Tuesday, 26 January 2010

bedtime reading: "a revolutionary moment in the world's history - a time for revolutions not for patching" (William Beveridge 1942)

Do Beveridge’s words, as he laid the foundations for the UK welfare state in the dark days of WWII have any relevance today?

Our public services do face an unprecedented set of challenges: increasing demand, rising expectations, seemingly intractable social problems and reduced budgets. Reform can’t confront these challenges effectively: radical innovation in healthcare now needs to move from the margins to the mainstream. The question is what analysis and principles should inform this radical innovation?

The challenge of co-production” by David Boyle and Michael Harris quote Beveridge in their foreword and argue that equal partnerships between professionals and the public are crucial to improving public services. Given the current diversity of uses of the term “co-production”, the paper also explains what co-production isn’t. They claim co-production looks set to create the most important revolution in public services since the Beverage report of 1942. The document doesn’t only deal with the NHS, it’s about all public services but it sounds like an important read for those interested in health and healthcare.

The chapter “getting more for less” might be particularly relevant.

CKD, what's new in 2010

Are people still asking you about CKD ? Well if they aren't you’re lucky!! When should GPs exception report ? How do the incomprehensible Read codes for raised albumin creatinine ratio or other measures of protienuria relate to the CKD 6 marker in the quality and outcomes framework?

These and many more questions from the simple to the complex are covered in a new guide from the NHS employers set out in an easy to follow question and answer style

Wednesday, 20 January 2010

NHS Kidney Care's website goes live

Bev Matthews (Director) and Kat Gill (Communications Officer) and the team at NHS Kidney Care have been working hard over the festive period to develop the Kidney Care website. It looks great, provides an overview of NHS Kidney Care’s work programme and is an easy place to find relevant national documents and has a “what works” section where real life examples of innovative practice in delivery of kidney care services will be highlighted.

Have a look and add it to your favourites.

Getting the finance director to look at the quality report first

…. because then she will know that the clinical service is sustainable and in good shape. That’s the name of the game and has been for some time. Mike Richards the Cancer Tsar, now Sir Michael, said that to me when I was considering taking on the role of National Clinical Director for Kidney Care in 2006. It’s even more true today but we now have a whole new vocabulary for quality – quality accounts, quality indicators, CQUINs, the National Quality Board, quality standards, to name a few.

In kidney services we are also fortunate to be ahead of the curve in having a mandated national renal dataset which we can use to help measure the quality of the services we provide. The move towards Payment by Results for dialysis is another piece of the jigsaw and yesterday “Kidney dialysis – developing costs to deliver an equitable and high quality service” was published on the DH website although many people will have received a copy last year. I am a little perplexed as to why it took so long to get on the DH site! It did however remind me to mention the road testing of the 2010/11 tariffs is drawing to a close. If you wish to comment you have until Friday 22 January. The proposed price for a haemodialysis session is £144, more detail and the relevant "small print" of the non mandatory tariff from April 2010 can be seen here.

You can read the full guidance note at pages 77-79 of Payment by Results Draft Guidance for 2010-11.

Many renal unit directors, Trust finance leads and commissioners are reviewing local arrangements. From what I have heard these are leading to mature discussions focussing on clinical quality and putting plans in place to be able to count and contract for haemodialysis on a sessional basis. Working out how to financially manage the transition from the historic system, one could say byzantine, to a mandated PbR system, hopefully with a best practice tariff for dialysis, from 2011 is a key quality and productivity challenge for the kidney community.

Tuesday, 19 January 2010

Twice weekly dialysis rears its ugly head again

I don’t know whether it’s the thought of the ghost of Christmas past or a Scrooge mentality, as is claimed to pervade football club boardrooms at this time of the year, that’s responsible or not but over the last few weeks several people have contacted me to enquire about the suggestion of adopting twice weekly haemodialysis as an efficiency measure. This is unacceptable and indeed as we move towards Payment by Results for dialysis the intention is to fund each dialysis session that patients receive.

The Renal Association Best Practice Guideline on haemodialysis makes it quite clear that haemodialysis should take place at least 3 times per week in nearly all patients with established renal failure. Reduction of dialysis frequency to twice weekly because of insufficient dialysis facilities is unacceptable.

