Programme Budgeting in Kidney Care : 17B has arrived

The Department of Health (DH) initiated the national Programme Budget Project in 2002 to develop a source of information, which shows ‘where the money is going’ and ‘what we are getting for the money we invest in the NHS’ collected on the basis of International Classification of Disease (ICD).

A focus on medical condition rather than input cost was adopted to forge a closer and more obvious link between expenditure and patient care. Analysis of expenditure in this way has helped Primary Care Trusts (PCTs) examine the health gain that can be obtained from investment such as statin use, expenditure and CHD rates. It will increasingly inform understanding around equity and how patterns of expenditure map to the epidemiology of the local population.

From 2003/4 onwards, PCTs and Strategic Health Authorities (SHAs) reported the totality of their expenditure on a programme basis. Data is collected as part of the annual accounts process and aggregate data is published each Autumn in the DH Resource Accounts, and PCT data is published in the form of an interactive Excel spreadsheet. This spreadsheet allows PCTs to benchmark their expenditure with PCTs nationally, locally, or PCTs with similar characteristics as classified by the Office for National Statistics (ONS).

Programme Budgeting is therefore a way of analysing NHS expenditure by medical condition, based on 23 programmes of care. Renal services were added as a sub-category programme in 2006/07, prior to this, renal costs were included in programme 17 ‘Problems of the genito-urinary system’. Programme expenditure linked to activity and outcomes can be viewed in the Programme Budgeting Atlas and on NHS Comparators. This provides a framework for analysis and evidence to support commissioning decisions.

The analysis shows that £1.3 billion was spent on renal services in England in 2006/07. That equates to 1.5% of the total expenditure of the NHS. Expenditure was predominantely in secondary care - 93%, with only 7% incurred in a primary care setting (of which approximately 4% relates to prescribing). Expenditure is calculated using NHS Trust reference costs using ICD10 primary diagnosis codes to identify episodes of admitted patient care and speciality to identify non-admitted care. The costs cover both dialysis and transplantation. Renal programme costs do not include GMS/PMS expenditure (included in programme 23a) or prevention expenditure (included in programme 21).

The Programme Budgeting Atlas brings together expenditure with specific activity and outcomes data including QOF data on prevalence and management of chronic kidney disease, an analysis of mortality and years of life lost and a range of activity data specific to kidney problems, eg admission rates, bed days, length of stay. We can’t yet map sub-category level expenditure, such as renal services, 17B, but this is planned for the future. NHS comparators links admitted patient care activity with programme budgeting expenditure including subcategory level data, so renal services spend is available using this tool. It is updated quarterly and allows you to drill down to practice level. Prescribing data by programme category will be available soon.

Programme budgeting is dependant on the quality of the financial and clinical activity data. It will need refinement over time . In particular, figures produced in the early years will be a best estimate of expenditure in kidney care, rather than a precise measurement. We know from the review of reference cost returns for dialysis that accounting errors do occur , similarly primary care coding of kidney conditions has historically been incomplete to say the least. However, PRODUCTIVITY is now one of the watch words of the NHS and getting our clinical coding and financial costing right will be vitally important for the delivery of high quality kidney care.

Exercise training in chronic kidney disease

As my annual cycling trip looms before me, my thoughts if not my legs, have turned to exercise regimes again and I have spent a little time reading and discussing the subject. Many people with advanced kidney disease complain of tiring easily, difficulty climbing stairs, rising from a squatting position and muscle fatigue after minor physical activity. We also know that as kidney disease progresses maximal exercise capacity falls – to about 50% of the expected muscle strength on dialysis. In the old days, renal anaemia was thought to be the main cause of this muscle weakness. Treatment of renal anaemia improves but doesn’t correct the physical exercise capacity and we now know that there is abnormal muscle energy metabolism in CKD. This is compounded by the effects of physical inactivity. People who have received kidney transplants also have problems sometimes related to the use of steroids as part of their antirejection treatment.

During the last 30 years an increasing number of studies have been published showing positive effects of different exercise training programmes on muscular strength and endurance and functional capacity such as walking distance and quality-of-life in patients with chronic kidney disease. Therefore it’s a surprise that most kidney specialists and teams do not offer physical exercise training programmes. My impression is that most kidney doctors, nurses and dietitians do endorse exercise as part of healthy living but don’t provide other support or guidance. “How much exercise is it safe for me to do Doc?“ is not the sort of question we find easy to answer and for instance some gyms actively discourage those with raised blood pressure or on antihypertensive drugs!! The advice to consult your physician that’s on the side of exercise bikes and other equipment might absolve the company of responsibility but will only rarely result in a personalised exercise plan or prescription from your doctor. A few units do offer the option of exercise on dialysis but that hasn’t really taken off. Perhaps that’s because of the uncertainty of what we should be offering. The various studies that have been reported used a wide range of approaches. Therefore I was very pleased when I recently looked into the subject to find that researchers from the Karolinska Institute in Stockholm, Sweden are conducting a Cochrane review to provide evidence on how exercise training programme at various stages of kidney disease should be constructed. It should identify the type of exercises, duration, intensity and frequency that are needed to be able to affect certain outcomes.

