Sequins and Quips

Staying on top of the mnemonics is one of the constant challenges. So what do you think this blog is going to cover? Well if you google sequin you will find a disambiguation page on Wikipedia; and did you know that Dr David Goldsmith (Consultant Renal Physician & Clinical Lead for the Kidney Care National Collection) is a regular user of the word disambiguate. But David could not be responsible for a quip: a clever, usually taunting remark (unless perhaps in relation to my particular football team).

The Kidney Care Specialised Commissioners Forum met recently and there was a lot of talk of CQUINs and QuIPs. CQUINs or the Commissioning for Quality and Innovation Framework aims to use payments to deliver real benefits for patients and improve quality. To quote from the Operating Framework “the aim of the CQUIN system is to support a shift towards the vision set out in High Quality Care for All of an NHS where quality is the organising principle”. For Acute and Foundation Trusts, the value of the CQUINs payment is to be 0.5% of total contract value and up to 25% of the scheme is allowed for improving data. Rob Lusardi (Assistant Director, West Midlands Specialised Commissioning Team (SCT)) gave a neat presentation on CQUINs for renal services. The West Midlands SCT have been working with their Kindey Care Network to develop and introduce quality improvement plans designed to support the renal units in submitting all the mandatory data of the National Renal Dataset. Getting robust, high quality data and turning that into information for patients, clinicians and commissioners is seen as a vital first stage in developing performance improvement targets for each provider unit for 2010/11.

If you haven’t already guessed it, QuIPs are Quality Improvement Plans.

Similar schemes are been considered and developed in other Strategic Health Authority and Specialised Commissioning Group areas. One of the great strengths of the kidney community is that colleagues in different parts of the country are happy to share their progress, methods and what worked and what didn’t work with others across the country.

I attach a link to the slides Rob showed at the Commissioning Event. I expect that many, perhaps even all, of the Kidney Care Networks and Specialised Commissioning Groups will want to consider how they can use these and other approaches set out in High Quality Care for All to ensure that quality is the organising principle for kidney care.

Liverpool leading the way

I visited the Royal Liverpool Hospital on 17 April and found happy motivated staff, well informed people with kidney disease and an innovative and caring senior team. I had checked out the MRSA bacteraemia rates before I visited and I knew that there had been a substantial and sustained fall over the last 3 years. Pauline Connelly can take some of the credit for that. Pauline, a medical secretary by background, took over the coordination and support of vascular access in May 2007. There has been a progressive rise in the use of arterial venous fistulas for the first dialysis (the incident population) and in the overall Arterial Venous Fistula (AVF) rate in those on haemodialysis (the prevalent population) with fast track systems now in place for those who start dialysis in an unplanned way. Now, over 85% of people on haemodialysis at the Royal Liverpool Hospital and its satellites at Broadgreen, Whiston, Warrington and Halton are dialysed through an AVF. I was pleased to learn from Matthew Howse (Consultant Renal Physician) that less than 3% of people in the dialysis programme are considered technically unsuitable for a fistula. Coordination and the weekly multidisciplinary team meeting between renal unit staff, interventional radiologists and surgeons are key to achieving these ambitious targets.

Matthew also raised the thorny issue of attribution of MRSA bacteraemias between the centres and their satellites. When Richard Fluck and our Kidney Care Healthcare Associated Infection Group discussed this with the Cleaner Hospitals Team and the Health Protection Agency, they decided that attribution should be linked with clinical governance and I am sure that’s correct. Medical governance is via the responsible renal consultant through the CEO of the Trusts. However, in commercially run satellites, the governance arrangements are shared – it’s a partnership. Contracts can’t specify the safety and clinical protocols that must be in place, even if they could, the risk would be fossilising of practice. Matthew’s point was that a Chlorhexadine concentration of 0.5% as skin preparation may not be sufficiently concentrated. We discussed the route cause analysis of the MRSA bacteraemias and agreed they should include and address the issue of variance in protocols between different settings. Patient safety being the overriding concern.

In my short visit I wasn’t able to see everything but 3 further initiatives stood out for me. Two that will directly and considerably improve patient experience and one change in practice that is already saving money that is being used to improve other aspects of quality of care for people with kidney disease at the Royal Liverpool Hospital. Eileen Newall (Holiday Dialysis Coordinator) has established a database of kidney units across the world that are suitable and willing to take UK patients. Eileen spends a considerable amount of time ensuring the database is up to date and her efforts have promoted an increase in uptake of dialysis away from the base unit, usually for holidays but sometimes for other reasons, in the patients on haemodialysis in Cheshire & Merseyside. In the region of 35-40% of dialysis patients in Liverpool now holiday abroad each year – a British Renal Society survey a few years ago showed that in most units less than 10% of people were actually getting away from base for up to or more than 2 weeks a year. This is a really valuable service and Eileen’s system is among one of the best that I have seen or heard about. Jonathan Davies (Lead Nurse) introduced me to one of the recent ABO incompatible transplant recipients who was doing really well and told me that his creatinine was below 100 and that Liverpool Football Club would win the Premiership. I wished him well with regard to transplant function! I also commented on how tidy the kidney unit looked, some VIP visits do lead to repainting of wards and other superficial and temporary changes but I don’t warrant such an approach. The tidiness resulted from the reduction of clutter and consumables by moving to each individual patient’s dialyser and canulation kit being pre-packaged resulting in a tremendous space saving, no boxes in the corridor (!) and a financial saving of around 12.5%.

