Wednesday, 25 November 2009

Q & A: Developing future kidney services

Q: I am writing from a large hospital without a renal unit, offering general nephrology and liaison with critical care for acute RRT. I work with a renal unit in a neighbouring town which provides end-stage RRT.

Over several years there have been initiatives to develop a more extensive service on site, to support our tertiary services as well as the local ESRF population but each one has foundered through a combination of inertia, funding and local politics.

Until recently there seemed to be some light in the tunnel of joint working but once again we seem to going back to square one in justifying a service based on site here - rather than one provided here by visiting clinicians from the renal unit based elsewhere, without an inpatient presence.

I would be very grateful if you could give me a steer on the national situation - I've have looked at various documents (and have even tried to play with MORRIS) but I can't find any hard information. Senior management have referred to a national strategy, from which they have the idea that there will be 30 new units some time soon? Is there any initiative at SHA level which supports local provision?

A: Many thanks for your email of 16 November about developing kidney services. It’s a timely letter as NHS Kidney Care have just produced a guide to “Achieving Autonomy for Kidney Services”. It’s a 7-step toolkit and was featured in the HSJ a few weeks ago.

You will be well aware of the history of renal medicine in the UK – from a slow start, interrupted by the Hepatitis B outbreaks, to the majority of teaching hospitals and then, in the 1980s, services becoming established in some of the bigger district hospitals. There has been little growth in the number of units over the last 15 years. The focus has been largely on satellite dialysis provision. It’s a highly unusual model of care, I think it is salutary to consider that in England with 50 million people we have 52 units and in the other home countries there are 26 units serving a population of 10 million. Nor is there a geographic explanation for the highly concentrated nature of kidney services in England. Now that kidney services have expanded to interact more closely with primary care in the management of early kidney disease which is recognised to affect in the region of 10% of the adult population, and with the focus on conservative care for those who elect not to have dialysis where getting local care in the community is often the preferred option, it’s perhaps timely to ask the question do we need bigger central kidney units or a more dispersed model of care providing more local support to both primary, secondary and tertiary care. The recent publication of the NCEPOD report on acute kidney injury also highlights the uneven spread of kidney services and recommends the development of on site renal services to support colleagues in acute medicine, critical care and other specialties looking after the acutely unwell where AKI is a frequent occurrence and of course to provide replacement therapy in the minority of AKI patients who need dialysis.

Conversely I am sure that one size does not fit all and planning does need to be done at a local level. I don’t see renal centres developing in every acute hospital. I have speculated that perhaps we should be moving towards 85 centre in England. I suspect I was quoted saying that in the HSJ and that’s maybe where your senior team got the number of an additional 30. However, there are a number of organisational, commissioning and professional challenges in developing new services as we know from the recent experience of places like Doncaster, North Hampton, Aintree and Worcester. “Achieving Autonomy for Kidney Services” draws on this experience to identify the various steps, tasks required and partnerships to be put in place and as well risks that must be managed. Of course now the focus is definitely on quality and productivity, but the need for kidney services in only going to grow and it may be that more units rather than just bigger units are both better value for money and the cheaper option.

I hope you find the 7-steps toolkit of interest. I am of course happy to discuss in more detail at a mutually convenient time. With best wishes, Donal.

Related blogs:
Establishing new kidney units

Monday, 23 November 2009

National tender for Peritoneal Dialysis

Peritoneal Dialysis is in the spotlight. NHS Kidney Care produced the specification for PD describing the pathway of care from shared decision making through training to home or assisted dialysis last month. Following on from that piece of work the group have drawn up a national PD tender that will be published shortly in the European Journal. This tender will allow kidney services and networks to put patient friendly contracts in place by April 2010.

The National Institute for Health and Clinical Excellence has also just announced a scoping exercise for the development of a short clinical guideline on PD. Details can be found on the NICE website. This short guideline will complement and build upon the soon to be published RA best practice guideline and provide a sound basis for offering this modality as one of the options for people approaching the need for renal replacement therapy. One question I would like to hear the answer to is how we can support shared decision making for people who arrive requiring dialysis when preparation and planning haven’t been possible. Increasingly such individuals are being offered PD but accelerated processes for patient education and fast tracking of, for instance, transplant listing remain a challenge on busy renal wards.

Establishing new kidney units

The model of renal care in England is really quite unusual with only 52 kidney centres for a population of 50 million. International health comparisons are always interesting but you don’t need to go as far as the USA or indeed Italy or Germany with its 1200 units. Those are very different systems. Looking closer to home, Scotland, Wales and Northern Ireland have between them 26 kidney centres; half the number of England for a combined population a fifth of the size!

