Bridging Cardio-Renal Care: A Nurse Practitioner’s Take

In this episode of For Kidneys’ Sake, Professors Jeremy Levy and Dr Andrew Frankel speak with Beverley Bostock, Advanced Nurse Practitioner in primary care, Editor-in-Chief of Practice Nurse Journal, and President-Elect of the Primary Care Cardiovascular Society. The discussion examines the expanding role of primary care nurses in the management of long-term conditions, including diabetes, cardiovascular disease, and chronic kidney disease (CKD). Beverley outlines how nursing roles in general practice have evolved from task-based activities to autonomous, multidisciplinary management of patients with multimorbidity.

The conversation focuses on the practical delivery of CKD care in primary care settings. Key areas include how CKD is explained to patients, the importance of recognising CKD as a marker of increased cardiovascular risk, and the role of urine albumin–creatinine ratio (ACR) testing alongside estimated glomerular filtration rate (eGFR) in risk stratification and prognosis. The episode also explores system-level factors influencing care, including incentivisation frameworks, team education, and strategies for improving the uptake of recommended monitoring and evidence-based interventions. The content is relevant to clinicians involved in the care of patients with diabetes, hypertension, cardiovascular disease, and CKD across both primary and secondary care.

Top 3 Takeaways

1️⃣ Primary care nurses play a central role in CKD management
Nursing roles in general practice have developed to include autonomous assessment and long-term management of patients with CKD and related cardiometabolic conditions, working within multidisciplinary teams.

2️⃣ CKD should be understood and communicated as a cardiovascular risk condition
Effective patient education focuses on cardiovascular risk reduction alongside kidney monitoring, helping to align treatment decisions with long-term outcomes.

3️⃣ Urine ACR testing is essential for risk stratification in CKD
Measurement of urine ACR, in combination with eGFR, provides critical information on kidney disease progression and cardiovascular risk and requires consistent implementation in primary care systems.

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Chapters

• 2:04 The Role of Nurses in Chronic Kidney Disease Management
• 5:13 How does your role differ from a diabetic specialist nurse?
• 7:10 Understanding Chronic Kidney Disease: Patient Perspectives
• 11:40 Integrating Cardio-Renal-Metabolic Health
• 14:51 The Importance of ACR Testing in Primary Care
• 19:22 Beverly's Vision as President of the Primary Care Cardiovascular Society
• 20:33 Key Takeaways for Primary Care Practitioners

Transcript

Joana Teles (00:05)
For Kidney's Sake makes kidney disease management easy. For Kidneys Sake is for primary care clinicians. For Kidney's Sake is nice, consistent, short and sweet. Welcome to For Kidneys Sake brought to you by Northwest London NHS Kidney Care Team.

Jeremy Levy (00:18)
So, hello everybody and welcome to another episode of For Kidney Sake. I'm Jeremy Levy, a consultant nephrologist at Imperial NHS Trust.

Andrew Frankel (00:29)
And I'm Andrew Frankel, a colleague of Jeremy's, also working at Imperial College Healthcare NHS Trust, and looking forward to this podcast, another in the series on For Kidneys' Sake.

Jeremy Levy (00:44)
So Andrew, today we're gonna have a very exciting guest, aren't we? Because we both know that to properly look after people with chronic kidney disease, we have lots of people in the team. And one of the crucial group of staff helping manage people with chronic kidney disease are the nursing staff. And historically, of course, many of the nurses were working in the management of people with diabetes. And these roles have often been extended. Historically sort of from diabetes to other chronic diseases and chronic kidney disease and of course now newly and today so it's a real pleasure to have with us Beverly Bostock's sister Beverly Bostock who's an advanced nurse practitioner from Mann Cottage Surgery she's editor-in-chief of the Practice Nurse Journal and most excitingly the first nurse almost certainly president-elect of the Primary Care Cardiovascular Society so a real expert on cardiovascular disease as well as her background of nursing. Beverly, welcome, and we're really thrilled to have you today.

Beverley Bostock (01:40)
Thank very much for inviting me. I must say I'm not sister. still, you know, after all these years, I'm still slightly scared of sisters. They were all a bit scary when I was training at St. George's Hospital. So Bev will be fine. You don't need to call me sister Bev. We're fine with Bev.

Andrew Frankel (01:56)
We're not frightened of you Bev, we are as I said excited to have you here. But perhaps a good place to start would be just to hear a little bit about your role in primary care. How would you describe this and what does it look like in practice?