Finally, I had the pleasure of sitting on the appointments committee for 2 new consultants. One of the those appointed, Dr Muhammed Ahmed will be developing the new service in Warrington and Dr Rema Saxena has been appointed to the Royal Liverpool Hospital and has a special interest in a conservative care programme pioneered by Dr Peter Williams who is now the Medical Director of the Trust.

I suggested to Gordon Bell (Consultant Nephrologist & Clinical Director) and Talib Yaseem (Deputy CEO) that all these initiatives: reduced MRSA rates, increased fistula rates, better holiday dialysis arrangements and new and successful ABO compatible transplant programme and the cost saving approach to consumables allowing reinvestment elsewhere, should be put forward for innovation prizes, but being in Liverpool, and coming from Manchester, I had to caution about the unrealistic prospect of getting all 5 prizes in the one year – that would be the elusive quintuple.

Bedtime reading: Quality improvement story - healthcare associated infection

Thanks to Chris Lacey (Renal Unit Matron), Tracey Harrison and the St Lukes Hospital team from Bradford for this improvement story about reducing MRSA and other healthcare associated infections - keep up the good work Bradford!

Q & A: Peritoneal Dialysis contracting & holiday entitlements

Q: I have been asked to contact you regarding concerns over peritoneal dialysis contracting. following discussions of the North West Collaborative Procurement Hub. All the NW renal units work through the Procurement Hub with the aim of achieving the best results from contracting for dialysis consumables.

There have been major anxieties within units about the recent withdrawal of Gambro from the UK peritoneal dialysis market leaving only Baxter and Fresenius. I believe there is work ongoing moving towards national supply agreements and that the present round of negotiations are a “stop gap” measure.

It is clear the companies are under financial pressure and there may be pressure to increase prices either in contracts being discussed now or when next major renegotiations take place. However there is considerable disquiet from the represented renal units because of the move away from therapy costs to itemised fees. Although there are potential pros & cons to this for individual units depending on their usage the unbundling of holiday dialysis is a major issue. The price increases are coming through as increased payments for “extras” such as help in training patients and holiday dialysis.

Enquiries show that most units do not have a separate holiday dialysis budget line and that previously bundled holiday costs would largely come out of the “allowance” made through the contract with top ups coming from the general renal/dialysis budgets. The top up monies were relatively small so tended not to cause any problems so most PD patients would be supported for all their proposed holidays. If the cost of PD holiday dialysis is now clearly separated there is a major worry that there are no National guidelines on what a patient might reasonably expect. Managers and clinicians were agreed that this could cause a rift between the groups as managers became the arbiters of holiday allowance for individual patients, holidays would no longer be supported if financial pressures were high and the budget might disappear prior to the end of a financial year.

Although it is recognised that it will be up to units/regional procurement organisations to arrange for the best contract terms, the lack of a clear stance from the renal community on what patients can reasonably expect in terms of holiday support will hinder units in supporting their patients. As a major selling point of peritoneal dialysis is independence, the ability to travel and be independent of the hospital this could further erode the uptake of PD and ferment patient dissatisfaction in the prevalent population.

From a local regional level we are unclear if it is being flagged as a problem nationally although suspect it is happening nationwide. Clarification across the renal community of what are reasonable expectations regarding holidays for PD patients would we believe be a major benefit when financially strapped trusts pressure managers to save costs and there is no agreed protected budget provision. Dr David Lewis Clinical Director Salford Royal NHS Foundation Trust

A: David, thank you. These are serious concerns, particularly the risk of further restriction on the ability of people receiving dialysis to travel for holidays, work, family or all the other reasons we all value the basic human right of freedom of movement. You are not alone – others have raised similar concerns in other parts of the country including the West Midlands, London and South Central SHA.

I have therefore convened a short life working party to design a clinical peritoneal dialysis pathway, create a national service specification and develop a national template contract for procurement of services and supplies. Lindsey Barker (Consultant Nephrologist, Royal Berkshire FT) is chairing this group that will report to the NHS Kidney Care Programme Board later this year. The terms of reference are:

1. Strategic
To maintain number of competitive providers in PD market
To maintain availability of the full range of PD products and services
To achieve national consistency in pricing across England
To achieve equity in patient access to all treatment modalities

2. Commissioning
To ensure that a full range of dialysis modalities is available from appropriate providers and is offered freely to patients
To inform development of Kidney Dialysis Tariff

3. Communication
To ensure effective communication with key stakeholders
To report appropriately to Kidney Care Programme Board
To develop Comunication Strategy to share outcomes

4. Patient-centred service
Ensure views of all stakeholders, including patients and carers, are considerd.

The group has representation from patients, nursing and medical experts, managers, procurement hubs, the national supply chain, the Department of Health and NHS Kidney Care.

The key outputs will be a nationally agreed pathway and detailed service specification that I hope will be a valuable resource for commissioners and procurement teams as well as clinicians and patients. The pathway will span modality discussions/choice of treatment, catheter placement and training, treatment regimes while on peritoneal dialysis through to change of modality or withdrawal from replacement therapy. It will include aspects of patient experience including dialysis away from home. Donal