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

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