Monday, 28 January 2013

Developing a currency for Transplantation

A new landscape for commissioning comes into place from April 2013, where all parts of the kidney transplant pathway will be commissioned directly by the NHS Commissioning Board. This will include transplant work-up, maintenance on the list, live donor work-up, the transplant operation and life long follow-up. This is a change from the current arrangements, where transplant surgery is commissioned at a regional level but clarity about assessment, arrangements for maintenance on the transplant list and long-term surveillance is often lacking, leading to unwarranted variation in practice and sometimes delays or worse for patients.

The NHS Atlas of Variation inhealth care for people with kidney disease shows some of these variations. There is nearly a two-fold variation in the rate of kidney transplantation from live-in donors between regions and a staggering thirty-fold variation in pre-emptive transplantation depending on where you live! NHS data is normally based on the financial year, but units do not have to wait until April to look at their 2012 performance. Some people are a bit apprehensive about the word performance but we should not be- it describes quality of care provided. Locally, for instance, our specialist transplant nursing colleagues Angela Bailey, Helen Flood and Jane Redshaw set themselves the task of improving on the very good figures in 2011/12, when 30 live donor transplants were performed and have increased that to 34 this last year, nearly half of which were pre-emptive transplants. If that were scaled to the country, it would result in 1,360 live donor kidney transplants being performed. That would be over 350 more live donor kidney transplants in the UK than in 2011/12.

To provide a more coordinated and holistic approach to kidney transplantation, our Clinical Reference Group under the masterful stewardship of Mr Keith Rigg – Consultant transplant surgeon in Nottingham, has developed a pathway approach for adult kidney transplantation with the aim of providing the best possible experience, quality outcomes for those who might be suitable for kidney transplantation.

The pathway has been designed from a clinical perspective, has widespread support and makes sense from whatever angle you view transplantation. The next step on the pathway, if I am permitted that play on words, is to record practice and activity in a consistent way – so we can measure quality and provide the service in an efficient manner, in terms of timeliness and costs. This builds on the NHSKidney Care Developing Robust Reference Costs for Kidney Transplantationreports in 2010 and 2011 and moves us onto a national currency to deliver a complete pathway of care for adult transplant patients.

The technical building blocks of a commissioning currency are the Health care resource groups (HRGs) or outpatient attendance and treatments (treatment function codes (TFCs) that group clinical activity requiring similar resources together and they in turn, are based on clinical coding to clearly identify the conditions patients have and what procedures they have undergone. That means the coding is based on the individual patients clinical record. Good record keeping is therefore the key, not only to good personalised patient care, but also, for clinical audit and improvement for the whole of the transplant population.

Introducing a national currency for the pathway of transplantation will not change this fundamental need for good quality record keeping. Some of the codes, particularly procedures and the parts of the pathway they mapped to will require a more precise definition and accuracy of coding will need to be quality controlled. This consistency will enable a clearer understanding of quality across the whole pathway; it should not interfere with practice but will allow benchmarking between teams and will help secure improvements in outcomes.

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