Improving identification and preventing progression of chronic kidney disease in North West London (NWL)
A multidisciplinary approach to transforming CKD care
Background
Over the last 10 years, there have been many successful initiatives in NWL to improve the management of CKD through better integration between primary and secondary care. However, the rising tide of CKD in NWL remains a major public health concern with growing cardiovascular complications and capacity issues associated with end stage renal failure.
An innovative approach was needed to identify and address the issues earlier in the management of CKD. Following successful pathway improvement programmes in type 2 diabetes and heart failure, the NWL DiscoverNOW consortium partnered with the London Kidney Network Prevention Workstream to identify and tackle the CKD related challenges facing primary care and patients. The partnership also included service designers from AstraZeneca, people with lived experience of CKD and experts in Patient and Public Involvement and Engagement (PPIE), health inequalities and public health from the NWL Applied Research Collaboration.
In April 2022, the project was granted 12 months funding by the NHS Insights Prioritisation Programme (NIPP), which was set up to accelerate the implementation of promising innovations that deliver ongoing benefits to patients.
Approach
A deep-dive multidisciplinary approach was used involving:
• NWL primary and secondary care
• People with lived experience of CKD and caregivers
• Academics and data analysts from Imperial Health College Partners
• Experts in patient and public involvement, public health and health inequalities from the NWL Applied Research Collaboration and the London Kidney Network
• Service designers and project managers from AstraZeneca
If you would like to learn more about the project approach you can watch this video.
The aim was to develop simple and effective solutions that supported primary care and patients to increase:
1. Identification and screening of patients at risk of CKD
2. Appropriate coding of patients with CKD
3. Patients’ understanding and ability to manage their CKD
4. Optimal care of patients with CKD in primary care
Results
A CKD toolkit / package containing solutions that primary care can use as part of existing activities and appointments with patients with type 2 diabetes, hypertension and/or cardiovascular disease. NWL has put in place a locally enhanced CKD service to support the delivery of this toolkit.
These are the solutions available to primary care clinicians outside of North West London:
Resources
Primary care patient searches and dashboard
Information for people at risk of CKD or living with CKD
Primary care CKD review templates
If you are interested in understanding how the project was delivered, you can read more about patient and clinician interviews, co-design workshops and solution development sessions in the additional project information section below.
Additional project information
Find out more about how the project was delivered
NWL CKD project overview
Summary of interviews and workshops with patients and clinicians
Summary of solution development and testing