Renal health in general practice

The RCGP defines a GP as follows:

A GP is a doctor who is a consultant in general practice. GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. GPs work at the heart of their communities, striving to provide comprehensive and equitable care for everyone, taking into account their health care needs, stage of life and background. GPs work in, connect with and lead multidisciplinary teams that care for people and their families, respecting the context in which they live, aiming to ensure all of their physical and mental health needs are met.

As core work, GPs would be expected to be aware of those at risk of CKD and screen for it and inform patients of their diagnosis and manage their risk factors for example hypertension and diabetes.  GPs would understand the risk of a family history of kidney problems, risk associated with gout, NSAID / other medication use / previous AKI diagnosis / symptoms of obstruction.  GPs would be aware of NICE guidance regarding management of CKD.  They would be aware of red flag concerns that require onward referral – for example deteriorating renal function, abnormal electrolytes, unclear cause.

A GP in this role will work to identify, diagnose, code and risk stratify patients with kidney related health issues and optimise their management accordingly. Those patients who are identified as being at higher risk (of cardiometabolic disease with kidney disease progression), or who need more support, will be offered an appointment for a comprehensive holistic assessment with this GP.

The post holder will be responsible for overseeing the clinic and could engage with delivery of clinical research projects relevant to the renal patient cohort. They will provide a point of contact and leadership for others within the primary and community care multidisciplinary team who care for these patients, liaising with secondary care when required for support or advice. The primary care team will include other healthcare professionals such as pharmacists, nurses, and the wider team including social prescribers, health coaches, health navigators/care coordinators and non-clinical administration team members to communicate with patients, families and carers. The GPwER will upskill and educate the primary care team through formal and informal interactions and teaching as appropriate.

Challenging cases could be discussed in regular multi-disciplinary teams (MDT) either in-person or virtual which may include a Clinical Pharmacist, Advanced Nurse Practitioner, Nurse Specialist, Practice or Diabetes Nurse and Consultant Nephrologist. The MDT may liaise with specialist Diabetes and Cardiology/heart failure teams where appropriate.

With the support of a Consultant Nephrologist and/or Clinical Pharmacist and/or other specialists (e.g. Advanced Nurse Practitioners/nurses), the post holder could be responsible for overseeing the programme, with examples of activities including engaging with delivery of clinical research projects relevant to a kidney health patient cohorts, and specific targeted Quality Improvement Activity related to kidney disease.

If the GPwER role is part of a service, then mechanisms of clinical governance need to be agreed as part of the service accreditation. This will ensure maintenance of local and nationally agreed standards in respect of patient care and patient safety.

GPwERs are expected to be involved in the monitoring of service delivery, which incorporates the following: 

• Clinical outcomes and quality of care 
• Access times to the GPwER service 
• Patient and carer experience questionnaires 
• Prescribing/medicines management (UK Kidney Association clinical practice guideline for SGLT2I prescription noting it makes recommendations that are outside licencing)
• Referrals
• Service governance (for example who regulates the service, premises etc)
• Services the role interfaces with
• Time commitment 
• Employment arrangements
• Sustainability considerations (two points - for example travel, green prescribing, but also sustainability of the role)
• EDI considerations include reaching patients who face barriers accessing health services or groups were there is a higher prevalence of kidney disease (genetics)
• NICE guidance: Community engagement: improving health and wellbeing and reducing health inequalities (External PDF)
• Kidney Research UK topics: 
  • Time to act on kidney health inequalities
  • Kidney disease is a public health emergency that threatens to overwhelm the NHS, major new report reveals
  • Kidney disease: A UK public health emergency interactive dashboard
  • Experts call for improved prevention and early diagnosis
  • Chronic Kidney Disease: An Action Plan for Scotland
• Develop, and deliver a safe, effective GP led service for patients with kidney health problems.
• Develop expert knowledge of renal medicine, to act as a specialist resource service and increasing the awareness of managing kidney health in primary care settings to enhance standards of care. Develop and deliver ways to engage communities which have barriers in accessing health services, working with the wider primary and community care teams, including public health, and related services such as diabetes, community pharmacies.
• Offer support and guidance on how patients can manage kidney health (AKI and CKD), alongside lifestyle guidance and signposting to support living well with kidney disease. 
• Offer teaching and education to other members of the multidisciplinary practice/primary care network (cluster) team.  
• Consider upskilling and supporting those with an interest in renal medicine and increasing the longevity/sustainability of the work, including those from other healthcare professions. 
• Offer appropriate patients the opportunity to participate in clinical research projects. Consider acting as a Principal Investigator (PI), Associate PI or Research Champion for kidney related research. 
• Contribute to the development of guidelines to support the operationalisation of the clinic, and local guidelines to support consistent improved care.
• Ensure the principles of clinical governance and risk management are applied to clinical practice within the speciality.
• Be aware of pre-eclampsia guidelines that patients should have urine dip at 6 weeks check with eGFR/uACR at 3 months and referral if abnormal and then to follow usual guidelines for CKD.
• Know that a patient with CKD 4-5 will need preconception or pregnancy counselling should be under nephrology (due to risk of premature/low birth weight plus need to amend nephrotoxics) or maternofetal medicine.

There are things that a GPwER will need to determine in their local area to ensure they get the most for their patients and their practice or other organisational setting. The GPwER should consider the following when setting up a local service include:

• Setting(s) where role takes place
• How referrals are made
• Services the role interfaces with
• Employment arrangements
• Prescribing / medicines management in the role
• Time commitment 
• Sustainability considerations
• EDI considerations
• Service governance (e.g. who regulates the service, premises etc)
• The role of the GPwER in the monitoring of service delivery