This page details the high level findings and outcomes for service users, staff and the wider south east London system from the implementation of consultant geriatricians in advanced kidney care clinics (AKKCs) within the multi-morbidity model of care (MMMoC).
To see our complete findings on the impact of consultant geriatrician input on people living with advanced chronic kidney disease, click here to see our report.
Our challenge
- Growing population of older, frail service users with advanced chronic kidney disease (CKD) and multimorbidity
- Complex treatment decisions (dialysis vs supportive care) often made without full consideration of frailty, quality of life and service user preferences
- Limited holistic assessment within traditional renal pathways
- Fragmented care siloed across renal, community, geriatric and palliative services
- Dialysis demand projected to exceed capacity by 2030, causing system pressure
Our ambition
- Deliver person-centred holistic care aligned to “what matters most” for frail service users with advanced CKD
- Embed comprehensive geriatric assessment (CGA) and shared decision-making (SDM) into renal pathways to ensure holistic care
- Strengthen MDT working across renal, geriatric, community and palliative care
- Improve advance care planning (ACP) and alignment of care with preferences
- Deliver better outcomes, and service user care through more appropriate treatment decisions
MMMoC: The wider programme of work
- Delivered proactive, person-centred care closer to home
- Enabled integrated, multidisciplinary working at scale
- Improved outcomes and experience for service users and staff
- Supported system sustainability and preventative transformation
Consultant geriatrician input: the approach
Embedded consultant geriatricians in Advanced Kidney Care Clinics (AKCCs) in Guy’s and St Thomas’ and King’s College Hospital NHS Foundation Trust
- 8 hours / week (2 programmed activities (PAs))
- Aim: align treatment with quality of life, prognosis and service user priorities
Target cohort
- ≥60 with frailty or ≥80 years
- Cognitive impairment or complex needs
- Uncertainty around treatment decisions
Core intervention components:
- Comprehensive geriatric assessment (frailty, cognition, function, comorbidities)
- Shared decision-making (dialysis vs supportive care)
- Advance care planning and DNACPR discussion
Key features:
- Extended consultations enabling deeper discussion
- Joint working with renal teams
- Family involvement and capacity assessment
Involvement across south east London system
- System-wide collaboration: Renal, geriatric, palliative care, community services, primary care
- Multidisciplinary approach embedded in care delivery
- Strong family/carer involvement: 84% of cases involved family in decision-making
- Support for complex decisions: 29% required best-interest decision-making due to impaired capacity
Value: service user
- More personalised care: Decisions based on “what matters most” to the individual
- Improved understanding: Better insight into prognosis and different treatment impacts
- Improved care planning: Increased advance care planning, DNACPR, and coordinated plans across settings
- Greater involvement in all decisions: Service users and families actively engaged in shared decision making
- Better alignment of care with preferences: Including decisions choosing supportive care or dialysis and place of death
Outcomes: Population impact
- 129 high-risk service users reviewed across two sites
- High frailty burden amongst cohort: Majority of service users over 80 years old, many with moderate – severe frailty
- Identification of unmet need: Approximately 30% new cognitive impairment diagnoses, and multiple new frailty-related conditions identified
- Clinical improvements: Medication optimisation – approximately 50% at KCH and referrals to wider services – approximately 47%
- Improved ACP uptake across cohorts
- Significant shift in treatment decisions following CGA and SDM: Supportive care increased from 5% to 74%, whilst dialysis reduced to 8% post-intervention
Value: Workforce
- Increased confidence managing frailty and complexity in AKKCs
- Improved capability in capacity assessment, best-interest decision-making and holistic care planning
- Enhanced multidisciplinary working – better collaboration between settings and specialties
- Supports more sustainable workforce model – shared responsibility
Outcomes: System
- More appropriate treatment pathways: Improved holistic assessment and shared decision-making supported service users to make more informed choices aligned with their values and priorities, with more people choosing supportive care where this was the preferred and most appropriate option
- Wider system benefits emerging from service user-centred care: Natural reduction in high-cost dialysis, transport and other procedures, contributing to more sustainable use of resources across the system.
- ACP supporting coordinated and preference-aligned care: ACP enabled clear understanding of service user wishes, supporting more coordinated care and early findings is associated with fewer hospital admissions and bed days in the last year of life
- Early indication of care becoming more aligned to service user preferences in the last year of life: Early findings suggest that care aligned to service user priorities, including supportive care pathways, may be associated with fewer hospital admissions and bed days (1.3 vs 2.6 admissions; 11.2 vs 31.5 bed days).
What next?
Consultant geriatrician input in AKCCs demonstrated a significant improvement in person‑centred care, enabling more informed treatment decision‑making, identification of unmet frailty needs, and better alignment of care with patient priorities.
The geriatrician input in this model will aim to:
- Sustain and scale geriatrician input in AKCCs across London and beyond: Continue to embed and expand geriatrician input to support holistic, person‑centred care
- Expand model to other pathways and long-term conditions: Explore application of this model to other pathways supporting people with complex needs
- Continue building integrated MDT and INT working across the syste: Strengthen integrated MDT and neighbourhood working to support coordinated, person‑centred care
- Strengthen data and evaluation with larger cohorts of service users: Continue to build the evidence base to understand impact on outcomes, experience and care alignment
- Move care closer to home for frail service users: Develop pathways that support service users choosing supportive care to be managed in primary care, including MDT discussions with specialist teams, reducing the need for hospital attendance
What are we most proud of?
Consultant geriatrician input in the MMMoC has:
- Delivered holistic, person-centred care for a highly complex, frail population
- Enabled a transformational shift in decision-making, prioritising quality of life and delivering cost-effective outcomes as a result
- Demonstrated clear potential for system-wide impact and sustainability