Beverley Bostock (02:15)
Great question, Andrew, because I think people don't necessarily understand what nurses do in primary care. So it's nice to have the opportunity to explain the different roles, in fact, that nurses undertake in primary care. I'm always reminded that as somebody working in primary care, having done my training predominantly in secondary care, I've experienced that. But many people working in secondary care don't know what happens in primary care.

So I'll do a potted history, but basically I went into general practice almost as soon as I qualified because I loved the idea of the autonomy that was possible in primary care, still working as part of a team, but actually having that autonomy, having your own list, having that responsibility for completing episodes of care. obviously...

You start off as a primary care nurse, usually doing things like childhood immunizations and smear tests and wound care and that sort of thing. But I had a very forward thinking GP who encouraged me to go off first of all to train to do some respiratory care. So I trained in asthma and then moved on to COPD.

And then that evolved into cardiovascular disease, evolved into diabetes, which evolved into heart failure, chronic kidney disease, and obviously all the elements of that, such as hypertension and lipid management. And then from that, I was invited to work with an organisation that did courses for the Open University. So I developed the courses, I taught the courses, I marked

the assignments for the courses. So that developed my more academic and education type role. And then that led into editorial board roles and as you said, eventually editor in chief and practice nurse journal. And so they've all really beautifully come together, all these roles as time's gone on. So there are many of my colleagues out there still doing the basic and very complex roles of cradle to grave in primary care, but I now focus exclusively really on multi-morbidity and long-term conditions.

Andrew Frankel (04:46)
That is hugely impressive. You really are a master of all trades in terms of long-term conditions. Okay then, Bev, on the ground, when you're seeing people with diabetes and kidney disease or just diabetes alone, tell me, how does your role differ? Is it similar to what I would perceive as a diabetes specialist nurse?

Beverley Bostock (05:14)
So my colleagues who work as diabetes specialist nurses are very much as the name suggests specialising in diabetes. I think it's fair to say that the role as a DSN has extended because it in the past was probably very much secondary care focused and very glycemic focused as well. There was that real intention to get HbA1Cs down as much as possible. And maybe there wasn't so much of a focus on hypertension, on dyslipidemia, on the kidneys. And then when the role extended out into the community, it was less focused on type 1 diabetes and they saw more complex type 2 diabetes as well.

And we started to see a lot of collaboration between our community DSNs and our general practice nurses. So that I think it's fair to say that the majority of cases that general practice nurses would see would be fairly straightforward, although increasingly they are getting more complex, particularly with the management options that are available to us. But, you know, when we need that extra bit of help, then we'll bring in our DSN colleagues either in the community or in secondary care to actually support us with the management of that patient.

Jeremy Levy (06:46)
That's really interesting and clearly these roles have spread and merged and evolved. So let's talk about chronic kidney disease and your role for doing it in primary care teams and your experience of nurses doing work with people with chronic kidney disease. What do you do to explain chronic kidney disease to both patients and your nursing colleagues particularly? What are the key aspects of it that you recognise?

Beverley Bostock (07:10)
I did a conference recently where I was on a panel and one of the panel members had chronic kidney disease and somebody asked me this very question, how do I explain it to patients? And I remember thinking, my goodness, I've got one sitting right here. If I get this wrong, then I'm really going to be in trouble. But he very much said that he liked the way that I described it, which is just generally, and particularly thinking about, you know, if you think about the pyramid of people that we're looking at, in general practice, obviously, most of the patients that I'm seeing have CKD 3, 4, we've got the multidisciplinary team involved as we get 4 to 5. So, I usually explain to the patients that their kidneys are under pressure, that they're struggling a little bit and...explain to them the reasons why that might be. So it might be because they've got hypertension or cardiovascular disease or they've got diabetes. But I think one of the biggest issues is that a lot of people don't understand the implications of that. So they will immediately see dialysis or be thinking that they're going to need a transplant. I feel like, you I need to play the part of good cop and bad cop. It's like, well, you know, that's less likely to happen than actually your increased risk of cardiovascular disease is going to have on your outlook. So I'm always at pains to explain to people all of the opportunities that we have to manage their chronic kidney disease and, but what we must do to reduce their risk of a cardiovascular event going forward. So people won't understand  necessarily why a diagnosis of chronic kidney disease means that we should immediately be looking at lipid lowering therapies and trying to make sure that they understand that is absolutely key. And I honestly think that when you're giving key messages to people who've been diagnosed with chronic kidney disease, the messages are not dissimilar to what I am sharing with my colleagues in primary care, because I think there is a real

