Q: Donal, I just can't get to grips with 18 week pathways being sensible in the vast majority of our patients, and your example only confuses things further.
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