Thursday, 23 December 2010

Transition arrangements for the NHS

This is a complex work in progress with different parts of the health and social care system moving at different rates. Shadow arrangements are being put in place in anticipation of Parliamentary approval of the Health and Social Care Bill that will be introduced next session. Pathfinders have been announced, consortia are forming, clustering arrangements are emerging and commissioning support units are being encouraged to set up as social enterprises or as joint ventures with private sector or civil society organisations.

This is perhaps the most significant and complex change agenda the NHS has ever faced, and of course the financial challenge remains, so there is much disquiet in the media, newspapers, clinical and managerial communities. There is also a considerable amount of confusion and maybe even dis-information so Sir David Nicholson’s letter Equity and Excellence: Liberating the NHS – Managing the Transition and the 2012 Operating Framework provides a helpful synopsis of where we are now, where we are going, how we will get there and includes a grounded call to remember that improving the quality of care is the core business of the NHS. You might want to read it alongside Michael Porter's recent New England Journal of Medicine article on What is Value in Healthcare?.

Both are well worth a read.

Monday, 20 December 2010

NHS Outcome Framework: highlights CKD but misses AKI

The NHS Outcomes Framework was published today (20 December 2010) and follows the format consulted on in July. Its aims are:

  • To provide a national level overview of how well the NHS is performing wherever possible in an international context;

  • To provide an accountability mechanism between the Secretary of State for Health and the NHS Commissioning Board;

  • To act as a catalyst for driving quality improvement and outcome measurement throughout the NHS by measuring a change in culture and behaviour, including a renewed focus on tackling inequalities in outcomes.

The level of ambition and the pace of expected improvement have not been sent for 2011/12 but although the targets have not yet been set and further work is needed on the majority of indicators have no fear, this will define the future direction of the NHS over the next few years. Integration across the separate public health outcomes framework and the adult social care outcomes framework will be required to deliver the NHS outcomes that matter to the public.

Chronic kidney disease is specifically mentioned in domains 1 and 2 – preventing people dying prematurely and enhancing the quality of life for people living with long term conditions and the graphic above explains how the outcome domains relate to the NICE quality standards, commissioning and payments.

Recovering from ill health, patients experience of care and safety are also highly relevant to CKD and AKI and of course, failure to mention them explicitly doesn’t mean that they are excluded. Indeed, safe prescribing, urgent and emergency care, end of life care, MRSA and urinary tract infection all figure prominently and all are relevant to kidney care.

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.

Health Survey England confirms CKD is common and shines a light on proteinuria

Health Survey England, commissioned by NHS Kidney Care, included kidney disease as a special topic for the first time this year. It recognises CKD as a global health problem and the link with stroke and heart attack. On the face of it, the headline figure of 5% of men and 7% of women having stage 3-5 chronic kidney disease (Fig 3C) might not seem that interesting. These levels are what we might expect from previous epidemiological work. But Health Survey England is the first large community based study of CKD in the English general population and also provides the first comprehensive study of proteinuria which we now know affects 10% of men and 8% of women (Fig 3D). Overall, 14% of men and 13% of women were found to have reduced kidney function or proteinuria (Fig 3E).

Looking at the data from primary care we know that 4.3% of the adult population are on CKD registers. So the Health Survey England report that only 1.5% of men and 1.3% of women have been told by their doctor that they have kidney CKD means that only one third of those on CKD registers have been counselled or involved in their own CKD care.

Elsewhere in Health Survey England report, personal care plans have been enquired about. Overall, about 16% of those with long term conditions have a care plan. The majority of those have received their care plans in the last 12 months. Two thirds of those with a care plan participate actively in the management of their condition. Less then one third of those without a care plan are actively involved in self care.

Other worrying information from Health Survey England shows that hypertension affects 32% of men and 29% of women of whom 46% and 57% respectively are on treatment but only 26% of men and 32% of women with hypertension have controlled blood pressure!

It was however reassuring to find that all those with stage 4 and 5 CKD identified in Health Survey England were already diagnosed.

Thursday, 16 December 2010

Squaring the circle

The English health reforms present a range of challenges. Currently there is much more focus on improving quality while budgets are reducing and both Primary Care Trusts and Strategic Health Authorities are in transition to general practice lead commissioning. One of the other central planks of the coalition government’s proposals is to extend choice and competition and to reduce reliance on targets and performance management. These proposals are designed to put patients at the centre of the NHS and improve outcomes.

