Tuesday, 29 April 2008

Q & A: Vascular Checks

The following are a series of questions asked further to the recent announcement regarding vascular checks. They can also be downloaded as a PDF file here

Q: When will it be possible to hear more about the fundamental principles lying behind the Department’s modelling?

A: A partial Impact Assessment has already been published on the DH website, which gives some details of how the modelling worked. There will be a technical consultation for the model during 2008. More details about timing for this will be available shortly.

Q: How will information be coordinated between pharmacies and GP practices?

We plan to examine the feasibility of developing a national call and recall type system operating through GP practices, although there have been no final decisions about the exact structures that we would use. If some of the risk assessment is to take place within pharmacies it is essential that we develop a mechanism for linking the results from these assessments into local and/or national systems, so that we can ensure completeness and avoid duplication.

There is already a system for developing national templates for activity by pharmacies and it is likely that we would use this to make sure that vascular risk assessment activity in that sector will be accredited and carried out to the same standards as employed in general practice.

Q: How will you access hard-to-reach groups?

A: We do not want to reinvent the wheel: we will be looking to work that is already going on, much of it pioneered by organisations found within the CVC to inform development of vascular checks. Jan Procter-King has been collecting existing examples of risk assessments from primary care, often developed as locally enhanced services (LES) and Kiran Patel has provided information on the work of West Midlands SHA, which has undertaken a programme of CVD risk assessment. The Healthy Communities Collaboratives, funded by DH, offer another source of information.

At the moment we think the most likely scenario is that PCTs would commission vascular checks and use their greater understanding of local populations through local needs assessments, to develop appropriate access plans. In some areas, GP practices may be the most common location for vascular checks, but in others, pharmacies or community projects may be better suited to the population.

Q: Might you use a risk-assessment card that each individual keeps with them?

This is a possibility. There are also avenues to be explored around web-based “health space”, LifeCheck links, and information services overall. Certainly, providing people with some form of card, whether paper-based or online, could increase a sense of personal responsibility and motivate action to reduce risk.

Q: How do vascular checks fit with the new NICE guideline on CVD risk assessment?

We have been working with colleagues at NICE, and have been aware of the work they are doing around CVD risk assessment. Vascular checks are not a substitute for clinical guidelines; rather they are a framework within which clinical guidelines can sit. Vascular checks as a policy will ensure best practice and knowledge about risk assessment and management is disseminated and available nationwide.

Q: What about implications for life and travel insurance?

This is an area of concern for the Department, and we want to find the right people to talk to in these industries. If anyone in the CVC has appropriate contacts they could put us in touch with, please let us know.

There is a potential for people who have taken up vascular checks to be penalised for doing so, and many insurance policies cost more if you have had a medical check-up recently, particularly if this gives you a risk factor for developing disease.

There is a particular concern over Chronic Kidney Disease, as this is not a clearly defined disease/not disease profile.

Q: How do vascular checks fit in with QOF? Will it be a stand-alone policy?

A: At the moment we think it unlikely that QOF would be the main implementation lever for vascular checks. However, there are already a number of points in QOF associated with CVD and diabetes assessment and management. We work closely with primary care colleagues in the Department and will ensure development of QOF and vascular checks are joined up.

Q: How fixed is the scope of vascular checks – could they be extended to incorporate urine testing for kidney disease?

The elements currently included in vascular checks are all based on the existing evidence base and have been put together on the advice of the relevant National Clinical Directors including the National Clinical Director for Kidney Services. Scope for change to the vascular checks does exist, but it depends on the cost effectiveness and the evidence base available. We will build into the policy an evaluation strategy that will keep abreast of new developments in research to ensure annual changes to the policy are possible where clinically indicated.

Q: What about the potential for research and the ethical questions this raises?

We have not yet extensively considered this point. Current models, for example, that of the West Midlands, invokes the SHA as custodian of the data, enabling research of the database to take place. This certainly needs to be considered during policy development.

