Hugh Rayner: Right patient, right time, right place—an example from kidney care

hugh_raynerDialysis treatment for end stage kidney disease is a burden on patients, taxpayers, and the environment. The carbon cost of dialysis is estimated to be seven tonnes CO2 equivalents per year. Although we can make the improvements to reduce this, the ideal is to prevent people from reaching end stage kidney disease.

Traditional systems of care do not always mean that kidney patients get the right care at the right time to avoid losing kidney function. A recent paper from Cardiff described the organisation of care for patients with diabetes and chronic kidney disease. It showed that many patients who should be seeing a nephrologist had not been referred. Conversely, many patients continued to attend a specialist clinic when they could be followed in primary care. Age seemed to play a big part in this, older patients being more likely to be in the “wrong” place. However, if all patients who merited seeing a specialist were referred, would the system cope?

I faced this problem about 10 years ago when I found the number of patients attending my diabetes-renal clinic was growing exponentially. I was definitely struggling to cope. And yet I realised that if I was going to make a difference to the natural history of kidney disease, I needed to see more patients at an earlier stage of their chronic kidney disease (CKD).

The answer was to take a step back and implement a system of care that worked across the local population. It is based on an IT system that allows me to track the kidney function of patients with CKD without them attending the clinic in person. This is done from a graph of the estimated glomerular filtration rate (eGFR) over time. I select those patients with deteriorating function who do need to come in person. Those with stable function continue under the care of their GP or in the general diabetes clinic. Discharging patients from clinic became easier and safer; indeed they are never completely discharged from my care. The appointments freed up are available for new referrals.

The graph of eGFR over time is invaluable for patients as well as clinicians. It allows everyone to see what is happening and whether the treatment is making a difference. A letter is written directly to the patient after each consultation, including the eGFR graph. This is also copied to the GP. The single most important issue is blood pressure control. Seeing the GFR stop falling when the BP comes under control is very motivating to continue taking the tablets.

The details of this service have been published in BMJ Quality and Safety. We showed that the number of patients with diabetes who started dialysis fell significantly after the service was introduced. Since then, thanks to funding from the Health Foundation, we have extended the way of working to cover all tests requested by GPs by incorporating it in the pathology service.

After a peak in 2005, we have continued to see a decline in patients needing to start dialysis. This year we are on track to start the same number as we did 10 years ago, despite the 10% growth in population that we serve. This is great news for patients, clinicians, and the wider NHS—one patient’s dialysis can cost £35 000 per year. However, because money flows to those parts of the NHS that do more activity (so called payment by results) I was blamed by some for cutting the income to the department by reducing the number of patients coming to outpatients and starting dialysis. Introducing a payment system that encourages people to do fewer rather than more low value activities would make it easier to persuade others to adopt this system.

Competing interests: I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Hugh C Rayner is a consultant nephrologist, Heart of England NHS Foundation Trust. He spoke on these issues at the CleanMed conference, which was held from 17 to 19 September, 2013.