Monday, 10 May 2010

What the future may hold for kidney care

“Prediction is very difficult, especially about the future” Niels Bohr.

We live in changing times and there is much talk of uncertainty. Globally healthcare demands are rising and in the UK the bank bail out has left our government with a large debt one consequence of which is reduced public service finance. The Kings Fund has predicted that the National Health Service will have to make 26 billion pounds efficiency savings between 2011 and 2014. How will that be achieved? What changes to the structure and financial systems of the NHS will we see? What will the new government’s priorities be? and how will they be achieved? What will the NHS look like and feel like in five years time?

One certainty is that the scale and pace of change is going to accelerate, but there are other certainties as well – the population will continue to age, the use of the internet in healthcare will grow, health literacy will improve and non communicable long term conditions in particular vascular disease will continue to be one of our greatest challenges. Kidney disease in all its various forms is not going away and the prize of better patient experience and outcomes laid out in the National Service Framework for Renal Services published just over five years ago not only remains relevant but also provides the goals and vision for that ambition.

Chronic Kidney Disease is now recognised as a public health problem, prevention, early detection and better primary care management of CKD is firmly on the agenda and over the last three years we have witnessed a shift in the understanding and confidence of non renal healthcare professionals in dealing with kidney problems. The job is not done – only half the expected number of people with CKD have been identified and blood pressure is not optimised in half of these, inappropriate referrals and avoidable “crash landings“ have declined but the variance we can now see between practices and across the country indicates that we can do better. Proteinuria was only introduced into the Quality and Outcomes Framework a year ago and we are yet to see its impact, it is still not recognised as the powerful cardiovascular risk factor that it is by many outside the kidney community.

With the growing experience and confidence of GPs practice nurses and pharmacists I expect more and more people with kidney disease will be told about their results, what they mean (and don’t mean) and what that person can do to reduce their future vascular and renal risks. The goal is for our public to understand kidney disease – estimated glomerular filtration rate and urinary albumin creatinine ratios in the same way they comprehend the link between cholesterol and heart disease, for people with CKD to be informed and activated to participate in their own care and remaining healthy strategies and for all those involved along the kidney pathways of care to support the individual to achieve the best outcome they can.

Preparation for timing and choice of renal replacement therapy modality or conservative kidney care remain essential for good outcomes in advanced chronic kidney disease. The key is shared decision making – where the multi-professional kidney care team provide detailed information about the options, their risks, benefits and uncertainties for that individual patient and the patient often with family and carers shares their values, beliefs and aspirations so that a truly informed choice can be made. This investment in time, building relationships with our patients provides high quality care and saves money. The shape of our End Stage Renal Failure services will change – in part that might be constrained by the current financial climate but I would prefer that to be shaped by our patients and believe we can provide a better service for more patients in three years than we do now.

Getting our metrics of success right is crucial. The UK public support transplantation, the transplant plan is on course, transplantation rather than dialysis then transplantation should be norm with live donor transplants. Live donors continue to rise year on year, in the centres that are ahead of game we see no sign of reaching a plateau – that’s good . There is an 18 week pathway but delays in transplant listing and surgery still exist – where those delays are avoidable the NHS could do better and unnecessary delays waste money. High quality care is actually cheaper than chaotic care.

In the coming year we will see a focus on Acute Kidney Injury and I hope see the foundations for improvement in services for people with rare kidney disease being laid. Acute Kidney Injury has been estimated to cost 5% of the whole expenditure of hospitals. AKI is common, harmful and treatable. Only 50% of people who die of AKI receive good or adequate care. In 20% AKI is predictable and avoidable. Improvements in the quality of kidney care will save money.

Rare kidney diseases often affect young people and frequently result in the early development of renal failure. Our understanding of some of these conditions is improving rapidly, novel treatments are in the pipe line. Research, expertise and a service responsive to the needs of these families in needed.

So the climate has changed, some of the rules are likely to be ripped up and rewritten but the destination remains the same and new opportunities will arise to improve the experience and outcome of kidney care.

“The best way to predict the future is to invent it “ Alan Kay.