Shocking statistics of the day

At the Mid-Staffordshire NHS Trust in the 2007 patient survey it revealed, only five in the 54 asked said “Yes”, to the question, “Were you ever asked to give your values on the quality of your care?”

Are you asking or being asked, and then acting on the answer to that question in your kidney service?

Do you know your rights? Do you exercise them?

I re-read the NHS Constitution again last week. It seemed an appropriate thing to do, on the day that what has become to known as Francis 2, the second inquiry into the standards of care at the Mid-Staffordshire hospital was published. A couple of things jumped out at me. In particular, the fifth principle “The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population”. This resonated well with me from a kidney care perspective.

Historically, renal services have usually worked seamlessly between dialysis and transplant services, which of course are often in different hospitals. Rather surprisingly the variance in proportion of people transplant listed, delays in listing, live donor and pre-emptive transplant rates, cannot be explained by a lack of focus in non-transplanting units. As a general rule the transplanting units are not necessarily better at timely listing than the non-transplanting dialysis services. As a system, we are now making improvements in the timeliness of transplant listing in both types of units. Once listed nearly all kidney patients receive high quality care across the boundaries of the different NHS hospitals.

Elsewhere in the kidney care pathway things are not so good. Although, unplanned starts on dialysis have fallen, overall 30% in the last 5-6 years they are still double, what they could be in many units. Time for preparation and support in  making shared decision about management  , treatment and care when end stage renal failure is reached, takes time, skills, commitment and systems that span the virtual, or is it virtually insurmountable, boundary between primary and secondary care. Many of the same skills and systems are essential for good conservative kidney care and to achieve a peaceful and dignified death in renal failure.

The NHS constitution sets the tone and values for the whole NHS including the NHS commissioning board, which will assume operational responsibilities for the NHS from April this year. It enshrines people’s rights and is a ‘must do’ alongside the outcomes framework in the NHS mandate. It ensures a waiting time targets remain in place (they apply to live donor transplantation as well as other planned surgery)– they are in the handbook of the NHS Constitution. Some of the other rights and pledges are less easy to measure, but are no less important. In kidney care, it is the fractures in the system that often carries a risk. The handover from the medical team to the renal team in acute kidney injury, the working relationship between GPs and kidney Consultants, the link between renal community staff and primary care nursing teams, and the commissioning of specialist services (dialysis and transplantation) with the other parts of the pathway.

The Constitution and Francis 2 are as relevant to kidney care, as they are to the rest of the NHS- this relates to treatment and care services. Have you read it?  Are you using it to improve patient experience and outcomes?

Shared Decision Making to Improve Care and Reduce Costs

I have just been reading this editorial by Lee and Emanuel, which makes the point that randomised trials have consistently demonstrated the effectiveness of patient decision aids. In 2011, a Cochrane collaborative review of 86 studies showed that, compared with patients who used usual care, those that used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions and a greater likelihood of receiving care aligned to their values. Moreover, fewer patients were undecided or passive in the decision making process- changes that are essential for patients’ adherence to therapies.

The authors note that progress in embedding shared decision making into routine care has been slow, despite the recommendation of the Institute of Medicine about SDM in the seminal publication "Crossing the Quality Chasm"  back in 2001.

The New England Journal of Medicine editorial, and you don’t get more influential than that, points out that studies in the USA also illustrate the potential for wider adoption of shared decision-making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgically options and more conservative treatment, than patients that do not use decision aids.

The authors suggest that providers who do not document shared decision making processes for preference sensitive health care choices about procedures, should face a 10% reduction in payments for those procedures with reductions in payment gradually increase to 20% over 10 years. It will be interesting to read the letters page of the NEJM next week!!

Consistent recording of pre-renal replacement clinic activity

Preparation and choice are essential to achieving good outcomes in end stage renal failure- whether that is a pre-emptive transplant, one of the modalities of dialysis or conservative kidney care. Good preparation for renal replacement therapy requires a whole team. Money well spent, when one considers the positive impact preparation can have on the experience of care and the clinical outcomes.

From April 2013, the NHS Commissioning Board will directly commission the care of patients approaching renal replacement therapy and today I have written to kidney care clinical directors, finance leads and commissioner colleagues, setting out the coding that will be required to identify this important activity. Details of the expected arrangements can be found below.