Wednesday, 14 November 2007

Q & A: The Renal NSF

Q: Dear Donal, as a part of my degree I am in the process of researching into the impact of a policy on service users. I have chosen to look at the renal NSF, in particular Part 2, the prevention and dectection of CKD. I was just wondering if you had an particular statistics or accounts of how its implementation has been a success. I have read the reoprt from 2007, plus the information on the eGFR implementation and wondered if you had any figures on the success of its uptake, how many PCTS are now referring or feedback from them about the difficulties they are facing with the policy?
Any information would be of great use. Thank you very much for your assistance.
Alice Kershberg, 3rd Year Nursing Student, Kings College London

A: Well Alice that is a great question. The topic of the pressures that introducing eGFR reporting have generated within the renal community was discussed in detail at the last Clinical Directors Forum of the Renal Association. A lot of examples of good practice were quoted from across the UK. In brief I think it would be fair to characterise success as joined up pathway working between primary and secondary care, a systematic approach to implementing the UK CKD guidelines along with adopting eGFR reporting and testing new referrals and follow up appointments in renal clinics with the question “is this adding value to patient care?”.

A number of the posters and presentations given at the Clinical Directors Forum on 3 March 2007 are available at .

However, it would be misleading not to acknowledge that in certain parts of the country pressures have been intense. A survey of clinical directors undertaken by the Renal Association (available
here) showed that 2/3 of units felt they had insufficient capacity to cope. Between 40-90% of referrals were being seen and the consultants felt that there had been an increase of about 50% in referrals that were considered appropriate. This was matched by a similar increase in inappropriate referrals. One individual felt there had been 1000 fold increase in inappropriate referrals! Clearly, they were under a lot of pressure that day!!

Finally, we have just received information from the Information Centre on primary care performance in the chronic kidney disease domain of the Quality and Outcomes Framework. It shows an overall prevalence of chronic kidney disease in England of 3% but there is marked variation between Strategic Health Authority and even greater variation at PCT and practice levels. This suggests to me that the system has managed the introduction of eGFR reporting and initial management of CKD in primary care well but there is still quite a bit to do particularly with regard to education and training and the early identification and management of kidney disease in the practices with lower than expected rates of detection. Of course the Quality and Outcomes Framework doesn’t contain information on proteinuria testing and this is likely to be a major driver for both the increased vascular risk and the risk of progressive kidney disease. We know from anecdotal information and some local studies that proteinuria testing has increased. I suspect that proteinuria testing in chronic kidney disease will become standard practice in line with the national guidance over the next few years.

Given the fact that we are only one year into the new world of chronic kidney disease being an issue for both primary and secondary care, I think we have come a long way. The increased awareness of chronic kidney disease will surely improve medicines management in this group of patients. Blood pressure and vascular control measures are likely to reduce vascular events in this high risk group and I like others am hopeful that it will reduce the number of people who “crash land” or present as an acute uraemic emergency previously unknown to kidney services.