Friday, 18 April 2008

Renal NSF Update April 2008

The Renal NSF update for April 2008 is available here

Wednesday, 16 April 2008

Supportive and end of life care workshop - 14 April 2008

Our workshop on supportive and palliative care for people and families with kidney disease was oversubscribed. A marker, I think, of the importance of the topic and the interest of the whole multiprofessional team in improving care during this phase of our patients’ illness. It also reflects the quality of the programme that Stephanie Gomm (Consultant in Palliative Medicine, Salford Royal), Ken Farrington (Consultant Nephrologist, Lister Hospital), Jane Heaton (Renal & Vascular Policy Manager, DH) and the Steering Group have put together.

The National Service Framework for Renal Services led the way in national policy by having a section on end of life care – it was the first NSF to do so. The kidney care community can be proud of the progress we have made from the mantra of “death from kidney failure represents a failure of dialysis” to the informed position of “kidney disease is linked with increased morbidity and mortality, dialysis is not the best option for every individual and supportive and palliative care are integral to a high quality care plan for individuals with kidney disease”. The pioneers who talked about the “no dialysis option” with individuals and families and who wrote up and presented their experience and outcomes were brave. For a subject that is an inevitability for us all it has been taboo for too long and is surprisingly easy to avoid in conversation.

One of the challenges is that modern life, the longevity of the population, the very success of modern medicine has made us one of the first generation in which many of us have not encountered or been involved in the care of close relatives or other loved ones in the process of dying. I am reminded by a phrase in The Godfather when, the dying Genco Abbandado , Consigliore before Tom Hagen, says to the Don "Godfather, Godfather .. save me from death".

In comparison with other organ failure such as heart failure or respiratory failure the clinical situation in advanced chronic kidney disease demands discussion during the process of choice or options for replacement therapy. Several units have a policy that information about palliative and supportive care is presented and discussed with all patients who have advanced kidney disease in the same way that transplantation and dialysis options are explored. Such an approach provides the opportunity to return to that discussion at a later date when the surprise question

"Would you be surprised if your patient were to die in the next 6-12 months?”

becomes positive even in those in whom the initial preparation was for a pre-emptive transplantation.

The workshop brought together recent developments in both the kidney and palliative care worlds – a lot of progress has been made through the work of the Renal NSF Action Learning Sets, the overarching End of Life Care Strategy and as part of the Next Stage Review.

Part of the exercise was to bring together the bits of the jigsaw that we have already worked out, and to share those with other kidney care teams. This helped the workshop to stop the gaps and to discuss ways of overcoming the barriers to implementation.

The key task of the day was to agree an action plan for delivering improved supportive and palliative care for people with kidney disease that can be implemented in the next 18 months. We will publish that in May. I am very pleased that Ken Farrington and Stephanie Gomm have agreed to continue to lead the work. Kidney care is there to work with networks and local teams to support delivery to people with established renal failure to live life as fully as possible and enable them to die with dignity in a setting of their own choice. To achieve this “people with established renal failure should receive timely evaluation of their prognosis, information about the choices available to them, and for those near to the end of life a jointly agreed palliative care plan, built around their individual needs and preferences” (quality requirement of the Renal NSF). The workshop brought together recent developments in both the kidney and palliative care worlds – a lot of progress has been made through the work of the Renal NSF Action Learning Sets, the overarching End of Life Care Strategy and as part of the Next Stage Review.

We hope to bring together all the relevant material soon so that the learning, techniques and tools are available to the whole kidney community.

Wednesday, 9 April 2008

News Release: National Diabetes & Kidney Support Team

A new team provides frontline support for improving diabetes and kidney care - the National Diabetes & Kidney Support Team (NDKST) has released its first news release.

For more information contact:

Diabetes care : Bill O'Leary 07887 653056
Kidney care: Bev Matthews 07500 607924

Monday, 7 April 2008

Proteinuria to be added to the QOF

Proteinuria is expected to be added to the chronic kidney disease domain of the QOF in this financial year, ie to apply from 1 April 2008.

