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Will care for kidney patients survive the age of austerity and the Health Bill?

Posted Jun 06 2011 12:00am
Modern healthcare is complex. Kidney care is no different . The field is huge, multi-faceted, and the already immense body of clinical and policy literature grows at a frightening rate. There is evidence that better treatment of common comorbid conditions improve health outcomes such as decreasing cardiovascular events and mortality in patients with chronic kidney disease and in end stage renal disease the way clinical teams work together and interact impacts on patient experience and outcomes. However, care of complex CKD patients is often fragmented among different specialists, consultants, nurses, general practitioners, dietitians, pharmacists and other health and social care professionals. As a result, a more cohesive multidisciplinary team approach to CKD is needed to optimise care for comorbidities and CKD, as well as to facilitate the transition to management of end stage renal disease, improve renal replacement therapy outcomes and the experience of conservative kidney care.

Kidney failure has a profound life-long impact on patients, their families and carers. During the course of their patient “journey” they will encounter numerous multiprofessional staff who each have a contribution to make to their management and care. Patients’ varied needs, physiological, practical, psychological and social, will form a focus for different staff at different times. In order to optimise clinical outcomes and to enhance quality of life, multiprofessional staff require a joint perspective on management and care issues, underpinned by recognition of the varied professional skills required, and an ability to work flexibly and in collaboration. Team-based care is a foundation of the chronic care model which calls for productive interactions between informed patients and proactive practice teams to improve health outcomes for people with chronic medical conditions. . A multidisciplinary team is essential but how our MDTs work deserves further investigation. We need to study attitudes , values and behaviours as much as the skill mix and technical competencies .

To support kidney care multi-professional team working new arrangements have been put in place in England for adult services from April 2011. Payment to Trusts for first outpatient visits that are multiprofessional will receive a 50% uplift (price for doctors only visits £198 versus £328 for first MDT visit) with ongoing multi-professional care attracting more than double physician only outpatient attendances (£128 versus £257). This support for MDT led “preparation and choice” applies equally to live kidney donation, setting or place and modality of dialysis and conservative kidney care. People with complex multi system disorders and those with primary kidney disease or post transplant receiving a high dose immunosuppressive regimes and requiring pharmacy or other MDT input will also be able to benefit from this payment for quality. The introduction of this payment system for hospitals has the potential to make another step change improvement to the experience and outcomes of care for people with advanced kidney disease and those requiring multi-disciplinary care because of intricate and potentially toxic treatment.

Multiprofessional care should promote shared decision making which is relevant across the whole of kidney care from risk assessment and management through to advanced kidney disease, replacement therapy and palliative care. Decisions about lifestyle, for instance in the management of hypertension; diet, exercise, moderation of alcohol and smoking cessation, are more likely to ensue if they are accompanied by behavioural change plans that encourage and promote health. Prescribing of medicines should always be preceded by discussion of the indications, potential adverse events and evidence base for the treatment. The patient’s views on the likelihood of a particular class of anti-hypertensive drug causing impotence or the effect of the route of administration, oral or intravenous, of cyclophosphamide in the treatment of vasculitis on subsequent fertility need to be explained by the clinician, considered by the patient and factored into the prescribing decision. The timing of ultrasound scanning in those with a family history of polycystic kidney disease should take into account the possible negative impact – psychological, emotional and financial – of a positive scan as well as the utility of accurate diagnosis. People need time and space to consider these big decisions if the best outcomes are to be achieved.

Good kidney care has always been based on teamwork. The complexity of renal failure, the wide range of treatment options – from an ABO incompatible live donor transplant or daily dialysis to conservative care requires detailed knowledge, precision and technical skills. The impact on physiology, diet, psychological wellbeing and social functioning brings added dimensions to kidney care. Achieving optimal outcomes and improving patients’ experience of care depends on the whole range of skilled and motivated individuals needed to manage different aspects of kidney care; but it also needs individual practitioners to work together and with patients as a multiprofessional team. No one group, single practice or characteristic can make a major difference on its own. A holistic approach including attention to supporting patients, staff working climate, inter-professional respect and integrated practices are required to provide kidney care in the Brave New World.
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