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Clinical Effectiveness Group

Improving management of Chronic Kidney Disease

View over the Royal London Hospital with east London beyond

The challenge

Chronic kidney disease progresses slowly and is often associated with other long-term conditions. That means many patients are managing a complex combination of symptoms, and their kidney function can decline under the radar until it reaches a critical level.

In 2015, people with chronic kidney disease in north east London were waiting more than two months to see a kidney specialist (nephrologist) after being referred by their GP. When the appointment came, many patients didn’t benefit as much as they expected. They found it frustrating that the specialist couldn’t access their full GP record so did not have a full picture of their health.

Specialists also felt they were often seeing the wrong patient group – people who would not benefit from further investigation at hospital but instead needed advice and the ongoing support of their GP. But without a referring a patient, there was no way for a GP to ask for that advice.

What we did

The problem spanned hospitals and GP practices, so our solution spanned both too.

First, we made it easier for GPs to proactively manage patients with poor kidney function and make timely decisions about referrals. We supported GPs at 166 practices to increase coding of chronic kidney disease in the electronic health records. This makes patients countable, searchable and easier to monitor. We built dashboards to display relevant information on these patients easily, including their blood pressure and the offer of statin medication to reduce cardiovascular disease (one of the key associations with chronic kidney disease that can be improved). And we developed ‘trigger tools’ to alert GPs when blood tests suggest kidney function is declining.

Secondly, we enabled nephrologists at St Bartholomew’s Hospital to view full GP records (with patient permission). With this system in place, it wasn’t usually necessary for patients to see a specialist face-to-face. The specialist set time aside to review the patient’s record (an ‘e-clinic’) and decide on the best course of action. For some, that would mean a trip to hospital for further investigation. But for the majority (more than 80%) it resulted in expert advice to the GP so they could be managed in the community.

Better outcomes

Using the service, the time to receive an expert opinion from a kidney specialist was reduced from two months to six days. For 80% of patients, it eliminated a visit to hospital - particularly beneficial for people managing numerous medical appointments, mobility issues or dementia.

Using our tools, GPs can now proactively manage patients with chronic kidney disease, meaning fewer cases of declining kidney function go unchecked. We have already seen improvements in blood pressure management and statin use. In the future we hope these will translate into fewer cases of an unplanned start to kidney dialysis.

Better decisions

Specialists can now see a fuller picture of their patient’s health and make better informed decisions about a course of action. GPs can make equitable decisions about who to refer for a specialist opinion without needing to consider the upheaval of a patient’s trip to hospital, the need for someone to accompany them, or the impact if they don’t attend. With incentives and the support of commissioners, the service makes it easy for professionals to do the right thing.

Local learning, national impact

Year-on-year, the Community Kidney Service allows the local health system to learn from its data. Hospitals and commissioners can identify over or under-referrers and reach out to provide extra training and support.

Our Community Kidney Service tools are now available to download nationally, for free. The service is highlighted as an exemplar in the NHS 10-year plan and NHSX Renal Digital Playbook, and we continue to share the approach with our networks across the country. Our ambition is to enable equitable outcomes for more patients with Chronic Kidney Disease, as well as encouraging responsible use of health data for more effective and joined-up care.


Team: Sally Hull, Isabel DostalCrystal Williams and Zaheer Ahmed in collaboration with Professor Nicola Thomas, London South Bank University, Dr Neil Ashman, nephrologist at St Bartholomew’s Hospital, and Helen Rainey, renal nurse specialist at Barts Health NHS Trust. Evaluation funded by the Health Foundation.

Published research: Do virtual renal clinics improve access to kidney care? A preliminary impact evaluation of a virtual clinic in East London.

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