Thousands of people across Hampshire and the Isle of Wight are benefiting from earlier diagnosis and support for chronic kidney disease thanks to a new NHS-led improvement programme delivered by primary care teams including GPs, pharmacists and other healthcare professionals.
By supporting primary care teams to identify those most at risk and offering timely testing and personalised care, the initiative is helping people better understand their health, reduce anxiety linked to diagnosis and, crucially, prevent progression to more serious kidney disease.
The Screening, Prevention, Outreach and Treatment for Health Equity (SPOT) Chronic Kidney Disease (CKD) programme is being delivered by NHS Hampshire and Isle of Wight, in collaboration with Boehringer Ingelheim, to improve how kidney disease is detected and managed in primary care.
How the programme works
The programme brings together pharmacists, pharmacy technicians, GPs, and other healthcare professionals within GP practices to identify patients at risk – such as those living with diabetes or high blood pressure – and invite them for screening and follow-up care.
Which practices are involved
Six GP practices across Southampton, Portsmouth, and Gosport, supporting around 9,000 people with known risk factors for CKD, have already taken part. These include Living Well Partnership in Southampton, Willow Group in Gosport, Portsdown Group Practice in Portsmouth, Woolston and Chartwell Partnership in Southampton, Alma Road Surgery in Southampton, and Solent GP Surgery in Southampton, with Brook House Surgery in Southampton set to join the programme.
The programme supports the government’s 10-Year Plan by focusing on prevention, earlier diagnosis and reducing health inequalities.
What early results show
Early findings show the programme is supporting primary care teams to identify more patients with CKD and optimise their diagnosis and treatment, particularly in areas experiencing higher deprivation.
At Living Well Partnership, all patients whose screening results indicated CKD have now been diagnosed and appropriately coded, helping ensure they receive the right ongoing care.
Cam Todd, Director of Population Health and Inequalities for NHS Hampshire and Isle of Wight, said,
“CKD is often described as a ‘silent condition’ because many people do not experience symptoms until it reaches an advanced stage.
“Through SPOT CKD, we are seeing the impact of proactively identifying patients earlier and supporting them to access treatment sooner. The programme is helping people understand their condition and take positive steps to protect their health.”
The role of pharmacists and pharmacy technicians
Multidisciplinary team members, including pharmacists and pharmacy technicians are playing a central role in delivering the programme, helping to ease pressure on GP services while improving patient experience and outcomes.
Working alongside GPs and wider practice teams, they carry out holistic medication reviews, coordinate tests, provide tailored advice and support people to better manage their condition, while pharmacy technicians help identify at-risk patients, organise testing and ensure records are accurate.
Arjun Grewal, Lead Pharmacist for Primary Care Services at Hampshire and Isle of Wight Healthcare NHS Foundation Trust, said,
“By working across GP practices as part of wider primary care teams, we are finding people who may not have known they were at risk and helping to prevent progression to more severe disease.
“Teams are using personalised, accessible communication approaches to improve understanding and engagement, including simple explanations, visual materials, and culturally appropriate resources.”
A model with wider potential
By embedding pharmacists within GP practices and strengthening collaboration across multidisciplinary primary care networks, community services and specialist teams, SPOT CKD is establishing a more consistent and sustainable model for early detection and management of kidney disease, with potential to be expanded more widely in the future.
News shared on behalf of Isle of Wight Integrated Care Board. Ed
