Renal Health Service
A community service that connects patients, GPs and specialists for better care of Chronic Kidney Disease (CKD)
CEG and the renal department at Barts Health NHS Trust have developed a 'Community Renal Service' in East London. The initiative combines rapid access to community-facing kidney specialists with innovative use of patient data to improve management of CKD in primary care.
The Community Renal Service involves:
- An 'e-clinic', making it easier to get a specialist opinion When GPs make a referral they request patient permission for consultants to view the GP record. The community nephrologist then runs a weekly 'e-clinic' to review the records of referred patients. Specialist opinions are recorded in EMIS Web and are visible to GPs.
- Searches and dashboards to support coding in the patient record Clinical system searches help practices to identify cases of CKD that are not coded in the patient record. Improved coding is associated with better CKD management and safer prescribing. Dashboards help practices to compare their performance with others.
- 'Trigger' tools to identify patients at greater risk of disease progression CEG's 'Falling eGFR Trigger' tool is used within the GP practice, alerting clinicians to review patients with CKD who have an eGFR fall of ≥ 10 from the previous value.
- Educational resources for patients and practices Patient education sessions and resources to support self-management.
- Barts Virtual Community Kidney Service
- Have a look at this set of slides [PDF 1,166KB] which explains why we developed the system. It also illustrates some of the system outcomes.
- Guidance to support community renal clinics, July 2015 [PDF 389KB]
- Community Renal Services for North East London, Service Summary 2018 [PDF 1,707KB]
Practice trigger tool
The Falling eGFR Trigger tool was developed by CEG for practices to use on a monthly basis. It flags patients whose kidney function may be declining and who may benefit from a review or referral to the Community Renal Service.
How do I get hold of the trigger tool?
This tool is available free of charge to NHS GPs within the UK. Please complete the form below to request the package, which includes:
- Falling eGFR Trigger tool
- EMIS patient list report
- User manual
CEG's CKD clinical tools are designed to be used with the EMIS Web electronic health record. Every effort is made to reduce errors and omissions during their construction (see clinical safety record in Information Governance). All electronic tools are an aid to clinical management. They do not replace the need for clinician judgement based on personal knowledge of the patient.
***DOWNLOAD PAUSED: We have found a problem with the Falling eGFR tool following changes to the labs in City and Hackney. We have temporarily paused new downloads until further investigation and correction can be made.***
The 2017 National Chronic Kidney Disease Audit (NCKDA) demonstrated that there is considerable variation in practice performance on CKD coding, BP management to target and secondary prevention of cardiovascular disease for those with CKD. Read the results.
Practices and NHS commissioners can compare their performance using a dashboard showing key metrics important for CKD management in primary care. An example of the east London CCG level dashboard is shown here CCG/practice dashboard [PDF 255KB].
Why doesn’t the QOF register provide accurate data on people with CKD?
QOF registers are based on READ codes. About 40% of people with biochemical evidence of CKD – that is two eGFR values less than 60, ninety days apart – do not have a CKD code and won’t appear on the register.
About 10% of people on the CKD register have no biochemical evidence to support the diagnosis of CKD.
- Patient Info How to look after your kidneys [PDF 2,964KB]
- Barts Health: Conversation map for CKD [PDF 1,784KB]
- Barts Renal Service: Patient Information
- CKD Newsletter August 2019 Tower Hamlets [PDF 428KB]