Tuesday, 28 June 2011

Attitudes to mental illness: in numbers

Annual surveys of the public’s attitudes to mental illness in England have been running for nearly 20 years and the most recent report makes interesting reading.

Compared to 1994 the number of people agreeing that “mental illness is an illness like any other” has increased from 71% to 77%. The percentage saying they would be comfortable talking to a friend or family member about their mental health has also increased and now stands at 70%.

Mild mental illness, anxiety and depression are common in all long term conditions and chronic kidney disease is no different. Mental illness significantly affects the quality of life of people with kidney disease but this is not yet well recognised. About a half of dialysis patients who are breathless on exertion or nauseated are correct identified by their doctors and nurses – that doesn’t sound great does it? But only a meagre 17% of those that are feeling sad and just 6% of those who are anxious or who have a reduced interest in sex are picked up in routine care, despite the fact that 40-50% of patients who are on dialysis or who have been transplanted experience anxiety or depression. What’s more, depression is associated with more hospitalisation, greater physical symptom burden and worse outcomes. This is really sad as there are very effective treatments for depression ranging from exercise, change in dialysis regime, talking therapies and medication. We should be talking, researching and doing more about it in the kidney world.

Of course mental illness is common in the general population as well. In the survey the majority of respondents (57%) reported that someone close to them had some kind of mental illness. Stigma and discrimination still remain a major issue. Half said they experienced a lot of discrimination and this hasn’t changed much in the last couple of years. That’s a pretty disappointing statistic and while a natural reaction to the fact that 21% of people feel anyone with a history of mental illness should be excluded from taking public office might be to smile or joke, it shouldn’t be because there’s a darker side. One in 8 feel that those with mental illness should not be given any responsibility and the same proportion that it would be foolish to marry someone who has had any mental illness in the past, even if they have made a full recovery.

Now that there is a definititive focus on patient experience in health and healthcare, how people with kidney disease or other chronic illnesses feel should be studied, recorded and firmly on the agenda.

Wednesday, 8 June 2011

Patient transport survey 2010

Travel - with its inherent uncertainties and seemingly inevitable delays – can be frustrating, tiring and unsettling for anyone, however healthy they may be. One need only look at the expressions and body language in a queue for a bus, train or plane to know that. A bad journey can have a big impact on the experience of the event for which the transport was needed. In contrast, when travel is comfortable, timely and efficient, it is a pleasurable experience that can leave us feeling relaxed and positive. That idea should be food for thought for anyone commissioning haemodialysis services.

Patient transport for hospital or satellite haemodialysis is different from all other transport to and from hospitals. No other medical condition requires such frequent travel back and forth for treatment for months and years on end. Six journeys a week, three to the haemodialysis unit and three back home – Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. Every week - Christmas and holidays included. Transport is therefore a significant component of the patient’s experience of haemodialysis, and it is no wonder that it is frequently cited as the part that most needs improving. As this patient survey shows, complaints are common. Difficulties in identifying who is responsible and
who can improve the service are almost universal.

This report shows that 95 per cent of eligible units participated in the survey, and I would like to thank the thousands of patients and the staff who took part.

By providing details of their experience of this aspect of care, they have highlighted an important issue for the kidney community in improving patient experience. I look forward to seeing this on the agenda of every kidney care network, on seeing ownership of the issue and working together to see what improvements we can make for patients.

NHS Kidney Care e-seminar Patient Transport, 16 June 2011
Recording of the e-seminar

Tuesday, 7 June 2011

Manchester demonstrates more for less - Innovation Challenge Prize Awards

The Department of Health has announced the first 3 recipients of its Innovation Challenge Prize which recognises ideas developed by frontline staff to deliver solutions to the problems facing their patients. Among the 3 is Manchester Royal Infirmary, awarded the maximum prize of £100,000 after developing an innovative approach to redesigning existing dialysis provisions in hospital. The money will be used to improve the service further and they hope to roll out the system across the NHS. Their innovation means that patients are able to choose home instead of hospital haemodialysis and has had substantial effects on service costs for the hospital. By continuing to use hospital dialysis costs would have been expected to be £45,628 per patient, per annum to NHS Manchester. The average home dialysis cost of £26,289 compares favourably with the annual average per patient cost of £40,145 for attendance at Manchester Royal Infirmary, and £45,628 for attendance at a satellite clinic. These figures include secondary costs such as patient and carer time costs in addition to the NHS costs.

