Friday, 28 October 2011

Funding for retro-fitting heat exchanges

Congratulations to the Centre for Sustainable Healthcare (CHS) who secured funding at the recent Pitch Pledge Party Event for the promotion of retrofitting heat exchangers to kidney dialysis machines throughout the UK.

Pitch Pledge Party is a new initiative by 10:10, The Funding Network and The Guardian to match carbon cutting projects with funders. CSH's project was one of three to secure donations via this new initiative. Thanks to the support of the Green Nephrology initiative.

The funding will support a project coordinator to promote the retrofitting of heat exchangers to kidney dialysis machines throughout the UK. The device has been tried-and-tested by Fraser Campbell and Steve Milne at the Kent Kidney Care Centre at East Kent Hospitals University NHS Foundation Trust achieving a 20% cut in the machine's carbon emissions.

To learn more about the CSH go to:

Or green nephrology:

Monday, 24 October 2011

Dialysis Capacity - What's needed in your patch in the next 3 years?

The census date for the Dialysis Capacity Survey is fast approaching. The survey now, in it's 3rd year, will be conducted on the 31st of October 2011.

Nationally we seem to be moving from the inexorable year on year l growth phase towards steady state. For the past 4 years, the acceptance rate onto our renal replacement therapy programmes has been stable at 109 per million of the population. No doubt that is due to a range of factors including better detection and early management of CKD, and a recognition that the 'no dialysis choice' isn't a no treatment choice. Although we don't yet have national data on conservative kidney care, I am encouraged by the high profile choice has in advance kidney care and the passion of the conservative kidney care teams up and down the country to provide high quality care and when the time comes a dignified death .

The sustained increase in live donor transplants also offers the prospect of moving from a dialysis and transplant paradigm to a transplant first model for many people with end stage renal failure. There are still a lot of variability in live donor rates and even more in pre-emptive transplant rates which suggests that our focus on timely transplant listing will deliver further quality improvements.

Mark Brady, formerly clinical advisor to Kidney Care, and now specialist registrar in renal medicine in the northern region presented MORRIS, the model for optimising renal replacement investment and services at the joint Renal Association and British Renal Society meeting in June. The model is freely available at NHS Kidney Care, so you can put your own network figures in and play with the assumptions to see the impact. MORRIS suggests that if the acceptance rate stays flat, as it has done for the last 4 years, and if transplantation continues along the same trajectory, then with the next 3-5 years the total number of people needing dialysis may fall.

There are a lot of ifs and buts and assumptions in that the total number of people needing dialysis may fall statement, but when considered alongside the reemergence of home haemodialysis, the variation in Peritoneal dialysis and the anecdotal stories of capacity led demand, the importance of good data to ensure adequate future planning is clear.

The national picture based on the 50 million population off England tells a aggregated story built from the national demographics, Renal Registry returns and UK Blood and Transplant data. It's very helpful for macro level planning but doesn’t tell the local story where individual populations may have very different needs, different capabilities maybe in place for historic reasons
and there maybe unique factors that must be borne in mind in developing local services at the unit and network level. That's why the dialysis capacity survey, which this year also begins to capture aspects of nursing capacity is so important. During the transition period as specialist commissioning of dialysis migrates to the National Commissioning Board I would say that this survey is vital.

I am pleased that we have always had a very comprehensive return and look forward to a similar response this year.

The previous surveys have been very useful in a range of areas including;

• Identifying current pressures on capacity and the varied potential growth in dialysis numbers within existing capacity across the country,
• understanding the balance of centre, satellite and home dialysis nationally and regionally,
• quantifying the plans to increase home dialysis in the future.

The survey aims to capture the national profile of dialysis service across England to help ensure kidney services can be prioritised at a national level. But using the maxim 'collect data once, use it many times' I do hope that the national collection will feed into local planning at network level. To see the details of last years survey and check out your capacity and plans compared to other networks go to:

Thursday, 20 October 2011

Give me more...

The autumn issue of the PKD Newsletter leads with results of a survey asking people specifically about the information they are given when they are diagnosed with PKD and what information they would have liked to receive.

Below is a summary of the key findings:

  • 366 surveys were completed
  • 315 by people with PKD
  • 51 by carers / relatives

  • 66% of respondents were female
  • nearly 70% were either given ‘no information’ or ‘not enough’ on diagnosis
  • minimal social, emotional and psychological information (including genetic counselling) was given
  • very few respondents were told about charity or support groups by their doctor
  • most had never been offered a Kidney Care Plan or other personalised healthcare plan
  • there were many requests for local support groups
  • more psychological help was felt to be needed

Sadly, many individuals reported, ‘I was just told I had PKD and that was all’. However, not all the responses were negative, and many positive points were made both about good doctors and the information the PKD charity provide.

