NICE Guideline on Peritoneal Dialysis

This short clinical guideline is now out for consultation until 18 February. It makes interesting reading and there are some key recommendations including:

• The offer to patients, and their families and carers, should include oral and written information about conservative care, pre-emptive transplantation and dialysis
• The importance of ensuring patients have been informed and understand that chronic kidney disease is a lifelong disease and that during the course of renal replacement therapy they are likely to need to switch between treatment modalities according to clinical and personal circumstances
• To enable an informed decision, or shared decision making, information about the description of the treatment modalities and as importantly, discussion about how treatment fits into patients’ lives including details of impact on body image, distance and time travelling for treatment, flexibility of the regime and support needed are considered
• The recommendations flag the importance of decision aids in helping patients make the right choice for themselves and the importance of presenting information to children in a form suitable to their age
• People who present late for renal replacement therapy need the same information and opportunities to make decisions about their care
• Consider peritoneal dialysis as a first choice for adults aged under 60 years and children older than 2 years
• If consideration is been given to switching between modalities, a shared decision process should again be used to decide future treatment options

The guideline also highlights gaps in our knowledge and makes research recommendations about how the process of decision making about the choice of dialysis modality should be supported and what factors determine the effectiveness of any modality of dialysis including what is the most effective sequence of treatment, are they differences in nutritional status between treatment modalities and which outcomes should be used in evaluating effectiveness.

I am sure people with kidney disease , carers , commissioners and clinicians will want to read the draft guideline and make comments

Eliminating mixed sex accommodation - what does it mean for dialysis units?

The Department of Health has recently issued further guidance on mixed sex accommodation. National Health Services organisations are expected to eliminate mixed sex accommodation, except when it is in the overall best interests of the patients or reflects their personal choice. The Operating Framework for the NHS 2011-12 confirms requirements for reporting and sanctioning breaches of national guidance. Organisations providing NHS funded care must agree with their commissioners how they will determine whether a particular episode of mixing is justified. One of the limited number of circumstances in which mixing can be justified, relates to patients who actively choose to share with others the same age or clinical condition rather than gender. One element of the new guidance specifically refers to “patients with long term conditions, including renal dialysis”. Here the guidance states that it can be acceptable for mixing to occur.

The guidance makes clear that dialysis units are not automatically exempt and that common sense should prevail. Clearly in units where acute patients might be dialysed (particularly those dialysed through femoral lines, thigh loop gortex grafts or those who are in inpatient beds) should be managed in single sex accommodation or with appropriate consideration. In the majority of maintenance and satellite units the dialysis floor is essentially an outpatient area and should be managed as such.

Common sense should prevail. There is actually a dialysis example on the Department of Health website and to quote directly from that “staff in these areas will need to make decisions on a day to day basis. For instance in a renal dialysis unit, if all the patients are well established on treatment, wear their own clothes and have formed personal friendships, mixing may be a good thing. By contrast a new dialysis patient, with a femoral catheter, wearing hospital gown, should be able to expect a much higher degree of privacy”.

The publication of the guidance has even led to a question in Houses of Parliament where Mrs Moon asked the Secretary of State if he would make an assessment of the likely effects on renal dialysis patients of imposing financial penalties on dialysis units which provide mixed sex accommodation. In a statement from the Government Simon Burns, Minister of Health, quoted the recent guidance and explained that it was not expected that renal dialysis will prompt a significant number of sanctions. If concerns are raised I would urge common sense to be applied by commissioners, Trust managers and renal unit staff to avoid unnecessary anxiety and confusion on the one hand but also to protect and promote respect and dignity on the other.

Related blog Single sex areas - hospital dialysis

How do quality accounts measure up?

Quality accounts were introduced into the NHS by the Health Act 2009. They are a new form of annual report to the public about the quality of services. They were introduced with the dual aim of increasing NHS accountability about the quality of services offered and to encourage Boards and senior managers to focus on quality improvement and state where they intended to make improvements. They remain a key part of making “quality the only organising principle of the NHS” – the current Secretary of State for Health stated vision for the NHS.

A Kings Fund analysis of findings from the first year makes interesting reading. NHS organisations collect lots (and lots and lots) of information about services and therefore they have to make choices about what information sources, services and specialities to include in their quality accounts. Most acute NHS Trusts, where kidney departments will be found, report on between 20 and 40 quality measures. The reports were generally strong on effectiveness, patient experience, safety, outcomes and achieved a balance between what’s going well and what needs to be improved. Few provided service level coverage and most reports were weak on staff feedback and measuring equality.

