Renal Medicine

Establish NHS-funded, regional renal networks to ensure quality and efficiency of care, monitor service effectiveness, embed sustainable kidney care and accountability for service delivery. a) Renal network priorities to reflect the needs of the region and be guided by the RSTP and GIRFT recommendations. b) Commissioning and clinical leads within networks to set clear priorities for delivery (including sustainable kidney care) and commissioners to hold providers to account. c) Network geographical footprint to take into account patient flows in all renal clinical pathways. d) Multiprofessional renal QI to be embedded within networks and supported by project management, with leads in each renal centre, driven by timely access to data and focused on addressing regionally set priorities. e) Regional renal networks to collaborate with related disciplines at network level to include imaging, critical care and vascular services. f) UKRR/NHSBT to continue with support for national and regional renal QI networks and to deliver leadership training and project management. g) Measures to address inequity of access to renal services, particularly in areas of high deprivation and/or ethnic diversity, to be implemented. (These measures are defined in the text of the relevant chapters throughout the report.)

Ensure that patients predicted to reach ESKD within 18 months are fully assessed in advanced kidney care services and are offered all possible care options. a) A multiprofessional outpatient tariff or alternative effective commissioning approach to be developed to resource optimal advanced kidney care, encompassing comprehensive multiprofessional input that includes psychosocial care and SDM for all patients. b) AKCCs to become a central focus of QI processes and monitoring to improve access to all modalities of renal care. c) Renal centres to incorporate trajectory monitoring of CKD to help optimise new patient nephrology referral service and ESKD preparation planning. d) All renal centres to adopt NICE NG107 which defines the minimum requirements for the AKCC pathway. e) Renal centres to ensure that home therapy options are effectively communicated to those patients for whom a pre-emptive transplant (Transplant First) or a conservative approach is not appropriate. f) Metrics of access of patients with ESKD to renal transplantation and home therapies to be monitored quarterly in all renal centres.

Ensure that access to a comprehensive renal conservative management pathway is available to all patients. a) NHS England and NHS Improvement to define what constitutes renal conservative management in order for UKRR to collect data on patients. b) Access to conservative management to be available for patients where appropriate. Patients will be identified by a comprehensive SDM process. c) Accountable commissioners to develop a year of care pathway tariff or equivalent commissioning tool for renal conservative management. d) A multiprofessional conservative management service to be co-ordinated including a written pathway for identification and management of all potentially suitable patients. (Delivery to involve partnership with community and palliative care teams across ICSs.)

Streamline renal transplant pathways to increase access and reduce unwarranted variation in deceased and living donor (DD and LD) transplantation. a) Discussions to be held in relation to options to improve the renal transplant commissioning pathway, as part of improved system-working. This should include equitable allocation of adequate resource for all steps in the recipient and LD pathways (assessment, surgery, follow-up) to all centres. b) Renal National Service Specification (NSS) to require all providers to track patients with progressive CKD 4–5 using the Transplant First tool or local equivalent, to monitor timely work up of transplant candidates and their donors. c) Renal centres to have a dedicated specialist nurse transplant workforce. d) Renal centres to ensure timely access to diagnostics and specialist opinions needed for transplant assessment. e) Work up pathways of recipients and donors to the point of listing to be tracked using an 18-week timeline, which will require clinically appropriate 'clock rules'. f) Renal transplant NSS to require effective partnership within transplant networks, including local surgical assessment and representation of the referring team on the listing and LD MDTs. g) NICE to develop a national guideline for suitability for transplant listing to be developed which is patient-centred and adopted in a consistent manner across all networks. h) Access to transplant listing, organ allocation and LD transplants needs to be equal for patients of all ethnicities and socio-economic groups.

Reduce variation in incident and prevalent definitive HD vascular access rates and deliver RA clinical practice guideline minimum thresholds* (*60% incident and 80% prevalent patients with AVF/G). a) NHS England and NHS Improvement to review differential pricing, and the effectiveness of the existing HD BPT. b) NHS England and NHS Improvement and professional societies to establish the surgical and IR capacity required to deliver an 80% prevalent definitive vascular access rate. (This will also require formal definition of the pathway urgency to be delivered by relevant teams.) c) Trusts with a renal service to ensure they have sufficient surgical and IR capacity to support their HD programmes. d) Trusts with a renal service to ensure their day case surgery rate for HD arteriovenous fistula/graft (AVF/G) formation is a minimum 70% of all cases. e) All renal centres to have a vascular access co-ordinator post or posts (depending on size). f) Accountable commissioners to explore network-based commissioning of HD vascular access, including commissioning of dedicated vascular access centres and IR support. g) Renal centres to optimise skill mix and competencies of clinical staff in the needling and monitoring of HD vascular access. h) Collaboration with regional vascular access QI initiative to identify local actions needed to implement effective pathways, to be agreed at network level. i) Intervention (+/- transfer where relevant) of failing or thrombosed vascular access to be sufficiently rapid to avoid central venous access (usually 24–48 hours). j) A curriculum, training and qualification process to be developed for credentialling in vascular access intervention.

