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How have GPs coped with CKD?

As GPs prepare for first QOF scores on CKD, we assess how the year has gone - and cast our eye to the future

By Lilian Anekwe

As GPs prepare for first QOF scores on CKD, we assess how the year has gone - and cast our eye to the future

Adding chronic kidney disease to the quality and outcomes framework was a controversial move and one that elicited conflicting responses among the medical profession.

While renal specialists were generally delighted with the opportunity to raise the bar on CKD care, many GPs were nervous at the prospect of having to learn a whole new disease, especially as the workload implications became clear.

Even the Department of Health concedes the introduction of eGFR reporting and inclusion in the QOF 'has resulted in a significant spike in referrals to renal units', as it admits in a progress report on the renal national service framework, published earlier this month.

As GPs prepare for their first year's scores on CKD, Pulse set out to investigate how the NHS has handled the changes.

The renal experts

Dr David Ansell, director of the UK Renal Register in Bristol which collects national data on the clinical management of CKD, says referrals to secondary care did rise following CKD's inclusion in the QOF and are yet to return to pre-QOF levels.

'There have been some studies showing that referrals have increased, and generally referrals have plateaued, but at a higher rate than before.

'We've seen a mix – appropriate referrals that may not have been picked up before, but also there are still inappropriate referrals because many GPs are quite new to it and learning.'

But GPs appear to have coped well with 1.5 million newly identified CKD patients, and renal units are not collapsing under the weight of referrals.

Dr Donal O'Donoghue, the Government's renal tsar, feels the evidence on GP management of CKD patients speaks for itself. 'We had a number of concerns about adding CKD to the QOF, but I think the QMAS data has shown how well GPs have done in managing people with CKD. It has been a fantastic achievement,' he says.

But even when heralding the successes of primary care, Dr O'Donoghue, who works at the Hope Hospital in Salford, admits there were significant teething problems.

'Referrals were a significant strain on many parts of the country, and many of them were inappropriate. There is a sense of familiarity now we have it out in the open and it's relatively clear. We have sat down with our colleagues in primary care so they know which patients are appropriate to refer, and which are not.'

The GPs

There is a sense of relief from many GPs as it becomes clear that most have handled the new workload well.

Dr Penny Ackland, a GP in Dulwich, south-east London, was part of the group that developed the NICE guidelines on anaemia management in CKD and she feels the disease is an area in which GPs are still 'finding their way'.

But while Dr Ackland does not necessarily think it has been overly onerous to take on kidney disease, she shares the view of many GPs that some patients benefit little from the 'disease' label.

'In the case of the elderly, where they're often already managed for hypertension or coronary heart disease, does it really matter if they have CKD?' she says.

Just last week a study found more than half of the elderly had CKD, and questioned the evidence for treating them all.

Professor Mike Kirby, professor in health and human sciences at the University of Hertfordshire and a GP in Letchworth, says the inclusion of CKD in the QOF has provided an opportunity to improve patients' cardiovascular management and reinforced the message that CKD is a risk factor for coronary heart disease.

'Initially eGFR was quite a lot of work because we're not really set up to provide that information, and we had to do it ourselves. Many of the patients we identified were already on our databases, but having it in the QOF is a much better way of formally identifying them.'

In the future

It seems likely that GPs will be asked to take on increasingly complicated CKD cases. The Government has already said, in the NSF report, that it will 'draw on the expertise and experience of the renal community as QOF indicators are refined over the coming years'.

Dr O'Donoghue says: 'We have been successful with 'GFR demystification' but the next stage is whether these people have proteinuria. That will be the challenge going forward for primary care.'

In a caveat that will please GPs, he adds that paying GPs for this would be 'only fair'.

And for those who are struggling, Professor Kirby strikes a note of hope for the future: 'Ultimately, CKD in the QOF is only a year old. It's been a learning curve and the next two years will be easier than the first.'

CKD in the future: What QOF revisions might includeCKD in the future: What QOF revisions might include CKD in the future: What QOF revisions might include

• Proteinuria and subdividing patients with stage 3 CKD
• Dealing with long-term kidney complications
• Preparing people for transplantation and dialysis
• Managing patients with stage 4 CKD
• 'Holistic' management of CKD patients, including management of cholesterol and other CVD risk factors
• The necessity for ACE inhibitors to be prescribed removed if the patient does not have proteinuria and their blood pressure is controlled

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