Working together to improve kidney care across London
Overview:
In early 2023, modelling of in-centre haemodialysis growth in London showed that demand would exceed capacity by 2030. Work to reduce the numbers of people reaching end stage kidney disease, and to improve access to other renal replacement options, was therefore vital.
Working collaboratively, the five London ICSs developed a Renal 3Ps transformation programme. These had proactive, predictive and preventative care at their centre, intending to reduce long-term costs, improve quality of life, and reduce pressure on services. Each ICS developed a programme based on their population’s needs and service priorities.
NHSE (London) funded this £10m programme of work, deliverable over a rolling two-year period, to improve kidney care and outcomes across London.
Working together
While every ICS identified their own priorities, there are key common areas of work across London. These are:
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- CKD Prevention and early detection
- Advance Kidney Care (including home therapies, transplantation and supportive care)
- Frailty
- Cardiorenalmetabolic management
The LKN clinical workstreams provide clinical leadership and peer support for their subject area projects. This has allowed London-wide clinical consensus to drive implementation of transformation and to minimise unwarranted variation.
The LKN has hosted two communities of practice. The first- the London Renal Collaborative- met intensively to support the programme development until funding was agreed, and then monthly for six months. This provided an opportunity for ICS leaders to share successes and concerns, and to support the set-up of their projects. Subsequently, oversight has come via the London Kidney Transformation Board, which meets quarterly.
The second, the Renal Evaluation Working Group, has sought to agree a shared data set to support evaluation across London and ICSs. Membership includes programme leads, clinical experts, data leads from the Trusts, and the Midlands and Lancashire CSU.
Progress:
The programmes of work started in 2023-2024. Each ICS’ programme of work is beginning to deliver, with end points and final reporting expected across the next year (staggered starts and different project aims and objectives mean projects will deliver at different points throughout 2024-25).
South West London
1. Early Prevention and Detection in Primary Care – Test and evaluate early detection and prevention of progression of CKD in the community by:
a)implementing SWL CKD management guidelines including deelping a CKD register, medical optimisting those who are elegible, and identifier those on the registers who are eligible for SGLT2is
b)reporting quarterly against agreed KPIs.
c)Participating in the education and training available
d)Undertaking and supporting community engagement to raise CKD awareness
2. Cardiorenalmetabolic MDT – to reduce admissions and LoS in frail ealdery with heart failure and CKD
3. GESH Supportive Care – Test new pathways of care, specifically geriatric assessment in AKCC, and enhance staff training
South East London
1. Implement the Multi-Morbidity Model of Care
build a person centred, holistic, horizontally and vertically integrated model of care for people with multiple LTCs across the pathway.
a) Prevention and Screening
b) Community-based patient optimisation
c) Community Case Management (inc Consultant input)
North West London
1. Improve CKD care in NWL (previously Ealing) – Review patients on GP SystemOne registry to help primary care improve screening, coding and optimisation of people at risk of and with early CKD and to support practices deliver against the NWL CKD enhanced service specification, in conjunction with secondary care specialists.
2. Cardiac Renal Metabolic (CRM) hubs in Harrow – Build a model for primary care based cardio-metabolic hubs including a multi-disciplinary and integrated care hub to decrease co-morbidities in the areas of CKD, CVD and diabetes.
3. Improving diabetes care in people on dialysis to improve transplant outcomes – People on dialysis with diabetes will be reviewed to audit standards of care against renal association guidelines. Educational packages for patients and clinical teams will be developed to improve care and a referral pathway for clinical support will be developed with diabetes leads in NWL Trusts and primary care.
4. Accelerated Pathway for advanced kidney care – Pilot will support enhanced infrastructure for acute kidney care to support patients decision-making in the correct choice of modality for renal replacement therapy (RRT) short and long term.
5. Patient education and support – Further develop existing education programme to improve accessibility to virtual seminars and additionally offer face to face, one to one and out of hours options and a greater range of information.
6. Embedding frailty support in advanced kidney care – 3x PA consultant geriatrician will be included in AKCC and provide specialist opinion and advice, including support advanced care planning for patients in haemodialysis units. Model of care that addresses the health, social and wellbeing needs of geriatric patients who are under the care of renal medicine to also be developed
7. Advanced Care planning – A CNS will work in partnership across the sector haemodialysis units to support training and development in advanced care planning, identification of patients who would benefit from ACP, support for patients to engage with ACP, and ensure robust methods of sharing ACP with other care providers such as GPs, allied health care and transport providers.
North Central London
1. Early Identification and Management
In order to reduce our NCL population requiring CKD or more complex renal services, two searches have been created to:
Search 1: Case finding for people with indicators suggestive of CKD but no diagnosis.
Search 2: Case finding for Haringey and Enfield patients who are at risk of CKD who are not on the CKD register and have not had an Estimated Glomerular Filtration Rate (eGFR) or Urine Albumin-Creatinine Ratio (uACR) done in the last 12 months.
2. Community CKD – Expansion of integrated Chronic Kidney Disease CKD support service to patients living in Enfield and Haringey boroughs.
