Charlie Tomson
Consultant Nephrologist, Southmead
Hospital, Bristol
Early
chronic kidney disease (CKD) is extremely common, and commonly unrecognised. It
is this unrecognised burden of CKD that is the iceberg that could sink the
Titanic of UK Renal Medicine. There is a real danger in that seeing only the
tips of the icebergs that we happen to run into – the late referred patients
whose increased morbidity and hospital stay is such an important, and
avoidable, part of our daily work – will lead us to sail further into the
iceberg field and demand earlier referral of all patients with CKD. This will
surely sink us all.
Although
the evidence base is far from perfect, we now have clinical practice guidelines
that set out what is required. We need a system that will ensure that we only
spend time and energy seeing patients to whose care we add real value – those
with progressive CKD, and of course the even smaller proportion of patients
with CKD due to treatable underlying disease. The system would deliver safe,
timely, effective, efficient, and equitable patient-centred care.
The system
of recognition, management, and referral of patients with CKD clearly needs
fundamental re-design. Achieving change in a system as large as the NHS
requires a greater understanding of what makes change happen, as well as
subject matter knowledge. Most other industries – car manufacture, aviation,
banking – have learnt these lessons over the last 20 years, but healthcare has
been extraordinarily resistant to change. Doctors have led the resistance (like
officers holding the steerage classes below decks at gunpoint on the Titanic),
claiming clinical freedom and resisting “cookbook medicine” (as though cooking
complex meals without recipes was a mark of being a “real professional”).
So, how
can we achieve breakthrough change in our system? An important lesson from
industry is to respect everyone in the system, and to empower them not only to
do their job but to encourage them to experiment to find better ways of doing
it. The second is to make teamwork a condition of employment. Doctors who show
disrespect for other team members or their patients have no place in modern
healthcare, and the same applies to everyone else on the team. Having achieved
a respectful environment (which requires support from senior management as
well), quality improvement teams can start working.
Often, we
know what works, or what treatment we want to deliver reliably; the difficulty
is making our system deliver it. Quality improvement requires clear aims, a
clear plan of how those aims are going to be achieved, and regular measurement
of outcome, followed by rapid, small tests of change using the
plan/do/study/act cycle.
So where
do we start? Improvement is hard work. The most important lesson is: steal
shamelessly. We’re all on the same side in healthcare, and there is plenty of
work to go round. Collaborative improvement projects – with active sharing of
ideas, tests, and results of improvement projects at meetings, on e-mail
listservs, and on phone conferences – have resulted in breakthrough
improvements in many places in the US, and also in the UK, where the
modernisation agency has tried hard to introduce the concepts outlined above.
It’s time that renal medicine in the UK learnt these lessons. The BRS has a
unique role to play in facilitating this learning.
Sources
for further information on health improvement
http://www.improvingchroniccare.org/