DESIGNED TO TACKLE RENAL DISEASE IN WALES DRAFT 2 nd STRATEGIC FRAMEWORK for

Transcription

1 DESIGNED TO TACKLE RENAL DISEASE IN WALES DRAFT 2 nd STRATEGIC FRAMEWORK for Aims, Outcomes and Outputs The National Service Framework Designed to Tackle Renal Disease in Wales sets standards of care for people at risk of or who have renal disease. The table below captures the formal aims of the NSF. The second column states the desired long term outcomes which are measurable and the third column sets out the key outputs needed in order to achieve the outcomes. AIM OUTCOME MEASURE OUTPUTS REQUIRED to achieve this outcome Demonstrable approaches to collaborative Renal Advisory Group and Renal Networks working working between National and local bodies collaboratively on the planning and delivery of services involved in planning and delivering renal care including evidence of patient and carer Renal services being delivered across Wales on an involvement integrated and responsive basis Care for All An integrated system of patient care across all levels of the service and involving patients at every step of the way Service providers working with Renal Networks to identify and agree investment of renal resources Use of current and any additional resources for renal services determined by the Renal Networks Representation and involvement from all those with an interest in renal care on the groups planning and delivering renal services. Costed plans for renal care agreed on a National Basis but which reflect local requirements 1

2 Prevent Renal Disease Reducing the rate of renal disease through primary prevention Improve detection of renal disease Ensuring that where renal disease does occur that it is identified at an early stage Reduce the progression of renal disease Proactive action taken to delay its progression Improve survival rates maximise quality life Achieve and sustain the best quality of life and survival rates for all people receiving renal replacement therapy in Wales Comparable incidence rates of CHD and diabetes with the lowest world quartile by 2015 Achievement of comparable population prevalence of renal disease to the highest European quartile by 2015 Achievement of comparable rates of decline in egfr to the lowest European quartile by Achievement of comparable mortality rates for all patients receiving renal replacement therapy comparable with the best survival rate achieved in Europe by 2015 Improved lifestyles, i.e. improved diet, increased exercise, reduced alcohol intake and smoking Effective management of those at risk in primary care, i.e. disease registers, management of blood pressure, cholesterol levels, referral as appropriate to smoking cessation services, alcohol services, walking for health schemes, exercise referral schemes, and any other relevant local lifestyle initiatives Locally adoption of the CKD early detection and management pathway developed by the Renal Advisory Group Reduced progression by appropriate interventions and early management of patients with renal impairment in line with patient pathways and protocols set by the Renal Advisory Group and Renal Networks Effectively planned renal services Optimal treatment for all prevalent haemodialysis patients delivered based on the agreed indicators All patients able to access dialysis services sufficiently to ensure optimal care as close to home as possible Peritoneal Dialysis for all patients for whom it is 2

3 clinically appropriate and who choose it Home haemodialysis for all patients for whom it is clinically appropriate and who choose it All opportunities for kidney transplants maximised for all patients for whom it is clinically appropriate and who choose it 100% of potential non-heart beating kidney donors considered for donation and the outcome documented All patients cared for by Renal Multidisciplinary Teams in accordance with national workforce planning recommendations and based on the all Wales Renal Competency Framework. All patients routinely receive information relating to key interventions along the patient pathway that is clear and meets their needs in terms of their linguistic, cultural and educational background. All renal patients have in place education programmes which empower them to become active partners in the management of their condition Local adoption of the NSF standards for conservative management for CKD, in line with the Renal Advisory Group s emerging pathway guidance. The All Wales Care Pathway for the Last Days of Life is routinely being delivered 3