A real issue with people understanding, for example, how important it is to do a urinary album and creatinine ratio measurements as part of our assessment of somebody's ⁓ future prognosis, their cardiovascular risk, to tell us what's going on with the kidneys. And if healthcare professionals don't understand that, then they're not going to be able to explain it to their patients. And then we're going to miss out on such an important test for working out what the future holds. So I think that we need to be really clear with people what it is. We had a big problem and I suspect it continues in primary care where now that patients have access to their own records, they may come across this diagnosis on their records and they haven't necessarily been told. I even had friends who when access to records was opened up, discovered that they had a diagnosis of chronic kidney disease. They'd never been told and importantly, they'd not been made aware of the interventions that should have happened as a result such as lipid lowering therapy and monitoring and so on. And it was really quite concerning that people were finding out that way.

So one of the things that I do in practice is group consultations where we bring people together to talk about what the diagnosis means and how we can manage things in the future. And I think all of that needs to be done with the general public and it needs to be done with our colleagues in healthcare as well.

Jeremy Levy (11:15)
You've touched on a couple of things already and we'll come back to the urine in a moment I think, but that whole issue about us moving away from siloed medicine, this just being a kidney problem to being cardio, renal, metabolic, that whole aspect of multimorbidity which you touched on and those three things particularly, cardiac disease, hypertension, vascular disease and renal disease. What do you do to bring those things together? How do you talk to people about the three things together?

Beverley Bostock (11:41)
Yeah, it's funny because there is an increasing focus on cardio renal metabolic and that's absolutely as it should be. Some people do describe this as multi morbidity, but actually I see it as being different sides of the same coin. think we have conditions here that are linked and so we need to be thinking of all of these elements when we're talking to people about their health, when we're reviewing them.

In primary care, we have a lot of sort of template based care, which is important because we know, for example, that if somebody isn't added to our CKD register, the research tells us that they don't get the care that they should get. So I think it's really important that we make sure that we metaphorically speaking tick the box, boxes, and I suppose it's not metaphorically, it's in real life, we have to tick the boxes that show that we're delivering the care that we need to. And in fact, general practice is very often incentivised in that way. But I do think we need to be very focused on the individual and we need to ensure that we're tailoring care to the individual, we're tailoring our conversations to the individual. But I have lots of aid memoirs that help me when I'm ⁓ speaking to people to make sure that I cover all of the areas that need to be covered. I always talk to myself about I need to keep watching the ABC when I'm seeing somebody with diabetes. That means ⁓ K for kidneys, W for waste or weight, BMI, that sort of thing, A1C, BP and cholesterol. And obviously I'm looking at LDL cholesterol primarily there.

Those are the ways that I remember when I'm reviewing somebody with diabetes or potentially other conditions. think these are the things I need to make sure that I am covering. And you will notice that the K for kidneys is first there. I just think there is so much that relies on us knowing how the kidneys are performing.

Andrew Frankel (13:53)
Really important message, I think it'd be helpful for anyone working with multimorbidity, sort of that sort of ABCD approach, just really thinking all the time what you're going to cover. I want to come back to two things you mentioned. ACRs, which we know are not a kidney test. They are a test for underlying cardiorenal risk and incentivisation. Because as you know, used to be have ACR on QOF as it was called.

It dropped off a quaff and then the testing of ACR fell off a cliff. Things are recovering. I may be a little bit controversial here, but do you think that it is incentivisation that is going to be important in re-establishing the annual review of kidney health with ACR? Or should this really be part of standard care of an individual who is at risk of kidney disease, such as a person with diabetes?

Beverley Bostock (14:51)
This is such an interesting topic because I always say I've been a critic of QOF forever. ⁓ And my various master's degrees, I always seem to have got into my final dissertation, how disappointing it is that we need to be financially incentivised to deliver good clinical care. But the reality is there, we know that when

So for anyone in secondary care who's not aware, QOF is basically the quality and outcomes framework which allows general practice to be paid for the work that they do in terms of standard of care and tasks within. And so ACR measurements were included in the past and if you got most of your patients, certainly in diabetes, if you got their ACR measured, then you would get a payment that would go to the practice for that. And regrettably, when it came off QOF, people just stopped doing it, which it blows my mind to think that that happened. I don't get paid by QOF. although, you you could argue I do, because actually if we didn't get our QOF payments, then the practice would probably go under and I wouldn't have a job. but I'm not directly paid by QOF. So I do things because they need doing. I do it because there is a clinical reason for doing it. And it is so important to be able to assess where we are ⁓ in a cardio-renal sense with the ACR and the EGFR. But the reality is that general practice is a business.

