On a recent visit to the John Walls Renal Unit in Leicester to speak to the East Midlands Renal Network, Jonathan Barratt (Consultant Renal Physician) took me to task on this question. Jonathan wondered what guarantees were in place that would ensure high quality of care for people with kidney disease when they are discharged back from specialist kidney clinics to local primary care community services. A couple of days later Nancy Tannahill (Conservative Management Nurse Specialist, Liverpool) made the same point and we discussed if the inclusion of chronic kidney disease in the Quality and Outcomes Framework (QOF) in the General Medical Services contract for primary care might provide a way to audit the care of people with CKD.
Inclusion of a CKD domain in the QOF in 2006 transformed the profile of kidney disease in primary care – it’s gone from none existent in awareness to being one of the hottest primary care topics. QOF provides incentives for structured care – registration , recall and review, control of blood pressure and blockade of the rennin angiotensin system. QOF data is reported as practice level information and therefore does not tell us in detail about the quality of care for individuals. However , we do know, from first year data, that there is great variability in the detection and registration of kidney disease between practices - a 50 fold difference at most primary care trusts! Overall only about 35% of the expected number of people with kidney disease were registered in the first year. A cause for concern? Or cause for celebration? Well, neither, but it would be a very “glass half empty” person who didn’t acknowledge that it was achieved from a standing start. So let’s give credit where it’s due. Rather than concern - wringing our hands and sighing – the variability demands action. From whom? Strategic Health Authorities and PCTs have statutory responsibilities for the healthcare provision of their populations. The specialist renal community, that is the providers and our specialised commissioning colleagues, also in my opinion, have responsibilities across the whole pathway. That responsibility is not to provide every aspect of kidney care from our renal units, but rather to work in partnership, and influence the system in which people with or at risk from kidney disease are managed. That pathway extends from public health measures, through risk assessment and management, shared primary/secondary protocols from moderate and advanced kidney disease and effective patient centred care for those approaching renal replacement therapy or electing for supportive and palliative care.
Back to the questions and comments of Nancy and Jonathan – we can’t guarantee that every practice will offer the quality of care we would wish for our relatives or ourselves. As an aside, one can ask what guarantees can be given that every patient under the care of specialist kidney units gets that high level quality of care - people crash land from our own clinics, not everyone starts haemodialysis via an AV fistula and it takes up to 3 years on dialysis for everyone who is going to be transplant listed to be placed on the list. So what are we to do for our patients and the population for which we and our units provide services and are part of the system of care? Well, we have the opportunity to use the visibility of kidney disease to begin a conversation with GPs and practice nurses. Clinical Directors, with PCTs and Commissioners, should be discussing how early and non progressive CKD can be managed and, as required by the NSF, all people with kidney disease should be provided with an individual care plan so that they, their family members and the whole team (primary, secondary and tertiary, social and medical care) know what has been agreed to optimise the individuals’ experience of care and outcome.
Over the next year the kidney care, our quality improvement team, will be working hard to provide tools and local support to primary and specialist kidney care so that people with kidney care requirements can feel more confident that high a quality service is being provided, whatever the care setting in which it is delivered. These tools will support the NICE CKD guideline implementation, include national care plans that can be adopted for local use and applied to the needs of the individual and web based knowledge management support.
I would like to know details of what you might be doing locally and also of local difficulties and ideas for improvement on the important issue of how primary and secondary care can work together as a team in providing better outcomes for those with kidney disease.
Email me at donal.o'donoghue@dh.gsi.gov.uk with your solutions, caveats and ideas. My job and the role of kidney care is to help individual practitioners and services to provide better kidney care.