4 2. Delivering the Required Outputs This section sets out a programme of work from April 2008 to March 2011 for each of the formal NSF aims. The key actions in the tables below are designed to direct and guide activity across Wales to meet the NSF Designed to Tackle Renal Disease in Wales standards published in April They also serve to underpin the Health Care Standards for Wales (2005) and play a vital role in supporting local improvements in service quality and healthcare organisation. Aim: Care for all Key Action Required By Whom By When (end of) 1.1(a) Plan renal services effectively through collaboration and sharing of best practice at both local and national levels. Renal Advisory Group and Networks through the Renal Strategy Forum 1.1(b) Further develop the Renal Strategy Forum to enhance integrated working between the Renal Advisory Group and the Renal Networks. Renal Advisory Group and Networks through the Renal Strategy Forum 1.2 Seek Network endorsement to all proposed renal service developments, including new and replacement senior staff appointments, where membership of a renal team/s is identified in the job plan. The intention of this requirement is to bring about consideration of such service developments on a wider geographical planning basis which in turn will help strengthen the role of the Network 1.3 Develop and implement long term costed delivery plans for renal services HCW, LHBs and Trusts Develop: Renal Networks, Implement: HCW and LHBs through the Renal Networks Immediately March 2009 From April (a) Cary out a resource mapping exercise to Renal Networks with all stakeholders April

5 identify current spend on renal transplantation, renal dialysis, dialysis patient transport and Erythropoietins (ESAs) based on out-turns for and planned investment for (b) Support new all Wales contract for Erythropoietins (ESAs) and invest 100% of savings made back in to renal services, based on the outturn as a baseline. 1.4 (c) Continue with further resource mapping to identify all spend on renal services Renal Networks with all stakeholders April 2009 Renal Networks with all stakeholders April (d) Review existing spend on renal services and redirect to meet the priorities identified in this strategic framework. 1.5 (a) Develop a self assessment tool that includes a set of key indicators to facilitate the routine monitoring and reporting of compliance with the National Service Framework standards of care locally and at a National level. Evidence of which is also to be used to underpin compliance with the Healthcare Standards for Wales. Renal Networks with all stakeholders Renal Advisory Group working with the Renal Networks and Health Solutions Wales March (b) Routinely monitor and report annually to Networks on compliance with the National Service Framework standards of care using the self assessment tool 1.5 (c) Prepare all Wales summary of compliance based on Network level reports HCW, LHBs and Trusts Starting April 2010 for financial year Renal Advisory Group Starting June 2010 for financial year 5

6 1.6 Develop a dataset and audit the quality of renal services. Develop: Renal Advisory Group working with the Renal Networks March Involve patients and carers in the development, delivery and evaluation of renal services. Input data: NHS Trusts Renal Advisory Group and Renal Networks April 2010 onwards 6

7 Aim: Prevent Renal Disease Key Action Required By Whom By When (end of) 2.1 As part of the local response to Health Challenge Wales, provide ill health prevention information and promote local activities particularly in disadvantaged and high risk communities Continuous Improvement (LHBs and NHS Trusts with Health, Social Care & Well Being partners) 2.2 Make available Stop Smoking Wales services to every smoker who wants to quit smoking within one month of referral, and support local smoke free policies and activities. 2.3 Participate in the delivery of the action plan resulting from the Welsh Food Debate/Nutrition Strategy for Wales, the Food and Fitness Implementation Plan for Children and Young People, and the work of the Welsh Assembly Government Sport and Physical Activity Working Group. 2.4 Support the National Exercise Referral scheme and ensure that all exercise referral schemes conform to the national standard protocol and take account of the exercise referral trial when available. 2.5 Increase participation in the Welsh Network of Healthy School Schemes. 2.6 Achieve the gold or platinum level of the Corporate Health Standard and encourage other organisations to participate. 2.7 Systematically identify all those patients at high risk of developing cardiovascular disease using practice based registers and offer lifestyle advice and appropriate treatment to reduce their risks. Continuous Improvement (LHBs and NHS Trusts with Health, Social Care & Well Being partners) Continuous Improvement (LHBs and NHS Trusts with Health, Social Care & Well Being partners) Continuous Improvement (LHBs and NHS Trusts with Health, Social Care & Well Being partners) (LHBs working with Local Government, NPHS and other Health, Social Care & Well Being, Children and Young People Partners) (LHBs working with Local Government, NPHS and other Health, Social Care & Well Being, Children and Young People Partners) Continuous Improvement (LHBs and primary care) ongoing 2.8 Develop and implement guidelines for GP Continuous Improvement 7

