Clinical Effectiveness Group

The Renal Health Service menu

The Renal Health Service

The Community Renal Service

A community renal service to connect patients, GPs and consultants for better care of Chronic Kidney Disease (CKD).


CEG and the renal department at Barts Health NHS Trust have developed the East London Community Renal Service. This combines rapid access to community facing renal specialists alongside innovative use of primary care data to improve coding, primary care management and “trigger” tools to identify patients with a falling eGFR who are at greater risk of progression.

The Community Renal Service involves:

  1. The community CKD virtual clinic
  2. The community nephrologist runs weekly virtual e-clinics in EMIS web. When GPs make a referral they request patient permission for consultants to view the GP record. All specialist opinions and reviews are recorded in EMIS Web and visible to GPs.
  3. Searches and dashboards to support coding and CKD management in practices
  4. Regular searches to identify uncoded CKD cases. Improved coding is associated with better CKD management and safer prescribing. Dashboards help practices compare their performance with others.
  5. Electronic tools to identify patients with a falling eGFR, which trigger an alert for review or referral
  6. Monthly practice safety alerts to review CKD cases with an eGFR fall of ≥ 10 from the previous value.
  7. Patient and practitioner education
  8. Patient education sessions and self-management resources are available from the Barts Health website

For more information visit: Barts Virtual Community Kidney Service

A guide to the system

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.
For more information you can download:

Prevalence improvement searches

We suggest that practices run a prevalence improvement search every six months to identify potential uncoded cases of CKD.
To download the EMIS CKD prevalence search click the link Prevalence Improvement Searches

Practice trigger tool

The trigger tool for falling eGFR is one of the tools developed by the Clinical Effectiveness Group (CEG). The aim is to flag up to practices, on a monthly basis, patients whose kidney function may be declining and who may benefit from primary care review, or referral to the community renal clinic.

How do I get hold of the trigger tool?
This tool is freely available to NHS GPs within the UK. complete the form below to download the Trigger tool package, it includes:

  • Trigger tool
  • EMIS patient list report
  • User manual

Comparative dashboard

The 2017 National CKD Audit (NCKDA) demonstrated that there is considerable variation in practice performance on CKD coding, BP management to target and secondary prevention of CVD for those with CKD. The results can be read here.

Practices and CCGs 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.

Useful links

CKD Coding Advice CEG v1 [PDF 345KB]
NICE Chronic kidney disease in adults 2015: assessment and management
National CKD Audit
Barts Renal Service for Clinicians

Information for patients

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 Project Newsletter TH, Feb 2018 [PDF 528KB]

Need help?

Ana Gutierrez
Senior Primary Care Facilitator

Return to top