Having the scientific evidence of what works will be the first step in develop exercise programmes for people with CKD, fostering the culture within our kidney services so that exercise has a higher profile and supporting the behaviorial change so that individuals optimise their own exercise capacity is a bigger challenge. The rewards are likely to be great .

Talking of exercise, are you keeping up with Tony Ward's progress – you can read Tony’s blog on NHS Choices. If I survive this years trip, to the Col de Tourmaline, then I will definitely train for next years – my sons have the Marmot pencilled in!!!

Bedtime reading: annual evidence on proteinuria and eGFR (NHS evidence - kidney disease)

The 2009 Annual Evidence Update on Proteinuria and estimated Glomerular Filtration Rate provides an update on the evidence presented during last year's Knowledge Week. The most useful papers on the following topics have been selected by Dr David Goldsmith and Dr Edward Sharples:

1. Basic science
2. Clinical aspects
3. Management

Provided by NICE, NHS Evidence is a new service which will develop, enhance and expand the services that were previously provided by the National Library for Health (NLH). The NLH and its Specialist Libraries became part of NHS Evidence on 1 April 2009. Release 1 of the NHS Evidence portal and search engine went live on 30 April 2009.

The specialist collections have been developed to identify and meet the information needs of particular communities of practice. They are web-based collections containing clinical and non-clinical information on the major health priority areas. Each specialist collection identifies and provides access to quality assessed information of relevance to the community that it serves. An aspect of this involves the production of Annual Evidence Updates, which aim to highlight the best current evidence for selected healthcare topics. Annual Evidence Updates consist of the good quality evidence from a search of research evidence on a particular topic over a 12 month period, plus user-friendly summaries written by relevant experts, and links to guidelines, secondary research and primary research, if applicable. All information included in Annual Evidence Updates has been subject to rigorous selection criteria.

Red smoke in Milano - Congratulations John

Milan 21 May 2009 : Red smoke rises above the Duomo, John Feehally elected President of the International Society of Nephrology (ISN). Congratulations John.

The ISN is the global Kidney organization . Those of us who know John, in whatever capacity that may be – Patient , Colleague, Researcher, Manager, Friend – to name a few, know the ISN is lucky to have such an energetic, charismatic and effective leader at the helm. I first met John when he was a registrar in Leicester and have enjoyed working with him for many years , I particular enjoyed being part of his team when John was Renal Association (RA) President and I was RA Treasurer. Happy memories. John is also the Vice Chair of our Renal Advisory Group for the implemention of the NSF, so I know John up close and personal. One of the great highlights and pleasures of my career has been to work with John. Whats more his energy is big enough to share – that's code for we need you as well John. At a time of major challenges this is great news for people with Kidney disease and the wider kidney community across the whole globe.

No pressure then John!!

Bedtime reading: Specialised Services National Definition Set (3rd edition 2009)

The Specialised Renal Services (Adults) Definition has now been published. The Specialised Definition Set for childrens kidney services has recently been consulted on and is expected to be published later this year.



http://www.nscg.nhs.uk/ssnds.htm

Q & A: Screening for MRSA carriage in day case attenders for intravenous iron

Q: Donal, you've addressed this issue in your blog, but that hasn't solved the problem. Our team are now being required to do MRSA screening swabs in ALL day case attenders who will stay for more than an hour. This is based on the CfH definition of a day case, as opposed to an outpatient attendance. This means that patients undergoing endoscopy don't need screening (because it takes less than an hour) but patients requiring iv iron dextran (currently cheaper than iv Ferrinject) do require screening - which often involves an extra visit to healthcare settings solely to get the swab performed, plus extra work to collate the results and, occasionally, to act on them. This seems to be to be nonsensical. This was discussed in our infection control meeting on Friday, but similar conversations must be going on up and down the land. As you know I am a strong supporter of the Cleaner Hospitals programme and an admirer of the successes (which we have seen here) of active performance management and 'raising the bar' relating to MRSA infections; and as part of the many conversations I've had with colleagues in other disciplines, have learnt that the most powerful way to get clinicians disaffected is to impose illogical interventions! Dr Charlie Tomson, Consultant Renal Physician, Chair, UK Renal Registry

A: Charlie I am in total sympathy with the point you have raised . I discussed this with Professor Brian Duerden, CBE (Inspector of Microbiology and Infection Control, Department of Health) who told me that these patients were clearly not what we had in mind under the term "admission". Brian advised using the Operational Guidance “get-out clause “. To quote Brian directly “this is a sub-set of patients who should be excluded and this should be agreed with the local PCT and the SHA “. I would also advise that the responsible Specialist commissioners should be involved in those agreements and that the rationale is made clear to patients.

