Renal services in Scotland are producing good outcomes for patients but there is still much to do to deliver the high standard of service that patients want, says a report from the country’s health watchdog, NHS Quality Improvement Scotland.
Renal services in Scotland are producing good outcomes for patients but there is still much to do to deliver the high standard of service that patients want, says a report from the country’s health watchdog, NHS Quality Improvement Scotland.
An assessment of the performance of Scotland’s 10 renal units found a general high level of compliance with most standards. However pressures were also evident on certain services which are affecting the treatment and care of kidney patients. The report calls for adequate numbers of medical and support staff to be provided to improve the care offered to patients.
The report has four key messages:
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Care of people with kidney disease needs to be flexible, of high quality and personally tailored. Renal units in Scotland are currently running at full capacity. Without forward planning of these services, treatment may be compromised;
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Investment is needed to promote pro-active treatment. Together with effective monitoring this can reduce complications and improve outcomes;
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Better support is required for patients. Key staff such as renal nurses, psychologists, dedicated pharmacists, dieticians and support workers need to be in place across Scotland;
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Transplants offer hope to many and should be encouraged by getting people to carry donor cards and registering with the national organ donor scheme. Donated kidneys should be retrieved by experienced transplant surgeons.
Kidney disease is a chronic, lifelong condition and the report highlights the fact that issues that affect the quality of life of patients are every bit as important as their medical management.
There are currently around 3,500 patients in Scotland who need renal replacement therapy either through dialysis or transplantation following kidney failure. The number of patients being treated has risen steadily in recent years as a result of improvements in therapy and from the rise in diabetes, which increases the risk of kidney disease. These trends are expected to continue and it has been estimated that the demand for hospital-based dialysis could increase by 60% in the next few years.
However, the report found that services at the moment are almost at full capacity. It found that only one unit met the standard of being able to offer all new patients an outpatient appointment within a month of referral. A shortage of medical staff was the main reason for this failure although many units had effective prioritisation systems in place to ensure that the most urgent cases are seen quickly.
Pressure on dialysis units has also meant that two were unable to extend dialysis sessions if required to provide adequate dialysis. Limited facilities, staffing problems and organisational issues are the reasons for this problem. The report calls on the Trusts which failed to meet this standard to review their services to ensure that patients receive adequate treatment.
Anaemia is a problem for kidney patients if haemoglobin levels are not maintained at an acceptable level. Only three out of ten units met the target for haemoglobin levels. There were a variety of reasons for this failure including the a lack of availability in some units of the drug erythropoietin (EPO), the most effective treatment for anaemia.
Six out of ten units failed to meet the standard for creating a ready access to the patient’s bloodstream to assist with dialysis. This involves a small operation to create a permanent access directly into the patient’s bloodstream. A lack of dedicated operating theatre time and a limited number of available hospital beds has resulted in patients being dialysed using temporary access which can compromise their treatment and increase the risk of infection.
Dialysis is a lengthy procedure. Patients need to attend for at least four hours, three times a week. It is important that services are organised efficiently to prevent any delays for these patients. However, the review found that no unit could demonstrate that all patients began dialysis within one hour of their appointment time. Only one unit met the standard of arranging for all patients to be collected for their return journey home within one hour after their dialysis.
Worryingly, the report notes that travel difficulties in remote and rural areas are resulting in patients continuing with home-based peritoneal dialysis despite suffering frequent episodes of peritonitis. It says that Trusts must work to develop innovative solutions to travel problems in remote and rural areas.
Attention to diet is also important in kidney patients and, if this is managed well, it can delay the need for dialysis. Assessments should be carried out at six-monthly intervals to help support patients and identify those at risk of malnutrition. The inspection found that good nutritional protocols are in place in Scotland but only half the units met the standard for the six-monthly checks. This is due to a shortage of dieticians in Scotland and the report express concern that this will get worse as patient numbers increase. It found some evidence that dieticians are too busy to review patients at risk of malnutrition as they have to concentrate on those who already have problems.
Kidney transplantation is a success in Scotland with high patient survival rates of more than 95% at one year in all three transplant units. However, the need for donor kidneys has never been higher which highlights the importance of encouraging members of the public to agree to become organ donors. It is also vital to make the best use of all available organs and the report expresses concern that donor kidneys are not always retrieved in Scotland by an experienced transplant surgeon. It also notes that variation exists between the three Scottish units in the criteria for acceptance of donor kidneys with one unit having a higher rate of acceptance from “marginal” donors which may result in an increased risk of failure.
Although kidney patients in Scotland have good access to clinical staff, there are problems with the availability of other services such as counselling help. The report says that as renal disease is a lifelong condition, it is important that non-clinical support services are provided.
The assessment visits were carried out by groups of staff experienced in kidney disease treatment, kidney patients and members of the public. Overall they found good compliance regarding the management, availability, effectiveness and monitoring of kidney treatment services. They also recorded many examples of good practice across the country. The report concludes that the care of renal patients in Scotland is well organised and effective but there is still much that can be done to improve services further.
Dr Bryan Junor, a consultant kidney specialist who chaired the group which produced the report said: “The standard of care has improved in Scotland over recent years but there is still much to do. We have identified where there is scope for change and improvement and it is now up to each trust in Scotland to review its service in the light of our findings. It is vital that planning takes place now to cope with the expected increase in patient numbers in the coming years. We need to ensure that there are adequate staff and facilities so that even better outcomes can be achieved in the future.”
Lord Naren Patel, Chairman of NHS Quality Improvement Scotland said: “This report gives us for the first time a detailed picture of renal services across Scotland. It has been produced with the active involvement of both patients and members of the public. It shows that renal services are generally well organised and are producing successful outcomes for patients. However it also shows that some services are under pressure and makes a series of important recommendations on how they can be improved. It is now clear where action is needed and we will be monitoring developments to see that services for kidney patients in Scotland are improved further.”
The report includes a checklist of questions that patients and their relatives can use to help to find out more information about their treatment.
Notes to Editors
NHS Quality Improvement Scotland (NHS QIS) has been established to improve the quality of healthcare in Scotland. To do this, it will set standards and monitor performance, and provide NHSScotland with advice, guidance and support on effective clinical practice and service improvements.
The clinical standards it develops, defined in partnership with members of the public and healthcare professionals, follow the ‘patient journey’ as they move through different parts of the NHS. This NHS QIS system of assuring quality is designed to complement the duty that has been laid upon the board of each NHS body by the Health Act 1999 to monitor and improve the quality of healthcare which it provides to individuals (clinical governance).
NHS QIS is independent from government. Although it is accountable to the Scottish Executive for delivering its work programme and for the public money it spends, NHS QIS reaches its own conclusions on the quality of services being provided by the NHS, and publishes its findings