Tuesday, 18 October 2011

Clinical Networks and Senates

Kidney care clinical networks emerged around the turn of the century to facilitate integrated care across the kidney patient pathway, spanning the range of different healthcare sectors. The presence of networks in the NHS, indeed in renal medicine and in particular transplantation, was not new as healthcare professionals have always worked together; but in the managed clinical networks that emerged after Sir David Carter's review of acute services in Scotland in 1999 patients, carers, management and commissioners were brought into the professional gatherings. The managed aspect of the role of networks became more prominent and with that the requirement for greater accountability.

Kidney care networks have been described as 'linked groups of healthcare professionals and organisations, from primary, secondary and tertiary care working in a coordinated manner, unconstrained by existing professional and organisational boundaries to ensure equitable provision of high quality effective services'. There has been no single model or master blueprint, each network developed according requirements and challenges, but all are virtual rather than statutory and the best have arisen out of an identified need for service change rather than being imposed for organisational reasons.

In early years of the kidney care networks, the 12 core principles advocated by NHS Scotland formed the basis of the governance and agility to balance clarity of purpose with flexibility of response.

The NHS Futures forum recognised the role of networks and recommended that clinical networks should be strengthened and embedded in the new system. This was accepted by the government and Kathy Mclean, until recently the Medical Director of NHS East Midlands and now Clinical Transitions Director at the Department of Health is leading the work on clinical senates and networks. Commenting on a recent workshop Kathy said, 'I was very pleased with the energy in the room, the support for the role of networks and the desire to make improvements. There were clearly some key themes coming out from the session, including the potential role of networks leading large scale change processes across pathways of care and coordinating complex pathways of care where a lack of a network could lead to harm'. Read the Kings Fund Workshop Report here.

The review will define the role of clinical networks and review their range, function and effectiveness. It will:

• Map the current patterns of networks and assess the current level of resources associated with them;
• Define what is meant by 'network' and the role of potential models in the new system;
• Propose which clinical and professional areas require formal network.

Kidney care networks place an emphasis on partnerships, information and relationships to achieve higher quality care and better outcomes often through more integrated care being delivered by the multi-professional, multi-sector team. This is in contrast to the older 'hub and spokes' model where it was often perceived that the 'hub' (as the title suggests) was where all the action took place, and the 'spokes' were considered relatively minor service providers in support of them.

The lessons from the last decade and the listening exercise have made clear how important clinical advice and leadership are in delivering improvements in health care outcomes. See the letter from Kathy Mclean and the details of how to get involved.

Thursday, 13 October 2011

Intergrating Care - Working smarter not harder

How do we integrate care between the... ologies, between primary and secondary care, between expert patients and healthcare practitioners and between health and social care is the big question of our times. Lots of big brains are working on it and not a week passes without a report or commission providing principles and recommendations. Examples directly relevant to UK practice have been thinner on the ground.

So I was delighted to see that Hugh Rayner and colleagues have published their renal diabetes system from Birmingham that we have heard so much about at meetings in the past 4 or 5 years.

Diabetic nephropathy is the most frequent primary renal diagnosis for patients starting renal replacement therapy. For many patients, loss in kidney function could be avoided by earlier treatment.Heart of England NHS Foundation Trust improved this situation by redesigning the traditional system of primary and secondary care. The Trust introduced a disease management system that linked a diabetes population database to the laboratory database. A nephrologist identified patients with low or deteriorating estimated glomerular filtration rate (eGFR) on a weekly basis. The nephrologist then shared management advice with the patient's diabetologists and primary care physicians. Savings of £48,000 per 100,000 population were achieved because the number of patients requiring dialysis was reduced.

Dr Hugh Rayner, renal consultant, explains in Eyes on Evidence: "The redesigned service reduced the rate of loss of kidney function in people with diabetes mellitus so that fewer people developed kidney failure and needed dialysis treatment. Our model of care includes a specialist diabetes kidney clinic and patient education to support self-management including home blood pressure monitoring.

"Patients are written to personally after every consultation and this is copied to the patient's GP. Implementing this system has reduced the number of patients attending clinic in person because many can be followed remotely from their eGFR results. There is now no waiting list for diabetes renal consultations. By making better use of the information in every pathology laboratory database, this model could be implemented across the UK.

"Visit NHS Evidence for more details of this and other QIPP examples.

Tuesday, 11 October 2011

Exercise as part of kidney care

The important role of exercise in the health and wellbeing of people with long-term conditions is often overlooked or relegated to a few encouraging nonspecific remarks at the end of a consultation. The publication of two systematic reviews and meta analyses of exercise training provides a useful prompt and reminder to both clinicians and patients about the value of exercise as part of patient care.

Coincidentally the need to take a proactive whole system approach was brought home to me last week when I visited the York kidney service where there are plenty of exercise machines available and the philosophy to encourage all to participate as much, or as little, as they wish. The dialysis unit is strategically placed just down the corridor from the physiotherapy gym. Staff encouragement, easy availability of exercise “bikes”, positive comments from other patients and closeness of the physio gym has resulted in most who are able responding to the exercise challenge … and feeling better! In York I was also struck by how few dialysis patients needed antihypertensive medicines. That might be partly due to the high rates of exercise but also by using bio impedance to measure fluid overload and giving authority to dialysis nursing staff to reduce dry weight targets, the team have developed a system that seems to work better than most at getting and keeping patients on haemodialysis at their ideal dry weight By contrast, any increase in dry weight needs a doctor’s review and sign-off. Remarkable figures – well done the York unit.

