Monday, 20 December 2010

Christmas message 2010

As 2010 draws to a close it is time to reflect on the last year, to say some thank-yous and to begin to set our priorities for 2011.

Before doing that it is worth remembering that our National Service Framework is approaching the 10th anniversary of its announcement in February 2001 by Alan Milburn, then Secretary of State for Health. The groundwork had been laid by the kidney community over the decade before which saw the publication of a Renal Services Specification, professional consensus on standards of care, agreed national audit measures and a voice given to patients and carers. Alan Milburn launched the process at the transplant summit held in the wake of the Alder Hey tissue retention scandal that provided the final political push for a national kidney strategy because of concerns about the scandal’s impact on organ donation. It seems a long time ago now – before the terms chronic kidney disease and acute kidney injury were in common parlance!

Fast forward; this year, quality has now moved centre-stage, from an organising principle of the NHS to the organising principle of the NHS by which we will always measure success; and 2010 was the year that Green Nephrology helped lever sustainability into the definition of quality healthcare. That’s care that is safe, timely, efficient, effective, equitable, patient centred and now also sustainable. It’s measurable, information is the new oil, and our Renal Registry, NHS Kidney Care and East Midlands Public Health Observatory continue to report on many aspects of care shining a light on where good practice is resulting in improved outcomes, challenging us where variation shows for instance inconsistent transplant listing by units or low chronic kidney disease registration in primary care and making us think about how services, patient experience and outcomes can be improved. The National Transport for Haemodialysis Audit will be reporting the 2010 census early next year. That, and easy, or should I say, enormously difficult, dialysis in the UK away from base unit remain the 2 big patient experience quality concerns for those receiving haemodialysis. How do we do better in these and other aspects of quality of life?

Part of the answer lies in improving choice. “No decisions about me without me”. Preparation and planning are essential for optimising outcomes in end stage renal disease. Support for conservative care, staffing to ensure live donor transplantation can occur pre-emptively and the nursing, technical and social care expertise needed for home dialysis programmes are all part of that planning. The new augmented tariff for multi-professional care is designed to help resource those choices. What became apparent from the NHS Kidney Care home dialysis roadshows was the importance of partnership, the role carers play in supporting patients and just how much better people feel when they are helped to take control of their own treatment. Read, listen and watch the stories at NHS Kidney Care. They are more powerful than any business case.

Prevention is better than cure. Control of blood pressure and treatment of proteinuria reduces vascular risk and can slow or even prevent end stage renal failure. Year on year early identification of kidney disease improves; there are now 2 million people on CKD registers. Despite exception reporting blood pressure control is better in these individuals and delayed referral has fallen; 2009/2010 was the first year proteinuria was a requirement of the CKD register in primary care and a remarkable 78% of people had a laboratory measure of proteinuria. Health Survey England have just released figures showing 6% of people have an eGFR below 60 mls/min/1.73m2 and that even more, 9% have a raised urine albumin excretion rate. So, with half the CKD population still to find, there’s no room for complacency in 2011.

Acute kidney injury (AKI) has again been highlighted as a major concern. “An Age Old Problem” the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) into surgical deaths in the elderly found that 36% of the over 80s developed AKI during their admission and that overall only a third received good care. They concluded that post-operative AKI is avoidable in the elderly and should not occur. This echoes the picture described in “Adding Insult to Injury”. Recognising risk, such as those with CKD or proteinuria, early detection of kidney dysfunction and prompt attention to simple things that perhaps could be best described as good clinical care, will make the biggest difference to outcomes in this common condition. Working with colleagues in acute medicine, surgery and critical care is starting to bring such benefits as reported by the North London AKI Network.

We seem to be ending 2010 the same way we started it, with snow causing travel chaos. Drivers, carers, renal unit nurses and technicians are to be congratulated on the sometimes extraordinary efforts they make to keep haemodialysis services working safely and effectively. That really puts the rest of our frustrations with the transport infrastructure into perspective.

Many thanks to all those in the kidney community who have raised the bar to improve the health, experience and care of those with kidney disease this year – well done. Particular thanks to NHS Kidney Care, our improvement organisation and for those working in the kidney care networks – keep up the good work and a special mention to families and carers who work so hard, often without recognition.

Looking forward to 2011, there are going to be big changes to our health system. We are heading for the largest ever financial squeeze on the National Health Service and the NHS Bill is likely to provide legislative powers to carry through the move to GP led commissioning. There will be an intense focus on reducing unnecessary hospital based activity. Kidney services will not be spared this scrutiny. So as we set our personal, team and organisation goals for 2011 let’s keep those 7 dimensions of quality in our sights, remember quality is the only organising principle of the NHS and measure our successes against things that really matter to people with kidney disease.