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.