Twice weekly haemodialysis has a small role:
  • In patients with significant residual renal function (usually at the start of a patient’s dialysis career)
  • As “palliative dialysis” usually in patients approaching end of life following the refocusing of the aims of treatment.

The dialysis prescription should be personalised to the individual’s needs. If individuals are to start on a twice weekly regime it’s important they know that an increase to thrice weekly is likely to be needed after a short while unless dialysis is being offered as part of end of life care.

I would strongly encourage clear unit policies and accurate documentation extending to individual patient care plans that take account of a full range of treatment options, including choice of treatment setting where clinically appropriate and in accordance with the patient’s wishes.

To be fair, one Clinical Director contacts me nearly every Christmas to enlist support to resist a push for providing less dialysis. In the bad old days of the 1980s and early 1990s, twice weekly dialysis was a scourge in several parts of the United Kingdom and I hope we have put that behind us for good. As we get over the bad weather and into the work of the year our focus does need to be on preparing for the harsher financial climate the NHS faces. No part of the system will be immune from the quality and productivity challenge, with the focus firmly on improving quality and efficiency simultaneously. The key challenge of delivering quality at lower costs can only be achieved locally. Frontline staff are in many ways the guardians of quality and have an essential role to play in ensuring high quality care and cost savings are delivered – that is not the code for twice weekly dialysis!

I have written out to commissioners, network leads and clinical directors to make these points and those of you with long memories will know I have actually blogged about this before.

Q & A: Pneumococcal vaccination

Q: Hi Donal, can you help to clarify the issue with regards to Pneumococcal vaccination in patients with CKD: I read with interest the question and response on this on a previous blog. However, the general guidance available on vaccinations still suggests the use of the PPV vaccine in patients with CKD rather than the PCV vaccine. I am not clear on a couple of things: - What is the rationale behind using PCV rather than PPV in high risk CKD patients? My understanding is that the PPV is more effective at preventing serious or invasive pneumococcal disease, and this should offset the slight increase risk of an adverse reaction to this vaccine compared to the PCV.
  • Will there be/is there some guidance on antibody testing before initial immunisation, or prior to subsequent boosters?
  • Do CKD patients need 2 doses of the PCV vaccine, and if so, how far apart should they be given?
  • I presume that pneumococcal vaccination of any kind is not recommended in CKD 1 or 2 patients (unless they have another reason for being considered “high risk”)?

Best wishes, Craig Gradden, Aintree University Hospitals NHS Foundation Trust

A: Hi Craig and thank you for this question. The JCVI reviewed the evidence on vaccine efficacy in February 2009. The minutes of the meeting can be downloaded.

The Pneumococcal chapter in the Green Book – Immunisation against infectious diseases is currently undergoing a major revision and the advice below is not in the currently available chapter. People who have chronic renal disease should receive two doses of PCV (with the second dose being given at least two months after the first) followed by a booster dose every five years. As per the current Green Book, page 304 of Chapter 25 on Pneumococcal, testing of antibody levels prior to vaccination is not required. In line with the Renal Association guidance your presumption that pneumococcal vaccination of any kind is not recommended in CKD 1 or 2 patients (unless they have another reason for being considered “high risk”) is correct. Best wishes, Donal

Deciding what’s best – how do you do it?

When the word choice first became so popular in Department of Health and NHS documents it always read like capacity to me – in kidney services it is not possible to offer choice without hospital haemodialysis capacity. That remains true but increasingly we know that home dialysis therapy offers real choice at the same time as reducing hospital based requirements. It’s good for those patients who want it and it certainly fufills the quality and productivity challenge . At the “Care of the Renal Patient Towards the End of Life” meeting hosted jointed by the Renal and Palliative Care section of the Royal Society of Medicine a few months ago there was a lot of discussion on how people with advanced kidney disease make decisions and on how much they are influenced by their doctors and nurses.

