Q & A: Paying for value not volume

Q: Dear Donal, I thoroughly enjoyed reading your article "Paying for value, not volume" in the recent BJRM but I'd be grateful for clarification on what constitutes a multi-professional clinic. I suspect after reading your article that we have similar views on what a multi-professional clinic should be: it would included seeing the renal physician, dietician, access nurse, transplant coordinator, education nurse, pharmacist for medicine reconciliation, vascular access technician etc all at the same visit. However, the DoH definitions seem to be quite different and I've included the relevant parts below:

139. Multi-professional attendances are defined as multiple care professionals (including consultants) seeing a patient together, in the same attendance, at the same time. The TFC of the consultant clinically responsible for the patient should be applied to a multi professional clinic where two consultants are present. Where there is joint responsibility then this should be discussed and agreed between commissioner and provider.

140. Multi-disciplinary attendances are defined as multiple care professionals (including consultants) seeing a patient together, in the same attendance, at the same time when two or more of the care professionals are consultants from different national main specialties.

142. They do not apply if one professional is supporting another, clinically or otherwise, e.g. in the taking of notes, acting as a chaperone, training, professional update purposes, operating equipment and passing instruments. They also do not apply where a patient sees single professionals sequentially as part of the same clinic. Such sequential appointments count as two separate attendances, should be recorded as such in line with existing NHS Data Model and Dictionary guidance on joint consultant clinics

It seems that instead of charging for a multi-professional clinic we should code the attendance with all the other professionals supporting the renal team in outpatients as separate attendances and charge separately.

The problem is the commissioners say that this is new clinical activity and has not been agreed which puts us in a no win position. What would you advise? The other option is to see them in the same room which seems a nonsense. Kind regards, Dr Chris Dudley, Renal Unit, North Bristol NHS Trust

A: Dear Chris, thank you for your comments and for the question regarding the definition of multi-professional attendance. I am sorry for the long delay in replying. The guidance for Payment by Results is long and complex, running to 136 pages.

You have quoted the relevant paragraphs and I think the 'sticking point' is section 139 where there is reference to seeing a patient together in the same attendance at the same time. Strictly speaking multi-professional out patient tariffs only relate to situations where the care professionals are in the same room at the same time, rather than the patient going into multiple rooms to see different care professionals individually, as outlined in paragraph 142.

In many instances of multi-professional kidney care out-patients attendances, individual patients see practitioners sequentially. When that is the case however, there is more often than not a multi-professional team meeting to agree and coordinate management. As mentioned in paragraph 142 of the guidance such meetings in the absence of the patient do not count as multiprofessional or multi-disciplinary clinics either.

However, there is some scope for local flexibilities and details of what is permitted is set out in section 11 of the PbR guidance and in particular paragraphs 428 and 444 et seq. It may be worth noting that the main flexibility is, in defined circumstances, for commissioners and providers to agree to use the national multi professional tariff where this is better for the patient and the NHS.

Strictly speaking the agreed tariff should be less than the national tariff but if mutually agreed this can be by a nominal amount. I would favour such an approach rather than rearranging your clinics to meet the tariff definition at the expense of a clinically determined, and more efficient model of care. I would be guided by the recent comments by Sir David Nicholson in his transition letter of 13 April 2011.

Here he states, “in taking forward decision this year you need to ask yourself two questions:

Will it improve care for my patients?
Will it improve value for tax payers?

If the answer to both is ‘yes’, then it’s the right thing to do.” In the fullness of time I would like to see clearer specification of the services to be provided in multi-professional kidney care clinics, ongoing national clinical audit of outcomes, patient experience and processes within those clinics, and a stronger evidence base for what works to improve quality of care with people kidney disease - my hunch would be that the attitude and behaviours of the team members are likely to be as important as the skills and competencies that are brought together within the multi-professional team.