This innovative approach to dialysis provision in Manchester allows the choice of home haemodialysis to all those who might benefit, and has transformed patient lives with improved outcomes. A dedicated and highly skilled team led by Dr Sandip Mitra and Sister Gill Dutton empowers patients and has so far trained 180 patients to be independent on haemodialysis at home.

The other 2 winners were MRC Cancer Unit (Cambridge) and NHS Bristol.

Congratulations to Dr Sandip Mitra and Gill Dutton on this latest award which comes soon after they scooped the NICE shared learning award in May 2011.

Brave new world of kidney care

Modern healthcare is complex. Kidney care is no different . The field is huge, multi-faceted, and the already immense body of clinical and policy literature grows at a frightening rate. There is evidence that better treatment of common comorbid conditions improve health outcomes such as decreasing cardiovascular events and mortality in patients with chronic kidney disease and in end stage renal disease the way clinical teams work together and interact impacts on patient experience and outcomes. However, care of complex CKD patients is often fragmented among different specialists, consultants, nurses, general practitioners, dietitians, pharmacists and other health and social care professionals. As a result, a more cohesive multidisciplinary team approach to CKD is needed to optimise care for comorbidities and CKD, as well as to facilitate the transition to management of end stage renal disease, improve renal replacement therapy outcomes and the experience of conservative kidney care.

Kidney failure has a profound life-long impact on patients, their families and carers. During the course of their patient “journey” they will encounter numerous multiprofessional staff who each have a contribution to make to their management and care. Patients’ varied needs, physiological, practical, psychological and social, will form a focus for different staff at different times. In order to optimise clinical outcomes and to enhance quality of life, multiprofessional staff require a joint perspective on management and care issues, underpinned by recognition of the varied professional skills required, and an ability to work flexibly and in collaboration. Team-based care is a foundation of the chronic care model which calls for productive interactions between informed patients and proactive practice teams to improve health outcomes for people with chronic medical conditions. . A multidisciplinary team is essential but how our MDTs work deserves further investigation. We need to study attitudes , values and behaviours as much as the skill mix and technical competencies .

To support kidney care multi-professional team working new arrangements have been put in place in England for adult services from April 2011. Payment to Trusts for first outpatient visits that are multiprofessional will receive a 50% uplift (price for doctors only visits £198 versus £328 for first MDT visit) with ongoing multi-professional care attracting more than double physician only outpatient attendances (£128 versus £257). This support for MDT led “preparation and choice” applies equally to live kidney donation, setting or place and modality of dialysis and conservative kidney care. People with complex multi system disorders and those with primary kidney disease or post transplant receiving a high dose immunosuppressive regimes and requiring pharmacy or other MDT input will also be able to benefit from this payment for quality. The introduction of this payment system for hospitals has the potential to make another step change improvement to the experience and outcomes of care for people with advanced kidney disease and those requiring multi-disciplinary care because of intricate and potentially toxic treatment.

Multiprofessional care should promote shared decision making which is relevant across the whole of kidney care from risk assessment and management through to advanced kidney disease, replacement therapy and palliative care. Decisions about lifestyle, for instance in the management of hypertension; diet, exercise, moderation of alcohol and smoking cessation, are more likely to ensue if they are accompanied by behavioural change plans that encourage and promote health. Prescribing of medicines should always be preceded by discussion of the indications, potential adverse events and evidence base for the treatment. The patient’s views on the likelihood of a particular class of anti-hypertensive drug causing impotence or the effect of the route of administration, oral or intravenous, of cyclophosphamide in the treatment of vasculitis on subsequent fertility need to be explained by the clinician, considered by the patient and factored into the prescribing decision. The timing of ultrasound scanning in those with a family history of polycystic kidney disease should take into account the possible negative impact – psychological, emotional and financial – of a positive scan as well as the utility of accurate diagnosis. People need time and space to consider these big decisions if the best outcomes are to be achieved.

