Thursday, 13 August 2009

Doing more for less: so what should we stop doing then?

Well, bringing people back to hospital for intravenous iron for one!

The papers and news channels are full of the effects of the recession. “Recession starts to threaten home life” pronounced The Times leader on 12 August. Unemployment with its increasing alcoholism, domestic violence and drug addiction is set to surge the paper claims. The social and health consequences of economic downturns are well known. Not a day goes by that the NHS and other public services are not in the limelight for how we will cope with the global financial crisis. As the NHS faces its biggest financial challenge for decades what is absolutely essential is that we don’t lose sight of quality in healthcare. We need to focus on high value activities – early detection of kidney disease and good control of blood pressure, planning of renal replacement therapy including pre-emptive transplantation, home dialysis and helping those on the conservative kidney care pathway stay in their own homes. We know that the number of people with advanced kidney disease will continue to grow over the next decade. That’s inevitable given the aging population let alone the increasing obesity, diabetes and hypertension epidemics. So how can we afford high quality care in a “flat cash” environment? Flat cash is a term you will hear more of, it means what it says, little or no absolute increase in funding for the NHS after 2011 for some years. Most sources speculate that the NHS will barely keep pace with inflation. Add in the increased demand of an older population and you will realise the serious questions the public, our politicians and the health service faces.

So how can we afford to increase quality for more patients at a time of effectively less cash? Well that was the subject of a Kidney Care Commissioning Workshop that Sir Muir Gray and I hosted last month. We do need efficient and effective pathways for those elements of care that add value – creating a fistula before the need for dialysis, using the 18 week pathway to accelerate live kidney donor transplantation, early recognition and prompt treatment of acute kidney injury to name a few. We also need to identify and eliminate low added value activities – hence the title of this blog.

Intravenous iron is an essential component of the management of anaemia of chronic kidney disease – of that there is no doubt. It improves the efficiency of EPO or, as we should call EPO now, Erythropoietic Stimulating Agents or ESAs. Now, I do have a bit of bee in my bonnet about this but why does so much intravenous iron entail long trips back and forth to the main kidney centre? Perhaps safety – well no; patient convenience – certainly not; what about clinical governance, by which I mean clinical responsibility since the hospital team have usually prescribed the iron treatment – well, no again.

The cynical might say it’s the budget. Who pays for the iron? And moving money from a hospital or secondary care budget to, for instance, a local health centre or community care team does feel a little like playing 3 dimensional chess. The budget is actually not an insurmountable problem – clearly giving IV iron locally without the inconvenience and cost of travelling to the hospital is better value for money than the IV iron service we provide for many patients at present.

Education, support and experience of colleagues in primary care has until recently been the stumbling block. That’s why I was so pleased to see “A guide to the administration of intravenous iron for people with anaemia of chronic kidney disease (CKD) in a non acute hospital setting” when it was published. It provides all that’s necessary to set up a local IV iron service.

What other low or no value activity would you like to confine to Room 101? Answers on a postcard (well email please); seriously, I would very much like to hear suggestions and views from patients, carers and all those working in kidney care. Anonymity will be preserved if you like.

Do let me have your ideas and do use the IV guide to improve local kidney anaemia management.