In the meantime I would advise that the entry and exit criteria for the multiprofessional kidney care clinics are discussed and agreed with commissioners so that where necessary the flexibilities within the system are used to improve the quality of care for patients and value for tax payers. Kind regards, Donal

2 August 2011, 0900am: NHS Kidney Care e-seminar presented by Dr O'Donoghue "Introducing the multi-disciplinary tariff". Register here

428. The following principles for the application of local flexibilities will ensure that we continue to protect the benefit of national tariffs and currencies, whilst allowing for local innovation and material redesign of services:
(a) the flexibility supports the provision of care that is better for the patient and the NHS – obviously, any local flexibility should be supporting better care for patients, whether it is closer to home, more convenient or of higher quality: examples include one-stop shops or see and treat services. A flexibility may also benefit the NHS as a whole, by reducing the costs to the whole health system
(b) the flexibility supports material service redesign or mutually desired outcomes – local flexibilities are not a means of simply reducing or increasing national prices without any change to how services are provided. This would negate the benefits of national pricing. They may, in exceptional circumstances, be a means of enabling the provision of services to patients which would not otherwise be provided
(c) the flexibility is the product of local agreement – with due regard to the PbR Code of Conduct, flexibilities should be agreed in advance by commissioners and providers and, where appropriate local discussions can be supported by SHAs

(d) the flexibility is clearly established and documented – an audit trail for the agreed flexibility is necessary and it should be documented as part of contract negotiations
(e) the flexibility should be time limited and reviewed as appropriate – flexibilities are not set indefinitely. For instance, innovation payments apply for three years. It may be that a local innovation becomes the national norm and the tariff changes to recognise this.

444. Tariff is a fixed price, however in exceptional circumstances, where providers and commissioners agree, they can seek approval to operate a variation to price which is lower, but not higher, than the published tariff, provided that there is no adverse impact on quality, patient choice or competition.

Attitudes to mental illness: in numbers

Annual surveys of the public’s attitudes to mental illness in England have been running for nearly 20 years and the most recent report makes interesting reading.

Compared to 1994 the number of people agreeing that “mental illness is an illness like any other” has increased from 71% to 77%. The percentage saying they would be comfortable talking to a friend or family member about their mental health has also increased and now stands at 70%.

Mild mental illness, anxiety and depression are common in all long term conditions and chronic kidney disease is no different. Mental illness significantly affects the quality of life of people with kidney disease but this is not yet well recognised. About a half of dialysis patients who are breathless on exertion or nauseated are correct identified by their doctors and nurses – that doesn’t sound great does it? But only a meagre 17% of those that are feeling sad and just 6% of those who are anxious or who have a reduced interest in sex are picked up in routine care, despite the fact that 40-50% of patients who are on dialysis or who have been transplanted experience anxiety or depression. What’s more, depression is associated with more hospitalisation, greater physical symptom burden and worse outcomes. This is really sad as there are very effective treatments for depression ranging from exercise, change in dialysis regime, talking therapies and medication. We should be talking, researching and doing more about it in the kidney world.

Of course mental illness is common in the general population as well. In the survey the majority of respondents (57%) reported that someone close to them had some kind of mental illness. Stigma and discrimination still remain a major issue. Half said they experienced a lot of discrimination and this hasn’t changed much in the last couple of years. That’s a pretty disappointing statistic and while a natural reaction to the fact that 21% of people feel anyone with a history of mental illness should be excluded from taking public office might be to smile or joke, it shouldn’t be because there’s a darker side. One in 8 feel that those with mental illness should not be given any responsibility and the same proportion that it would be foolish to marry someone who has had any mental illness in the past, even if they have made a full recovery.

Now that there is a definititive focus on patient experience in health and healthcare, how people with kidney disease or other chronic illnesses feel should be studied, recorded and firmly on the agenda.

Patient transport survey 2010

Travel - with its inherent uncertainties and seemingly inevitable delays – can be frustrating, tiring and unsettling for anyone, however healthy they may be. One need only look at the expressions and body language in a queue for a bus, train or plane to know that. A bad journey can have a big impact on the experience of the event for which the transport was needed. In contrast, when travel is comfortable, timely and efficient, it is a pleasurable experience that can leave us feeling relaxed and positive. That idea should be food for thought for anyone commissioning haemodialysis services.

Patient transport for hospital or satellite haemodialysis is different from all other transport to and from hospitals. No other medical condition requires such frequent travel back and forth for treatment for months and years on end. Six journeys a week, three to the haemodialysis unit and three back home – Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. Every week - Christmas and holidays included. Transport is therefore a significant component of the patient’s experience of haemodialysis, and it is no wonder that it is frequently cited as the part that most needs improving. As this patient survey shows, complaints are common. Difficulties in identifying who is responsible and
who can improve the service are almost universal.