As the demand for kidney services grows one of the questions to be asked is should kidney units just get bigger or would there be advantages in establishing new units? The reasons for the English model can be debated but NHS Kidney Care have done better than that and have produced a 7-step tool kit for achieving autonomy for kidney services. The service configuration in England has evolved from a traditional hub and satellite approach to a formal network of kidney care where partnerships and synergies are developing. In the future we must deliver more services locally. In some, but not all instances, this care will be delivered to a higher quality and offer better value for money from a new kidney service that is fully integrated into the local health economy.

We have the trainees to create new units. The NCEPOD report on acute kidney injury highlights the uneven spread of kidney services and recommends development of on site renal services, we need to work closely with primary care in the management of early kidney disease and to deliver better quality conservative kidney care close to peoples’ homes. So it’s not just dialysis growth driving this evolution.

A fully stand-alone kidney unit might need 4-6 consultants depending on whether they are full time or part time and also the extent of the kidney team’s involvement in acute medicine, research and training. That would be difficult if all those set up costs were needed from day one. They are not. New centres can be established incrementally. Separation from the parent unit indicates that autonomy has been achieved but that’s not the first step nor is it the driver for new units. The driver must be better quality of care for people with acute kidney injury and chronic kidney disease.

Thursday, 19 November 2009

Does improving quality save money?

All bets are off. We need to move away from the NHS being built for growth to being able to sustain itself in a prolonged limitation of resources … the NHS will need to make efficiency savings of £15-20 billion from 2011-14 NHS CEO David Nicholson 4 June 2009.

I am just back from the EDTNA meeting in Reading, and what a fantastic programme Rebecca Kinton and her team put together. I was invited to speak on the topic of “Quality: your role” and was sandwiched between 2 engaging and provocative talks. Jane Macdonald, President of the BRS and one of my nursing colleagues at Salford Royal spoke on small tests of change and local quality improvement. I had seen some of the data before but it never fails to impress. The quality improvement approach has resulted in an increase in haemodialysis via fistula from about 65-70% to consistently over 85%. Cardiac arrest on our kidney wards have been reduced by over 75%. Vascular access complications requiring admission to hospital are down by over 50%. Bev Matthews another close colleague and Director of NHS Kidney Care, with whom I work closely on national and strategic matters spoke on the programme of establishing kidney care networks across the country and on the whole range of quality improvements NHS Kidney Care has supported from early management, through preparation and choice to home therapies, transplantation and conservative kidney care. There is now a wealth of material that can help drive quality – you can access it at Kidney Care Matters online. Bev and Jane also spoke about costs, the work that has been done to improve national dialysis and transplant costings and the “savings” that local quality improvements can achieve. In Jane’s examples there was a considerable reduction in costs associated with bank and agency staff use.

Now, the kidney care networks provide a system for local quality improvement initiatives to flourish so my task speaking on “quality: your role” was no easy one between these two talks. One of the things that I tried to address was “does improving quality save money?”. The Department of Health is dedicated to a quality and productivity approach to the impending crunch for the NHS. I have to declare that I am a believer that quality can reduce cost but the honest answer to the can quality save money question, after reviewing the evidence is that that we don’t know. To an extent we are entering uncharted waters. There is a great potential for savings, but it depends what we mean by quality improvement, who makes the savings and when. Poor quality is common and costly. It has been estimated that the cost to the NHS of hospital acquired infections is £1 billion a year, renal services make up about 10% of that, and adverse drug events are estimated to be between £0.5 billion and £2 billion. But quality improvement itself can be costly, especially in services with little experience or infrastructure to support improvement. I have been reading John Ovretveit’s review, “Does improving quality save money? A review of evidence of which improvements to quality reduce costs to the health service providers” produced for the Health Foundation in September 2009. The report identifies gaps in our understanding of how to achieve substantive and sustainable change and lays down challenges to managers, clinicians, policy makers and academics.

