Monday, 14 December 2009

Q & A: Paid leave for live donors

Q: Dear Dr O’Donoghue, I have a kidney policy type question/thought that might help a little with the situation with Donors.

As some background, my sister has PKD and I am prospective donor for her. We are now at the stage where we are waiting for her to be sick enough for the transplant to take place and I am cleared for surgery. Unfortunately my questions\thoughts are not with the medical side, which by standards is mostly logic.

I work for a large multinational company and approached the HR team to explain that I was donating my kidney and asking for clarification of cover for a) testing days as normal treatment type leave and b) post operation as normal sick leave. Their response was “no” until after further discussion (where I pointed out cover is allowed for blood donors, normal accidents, pregnancies etc) HR finally agreed that absences related to the kidney donation would be covered as normal sick leave.

What would help donors is if it was made law for firms to effectively treat the above as a normal condition - much as normal sick leave (under reasonable circumstances). As Renal Tsar, would you be in a position to carry this thought forward at a national level?
My sister and I are currently chasing around our various health insurers to see how we are covered. I suspect that the answer initially will be no – since I am not technically sick (in fact the opposite) but hope to point out the error of their policies and get it changed, otherwise she could be in one hospital, whilst I am operated on in another and the kidney transported between them.
Any thoughts on the above would be great, Thanks in advance

A: Thank you for your email about your discussions with your company to support your living donation of a kidney to your sister. I am delighted that they have agreed to continue to pay your salary.

From the description in your letter, it appears that you are employed by a large company that no doubt runs a "contractual" sick leave scheme (ie that you receive so many days, weeks or months at full pay, half pay etc as long as medical certificates are provided).

I understand that under employment law, there is no obligation for firms to pay contractual sick pay (probably many very small firms cannot afford to do so). However, employers do have a duty to pay statutory sick pay (SSP) for the first 28 weeks if an employee is absent due to sickness in any period of 3 years.

Therefore, I suspect that it would be difficult to make legislation forcing employers to pay employees for the period of absence due to live organ donation as they are not obliged to pay anything other than SSP for any type of sickness absence. One avenue to explore might be with Department of Work and Pensions (DWP) on the criteria for SSP, to clarify that someone in your circumstances (who would presumably get medical certificates) would qualify for SSP and to ensure that this is communicated to employers. A change in legislation might not therefore be necessary.

We are also working with Trade Unions to discuss generally how they could work with us to raise the profile of organ donation with their members. This seems an issue that they could raise to encourage organisations to agree to meet salary costs when absent from work as a live donor.

My best wishes to you and your sister for a successful transplant

Christmas message and mid-term report

Seasons greetings. It’s been a busy year for kidney care again. Many people have been working hard and progress has been made on many fronts, some of which I have recorded here in my blog. National and international news has been dominated by the global financial crisis and we are all aware of the impending crunch on public service spending from 2011. The focus remains on quality but the challenge is to provide quality with productivity.

Achieving excellence in kidney care: delivering the National Service Framework for Renal Services positions kidney care in the new environment laid out in NHS 2010-2015 from good to great. Preventative, people centred, productive. It cites examples of innovative ideas and excellent practice in various places across the country in most aspects of kidney care. It also highlights the variation in practice that identifies crucially important elements of care where local service improvements can drive better quality and experience for our patients. Change happens locally. Fundamental service improvements are led by local teams working in an empowering environment. They need to be given the responsibility to achieve, permission to take risks, as part of a learning organisation. National policies and guidelines set the framework, but it is through the grass roots understanding of quality and productivity that development of innovative approaches, which lead to lasting improvements, happen. At the centre of this are patients and the high quality relationships built between them and empathetic motivated and skilled practitioners.

We need to accelerate implementation of what we know works such as earlier and better blood pressure control, implementation of the NICE Guidance on chronic kidney disease and anaemia management, and timely preparation for replacement therapy or conservative care. We need to be bold, to innovate and challenge the norm so that we can achieve improvements. This requires co-ordination, partnership and leadership by commissioners and providers, and by clinical, social care professionals and managers in and between primary and specialist care.

We know there is still considerable variation in access to care, there are missed opportunities for prevention, unnecessary delays in treatment and often a failure to provide the conditions for shared decision making. The National Kidney Care Audit on patient transport for haemodialysis, the National Confidential Enquiry into Patient Outcome and Death report on Acute Kidney Injury and the difficulties people on haemodialysis experience in dialysing away from their base unit are 3 areas where we must make real improvement at scale and pace.

The National Renal Dataset is a big step in the right direction and the development of quality metrics will enable best practice to be incentivsed. Improved coding, measurement, analysis and reporting of patient experiences, clinical effectiveness, costs, safety and outcomes are also necessary to achieve the prize - moving our services from being good in parts to being great everywhere. This will not be easy. Enjoy the break over the festive season. I would like to thank the kidney community for their enthusiasm, passion and dedication to improving care across the entire kidney care pathway. I look forward to working with you in 2010 which is shaping up to be a key year for kidney care.