A Cochrane review, Exercise training for adults with chronic kidney disease
by the Karolinska Institute concluded that there is a good evidence base showing benefit from exercise for all patients with Chronic Kidney disease (CKD) (whatever their stage).

Forty-five studies, randomising 1863 participants were included in the review. Thirty two studies presented data that could be included in the meta-analyses. The review showed that regular exercise training significantly improved physical fitness, physical functioning (eg walking capacity), and health-related quality of life in adults at all stages of CKD including those who were a receiving dialysis or had a kidney transplant. Beneficial effects were also seen on other outcome measures, such as blood pressure control.

This systematic review and meta-analysis presents evidence-based data for clinicians and patients on which type of exercise regimen (type of exercises, intensity, frequency and duration of exercise) should be used, in which settings and patient groups to optimise the training regime and improve outcomes. The results should be reviewed and used by individual clinical teams working with patients to consider how to implement exercise as part of the care plan for people with kidney disease . This information should encourage patients with CKD that there is scientific evidence for the beneficial effects of regular exercise training. It should identify who will benefit from which exercise intervention and allow patients to tailor their exercise regime to their needs and goals.

Exercise training specifically in haemodialysis patients was also the subject of a systematic review and meta-analysis from Australia; Exercise training in haemodialysis patients: A systematic review and meta-analysis. These authors reached the same conclusions as the Cochrane Group. Exercise training is safe and imparts large improvements for patients on dialysis.

Thursday, 6 October 2011

Patient experience: how to measure it?

No decision about me without me” has put the patient firmly the centre of the many hundreds of millions of individual clinical encounters in the NHS each year and patient experience is now one of the 5 domains of the Outcomes Framework. Up there with amenable mortality, long-term conditions, rehabilitation/recovery and safety; patient experience is set to become a cornerstone of quality of care. So how do we measure it? What counts, what’s important to the patient?

Already, patient feedback tools and services to rate GPs are increasingly available, not least on NHS Choices which attracts 5.7 million users per month - showing how channels for knowledge and comment are fast becoming central to how service users appraise their care choices.

Organisations such as NHS Direct have adopted the Net Promoter Score (NPS) which is widely used across many industry sectors. It focuses on understanding whether a patient would or would not promote the service they receive. NHS Direct found the system simple to deploy, simple to understand and simple to respond to.

At first glance, it may seem more appropriate to customer care rather than clinical encounters but there are many ways in which it’s relevant to healthcare providers. A clear understanding of whether a patient would or would not promote a provider based on a service they received should enable provider organisations and clinical teams within those organisations to identify where key service provision is lacking and to implement steps to address these issues.

For example, a detractor score could be the result of a patient returning to clinic to review various results and investigations that then turn out not to be available. There could be a failure to communicate. They may have to travel a long distance to have intravenous iron that could quite easily have been given in their local community. The specific response allows the provider team to then look into the issues and address them to avoid the same situation arising again.

In summary, net promoter scores is based on the principle that every service’s users can be divided into 3 categories: promoters, passives and detractors. By asking one simple question “how likely is it that you would recommend the service to a friend or colleague?” you can track these groups and get a clear measure of a service’s performance through its users’ eyes. Results can be used for the purpose of tracking performance in individual services over time or for comparison across similar services. The NPS questions can be used in a face to face, remote access such as telephone or self service such as web environment. Users respond on a 0-10 point rating scale and the categories are as follows:

• Promoters (score 9-10) are loyal enthusiasts who will advocate on behalf of the service.
• Passives (score 7-8) are satisfied but unenthusiastic customers who are vulnerable to competitive offerings.
• Detractors (score 0-6) are unhappy customers who can damage your brand and impede growth through negative word-of-mouth.

To calculate NPS take the percentage of customers who are promoters and subtract the percentage who are detractors (the calculation ignores passives).

If you choose to use this in your kidney service or are using something similar, do let me know.

Green Nephrology needs your vote!

The Green Nephrology project to retro-fit heat exchanges to kidney dialysis machines is one of 3 projects shortlisted for the final of the Pitch Pledge Party. The Centre for Sustainable Healthcare will be presenting the project at the event taking place at The Guardian Newspaper offices in London next Monday (10 October) and needs your support – go to the website to check out the three finalists and cast your vote.

This is a new 10:10 initiative designed to bring practical carbon-cutting projects together with donors looking to support the fight against climate change at ground level. The work is based on the excellent case study carried out by Fraser Campbell and Steve Milne at Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, together with Paul Stevens and Andrew Connor, the NHS Kidney Care Green Fellow at the time.

Find out more about green nephrology, this project and the dragons den pitch Rachel Stancliffe will be making at the Green Nephrology website.