One of the big difficulties is that many of the studies which report “savings” did not assess the cost of the intervention, left out some costs or didn’t use actual cost data from the service. Crucially, savings depend on the financial system and who bears the costs that are distributed between different stakeholders. Providers such as Acute Trusts often do not save because our financial system does not yet measure or reward higher quality care to the extent that it should. Often, an Acute Trust bears the intervention costs of a solution or cannot get the investment financed, and is financially rewarded for poor quality, giving a triple financial disincentive to improve. Patients with chronic diseases do not always receive optimal care and the costs of avoidable emergency admissions is high. Take the example of vascular access, currently we don’t yet have a system to incentivise creation of vascular access prior to the need for dialysis and if people on haemodialysis via a line get a HCAI such as an MRSA endocarditis admission to hospital for treatment of the complications isn’t penalised, it’s paid for. So for kidney services a big challenge is to commission across pathways of care so that timeliness, a key dimension of quality is encouraged and rewarded. Timeliness in preparation for renal replacement therapy, encouragement of pre-emptive live donor transplantation, encouragement and inducements to primary care to reduce late presentation and “crash landing” and recognising the multi-professional support, clinical and social care resources needed for shared decision making in choosing the modality of replacement therapy and particularly in choosing conservative kidney care .

To an extent, savings also depend on which timescale is used: interventions usually incur initial high costs and some, such as preventative care, may only return savings many years later. The clinical community must work on quality but we must also work with our managers, commissioners and policy makers to avoid a knee jerk move to the metaphorical slash and burn activities that we have seen so often in the past which can be so damaging. Policy is changing, NHS Trusts now have quality accounts – do you know if the institution within which you work or are cared for has quality kidney markers in that account?

Commissioning for quality and innovation, the so called CQUIN scheme that provides 0.5% of Trust income specifically for “stretch” quality goals that was introduced last year is proving a success and is likely to be extended. Bev Matthews and I with others in the kidney community are working with the payment by results team to develop best practice tariffs that will provide a financial as well as clinical incentive for haemodialysis via a fistula to avoid lines. We also hope to use PBR best practice tariffs to encourage more support for the uptake of home dialysis – both peritoneal and home haemodialysis.

Ovretveit concludes that we should be both more sceptical and more adventurous – sceptical of both statement of savings which do not give details of which intervention costs were considered and in which situations, and more sceptical about the time, effort and support needed to implement a quality solution effectively and to sustain it. But we should be also be more adventurous in adapting and testing interventions which show promise of effectiveness and savings, from research or from experiences of others, more willing to measure quality and to change our financial system within the NHS to pay for value not volume.

There is enough evidence to show which changes to focus on, in the kidney world these are identified in our National Service Framework. The future is already here but it is unevenly distributed. Some units have made great progress in achieving the vision of the NSF, some general practices are providing a fantastic service for early and moderate chronic kidney disease and have systems in place to work closely with renal specialists in the local community delivery of conservative and end of life care. We do need more research on how to make changes and the support that’s needed to provide consistency. The NHS Kidney Care projects are filling part of that gap. What we can’t do is stand still. The cost of inaction and of not using the knowledge we have is likely to be high, both financially and with regard to human suffering. Quality is the organising principle of the NSF and kidney services must keep quality as our watch word.

Related blogs
Sequins and Quips

Tuesday, 17 November 2009

Bedtime reading: NICE Guidance on Depression in CKD

Under-recognition of depression remains a major problem. As does the assessment of depression in the presence of chronic physical problems. NICE have issued a new guideline on depression focussing on adults with chronic physical health problems.

Kidney disease figures prominently in many sections of the report and the recommendations are highly relevant to the care of those with chronic kidney disease or recovering from acute kidney injury. I was struck on reading the guidelines of the parallels between depression in people with advanced kidney disease and acute kidney injury in acutely unwell patients. Both are common but often unrecognised, basic assessment of depression should be a core competency but often isn’t given prominence and when identified both are frequently mismanaged. The key message is to be alert to the possibility and questions to consider are:

“during the last month have you often been bothered by ‘feeling down’, depressed or hopeless?”
“during the last month have you been bothered by having little interest or pleasure in doing things?”

Depression in chronic physical conditions, including CKD is treatable. It is a major cause of avoidable morbidity, it prolongs length of stay and is independently associated with an increased risk of death. Read the full document (400 pages), quick reference guide or the excellent article in the BMJ (published on 27 Oct 09) by Stephen Pilling and colleagues on behalf of the guideline development group (Pilling et al. BMJ.2009; 339: b4108).

NICE have also produced guidance to promote mental wellbeing through productive and healthy working conditions that aims to help reduce the estimated 13.7 million working days lost each year due to work-related mental health conditions including stress, depression and anxiety. Sick leave in the NHS costs over £500,000,000 a year – staggering I know. David Nicholson, CEO of the NHS has highlighted this guidance to all his NHS Chief Executive colleagues because of its importance