Information isn’t the key to making good choices, it’s actually the relationship between the person with advanced kidney disease, and often also the people who are close to them, with the multiprofessional kidney care team that is the most important factor. Conversation eats documentation for breakfast; but recording patients’ wishes can also drive communication processes that can and does ensure plans are in place in the weeks and days before death to, for example, manage the high symptom burden that goes with very low kidney function when people are on the conservative kidney care track or withdraw from dialysis. This can keep people at home and avoid urgent admissions during which dialysis might be started even though that isn’t what the patient wants and is only likely to prolong death rather than add value to life.
Conversations about death can be hard. At the meeting Professor Renee Fox (Annenberg Professor of the Social Sciences Emerita) gave a fabulous talk entitled “from dialysis to transplantation to palliative care, a trajectory” . Renee is a sociologist who began her career on ward F 2nd at the Peter Bent Brigham Hospital in Boston. In these wards Renee saw the emergence of dialysis and then transplantation and has spent a lifetime studying the impact of renal failure and its treatments have on patients’ families and healthcare professionals. Her seminal work “Experiment perilous: patients and physicians facing the unknown” is still in press and provides not only a fascinating insight into the development of modern kidney care which was led by pioneers whose names now adorn seminar rooms , prizes and named lectures across the globe . It also contains observations and lessons that are of prospective clinical value. Renee’s comments on the decisions to treat or not to treat, to elect for dialysis or what she points out, we rather euphemistically call ‘conservative kidney care’ was very thought provoking and raises many questions of far reaching significance. I am most grateful to Renee for allowing me to make her talk available for you to read here on my blog.

These are difficult conversations for all concerned. Knowing how particular patients make their everyday decisions gives important clues as to how that person may want to discuss their kidney care options. “What was the last big decision you made – buying a car, moving house, deciding which school for the children? Who did you involve? What information did you find useful? How long did it take you? What did you feel about the decision? How would you do it differently?”. These can be revealing questions and Robert Elias’s (Renal SpR at St George’s, London) has been studying the process and his work suggests that knowing how our patients reach such decisions is useful if we are to support patients with advanced kidney disease in shared decision making.

Thursday, 14 January 2010


CQUIN payments could put AKI on the acute trust map. Commissioning for Quality and Innovation, CQUINs, were introduced as part of the quality framework in the wake of the vision set out in “High Quality Care for All”. The framework was launched in April 2009 to strengthen quality as the organising principle of the NHS. In the first year 0.5% of overall Trust income came in the form of CQUIN payments.

In some Strategic Health Authority areas commissioners agreed with Trusts that the extent of the mandated National Renal Dataset completion would be part of the scheme. I haven’t heard specifically about the impact of the NRDS inclusion yet, and of course the year 2009/10 still has a quarter to run, but overall CQUINs seem to have been well received.

So this coming year from 2010/11 1.5% of Acute Trust income will be conditional on meeting the CQUIN goals. Venous thromboembolism has been chosen as a national CQUIN and the Department of Health has also developed exemplars in other areas including AKI. The AKI CQUIN identifies a basket of measures aimed at improving the prevention, detection and management of cases of AKI in patients admitted to hospital through appropriate screening and monitoring checks. These include a risk assessment for AKI at initial clerking, check and recheck of serum creatinine within 24 hours, urinalysis, senior review within 12 hours and care planning to spot deterioration and manage appropriately. It is suggested that this should apply to all emergency admissions with ratcheted payments to the Trust dependent on achieving the targets. Such that 70% compliance would attract 50% of the allocated payment, 80% compliance – 70% payment and 90% - 90%.

These CQUINS need to be negotiated locally.

Full link from which AKI CQUIN is taken (NHS Inst for Innovation & Improvement):
Commissioning for Quality and Innovation (CQUIN) payment framework
Dept of Health publications & policy : CQUIN

Renal NSF update January 2010

The Renal NSF update for January 2010 is available here.

What about a 4223% return on investment?

If I received an email of that title I would delete it without reading. If something looks too good to be true it usually is and should be avoided!

When it comes to healthcare and green nephrology in particular, returns on investment can be staggeringly high. Andy Connor (NHS Kidney Care sponsored Green Nephrology Fellow) has worked out the costs, risks and rewards of conserving and recycling water used in haemodialysis. Case studies from the Canterbury and Ashford dialysis units provide a guide for salvaging “reject water” that in most units is needlessly “lost to drain”. For a small capital outlay this water can be salvaged and put to alternative use such as in the hospital laundry or sanitation systems to provide steam for equipment sterilisation or to feed low pressure boilers.

