Monday, 24 December 2007
By summer of next year Primary Care Trusts will be expected to be putting together plans setting out how they will achieve both the vision and meet the competencies; plans will be assessed against more specific criteria to be launched next year.
Tuesday, 18 December 2007
I am sure we will all have many opportunities to improve kidney care in 2008 and you will have my support to help make your services world class for local people with kidney disease.
I have listened a lot in the last 12 months – I appreciate staff are under a lot of pressure, for many patients I understand that the experience is the outcome and I realise that we have a long way to go before we can put hand on heart and say our kidney care service is truly world class. I have no doubt we can get there – that’s why I took this job.
It’s been a roller coaster of a year for me. Standing down at President of the Renal Association to take on the National Clinical Director role was a very difficult decision. The support and advice I received from colleagues, my family, patients and carers had been marvellous. I am going to enjoy the break and will be back working for better kidney care and blogging with renewed enthusiasm on 2 January.
Best wishes to all.
The purpose of updating the definition is to produce a set of classifications (ICD and OPCS codes plus text where codes are lacking/insufficient) to enable providers and commissioners to identify and cost specialist service activity. It is important to recognise that the definitions are not service specifications or descriptions of best/evidence based practice or service models. Normally, specialist services are those services where the catchment planning population is greater than 1 million. In other words, these services would not be provided in every district general hospital.
The Renal NSF recommends that preparation for replacement therapy, dialysis and transplant services are best commissioned through a “network” approach in order to ensure equity of access and cohesive planning responsive to the needs of the whole community. The natural population for such effective planning remains in excess of 1 million and may more typically be covered by a Strategic Health Authority (SHA). The Specialist Commissioning Groups (SCGs) are co-terminus with the SHAs and the need to plan for increased dialysis capacity was flagged to the SCGs in the recently published Operating Framework.
Clearly the pathway for patients with CKD involves elements of care which are best delivered at local level and there needs to be clear lines of accountability to ensure that early kidney disease management is provided in line with the principles laid out in Part 2 of the Renal NSF. Acute kidney injury and the “conservative management pathway” also need to be clearly defined for the same reasons.
The unanimous view of the Renal Association and of the National Kidney Federation is that renal services should remain included within the specialist services national definition set. Clearly the update of the specialised commissioning definition links with the current PbR project and with the coding initiatives including the renal SNOMED exercise and the review of the HRGs. They are all important pieces of the jigsaw that, when in place, will enable us to translate between clinical activity and financial returns.
We will be working to update the specialised definition for renal services over the next couple of months. I have asked Kevin Harris (Clinical Vice President of the Renal Association) and Bob Dunn (Patient Advocacy Officer of the National Kidney Federation) to help with this task. I would also welcome the views and comments of individuals – if you would like to contribute please contact me.
Monday, 17 December 2007
The Operating Framework sets out the specific business and financial arrangements for the NHS in 2008/09. Coming at the beginning of the next 3 year planning cycle following the recent comprehensive spending review it identifies priorities and ambitions in detail. Many of its key aims are central to delivering world class kidney care including:
- Reducing healthcare associated infections
- Keeping people well
- Delivering the 18 week standard
- Reducing health inequalities
- Improving patient experience
- Improving staff satisfaction and engagement
- Co-ordinating end of life care.
Specialised services commissioning is highlighted as one of the key enabling strategies.
The 10 Specialised Commissioning Groups (SCGs) were created as a result of the Carter Review and are charged with driving up the quality of specialised services.
“In commissioning for world class health services, SCGs should pay particular attention to areas where significant increase in demand is likely to lead to pressure on services. For example, demand for renal replacement therapy (dialysis and transplantation) is projected to rise by around 5% per year until at least 2030. SCGs will wish to consider options for expanding the provision of satellite dialysis centres and offering more people the option of home dialysis, as well as expanding acute dialysis units”.
The Operating Framework sets out the vision that will shape our future. It's short and readable.
Perhaps a grey day at Quarry House in Leeds does not compare with New England in the summer but the first meeting of the Payment by Results Group was remarkable. The finance directors and clinical directors, representing 16 Trusts across the country that provide over 30% of the specialised renal services in England, certainly had not read the recent Audit Commission’s “A prescription for partnership” (13 December 2007) that criticised clinicians and finance colleagues for not communicating. Or if they had, they were doing something about it!! I have never seen such a sight before – clinical and finance directors working together, clearly respecting each others opinions, different views of the world and experience to grapple with the complex task of developing a tariff for dialysis that will work to drive improvements in quality of kidney care. To be fair, the Audit Commission report is of course correct and we have a long way to go before the finance director asks for the quality report ahead of the income and expenditure spreadsheets but our PbR meeting was a step in that direction.
