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