Friday, 18 May 2012

Think about rationing

 Resources for health care be they people, knowledge, time or money are and always have been limited. Rationing seems to be a word not terribly much used in polite company. For the kidney community it has uncomfortable connotations harking back to our history of slow uptake of dialysis and hospital committees to decide who will be the lucky few.

I remember as a house officer presenting the clinical details of individual patients with end stage renal failure in the seminar cum coffee room. Followed by the nursing assessment of suitability and ability to cope, social work comments on employment and family circumstances and then a discussion about who would benefit most, what the implications for the dependents might be and how to allocate resource. Said another way, who should be started on dialysis, it was not really an offer, and who did not make the cut because of the limited dialysis space that we had available. Back then the acceptance rate was about 32 per million of the population per year compared to 110 PMP now. Peritoneal dialysis was just about to start. Occasionally, a space did become available when sadly; a dialysis patient died or someone was transplanted. It was a time, when uraemic frost and pericarditis were frequent clinical signs and the management of the intractable hiccups of renal failure were second nature to our ward sister who taught us  the ropes and kept us in line.

While those days are long gone, concerns about resources, choice for patients and the prospect of a return to rationing are again rising. The Nicholson challenge, to save £20 billion pounds over the next 4 years, has bought health care costs centre stage in England. Other western economies face similar financial challenges. In the USA for instance, the spending on health care is predicted to rise to 19% of gross domestic product by 2019. That is only 7 years off and it would be nearly double the UK cost. Our populations are also aging and the number of adults of working age  in the UK  to the elderly will  halve in my lifetime. The pattern of disease is changing from acute to long-term conditions; from single conditions to multi-morbidity and from health care managed to self-care.

So, “can you cut health care spending without undermining the quality of care?” yes, there are significant inefficiencies, yes, we can do things differently and yes, the “new technology” can help, but it is still the £100+ billion pound question. I am a believer that we can have a healthy population, deliver efficient and effective health care and support self-care with the resources we have as a nation. We need to tackle some of the wider determinants of poor health and outcomes- poverty, education, joblessness; be good stewards of the NHS and promote greater health literacy and self-management. There are many individual examples of high quality and high value care that costs less than traditional models of care in the kidney world and wider health economy. I do not know if we could deliver the Nicholson challenge by adopting all these practices more widely but I do know that the more people who do adopt them, the more likely we are to achieve our quality and financial goals.

To invest in higher value activity, we will need to disinvest in lower and no value activity. Therein lies the problem and perhaps lurks rationing. There are few things we do on purpose in health care that add no value to anyone.  Unsafe practice that causes harm is perhaps the exception- of course that is not done on purpose. Certainly unnecessary falls resulting in fractures, health care associated infection and drug errors are still common, and do cost an awful lot of money. I doubt we can save £20 billion pounds from better safety alone. 

So the publication Thinking about rationing by Rudolf Klein and Jo Maybin from the King’s Fund is certainly timely. The authors argue that rationing has been a fact of life for the NHS since its launch and that it is going to be a dominant issue in the hard times ahead. They carefully identify the different types of rationing- by denial, selection, deterrence deflection and perhaps most insidiously of all by dilution. Rationing by dilution refers to a situation where a service may continue to be offered, but its quality declines as cuts are made to staff numbers, equipment and so on. This form of rationing may be the least visible, but it may also be the most pervasive.

How should priorities be set? Who should be making the decisions about which patients should be treated and how? Can we reconcile a utilitarian approach to maximise the benefit for the whole population with the needs of the individual? Will the rights of the individual as laid out in the NHS Constitution provides sufficient safe guards? How much do we know about “bed side rationing”- the effects of decisions by clinicians determining who gets what? This well-written and thoughtful paper argues that geography should not determine the care people get as it currently does.

Debates about priorities and rationing place great emphasis on accountability, but exactly who should call commissioners and providers to account is less clear. The courts, clearly have a role. However, they cannot routinely scrutinize decisions, far less outcomes. In the future system there could be an important role for Health Watch, especially if it is linked to the Care Quality Commission and the analytical ability of local agencies is strengthen. The challenge, for both health watch and local authority scrutiny committees, will be to sound the alarm when efficiency saving become a euphemism for rationing by dilution. I would recommend reading Thinking about Rationing – it provides insights and a vocabulary that will be of use in the months ahead.

