Improving the care of patients living with Chronic Kidney Disease
North London Partners’ chronic kidney disease (CKD) project has developed an innovative virtual healthcare model to improve the care of patients living with the condition, blogs Dr Jenny Cross, Clinical Director Nephrology, Urology, Transplantation.
The project aims to provide an integrated service between primary and specialist care, against consistent nationally agreed criteria across north central London (NCL). The aim is to:
- Reduce inconvenience for patients by preventing unnecessary hospital visits where appropriate
- provide consistent, improved quality of care
- maximise the number of patients cared for by their GPs closer to their homes
- reduce the waiting time for face-to-face appointments for those patients who are complex and need specialist care
Between 5 and 11% of the adult population suffer from some degree of CKD. The condition is usually asymptomatic with patients only developing symptoms at an advanced stage.
The Royal College of Physicians has highlighted the rising demand for specialist services to assess patients with CKD as awareness grows of the importance of identifying patients at risk of CKD. However, there has not been a commensurate expansion in the number of specialists to manage the workload and provide effective timely and responsive care to patients. This has led to long waiting times for patients to be seen in specialists clinics. The Royal Free London (RFL) pioneered this innovative, virtual CKD consultation service.
There are many causes of CKD but the commonest are diabetes and hypertension which account for approximately 80% of those on dialysis.
CKD, like smoking, diabetes and hypertension, is a powerful independent risk factor for cardiovascular disease. The number of people with CKD is estimated to increase from 2.5m in 2011 to over 4m by 2036. Routinely screening high risk groups, such as hypertensives, diabetics and those with vascular disease, stroke or ischaemic heart disease, results in earlier early identification of CKD. Investigation required for identification are renal function, a urine dipstix test and a urinary albumen creatinine ratio. These provide an opportunity to address the 40% prevalence gap in the identification of CKD and in earlier management of the cardiovascular risk and thus improved outcomes for patients.
The virtual clinic was first trialled by Camden CCG six years ago, it was effective and subsequently Islington and Barnet CCGs adopted the model. The clinics are managed by experienced consultants within Royal Free London (RFL) known to local GPs which provides them with confidence in the model. Consultants are given secure access to EMIS, the patient’s GP record, which can be reviewed in real time and provides the consultant with the most complete detailed information about the patient’s medical history. This enables the consultant to provide the GP with advice and guidance and a written comprehensive care management plan, which can be stored within the patient’s notes. Those patients who need to be seen are selected and offered a more timely appointment in an appropriate specialist clinic giving primary care access directly to our specialist services which reduces patient clinic visits.
Data from the three CCGs participating in the service (Barnet, Camden and Islington), covering a registered population of almost a million patients, demonstrated a reduction in both waiting times from 14 to 5 weeks and the need for face to face appointments by 50%. This enables GPs to confidently manage patients in a primary care setting.
Patients that consultants and nurse specialists judge require a secondary care assessment are now seen more quickly, often with pre-investigation (so if they need an ultrasound scan before the visit this is organised) to make the most efficient use of a single visit. It also allows direct access to specialist services that GPs cannot currently book into such as, reno vascular, vasculitis, genetic, tubular, stone or dialysis clinic.
There are benefits for all. It is good for patients as it reduces waiting times and reduces unnecessary hospital visits while ensuring they still get access to consultant-led care plans based on their full medical record. Those most at risk are seen in clinic earlier. It is also good for GPs who are being upskilled in managing CKD in primary care as the referral algorithm describes the source and rationale of the guidance.
The virtual clinic was pioneered by Dr John Connolly and nurses from the renal services Sheila Johnson and Sara Milne, along with Dr Kin Yee Shiu.
When it was first trialled there was a concern that the virtual review would result in bounce-back in patients needing to seen in clinics. But when the scheme was audited the results showed that between 5 and 8 per cent patients have a second virtual referral within 6 months and, typically, this results in more advice to primary care on management.
It means that consultants are working with GPs and providing timely support not possible before. The time that would have been spent on one-to-one appointments with the consultant is now used to work directly with GP practices on educational events to develop the principles of care management in order to extend it to their own population.
None of this would have been achieved with the pioneering spirit of can do in primary care and the CCGs.
There are plans to roll out a virtual clinic in Haringey in 2019 followed by Enfield, it is hoped, at a later date.
Barts Health quickly saw the advantage to the approach and adopted the process for Tower Hamlets. Imperial, the West London unit, has also adopted the principles of the virtual review.
Consultants taking part in the CKD virtual clinics across the NLP include:
- Dr Peter Dupont, Barnet CCG
- Dr Jenny Cross, Royal Free London
- Dr Ciara Magee, Barnet CCG
- Dr Phil Masson, Royal Free London
- Dr Kin-Yee Shiu, Haringey CCG
- Professor David Wheeler, Camden CCG
- Dr Robin Woolfson, Islington CCG
Dr Jenny Cross is Clinical Director Nephrology, Urology, Transplantation Consultant Nephrologist and Honorary Senior Lecturer UCL Centre for Nephrology. Email firstname.lastname@example.org