Ensure home therapy is promoted and offered for all suitable dialysis patients and that a minimum prevalent rate of 20% is achieved in every renal centre. a) All centres to ensure adequate training facilities and staffing for home HD (HHD) and PD, sufficient to deliver the 20% target. (Centres to consult the staffing models outlined in the British Renal Society (BRS) workforce document.) b) The reduced risk of transmissible infection (e.g. COVID-19) for patients on a home therapy compared with in-centre HD (ICHD) to form part of the SDM process with patients. c) All centres to ensure they have a timely PD catheter insertion service. (Local resources will determine service design but a percutaneous method of insertion will become standard in most centres.) d) All centres to establish a late start PD service. e) All centres to ensure collaborative working within renal networks is in place to improve the resilience of services such as assisted automated PD (AAPD) and HHD, particularly for smaller services. f) All centres to ensure that shared care HD becomes a feature of all ICHD facilities in the independent sector and the NHS. g) Research to be undertaken to develop successful strategies to address inequities of access to home dialysis in deprived and black and minority ethnic (BAME) populations.

Ensure that all acute trusts implement patient safety measures (as set out in NICE NG148) to deliver highly effective prevention, detection and management of AKI. a) All trusts to implement the recommendations set out in NICE NG148. b) All trusts to ensure delivery of AKI care bundles as the first response to an AKI alert (shown to improve care quality and reduce length of stay (LoS)). c) UKRR to report comorbidity and casemix-adjusted AKI incidence and mortality in all acute trusts and publish this data in Model Hospital and the UKRR annual report.

Mandate clinically-approved AKI patient transfer to a renal centre within 24 hours of the decision by the receiving consultant nephrologist. a) NHS England AKI NSS to include the requirement for regional network working and to issue AKI patient transfer policy requiring transfer within 24 hours. b) Regional renal networks to monitor delayed transfer by means of exception reporting by referring or receiving centre. c) NHS England and NHS Improvement to develop a mandatory tariff or equivalent commissioning mechanism for AKI requiring HD which will support AKI service delivery and ensure accurate reporting of AKI HD. d) Renal networks, acute trusts and ICSs to ensure urgent nephrostomy insertion (within 12 hours, 7 days per week as per NICE NG148) is achieved through network collaboration making best use of available IR resource; efficient inter-hospital transfer will be required.

Ensure that outpatient services are reformed in line with the NHS LTP to improve equity of access, patient experience and timeliness. a) Renal centres to provide a comprehensive e-referral and non-face-to-face new and follow-up outpatient service across all general nephrology and specialised clinics. b) Provision of remote blood and urine sampling, either in community hubs or by dry chemistry, to be established to facilitate non-face-to-face consultations. c) Improvements to be made to ensure appropriate primary care referral to nephrology services and AKCC transfer through adoption of CKD progression prediction equations embedded in biochemistry laboratory and renal centre IT systems. d) Trusts to ensure equity of patient access to sub-specialty renal clinics within each regional network through a hub and spoke model. e) Renal and transplant centres to transform post-transplant follow up, embedding remote consultation and blood sampling whenever suitable, and reduce default frequency for early post-transplant follow-ups to bi-weekly. f) Ensure sufficient pharmacy input to allow for safe and efficient hospital prescribing and supply of immunosuppressant therapies usually involving homecare services. g) Ensure there is adequate workforce to support psychosocial and physical enablement needs in all outpatient settings.

Ensure that patient experience and SDM are central to the planning and delivery of renal services. a) Patient experience to be made a central component in assuring the quality of care, shaping local QI direction and optimising service delivery strategy. b) Effective, adequately resourced and culturally sensitive SDM, facilitated through clinician training, to be embedded in all aspects of renal care, especially in the AKCC. c) Data returns to the UKRR PREM portal to be mandated in the NSS. d) Sampling strategy for the UKRR PREM to be developed to facilitate inter-centre comparability. e) ICHD non-emergency patient transport to be incorporated in the HD tariff or equivalent and responsibility for the management of these contracts to be transferred to renal providers.

Reconfigure the multiprofessional renal workforce to reflect service requirements and provide optimal care, as defined throughout this GIRFT report, delivering the best outcomes and best patient experience. a) GIRFT benchmarked staffing data, GIRFT recommendations and the BRS workforce document to inform how the workforce needs to adapt to match service need. b) Allocation of regional renal trainee numbers to be reviewed to support current need and address projected need. c) A national strategy to be developed aimed at increasing recruitment into renal medical training. d) A comprehensive national renal nurse training curriculum and accessible online educational resources to be developed (through accredited university courses for NHS and independent sector renal providers). e) The appropriate skill mix necessary to deliver future renal care to be developed, including expansion of multiprofessional ACP roles, physician associates (PAs) and non-medical consultant roles, in alignment with the multi-professional framework for advanced clinical practice.

