Wednesday, 31 October 2007

Using the QOF data locally

“If you can measure that of which you speak and express it is numbers, you know something about your subject; if you cannot measure it, your knowledge is of a very meagre and unsatisfactory kind”, William Thompson (Lord Kelvin) (1824-1907).

In the same city, 100 years after the death of Lord Kelvin the Scottish Primary Care Collaborative chose (SPCC) CKD as one of their target areas for 2008. Mark Macgregor (Consultant Nephrologist at Crosshouse Hospital, Kilmarnock), tells me that he thinks the focus will be on proteinuria and adding quality to care rather than just a kneejerk response to the low prevalence of 1.8% reported from Scotland in comparison to the other home countries. This low prevalence is thought to relate to delays in systematic eGFR reporting and that in many parts of Scotland, General Practitioners only get the results that they have requested into their EPR systems. As we know, many people with CKD are seen in a variety of secondary care settings because of their associated co-morbidities.

The Scottish Primary Care Collaborative is a programme designed to remodel the way general practice works and The Improvement Foundation (previously known as the National Primary Care Development Team – why do things change their names so quickly?), headed by Sir John Oldham, have assisted with the Scottish programme.

To date there have been almost 500 GP practices participating in the SPCC and their improvement results are impressive. Take diabetes or CHD as examples

I think this is great news for people with CKD in Scotland and it is perhaps a model that can be adopted elsewhere to build on the platform of the visibility that the CKD domain of the QOF has brought to add real value.

Similar approaches are being taken in parts of England. Nicky Coffey (Associate Director, South East Coast, SCG) with Ian John (Consultant Renal Physician, East Kent Hospitals NHS Trust) who have established a formal CKD Network across primary care across the catchment population of East Kent Hospitals NHS Trust. The Terms of Reference make it clear that this Network is about processes and pathways rather than structures.

The percentage of the population with an MDRD eGFR below 60 mmols/min/ 1.73m2 is not the issue. The issue is, of course, the quality of care that can be delivered using the chronic disease management model for registered populations.

A word of caution about measurements. “Not everything that counts can be counted, and not everything that is counted counts” Albert Einstein (1879-1955),

Tuesday, 30 October 2007

Renal NSF Update, October 2007

The Renal NSF update for October is available here

Friday, 26 October 2007

bedtime reading: The End of the Disease Era

The American Journal of Medicine, February 2004 Bol 116
Mary E Tinetti MD, Terry Fried MD

bedtime reading: Hope and advance care planning in patients with end stage renal disease: qualitative interview study

BMJ 28 October

Objective: to understand hope in the context of advance care planning from the perspective of patients with end stage renal disease.

bedtime reading: Fistula First Initiative: Advantages and Pitfalls

Clinical Journal of the American Society of Nephrology, Sept 2007, Vol 2 No 5
Charmaine E Lok

bedtime reading: Renal Provider Recognition of Symptoms in Patients on MHD

Clinical Journal of the American Society of Nephrology, Sept 2007,Vol 2 No 5
Steven D Weisbord, Linda F Fried, Maria K Mor et al

bedtime reading: NICE: Behaviour change at population, community and individual levels, October 2007

NICE public health guidance 6

Can be downloaded from

Summary - the guidance highlights the need to:
  • Plan carefully interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community.

  • Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools. (Education providers should ensure courses for practitioners are based on theoretically informed, evidencebased best practice.)

  • Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component.

Thursday, 25 October 2007

Champions - Renal Team of the Year!

Earlier this month it was my pleasure to visit 3 outstanding renal units - St Helier, Derby and Portsmouth. I hasten to add I visited in this order! (I don't want to give anything away regarding the final "scoring"). I was visiting to judge the Hospital Kidney Doctor and Team of the Year Award and had hoped to visit with other members of the multiprofessional renal team and with service users. That request came as a bit of a surprise to the organisers. It also demonstrates how far kidney care is ahead of the mainstream. We recognise that the patient experience and clinical outcomes are determined by every member of the team - including patients and carers.

I am pleased that Fiona Loud, a lady who is a renal transplant recipient and who was previously on dialysis, will be making the award to the top team with me in London next month. Fiona is Chair of the Kidney Alliance and we will make the award jointly to emphasise the fact that patients are the true judge of the quality of our services and care.

I knew that the job would be tough. There were 25 submissions in all - over a third of renal units. All were good and many were very good. Shortlisting to identify the top 3 was difficult enough!

