Tuesday, 9 March 2010
The context of the review was the commission on social determinants of health which was set up by the WHO that published its report “Closing the Gap in a Generation” in August 2008. The title was a statement that we do have the knowledge to do it; it was a statement that we have the means to do it; the question was, do we have the will to do it?
“Fair society, healthy lives” has been widely quoted as showing that health inequalities have not narrowed, if anything they have got wider over the last decade. That is true, but if we look at what’s happened to the worst off in the decade from 1997 to 2007, life expectancy improved by 2.9 years in only 10 years. That’s about 7 hours every 24 hours. The issue is improvements were even better for the average and well off, so the gap between rich and poor didn’t narrow. Sir Michael argues that we need to focus on addressing the gradient or variation across social class and deprivation. The gradient suggests that we have to have universal solutions that run across the whole of society rather than the traditional targeted approach.
If everyone in society had the mortality rate of those with a University education, in other words we brought everyone up to the standard of the best off, we would prevent 202,000 people dying aged 30+, dying prematurely, which is 40% of the deaths and that translates, looking at the premature deaths avoided to 2.5 million life years. It would also bring 2.8 million extra years of life free from limiting illness of disability. Putting £ signs on those deaths or life years would be telephone numbers. The economic case us unarguable, we cannot afford to do nothing.
Sir Michael and his team took a life course approach and identified 6 policy areas that could make an enormous difference to improving health and reducing health inequalities. Every child the best start in life, education, a life long education, fair employment and good work for all, a healthy standard of living for all. Create and develop healthy and sustainable places and communities, strengthen the role and impact of ill-health prevention and 2 policy mechanisms, quality and health equity in all policies and effective evidence based delivery systems.
The report is packed full of interesting things, for instance, child development we know is influenced by children being read to every day at age 3. Reading to children every day positively affects cognitive development, it’s really a pretty simple intervention. Data from Canada shows that children read to daily reverses half of the disadvantages associated with low income in readiness to learn when children start school. A really simple intervention and if it wasn’t done by parents it could be done by others. There are lots of other examples and even a plug for the NHS Kidney Care funded Green Nephrology project that Andy Connor and others are driving forward.
But is it just another report? Several have drawn analogies with Douglas Black’s report at the beginning of the 1980s. The Black report was commissioned by a Labour Government and presented to a Conservative one. It was actually published in rather poor photocopy form over the August Bank Holiday weekend. It did have an enormous impact on our understanding and the research community and perhaps should be credited with helping to shape the thinking and trial design for Marmot and other research groups around the globe. In contrast “Fair Society, Healthy Lives” has broad cross party support from all the 3 main political parties. After the election there are likely to be differences in how the programme of work will be approached but this report clearly articulates what’s needed and how progress can be measured.
Chairman of the Mid Staffordshire NHS Foundation Trust enquiry
The Francis report is a lesson in communication – well written and easy to read but remarkabley disturbing. The patient stories that make up volume 2 deserve to be read by anyone seeking to understand the impact of poor care on those who seek help in hospital and on their families.
“There were often only 2 nurses for as many as 24 patients, and on occasion there was only 1 nurse attempting to treat everyone on the ward”
“I cannot believe that my husband spent his last few days in such an uncaring and appalling environment”
“On one occasion she attended the hospital at about 6.00am to find her mother in a side room calling ‘please help me, please help me’”. The patient was covered in dried faeces and was completely naked. She ran down the ward to find the staff “chatting and laughing”. She assisted on washing her mother and it was “awful”. Her “hands were absolutely caked” and it “was dried and it was all up her arms and it was round her neck”.
The patient died later that night.”
“The least important people on these wards were the patients”.
The report found a culture where patients were reluctant to insist on receiving basic care for fear of upsetting the staff, the consultant body was largely disassociated from management, where there was lack of openness and target driver priorities.
“Safety is the responsibility of all staff, clinical and non clinical”. Lord Darzi defined safety and quality as the organising principles of the NHS. Robert Francis quotes 4 earlier reports on safety beginning with Sir Ian Kennedy’s enquiry into children’s deaths in Bristol. Francis states “it should have been obvious to any Trust management between 2006 and 2009, if not before, that a high priority was to be accorded to patient safety in all its aspects”. In mid Staffordshire the Board concentrated on financial balance and achieving Foundation Trust status rather than quality of care. There was a focus on process at the expense of outcomes, a failure to listen, lack of support for staff and a weak professional voice in management decisions. I would encourage everyone to read the executive summary and the chapters on safety, record keeping and communication. Francis makes 18 recommendations. They are all directed at the Board, the Trust Management, Secretary of State, Department of Health and Monitor apart from recommendation 13: all wards admitting elderly, acutely ill patients in significant numbers should have multidisciplinary meetings, with consultant medical input on a weekly basis and recommendation 18: all NHS Trusts and Foundation Trusts should review their standards, governance and performance in light of this report. Many of the insights and comments are relevant to kidney care and indeed all care. Our understanding of human behaviour can be improved by appreciating how people systematically go wrong. Two things shouting out from this enquiry for me are the importance of encouraging our public and patients to expect and demand quality as a right and the important leadership role that all clinicians have as the custodians of quality for individuals and groups of patients.