Good kidney care has always been based on teamwork. The complexity of renal failure, the wide range of treatment options – from an ABO incompatible live donor transplant or daily dialysis to conservative care requires detailed knowledge, precision and technical skills. The impact on physiology, diet, psychological wellbeing and social functioning brings added dimensions to kidney care. Achieving optimal outcomes and improving patients’ experience of care depends on the whole range of skilled and motivated individuals needed to manage different aspects of kidney care; but it also needs individual practitioners to work together and with patients as a multiprofessional team. No one group, single practice or characteristic can make a major difference on its own. A holistic approach including attention to supporting patients, staff working climate, inter-professional respect and integrated practices are required to provide kidney care in the Brave New World.

Slides BRS/RA 07-06011

Monday, 6 June 2011

Will care for kidney patients survive the age of austerity and the Health Bill?

Yes, but what we mean by care and how we deliver that care is set to change. We, the kidney community have the knowledge and ability to ensure those changes will improve the experience and outcomes for people with kidney disease. But we also have the responsibility to use that knowledge, evidence and know how to drive quality improvement across the whole pathway of care, across our training, accreditation and appraisal programmes and to strengthen our evidence base, refine our research strategies and add to our understanding. The questions we must always ask about our own work every day are, does this add value? How can we do this better? How do we contribute to learning?

The focus should be on value for patients, not just lowering costs. Value is the quality of patient outcomes relative to the resources expended. Minimising costs is simply the wrong goal and leads to counter-productive results. Eliminating waste and unnecessary services, care that isn’t adding value, is beneficial but cost savings must arise from true efficiencies not from cost shifting, restricting or rationing of care, or reducing quality. Everything we do – every policy, every practice, every patient contact must be tested against the objective of patient value. Measuring value is however far more complex than costing discreet interventions or procedures. Patient outcomes are multi-dimensional. Value must be measured from the patient’s perspective, it is much less revealing to attempt to measure the country’s or even an individual hospital’s results overall. Both outcomes and costs must be measured over the full cycle of care, the whole pathway, for particular conditions, such as chronic kidney disease, diabetes or acute kidney injury. This encompasses assessment of risk and steps to prevent its occurrence or progression as well as long term management and rehabilitation. A focus on value at the level of medical conditions over the care cycle should provide high quality care and cost less. Planned multiprofessional care delivered by a team is better care and more productive care than chaotic or fragmented care however good the individual isolated components.

The Health and Social Care Bill poses a range of challenges but does focus on quality and outcomes and long term conditions, such as kidney disease, figure prominently in the thinking and wording of the Bill. International, and national experience demonstrates that integrated healthcare services can deliver more efficient, patient focussed care. Removing the policy barriers to integrated care requires the explicit recognition that although competition has a contribution to make to improve performance, this needs to be used alongside collaboration. Patients with kidney disease require access to care from different providers at different times and need these providers, GPs, hospitals and social care, to work together to provide value by offering effective co-ordination across the care pathway. This will require reform of the payment and incentive system. We need to move beyond the tariff to enable capitated budgets and other means to be tested to support development of integrated care. This requires commissioners of specialised services such as dialysis and kidney transplantation to work together with GP commissioners, to be encourage to integration of resources where appropriate and to use flexibilities to work in a more integrated way to avoid fragmentation, erosion of value by inefficiencies and confusion for patients and professionals. Smarter regulation must be across the whole health economy with organisations seen as part of local systems of care and experience of patients evaluated across the care cycle, including at key points of transition.

The kidney community are the stewards of kidney care. To use the financial crisis and the challenges of the Health and Social Care Bill to create the opportunity for innovation and improvement requires leadership and information. If we look only to the past or the present we will miss our chance. High quality kidney care has grown out of multiprofessional working. Kidney care will remain a team activity. Understanding success, learning from failure and having the resilience to provide continuity are some of the key qualities of a winning team. We need to do more to promote a culture of quality improvement to understand the importance of behaviour and values as well as skills and competencies. We need to inform and activate our patients, to value their attitudes and experience and make shared decision making the rule rather than the exception. This requires us to identify the gaps as well as to understand the information about quality, value and outcomes; judgement and common sense should not be replaced by blind reliance on numbers but where reliability can be achieved we should not tolerate unacceptable variation. This new approach will almost certainly lead us to question how we train colleagues of the future, to do more research on how care organisations interact and teams work and to keep quality, with all its dimensions and current uncertainties about what we should measure, in our sights.

Slides BRS/RA 06-06-11