Renal patient transport - related blogs:
Use iView to get the most out of the Patient Transport results
FOR ACTION: Patient Transport survey results launched
Patient Transport Survey 2008, first phase launch
Two in three patients take part in patient transport survey

National Renal Dataset - related blogs:
Contact details for questions about the National Renal Dataset
Q & A: national renal dataset

Thursday, 10 December 2009

Bedtime reading: NHS 2010-2015: from good to great - gives a plug to home dialysis

Andy Burnham, Secretary of State for Health, launched this 5 year plan which maps out the journey of improvement that's going to be required to make the step change from good to great. It aims to give people working in the NHS a clear direction and time to plan for the quality and productivity challenge we face. There is a strong steer on prevention, patient engagement is highlighted and the NHS staff are acknowledged as its greatest asset.

There is an emphasis on care closer to home and "the tariffs payment system must incentivise the shift for care out of hospital settings if this is what patients want". Home dialysis is cited as a good example where quality and efficiency come together. From good to great identifies the need to link payment systems to whole pathways of care so that long term conditions like kidney disease can be managed across the whole local health environment.

Wednesday, 9 December 2009

MRSA bacteraemia and Clostridium difficile infections

The Health Protection Agency is now publishing quarterly analyses on MRSA and Clostridium difficile rates. These make interesting reading. There has been good progress in reducing MRSA bacteraemias. For kidney services in 2008 beween July and September, the rate was 15 episodes representing 4.2% of all the episodes giving an incidence of 11.5 MRSA infections per 100,000 bed days. During the same 3 month period in 2009, infections had fallen to 8 (3.5% of the total) and incidence of 6.1 per 100,000 bed days. That’s good news but we shouldn’t be complacent. Kidney services remain with the highest rate of all specialities, zero tolerance needs to be maintained.

Clostridium difficile infection rates are also collected by the HPA. Again the rates have been falling over the last few years. For kidney services during the 3 month period July to September 2008 there were 107 episodes representing 2.7% of the total or an incidence of 8.2 Clostridium difficile infections per 10,000 bed days. This remained essentially unchanged at 105 episodes representing 4% of the total Cdiff infections FOR the corresponding period in 2009. This is the second highest rate for all specialties with critical care medicine where there is an incidence rate of 10.6 episodes per 10,000 bed days being the highest rates . For comparison general medicine and general surgery have rates of 4.5 per 10,000 bed days and 3.3 per 10,000 bed days respectively.

Full details are availabe by following this link which also gives dates of future publications of the monthly MRSA and Cdiff tables and the dates for quarterly analysis release.

Bedtime reading: drug safety update Ciclosporin

Ciclosporin must be prescribed and dispensed by brand name. The medicines and healthcare products regulatory agency issued a drug safety update at the beginning of December emphasising the importance of prescribing and dispensing Ciclosporin by name. Ciclosporin has a narrow therapeutic index which means that the dose has to be very carefully adjusted to ensure the blood and tissue levels are spot on, not just close, and patients should be stabilised on a single brand of Ciclosporin because switching between different types or formulations without close monitoring may lead to clinically important changes in blood levels even if the same dose is taken. For kidney transplant recipients that risks rejections or toxicity from the Ciclosporin. All products that contain Ciclosporin are interchangeable ONLY if careful therapeutic monitoring takes place. Prescribing and dispensing of Cyclosporin should therefore be by brand name to avoid inadvertent switching. Patients as well as prescribers and pharmacists should be fully aware of the brand prescribed. It’s important for patients to challenge the prescriber of pharmacist if a different brand or formulation seems to have been provided eg if the drugs look different in colour or shape or even when the box or packing have changed. If switching of a patient stabilised to one brand of Cyclosporin is unavoidable, the patient should be closely monitored for side effects. Ciclosporin drug concentrations, serum creatinine levels, blood pressure and transplant function must be monitored if a switch is to be made.

Thursday, 3 December 2009

Peer Review in the West Midlands

Steve Smith, Clinical Lead for the West Midlands Renal Network, has been an advocate of peer review for many years so it was no surprise when I visited the Network recently that peer review was on the agenda; and what a good job Steve and his multiprofessional renal team colleagues, patients and the West Midlands quality review service have done! This has been as much about patient experience as policies and protocols.

The purpose of the peer review programme is to help providers and commissioners of services for people with end stage renal failure to improve the quality of services by:

  • Ensuring evidence based quality requirements are developed and kept up to date
  • Undertaking peer review visits to ensure compliance with quality requirements for services with
  • people with end stage renal failure, including renal transplantation
  • Providing development and learning for all involved in the peer review programme, especially those who act as reviewers
  • Providing comparative information on compliance with ESRF quality requirements and identifying common themes across the West Midlands
  • Monitoring action taken by providers and commissioners to address issues identified by quality assurance visits and if necessary ensuring appropriate action is taken.

As far as possible the peer review visits took a patient pathway approach including for example links between the renal units and the acute hospitals within which they are located. The review teams consisted of service users and carers, nursing, medical, technical, dietetic, specialist commissioners and public health. Individuals were chosen for their good communication and interpersonal skills including ability to listen but also to probe and search for evidence on which to base conclusions.

The cycle of visits in the West Midlands has now finished and the Network team are pulling the individual unit and regional reports together. I will be interested to read them and see what conclusions are drawn. I bet Richard Fluck, Clinical Lead for the East Midlands Renal Network will also look at take what’s best from it for their development of a patient inspectorate for the Network. In the meantime, the "Standards for Services for Patients with End Stage Renal Failure, Including Renal Transplantation" documentation which the peer review teams used makes interesting reading and provides a template that can be applied locally or Network-wide elsewhere in the country.