Thursday, 4 March 2010
It was refreshing to see a multi-professional approach being adopted across the whole secondary care system in this patch with a focus on early identification of AKI risks, simplifying advice for busy junior doctors and nurses looking after acute admissions and working on surgical wards, and putting systems in place to provide timely, specialist input or transfer when needed.
There definitely are some quick wins – avoiding contrast induced nephropathy, automatic flagging of raised serum creatinine and mandating an AKI risk assessment as part of the admission protocol.
Chris Laing (Consultant Renal Physician, Royal Free) chaired the group and I think I very smart move was to get the Medical Directors of all 5 Acute Trusts in the North Central London cluster to be the sponsors of the Network. I was also pleased to see David Myers (President of the Royal Free KPA) is also a core member of the committee. It was the first time I had heard the “STOP” acronym to categorise the various causes of AKI that should be considered when the serum creatinine rises.
Chris and the group have the senior sponsors and are leading the cultural change to achieve “buy-in” across the system so that the pathways of care, flow diagrams and protocols that are being produced will have the best chance of getting embedded into routine practice. They aim to audit across their whole network and are exploring the use of CQUINS or inclusion of AKI metrics in quality accounts to maintain AKI on the agenda. I am sure the North Central London AKI Network would be pleased to share their approach and learning with other interested teams. I will be watching closely.
The clinical guideline will require improvements in training of undergraduates and post graduates to prevent, detect and manage acute kidney injury. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) “Adding Insult to Injury” acute kidney injury study, identified a need to improve the provision of appropriate facilities and resources within hospitals.
“Adding Insult to Injury” study demonstrated that only 50% of patients with AKI received good care. So I am very pleased that NICE has agreed there is an immediate need to undertake the development of this clinical guideline to improve the quality of care for people with AKI . There may also be potential cost savings to the prevention and early detection of AKI.
The target group will include a wide range of healthcare professionals including medical, surgical, nursing, pharmacy and dietetic colleagues as well as patients and patient support groups.
The over-riding purpose of the guideline will be to improve prevention, detection and management of AKI across the NHS.
Guidelines do take time to develop, by the time this AKI clinical guideline is published I expect that all the recommendations of the NCEPOD report will have been implemented throughout our health system.
Tuesday, 2 March 2010
The introduction of a non-mandatory tariff for adult dialysis is an initial step towards a best practice tariff. Children’s renal services are not covered by Payment by Results. The best practice tariff will encourage haemodialysis via a fistula and providing access to home dialysis, whenever clinically appropriate. The non-mandatory prices for 2010-11 are set in order to signal the intention for mandatory pricing of dialysis in subsequent years, which will bring dialysis into the scope of Payment by Results.
The haemodialysis tariff covers a session of dialysis, defined as each session of dialysis treatment on a given day for each patient. Identifying the actual number of sessions may be problematic if units do not currently use their patient administration system (PAS) for activity recording. If that’s the case work should start to address now so systems are in place for April 2011. The peritoneal dialysis tariff covers a day of treatment.
The guidance recommends applying the prices per haemodialysis session to each session of home haemodialysis while acknowledging that patients dialysing at home may wish to have 4 or 5 sessions of dialysis a week, as opposed to the 3 sessions a week in a hospital or clinic that are recommended as minimum practice by the Renal Association. This recommendation is intended to incentivise an increase in the provision of home dialysis options for patients. The guidance also outlines which high cost drugs are not included in the tariff and discusses mechanisms for agreeing reimbursement. The tariffs may also be used in agreeing reimbursement for dialysis away from base.
If you want to know more, read the Frequently Asked Questions on the website of NHS Kidney Care.
