Development and evaluation of a renal learning health system across inner east London

Chronic kidney disease (CKD) affects approximately 6% of the adult population in the UK, and in east London there is a particularly high rate of the disease. The early stages of CKD are asymptomatic, so it is important that people who at risk are regularly tested. However, the current system is reactive rather than proactive.

This project aims to improve upstream detection and primary care management of CKD, with a system that supports knowledge transfer and increased GP confidence in disease management, and the use of real-time population data to identify those at risk of CKD progression.

It includes the development of a proactive community kidney service, including virtual renal clinics and an education programme for patients to improve their knowledge and ability to self-manage CKD-related conditions.

The project also involves innovative use of population data, with dashboards for GP practices and trigger tools that provide a safety alert for patients whose estimated glomerular filtration rate (eGFR) has fallen, suggesting they may be at risk of CKD progression.

A practice support package will provide education and quality improvement tools for GP practices, and educational resources to be used with patients.

In addition, a case study exercise will be undertaken to examine the primary care characteristics and prior care of the 20% of renal patients who require unplanned dialysis. Results of this will form part of the learning used to encourage behaviour change across hospitals and practices. 

Contact information

For more information about this project, please contact Dr Sally Hull, Reader in Health Care Improvement, Centre for Primary Care and Public Heath, Queen Mary University of London.