8 Practices for the management and referral of those (LHBs and primary care) patients at high risk of cardiovascular disease Key actions 2.7 and 2.8 should take into account NICE Clinical Guideline 67 (May 2008) on Lipid Modification (Cardiovascular risk assessment and the modification of blood lipids fro the primary and secondary prevention of cardiovascular disease Aim: Improve detection of renal disease Key Action Required By Whom By When (end of) 3.1 Establish GP education programmes on CKD NLIAH, Welsh Assembly Government, Local Health March 2010 risk factors and early detection and management. Boards with support of the Renal Networks 3.2 Provide annual QOF data about CKD registers LHBs and GPs including comparisons of practice and hospital held patient data 3.3 Locally adapt, implement and audit the CKD early detection and management pathway developed by the Renal Advisory Group which defines how the disease will be detected and delayed through proactive management Primary and secondary care in conjunction with Renal Networks March

9 Aim: Reduce the progression of renal disease and Aim: Improve survival rates and maximise quality life Key Action Required By Whom By When (end of) 4.1 Locally adapt and implement the CKD early detection and management pathway developed by the Renal Advisory Group which defines how the disease will be detected and delayed through proactive management. The level of crash landers, CKD registered practice population and blood pressure monitoring will be included in gaining assurance of early detection and effective management. Primary and secondary care in conjunction with Renal Networks and NPHS March Plan and deliver services so that (a) At least 80% prevalent haemodialysis patients are receiving dialysis using arterio-venous fistula/ grafts where this clinically appropriate (b) There will be a maximum component waiting time of 14 weeks from accepted nephrology referral to creation of arterio-venous fistula/ grafts for haemodialysis and for canular insertion for peritoneal dialysis, both in line with National waiting times targets for inpatient / day case treatments Plan and deliver services so that 100% of patients for whom it is clinically appropriate and who choose it receive dialysis 3 times a week. 4.4 Plan and deliver Peritoneal Dialysis for all patients for whom it is clinically appropriate and who choose it 4.5 Support expansion of home therapy in order to meet the target output: Provide training for all patients choosing home HCW and Trusts in conjunction with Renal Networks By March 2009 and sustained thereafter. HCW and Trusts in conjunction with Renal Networks March 2011 HCW and Trusts in conjunction with Renal Networks March 2011 HCW and Trusts in conjunction with Renal Networks All actions by March

10 haemodialysis as part of a planned home training programme involving specialist nurses and including home visits as appropriate For all patients provide appropriate adaptations and installations for home dialysis facilities in a timely fashion Ensure all patients on home haemodialysis have equal access to the Multi-disciplinary Renal Team. Make adequate planning and provision for all patients who require carers to support home therapy 4.6 Plan service provision and identify the resources required to deliver a responsive and flexible patient transport service inline with the NSF standards and those adopted by the Network Boards. 4.7 Agree and coordinate with service providers and patient groups appropriate renal patient information and education programmes including self care programmes for dialysis patients 4.8 Launch campaigns to raise awareness of the need to register as an organ donor HCW and Trusts in conjunction with Renal Networks March 2010 Develop and Monitor: Renal Networks in collaboration with patient and charitable groups Implement: NHS Trusts Welsh Assembly Government / UKT in collaboration with patient and charitable groups March 2010 March Consider all potential non-heart beating kidney NHS Trusts March 2010 donors for donation and document the outcome Develop an all-wales Renal Competency Renal Networks in collaboration with the Renal March 2010 Framework Guide Advisory Group 4.13 Develop and implement a care pathway for the Develop: Renal Advisory Group in conjunction with March 2009 conservative management of all renal patients for the Renal Networks whom renal replacement therapy is not suitable Implement: Trusts, LHBs working through the Renal From April 2009 Networks 4.14 Ensure the All Wales Care Pathway for the LHBs and Trusts in conjunction with Renal Networks ongoing 10

11 Last Days of Life continues to be routinely delivered 4.15 Routinely audit service capacity and prevalence of all modalities of renal replacement therapy in Wales including dialysis, home therapy and transplantation and review strategic investment plan accordingly. Renal Networks, Renal Advisory Group, 6 monthly 11