A virtual community clinic for renal patients in East London

Early identification of people with chronic kidney disease (CKD) in primary care enables proactive management and referral to specialist services.

This is particularly important for those with risk factors like:

• diabetes
• hypertension

Sharing all the health data in the primary care electronic health record (EHR) can better connect primary and secondary care. It's a practical way to quickly access specialist advice.

Situation

Barts Health NHS Trust has one of the biggest renal services in London, and undertakes approximately 220,000 dialysis sessions a year.

The number of people with end-stage kidney disease (ESKD) who need dialysis or a transplant has steadily grown in recent years. It's surpassed expected numbers.

To manage the epidemic of CKD in East London, a virtual clinic was set up in partnership with:

• the Clinical Effectiveness Group (CEG) at Queen Mary University of London
• City and Hackney Clinical Commissioning Group (CCG)
• Waltham Forest CCG
• Newham CCG
• Tower Hamlets CCG

Aspiration

Barts Health NHS Trust wanted to improve the detection and management of CKD in the community. They also wanted to review patients who need specialist input earlier.

The virtual clinic’s objectives include:

• giving patients easier and quicker access to renal specialists through weekly clinics
• improving response times for renal patients, giving them a better experience
• avoiding the need for hospital visits by caring for 90% of referrals in primary care
• improving communication within primary and secondary care to avoid test duplication
• reducing the number of ESKD cases and the proportion of patients “crash landing” onto dialysis

Solution

The Trust set up a virtual clinic for GPs to directly ask consultants questions and get a quick reply. This is recorded in both primary and secondary care.

The virtual clinics introduced EMIS Web to the renal department. This includes an electronic trigger tool which alerts GPs to possible cases of CKD progression for review or referral.

All specialist advice and guidance is recorded in EMIS Web and visible to GPs.

All practices are signed up to a data sharing agreement so consultants can view the complete primary care EHR.

Consultants document advice in the shared record which all GPs can view. GPs are advised when the notes are reviewed by an alert in EMIS.

When GPs make a referral, they request permission from the patient for consultants to view the GP record.

Practices also have access to IT tools and dashboards to improve coding, which is associated with better CKD management and safer prescribing. Dashboards also help practices compare their performance with others.

Patient education sessions and self-management resources are available from the Barts Health website.

Impact

• The average waiting time for specialist advice reduced from 64 days to, on average, 5 to 10 days.
• Only 10% of patients referred to the virtual clinic need a face-to-face hospital appointment. This has freed up time and money for reinvestment in NHS services.
• The virtual clinic made significant improvements to GPs identifying, coding and managing CKD.
• Nurses now educate patients on how they can self-manage their condition.
• 96% of GPs said they were satisfied with the clinical advice they received.
• The virtual clinic has helped to improve access for patients who are unable to travel to face-to-face appointments.
• Because fewer patients are travelling to hospital, the service has reduced its environmental impact by the equivalent of 12 transatlantic flights.
• Patients have responded positively. They were happy to share their medical records and that their care was discussed with a specialist without needing to go to hospital.

Functionality

• Patients are referred to the virtual clinic by their GP through NHS e-referral. The virtual clinic consultants then view the patient’s primary care record and provide advice.
• Consultants can refer patients to specialist clinics as needed.
• The GP is notified of the outcome of the virtual clinic assessment.

Capabilities

• Consultants are given secure access to EMIS and can review the patient’s GP record in real time.
• Consultants have access to the patient’s complete and detailed medical history which helps them give advice and guidance to GPs.
• A comprehensive care management plan can be stored in the patient’s notes.
• Patients who need to be seen are offered a timely appointment in an appropriate specialist clinic.
• Primary care is given direct access to specialist services which reduces the number of visits a patient has to make to the clinic.

Scope

• EMIS supports electronic referrals from GPs into local services, helping to establish relationships between primary and secondary teams.

Key learning points

• The virtual clinics model can be replicated to other areas. This includes clinical services that rely heavily on test results for management decisions, like haematology.
• It’s important to develop the virtual clinic locally and take into account the health service geography and context.

Digital equalities

• Patients do not directly access the service themselves. The system reduces any chance of patients not attending appointments in a clinic due to the digital nature of the service. It can reduce any referral selection bias to specialist renal services.

Key quotes

“We have an ambition to reduce 50 percent of our outpatient appointments in a similar way because we know patients want to be seen conveniently, quickly and close to home.”

“If I have a question for Neil I get an answer in a few days. He can see the GP notes remotely and I can see the important hospital clinical notes from my computer in general practice. If either of us is worried about a patient, we can make sure they go in straight away. All of the clinicians get along well together and are extremely courteous so the system works.”

Sir Sam Everington, local GP and clinical lead for the North East London Sustainability and Transformation Partnership (STP)

Key contact

Dr Gavin Dreyer, Consultant Nephrologist and Clinical Lead for the virtual CKD service, Barts Health NHS Trust

g.dreyer@nhs.net

Dr Sally Hull, GP Tower Hamlets, Clinical Lead for CEG

s.a.hull@qmul.ac.uk