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From hospital to community: Delivering specialist kidney care at scale in partnership with primary care - The LUCID Programme

Project summary:

The Leicester, Leicestershire and Rutland (LLR) Chronic Kidney Disease Integrated Care Delivery Programme (LUCID) aims to improve patient outcomes through early detection of CKD, early intervention and optimisation, as well as maximising productivity and value for money.

By integrating condition management, it bridges the gap in care between primary and secondary care. It has four main principles:

• LUCID meetings to upskill the primary care workforce, including medicines optimisation. ​
• Case finding and risk stratification.​
• Clinician upskilling and patient education/ self-management.​
• Ongoing healthcare management​.

Since 2023 LUCID has been part funded by AstraZeneca UK as part of a Joint Working Agreement with University Hospitals of Leicester NHS Trust (UHL).

The LUCID programme is now being scaled nationally via the Health Innovation Network. It is being led by Health Innovation East Midlands.

Staff feedback:

“This helps identify patients with kidney problems early, prevents emergency presentations in ED, supports the primary care team to support patients in primary care and links to other LTCs such as diabetes and cardiac. It represents value for money.”

The challenge:

In the UK, over 3m people live with the most severe stages of kidney disease and this is rising rapidly. People with kidney disease face increased risk of heart attack or stroke. Risk factors, such as diabetes, CVD and obesity that contribute to kidney disease, are also growing.

The total annual economic burden of kidney disease in the UK is £7.0 billion, with £6.4 billion being direct costs to the NHS – about 3.2% of NHS budgets.

People living with CKD and those who support them experience a dramatic impact in their daily lives, with £372 million in productivity loss to the UK economy annually from missed work due to dialysis alone. This could rise to £2bn by 2033.

(ref: https://www.kidneyresearchuk.org/about-us/policy/health-economics-report/)

The solution:

The Leicester, Leicestershire and Rutland (LLR) Chronic Kidney Disease Integrated Care Delivery Programme (LUCID) integrates specialist management of chronic kidney disease (CKD) into primary care.

The project provides PCN level interventions including virtual CKD clinics to improve secondary prevention through early intervention, management of risk factors and early detection / timely referral. It supports better kidney care through education, specialist medicines, wellbeing and social support. It also helps address health inequality.

Across LLR, LUCID offers (as of the 2024 evaluation report):

• Clinics and MDTs run at PCN and/or Federation Level
• Approximately 1 clinical session per PCN every five weeks
• Support using the NICE recommended Kidney Failure Risk Equation tool to assist with risk stratification

HIEM funded the independent evaluation of the LUCID pilot service (published in June 2024).

The evaluation found:

• Total benefits per clinic (in the evaluation period) were £830 (excluding benefits from medicine optimisation).
• If rolled-out across all 26 PCNs in LLR, annual benefits could reach £697,747. When comparing this to the anticipated costs, the benefit cost ratio (BCR) is 2.76. A similar BCR is seen when looking at roll-out across the whole of the Midlands (2.47).
• Improved clinical outcomes with patients receiving faster referrals and earlier intervention to slow down disease progression.
• Treating more patients in the community potentially also means a positive impact on NHS Net Zero targets as fewer trips are needed to the hospital, resulting in a reduction of CO2 emissions.

The project was shortlisted for two HSJ Awards

Impacts and outcomes:

The pilot was sustained post-evaluation, and further impacts (up to 29 May 2025) have been seen:

• 2816 clinical discussions about 1828 people with CKD
• 1358 (48.2%) MDT episodes led to medicines optimisation
• 296 (10.5%) and 228 (8.1%) expedited or avoided referrals, respectively.

The education tools and the MDTs are also helping to upskill staff. The LUCID team hold education sessions (intermediate and introduction levels) for staff to learn more about CKD care. They also created 16 public education videos which are available on Youtube.

The team has also developed a theory and evidence based digital self-management programme for people living with non-dialysis CKD called My Kidneys & Me, which includes structured 10-week education. This was co-developed with people with CKD, their relatives, CKD multidisciplinary team and digital health experts.

Contact:

For more information email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Resources:

Request the evaluation report of the LUCID pilot (2024)

Updated results: https://academic.oup.com/ckj/article/18/12/sfaf312/8275740)

HIEM has held a webinar to share learning with health systems. Watch the webinar about the project and download the slides

https://www.leicesterkidneylifestyle.team/my-kidneys-me-resources