A campaign to reshape kidney care within the National Health Service (NHS) in England was the subject of a centrepiece session at the recent UK Kidney Week event in Wales (5–7 June, Newport, UK), with a host of speakers setting out the ambitions of the Renal Services Transformation Programme (RSTP). The multi-agency programme is led by Ahmad Saleem Ullah (Head of Renal Services Transformation Programme at NHS England) and Smeeta Sinha (Salford Royal NHS Foundation Trust, Salford, UK), national clinical director for renal services in NHS England. Both were in attendance to outline the project, which has just completed its design phase.
Speaking to introduce both the programme and the session, Richard Fluck (Royal Derby Hospital, Derby, UK), national clinical director of the Internal Medicine Programme of Care at NHS England and clinical senior responsible officer for the programme, said that its aim is to build a service model “that moves towards a learning system” and “a structure that allows us to continually improve and develop our service”.
Expanding on this, Fluck stated: “To do that, the system needs to join up the care pathway for individuals and tackle unwarranted variation. We also need to look at population health and not just provider delivery.”
The core principle behind the RSTP is to expand clinician thinking across systems to a “whole pathway approach”, one which creates the maximum number of opportunities for early intervention. Fluck highlighted the concept of “vertical integration” of care, meaning the consideration of all of a patient’s needs at a particular stage rather than limiting the scope of their care to their kidney disease. He gave the example of frailty, something which must be managed alongside renal disease for many older patients, and he also noted that patients with cardiovascular disease, for instance, need to be treated in a way that limits their cardiovascular risk.
Before giving the floor to the next speaker, Fluck said the programme “has provided a roadmap for delegation of services”, allowing local NHS England services to find their own tailored solutions to their unique challenges. With the programme’s design complete, he concluded that 2023 will be the year to deliver it in practice and support implementation through renal clinical networks.
Next up came Sinha, who started by outlining the collaboration that allowed for the development of the RSTP. “Renal community has always had a multidisciplinary approach to the way we deliver care,” she stated. “This programme is no different—we have engaged with the charitable sector and other people within NHS England, and we have been going to various committees to highlight how important renal services are.”
Sinha explained that part of the programme included regional renal clinical networks, which help each region to deliver the programme’s aims. Some of those aims, she suggested, could be “quick wins” that could be accomplished with relative ease, among them an expansion of access to home haemodialysis.
More broadly, the programme’s “toolkit”—detailed later in the presentation—highlights the need for more preventative care, particularly in the areas of chronic kidney disease (CKD) and acute kidney injury (AKI). One of the challenges in CKD care in the NHS that Sinha outlined was the “significant variation in the services offered […] and outcomes achieved” for patients. Early detection, foundational to the toolkit, is crucial to improving the situation, she said.
Cost is another major health system challenge. Highlighting the work of another presence at UKKW, Kidney Research UK, Sinha pointed to their recently published report on the health economics of kidney disease to 2033. This report, she noted, suggests that previous estimates of the cost of kidney disease to the UK healthcare system of £2 billion were a considerable estimate—with the real cost estimated now to be £6.4 billion. This represents a cost that could be mitigated by service improvement. The same report, Sinha said, suggests that implementation of improvements like those recommended in the RSTP could prevent 10,000 premature deaths by 2033.
With the focus of the session turning to the resources the programme is launching, Sinha handed over the spotlight to Saleem Ullah. He began by explaining that the “drive” of the programme was to identify what kind of environment is required for systems to improve the quality of renal care. RSTP, he explained, was developed in response to a need to transform renal care and incorporated recommendations outlined in a report on renal services from the Getting It Right First Time (GIRFT) team, and looks to improve care through, in particular, better collection and integration of data.
With that in mind, the programme is launching two products. First is the toolkit, which comprises a collection of case studies, alongside principles for best practice that can be explored through self-assessment questionnaires and help systems with driving improvement. “It is not a mandated document or a commissioning guideline, or even national clinical guidance that we expect systems to adhere to,” Saleem Ullah specified—it is designed to provide supporting information on all elements of renal clinical pathway and cross cutting themes, and is not meant to be read in its entirety.
The toolkit is broken up into two sections, first a short-read summary which “summarises key messages we are trying to get across to drive transformation”, Saleem Ullah explained, and second an interactive section containing more details including actions that could be taken achieve transformation principles, self-assessment questionnaires, patient stories and links to other resources. He recommends that it is used in collaboration by a whole renal care system, rather than alone as an individual. It includes research and information from a variety of charities such as Kidney Care UK and the National Kidney Federation and amounts to a “one-stop shop” of information and resources in the area. The dashboard, launched alongside the toolkit, has been developed following an engagement process similar to developing the toolkit and provides information and data to clinicians to inform their decision-making, Saleem Ullah divulged.
With the details sketched out, Sinha then retook the stage. She explained a little more on the philosophy behind the project—how it aims to look at CKD across a patient’s whole experience of the disease, rather than only involving renal services as the disease progresses. Further, she outlined the principles at the heart of the RSTP’s approach. The development of integrated CKD clinics, as well as shared decision making with patients, are prime among them. They also include greater focus on patient monitoring and risk reduction, as well as the integration of CKD dashboards and coding—“because we know that by coding people, their outcomes are better, as it helps with their treatment”.
Later speakers at the session included Nitin Kolhe (University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK), who focused on reforms to the treatment, management and prevention of acute kidney injury (AKI). The AKI section of the programme calls for improved identification of those patients at risk, as well as “timely intervention” and better post-discharge care.
In the penultimate part of the session, Nicholas Torpey (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK) weighed in on the kidney transplantation first approach. Its key principles, he outlined, include a reduction in inequities in transplant and waiting times across NHS units. The aim is optimisation of the use of each donor organ, achieved in part through the minimisation of cold ischaemic time. Following Torpey, Saleem Ullah returned to cap the session, calling for clinicians to adopt the same multidisciplinary, co-operative approach used in the development of the programme in their own implementation of its recommendations.