As part of the negotiations on the General Medical Services contract for the financial year 2008/09, NHS employers have been consulting the General Practitioners Committee (GPC) on changes to the Quality and Outcomes Framework. The results of the pole of all GPs which GPC carried out was in favour of accepting the proposals which NHS employers put to the GPC. The negotiating parties are now working toward the practical implementation of these proposals.

For Chronic Kidney Disease CKD 4 will be amended and renumbered as CKD 5 to only include those patients with hypertension and proteinuria as detailed in the CKD frequently asked questions.

CKD 5: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded).

There are other significant changes to QOF to reallocate points to reward patient satisfaction with access, through new QOF indicators in the patient experience domain. Proposed changes to the financial and accounting arrangements are also being considered.

Taken together with the NICE Guideline, currently out for consultation, I think it is fair to consider 2008 as the year of proteinuria or should I say the year of urinary albumin creatinine ratios.

Friday, 4 April 2008

Your chance to shape your future ….

This has been a busy week! It is always encouraging when seeds that have been sown many months ago begin to start to bear fruit. There are three key issues that I think may be of interest to you and that give you opportunities to influence the future of kidney care;

Development of the National Diabetes and Kidney Support Team (NDKST)
The Office of the SHAs has this week given approval for the transformation of the National Diabetes Support Team to become the National Diabetes and Kidney Support Team (NDKST). This is more than just a name change. It is an opportunity for us to create a structure of support mechanisms to implement kidney care improvement across England. An important part of us developing the central functions and local kidney care interface of the NDKST is taking the time and opportunity to listen to the views and aspirations of all of the kidney community; children and adults, patients and families, primary care and commissioners, specialised multidisciplinary teams managing advanced CKD as well as secondary and tertiary services involved in the management of Acute Kidney Injury

I am delighted that Bev Matthews, Manager of the West Midlands Renal Network, has agreed to a secondment to the Renal Policy Team at the Department of Health to help shape the concept and vision of what the future NDKST structure will look like.

We would welcome your contribution – please get involved by reading more about the NDKST at the end of this blog and sharing your thoughts on the key issues.

Vascular Risk Assessment
On Tuesday morning the Government announced plans for the NHS to introduce a systematic and integrated programme of vascular risk assessment and management for those aged between 40 and 74. It released a document which explains in more depth what vascular disease is, why undertaking risk assessment and management is important, and how these checks might be performed throughout England.

It calls for stakeholders to work with the Department of Health to help develop the approach to implementation and delivery over the next few months and in due course you will hear more detail about the ways in which you can engage in this work.

More details on the announcement and publication can be found on the DH website

Appointment of a National Clinical Director for Transplantation
I am delighted to see Chris Rudge appointed as NCD for Transplantation. It is an important time for the transplant community to have this leadership role within the Department of Health to implement the recommendations of the Organ Donor Taskforce. The renal and transplant policy teams will continue working together as a team to ensure all kidneys donated are transplanted into the most suitable recipients.

National Diabetes and Kidney Support Team (NDKST)
The publication of the Renal NSF in 2004 focused our hearts and minds on meeting the Standards (Part 1) and Quality Requirements (Part 2) with limited resources in comparison to Cardiac and Cancer services for example.

There have been patches of commitment to innovation and improvement, such as the West Midlands Renal Network and the Guys and Thomas’ Modernisation Initiative where local investment has enabled health economies to maintain a kidney care focus. With this in mind I have been exploring opportunities for generating a resource for Kidney Care to develop, and enhance, structures for improving kidney care across England.

The 2007 Hosted Bodies Review now gives us that opportunity. The former National Diabetes Support Team has now been devolved and the creation of the National Diabetes and Kidney Support Team (NDKST) provides us with the exciting prospect of moving Kidney Care into the 21nd Century.