In all 3 units I found a culture of patient centred care, multiprofessional working and commitment to quality. In each I had a chance to look around the facilities and talk with patients and staff. Chatting to patients on dialysis can be very revealing. In each unit, patients were also members of the team that presented to "showcase" their unit's successes. I was particularly encouraged to see that patient representatives and carers were part of the decision making in clinical governance groups in each centre. The professional team spirit was strong at each site despite the differences in their histories, models of care and research activities.

The "acid test" - would I go there or recommend the service to a close friend or relative - "yes" for all 3! Training in each of these units would add value - for nurses, doctors, pharmacists, dietitians ..... the lot. Apologies for trunkating the list but if I didn't and I missed a group off I would be in trouble! The experience in these units would teach team work, joint problem solving with patients and would be tremendous fun. The standard of care, attention to detail and support for people with kidney disease is exceptional in all 3. Portsmouth have a mission statement, renal patients come first, organisation comes second. The same philosophy pertains at St Helier and Derby City Hospital.

Epsom & St Helier University Teaching Hospitals NHS Trust was my first port of call. Jonathan Kwan met me, introduced me to lots of staff and showed me around. It was Monday and many of the consultants were out at local clinics. The number, frequency and range of local support this team provides across their whole patch is remarkable. Patients don't travel unless absolutely necessary. The inpatients, outpatient suite, dialysis and transplant units and research laboratories are all integrated - if not necessarily purpose built. I was struck by the comment made by Dr Paul Colville-Nash "walking by the dialysis unit to the lab every day really brings it home to you, why we are here and what we are trying to do". The South West Thames Institute for Renal Research is funded primarily by charitable donations - not least, major income from Jonathan Kwan’s marathon running!

Education is high on the agenda at the South West Thames Renal & Transplant Unit. The team have undertaken a root and branch analysis and reform of their education strategy over the past 5 years. Sue Woodcock and Blossom Keddo gave a overview as part of the team’s presentation. The effect of education, learning and development has been improvement in recruitment and retention, a virtual academy of nurses, doctors, dietitians and other healthcare professionals engaged in higher diplomas and degrees and development of good practice. The unit is always well represented at meetings and not only sustains its good practice but builds on that with new quality initiatives and writes up and promotes systems that can be adopted by others across the NHS. The team don’t just “do” education, they evaluate it and link it to the Trust’s key performance indicators. I wasn’t surprised to learn that the unit has the Investor in People award but the fact that there are zero staff vacancies did raise my eyebrows and underlines the quality of the organisation.

Next up were Derby. I was able to drive which was a bonus and I was able to park at the hospital! Over the past 10 years, Derby has gone from a single handed consultant practice to a thriving service, research and teaching centre. That hasn’t been achieved without hard work but Richard Fluck is more than just a hard working chap. What Richard brought was a vision of what could be achieved. His energy and motivation coupled with an attention to detail and the ability to make progress on the small things are behind the strength of the unit today. He has chosen the people he works with wisely, some pre-date his arrival but all regard him with affection and seem to set his passion for high quality care for individuals as the benchmark against which they should be judged. In turn, Richard has supported and mentored colleagues and is rightly proud of the achievements of the staff he works with. The secret may be Rani Uppal whose title is personal assistant to the consultants but who might be more difficult to replace than any of the 5 consultants! I sat down with a few patients for an hour or so and their stories were very powerful. The message they gave was that “nothing is too much trouble” for the Derby team. I visited on a Tuesday morning and was somewhat surprised to see the clinic waiting room virtually empty. Richard explained that they have done away with queues by staggering appointments. Using flow methodology, waiting around is something that used to happen in the 20th century for Derby patients.

When clinical problems are encountered, they are approached from a scientific perspective – if the literature to support best practice is found to be wanting – that may spell a research opportunity. The research undertaken is truly translational from the bedside to the bench and back again. One of my deep concerns is the evidence base for kidney care. Kidney research is not yet a national priority and the funding for it is disproportionately low in comparison to clinical and economic impact. The NHS has been a difficult research environment. Over the past 5 years the Derby kidney team provides an example of what can be achieved even if the environment seems adverse. By aligning their research agenda to the needs of their patients and the markers of best practice of the Renal NSF key questions about vascular access related infections, haemodialysis and early kidney disease have been answered. As ever, the answers to the questions beg more questions so rest assured, the research team isn’t resting on its laurels.

