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.

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