The Getting It Right First Time (GIRFT) national report on renal medicine represents a “call to action” for the UK renal community, and provides greater focus in driving quality improvement across care pathways for kidney disease. These were among the prominent take-home messages from an hour-long webinar that took place on 7 December 2021 to discuss the report’s findings and how best to implement its recommendations.
“I truly believe that this is the best opportunity in over a decade to be able to deliver these important changes, and the GIRFT report gives a clear roadmap of recommendations for how this may be achieved,” said Graham Lipkin, a consultant nephrologist at the University Hospitals Birmingham NHS Foundation Trust (Birmingham, UK) and joint clinical lead for the GIRFT report on renal medicine.
He noted that the report, which was published in September 2021 and is now available online, centres on data analysis involving all 52 of the adult renal centres in England. The key finding of these analyses, in addition to insight gained from in-person visits to each unit, is that—despite there being “well-working, multidisciplinary teams of clinicians and managers, all committed to delivering excellence of clinical service” across the country—there was also “widespread, unwarranted variation” between centres in terms of patient access, experiences and outcomes.
GIRFT report recommendations
As such, Lipkin outlined, the national report contains a total of 18 key recommendations intended to improve NHS services for the hundreds of thousands of advanced kidney disease patients in the UK. One of the more noteworthy of these recommendations centres around increasing opportunities for patients to receive home dialysis therapies by promoting and offering these at-home options to all suitable patients—with the ultimate goal being to have at least 20% of all dialysis patients using an at-home modality like peritoneal dialysis (PD) or home haemodialysis (HHD) in every centre.
Ensuring more equitable access to kidney transplantation is also among the key points outlined in the report, Lipkin stated, with the overarching recommendation here being to streamline current renal transplant pathways and reduce existing variation in both deceased and living donor transplantation. The GIRFT report’s emphasis on improved overall management of patients with acute kidney injury (AKI)—particularly regarding prompt detection and transfer—and the introduction of more definitive target rates and success measures in vascular access, were highlighted by Lipkin as well.
Following this, Will McKane, a consultant nephrologist and clinical lead for transplantation in the Sheffield Kidney Institute at Sheffield Teaching Hospitals NHS Foundation Trust (Sheffield, UK), stated that the renal community in the UK is “incredibly lucky” to have many rich sources of data, including those from the UK Renal Registry (UKRR). He also noted, however, that the GIRFT report found a lack of completeness across datasets from individual units within the UKRR, with many centres claiming their datasets were not up-to-date enough to truly support core quality improvement. A subsequent GIRFT recommendation focuses on ensuring renal centres and patients alike have timely access to contemporaneous, clinically relevant outcome data moving forward.
McKane, who is also the joint clinical lead for the GIRFT report on renal medicine, asserted the importance of infection prevention and control—and the need for bacteraemia in HD and peritonitis in PD to receive equal priority—before concluding that the reestablishment of National Health Service (NHS)-funded, regional Renal Networks is another key component of the report. “The dissolution of the Renal Networks in 2014 was to the great disadvantage of renal care,” McKane said. “We see them as being a really important vehicle for improving renal care.”
Key recommendations from the report include:
- 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.
- Ensure that patients predicted to reach end-stage kidney disease (ESKD) within 18 months are fully assessed in advanced kidney care services and are offered all possible care options.
- Ensure that access to a comprehensive renal conservative management pathway is available to all patients.
- Streamline renal transplant pathways to increase access and reduce unwarranted variation in deceased and living donor (DD and LD) transplantation.
- Reduce variation in incident and prevalent definitive haemodialysis vascular access rates and deliver Renal Association clinical practice guideline minimum thresholds (60% incident and 80% prevalent patients with arteriovenous fistula or graft [AVF/G]).
- 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.
Implementing GIRFT in practice
UK Kidney Association (UKKA) co-president Paul Cockwell (Birmingham, UK) kicked off a subsequent roundtable discussion by thanking Lipkin and McKane for their leading roles in putting together the GIRFT report, and noting that—based on feedback from a number of UK renal centres—their supportive efforts have already made an impact on both the clinical and operational management sides of things. He then introduced Fiona Loud, policy director at Kidney Care UK (St Albans, UK), who asserted that “the wake-up call here is around the patient voice”. “Through many years of looking back at the way in which we have seen kidney care, that voice has not been represented enough,” she added.
Loud went on to note that shared decision-making, psychological support, and available transport options and modality choices in dialysis specifically, are all “huge concerns” for patients, before echoing McKane’s earlier point on the critical importance of the UK Renal Networks coming together again. “But, none of this will work if we do not listen to that patient voice and if it is not acted upon,” she added.
National Kidney Federation (NKF) president Kirit Modi (London, UK) followed this by claiming that, despite the profound impact COVID-19 has had on kidney disease patients in the UK over the past two years, he is currently “optimistic” following publication of the GIRFT report on renal medicine. “We have—for the first time—a fantastic and detailed report that analyses what is happening in our centres, gives us up-to-date data, and makes amazing recommendations,” he said.
Modi also noted that the UK renal community’s record regarding home dialysis is “not very good”, with many of the same issues, such as the need to increase usage of at-home modalities, having been around for “a long time”, as well as being underscored in a number of previous reports. “The case for home dialysis is very strong and I sense now that there is a general feeling among the kidney community that it is something we should address now—which is why I was so pleased to see it highlighted as one of the key aspects within the GIRFT report.”
In the discussion, Modi touched on the role the Renal Service Transformation Programme (RSTP) looks set to play alongside GIRFT—providing an appropriate introduction for Neil Ashman, clinical lead for RSTP (London, UK). Ashman stated that the two programmes are very much aligned in their goals moving forward, in spite of the disruption COVID-19 has caused, and detailed key RSTP targets designed to support the development of accountable strategic networks in every UK region and ensure quality, guide strategy, and continuously assess and improve care offerings. He reported that there is still a lot of work to be done on this front, but that a “line in the sand” has now been drawn, with a “finished product” for implementing change hopefully being ready by April 2023.
UKKA co-president Sharlene Greenwood (London, UK) further alluded to the widespread variation identified in NHS workforces by GIRFT, adding that this is a “really important” part of the discussion—because that same workforce will be responsible for carrying out the report’s recommendations. Enhancements to the current system, and the introduction and development of new working roles, such as physician associates and consultant positions, may aid this, she stated.
“This is where KQuIP [Kidney Quality Improvement Partnership] is going to be incredibly useful, as it is embedded across all of the different [renal] networks that have re-emerged, and I think we need to be supporting our local workforces to be able to deliver on all of these great ambitions,” Greenwood said. Rachel Gair, KQuIP programme lead at the UKKA (Exeter, UK), agreed with Greenwood, asserting that KQuIP is “dependent” on a workforce that is skilled in quality improvement (QI). “So many units are doing QI—and doing it really well—but we have to understand that change does not happen in isolation,” she claimed. Gair also stressed the importance of workforces being upskilled and also celebrated, particularly at a time when NHS staff are severely fatigued due to the pandemic, with information sharing between centres and data usage being key in this process.
Fittingly, the webinar discussion was then closed by Tim Briggs, chair of the GIRFT programme and national director of clinical improvement for the NHS (London, UK), who applauded Lipkin and McKane for their work on the renal medicine report. He also went on to reiterate Loud and Modi’s points on the importance of shared decision-making and patient involvement. “I think we now have a focus on how we can drive quality improvement going forward,” Briggs concluded.