The integrated CKD service comprises a consultant-led triage service, community-based specialist nurse/pharmacist-led CKD clinics, provided by the Royal Free London (RFL) in primary care locations, an education programme to support CKD management in primary care and prompt CKD management advice for primary care.
3. Increase access to transplantation –
a)Establish a multi-professional weight loss clinic for transplantation
b) Establish a link nurse to grow living donor and pre-emptive transplantation
4. Create a Dedicated home therapies team and MDT – with a particular emphasis on growing home haemodialysis
5. Establish a frailty, ACP and supportive care MDT – with dedicated time for elderly care physician, OT and psychologist
North East London
1. Early identification and management of CKD and CVD risks:
a)Trained pharmacists will provide training and advise to PCN pharmacists in medicine optimisation. The PCN pharmacists will then prescribed the appropriate medications
b) Work with VCSE and local communications to education and inform peopole about key public health messages realating to cardiorenalmetabolic, and respiratory disease (co-funded from other incomes streams)
2. Young adult Unit – This aims to provide a purpose built dialysis unit for Young Adults, to improve experience, reduce crisit admissions, and co-locate with other young adults (providing funding for young adult worker and unit fit-out to support existing plans)
3. Home Therapies and Self-care – Funding from 3Ps will provide additional staff for the Independent Treatment Centre (ITC). PAs will support and educate patients on performing self-care dialysis in a home from home setting.
4. Accelerated AKCC Pathway – Provide a better patient experience and outcomes for late presentated. This includes increased uptake of home therapies, and rapid work up for transplant waiting list.
5. Frailty CNS – to provide more effective and efficent support to the growing cohort of frail and/or eldery patients iwth advanced kidney disease, including those who may not benefit from dialysis and wish to be managed conservatively.
You can see examples of work from ICSs below. This page will be regularly updated as work is completed and is ready to share.
South East London
What is the project?
The South East London (SEL) ICB multi-morbidity model of care project (MMMoC) aims to build a person centred, holistic, horizontally and vertically integrated model of care for people with multiple long term conditions (LTCs) across the pathway. We are risk stratifying our project site populations and using local resources (CESEL guidelines and NEL CEG risk stratification tool) to:
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- Target the use of at home urine ACR test kits to identify undiagnosed CKD in the population that we historically struggle to reach
- Conduct community work to identify undiagnosed CKD among the population we historically struggle to reach
- Run medicines optimisation work for a ‘long list’ of patients including point of care testing clinics
- Provide holistic and personalised case management for a short list of complex patients with a vertically and horizontally integrated team of clinical and non-clinical staff
- Run regular multidisciplinary team meetings to ensure support from a range of experts to augment patient care and keep it in community
We have also employed two multi-speciality pharmacists to work across primary and secondary care in SEL and are developing a supportive care offer to ensure those with end stage kidney disease receive holistic care and support.
Why choose that area?
Those with multiple LTCs often experience a lack of coordination in their care, multiple appointments in multiple settings and a lack of personalisation or holistic approach. One third of the SEL population have one LTC, with 300,000 of these people having two or more, and this population suffer from significant inequalities. Meanwhile, LTCs account for 50% of all GP appointments, 64% of all outpatient appointments and 70% of all inpatient bed days. Therefore, in SEL we have identified a clear near for proactive, preventative interventions across the multiple LTCs pathway. This approach is inspired by the Fuller Stocktake Report, The House of Care model and the SEL LTC Framework.
Findings so far
We have seen approximately 2000 patients across our various clinics and interventions so far. Patients have shared positive feedback about the service, with 93% of patients saying that they would refer this service to their friends and family. Meanwhile, staff have expressed the benefit of the integrated approach to working, stating how it ‘enhances communication and reduces silos, creating a supportive environment where I feel valued and empowered’.
To find out more
Please get in touch with the project manager, Lauren Blum at [email protected] or with the SEL ICB LTC lead, Rob McCarthy at [email protected]. Alternatively, you can request to join our NHS futures page here.
Further resources
Keep a look out for our staff video and ‘How to’ guide for setting up this style of working in the new year.
South West London
What is the project?
People and community engagement, activation, and empowerment.
Why choose that area?
Increasing CKD awareness within the community not only motivates more individuals to get tested and seek advice on managing their condition, but it also significantly bolsters primary care initiatives. By raising awareness, we can enhance the early detection of patients at risk of developing CKD, optimise the use of medications, and ensure that treatment is provided to all eligible individuals in accordance with NICE guidelines. This concerted effort helps to identify at risk populations, improve management strategies, and ultimately supports better health outcomes for those affected by CKD.
Over the past months, the SWL Renal Programme has successfully conducted a number of awareness and engagement events, making significant strides in educating and mobilising our community around CKD prevention and management. Our plans for future events aimed at further strengthening our collective efforts, present the opportunity for shared learning ahead of Year 2 community engagement and awareness activities.
