Gerry's last day

A Belfast accent. A trilby at a jaunty angle. A jolly faced, well nourished, Irishman in a brown, large check suit, burgundy waistcoat - with gold chain and yellow paisley dickie-bow. That was my introduction to Gerry Lynch who today, 29 August, steps down from his post as policy lead for renal services. Gerry has been looking after our patch for the past 2 years - all those who have met or had dealings with Gerry have been struck by his quick mind, dedication to the needs of people with kidney disease and ability to negotiate the system.

When I took up the National Clinical Director role, one of the other Tsars, Harry Cayton, National Director for Patient and the Public, took me to one side and said "whatever you do, don't let the civil servants control you". I had received similar advice from a different quarter but not put so eloquently - that person pointed out that civil servants were there to serve. But we are all of course here to serve - the question is who?

Working with Gerry has been a real pleasure. Not only his dress sense but mainly his common sense. He has acted as a minder and friend and saved me from making the naieve mistakes that can easily be made in a new and challenging environment. If Gerry has controlled me it has been in the gentlest way - he is a skillful behind the scenes negotiator. He is pleased, and I am beginning to learn, that if nothing appears to happen but the experience of people with kidney disease improves that's infinitely better than the razzamatazz of a new initiative every week, the illusion of progress and the situation on the front line not changing.

Gerry is returning to Belfast to take up a leading role in the Alliance Party - a historical time in Irish politics. One may wonder what time in Irish politics isn't historic, but seriously, what an opportunity for Gerry to make a difference. He will be behind the scenes so we won't see Gerry's smiling face between (was that a real smile) those of Martin McGuinness and Ian Paisley.

Gerry's skills and enthusiasm will be missed, by myself certainly, by the Renal and Vascular Team at the DH and, although everyone will not know it, by the wider renal community. I will be watching his progress and that of his Alliance Party, in much the same way that I now look out for the Sunderland scores. Although there are many differences Gerry does share the focus on sucess with the Sunderland manager. We wish him well - that's Gerry, not necessarily Roy!.

Q & A Haemodialysis Capacity - ISTC?

Q: Dear Donal, I wonder whether you can provide me with some clarity regarding the state of play of securing ISTC procurement for the expansion of satellite haemodialysis facilities.

Over the last 10 years at St Helier we were able to develop 5 (6 in all as the last one replaced one of our old ones) satellite units through a mixture of Renal Modernisation monies, charitable funding and working in partnership with commercial providers. Up until now we were able to keep abreast with the needs but no longer!

We in SW London are about to hit another predicted dialysis capacity buffer iminently. I was going to consider drafting a tentative submission to the DH Commercial Directorate to see whether the ISTC route is one route I can pursue as all of the NHS organisations (Acute Trusts and PCTs) locally in SW London are in official turnaround with no spare capital in the system. Yesterday, I read in the press that Alan Johnson has reported to have said there will be no further waves of ISTC being introduced by the DH.

Before I start a wild goose chase, I wonder whether you can give me some clarity of the current situation. Your early response would be appreciated.
Dr Jonathan Kwan, Medical Lead for Renal Services, S W Thames Renal & Transplantation Unit

A: Dear Jonathan, thanks for the question. Capacity, unit and satellite haemodialysis capacity in particular remains a major concern of mine. At Hope Hospital people are being admitted and waiting months, not weeks, for regular dialysis slots!

I have recently written to Chief Executive Officers of the provider units in England emphasising that starting individuals on twice, rather than thrice weekly, regimes is not appropriate as it comprises patient safety. I am also awaiting details of the ten SHA renal strategy plans from our specialist commissioner colleagues so as to get a clearer national picture.

Several colleagues, well two to be precise, have mentioned that HD capacity is not a current issue - in one of these areas I know there are agreed plans for next three to five years already - ahead of 2008-2011 local delivery planning exercise! Aren't they ahead of the game!! The other colleague commented that their more pressing concern, at present, was organisation and funding of supportive and palliatitive care for those who elect for the no RRT option. I appreciate that they are probably the exception but it does demonstrate that 'we' can get planning for haemodialysis right - and when we do there will be other things that require our attention.

Turning directly to your question. Yes there has been a change in tone and emphasis since the new Prime Minister and Secretary of State came in to post. In short its not a 'wild goose chase' but its worth having some detailed discussions at this stage. I don't think there have been any specific comments on Renal Services, but we are of course part of the whole. The current projects will progress as planned. The E16 scheme - that includes renal facilities in Cheshire and Merseyside, South Yorkshire and Hull is now nearing financial close.

The recent comments made by the Secretary of State were in relation to centrally - driven procurements of independent sector capacity analogous that have been implemented until 2002. It remains possible for any NHS bodies to procure services from the independent sector and it may be possible for the Department of Health Commercial Directorate to work with renal networks to support them in the procurement of IS capacity. Such a procurement would be 'owned' locally but the commercial directorate at the Department of Health might be able to assist by bringing the knowledge accumulated during the recent haemodialysis procurement exercise.

I will arrange for you and the South West London network to discuss your local options more fully with our collagues in the Central Clinical Procurement Programme section of the Commercial Directorate. I would of course be happy to do the same for others who wish to explore the independent sector option.

Holiday time

I will be taking a holiday in August so may be out of touch for a while. Rest assured I will be checking my "inbox" and back with updates soon!

