Supporting Primary Care with Diabetes and Chronic Kidney Disease Management


Diabetes and Chronic Kidney Disease (CKD) commonly co-exist and management is complex, with frequent cardiovascular, retinal, foot and bone multi-morbidity and increased risks of hospitalisation. East and North Herts Clinical Commissioning Group (CCG) commissioned a pilot service to identify and provide a holistic virtual review of high-risk patients. The team worked with primary care to establish 15 pillars of care. A virtual specialist diabetes consultant review was carried out on each patient, followed by Skype case-based discussions with GP practices, to educate and upskill primary care colleagues to help manage vulnerable patients. The five core objectives were to: investigate the feasibility of extracting comprehensive ‘big data’ from primary care information systems; enable clinical data utilisation for individualised virtual diabetes specialist review; evaluate the practicality and acceptability of a Skype telehealth virtual case-based discussion for patient care and primary health care team training; record the extent of unmet clinical need and frequency of suggested therapy changes and to develop strategies to improve self-management of foot health and acute illness with metabolic-renal decompensation.

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The project investigated new ways to review multiple, high-risk vulnerable patients who were mostly managed by primary care. These patients would benefit from specialist input, but lack of capacity in secondary care and the volume of patients made this impossible. The solution was to upskill and provide holistic management review to GPs and other healthcare professionals via case reviews using Skype. Four pilot practices were used to test patient data acquisition and refine the process. All 55 GP surgeries in East and North Herts were invited to participate in a systematic review of patients with CKD on their diabetes registers (CKD was defined as an eGFR < 60 and/or urine albumin:creatinine ratios >= 10). Twenty practices that represented the sociodemographic characteristics of the area took part. The diabetes consultant carried out a virtual review of the pillars of care to enable recommendations in treatment management or referral. This included declining patterns of renal function, inadequate glycaemia , blood pressure and lipid control, consideration of hypoglycaemia risk, assessment for and investigation of anaemia, consideration of obesity in selection of diabetes therapy, assessment of cardiovascular status and record of antiplatelet therapy, assessment of bone health with parathormone measurement, assessment of retinopathy enabling consideration of non-diabetes basis for CKD, identification of foot risk requiring proactive podiatry advice or care, smoking as a prompt to enable access to smoking cessation and identification of hospitalisation for diabetes-related and non-diabetes events.


Each practice manager downloaded the pillars of care needed for review. The data was reviewed using agreed guidance. Uniquely, the diabetes consultant could virtually review large numbers of patients, looking at all aspects of their care, in one place. Actions and recommendations were made when clinical aims were not met; this involved either referral into secondary care or changes in treatment regimens, which the GP could address. In addition, a Skype consultation with the primary care team reviewed 20 patients to promote discussion, teaching and education. Patients had access to a diabetes ‘sick day rule’ card to help manage acute illness with risk of acute chronic kidney injury through temporary withdrawal of potentially nephrotoxic medication and appropriate management of glycaemia. The team also produced a ‘high risk foot’ card for patients whose feet were deemed ‘at risk’. After each Skype session an individual patient letter was emailed to the practice highlighting actions and recommendations and uploaded to the patient record. Each practice also received a ‘holistic management’ guidance document and a feedback questionnaire.


To date 20 surgeries have provided information on 2,874 people with diabetes and CKD, who have undergone virtual case review, representing an average of 23% of individuals on the GP diabetes registers. On average 83% of these were managed in primary care with the remainder under specialist diabetes and/or renal hospital clinics. Substantial unmet clinical need was demonstrated, requiring specialist diabetes and/or renal review in 13- 20% of cases, and therapy changes/podiatric advice in 16-50%. Outcomes included: identification of 818 (38%) who required advice-input regarding high risk for neurovascular foot complications; 771 patients (36%) needing a change of glycaemia management; 435 patients (20%) with progressive changes in renal function; 978 patients (45%) needing measurement and identification of metabolic bone health; 746 (35%) needing a change in blood pressure medication; 1,085 (50%) requiring changes or to start on lipid medication; anaemia (Hb <110g/l) was present in 13% and predominantly in those with CKD over the age of 70. GPs’ holistic guidance document will help them manage patients with Diabetes and CKD. Virtual reviews could reduce referrals into specialist care as deteriorating patients would be identified earlier and treatment plans could be actioned sooner. Early identification could reduce the progression of end-stage renal disease.

Sustainability and Spread

This approach has demonstrated that specialist physicians can work more closely with primary care to evaluate large numbers of complex patients virtually and use alternatives to traditional outpatient consultations. This can be applied to other long-term disease areas and, importantly, offer better, patient-focused care of multi-morbid disease through effective, one-stop specialist collaboration and communication. Skype virtual consultations could provide specialist primary care consultations with high risk patients at general practices who have defaulted from regular outpatient clinic attendance. To improve their care the following steps are recommended: collaborate with clinical expertise and health care analysts to design and implement an automated solution which integrates, primary, secondary, pathology and other clinical information systems; develop a complex clinical management algorithm that can be applied to larger populations on a case-by-case basis; establish a new, accessible more cost-effective service for the highest-risk population; explore provision of multiple aspects of care in one appointment. The scalability of this pilot requires digital solutions to improve coding, integration of data, and generate an algorithm to enable timely individual review and management plans.

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QiC Diabetes Highly Commended 2019
Patient Care Pathway - Adults
Supporting Primary Care with Diabetes and Chronic Kidney Disease Management
by East and North Herts NHS Trust

Quality In Care Diabetes

QiC Diabetes is partnered by:
Supported by:
  • 2021 KEY DATES
  • Open for entry:
    Tuesday 20 April 2021
  • Extended Entry Deadline:
    Monday 12 July 2021
  • Judging day:
    Tuesday 7 September 2021
  • Awards ceremony:
    Thursday 14 October 2021