Tuesday, 20 November 2007

Kidney care pathways

Eighteen week pathways are being developed with the aim of transforming service delivery. The start, stop and pause rules are important but not the biggest issue. A good test of the rules is do they make sense to the man on the proverbial Clapham omnibus? Let me give you an example – someone with normal excretory kidney function but with proteinuria and a protein creatinine ratio of 110 g/mol and the doctor is recommended to have a kidney biopsy in line with the UK CKD guidelines to find out the cause of proteinuria. Well, the clinicians reading this and patients who have been there, know the likelihood is that the biopsy might give prognostically useful information but the therapeutic intervention of blocking the rennin angiotensin system with an ACE inhibitor or ARB is unlikely to change on receipt of the biopsy result. Yes, treatment has started when the ACE inhibitor is prescribed but no, you don’t pause the clock – the person awaiting biopsy would almost certainly take the view that, until they have been told the result of the histological examination, and had the implications explained, they are still waiting to get this problem sorted out. So first rule - plain English and second rule, common sense when it comes to stops and starts.

We had our pathway initiation meeting with Pip Robinson’s 18 week team on 15 November. John Scoble (Consultant Renal Physician, Guys Hospital) and Mike Nicholson (Consultant Transplant Surgeon, Leicester General Hospital) are leading on the Live Donor Pathway and Lawrence Goldberg (Clinical Director of Renal Medicine, Brighton) and Kathryn Griffiths (GP with specialist interest in vascular disease, University Health Centre, York) are leading on the Kidney Disease Pathways. The latter are planned to cover all specialist kidney referrals and will be developed in 2 parallel sections - early CKD and advanced CKD. Lisa Hollins (Service Manager, University College London Hospital) will be managing our project and keeping us on track. Lisa has been working on 18 week pathways for some time with Steve Laitner (Consultant in Public Health Medicine and GP, St Albans & Harpenden PCT). They have led on the introduction of the Quality of Life domain into the pathway work.

The timelines are challenging – draft to be ready to share with patients, the professional societies and the colleges by January and a consensus meeting to sign off February with implementation from March 2008!. But it’s not about reinventing the wheel – lots of work on chronic kidney disease has been done over the last 3 or 4 years and this will form the basis of the project.

The power of the pathways isn’t so much that they produce a national template for Trusts and units to adopt although that in itself is helpful, but rather that they provide structured clarity for primary care, clear guidance for exit from secondary care and promote a means by which to judge some aspects of quality. They are commissioning pathways not detailed clinical algorithms. I am delighted that we have Rob Lusardi (Assistant Director, West Midland Specialised Commissioning Team) on the group because of his experience as a commissioner with the West Midlands Renal Network.

For many people with kidney disease the pathway in secondary care will end with an information prescription with what the condition means, what the person with kidney disease can do to avoid the complications of chronic kidney disease and how this long term condition should be managed. A care plan by any other description and a core aim of Standard 1 of the Renal NSF that can be audited.

The real power of the pathways resides in the second phase. Mapping technology enablers, workforce requirements, education and training needs to the pathway; identifying the barriers and tackling them – be that the volume of day case vascular access, timely ultrasound service, electronic handshakes of care planning between primary and secondary or the need for translation services. The pathways are also likely to be linked to the map of medicine and the NHS Choices site but more about those on another day.

We made great progress on this until the fire alarm but we all got out safe and sound so I am expecting great things from Kathryn and Lawrence, Mike and John over the next 2 months.

As ever, I would welcome your comments and a spare pair of hands or brain is always a bonus. Come and get stuck in.