Wednesday, 4 July 2007

A New Top Team and PbR

A new ministerial team has arrived at Richmond House (the DH Headquarters on Whitehall). alan Johnson is the new Secretary of State replacing Patricia Hewitt; the new Ministers of State are Dawn Primarolo and Ben Bradshaw (also Minister of State for the South West) and Professor Sir Ara Darzi who our London colleagues will know well has joined the Government and will be sitting in the House of Lords. Read more about the new team on the DH website pages.

I met Sir Muir Gray, Chief Knowledge Officer of the NHS on Monday and he commented that reorganisation in itself never solved any problems. Hopefully the enthusiasm and energy of the new team, coupled with the high priority of the NHS in the run up to the next election will help drive the quality agenda. I will certainly be making the point that we now have 1.5M people identified on primary care registers - as it happens all voters above the age of 18 years! The variation between PCTs, SHAs and most notably practices, reflects inequality for people with kidney disease and for you and I identifies the education gap - the practices where we should be giving talks, going through examplar cases and supporting audit. Do the practices who are good at identifying CKD have lower than expected crash lander rates?

I will also be making the point that the real preventative dividend is a long way off. If we can quickly, over the next 3 years, reduce unplanned starts on dialysis and improve dialysis provision the result is likely to be a need for more not less dialysis as survival rates increase. So the aphorism that "choice spells capacity" still rings true. To offer choice to our patients we need a skilled and knowledgeable multi disciplinary workforce to explain options and their consequences, a mind set that puts people with kidney disease at the centre of the decison making, lean processes so our activities are timely - be they pre-emptive transplantation, access surgery or hospice care, and of course the haemodialysis capacity that necessarily underpins quality kidney care. These are not woolly concepts - they are measurable.
One of the key reforms that Ministers will have to grapple with is the speed of Payment by Results (PbR) rollout. You would have thought that haemodialysis, a repetitive structured process, would be ideally suited for such a reimbursement model. Despite the NHS finance rule books, each organisation seems to account and apportion in a different way. The West Midlands Renal Network looked at this process for 8 Trusts on their patch - they got 8 different answers. What is included and what is excluded is opten impossible to know - a bit like eating at a posh restaurant where the veggies may be extra or going on a package holiday without reading the small print. Of course PbR is currently payment by activity - correcting that is going to be a long term challenge. We will know we have won when the finance director asks for the quality report before the spreadsheet. Most of you will know that the DH has pushed back aspects of PbR initially due to be introduced in April 2008, including dialysis, and have recently held a consultation exercise. I asked Paul Jennings, CEO of Walsall Teaching PCT and member of the Renal Advisory Group to chair a group from the RAG and wider renal community to respond to the consultation and to make suggestions for how PbR could work for both kidney patients and services. Read our response below where you can also find details of the West Midlands costing exercise.

PbR Consultation June 2006 Appendix 1 - Renal Dialysis Cost ComparisonWest Mids - Renal Finance Group Reference Cost Comparison

John Bradley, Consultant Renal Physician at Addenbrookes Hospital is a real expert on PbR and I attach a powerpoint presentation that he gave recently at a meeting - even without notes I think it describes the situation very well.