The challenge
CKD is often linked with other health conditions such as diabetes, heart failure and metabolic disorders and is associated with significant cardiovascular morbidity and mortality, as well as prolonged hospitalisation. There are 75 unplanned hospital admissions for every 100 individuals with CKD at stage four (kidney function less that 30%) each year. CKD costs around £10 billion of NHS funding per year (NHSE figures 2010-2011).
CKD is also associated with a high degree of clinical variation and clinical inequalities of care, related to deprivation and ethnicity. Therefore, the management of CKD often requires a holistic approach to patient care.
The solution
Improving clinical variation and clinical inequalities of care for patients with CKD is dependent on the following actions:
- Early identification of CKD and risk stratification of high-risk individuals, including urine albumin creatinine ratio (ACR) measurement and the vanguard implementation of the locally developed and NICE recommended Kidney Failure Risk Equation (KFRE), for prediction of progression to needing dialysis or a kidney transplant.
- Early intervention to manage risk factors and slow down CKD progression, including medicines optimisation with SGLT2 inhibitors, which are effective in reducing the progression of CKD, leading to improved health outcomes in relation to delaying the need for dialysis/kidney transplantation, hospitalisation, cardiovascular events and all-cause mortality.
- Timely and appropriate referral to specialist services
We set out to achieve these ambitions through:
- Patient and multi-disciplinary team standardised education material in relation to CKD, including YouTube videos
- Implementation of the KFRE into routine clinical practice to risk-stratify referrals
- Integrated, multi-disciplinary, virtual clinics for the management of patients with CKD
At Willows Health Primary Care Network (PCN) we were working on improving chronic disease management, when we came to know of a similar project being run at the renal department at University Hospitals of Leicester NHS Trust (UHL) and we took this opportunity to integrate the two services. Medicines optimisation through this collaboration involves primary care pharmacists and hospital-based pharmacists prioritising medicines optimisation for CKD and CVD prevention.
The project started with two pilot PCNs, Willows Health and Belgrave and Spinney Hill, and now has almost all of Leicester city’s and half of the county’s PCNs onboard, covering a patient population of almost 700,000. This service provides a consultant-led service for a monthly multi-disciplinary team meeting with a PCN to optimise patients with CKD at stage 3 and 4. The multi-disciplinary teams are led by renal consultants and pharmacists, to help promote education and patient care at the same time.
There was no system funding available and we approached pharmaceutical companies to support the project, in addition to personal time and resources which was not funded.
The biggest challenge was to introduce the PCNs to this multi-disciplinary team style of working with UHL and to upskill the primary care workforce. CKD was discussed with all the clinical directors of the Leicester city PCNs and the decision was taken to highlight CKD as one of the five priorities to be delivered this year. This approach helped onboard the PCNs and helped to facilitate this project being rolled out to the whole of Leicester city.
Impact
As well as ensuring medicines optimisation for 100 individuals in 2022/23, the LUCID pilot has allowed for the management of approximately 300 individuals in a virtual setting. It is estimated that when all 26 PCNs in LLR are participating in LUCID clinics, this could lead to a reduction in approximately 200 referrals a year with estimated savings of £130,000, whilst still delivering optimum treatment for these patients.
The LUCID pilot has achieved:
- Better clinical outcomes and improved patient safety – faster referrals, quicker optimisation to stop disease progression and provide holistic care.
- Improvements to staff wellbeing and general working – integrated working, shared management plans, enhanced skills of clinicians to understand the disease, pathways and challenges/limitations in the system in both primary care and secondary care settings.
- Workforce integration at all levels – consultants, GPs, pharmacists, nurses, trainees and managers.
Patients are made aware of the discussions about their case, with the view of optimising their CKD care without the need to visit the hospital. This has led to positive feedback from patients and their families, such as: ‘I am impressed by the care my husband has received, It’s lovely to know he has a team….looking after him in the background’.
This initiative has the potential to form a basis for the integration of other specialities and has been shortlisted in the HSJ Awards for Medicines, Pharmacy and Prescribing Initiative of the Year.