Wednesday, 29 July 2009

Q & A: Kidney Outpatients

Q: Dear Donal, we have been told by our PCT that they will no longer pay for consultations if our follow up to new ratio is above the national average. Please could you comment on this? Dr Fiona Dallas, Consultant Nephrologist, Renal Unit, Carlisle

A: Dear Fiona, It was a pleasure to meet at the Cumbria & Lancashire Kidney Care Network on 29 June. Thank you for raising the issue of kidney outpatient visits and seeking my views and comments on new to follow up ratios.

The Modernisation Agency’s publication 10 High Impact Changes for Service Improvement and Delivery published in 2004 highlighted the need to avoid unnecessary follow-ups. It identified orthopaedics, ENT, ophthalmology and dermatology as specialities where there could be 0.5 million fewer follow-up appointments per year. The first question should be “is a follow up visit really necessary?”. Automatic secondary care follow up should be used only where necessary and clinically appropriate. Ten High Impact Changes suggested that hospitals should aim to have an overall new to follow-up appointment ratio of below 1:3. It is worth reading this document because it contains advice which is still relevant today such as co-developing services with patients and carers, setting local goals and working closely with commissioners. The 18 week pathway for chronic kidney disease is another valuable tool that you could use to monitor flows and activity.

Kidney care has changed considerably over the past few years since the publication of the NSF and the move to systematic estimated Glomerular Filtration Rate (GFR) reporting with inclusion of a CKD domain within the QOF for primary care. Prior to 2006, early kidney disease was rarely detected in primary care and indeed advanced kidney disease was often missed until very late. In many parts of the country colleagues in primary and secondary care are working together to achieve the local implementation of the Royal College of Physicians and now NICE Guideline 73 so that people with kidney disease are seen and managed appropriately across the whole pathway.

For instance, Wirral NHS has developed a local enhanced service for primary care management of chronic kidney disease and should be one to watch. It is based on NICE Guideline 73 for chronic kidney disease and the local operational guidelines have been developed by general practitioners and renal physicians together.

In chronic diseases and particularly where the situation has been changing so quickly, with all the education and system support gaps that that has revealed, I think there are considerable advantages to approaching service design including outpatient capacity and metrics based on the patient pathway rather than an arbitrary ratio.

Clearly, people with stage 4 or 5 kidney disease, require considerable interaction with secondary care for the planning of renal replacement therapy, delivery of dialysis and transplant follow-up. Many people with primary kidney disease eg PKD or those on treatment for glomerulonephritis benefit from regular care follow up and clearly people receiving dialysis or with a functioning kidney transplant need follow-up care. Conversely, the majority of people with stage 3 CKD do not require continuing follow-up in secondary care but in a proportion with primary kidney disease, rapid decline, complications of chronic kidney disease or “treatment failures” specialist input is necessary to optimise outcomes.

NHS Kidney Care is currently supporting a range of initiatives to support early detection, provide decision support into primary care and to pilot virtual nephrology services. This is in addition to the broad range of education materials that we have produced and the development of quality metrics across the whole pathway. I would be more than happy to share details of these other initiatives with you at an early stage if you think it would be helpful in your local service design planning.

I am encouraged by the excellent work that I have seen across the country. Early detection and appropriate management of chronic kidney disease aligns completely with the quality, innovation, productivity and prevention agenda.