Abstract
BackgroundEarly identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease.The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care.Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice.MethodsWe describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices.ResultsPrior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices.Conclusions‘Virtual’ specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.
Highlights
Identification of people with Chronic Kidney Disease (CKD) in primary care, those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease
In the 2011 UK Census, almost half of the population in each of these Clinical commissioning group (CCG) was recorded to be of non-white ethnic origin [15], and the English indices of deprivation 2015 show that all three inner east London localities fall in the lowest decile for social deprivation in England [16]
The majority of practices engaged with the Information technology (IT) tools, and within the first year CKD coding rates improved, with the lowest coding CCG improving performance by 50% [23]
Summary
Identification of people with CKD in primary care, those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease. The NHS Long Term Plan, released in 2019, envisages efficiencies in the management of chronic diseases and major changes to the delivery of hospital outpatient care which is described as outdated and unsustainable. It endorses digitally-enabled primary and outpatient care, which ‘will go mainstream across the NHS’, and ‘will free up significant medical and nursing time’. It endorses digitally-enabled primary and outpatient care, which ‘will go mainstream across the NHS’, and ‘will free up significant medical and nursing time’. [7]
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