Case studies

Since May 2014, NHS Salford Clinical Commissioning Group (CCG) and Salford Royal NHS  Foundation Trust (SRFT) have been working together to prevent acute kidney injury (AKI) and improve kidney care. In December 2014, we formed a new group, SPARC (Salford Partnership for Advancing Renal Care), which brought together all primary and secondary care initiatives to ensure a shared strategy and optimise kidney care across the City. This case study explores our journey over the past 18 months.

Spring 2014: Working together

NHS Salford CCG is committed to investing in primary care, innovation and research. Our Long Term Conditions Commissioning Group started work on a Long Term Conditions Locally Commissioned Service (LTCLCS) to include chronic kidney disease (CKD), a long term (five years plus) and significant investment (over £2.5million per year) in primary care, which builds on existing standards to ensure equitable access to high quality care across Salford.

The LTCLCS service takes a holistic approach to care, focussing on early detection, care planning and facilitated self-management using a health coaching model and education for all. It has four parts:

1. Standards of care
2. Education and training for practices
3. Engagement with patients via the patient and practice agreement
4. IT and reporting, including end of year evaluation.

As part of a longer term idea to develop a totally integrated primary and secondary care kidney service across Salford, the Clinical Director for Renal Services from SRFT and the NHS Salford CCG Clinical Lead for CKD met to discuss the development of indicators for the kidney component of the LTCLCS. SRFT had already started work on a secondary care based AKI prevention programme, and NHS Salford CCG kidney/medicines optimisation were interested in developing a ‘sick day rules’ project based on the work of NHS Highland, with the aim of reducing the incidence of community acquired AKI. Both agreed to investigate further and work together on AKI and CKD.

To this end, an indicator to raise awareness and minimise the risk of AKI was added to the kidney component of the LTCLCS.

June and July 2014: Adding to our collaboration

The team at NHS Salford CCG agreed that their National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester funding for the year could be allocated to AKI, and work began in partnership with SRFT and the NIHR CLAHRC on a sick day rules project. The NIHR CLAHRC and  NHS Southern Derbyshire CCG were already working on separate sick day rules project and they and NHS Highland were happy to share their work.

A joint working group was formed which agreed to meet monthly. Membership comprised:

• The Head of Medicines Optimisation
• The NHS Salford CCG CKD Clinical Lead and Service Improvement Manager
• The SRFT Clinical Director for Renal Services, Renal Pharmacist and Acute Medicine Lead for AKI
• The NIHR CLAHRC Project Team.

The NHS Salford CCG Clinical Lead for CKD was invited to join the fortnightly SRFT AKI working and assurance group and the team was invited to join the implementation work stream of the national AKI Pathfinder Project, which is part of the national NHS Think Kidneys programme.

Through an innovation initiative, NHS Salford CCG had already agreed to fund community pharmacists to work as part of the practice team in around 50% of Salford practices. We therefore had the opportunity to design our sick day rules project around this initiative.

Autumn 2014: Planning to succeed

The Advancing Quality Alliance (AQuA) care bundle for AKI was launched. At the time, SRFT was unable to take this on as a Commissioning for Quality and Innovation (CQUIN), but agreed to implement all indicators.

Work continued on the sick day rules project, to be implemented in two phases. The first was a general roll out of sick day rules cards by health professionals in practices and community pharmacies – exactly as in the NHS Highland project. Phase two was a targeted and individualised approach to people at high risk of developing AKI, led by the new practice-based community pharmacists.

The cards list medicines that should be temporarily stopped during illness (being sick or having diarrhoea or fever) to avoid AKI. Ultimately, the cards help people to keep their kidneys healthy.

We hope that the learning from this project will help inform larger scale evaluation of sick day rules to prevent AKI.

Winter 2014: Rolling out the resources

In recognition of our continued commitment to joint working, and increasing the number of shared and proposed projects across both AKI and CKD, we formed SPARC.

SPARC successfully secured funding from the NHS Salford CCG innovation fund to develop an academic detailing programme. This was in preparation for the development of a care bundle for primary care. The multidisciplinary team was accepted onto the IS4Leaders programme, an improvement science course supported by the Manchester Academic Health  Science Centre.

For 2015, three AKI indicators were agreed within the LTCLCS:

1. Participation in the sick day rules project
2. Correct coding, follow up and medication review for patients discharged after an episode of AKI
3. Implementation of practice processes to respond to the primary care AKI e-alerts when introduced.

The local pharmaceutical committee and all local pharmacies agreed to support the sick day rules project. The project plan was finalised, qualitative and quantitative evaluations discussed and cards, information sheets and posters printed.

The project was launched at two well-attended joint pharmacy/practice education sessions.

Current position (at August 2015): Getting ready for phase two

Phase one of the sick day rules project is underway with NIHR CLAHRC facilitators supporting practice and pharmacy roll-out, with cards having been delivered to 47 practices  and 59 pharmacies. Details of phase two have been finalised and will start as soon as community pharmacist training is complete.

45 out of 46 Salford practices have signed up to the LTCLCS which started on 1 April 2015.

The academic detailing project team has linked up with NHS Southern Derbyshire CCG and are using the same model, though NHS Southern Derbyshire CCG has managed to mandate sessions whilst at NHS Salford CCG we are approaching teams via the IS4Leaders programme. We are currently validating the toolkit we will use to support academic detailing as well as exploring different methods to facilitate primary care engagement.

Other AKI initiatives and links

SRFT is implementing the national AKI CQUIN.

An AKI app for secondary care has been developed in conjunction with the renal strategic clinical network and is available for download at www.akicare.co.uk. We hope to develop an AKI app for primary care.

SPARC has linked with Central Manchester University Hospitals NHS Foundation Trust (CMFT) regarding switching on e-alerts to primary care and has also met with the Greater Manchester Primary Care Transformation Group regarding proposed AKI initiatives.

Summary: Joint working to prevent AKI

Joint working via SPARC, coupled with NHS Salford CCG’s commitment to investment in primary care innovation and research, has enabled us to develop an ambitious strategy for Salford and has facilitated the on-going development of an integrated and quality assured AKI service across all Salford healthcare providers.

We’re very grateful for the help we’ve received along the way from NHS Southern Derbyshire CCG, the NIHR CLAHRC Greater Manchester, NHS Highland, CMFT, NHS Think Kidneys and many others. Full information about the sick day rules element of this work is available via www.clahrc-gm.nihr.ac.uk/salford-sick-day-rules. SPARC is happy to share and collaborate so please get in touch if you would like any further details.

Contact Details:

Dr Sheila McCorkindale, GP Clinical lead for diabetes and kidney, NHS Salford Clinical Commissioning Group, Sheila.mccorkindale@nhs.net

Dr Smeeta Sinha, Renal Department, Salford Royal NHS Foundation Trust 0161 206 5710 Smeeta.sinha@srft.nhs.uk