PrescQIPP

Southampton West PCN Kidney Health Programme (2025)

Southampton West PCN

Project summary

Chronic kidney disease (CKD) is a common condition, estimated to affect up to 10% of adults in England. If CKD progresses to end-stage renal failure (ESRF – approximately 6,600 people in England per year, according to NHS England data), it can significantly impact health-related quality of life and result in substantial costs to the healthcare system.

To address this, we co-designed a structured, group-based Kidney Health Programme targeting adults with stage 3–5 CKD. The aim was to improve knowledge, encourage proactive behaviour, and build patient confidence. The programme involved 12 patients aged 65–85 from one GP practice. Six fortnightly, face-to-face sessions were delivered by a multidisciplinary team: GP/nephrologist, pharmacist, dietitian, wellbeing coach, social prescriber, mental health practitioner, and a patient champion.

Topics included kidney health, nutrition, mental health, medicines, physical activity, and social support. Patients completed evaluation forms before and after the programme.

At baseline, most patients scored 1/10 for kidney knowledge, with only 5 aware they had CKD. By the end, all participants scored ≥7/10, and rated the programme ≥8/10. Key lifestyle changes included reduced salt intake and improved hydration. Patients found all sessions helpful, with many ranking the nutrition, medication, and mental health sessions most useful.

A few patients requested pharmacist-led medication reviews after the project, leading medicine optimisation and deprescribing of unnecessary medicines. Peer support played a key role in fostering a safe space and sustained engagement.

This project demonstrated that an MDT-led group education programme significantly improves CKD knowledge and promotes patient-led action. It was awarded “Best Poster” at UK Kidney Week 2025. The plan is to roll out the education session across the PCN and include digital and hybrid formats to expand accessibility to younger patients and ethnically diverse groups.