Approximately 15% of the adult population have CKD
The current model of kidney care is referral pathways that are based on eGFR; this is consistent with the national guidelines
The proposed model of kidney care utilises the CKD expertise within the catchment area
The core issues are that
1. Identification
2. Monitoring
They are then seem people aged 18 years and  older included on the QOF CKD registers in the West Midlands. CKD is a major  risk factor for cardiovascular disease and mortality but is largely  asymptomatic until it reaches an advanced stage. It is estimated that there  could be approximately 83,000 people who are undiagnosed in the West Midlands.     Kidney function is measured by a simple blood test (eGFR). In CKD,  depending upon the underlying cause, eGFR can remain stable or decline  (progressive CKD). The majority of patients retain sufficient kidney function  to live out their natural life. However, those whose eGFR progressively  declines benefit from early specialist treatment to reduce the rate of decline  and hence the likelihood of requiring dialysis or a kidney transplant [1].     The traditional model of referral of  patients with CKD from primary to secondary care is based upon the staging of  CKD which is defined by the level of eGFR. Patients with CKD stage 3 are  generally cared for in primary care and referred to secondary care if they  reach stage 4 (defined by the patients’ eGFR falling below 30 ml/min/1.73m2)  as defined by NICE guideline CG 73. Patients with declining function but still  within stage 3 may not be recognised and so miss an opportunity to have earlier  specialist care [2]. This can lead to late presentation for RRT, which remains  an important cause of avoidable harm and premature death.    Once in secondary care, many patients  with stable CKD continue to attend outpatient clinics. They could be monitored  in primary care if there was a system of remote surveillance of their eGFR  trend to ensure it stays stable [2].      Optimal management of CKD relies upon: a) the patient having a  sufficient understanding of his/her condition and its treatment; b) the primary  care team monitoring the patient’s progress and modifying the treatment plan  accordingly; and c) the nephrology specialist in secondary care providing  advice and guidance at appropriate times and seeing patients in outpatient  clinics only when that adds value to the patient.     The HEFT renal and pathology departments operate an innovative  system for early detection and treatment of patients who are at the highest  risk of developing end stage renal disease (ESRD) [3]. In this system, the pathology  laboratory uses a database containing biochemical data from patients  (integrating results on blood samples taken in all settings) to generate  cumulative graphs of eGFR. The software facilitates the identification of those  patients with deteriorating kidney function, classifying them as low,  intermediate or high risk. For intermediate or high risk cases, the requesting  primary care clinician is sent a paper report of the eGFR graph with advice  about how to access nephrology advice. Once stable, patients can be discharged  from the outpatient kidney clinic and their kidney function followed remotely  via their eGFR graph.     Late presentation for RRT is a powerful and modifiable predictor  of poor outcome. Consequences of late referral include anaemia and bone  disease, low prevalence of permanent access, delayed referral for transplantation,  reduced choice of renal replacement modality, worse psychological adjustment to  ESRD, longer initial hospitalisation and increased mortality [5]. The rate of  patients presenting late to HEFT before starting dialysis, i.e. within 90 days,  has been the lowest in the UK since 2009.