Credit goes to Bev Matthews (West Midlands’ Renal Network Manager), Chris Newton (Divisional Finance Manager, University Hospital Birmingham) and John Bradley (Consultant Renal Physician, Addenbrookes Hospital Cambridge) who have worked so hard with the DH PbR team to get us all to the same start line – well done all!
Concerns of course were expressed. We know where we want to get to – an effective translational process between the financial and clinical worlds - but we must acknowledge and manage the risks in that journey.
Donald Richardson (Consultant Renal Physician in York) was I think you would say sceptical about that whole exercise and pointed me in the direction of “competition in a publicly funded healthcare system” by Steffie Woolhandler and David Himmelstein in the BMJ 1 December whose principal thesis was that the appropriate response to the US experience with market based models for health services is quarantine not replication. Donald raised important caveats, but payment by results antecedence is of course in Australia not the USA.
One of the concerns I share is that “everything that counts can’t be counted” . I am pleased that specialised commissioning leads are part of our PbR team so they can be party to discussions and so they understand that getting robust dialysis costs are only part of the story. The year before dialysis, or as I am increasingly calling it “the year before pre-emptive transplantation if possible” and support for conservative and palliative care are essential components of a world class kidney care service. I think it is too soon to fix a tariff for these aspects of care – the definitions, data capture, models of care and performance markers are not yet in place. To introduce metrics in an effort to try to measure quality in these circumstances risks establishing arbitrary and unrealistic boundaries – judgement and commonsense could be replaced by blind reliance on numbers . The NSF standards and quality requirements in these areas of care highlight their importance and there was complete agreement in the group that we need to flag these elements of care to commissioners and providers in parallel with the PbR work on dialysis.
Roger Greenwood (Clinical Director at the Lister Hospital Stevenage) made another important observation – the risk that getting tariff right now might fossilise the service and prevent innovation in the future. Several people commented that innovation in dialysis has usually been driven by colleagues in industry. It is likely that community care will be the place for most innovation – daily haemodialysis, assisted peritoneal dialysis and the re-emergence of overnight haemodialysis spring to mind.
Having identified some of the risks, Bev Matthews has drawn up a risk management strategy. Bev is a great project manager. So we are up and running. The Project Group will meet face to face again in February to look at our various costs and their components so that we will be able to inform the reference cost submissions for 2007/08 that will be required in June 2008.
It is perhaps fanciful to liken the exercise to the Bretton Woods agreement that established the international monetary fund and the system of convertible currencies, fixed exchange rates and free trade but it was a most extraordinary meeting.
Paul Jennings couldn’t be in Leeds for the launch meeting because he was speaking about commissioning at the NHS World Class Commissioning Conference hosted by Mark Britnell (Director General of Commissioning & System Management at DH). That tells me 3 things – Paul is a well connected and respected guy, we have the right person leading our process and you can feed into things virtually.
This report is aimed at clinicians, managers and finance professionals currently working within the NHS and attempting to combine high quality clinical care with sound financial management. It is also aimed at NHS trust and PCT boards which set the tone for their organisations. Two short briefing papers will also be published; one aimed at clinicians and one aimed at finance staff.
Wednesday, 12 December 2007
The CKD guidelines suggest PCR > 100 mg/mmol warrants referral, but who says it needs a biopsy (and it would be the patient not the doctor needing it, by the way!)?
Almost every CKD patient I see has multiple separate but linked problems with overlapping treatments, some of which they are on at time of referral. It is impossible to have a meaningful 18 week to treatment target for, for example, a new patient with polycystic kidneys, or an elderly hypertensive vasculopath with imperfect BP control, proteinuria, a creatinine of 275 already on an ACEi .
As a Tsar you will be well aware of the dangers of Potemkin villages and this target looks like one of them to me.
Dr John Main, Consultant Nephrologist, James Cook University Hospital, Middlesbrough
A: They will be the first, or one of the first long term conditions 18 week pathways, one challenge is how to use these acute care constructs as levers for better quality for CKD management , another is how to modify them to fit with the underlying aims and principals of the NSF so they work better.
Some secondary gains of being at the 18 week pathway party are the system opportunities they offer eg if delay for USS is an issue an 18 week priority escalates that problem . Another is the education it hopefully will help drive re appropriate referrals into specialist services.
They are commissioning level pathways rather than detailed clinical protocols but they map across to make sense /drive quality.
Thanks John and I will, as they say, feed those challenges in.
John: Crikey, you're even speaking in Russian now!
Donal: Ya znai-oo
Thursday, 6 December 2007
physical and emotional pressure; respite care; improved access; detays; postcode lottery; inconsistencies; bureaucracy; financially worse off; opportunity to be able to go to work; recognition of the role that they play.
The report "New Deal for Carers" identifies the factors that would make the biggest difference to carers lives both in their role as carers and in their lives outside caring. It should provide the basis for updating the 1999 Prime Minister's Strategy. It uses an interesting technique of an online ideas tree as well as more traditional stakeholder engagement.