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Seminars in Nephrology

Volume 29, Issue 5, September 2009, Pages 475-482
Seminars in Nephrology

The UK Model for System Redesign and Chronic Kidney Disease Services

https://doi.org/10.1016/j.semnephrol.2009.06.004Get rights and content

Summary

The British National Health Service is a closed managed care system. This single health care system for the United Kingdom is funded by the government and paid for by general taxation. All UK citizens are registered with primary care physicians who control access to secondary care services. As a managed care system it should be able to offer integrated care across the whole patient pathway. In reality there are professional, organizational, and institutional barriers to coordination and delivery of care in the NHS. Historically, the United Kingdom has been among the lowest health care spenders of organizations for economic cooperation in developed countries, in absolute terms as well as proportion of the gross domestic product. However, since a Government pledge to place quality at the heart of the NHS and a commitment in 2000 to increase spending on the NHS, the NHS budget has more than doubled—an unprecedented rate of growth, roughly by 7.5% annually in real terms. A quality and outcomes framework has been introduced into primary care to systematically incentivize process measures such as computerization and chronic disease management by establishing practice-based disease registers. The strategic planning for kidney services in England has been developed in this national environment complemented by local research findings and the wider international consensus that has emerged since the publication of the classification of chronic kidney disease in 2002. This program of work has resulted in a paradigm shift from kidney disease being viewed as a secondary care condition to being a primary care priority as part of vascular disease control and management. In the first 2 years of the initiative more than 40% of the expected chronic kidney disease stage 3 to 5 population have been registered in primary care. Kidney disease now is recognized as a public health problem in the United Kingdom, preventative strategies are being integrated into comprehensive vascular risk assessment and management programs, and kidney disease has become an NHS priority area.

Section snippets

National Policy

The UK National Health Service (NHS) is in essence a closed managed care system in which more than 99% of the population are registered in primary care. The principles on which the NHS is based lend themselves to creating a structured delivery of health care for people with kidney disease across the whole system, from risk all the way through to ESRD. Initiatives that have been introduced to help deliver this include the National Service Frameworks (NSFs), a national program for information

CKD Guidelines

UK CKD guidelines were developed in parallel with, and to support implementation of, the Renal NSF by the Joint Specialty Committee of the Royal College of Physicians of London and the Renal Association in conjunction with a number of stakeholder specialist societies, the Department of Health, and the National Kidney Federation.10 These guidelines sought to promote optimal management of people with CKD and identify those requiring referral to renal services. Full and concise versions of the

Implementation of eGFR Reporting

The Renal NSF recommended that local health organizations work with pathology services and networks to develop protocols for measuring kidney function by serum creatinine concentration together with a formula-based estimation of GFR, calculated and reported automatically in all samples from adults by all clinical biochemistry laboratories. To deliver this recommendation, the Department of Health set up an expert advisory group to ensure a consistent approach and reduce the variation between

Introduction of Renal Indicators in the QOF

One of the benefits of a publicly funded health care system is the ability to introduce related initiatives aimed at identification of disease simultaneously throughout the system. From April 2006 a CKD domain was included in the QOF for the first time. This coincided with the implementation of eGFR reporting and formed part of the drive to identify people with CKD in primary care. The indicators required primary care to produce a register of adults with stage 3 to 5 CKD, to measure blood

Impact of GFR Reporting, Guidelines, and the QOF

There is no doubt that the introduction and implementation of GFR reporting, guidelines, and the QOF has led to an increase in the identification of people with CKD. Analysis of the first 2 years of CKD data returns to the QOF has shown an increase in the prevalence of reported CKD stage 3 to 5 by all strategic health authorities (Fig. 1). The variance in CKD ascertainment by individual general practices is marked at 50-fold in each Primary Care Trust area, perhaps reflecting the variance in

Formation of Kidney Care Networks

The introduction of measures enabling earlier identification of CKD and the implementation of CKD guidelines require an infrastructure to ensure that there are both adequate facilities to manage the increased recognition and referral, and that those charged with providing the requisite health care know what to do, when to do it, how to do it, and to whom. This involves both professional and patient education and development of a CKD management and referral program. One way of achieving this is

Development of a Clinical Decision Support System

The existence of comprehensive primary care databases lends itself to the development of clinical decision support systems (CDSS) to aid identification, management, and referral of CKD. The New Opportunities for Early Renal Intervention by Computerised Assessment project is one example of this. The first phase of this project used morbidity information query and export syntax, a piece of Department of Health–sponsored software, to extract coded and structured data pertinent to CKD from primary

Disease Management Programs

An alternative approach is the introduction of a primary care–based Disease Management Program (DMP) using an algorithmic approach based on CKD management guidelines. Such an approach has been used in another area of the United Kingdom.18 The program relied on identification of CKD stage 4 and 5 using an eGFR derived from all serum creatinine values requested in routine clinical practice in a defined population (the West Lincolnshire Primary Care Trust, population 223,287). Patients identified

What Can We Conclude and Where Do We Go From Here?

Many of the measures described earlier have been implemented concurrently so it may be difficult in the future to tease out the specific benefits of each strategy. What is clear, however, is that the United Kingdom over recent years has developed a coherent strategy in terms of primary care, laboratories, and hospital providers of renal services. This strategy also has included patient groups and care networks and critically has sought, and continues to seek, to link all areas through a

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