Integrated vascular control programmes

We have heard much talk that CKD spells cardiac, kidney and diabetes over the last few years. Speaking with practice nurses, integration is now becoming a reality for some patients. The publication of “The Handbook for Vascular Risk Assessment , Risk Reduction and Risk Management” or “the blue book” as we have come to know it over its long gestation, by the National Screening Committee should help drive co-ordinated vascular care. It draws together the evidence base and best practice models that can be adopted or adapted for local use in practices or across primary care organisations.

Melanie Davies (Professor of Diabetes Medicine at the University of Leicester) and her team have done a sterling job of sifting and compiling the literature. CKD is flagged as a vascular risk marker and the benefits of early detection followed by risk assessment and management are highlighted. If there is a feeling that kidney disease doesn’t get the same sort of look in as diabetes then that frankly reflects the amount and level of evidence in diabetes care compared to early CKD. If we, the system – because that is what the NHS, us; achieve the level of integrated care and quality of risk management that has already been achieved by individual earlier doctors of the approaches cited in the blue book a lot of people with stages I-3 CKD will benefit. I have also added it to the bedtime reading list of the blog but at 150 pages it’s really a document for the team to dip in and out of and from which local services can pick and mix the tools they wish to employ to manage vascular risk for individuals in their populations.

bedtime reading: integrated vascular control programmes ("the blue book")

The publication of “The Handbook for Vascular Risk Aassessment , Risk Reductionand Risk Management” or “the blue book” as we have come to know it over its long gestation, by the National Screening Committee should help drive co-ordinated vascular care. It draws together the evidence base and best practice models that can be adopted or adapted for local use in practices or across primary care organisations.

An away game in Europe

While Cesc Fabrigas was preparing psychologically for Arsenal’s historical encounter with AC Milan at the San Siro stadium on Tuesday 4 March, MEPs and policy makers were attending a European Kidney Health Alliance (EKHA) Seminar at the Parliament in Brussels. The EKHA is an alliance of not-for- profit organisations who represent the key stakeholders in kidney health issues in Europe. The member organisations are CEAPIR (European Kidney Patients Federation), EDTNA/ERCA (European Dialysis and Transplant Nurses Association/European Renal Care Association) ERA/EDTA (European Renal Association/European Dialysis and Transplant Association) and the ISN (International Society of Nephrology). Andy Rees (recently a Professor of Medicine in Aberdeen and a past President of the Renal Association who is now working full time in research in Vienna) chairs the Alliance. EKHA takes a multi-disciplinary approach involving patients and their families, doctors and nurses, researchers and other healthcare professionals who work co-operatively for a European health environment in which there is a sustained decrease in kidney disease and its consequences.

Mrs Freda Brepoels, (MEP, EPP-Ed Shadow Rapporteur ‘Organ Donation and Transplantation: Policy Actions at EU-Level’) hosted the event. Valerie Twomey (Patient) set the scene with a beautifully measured talk about what CKD, various forms of dialysis and transplantation had meant for her. Valerie worked the MEPs and others like a true master – plenty of body language, questions to the crowd and pauses as well as animation and cool graphics in the talk. One of the slides showed a poem a friend had written about donation. The deadpan voice-over in the manner of a railway station announcement rang out “organs not required at your onward destination” that’s to give you a flavour at what the kidney care professionals were up against!

Karen Jenkins (Renal Clinical Nurse Consultant in Kent and Chair of European Dialysis & Transplantation Nurses Association/European Renal Care Association CKD Group Chair), brought care planning to life by weaving a picture of the added value that each member of the multi-professional team contribute across the whole spectrum of kidney care. Paul de Jong (Professor in Nephrology from Groningen, Netherlands) presented the compelling data from the Prevend and other studies implicating proteinuria as one of the main therapeutic targets that must be controlled to achieve the “preventative dividend” of early detection. I spoke about our UK policy initiatives and our early experience with a structured managed care approach to CKD. Andy Rees summed up proceedings and the audience probed the panel on the health economics, linkage between CVD, diabetes and CKD and strategies to improve outcomes for people with kidney disease. Mrs Brepoels had listened carefully and contemplatively throughout. I think she will be a good ally in raising awareness in policy makers. From conversations afterwards, Frieda clearly had a good grasp of the issues.

At the reception we were treated to a medley of dialysis songs from the Brussels kidney community. Lyrics had been written by people on dialysis and the performance, sound engineering and CD production was co-ordinated by Vera Vertessen (Transplant co-ordinator at the University Hospital of Brussels). It gave an insight into the life and emotional relationship people on haemodialysis have with the machine. Everyone involved in that project is a member of the Brussels multi-professional kidney care team.

Oh, and by the way, I did get to see Ronaldo score his 30th goal this season, not from my seat at Old Trafford but from a sports bar in Brussels – through to the next round!

Photographs
listen - "close to you" is about the relationship between dialysis patient and haemodialysis machine
watch & listen - video clip of the dialysis song "close to you" (You Tube)

Payment by Results for Dialysis, the first peice of the jigsaw

This week I wrote to all the Chief Executive Officers and Directors of Finance of the 53 Acute Trusts providing renal services in England and the 10 Specialised Commissioning Groups to update them on the work of the Renal PbR Group and have included copies of the letter and the checklist here (also posted under bedtime reading). Information will be presented in detail at the Clinical Directors forum on 7 March 2008.

The Renal PbR Group was set up following the consultation on the future of PbR last year and brought together clinical directors and finance directors from 16 Acute Trusts. We focussed on dialysis costs as the key revenue driver for the first piece of work. Together the units provide over 40% of the dialysis in England. Reviewing the financial returns that each Trust must make each year revealed a number of anomalies and indeed errors that we hope the template the group developed and the clarification in the frequently asked questions published to complement the reference costs returns manual will help correct.

BUT the success of the PbR project was the bringing together of the clinical and finance leads to work alongside each other on the coding, attribution and costings. AND that’s my message too – closer working arrangements between the finance and renal departments are needed. I hope this will be achieved in the next costing round that Trusts are just embarking on.

Another key part of the Group’s report will be the emphasis at the start, in the middle and at the end that dialysis isn’t the only thing kidney care services provide. The quality of dialysis care and the outcomes are dependent on support and preparation of individuals with kidney disease receive. Kevin Harris (Clinical Vice President of the Renal Association) and Donald Richardson (Consultant Renal Physician, York) are helping me draw up plans to ensure that the “year before replacement therapy” and supportive and palliative care are not forgotten.