I was hoping to get to see around the new 40 station state of the art unit at Hull Royal Infirmary but it was a hive of activity and I certainly didn’t want to be responsible for slowing things down by interrupting the workmen for a sneak preview. It will be open in a few months and hopefully I will get to visit again soon. Helen Collinson (Clinical Director of Kidney Services at Hull) and Elaine Harrison (Renal Nurse at Hull & East Yorkshire Hospital & Nurse Lead Network) did show me round the current “unit” – having to manage 3 physically separate outpatient dialysis areas must be a logistic nightmare! Despite that the staff and patients were really quite cheerful. To have outgrown not 1 but 2 dialysis units while waiting for a new facility is something of an achievement! The buildings themselves had seen better days but I was struck at how much effort is going into keeping the patient environment the best it can be until the move. However, I don’t think anyone will miss the old place when the transfer does occur.
The buildings may have seen better days but the staff were definitely in good form and indeed shape. A team from Hull are doing the coast to coast walk for Kidney Research UK. If you want to sponsor them go to http://www.kidneyresearchukevents.org/coasttocoasters. There was a big emphasis on supporting patients and their families, providing local clinics, linking with primary care, not only for early kidney disease but also for the delivery of conservative and end of life kidney care, and a thriving pre-emptive live donor transplant service linked to Leeds. The multiprofessional philosophy and “can do” mentality will stand the team and their patients in good stead to tackle the quality and productivity challenge facing the whole NHS. Part of that philosophy is understanding that we don’t have all the answers. That’s evident in the Hull clinical team’s approach to quality improvement for the service but also in the way they ask research questions and contribute to our evidence base. Sunil Bhandari (Honorary Senior Lecturer in Renal Medicine) leads an active research group conducting a range of clinical and basic science projects. Time did permit for Sunil to give me a short tutorial on erythropoetic stimulating agents and cardiac modelling, the subject of a recent successful PhD.
Hull seems pretty representative of the whole network with lots of energy, innovative approaches and a real desire to make significant improvements in patients’ experience and outcomes. I was pleased to learn that the Yorkshire & Humber renal strategy has been approved. It’s based on realistic planning assumptions and sets ambitious targets covering the whole pathway. There was a healthy discussion about providing support to home haemodialysis as part of the network rather than each unit trying to do what could be better done as a group. There is already a track record of working together with the northern part of the patch recently investing in a single IT system across the 4 provider Trusts; the vital pulse system will also link directly into primary care and should facilitate the award-winning “virtual nephrologist services” that John Stoves (Consultant Renal Physician) and John Connolly (GP) in Bradford have been leading on. Five CQUINS have also been approved and cover setting thrice weekly haemodialysis as the acceptable minimum, haemodialysis starting as an outpatient, early transplant listing and peritoneal dialysis. Michael Gordon (GP in Sheffield and lead GP for the network) with Greg Fell (Public Health lead) have also produced some neat graphs and statistics to compare individual GP practices’ management of chronic kidney disease with adjacent practices. Capital for refurbishment is an issue in West and North Yorkshire and I think this will be a challenge nationally in the lean years to come. Will McKane (Consultant Renal Physician in Sheffield) also expressed concerns that the move to Payment by Results for chronic dialysis may undermine the provision of an acute kidney injury dialysis service. I always seem to come away with more questions that I need to do homework on when I meet with Will.
PS Les Sellers (Consultant Renal Physician at Hull) told me Hull was the Venice of the North but I was also told that when I was a Senior Registrar in Edinburgh (or perhaps that was "Athens") and have heard the same comment about Aberdeen; according to Wikipedia “the term Venice of the North refers to various cities in northern Europe that contain canals, comparing them to Venice, Italy which is renowned for its canals”, strangely none of the places mentioned above are included!
1. The need for blood transfusions for some patients, therefore jeopardising their transplant status because of antibody increase, plus transfusion risk itself.
2. National shortage of blood, so the above will stretch resources further.
3. Some patients will probably start dialysis sooner than really needed as more symptomatic from lower HB's, so not good for the individual or dialysis space provision.
4.Quality of life for individuals from whom it is withdrawn, who know they have improved since they started it- - at least not starting new patients they would never have known anything better.
5. Conservative management patients for whom symptom control and quality of life is paramount, who are then likely to feel worse and perhaps require travel etc for transfusions that could have been avoided.
I would be grateful for your thoughts or any guidance that may help us convince the PCT this is not the way to go. Thank you, Nicky Moncrieff, Renal Nurse Specialist, Addenbrookes Hospital, Cambridge
A: Dear Nicky, thank you for your email concerning ESA prescribing and funding arrangements for those not on dialysis. As you can see I have broadened the issue to the whole of renal anaemia management in those with CKD not on renal replacement therapy. I think a number of people are beginning to look at this issue because of the cost, commissioning arrangements and recent trial data.
