Walking the walk or just talking the talk

Walking the walk or just talking the talk: how do we make progress? Richard Fluck Date: 16 th March 2016

The strategic challenge • Numbers requiring RRT are growing • Population is older with more comorbidities • Home therapies are in decline – especially PD • Economic downturn has implications for healthcare expenditure 19/03/2018 Home Therapies Richard Fluck 2

Figure 2. 2. Growth in prevalent patients by treatment modality at the end of each year 1997– 2012 19/03/2018 UK Renal Registry 16 th Annual Report Home Therapies Richard Fluck 3

Falling PD Figure 2. 9. Modality changes in prevalent RRT patients from 1997– 2012 19/03/2018 UK Renal Registry 16 th Annual Report Home Therapies Richard Fluck 4

Rise in home HD Figure 2. 10. Detailed dialysis modality changes in prevalent RRT patients from 1997– 2012 * Scottish centres excluded as information on satellite HD was not available 19/03/2018 UK Renal Registry 16 th Annual Report Home Therapies Richard Fluck 5

Variation Figure 2. 8. Percentage of prevalent haemodialysis patients treated with satellite or home haemodialysis by centre on 31/12/2012 ∗Scottish centres excluded as information on satellite HD was not available. No centres in Northern Ireland have satellite dialysis units 19/03/2018 UK Renal Registry 16 th Annual Report Home Therapies Richard Fluck 6

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Ambitions • 3. Self-management: All people with kidney disease are offered as much information as they would like in order to understand manage their condition. • 4. Person-centred care: Care is centred on the person, taking into account individual needs and preferences, quality of life, symptom burden and the presence of co-existing medical conditions. 19/03/2018 Home Therapies Richard Fluck 9

• 6. Preparation and Choice: All people approaching end-stage renal disease, or moving from one type of treatment for end-stage renal disease to another, understand are given sufficient time and support to prepare for a treatment that is suitable for them, chosen from the full range of options. 19/03/2018 Home Therapies Richard Fluck 10

The House of Care 19/03/2018 Home Therapies Richard Fluck 11

Commissioning of RRT The base

Key principles • Ensure patient pathway integrity • Enable CCGs to better allocate their resources efficiently • Move to accountability linked to population outcomes • Improve financial incentives for commissioners and providers • Offer value across the system and to individuals 19/03/2018 Home Therapies Richard Fluck 13

But at all times our guiding principle will be: walk in the shoes of the people we serve. Think like a patient, act like a taxpayer Simon Stevens, April 2014, Newcastle

Reimbursement • Short term • Mitigate short term issues • Long term • • • Process of internal and external consultation Review of pricing engine Challenge re reference costs Renal specific – strategic review of reimbursement structure Incentives? 19/03/2018 Home Therapies Richard Fluck 15

Service specifications • Modality specific • Clear pointers to shared care • CQUIN re shared care • Better metrics 19/03/2018 Home Therapies Richard Fluck 16

Specialised status • Advantages • High costs and complexity • Disadvantages • Reimbursement structure • One aspect of patient pathway • Collaborative solution • Reintegrate patient pathway • Plan A, B and C • Reestablish provider networks driven by peer review 19/03/2018 Home Therapies Richard Fluck 17

Patient participation The left hand wall

Engaging the patient on multiple levels Carmen, Health Affairs Feb 2013 32: 232 Therapies Richard Fluck 19/03/2018 Home 19

Integration Care delivery Location Dependent Independent Home AAPD ? AHHD PD HHD (>4 x week) In-centre HD (3 x week) Self care HD (3 -7 x week)

Education, self-awareness, changing beliefs about patient‘s role, self-management support, skills development Skills, knowledge and confidence matrix CSPAM scores (Clinician support for patient activation) High Low 19/03/2018 High PAM scores (patient activation) Home Therapies Richard Fluck Changing beliefs about clinician’s role, leadership, skills training e. g. MI, communication, coaching Interventions 23

Measurement and improvement: the ceiling

Data • Numbers • Organisational process • Outcomes • Clinical • Patient centred • Value 19/03/2018 Home Therapies Richard Fluck 25

Survival by Dialysis Modality—Who Cares? All-cause patient mortality rates, overall and by modality, US Renal Data System ESRD Database, 2011. Adjusted for age, sex, race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis. 19/03/2018 Home Therapies Richard Fluck CJASN 2016 e. Pub Martin B. Lee* and Joanne M. Bargman† 26

Value The Renal Alliance: UKRR, PHE, CVIN, Right. Care and Commissioning for value 19/03/2018 Home Therapies Richard Fluck 27

Recovery time after HD 19/03/2018 Lindsay Clin J Am Soc Nephrol. Richard Fluck Sep; 1(5): 952 -9. Home Therapies 2006 28

Home therapies: Patient Quality Markers - Restless legs and depression 19/03/2018 Jaber Clin J Am Soc Nephrol 6: 1049– 1056, 2011 (FREEDOM study group) Home Therapies Richard Fluck 29

The right hand wall: professionals

What do the professional stakeholders need to offer? • Leadership: vision, courage and commitment • Individual • Organisational • Expertise • Drive improvement – e. g. quality improvement 19/03/2018 Home Therapies Richard Fluck 31

Home therapies QI • KQui. P • Stakeholder led • RA, BRS, BKPA, NKF, KRUK, BTS • NHS England home nations • Strategic alliance to foster QI 19/03/2018 Home Therapies Richard Fluck 32

Improving the pathway Establish an MDT to assess new starters • Consider legibility • Shared decision making – • ? Physician led PD insertion • Training • Late presentation • • Perit Dial Int. 2013 May-Jun; 33(3): 233– 241. 19/03/2018 Dialysis Measurement, Analysis and Reporting (DMAR: Oliver Medical Management, Toronto, ON, Canada) Home Therapies Richard Fluck 33

Home haemodialysis 19/03/2018 Home Therapies Richard Fluck 34

Summary 19/03/2018 Home Therapies Richard Fluck 35

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