But alongside the emphasis on choice and competition there’s been increasing interest in integrated care. The belief is that more integrated care will achieve more personal, responsive care and better health outcomes for a local population. On the face of it, integration and any willing provider make strange bedfellows. Integrated care could act as a barrier to choice and competition if it were to entail establishment of organisations that become monopoly providers of care in their areas. Can this circle be squared? An alternative view to the monopoly provider argument is that integrated care organisations could be at the vanguard of the disruptive innovation needed to improve performance, especially if there is competition among integrated care organisations. Taking this view, there is no inherent contradiction between integration and competition provided that patients are able to exercise choice either within or between integrated care organisations.

Chris Ham and Natasha Curry from the Kings Fund make these points in “Clinical and Service Integration, the Route to Improved Outcomes” to emphasise the need for a more nuanced debate about the direction of reform that recognises the possibility of integration and competition both having a part to play in improving performance. To simulate that debate Natasha and Chris have drawn together the evidence on the performance of the integrated systems and the many ways in which integrated care can be achieved. They argue for greater clarity on the meaning of such terms as integration, integrated care and integrated care organisation. These terms are often used synonymously but have many different meanings. Clinical and service integration summarises the evidence for whole system approaches such as Kaiser Permanente in the USA, examples of chronic care models for particular groups of patients such as the elderly in Europe and North America or disease specific managed clinical networks in Germany, Sweden and the United Kingdom. Finally, they make the point that for the individual patient and to improve population outcomes, co-ordination of care is essential. They found that the adoption of multiple strategies to achieve this goal were more successful than those using single strategies alone. Concluding that improved communications between providers and the provision of support for patients maximises the chance of improving quality and outcomes.

What role might information on providers play in this drive to improve quality? Martin Marshall and Vin McLoughlin from the Health Foundation examined this question in a recent British Medical Journal analysis “How do patients use information on health providers?” BMJ 2010; 341: c5272. They cite the recent literature that shows the public want information about performance to be published but do not look at it and that it has had limited impact on improving quality. They argue that decision making in healthcare is more complex and at first sight less rational than, for instance, getting a good deal on your next car or holiday. They point to the various social processes in addition to the cognitive ones involved in how individuals make trade-offs to reach decisions. These might seem irrational to the outside observer but yet have strong internal logic. Data that is important to clinicians and commissioners is often perceived differently by patients.

So providing useful information to patients is much more of a challenge than we have traditionally thought. This is not a good reason not to include the relevance and accessibility of performance data or not to provide the information at all. On the contrary, as Martin and Vin state not only should it be seen as “a good thing on its own but may also start to engage a large number of people in the future”. We need to make information more appealing, to develop patients and the public’s health literacy and to be aware of the different health beliefs that exist in our population. Co-producing health with patients brings integration, competition and information together for the goals of improving both the health and the experience and outcomes of care.

Wednesday, 1 December 2010

Three national CQUIN goals for kidney care

The Commissioning of Quality and Innovation (CQUIN) payment framework established after the “Next Stage Review” conducted by Lord DArzi is supported by the coalition government indeed the current Secretary of State has gone so far as to state that “quality is the only organising principle of the NHS”. CQUINs are one way to achieve that goal.

A range of CQUIN exemplar goals that broadly align with the White Paper “Liberating the NHS” as well as with national Quality Innovation Productivity Prevention workstreams and the nursing high impact actions have been developed to provide well defined evidence based quality improvement goals that can be linked to provider payment through the CQUIN framework.

The renal CQIUNS cover acute kidney injury and home dialysis. The indicators of quality that have been chosen are:

  • Percentage of emergency admissions to have both 1. physiological scoring performed to identify patients at high risk of clinical deterioration (eg MEWS score) and 2. senior review (consultant or equivalent within 12 hours of admission).
  • Percentage of emergency admissions with a major risk factor for AKI to have both: 1. medication review and 2. serum creatinine re-checked within 24 hours of admission.
  • Percentage of patients requiring maintenance dialysis to be receiving home haemodialysis, peritoneal dialysis or assisted automated peritoneal dialysis.

These aren’t ‘must dos’. But they do provide a resource for commissioners, providers, clinicians and patients to draw on when agreeing local CQUIN schemes. Several of the other CQUIN exemplars are relevant to kidney care including those covering transport and care planning in long term conditions. A full set of exemplar CQUIN goals are available shortly from the NHS Institute website (pages 37-39).

As ever, I would be interested in any feedback on their use, how they have been modified locally and views on their impact.