Bedtime reading: Tackling health inequalities: 10 years on

This is a lengthy report but one that is filled with lots of information about indicators and trends relevant to the social determinance of health. Between 1995-1997 and 2005-2007 average life expectancy for all groups in England has increased significantly - for males by an extra 3.1 years and for females by an extra 2.1 years. The report highlights some developments that have worked well but also the challenges that need to be addressed to get further improvements in the health of disadvantages groups and areas, and a long term narrowing of the gap. This will be particularly important in the wake of the more difficult economic conditions, especially through its impact on unemployment, together with environmental challenges like climate change.

Acute Kidney Injury, hyperkalaemia and the safe use of insulin

Acute Kidney Injury (AKI) is gaining visibility. The move to a standard definition and staging system based on the rise in serum creatinine will, I hope, have the same demystifying effect that introducing systematic eGFR reporting has had for chronic kidney disease. One of the complications of AKI is hyperkalaemia or an increase in the serum potassium and my colleague Dr Rowan Hillson (NCD for Diabetes) drew my attention this week to the work of Professor David Cousins from the National Patient Safety Agency work has done on risks to patient safety from insulin therapy. Between 2003 and 2009 a total of 13,180 incidents were reported from the NHS in England and Wales. These included 9 deaths, 863 cases of severe or moderate harm and a number of these cases included the use of insulin in the treatment of hyperkalaemia. In one such case a letter from the prescribing doctor read out in Court said that he believed “one unit of insulin was equivalent to one millilitre”. “I have not received any previous instruction in handling of insulin”. In the National Patient Safety Agency report 3,417 cases involved giving the wrong dose, strength or frequency of insulin.

In Northern Ireland the Clinical Resource Efficiency Support Team (CREST), have produced an excellent guideline for the treatment of hyperkalaemia in adults. One of the clinical pearls in that document was “always consult with a senior doctor responsible for the patient with hyperkalaemia”. Damian Fogarty (Consultant Renal Physician, Belfast) tells me that the Northern Ireland team went further and produced a hyperkalaemia kit that is now present in every adult ward.

We are all awaiting the national confidential enquiry into Patient Outcome and Death report “Adding Insult to Injury” on Acute Kidney Injury; I don’t know what it will say about hyperkalaemia and its treatment but it has looked at the following areas:

· Diagnosis and recognition of AKI
· Recognition of risk factors associated with AKI
· Prevention of AKI
· Assessment of patients recognised as being in AKI
· Management of established AKI
· Recognition and management of complications of AKI
· Organisational factors for the management of AKI patients

The report is to be launched at at the Royal Society of medicine on Thursday 11 June and a place at the event can be booked here

Vascular & kidney disease briefing pack: get your slides here

The vascular branch of the Department of Health includes cardiac, stroke, diabetes and kidney policy teams and also covers the NHS Health Checks Programme that from 1 April this year, is offering a vascular risk assessment for all adults in England aged 40-74.

A briefing pack with over 90 slides for each SHA has been prepared and is now available.

Feel free to download and use the information and slides in local network, primary care trust and commissioning discussions and to develop your own presentations.

Q & A: Haemodialysis nurses and work permits

Q: Dear Donal, a limit to opening HD capacity is getting trained HD nurses. They are a scarce and valuable resource. I gather that the Home Office will not grant them work permits to work as HD nurses even though they are already here working in other roles. This restriction does not apply to theatre nurses. Can you use your influence to get this ruling modified? Dr Chris Winearls, Oxford Kidney Unit

A: Dear Chris, although renal nurses have been taken off the occupation shortage list the NHS employers do provide some further guidance


“Removal of a particular occupation from the list does not mean that a tier 2 application will not be granted for any vacancy that exists. Providing the employer can demonstrate that the post has been advertised and there were no suitable applicants from the resident labour market, an individual from overseas may be selected and appointed providing they meet all the eligibility criteria for tier 2.
The job vacancy must have been advertised to settled workers. If the salary for the job is £40,000 or under, you must advertise it for a minimum of two weeks. If the vacancy is over £40,000, you must advertise it for a minimum of one week”. Donal