Wednesday, 16 May 2012

Official Opening of the Edgware Renal Centre

Patients with kidney conditions in north London are benefiting from a new facility which has brought treatment closer to their homes.Royal Free chairman Dominic Dodd, the mayor of Barnet, councillor Lisa Rutter, chief executive David Sloman, Dr John Connolly,  clinical director for renal services, Matthew Offord MP and Dr Donal O’Donoghue unveil a plaque at the official opening of the kidney care centre at Edgware Community Hospital.
The Royal Free has invested £3million in a brand new kidney care centre at Edgware Community Hospital which opened at the end of last year. The centre was officially opened on Monday, 26 March, by the mayor of Barnet, Councillor Lisa Rutter. Guests at the event included Matthew Offord, MP for Hendon, and Dr Donal O’Donoghue, the national clinical director for kidney care.
The centre has 29 dialysis stations and five clinic rooms offering a full range of renal services. This includes haemodialysis and peritoneal dialysis, preparing patients for dialysis and the treatment of chronic kidney disease. The Edgware centre has a self care area, which allows patients to dialyse themselves with minimal staff supervision or prepare for dialysis in their own homes.
The new centre is more convenient for many patients, who previously had to travel from the Edgware area to other dialysis centres across north central London. Care is delivered by the same high quality team of Royal Free staff, saving patients time and making treatment more convenient.
The mayor of Barnet, councillor Lisa Rutter, and Dr Donal O’Donoghue, the national clinical director for kidney care, speak to patient Lynda Mizon at the official opening of the kidney care centre at Edgware Community Hospital.Dr Jenny Cross, dialysis lead clinician at the kidney care centre, said: “We know that if you are travelling several times a week for dialysis, having a shorter journey time is really important. We have listened to the needs of our patients, and we wanted to provide them with a modern, purpose-built facility closer to their homes.
“The opening of Edgware is part of a wider strategy transforming the way we deliver renal services. We want to give our patients more choice about where they have treatment, to offer a range of treatment options in comfortable surroundings and to be able to treat patients in one place without them having to travel to different locations.
“We have begun to offer a more integrated pathway of care for patients with chronic kidney disease in the area, which will deliver diagnostic clinics with a detailed care plan provided for GPs at the new centre.”Dr Donal O’Donoghue, senior nurse Nasser Juhoor, Matthew Offord MP, mayor of Barnet councillor Lisa Rutter and Royal Free chief executive David Sloman at the official opening of the kidney care centre at Edgware Community Hospital.
Karen Nathan from Bushey has dialysis for three and a half hours, three times a week, at the new Edgware centre. She said: “I used to have to travel to Camden for dialysis but this new centre means I can receive treatment just 10 minutes away from my house. I have to come here three times a week so it’s important to be able to come to facilities that are closer to my house.
“All the staff, including doctors, nurses, healthcare assistants and domestic staff, are helpful and provide an excellent standard of care. We are very fortunate to have this excellent facility.”
Adrian Levy, from Woodside Park, comes to the new centre for regular tests to check on his kidney function. He said: “The facilities at the new centre are like a five-star hotel. All of the staff, from the nurses to the cleaners, are very polite and helpful.
”When you have caring staff around you, it makes you feel so much better as a patient. The new centre is much closer to where I live and it is easier to park here. I feel completely relaxed and special whenever I come here.”
Following the opening of the new centre, the Royal Free will offer a full range of kidney services on one site. By working more closely with local GPs, the aim is to provide a seamless service between GP practices and hospital specialists.
The Edgware centre is the first of three new kidney centres planned over the next 18 months. The Royal Free is preparing to expand the existing Mary Rankin unit at St Pancras and there is also a brand new kidney centre in Tottenham planned.

Tuesday, 1 May 2012

Balancing Quality, Safety and Value- an Olympic challenge

Kidney care teams up and down the country are facing an Olympic challenge to deliver the best possible healthcare for people with kidney disease in a timely, efficient and effective way. Our kidney care challenge is part of the broader health, healthcare and self-care challenge facing the health system globally, as we shift from a 20th century cure focused system to a 21st century long-term conditions chronic disease management paradigm.

To take the Olympic analogy further, our job is not to be the best individual kidney care professionals in the country. We are the support teams for patients and carers; our job is to help each and every one of our patients to achieve their aims and gold medals in life. We are the construction teams, the coaches and trainers, the safety, communications and measurement experts. The stars are the patients and populations we serve. We need to motivate and enable. We should not be good losers- when our patients do badly we should consider why, and learn from that so that month-by-month outcomes improve. We need to measure what is important to patients and judge success by those standards.

I am confident we can compete at Olympic level. The work individuals and kidney care teams with patients have been doing over the last view years has earned us that place.