It took me a little while to understand that when I moved into general practice and more and more over my career it's become more and more of a business. you know, we have an NHS that relies on hundreds of little businesses, which are our GP practices, doing things that make money for them. So I would far prefer that we were doing it because it's clinically the right thing to do. But we know that when ACR came off QOF, ⁓ people stop doing it. So I think we have to say that the more something is incentivised financially, the more likely it is to get done. Sad but true.

Jeremy Levy (17:17)
Tell us quickly, how do you get your teams to actually measure your ACRs? For us in secondary care, it's sort of quite easy. Every patient coming to my clinic gives a urine sample and it's that easy. Primary care, that's much, much harder. So practical terms, how do you get urine samples off patients when they've got cardiovascular disease, risks?

Beverley Bostock (17:32)
So we make sure that everybody knows how important it is right from our receptionist, our dispensary staff, I've got a fantastic healthcare assistant who will not allow people out the building until they've provided that sample if it's not there. in terms of our clinicians, we make sure that everybody, no matter what their role from GPs through to other nurses in the practice to pharmacists, we make sure that everybody understands that if we're looking at the kidneys without an ACR, we're looking with one eye covered or one hand tied behind our back. We've only got half the story there. So we need to make sure that everybody realises how important that ACR is. And then everyone gets on board with ensuring that our patients do get it done. And we extend that because we know that numbers aren't great for people with diabetes, they're even worse for people with hypertension, cardiovascular disease, know, gout. How many patients with gout actually get their ACR measured? But it's in the NICE guidelines. So, you know, I think it's nice if we've got a reminder in our IT systems, that would be great to see that happening. But the bottom line is we need everybody to know why we're doing this. And then that will translate into the patients knowing why we're doing it so we can all crack on and make sure that our capture level is high.

Andrew Frankel (19:05)
So Beverly, it's been fantastic to hear from you, but we can't let you go without hearing a little bit about your exciting new role as the president of the Primary Care Cardiovascular Society. What are your key aims and ambitions?

Beverley Bostock (19:23)
Well, ⁓ we've really developed as a society with just about 7,000 members and we are multidisciplinary. So we've got doctors, nurses and pharmacists all in similar sort of levels and we've even got some secondary care people involved as well. So that's really helpful for us. We want to make sure that primary care delivers exemplary cardiovascular care and CKD will come into that remit.

We do want to find those people who are not members. We need to make sure that people can attend conferences and learn from us. Our membership is free, all of our resources are free, all of our conferences are free, so there's no excuse not to join. So we very much hope that we're out there to support people to do the best job and it's hard out in primary care. We're an awful lot in an awful lot of different areas, so hopefully we're supporting people to do that.

Andrew Frankel (20:19)
Thank you so much Beverly, that's been really helpful. And I'm going to finally ask you, we always ask this, what would be your three key takeaway messages in relation to your role and what you would advise other people within primary care who doing similar roles to undertake?

Beverley Bostock (20:38)
So first thing, we need to be proactive. You know, the work will come to us whether we do it proactively or whether we have to do it reactively when people have had events. So let's be proactive. Let's be curious about new ways of working. That would be my second thing. Think about...newer opportunities, whether it's IT based or other ways of working like group consultations, let's do things differently, because sometimes that means we can do things better. And let's be evidence based. know, people can be a slave to guidelines and formulares. Let's just think about the evidence behind what we do. know, guidelines are generic and I've yet to meet a generic person. I'm just going to throw in a fourth here.

Don't forget the expertise and knowledge within the extended team. know, primary care to secondary care, secondary care to primary care. We are doing a lot out there, so do use us, but also, you know, think about all the individuals within your team, your pharmacists, your healthcare assistants, your nurses, your GPs, your specialists like you guys. You know, we can all pull together and make things better. Thank you very much.

Jeremy Levy (21:52)
that's been fantastic Beverley, really good to chat to you and talk to you just hear things from the other side. So thank you again it's been great listening to you.

Beverley Bostock (22:01)
Thank you.

Andrew Frankel (22:03)
So Beverly, thank you. Absolutely. That's been fantastic. And to our audience, do consider listening to our previous episodes. They are all available on your favourite podcast stream, all from our website. So do also prescribe to our newsletter. Thank you very much and goodbye.

Joana Teles (22:27)
Thank for listening. We hope you enjoyed this episode. All information is fully consistent with NICE and Northwest London guidelines. You can find out more in the show notes and contact us with any suggestions or questions. Send us a text using the text function at the top of your show notes. Thank you for listening to For Kidneys' Sake podcast and we see you at the next episode.