The majority of quality accounts cover healthcare associated infections, patient experience, delayed transfers, prescribing errors and complaints. All of these are relevant to kidney care but I wonder if Trusts are missing a trick by not providing details of individual specialities? This is not surprising given the wide range of services provided by our hospitals and the need to keep quality accounts to a readable length and format for a lay audience. However, this does highlight a key tension in quality accounts, between comprehensiveness of coverage of the range of service provided on the one hand, and length and complexity of the document on the other. But, if the collected data that form the report is to be useful information so that front line staff can gain greater knowledge and understanding of their particular service, be that orthopaedics or kidney care, then the service level detail is much more powerful than the aggregated data.
The Kings Fund comment that the views of staff are an important marker of an organisation’s managerial competence, workforce wellbeing and hence its ability to deliver high quality care. In short, the NHS is its staff. Kidney care healthcare professionals, commissioners of kidney care, local kidney patient associations and individual service users should make a point of looking at your hospital’s quality accounts and should be considering the questions – “so what does this mean for kidney services?”, “how can kidney teams be involved in quality initiatives across the whole pathway of care?” and, to paraphrase Kennedy, asking “what you can do to leverage quality accounts to drive local quality improvement”.

Q & A: Best Practice Tariff for adult haemodialysis

Q: Dear Donal, I speak as someone who would welcome a financial "grenade" to try to prove to our local surgeons and management that dialysis access is worth investing in. Nevertheless even as grenades go I feel that what is proposed and the way it is to be implemented will lead to serious unintended consequences.

In a unit such as ours where approximately 40 % of patients are on peritoneal dialysis and where we struggle to get more than 60% of haemodialysis patients dialysing via permanent vascular access (PVA) we will be heavily penalised by setting the "income neutral" rate for haemodialysis by PVA at 75% never mind 85%. There are three main reasons why we are different or lag behind depending on your point of view:

a) our access to surgical procedures and our surgical success rate are suboptimal.
b) many of our younger and fitter and therefore arguably "fit for a fistula" patients are on PD thus skewing our HD population as regards fistula suitability compared to other units who may have proportionately fewer patients on PD.
c) we have a very low catheter related bacteraemia rate, much lower than that reported for other units, where the need to avoid catheter based access is clearly more pressing. As a result of what they do and do not see many of our patients are simply unwilling to consent to a fistula procedure despite our genuine efforts to promote them. On the basis that "no decision about me, without me" is now one of our guideline principles and we are sometimes asking patients to endure a series of unsuccessful and mutilating operations I can not believe that the ultimate figure of 85% with a functioning fistula is anything like appropriate for our unit.

To impose this central target upon us, and let us be clear this is as much a target as any direct target imposed by New Labour, would leave me hopefully with a slightly more accessible, but perhaps no more successful, surgical vascular access service which is partly good, but, it also leaves me with the ethical conundrum of whether to accept a drop in funding or to coerce or corral patients into having fistulas done when that would not be their wish given a free and fully informed choice. I think our energies should be directed at promoting and incentivizing provider trusts to ensure that surgeons allocate sufficient time and resources to the often technically demanding discipline of vascular access surgery rather than to penalising dialysis units and ultimately the patients as well. Otherwise I shall have the New Year to look forward to discussing with my Trust which members of the multidisciplinary team we will be letting go in order to make ends meet.

The effects of this BPT implemented over this timescale really need to be thought through a little better and some "Localism" allowed to operate in the details of its implementation if we are to avoid causing a lot of distress to patients, at least here in Ipswich. Gerald R Glancey, Consultant Nephrologist

A: Dear Gerald, thank you very much for your letter of 24 December. I would like to say first of all that I very much appreciate your concerns about the introduction of Best Practice Tariff for dialysis and I would just like to take the opportunity to answer a few of your questions and hopefully address some of your concerns.

As you know, the introduction of best practice tariff for dialysis is part of a wider shift in the NHS towards rewarding quality in healthcare services and for providing financial incentives for commissioners and service providers to invest in services that result in better care for patients. At the same time, the NHS is facing an enormous productivity challenge to find savings in the order of £20 billion over the next five years to help resource services in the face of a very tight budget settlement. Unfortunately, this means that every trust will be faced with very difficult decisions about how best to allocate resources. The move towards a mandatory best practice tariff offers renal units a degree of financial security at this time of uncertainty – combining a clear signal of the renal community’s commitment towards better quality care at the same time as offering a stable, nationally mandated, financial settlement. Dialysis services have historically often been used to cross subsidise other areas of activity outwith renal units and any negative impacts on income resulting from tariff should be dealt with at trust level by keeping the income generated from tariff within renal units.