This report shows that 95 per cent of eligible units participated in the survey, and I would like to thank the thousands of patients and the staff who took part.

By providing details of their experience of this aspect of care, they have highlighted an important issue for the kidney community in improving patient experience. I look forward to seeing this on the agenda of every kidney care network, on seeing ownership of the issue and working together to see what improvements we can make for patients.

NHS Kidney Care e-seminar Patient Transport, 16 June 2011
Transcript
Presentation
Recording of the e-seminar

Manchester demonstrates more for less - Innovation Challenge Prize Awards

The Department of Health has announced the first 3 recipients of its Innovation Challenge Prize which recognises ideas developed by frontline staff to deliver solutions to the problems facing their patients. Among the 3 is Manchester Royal Infirmary, awarded the maximum prize of £100,000 after developing an innovative approach to redesigning existing dialysis provisions in hospital. The money will be used to improve the service further and they hope to roll out the system across the NHS. Their innovation means that patients are able to choose home instead of hospital haemodialysis and has had substantial effects on service costs for the hospital. By continuing to use hospital dialysis costs would have been expected to be £45,628 per patient, per annum to NHS Manchester. The average home dialysis cost of £26,289 compares favourably with the annual average per patient cost of £40,145 for attendance at Manchester Royal Infirmary, and £45,628 for attendance at a satellite clinic. These figures include secondary costs such as patient and carer time costs in addition to the NHS costs.

This innovative approach to dialysis provision in Manchester allows the choice of home haemodialysis to all those who might benefit, and has transformed patient lives with improved outcomes. A dedicated and highly skilled team led by Dr Sandip Mitra and Sister Gill Dutton empowers patients and has so far trained 180 patients to be independent on haemodialysis at home.

The other 2 winners were MRC Cancer Unit (Cambridge) and NHS Bristol.

Congratulations to Dr Sandip Mitra and Gill Dutton on this latest award which comes soon after they scooped the NICE shared learning award in May 2011.

Brave new world of kidney care

Modern healthcare is complex. Kidney care is no different . The field is huge, multi-faceted, and the already immense body of clinical and policy literature grows at a frightening rate. There is evidence that better treatment of common comorbid conditions improve health outcomes such as decreasing cardiovascular events and mortality in patients with chronic kidney disease and in end stage renal disease the way clinical teams work together and interact impacts on patient experience and outcomes. However, care of complex CKD patients is often fragmented among different specialists, consultants, nurses, general practitioners, dietitians, pharmacists and other health and social care professionals. As a result, a more cohesive multidisciplinary team approach to CKD is needed to optimise care for comorbidities and CKD, as well as to facilitate the transition to management of end stage renal disease, improve renal replacement therapy outcomes and the experience of conservative kidney care.

Kidney failure has a profound life-long impact on patients, their families and carers. During the course of their patient “journey” they will encounter numerous multiprofessional staff who each have a contribution to make to their management and care. Patients’ varied needs, physiological, practical, psychological and social, will form a focus for different staff at different times. In order to optimise clinical outcomes and to enhance quality of life, multiprofessional staff require a joint perspective on management and care issues, underpinned by recognition of the varied professional skills required, and an ability to work flexibly and in collaboration. Team-based care is a foundation of the chronic care model which calls for productive interactions between informed patients and proactive practice teams to improve health outcomes for people with chronic medical conditions. . A multidisciplinary team is essential but how our MDTs work deserves further investigation. We need to study attitudes , values and behaviours as much as the skill mix and technical competencies .

To support kidney care multi-professional team working new arrangements have been put in place in England for adult services from April 2011. Payment to Trusts for first outpatient visits that are multiprofessional will receive a 50% uplift (price for doctors only visits £198 versus £328 for first MDT visit) with ongoing multi-professional care attracting more than double physician only outpatient attendances (£128 versus £257). This support for MDT led “preparation and choice” applies equally to live kidney donation, setting or place and modality of dialysis and conservative kidney care. People with complex multi system disorders and those with primary kidney disease or post transplant receiving a high dose immunosuppressive regimes and requiring pharmacy or other MDT input will also be able to benefit from this payment for quality. The introduction of this payment system for hospitals has the potential to make another step change improvement to the experience and outcomes of care for people with advanced kidney disease and those requiring multi-disciplinary care because of intricate and potentially toxic treatment.

