An integrated kidney care system?
Where you live, does everyone with kidney disease know that they've got it and what it means? Are local GPs confident about how to manage them, and who will benefit from referral?
It was inspiring to hear from at least three nephrologists presenting at the Renal Service Change Management study day last week, who clearly feel that what happens to people in primary care is their business too.
I'm coming at the topic from a sustainability angle: squeezing maximum value to patients from everything we do - every blood test, every car journey, every intervention. Having a really clear system which identifies CKD early, encourages self-management and excellent BP control, and targets specialist resources where they can make a difference - intuitively this has a lot to offer patients, the NHS and the environment.
Dr Paul Cockwell from Birmingham described work with local GPs to develop primary-secondary care links, improve risk stratification of CKD patients and develop local treatment & referral guidelines. He highlighted capacity problems in secondary care - if everyone meeting NICE guidelines were suddenly referred, services would be swamped. Dr Arif Khwaja presented the Sheffield remote monitoring service, which could provide part of the solution: patients follow a management plan drawn up with renal specialists but bloods and BP are monitored in primary care - supported by telephone follow up from a nurse specialist. Documented carbon savings in their pilot service amount to 507kg CO2 equivalents (from reduced patient travel) so far.
So some good ideas already in practice… Unfortunately, under current funding arrangements, they could spell financial suicide for specialist units. The NHS tariff system (which rewards hospitals for carrying out as many clinic appointments as possible, regardless of whether they are necessary) is clearly the wrong mechanism to incentivise efficient, high quality care. But what to do about it?
Dr Hugh Rayner had some practical suggestions: return to block contracts (after all, a lot of current negotiations are really sham - Trusts always get paid in the end); and create local commissioning agreements around new indicators, such as a low ratio of outpatient appointments to CKD registered population (smart! this would incentivise more registration as well as avoidance of low value clinic attendances).
One part of the answer could be a more holistic approach to service evaluation, one which measures environmental, social and financial sustainability across the whole care system, and can inform commissioning decisions which are fit for the future. This is something that CSH is working to support through creation of new Green Nephrology fellowships, working with pioneer renal services.
We'd be keen to hear from more renal services with ambitions for change!
Medical Director, Centre for Sustainable Healthcare