Going upstream: the implication and opportunities of early detection

Chronic kidney disease (CKD) is common, harmful and treatable but has, until recently not been recognised in its early stages. The British National Health Service (NHS) provides a unique opportunity to study CKD because it is in effect a closed-managed care system. This single healthcare system for the United Kingdom is funded by the Government and paid for by general taxation. All UK citizens are registered with primary care physicians who control access to secondary care services. As a managed care system it should be able to offer integrated care across the whole patient pathway--allowing early identification of CKD, interventions to reduce risk and prompt management of complications. In reality, there are professional, organisational and institutional barriers to coordination and delivery of care in the NHS. The establishment of general-practice-based disease registers linked to a quality and outcomes framework in 2004 provides a basis for implementing the chronic disease model of care. The publication of the National Service Framework for renal services complemented by these changes in primary care has resulted in a paradigm shift from kidney disease being viewed as a secondary care condition to being a primary care priority as part of vascular control and management. In the first two years of the initiative, over 40% of the expected CKD stage 3 to 5 population has been registered in primary care. Kidney disease is now recognised as a public health problem in the United Kingdom, preventative strategies are being integrated into comprehensive vascular risk assessments and management programmes and kidney disease has become an NHS priority area.