Multiprofessional care should promote shared decision making which is relevant across the whole of kidney care from risk assessment and management through to advanced kidney disease, replacement therapy and palliative care. Decisions about lifestyle, for instance in the management of hypertension; diet, exercise, moderation of alcohol and smoking cessation, are more likely to ensue if they are accompanied by behavioural change plans that encourage and promote health. Prescribing of medicines should always be preceded by discussion of the indications, potential adverse events and evidence base for the treatment. The patient’s views on the likelihood of a particular class of anti-hypertensive drug causing impotence or the effect of the route of administration, oral or intravenous, of cyclophosphamide in the treatment of vasculitis on subsequent fertility need to be explained by the clinician, considered by the patient and factored into the prescribing decision. The timing of ultrasound scanning in those with a family history of polycystic kidney disease should take into account the possible negative impact – psychological, emotional and financial – of a positive scan as well as the utility of accurate diagnosis. People need time and space to consider these big decisions if the best outcomes are to be achieved.

Good kidney care has always been based on teamwork. The complexity of renal failure, the wide range of treatment options – from an ABO incompatible live donor transplant or daily dialysis to conservative care requires detailed knowledge, precision and technical skills. The impact on physiology, diet, psychological wellbeing and social functioning brings added dimensions to kidney care. Achieving optimal outcomes and improving patients’ experience of care depends on the whole range of skilled and motivated individuals needed to manage different aspects of kidney care; but it also needs individual practitioners to work together and with patients as a multiprofessional team. No one group, single practice or characteristic can make a major difference on its own. A holistic approach including attention to supporting patients, staff working climate, inter-professional respect and integrated practices are required to provide kidney care in the Brave New World.

Slides BRS/RA 07-06011

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

Q & A: Will my transplant centre close?

Q: I am worried about the possible closure of selected UK transplant centres so that we have only a limited number of specialised centres, and the impact this will have on travelling times for living donors and all recipients. Do you think that this may end up having a negative effect on transplantation in general? My Transplant centre is Newcastle, which covers an area from the west coast of Cumbria across to the east coast and down as far as Hull. If this plan is put into action, which centres are being considered for specialised status and how will this impact upon my local Transplant centre's patients?

A: Thank you for your question. First of all, let me reassure you; I am not aware of any plans to close any UK transplant centres. The number of kidney transplants being carried out is increasing.

Data from NHS Blood and Transplant show that the annual number of kidney transplants undertaken in England grew by 25% between 2007 and 2010. We want to increase the number of kidney transplants taking place even more, so there should be no reason for any transplant centres to close. The only reason why a transplant centre might conceivably close would be if there were safety concerns – not an issue I am aware of at any of our current centres.

We have a UK Donation Taskforce plan which aims to increase kidney transplants from deceased donors by 50% over five years. That means increasing the number of people receiving a deceased donor kidney from 1450 in 2007/8 to over 2150 by 2012/13. Although it is a complex and serious operation, wherever possible a kidney transplant is the best treatment for someone with kidney failure. Quite simply it means freedom from dialysis and all the health and lifestyle limitations that dialysis entails. While we all work very hard to reduce the risks of infection for dialysis patients, it is still an unavoidable risk. A replacement kidney is a better, safer, more cost effective way for the NHS to treat people with renal failure.

Transplant rejection, greatly feared in the past, is still an issue but modern drugs have reduced the risk considerably. Patients still have to take drugs throughout their lives, but this is a much better prospect than lifetime dialysis. However, as many of us are all too aware, still too few transplants are happening.

The main challenge is that there are far more people waiting for a kidney transplant than there are donor organs available. The shortage of organs for transplantation is not unique to this country but we lag behind some other countries in the number of citizens donating organs and tissue. The problem is exacerbated because the numbers on the waiting list far exceed those being operated on each year, so every year we need to catch up with ourselves, before we can even begin to make inroads into reducing the waiting list. Black and minority ethnic groups are in double jeopardy because they have more need of organs but a reduced pool of donors.

We have a taskforce in place across the NHS to try to make donation the norm rather than the exception. We are working to make sure that all NHS staff are aware of the urgent importance of transplantation and to encourage donors to be identified. Virtually every acute hospital trust in the NHS now has a donation committee, reporting directly to the board on the hospital’s donor rates. They are responsible for closing the significant and unacceptable gap between the numbers of potential organs that could be donated each day in our hospitals with the number that actually are.

