Newham GP practices praised for improving kidney care

Work undertaken by GP practices in Newham is helping to deliver major improvements in the care provided to people with chronic kidney disease (CKD), latest figures show.

Under the East London Community Kidney Service, practices in the borough are working with Barts Health NHS Trust and the Clinical Effectiveness Group (CEG) at St Mary University of London to improve the identification and management of CKD.

As part of this, practices have been seeking to improve their coding patients with evidence of CKD – allowing GPs to work closely with hospital consultants to better manage their care.

Before the service was rolled out in July 2017, Newham Clinical Commissioning Group (CCG) had an average coding rate across its member practices of 50 per cent.

Figures for April 2018 show the rate for Newham has risen to 81 per cent – with some practices improving from 35 per cent to 80 per cent over the past 10 months.

Dr Prakash Chandra, chair of Newham CCG and clinical lead for the project, said: “I’m delighted – these figures highlight the excellent work that our GP practices are doing to improve care for patients with CKD. It’s an outstanding achievement.

“Chronic kidney disease affects about six per cent of adults in Newham and east London has high rates of diabetes and hypertension which are major risk factors for CKD.

“Coding of patients is important in addressing this – it’s a key marker that aids diagnosis and clinical management – so the improvement we’ve seen since July 2017 is hugely significant. It builds on the great work that our practices have been doing alongside our partners at Barts and the CEG as part of the East London Community Kidney Service.”

The East London Community Kidney Service was shortlisted for an HSJ award last year in the Acute Sector Innovation category for the way technology has been used to improve care.

Under this approach, lab data in electronic health records is used to identify patients with renal problems who have not been diagnosed, and those at risk of rapid progression. GPs then review the at-risk group and, if indicated, make a referral to the nephrologist using e-referral.  Via a data-sharing agreement, Barts’ consultants can then access patients’ records to provide management plans and record them in the GP notes.

Enabling GPs to work more closely with consultants in this way means patients can be effectively managed in primary care and via ‘e-clinics’. This provides a speedy service, with fewer patients needing to attend outpatient hospital appointments – allowing waiting times to be cut and Barts’ renal clinics to prioritise patients who require face-to-face appointments.

Meanwhile, Barts’ specialist nephrology nurses have visited practices and attended practice nurse forums in Newham to help manage patients and provide information and advice to primary care colleagues. This has improved GPs’ and practice nurses’ knowledge of CKD and delivered major savings for the local NHS.