The 75% threshold for definitive dialysis access for 2011/2012 has been set with reference to the Renal Association Vascular Access Guidelines and the Joint Working Party Report on Vascular Access from the Renal Association, The Vascular Society of Great Britain and Ireland and the British Society of Interventional Radiology. The threshold has deliberately been set, following sense check, below their recommendations specifically to allow time for units more reliant on tunnelled lines to move towards the suggested 85% of prevalent dialysis patients dialysing through an arteriovenous fistula. Indeed, even at 85% the best practice tariff remains more conservative than the guidelines by its inclusion of grafts in the higher tariff rate, in recognition of the fact that a proportion of patients cannot have an arteriovenous fistula for technical reasons.

I acknowledge that your rates of vascular access bacteraemias are very low and feel that renal units generally have done fantastically well at improving infection control and reducing bacteraemias. Nonetheless, people with tunnelled vascular access remain at an increased risk of bacteraemias and infection related deaths compared to those with a fistula and so trying to minimise the use of intravenous catheters should remain a priority.

I think that the issue of informed consent that you raise is a vital one and the best practice tariff is in no way meant to be used as a way of limiting patient choice or of coercing patients into undergoing fistula procedures. However, the large variation in fistula use both nationally and internationally is more likely due to the availability and success of local vascular access services rather than reflecting fundamental differences in patient preference. I believe that fully informed consent for a dialysis access procedure could include information about all modalities of renal replacement therapy and conservative kidney care and should be undertaken using principles of shared decision making. Some patients having weighted the pros and cons for themselves, will undoubtedly prefer to have a tunnelled line instead of a fistula or graft but this is unlikely to be more than the 15-25% included in the tariff.

Thank you for highlighting the high proportion of patients choosing peritoneal dialysis in your unit. I have been very keen to promote home based dialysis therapies and unfortunately many units have been less successful at offering these to patients than you have. I understand the challenges that this will have in terms of potentially leading to an older, frailer and more co-morbid haemodialysis population. Some units have achieved both a high rate of PD and high fistula rate, but this can be challenging and may require the trust to invest in better vascular surgery services. In Salford we have always had a strong PD programme and like yourselves in Ipswich have previously had concerns regarding surgical capacity for vascular access. Locally we were able to improve our AVF rate for haemodialysis from 62% to 83% by addressing these concerns and using quality improvement methodology.

Finally, I would just like to conclude by saying that the intention of the best practice tariff is to encourage and provide financial support to locally led innovation in quality improvement. The price signal generated by the best practice element will be felt at trust level, and that signal should lead to an improvement in vascular access services for patients. I am very keen to help support renal units both with the introduction of tariff and with the undoubted
further challenges that will occur over the next few years. Please do let me know if I can help in any way or if you have any further questions or queries I can help with. Donal

PbR 2011/12 Road Testing letter 231210

New Year resolutions

Once I got over the fact that the snow had returned, my drive to the hospital on the first day back proved quite interesting and somewhat amusing. Like others, I guess, I was thinking about not only the day and week ahead but also what 2011 will bring.

The radio told me not to look directly at the sun! I was driving into Manchester (and it was a pretty grey day on 4 January) rather than home from the final Test of the Ashes series in Sydney, so I didn’t get too worried about the risk to my eyesight. But I did wonder if the description of the partial eclipse with the upper part of the sun obscured leaving a “smiley face” might be a good omen. It was followed immediately by the news that the Chancellor would be on the programme in the next hour discussing the economy and explaining the reasons behind the increase in VAT to 20%. I concluded the year might be one of ups and downs.

Of course none of us can predict the future but we can all shape it. The NHS family – the workforce, the patients and citizens are the system. So I wonder what your New Year resolutions were? The origins of new year resolutions goes back to 135BC and Janus, a mythical king with 2 heads. The Romans put his head at the top of their calendar, facing the future and the past, looking for forgiveness from their enemies and exchanging gifts with friends; thus Janus became January.

So looking back, one of the key themes of 2010 was quality. Well, not just “one of”, the key theme – quality - moved from being one of the organising principles of the NHS to THE organising principle of the NHS. Rhetoric you may say and I would retort “scepticism is good”. Whatever your views as we look forward to 2011, quality is now at the heart of the NHS. It is also measurable, it has 7 domains – safety, timeliness, efficiency, efficacy, equity, it is patient centred and it is sustainable. People reading this blog added the seventh dimension – sustainability. So what are your ambitions for 2011? What are your New Year resolutions? Have you got them mapped to measurable, achievable and relevant markers of quality of patient care? We are the system so I hope so.