In the Duty Room

I visited Chris Rudge, Managing Director of UK Transplant at the beginning of August to meet his team and hear about the progress of the Donor Organ Task Force. Every time I visit UKT I am struck by the setting - the offices are in a business park. They work perfectly well there - and unlike a clinical unit there is parking! The setting does however underline that UKT is a quintessential knowledge organisation. It could be anywhere. It's 4 key functions - maintaining the recipient waiting list, allocating organs by the nationally agreed schemes, promoting donation and maintaining the Organ Donor Register (ODR) - all require coordination of information and translation of that information into knowledge. Knowledge about which is the best match, correct allocation of a liver to a high priority recipient, telling a story - so that the technical information we regard as second nature becomes knowledge and understanding by the general public.

That message is getting across. In the foyer there is a large flat screen - when I was there it had a loop describing the various activities of UKT. The counter showed that over 14 million people have placed themselves on the ODR. A remarkable success - over 25% of the adult population of the UK. It's a great pity that this success hasn't lifted us off the bottom of the European donor league table. The Donor Organ Task Force aims to correct that. It was set up to advise on what can be achieved now, under the current legislation and with our current knowledge and expertise. It has always seemed pretty obvious to me that we need to put some resource into understanding how families make their decision to donate or refuse. Even without the research evidence it seems inescapable that the skills and attitudes of those initially raising the possibility of donation, the physical surroundings - it's not something to be broached in the corridor - and the time and space families are given to consider donation are key elements. I am sure the Task Force recommendations will advise on these issues and the wider organisational arrangements that will promote donation. Unfortunately, in many places it's not yet on the radar - how many Trusts have an Executive with responsibilies to support the donor families and the front line staff managing these processes?

I know 3 people/families who have donated the organs of their son or daughter - I can see one of them now in my mind's eye. In 2 of those situations the family took the lead in the donor discussions when the inevitable became obvious - would the opportunity for those families to donate have been lost if they hadn't have done? In all 3 families the act of donation brought some lasting comfort if not meaning to their tragedy.

Liam Donaldson's article "the waiting game" has opened the door to further discussions about changes in the law on assumed consent. I welcome that. On the day Sir Liam was on Radio 4, over 22000 people joined the ODR. Of course many people say surgeons will never take organs against the family's wishes and feel that past Parliamentary discussions have missed the point. But a public debate can only be a good thing - unless of course we, our ITU colleagues, the public and our Trusts delay what we should be doing today whilst we await the outcome of that debate.
The duty room, the operations room at UKT, did have a feel of an air traffic control room - assuming the movies protray that accurately. Coffee, no cigarettes, lots of screens, messages on post-its, the whiteboard with an SOS paediatric heart wait-listed infant and urgent potential liver recipients with their MELD scores, the nerve centre of this knowledge organisation. Very dramatic stuff for a kidney doctor who these days spends a lot of time in meetings. The staff at UKT are some of the unsung heroes of the Health Service. The guys in the duty room pointed out to me that the donor families are of course the real heroes.
So all that's very good and uplifting. If you are reading this and work in a kidney unit - or if you are a patient or relative of someone who might benefit from a kidney transplant, take a moment to look at some of your stats. The UKT Annual Report and the Renal Registry Report will make interesting reading. The information here in table form and above graph (data from Dr Richard Fluck, Consultant Nephrologist at Derby City Hospital), shows the variation in pre-emptive and live donor rates between units. Where does your unit stand? The question isn't "could you do better?" but "how do you do better?"- why does it take up to, or beyond 12 months to list dialysis patients for transplantation?

Q & A Funding from the Secretary of State to Reduce HCAI

Q: I have read the email you sent regarding the support from the Secretary of State to reduce HCAIs and the particular emphasis that is being put on vascular access and care of lines etc. We were visited by the Department of Health recently and have identified some areas in the Renal Unit where we would like to do some work around this. I wonder if you have any further information on how to gain funding to move some of our ideas forward and specifically what might be an area within this that would be considered appropriate?

July email reproduced here in part for reference:
Dear Clinical Directors
Re Funding to reduce HCAI
One of the first actions of the new Secretary of State was to announce further funding of £50M for HCAI – in particular to reduce MRSA. I have flagged the central role of vascular access in renal services related HCAI and if your Trust has been visited by the Cleaner Hospitals Team you will know that access, line care and protocols to fast track those starting haemodialysis without a fistula are part of the review. The central funding will be distributed by SHAs who will request proposals from Trusts. If your unit has HCAI concerns and have identified interventions that you require funds to introduce (ie enabling day case vascular access, vascular access coordinator posts, pharmacy costs for antibiotic locks, radiology sessions) then I strongly urge you to lobby your Directors of Nursing so that a case can be made to the SHA from your Trust for funding of these initiatives.
Richard Fluck, in Derby, has been helping me with the Renal HCAI projects and if you would like to discuss the matter further please contact myself or Richard.
Some further analysis of HES is available please contact me via email (address at foot of page) if you require copies. The activity rates by old SHA are striking – I am not sure that the wait time (displayed in pmp) is the best way to describe delays.

A: The funds will go to SHA level (£5M for each SHA) and Trusts will be asked to bid for money for projects to bring down their HCAIs. Your director of Nursing might be the best person to speak to about this. I hope this helps.