Shared learning database

Type and Title of Submission


Developing resources for improved CKD management in primary care


Teams from the Greater Manchester (GM) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) and Leicester, Northamptonshire and Rutland (LNR) CLAHRC have both been working to help improve care for patients with chronic kidney disease. The two teams have each developed various resources for the purpose of implementing NICE guidance, in conjunction with general practices undertaking improvement work. By working in partnership with the LNR CLAHRC since January 2011, the GM team have enabled practices to implement NICE guidance with much more efficiency through the spread and further development of these resources.

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG73 - Early identification and management of chronic kidney disease in adults in primary and secondary care

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

Identification of undiagnosed CKD patients and improved care, with a focus on appropriate blood pressure management, leading to improved health outcomes and prevention of related cardiovascular events. This project also aimed to provide practices with the confidence to manage early stage CKD in primary care and transferable skills in maintaining accurate registers and effective management protocols in CKD and other disease areas.


Chronic kidney disease is common, affecting around 5-10% of the adult population. CKD stages 3-5 represent moderate to severe disease and ascertainment of these stages has been included in the NHS Quality Outcomes Framework (QOF) since 2006/07. The National Institute for Health and Clinical Excellence (NICE) developed guidelines for chronic kidney disease in 2008, which aimed to promote earlier detection, intervention and prevention or delay of complications including end stage kidney disease. However, research findings and QOF data have shown that there is a gap between recorded and estimated prevalence and that approximately 30% of those patients who are diagnosed are not receiving adequate care. The GM CLAHRC and LNR CLAHRC have been undertaking projects to address this issue and have in the process developed tools and resources for primary care practitioners. The GM CLAHRC developed a guide that combined all the learning from a first phase of improvement work (September 2009-September 2010) and provided practices with advice on the effective ways to improve CKD care. The LNR CLAHRC developed a comprehensive audit tool that enabled practices to quickly and efficiently identify undiagnosed patients, incorrectly diagnosed patients and patients at high risk of developing CKD, or of quicker progression in existing patients. This audit tool also provided practices with information on how well they were managing the care of their patients, helping them to target improvements where it was needed most. These two resources have both been effective individually as implementation tools and both CLAHRC organisations feel that the benefits of each could be maximised by combining the two elements into a single package for more widespread improvement capacity.


The GM CLAHRC recruited eleven practices (ten from NHS Ashton, Leigh and Wigan and one from NHS Salford) to take part in the second phase of CKD work. The 12 month project, due to be completed in March 2012, involves teams of two to four staff from each practice and encourages collaboration between practices through workshops and WebEx sessions. The GM and LNR CLAHRCs have both worked with local nurses for their implementation, which supports their clinical development as well as improving teams' understanding of CKD. The GM work is facilitated by a Knowledge Transfer Associate and one of the practice nurses who was involved with the first phase of work and who uses her local experience and improved CKD knowledge to support the teams. Practices were provided with the CKD Improvement Guide (available on and the audit tool from the LNR CLAHRC. Security settings for the practices' computers caused problems in some cases, but the audit tool was eventually installed and run in all cases with the help of the local Data Quality Facilitation teams. The CLAHRC team helped practices use the audit results to create 'trackers'-lists of potential and already diagnosed patients on which they could record their actions for each one. For example, some patients needed repeat eGFR tests to confirm their diagnosis, misdiagnosed patients needed to be removed from register, and some patients needed to be called in for an ACR test to check for proteinuria. The practices worked through these trackers in a structured way, often splitting the lists to divide responsibility for the actions amongst the team without the risk of duplication. Teams also used the audit tool and additional searches to identify patients who had poorly controlled blood pressure, enabling them to target these patients for better care.

Results and evaluation

Practices submit data to the CLAHRC team each month and the results from the audit tool are also used to evaluate progress. At the end of December 2011 with two months of the project remaining, practices had found 501 previously undiagnosed patients (143% of the aim), had tested 87% of patients for proteinuria and were achieving NICE recommended blood pressure targets in 65% of patients (76% in patients without proteinuria, 51% in patients with proteinuria). This was a big improvement on success in the first phase where practices working without the benefit of the audit tool identified 1,324 patients - only 92% of their aim. In addition to these additional diagnoses, practices have also removed a number of patients who were mistakenly added to registers in the past; the improved accuracy of registers should be apparent when audit results from the end of the project are compared with those from the beginning. The audit tool has enabled practices to achieve their objectives with much more efficiency than those working without the audit tool in the first phase. This has meant that practices can undertake additional work that add value to the project, such as training in motivational interviewing and evaluation of a new self-management guidebook developed by the CLAHRC research team.

Key learning points

Previous work had shown that projects to identify and improve care for CKD patients had been successful. This project has shown that the process can be completed efficiently and effectively using the resources from the GM and LNR CLAHRCs. The CLAHRCs are currently developing these resources into a single package and it is intended that this will be available shortly.

Contact Details

Name:Brook Butler
Job Title:Knowledge Transfer Associate
Organisation:NIHR CLAHRC for Greater Manchester
Address:Salford Royal Foundation Trust, Stott Lane
Postcode:M6 8HD


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This page was last updated: 30 January 2012

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.