Reduce variation and co-ordinate improved provision of protocoled, holistic care for patients with diabetes and ESKD. a) Implement the multidisciplinary recommendations set out in the Joint British Diabetes Societies for Inpatient Care (JBDS-IP)/RA guidelines across primary and secondary care. b) Renal centres to ensure that optimising the care of patients with ESKD and diabetes becomes an urgent focus for QI, with a lead in each centre responsible for co-ordination and quality of care.

Ensure that all renal centres adopt a systematic QI approach to infection prevention and control (IPC), with HD bacteraemia and PD peritonitis given equal priority. a) Easily accessible national data to be published quarterly on renal service bacteraemia and peritonitis to drive QI by working with centres and Public Health England (PHE) to improve data reliability. b) Renal centres to appoint a lead from any relevant professional background with responsibility for IPC and oversight into microbial stewardship. c) Relevant national and international practice standards to be comprehensively implemented for IPC in dialysis patients. d) Patient partnership and education to be at the centre of QI efforts in IPC for dialysis patients.

Ensure that data on hospitalisation of RRT patients are available and adopted as a routine element of the quality assurance process in renal care. a) Linked data in prevalent patients with ESKD in the UKRR annual report to be used to report patterns of hospitalisation. b) Monthly quality assurance review and regular access to healthcare professional support for all dialysis patients is an essential part of care that is required to reduce hospitalisation. c) NHSBT to incorporate hospitalisation patterns using data available from HES on incident renal transplant recipients in NHSBT annual reports on kidney transplantation. d) NIHR, KRUK and UKRR to promote research to better understand the factors that drive hospitalisation in renal care and to inform future QI initiatives aimed at reducing variation and hospitalisation overall. e) All renal and transplant centres to incorporate analysis and tracking of hospitalisation data into local renal and transplant service quality assurance process.

Ensure renal centres and ICSs deliver effective medicines optimisation in order to improve the safe care of patients with kidney disease and increase healthcare value. a) Renal centres and ICSs to increase the number and scope of work of the renal pharmacy workforce, guided by the recommendations of the pharmacy section of the BRS workforce report. b) Advanced clinical practice pharmacy roles to be further developed and supported to achieve optimum renal centre care delivery. c) Repatriation of transplant and other immunosuppression from primary to secondary/tertiary renal centre care to be completed with adequate pharmacy resource to ensure safety and supervise generic conversion wherever clinically appropriate. d) Optimisation of CKD-mineral and bone disorder (MBD) medicines, especially generic conversion of calcimimetics, to be delivered in primary and secondary care. e) All centres to ensure there is collaboration with the pharmacy department and adequate staffing to ensure home delivery of medications to support home therapies.

Ensure that renal centres, commissioners and patients have timely access to contemporaneous, clinically relevant outcome data, in order to support quality assurance and quality improvement. a) UKRR, NHS England, NHS Digital and renal centres to revise the core renal dataset, including only essential items. b) UKRR and NHSBT to establish linked datasets with relevant NHS data streams to minimise centre manual data entry and provide new insights into care quality. c) Mandated data returns to be developed and collected for patients with CKD 4–5. d) All centres to have a data manager dedicated to renal informatics, with sufficient time to meet the requirements of mandated data returns. e) All renal centres and renal IT providers to return real time data to UKRR by the end of 2021, as mandated by NHS England. f) Expand the NHS England Renal Quality Dashboard to include key benchmarked metrics from the GIRFT dataset (available quarterly). g) The correct currencies to be adopted for all aspects of the transplant pathway and used to report accurate activity and reference cost data.

Ensure that procurement of HD facilities and home therapies delivered in partnership with the independent sector offers consistent quality and cost-effectiveness across the NHS in England. a) Minimum specification contracts to be developed for independent sector HD and managed equipment service facilities, with scope for local flexibility. Contracts to include framework for price and clinical governance arrangements. b) A central register of procurement activity of dialysis facilities and services to be developed; price per therapy should be transparent in the NHS Spend Comparison Service (SCS) or an alternative NHS Digital mandatory contracts register. c) NHS England and NHS Improvement to develop a catalogue of standard consumable, equipment and service codes that can be used in purchase orders, enabling benchmarking of costs and ensuring consistency across the system. d) National contracts to be developed with the independent sector for home therapies which are patient-centred and include guarantees of geographical completeness.

Reduce litigation costs through application of the GIRFT programme's five-point plan (actions a-e) in addition to actions f and g which are specific to renal medicine. a) Clinicians and trust management to assess their benchmarked position compared with the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT litigation data pack. b) Clinicians and trust management to discuss with the legal department or claims handler claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Trusts to inform NHS Resolution of any claims that are not coded correctly to the appropriate specialty via CNSTHelpline@resolution.nhs.uk. c) Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SIs); where a claim has not already been reviewed as an SI, this should be carried out to ensure no opportunity for learning is missed. e) Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trust examples of good practice where it would be of benefit. f) NHS Resolution, in collaboration with GIRFT, the renal providers and professionals, to define and publish the criteria by which they identify cases attributed to renal medicine, including all relevant surgical cases. g) Trusts to adopt these criteria when cases are referred to NHS Resolution and use them when reviewing claims as part of the GIRFT Programme's five-point plan.