in England, approximately 1 in 16 people. Over the age of 75, 1 in 3 are affected.

We have already developed new ways of working in CKD locally, and reduced waiting times for new appointments by improved triage processes, shifting the identification, initial investigation and management away from secondary care and into the community and at the same time improving the quality and timeliness of kidney care by using integrated IT solutions, pan-network collaboration, community nurse clinics and workforce education through guided experience can deliver faster, more effective care, and at the same time improve patient experience.

However, many of our patients have co-morbidities, including diabetes, cardiac disease, peripheral vascular disease and they are also increasingly frail. The challenge is to meet the patients’ needs, providing individualised, patient-centred care and pathways in a co-ordinated and holistic way.

What does your project aim to achieve?

The objectives will include:

  • Improved patient experience
  • Co-ordinated medicines management
  • Reduced number of different specialty outpatient appointments (e.g. diabetes, renal and cardiology) for a single patient
  • Better communication across hospitals and between primary and secondary care, with the avoidance of delays due to lack of relevant documentation

How will the project be delivered?

Our aim is to develop an integrated care platform and face to face clinic service, using GP-based records and community nurse clinics with hospital-based specialist support which can provide multi-specialty care.

The template for CKD care is already in place in some of our local CCGs.

We would work with local

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

There is great potential for our current integrated IT platform / system to be disseminated more widely, both geographically, but also across other specialties.

GPs will be learning through direct experience and support from hospital consultants.

Patients will have the opportunity to work with nurses trained in motivational interviewing techniques as well as access to community services for social and psychological support which will help them self-manage their diseases


  1. Thanks Nicola - yes, RFH and RFL have been sharing ideas and this work for a long time. As a team have decided to go forward with our other idea, working across boundaries to reduce the prevalence gap and thereby improve patient outcomes in CKD - do please take a look and see what you think.

    Kin Yee

  2. You might like to be in touch with the team at Barts Health who have made great strides i this area already - whole new approach to CKD management including trigger tools, e-clinics and community patient education led by specialist kidney nurses

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