Steve Milne (Renal Technical Manager, Kent and Canterbury) who introduced the systems commented that “back in 1999 I was amazed how simple this all was to do – 10 years later, given the savings we have made, I am amazed nobody else has done it too”.

Read the detail about the investment appraisal, environmental savings and how to do the same in your own local unit on the Greener Healthcare website.

Tuesday, 12 January 2010

Travel chaos - improvements expected soon

Guy Hill transfixed the audience with his story. The taxi was late. The lady at the end of the phone said “don’t worry, it will be there shortly”. Guy had been ready for a good 20 minutes before the agreed pick-up time; he always was – sometimes the taxi was early. Missing the plane would be a major headache. It would knock everything out of sequence. Guy was getting anxious and from the tone of his voice a bit angry I think. The taxi did arrive – but then the snow, the roadworks (!) and every traffic light seemed to be against him. The driver then announced he was going to take a “short cut” diversion to pick up some more passengers. Have you got it yet? Guy told this story 5 or 6 years ago now at one of the Greater Manchester Kidney Care Network Meetings – he used the story of a journey to the airport to go on holiday to illustrate the importance of getting transport right for people receiving regular haemodialysis in hospitals on satellites. It was very powerful.

Since the New Year travel has been a real struggle for everyone. It seems to have brought out the best in most people, the Dunkirk spirit has been palpable in hospitals. The internet, mobiles and texting has made communications much easier than the last time we had such weather. My difficulties getting from Manchester to London, Bristol, Birmingham and Nottingham this last fortnight gave me an uninvited insight into the worries and concerns people using hospital transport for their journeys to and from dialysis 6 times a week have all the time. Patient reported outcome measures (PROMS), are all the vogue and rightly so too. Patient quality of life, that’s what PROMS record, is as important as the clinical outcome measures we use to determine quality of care. For someone on 3 times a week hospital dialysis the timeliness, friendliness and cleanliness of patient transport services is an important, to many, more important, than their haemoglobin, dialysis adequacy and serum bicarbonate. The quality of transport affects quality of life and patient experience of care.

The National Kidney Care Audit report on patient transport published last year was an important milestone for the Renal National Service Framework . All but 5 units participated. Over 2/3 of people receiving haemodialysis completed the survey. That’s a remarkable figure. It reflects the importance of the subjects. Patients in every kidney unit where they were asked, volunteered to help with the development and action plans to address the inadequacies of local transport provision. Commissioners of care and kidney unit staff themselves all responded positively.

The Renal NSF recognised that long travel times and waiting time adversely affects quality of life for haemodialysis patients. Indeed there is some evidence that longer travel time is associated with a greater adjusted risk of death as well as a lower score in quality of life questionnaires. The Renal Association Clinical Practice Guidelines set a 30 minute standard. Haemodialysis facilities should be within a 30 minute travel time, patients should be collected from home within 30 minutes of the allotted time and to be collected to return home within 30 minutes after finishing dialysis.

Nearly ¾ of people are collected within 30 minutes of the allotted time and over ½ have a travel time of 30 minutes or less so there is some very good practice. In Sunderland for instance 95% of patients were satisfied with their transport arrangements. In 6 units however, less than ½ the patients were satisfied. Some of the units with the lowest satisfaction scores have the most patients travelling 5 miles or less to their unit! At Arrowe Park in the Wirral 80% of patients had a travel time of less than 30 minutes but in 5 units over 20% of people had a travel time to and from dialysis over one hour – adding in delays in collection, waiting in the unit to start dialysis and the time waiting to be picked up at the end of the dialysis session it is easy to see how a 4 hour dialysis session turns into a full day of up to 8-10 hours! In York, Ipswich, Carlisle, Stoke and Portsmouth over 90% of patients waited less than 30 minutes from arriving in the unit to starting their treatment. In Portsmouth and York over 50% were on in less than 10 minutes.

At the other end of the spectrum, in one unit only 48.3% of patients were on within 30 minutes and in some there were as many people waiting an hour or more as were commenced within 10 minutes of arrival!!