I am very aware that this is a difficult area, summarised very well in the previous Chief Medical Officer, Sir Liam Donaldson’s 2006 annual report in the chapter titled ‘The Waiting Game’. It is a highly emotive issue, combining matters of life and death with the law at what is an emotional time for the families of potential donors. So it is understandable why healthcare professionals have sometimes been reluctant to raise the subject of transplantation. However, with surveys showing that while 70% of people want to donate their organs after death only 27% are on the NHS organ donor register, healthcare staff have a responsibility to explore this possibility. For example, on intensive care units, every legitimate opportunity should be taken to retrieve organs from heart-beating donors, after brain stem death has been confirmed.

We are also doing more to promote the organ donor register. A further million people signed up during 2009/10 taking the total to nearly 17.5 million who have pledged to help others after their death. However, this is still nowhere near enough. Estimates suggest that the number on the register would need to double if we are to find organs for all those who need them. It is important that people on the organ donor register make sure that their relatives know their wishes so they can be put into effect swiftly if the need arises.

Of course, unlike other kinds of transplant, kidney transplants can also come from living donors. Living donors now make up around one third of all kidney transplants. This requires greater surgical expertise and co-ordination, with two “patients” involved rather than one, but now that all transplant centres offer this possibility we will see the numbers of transplants continue to increase. The paired donation scheme is now also up and running whereby a potential live donor for a recipient, let’s say their spouse in Newcastle, can if the match is not good enough donate to another kidney patient at the other end of the country in a similar position, in return for their live donor giving a kidney to the Newcastle patient. We are also seeing transplant centres becoming more sophisticated in other ways. For example, every centre is now offering minimally-invasive laparoscopic surgery (also known as keyhole surgery) for live kidney donation operations. Recovery times with this kind of advanced surgery are much quicker, with a lower risk of complications or infections, and patients are back on their feet much sooner. Some units are now also carrying out highly specialised blood group or ABO incompatible transplants. Previously, transplant recipients could only receive organs from a donor with the same blood type as them. This has made it harder to find suitable donors for some patients, particularly those with less common blood types. However, new techniques are making these transplants possible by suppressing aspects of the recipient’s immune system through drugs and treatments that reduce the risk of the donor organ being rejected. Similar techniques can be used for highly sensitised patients. All these new treatment options mean that patients are able to exercise far greater choice about treatment and care. For me this is crucial. For NHS patients there should be ‘no decision about me without me’ and it is vital that the NHS gives patients as much say and control about their treatment and care as possible. For kidney patients, this means that they should be offered choice about how they want to manage their kidney disease at every stage. Patients have a right to choose to be transplant listed as when they are within 6 months of needing dialysis, ideally so that they can have a transplant before they start dialysis if they wish. There is still far too much variation across the country in how long it takes people to exercise their choice to go for transplantation and then to be added to the transplant list.

The latest published data we have, albeit from 2005 shows that on average it was taking 2 years from starting dialysis to be transplant listed – I am expecting to see considerable improvement as this is an unacceptable delay. A change to the NHS 'payment by results' funding system to support more multiprofessional clinics for preparation is helping to ensure that patients get to exercise this choice sooner by introducing financial incentives for kidney units to ensure that patients get transplant listed at the right time for them. This is, I have to say, almost always earlier than currently happens. Patients can also help the NHS up its game here by asking to have these discussions as early as possible.

Therefore, going back to your original question, I see absolutely no reason why any transplant units should close unless there were any concerns about safety. Transplantation, where possible, is the best treatment for renal failure. With all the work going on to increase transplant rates, it is estimated that - if we do as well as we can - by 2018 we can expect to have turned around the steady rise in the number of people on dialysis because more people will have had transplants. As medical science continues to develop, there will be even more options for transplant than there are now. Currently, US surgeon Anthony Atala is experimenting with a ‘3D printer’ that uses living cells to create a transplantable kidney (see Print a Kidney if you don’t believe me!). Printable kidneys may be a long way off, but as we look forward, we can be certain that if we keep up the focus on transplantation and patient choice we will see more and more people receiving life-saving and life-changing kidney transplants and a continuing need for our vital network of transplant centres.



Published in Kidney Life, Spring 2011