Conceptually the anaemia of advanced CKD is similar in the pre-dialysis, dialysis and conservative kidney care patient group although the severity and balance of underlying patho-physiological processes vary, largely with the level of renal function.
It is helpful that we have a NICE guideline on renal anaemia. It was published in September 2006 and would therefore be due for review in September 2010. I believe its underlying principles and advice remain valid but you will no doubt be aware that the TREAT study was published in November 2009. TREAT is by far and away the largest randomised controlled trial of anaemia management in patients not on dialysis ever conducted.
Its conclusions are starting to influence practice and NICE may well consider an earlier review than September 2010 to provide clarity for the NHS.
In TREAT over 4000 patients were randomly assigned to Darbepoetin Alpha treatment to achieve a haemoglobin level of approximately 13 gm per decilitre or placebo. Importantly rescue therapy with Darbepoetin Alpha when the haemoglobin level was less than 9 gm per decilitre was part of the protocol. There was only a modest improvement in patient reported fatigue in the Darbepoetin Alpha group as compared with the placebo group. The use of Darbepoetin Alpha in these patients with diabetes, chronic renal disease and moderate anaemia who were not undergoing dialysis did not reduce the risk of either of the two primary composite outcomes, either death or cardiovascular event or death or a renal event. It was associated with an increase risk of stroke. The author’s concluded that for many personnel involved in clinical decision making this risk will out weigh the potential benefits.
It is important to be aware that in the Darbepoetin treated group many of the patients received very high doses of ESA and that might have a bearing on safety. Equally important the placebo group were not allowed to develop severe anaemia i.e. they did receive ESA treatment to prevent haemoglobin falling below 9 gm per decilitre.
How will patients, commissioners and prescribers in the UK respond to this new information? Certainly it would be perverse and costly to increase transfusion needs, which as you say might have a negative impact on future transplant chance, or to have to commence dialysis earlier than would otherwise be needed because of restrictions in access to ESA therapy. My biggest concern however is that those opting for conservative kidney care might have to tolerate the low haemoglobins we saw in the pre-EPO era. This would severely compromise the quality of life of these individuals in the final years and months of their lives. There is good evidence that active anaemia management has a positive beneficial effect on quality of life and feelings of well-being independent of individual’s age or functional status. Anaemia management is a key part of conservative kidney care.
Arrangements for commissioning the care of people with advanced kidney disease not receiving renal replacement therapy vary across the country. In some localities PCTs directly fund all aspects of kidney care except renal replacement therapy, in others pre-dialysis management is considered as part of the specialised commissioning contract for renal services. In some areas the situation is not clear to all concerned. This later situation does not lend itself easily to the mature conversations that are needed between commissioners of care, providers, clinicians and patient groups that should provide the best forum for decision making. Such groups with key representation across the whole pathway are ideally placed to drive quality, equity and productivity. Commissioning across pathways of care is not easy because traditionally the health service has ‘paid’ for particular treatments or episodes of care but for kidney patients considering the whole pathway, what patients benefit from, how to provide optimal therapy at the best value factoring in patient experience and outcomes are essential for high quality care.
Access to treatment should be equitable. Commissioning and delivery of care should both aspire to a seamless continuum across the patient pathway with clinical teams playing to their individual strengths and working collaboratively between the various organisations of the NHS. Easy to say, more difficult to deliver, even more important than previously as we face the challengers resulting from the global financial crisis.
Anaemia management is broader than ESA treatment. We know that intravenous iron is very useful in directly improving renal anaemia as well as in reducing the dose of ESA when they are needed. ANSA, the renal Anaemia Nurse Specialist Association produced a neat guide on IV iron that you may well be aware of. It provides clear protocols for delivery of iron close to patients’ homes and avoiding the unnecessary trips back and forth to hospital, particularly in those not receiving dialysis, both improves their quality and reduces costs for the health service. Kind regards, Donal
Monday, 1 March 2010
But there is much to be done. Less than half of PCTs have an individual or group responsible for quality assurance and clinical governance of the renal screening programme and over one third of PCTs and their providers don’t have an agreed care pathway to support people with diabetes who have end stage renal failure. A new commissioning guide for diabetes and kidney services published last week by NHS Diabetes and Kidney Care should help primary care commissioners address these gaps. Priorities have been set and hopefully the focus on diabetes and kidney disease that World Kidney Day 2010 will bring will be an impetus for substantial improvement over the next 12 months.