The beauty of the data isn’t that the units that scored well can sit back on their laurels – they need to go from good to great. The beauty is that the variance shows that an excellent haemodialysis transport service is possible in some place so it should be possible everywhere. What are the lessons that can be learned from the excellent units? What recommendations and suggestions from the NSF Action Learning Sets can be used in the local action plans each unit is drawing up? One clear message of the National Survey was that patients do wish to be involved in the planning and monitoring of transport. There was little evidence of that in 2008, yet in nearly all units over 50% of patients wished to be involved. I hope the 2010 survey will show they are.

Communications are a key part of the haemodialysis transport service. ScHARR, the School for Health and Related Research at the University of Sheffield have evaluated a dedicated telephone service introduced by the Cheshire & Mersey Kidney Care Network that reports encouraging results. This service led to significant improvement in communication. That is an important part of the jigsaw but not the whole picture. Transport remains on the agenda for 2010.

useful links:
Cheshire & Merseyside Action Learning Set report "recommendations for the provision of a patient centred renal transport service"
Renal Patient Transport Survey 2008

Thursday, 7 January 2010

New Year resolutions - goals for the year ahead

With the festive period behind us, minds are focussed on the year ahead and what we hope to achieve. The pundits say that “you should have 3 goals or less. Any more and you won’t be able to focus on them”.

Taking that advice I have set 3 goals that I will prioritise over everything else. They are raising the profile of acute kidney injury so that it gets on every healthcare professional’s radar and every healthcare organisation’s agenda; driving the data into knowledge initiatives that will support improved quality and outcomes for people with kidney disease and promoting shared decision making which I believe is at the centre of high quality personalised care planning for long term conditions.

The risk with New Year resolutions is always that we either set our sights too high or that all those urgent things that clutter our days push out the important things we need to do to achieve the goals. The trick is apparently to break the tasks down into bite size chunks that are within reach and to share the goals which provides increased accountability to help achieve your aims.

The challenge of managing acute renal failure, as it was then termed, and the prize of seeing desperately sick people recover was one of the main reasons clinicians of my generation chose kidney medicine as a career. Last year’s NCEPOD report on AKI confirmed what many people thought – services provided for those with AKI are poor. We need to do better. To address the concerns highlighted by the NCEPOD report and to co-ordinate a whole system approach to improving care, I have established an Acute Kidney Injury Delivery Board that will bring together all the necessary expertise to implement the report’s recommendations.

The kidney community led the way in using data to manage both individual patients and the end stage renal failure populations we serve. The Renal Registry has been pivotal in raising the understanding of renal replacement therapy and helping local teams to drive up quality. The NHS collects as much, if not more data, than any other healthcare system but we haven’t yet capitalised on that goldmine. Now that we have the National Renal Dataset that was mandated last May, we have the opportunity to establish data linkages, develop quality metrics and turn that information into knowledge to support improvements and efficiencies in care. That’s what the Kidney Quality Improvement Partnership (KQIP) set up last year and supported by NHS Kidney Care is all about. We will be appointing a clinical lead for that programme later this month.

World Kidney Day 2009 saw the launch date of our Kidney Care Plan. Engaging, educating, empowering and encouraging all people of every shape and size, and every colour and religion, with or at risk of chronic diseases is perhaps the biggest challenge healthcare faces globally. It cuts across all the long term conditions – vascular, obesity, cancer and mental health. It’s also one of the ways to reduce infectious diseases, accidents, trauma and the other causes of premature mortality. We have to move from the sickess/cure paradigm to a health/risk management one which means moving from a “doctor knows best” to team working in partnership with the public and patients. Care planning in short. Coming from a secondary care renal background, one of the areas I am most passionate about is “the year before” as our NSF calls it. Advanced kidney disease before replacement therapy or the decision to opt for conservative care has been made. There is a lot happening in this space – cause for concern registers, increased pre-emptive live donation now increasing across ABO and HLA barriers and encouraging home dialysis therapies to restrict the list to 3.

Setting these 3 priorities - AKI, linking routine data flows to improve quality of care and supporting patients to make the best choices to optimise experience and outcomes for themselves doesn’t mean everything else stops. What it does mean is that working towards these goals will not constantly take a back seat to ordinary work.

I hope that you have had a good break, that the snow hasn’t disrupted your goal setting and that 2010 will be a year for progressing quality of care. Quality if the organising principle of the NHS. As we tackle the issues the financial crisis will raise we need to stay focussed on that central goal.