A pioneering project aimed at managing chronic kidney disease (CKD) outside hospital settings is demonstrating promising results in Leicester, Leicestershire, and Rutland. The Leicester, Leicestershire, and Rutland Chronic Kidney Disease Integrated Care Delivery Project (LUCID) has improved clinical outcomes, accelerated referrals, and optimized patient care, moving services closer to home for better efficiency and safety.
The LUCID initiative is led by Professor Fahad Rizvi, a GP partner and clinical director at Willows Health in Leicester. The project is part of a broader effort to integrate healthcare services within local communities. In 2023, kidney disease accounted for 3.2% of NHS spending—around £6.4 billion—which highlights the need for more efficient management of the condition.
Drawing on his background as a surgeon specializing in urology, Prof Rizvi is keen to bridge the gaps between primary and secondary care, a goal that has gained momentum since the introduction of Integrated Care Systems (ICS) in 2022. “I’ve seen firsthand how these two systems can work together to benefit patients,” he explains.
Before the LUCID project, patients diagnosed with CKD were typically referred to hospitals for treatment, often waiting three to six months for specialist care. Prof Rizvi aimed to shorten these waiting times, improve patient outcomes, and reduce the need for dialysis by optimizing care in primary care settings.
Launched in April 2022 with two pilot primary care networks (PCNs), Willows Health and Belgrave and Spinney Hill, the project now includes nearly all 10 PCNs in Leicester city and half of the 16 PCNs in the surrounding county. This expansion serves a combined patient population of nearly 700,000.
The project operates through a multidisciplinary team (MDT), comprising a consultant nephrologist, primary care clinicians, and pharmacists from both primary and secondary care. Monthly MDT meetings focus on reviewing patient cases, discussing diagnoses, medications, and co-existing conditions like diabetes, hypertension, and heart failure. This holistic approach to care addresses the broader health issues impacting patients with CKD, ultimately optimizing treatment for kidney disease and related conditions.
From 2022 to 2024, Willows Health PCN reviewed 526 CKD patients, with 371 deemed eligible for intervention. By managing care through the MDT, patients have been seen within three to four weeks of referral, instead of waiting months for a hospital appointment. Additionally, fewer patients need to travel long distances for treatment, a significant improvement in patient convenience.
The success of the initiative is evident in its impact on hospital referrals. Willows Health PCN, for example, reduced the percentage of patients needing outpatient care from 42.9% in 2021-22 to just 10% in 2022-23. The number of patients requiring referral to hospital has also decreased, freeing up secondary care resources.
In April 2023, Leicester city identified 8,800 patients with stage 3-5 CKD. By January 2024, the number had increased by 29% to 11,400 due to improved testing and detection in primary care. Notably, 7.7% of referrals to secondary care were avoided, 12.2% were expedited, and 54.4% of patients were successfully managed within primary care.
Once fully implemented across all 26 PCNs in the region, the project is expected to prevent around 200 hospital referrals annually, potentially saving £130,000 while still ensuring high-quality care for CKD patients.
The LUCID project faced challenges, particularly in securing funding and engaging GP practices without direct financial incentives. Prof Rizvi and his team sought support from pharmaceutical companies and emphasized the benefits of the initiative in meetings with clinical directors and practices. Looking ahead, efforts are underway to secure more sustainable funding and expand the project to other specialties, including rheumatology and respiratory care.
Prof Rizvi emphasizes the importance of collaboration between primary and secondary care to improve service delivery. “Secondary care gets more funding, but by managing conditions jointly, we can deliver quicker, cheaper, and more efficient care,” he says. He is hopeful that this model will inspire similar initiatives in other healthcare specialties.
The success of the project owes much to the commitment of the Integrated Care Board (ICB), which has provided both commissioning support and a platform for collaboration. Prof Rizvi highlights that education and training for both primary and secondary care staff have been crucial in reducing unnecessary referrals and improving patient care standards.
Ultimately, the LUCID project represents a shift towards more patient-centered, community-based care. By reducing waiting times and providing comprehensive management for CKD patients, it offers a blueprint for transforming healthcare delivery and improving patient outcomes.
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