Monday, 3 August 2009

Quality, innovation, productivity and prevention

The health service is facing a major challenge and that challenge is not one of its own making nor is it an ideological threat. We are all aware that the public debt has doubled from 40% of the gross domestic product to 79% of GDP as a result of the banking bail out. However soon the recovery comes that debt will still have to be repaid and that will put unprecedented pressure on the NHS and other public services. David Nicholson, the Chief Executive of the NHS, has estimated that we will have to find between £15-£20 billion and the Kings Fund have predicted an even bigger shortfall after 2011 – between £20-£26 billion. Figures almost too big to comprehend. It may not be possible to predict the future but one thing is for certain, the next 7 years will be years of relative famine and it will be a period of massive change.

Put another way, the challenge is to continue to drive up quality whilst improving productivity – a challenge which means harnessing and spreading innovation. It means going further faster rather than slowing down. No one in the health service wants to see a reduction in quality of care. Neither do the patients nor the public, who fund the system, wish to see that. So quality remains the organising principle of the NHS but now innovation, productivity and prevention are sitting alongside quality as core objectives for the whole health system and everyone who works in or with our health system.

What will this mean for kidney services? Well we know that the number of people with kidney disease will continue to grow because the population is aging and because of vascular disease and diabetes. The number of people needing a kidney transplant or dialysis will continue to grow. Conservative kidney care, the no dialysis option, has been highlighted by NHS Kidney Care as an area for quality improvement. The recent NCEPOD report into acute kidney injury is a chilling read – acute kidney injury is often unrecognised and when identified poorly managed. None of these aspects of kidney care can be put on a back burner. Lord Darzi’s Next Stage Review put in place a compelling, ambitious and patient-focussed vision. We must plan to deliver significant efficiency savings whilst remaining true to our vision of high quality care for all. I believe that is possible because doing the right thing, at the right time, every time almost always costs less and the staff in the health sector really believe in providing quality of care.

Over the past 5 years, since the publication of the National Service Framework for kidney services I have seen quality move from a rather ill defined concept to clear objectives in the plans of every kidney service covering all the dimensions of quality-safe, timely, effective, efficient, equitable and patient centred. Since 2006 chronic kidney disease has been part of the primary care quality and outcomes framework. Quality metrics have recently been published covering much of the kidney care pathway including end of life care. The development of a comprehensive mandated data set means we will get even better information in the future. The dataset has also led to inclusion of aspects of kidney care in the Commissioning for Quality and Innovation (CQuIns) payment system for acute trusts and raises the possibility of kidney care being considered as part of the quality accounts.

In my visits across the country I have the privilege of meeting many patients and frontline staff. Nearly everywhere I go I learn about innovations that have been tried and tested locally. At the British Renal Society meeting in June there was a wealth of good practice on show, but we have to sustain, spread and systemise our quality improvement projects.

Productivity in chronic kidney disease management is sometimes difficult to demonstrate. Let me ask you a question – what is cheaper – a high rate of line use for vascular access with a high rate of MRSA and other infections leading to unnecessary bacterial endocarditis and spinal abscesses or good pre end stage renal failure care offering choice with shared decision making and establishing vascular access before the need for haemodialysis. Or for that matter performing a live donor kidney transplant before the start of dialysis. No need to answer. The 62% reduction in MRSA we have achieved by improving our systems for advanced kidney disease care and establishing vascular access at the right time has resulted in massive productivity gain as well as improved the experience and outcome of kidney care. So in chronic diseases, as opposed to for instance some surgical specialties, we need to consider the whole pathway of care not just the cost of a single procedure or admission. We need to focus commissioning on pathways of care and on population needs rather than episodes of care. At NHS Kidney Care we are taking just that approach for peritoneal dialysis and will extend the work to other modalities.

Kidney disease is part of NHS checks the ambitious programme to offer vascular risk assessment to every person between 40 and 74. This programme will result in people understanding their individual risk much earlier than they do at present. The preventative dividend of including chronic kidney disease in the Quality and Outcomes Framework is already being seen in a reduction in “crash landers” or unplanned starts on dialysis.

So the quality, innovation, productivity and prevention agenda is already part of our culture and is embedded in the workstreams of NHS Kidney Care whose mission is to ensure a complete, equitable and consistent implementation of our NSF. When the NHS was formed in 1948 the national debt to GDP was 213%. Together we can deliver better services at a better price.