In alignment with these goals, we are planning to deliver a CKD community engagement learning session. This session is designed to bring together stakeholders from various sectors to foster collaboration, share knowledge, and enhance our collective efforts in promoting renal health within our community.
The benefits of engaging directly with the community are multifaceted. By empowering individuals with the knowledge and resources they need, we can make a profound impact on the detection, prevention, and management of CKD. Together, through these initiatives, we aim to build a healthier, more informed community that is well-equipped to tackle CKD and support those affected by it.
Findings so far
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- Communities are keen to learn more about CKD and how to prevent it.
- Engaging a wide range of stakeholders has highlighted the importance of diverse perspectives in addressing CKD, leading to more innovative and comprehensive strategies.
- These events have enhanced collaboration among healthcare providers, patients, caregivers, and community organisations, resulting in a more unified approach to CKD prevention and management.
Further resources
CKD Toolkit Chronic Kidney Disease in our local commmunity
View PDF
Toolkit accompanying materials
Download ZIP file
North-Central London
What is the project?
Kidney Fitness in Transplantation Pilot Project
The Kidney Fitness in Transplantation (K-Fit) Pilot is a Multidisciplinary weight loss & fitness program for renal patients living with obesity. Its primary aim is to help patients meet criteria for activation on the transplant list through a 6-month MDT intensive intervention with the opportunity to extend to 12 months; combining lifestyle changes, psychological support, and the use of weight loss medication (Semaglutide).
Our team includes a Consultant Health Psychologist, Cognitive Behavioural Therapist, CKD Dietitian, Renal Pharmacist, Physiotherapist & Consultant Transplant and Access Surgeon – Lead Clinician
Why choose that area?
Within North Central London there is unfortunately no structured Tier 3 weight management service to offer renal patients to support with weight loss. There is also no funding to support the use of GLP-1’s such as Semaglutide for weight management in our patient group.
Local data has shown us that approx. 30% of renal patients are living with obesity and in approximately 60% of those patients, obesity is the leading modifiable barrier to listing for kidney transplantation. Prior to the K-Fit service many of our patients would be un-listable for transplant. They would be offered repeated 6-month follow-ups with the transplant team however in view of limited MDT funding & support, most patients were unable to loose the required weight to be listed.
By offering a multidisciplinary weight loss & fitness program for renal patients with the option to consider the use of Semaglutide – we are offering a novel collaborative programme which will offer patients the chance to be supported with weight loss and potential activation on the transplant list if the criteria is met. Dialysis patients especially those precluded from transplantation secondary to obesity are benefitting from this programme.
Findings so far
We are pleased to have recruited all 44 patients onto the K-Fit programme and now have a short waiting list. Approx 17 patients have entered the programme and seen all the members of the MDT. They are showing positive steps towards their weight loss goals with and without the use of Semaglutide. 2 patients have met their weight loss goal and have been activated on the transplant list. The remaining patients have appointments to be seen.
To find out more
To find out more about the K-Fit Pilot Project, please contact the North Central London Integrated Care System or reach out directly to the project team.
North-East London
What is the project?
The North-East London Renal Chronic Kidney Disease Cardiometabolic pilot.
The Cardiometabolic approach pilot aims to:
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- Improve diagnosis and coding of chronic kidney disease (CKD)
- Improve medication optimisation to reduce CKD and cardiovascular disease (CVD) progression in Primary Care.
Pharmacists have been commissioned to deliver training and advisory of PCN pharmacists across North East London in medicines optimisation to improve prevention of CKD and outcomes via early detection and management of CKD and CVD risk factors.
The PCN Pharmacists will therefore play an active role in the early identification and management of CKD and CVD risk factors, reducing the proportion of patients with end stage renal disease requiring dialysis and transplantation, and the risk of cardiovascular disease such as heart failure and heart attacks by medicines optimisation to manage their conditions.
Medication optimising therapies include Blood pressure threshold attainment; Renin-angiotensin system inhibition (RASI); and Lipid-Lowering therapy (LLT).
Why choose that area?
Across North East London 489,000 people (25%) live in areas ranked in the most deprived in England. Local data shows approximately 66,000 registered adults live with CKD in North East London where CKD diagnosis rates are lower than average within England.
Prevention interventions are key to ensuring we keep our population healthy for longer, preventing progression of CKD and thereby reducing demand on acute services.
Findings so far
Local data in showed 26% of patients with CKD in North East London were not on Renin-Angiotensin System Inhibitors, only 50% of patients were on a statin and less than 30% were on Sodium-Glucose Cotransporter 2 Inhibitors (SGLT-2i).
PCNs and GPs have shown real interest to this CKD prevention work and have engaged well resulting in a joint approach in tackling inequalities and CKD progression. Since the inception of the pilot, we have seen attendance of over 160 PCN Pharmacists undertaking the CKD training sessions.
To find out more
To find out more please get in touch with the Long-Term Conditions Project Lead, Harwinder Aujla [email protected]
Further resources
APL Renal tool https://www.qmul.ac.uk/ceg/support-for-gp-practices/resources/software-tools/apl-renal/