It is clear that there will need to be some central functions of the NDKST around Knowledge Management and Communications and you may already know that we are keen to listen to your thoughts and experiences to help define the local interface the NDKST will develop.

The key areas that we are looking for feedback are:

  • How would a kidney care structure interface with your organisation and community?
  • What lessons can be learnt from implementation of local structures that you have been involved in establishing?
  • What will be the key priorities?
  • Were/are there any barriers and if so what strategies were/are required to working around or overcome these?
  • How can wide multidisciplinary team engagement be ensured?

Your views and experiences are key to ensuring the success of the NDKST and I would encourage you to contribute. You can:

  1. email Bev direct on Beverley.matthews@dh.gsi.gov.uk or
  2. invite Bev and myself to any local meeting that you feel would give us insight to inform our vision for the future.

This listening exercise will be completed by early summer and I look forward to sharing with you the aims and objectives in June 2008, giving you a clear timeframe for implementation.

Thursday, 3 April 2008

Welcome aboard Chris

Chris Rudge became the newest Tsar when he was appointed National Clinical Director for Transplant today. That is great news for people awaiting transplants and the whole transplant community. No-one is better equipped for the role than Chris who is a kidney transplant surgeon.

Chris was appointed UK Transplant's first Medical Director in 2001 and has provided the clinical leadership that has increased the profile of transplantation over the past 7 years. Chris continues to work at the Royal London Hospital for 1 day a week. He will be leading the day to day implementation of the Organ Donation Task Force recommendations.

The Task Force has identified the barriers to Organ Donation and made 14 recommendations that aim to increase transplantation from deceased donors by over 50% in the next 5 years. The Government has committed £11 million extra funding in 2008/09 to support implementation. It is not just about the kidney and I am sure Chris's appointment will be welcomed across the whole transplant community.

Welcome aboard Chris!

Tuesday, 1 April 2008

Cardiac Kidney Diabetes : CKD

CKD spells cardiac, kidney and diabetes as well as Chronic Kidney Disease. The Secretary of State launched this report on vascular checks or more precisely in the jargon – vascular checks: risk assessment and management – on Tuesday 1 April. The target audience includes General Practitioners, Primary Care Trusts and Strategic Health Authorities. There is an explicit call for stakeholders to work with the Department of Health and NHS to develop an effective implementation and delivery strategy. The announcement outlines proposals for a system of vascular checks to be carried out in primary care. The document includes initial results of modelling work around a “predict and prevent” approach to identify vulnerability to vascular disease – heart disease, stroke, diabetes and kidney disease.

The multiplication effect of risk factors and/or the presence of disease itself is emphasised. The link between kidney disease and other vascular diseases is highlighted.

The vascular risk assessment is based on the modifiable risk factors – smoking, physical inactivity and a sedentary lifestyle, hypertension, raised cholesterol levels and obesity.

The programme is designed for everyone between the ages of 40 and 74 in the population; that is individualised risk assessment for 3M people a year, with additional funding of £250M per year (from 2009/10), been allocated to implement the programme.

It will be based on straightforward questions and measurements. These will record basic information such as height, weight, current medication, age, family history, smoking and blood pressure and include assessment for cholesterol and, in some cases, glucose levels. Those who have been identified as at risk of kidney disease may then have further blood and urine tests. It is estimated that the programme will enable earlier detection of at least 25000 additional people per year with diabetes or kidney disease. This is over and above the large numbers now being picked up opportunistically through the inclusion of a chronic kidney disease domain in the Quality and Outcomes Framework.

This announcement comes hot on the heels of the publication of the handbook for vascular risk (or the blue book) that contains examples of best practice and tools to implement vascular and kidney risk reduction strategies in the community.

What next? A real opportunity for the kidney care community to get involved in shaping this programme which offers the prize of early detection and risk reduction of both vascular and progressive kidney disease in people at risk of or with kidney disease.

Press Release
BBC website