Last, but not least, Portsmouth Hospitals NHS Trust. I had to change the time of the visit at short notice but despite that, Rob Lewis and his team gave me a warm reception. Rob made the point that it’s not just where you are, it’s where you came from and where you are going. The Portsmouth unit is going from strength to strength. But look where it’s come from. In 2002 an external review judged the unit to be “backward and unsafe”. A highly critical report concluded with the statement “ … the combined result is a risk to patient care”. Well not any more. The enthusiasm, skills, attention to detail and team spirit were as strong in Portsmouth as in St Helier and Derby. The one striking difference was that Portsmouth “hide their light under a bushel”. I saw lots of innovative practice – a DVD for people with advanced kidney disease to help them with their choices, a peritoneal dialysis team who visit the ward and counsel crash landers so that they can benefit from this modality and avoid the risk of catheter related sepsis, a close working relationship with primary care that has helped avoid unnecessary and inappropriate referrals since the introduction of eGFR and a “can do” attitude to solving real problems that people with kidney disease and the staff managing them face in the NHS.

The clinical governance structures and systems that Dr Lewis and the team have put in place testified to the power of governance in improving quality of care. With the structures in place the focus is on processes and pathways – the things that matter to patient experience and clinical outcomes.

Instead of losing the transplant service it is, to use transplant surgeon Paul Gibbs phrase “not just alive but kicking”. Paul and his colleagues ensure that vascular access waiting times are minimal. MRSA rates have fallen dramatically. Practices that don’t add value such as taking a long car or ambulance journey to receive intravenous iron are eliminated.

Delivery of the service is as close to patients’ homes as possible. More than half of the outpatient consults take place away from the Portsmouth base. Community care is supported by a nursing team. Peritoneal dialysis is strong but surprisingly, to me, no patients have elected for home haemodialysis even though I saw with my own eyes that this choice is being offered and is included in the patient facing material.

Every kidney unit in the country has been faced with an increased awareness of kidney disease since the publication of the Renal NSF, adoption of the chronic kidney disease staging system and introduction of both standardised eGFR reporting and a chronic kidney disease domain in the General Practice Quality and Outcomes Framework. The clinicians in St Helier, Derby and Portsmouth have each used the uncertainty these changes have introduced into primary care to begin a conversation about the management of early kidney disease. Each have had a systematic programme of post-graduate education for their local GPs and practice nurses. Electronic and fax systems for providing advice have been introduced in St Helier. Derby has a web-based system for education and support and as a consequence of this development have actually seen at reduction in referrals since the introduction of eGFR. In addition to being Clinical Director in Portsmouth Rob Lewis is also co-Chair with Nicola Thomas of the CKD Forum and you won’t be surprised to know that Rob and the Portsmouth team have worked closely with their primary care trust colleagues to fill the education gap that eGFR uncovered.

You may pour over what I have said to see if it reveals any inner secrets as to which unit I favour – the reality is they are all 3 super units. I would strongly encourage teams to visit these units and pick their brains – when it comes to patient quality don’t be afraid to steal good ideas. I said at the beginning of the piece that it was difficult to shortlist – well I can tell you, it is even more difficult to choose a winner and I haven’t yet been able to do that so watch this space.

Thursday, 4 October 2007

Our NHS our future

The interim report on the NHS written by Lord Darzi was published at 11.30 this morning – there were a lot of people involved in drafting the document. Many discussions about the placement of commas but Ara Darzi himself was up late and up again early doing much of the writing himself. It’s a high level synthesis of the views of staff, patients and the public of where we are now: a reiteration of our core principles and, to borrow a phrase from Sir Derek Wanless, it sets out a vision for “full engagement”.

The letter to the Prime Minister sets out some of his personal views. Reading it will give you some insight into Lord Darzi’s values and beliefs.

Guess what I did when I got the final draft? No prizes; a word search on kidneys and renal!

The report is of course about generic issues and the kidney care pathway spans all of the workstreams that are being set up for the next stage of the review – maternity to end of life care. Primary care services, safer hospitals – for that read less healthcare associated infection and speedier innovation, are the main themes picked up by the press but the substance is in the detail of the next steps.

The Kings Fund Wanless report provided a clear assessment of how far we have come since the NHS Plan was launched in 2000. It demonstrates that the system isn’t fully engaged, progress has been patchy – coronary heart disease and cancer services are much improved but kidney services amongst others still lag a long way behind our European counterparts.

In many ways, I think how kidney services develop will be a real test of the reform. A service that needs to be developed almost from scratch in primary care, whose outcomes are so dependant on integration of care and a specialist service that grows year on year by 6-8% would challenge any system.

The next stage of the review gives everyone in the kidney community the opportunity to get involved in taking up these challenges. Big changes are afoot. Find out more and contribute at