As part of Healthcare Leader’s focus on shifting care out of hospital and into the community Kathy Oxtoby writes about an innovative CKD project in Leicester, Leicestershire, and Rutland ICB
Better clinical outcomes, improved patient safety, faster referrals, and quicker optimisation to stop disease progression and provide holistic care. These are just some of the achievements of the Leicester, Leicestershire, and Rutland Chronic Kidney Disease Integrated Care Delivery Project (LUCID) – a consultant-led service that highlights the benefits that moving care closer to home can bring.
Driving the project is Professor Fahad Rizvi, a GP partner and clinical director of Willows Health – a PCN in Leicester with 11 practices – and ICB Place lead for Leicester city for Leicester, Leicestershire, and Rutland (LLR) ICB. In 2023, kidney diseases accounted for 3.2% of total NHS spending, representing £6.4bn.
Prof Rizvi was also a surgeon for seven years specialising in urology before moving to general practice, ‘so I’ve seen the differences between the two systems and how they work – and I’ve always thought they work better together’. He has worked in over 20 different NHS hospitals and a similar number of GP practices all over the country during and after his training.
Since ICSs were established in 2022, he says there has been ‘more integration between primary and secondary care, and this means we have access to secondary care clinicians on our ICB board who can give advice and guidance’.
In setting up the LUCID project, Prof Rizvi ‘wanted to see how primary and secondary care can work together better for the benefit of patients’.
Prior to the project, patients with a CKD diagnosis were referred to hospital for optimisation of medicines and consultant led care.
Prof Rizvi wanted to look at how the service for patients with CKD at stage 3 to 5 – those who typically need a consultant’s opinion on their management – could be made better, quicker and faster’. He sought to replace the ‘old style referral from primary care’ approach, ‘where patients have to wait between three to six months before they are seen by a consultant in hospital’.
Reducing waiting times would also reduce the risk of patients needing dialysis, he says.
The project started in April 2022, with two pilot Leicester city PCNs, Willows Health and Belgrave and Spinney Hill. It now has almost all of Leicester city’s 10 PCN’s and half of the county’s 16 PCNs onboard, covering a patient population of almost 700,000.
The service involves a multidisciplinary team (MDT) monthly meeting between a consultant nephrologist, a primary care clinician, and a primary and secondary care pharmacist to help promote education and patient care at the same time.
At the meeting, a list of patients with CKD are discussed, looking at, for example, whether they have had a diagnosis, and what medications they are already taking.
CKD is often linked with other health conditions such as hypertension, diabetes, heart failure and metabolic disorders and is associated with significant cardiovascular morbidity and mortality, as well as prolonged hospitalisation.
The clinicians’ focus is therefore not only on the patient’s CKD, but also their blood pressure and cholesterol, and other conditions they may have, such as diabetes or obesity. ‘This approach leads to the management of multiple conditions at the same time,’ says Prof Rizvi. ‘It’s about treating the whole person – a holistic approach to patient care.’
Following the meetings, ‘patients’ medications are optomised’, and they are prescribed the ‘right regime of medication’ to prevent the progression of their kidney disease and to manage other conditions such as diabetes, hypertension and hypercholesterolemia, besides smoking cessation and weight management, he says.
The consultant-led service also provides education to patients and clinicians in primary care about CKD management.
From 2022-24, 526 patients were reviewed by Willows Health PCN and 371 were found to be eligible for intervention. All those interventions were carried out via the MDT structure.
Early intervention, rather than a hospital referral, means that instead of waiting three to six months, patients are seen within three to four weeks, and are also not having to potentially travel long distances to attend hospital appointments.
The outpatient discharge at first attendance in secondary care at nephrology clinics was 42.9% for 2021-22 and this was reduced to 10% for 2022-23 for Willows PCN. ‘We did not have to refer any patients to hospital, because all of them had their conditions managed in primary care. From previously bringing 30 patients to an MDT this was reduced to two patients every eight weeks as they were now being optimised by the PCN pharmacist team within two weeks of an internal referral,’ says Dr Rizvi.
With patients’ care being managed by primary care teams, this has freed up secondary care appointments and patients are being seen more quickly, says Dr Rizvi.
In April 2023, there were 8,800 patients identified in Leicester city with stage 3-5 CKD. Due to increased testing and CKD identification in primary care, the prevalence of CKD increased by 29% to 11,400 patients by Jan 2024.
Some 7.7% referrals to secondary care have been avoided, 12.2% expedited and 54.4% were optimised in primary care across Leicester, Leicestershire and Rutland.
It is estimated that when all 26 PCNs in LLR are participating in LUCID clinics, this could lead to a reduction in approximately 200 referrals a year with estimated immediate savings of £130,000, while still delivering optimum treatment for these patients.
There was no system funding available for the project, but pharmaceutical companies were approached to support it.
The biggest challenge was to introduce the PCNs to this multi-disciplinary team style of working with University Hospitals of Leicester NHS Trust and to upskill the primary care workforce.
CKD was discussed with all the clinical directors of the Leicester city PCNs, and the decision was taken to highlight CKD as a priority. This approach helped onboard the PCNs and helped to support the project to be rolled out to the whole of Leicester city.
Another challenge has also been around the involvement of GP practices, as without funding this has ‘relied on their good will’, says Prof Rizvi. He regularly highlights the importance of taking part in the scheme and the benefits it brings at meetings with clinical directors, PCNs and practices.
Looking ahead, a funding process is being developed, and a business case passed to various ICB boards with ‘positive outcomes’, says Dr Rizvi.
The ICB is also looking to other specialities to do similar work including in rheumatology and respiratory.
Prof Rizvi says: ‘Secondary care gets more funding. But, as demonstrated by this piece of work, if we can manage conditions jointly, quicker, faster and cheaper, then that funding has to follow and can be given to primary care, or as a shared pot between primary and secondary care.’
Key to making the project a success has been the support of the ICB, says Prof Rizvi. As well as commissioning the service, this support has included involving the ICB primary care team, and inviting secondary care consultants to various educational meetings for GPs.
To get these initiatives off the ground ‘you need passion and perseverance’, he says, ‘and that passion influences team members to actively work with the system in an integrated way’.
Education and upskilling of staff in both primary and secondary care in this project has also ‘helped to reduce unnecessary secondary care referrals and therefore decrease patients’ waiting times. It also provided a standardised approach for managing patients with CKD in primary care.’
‘We can optimise care and manage patients in a much better way by integrating teams between primary and secondary care,’ he believes.
‘The essence of ICSs truly comes into play when we have these kinds of examples of projects to show that primary care, and the whole system, including GPs, pharmacists, nurses, consultants and all those involved in patient care, come together across the boundaries.’
Ultimately, it is patients who benefit. Patients who would have been referred to the hospital no longer have to wait anxiously for three to six months for answers about their condition.
‘And it’s also satisfying that we’re not only managing patients’ kidney disease, but also their holistic care,’ says Prof Rizvi.
