Managing demand for specialist services

A new way of looking at renal impairment in Wales has suggested it affects about 10% of the population. This has created a 'tidal wave' of referrals that could potentially swamp secondary care. Map of Medicine is delivering a pathway to manage that demand. It ensures that the right people are referred to specialists, and those who aren’t are still treated appropriately.

Professor Aled Phillips of Cardiff’s Institute of Nephrology explains how the Map is managing a potential 'tidal wave' of referrals. (4:32)

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Transcription

Aled Phillips: Well I think the nephrology needs in the whole of the UK have been transformed radically in the last 18 months in that we’ve now got a realisation that about 10% of the population have got renal impairment and this has come on the back of a new way of looking at renal impairment so we now have a novel and more accurate way of determining renal function and now we’ve realised 10% of the population have it which is generated a tidal wave essentially of new referrals.

Inerviewer: So how is the Map of Medicine helping the development of the National Service framework for renal disease in Wales?

Aled Phillips: Well within the National Service framework we have an agreement that we will have a care pathway adopted by March of next year. The problem that we have, that although 10% of the population have renal impairment, very few of those will have end stage renal failure so we need to select which patients need to be referred appropriately and we need to manage those who don’t need to be referred because we know that their risk factor in terms of cardio vascular disease are huge because of their renal failure. So we need to have the ones that we don’t see treated appropriately and those that we do see referred appropriately and so the whole purpose of the Map of Medicine in the patient pathway that we’ve generated through that is to manage that demand.

Inerviewer: So obviously you are working very closely with Primary Care on that and you are going to be talking to the conference about increasing collaboration with Primary Care. Is Primary Care open to that?

Aled Phillips: I think they are because for the first time now in their GMS contract, renal medicine featured, so whereas previously renal medicine was thought to be a post graduate subject, it was a bit scary maybe and not relevant, there is realisation that a huge proportion of their patients, as many renal failure patients as diabetic patients are sitting within their practice. That has created an urgency and a need for them and so that they are very open to how to manage these patients now that they have been identified because of the consequences of the new contract.

Inerviewer: So what are the main obstacles to collaboration and how have you overcome them?

Aled Phillips: Well I think it’s managing expectation, it’s explaining that we don’t need to see everybody, but we need to see the appropriate people with the appropriate information so we are trying to get away from the knee jerk reaction that any renal impairment means new renal referral because that would swamp the system and that would probably mean that the ones that we do need to see aren’t being seen because the system becomes bunged up essentially. So it’s really making sure that we get the right people seen at the right time rather than just seeing everybody.

Inerviewer: So the Map can help with your resources?

Aled Phillips: Absolutely because what we need is as I said, to make sure that we only see the ones that need to come in, so it really is managing the entry and exit of patients from nephrology services so it’s not a management protocol in terms of treatment and diagnosis it’s a management protocol in terms of patient journey, entry and exit through the nephrology services.

Inerviewer: And so have you been able to gather evidence which is able to prove that to the clinicians, the other health professionals who are using it?

Aled Phillips: The Map itself will be launched later this year in terms of being rolled out to Primary Care, what we do have is the evidence of the increasing demand and the inappropriate nature of some referrals, so we know that there is a shortfall if you like in the service at the moment and having launched it then we will be able to re-audit in terms of the use of the Map and also its impact on our service.

Inerviewer: When will you be rolling out the National programme for Wales?

Aled Phillips: Well the Gwent programme is the pilot if you like and that will be coming out at the end of the year. When we have evidence that that is working and is effective armed with that strong evidence then we roll it out across Wales because it will make the acceptance of it in Primary Care and Nephrology Service across Wales a lot easier.

Inerviewer: And are you hoping to gain evidence that it’s effective for the patients as well?

Aled Phillips: Well yes I think the patient is the centre of all of this and as I said part of the problem now is we think the patients that we should see aren’t being seen. We know that late referral and inappropriate referral can translate to poor outcome both in terms of the need for renal replacement therapy and the success of renal replacement therapy. So yes, we are hoping it will translate to early referral of the appropriate people, slowing progression of their renal disease and so minimising their need for renal replacement therapy.

Inerviewer: Some teams looking at the Map may feel that there’s going to be too much work in order to make it fit for their purpose if you like, how difficult has it been for you to make it fit for your purpose?

Aled Phillips: I think that’s a very interesting observation if you like and a lot of people, their criticism will always be this makes more work for us and we have limited resources and we are very aware of that but what is clear with renal disease is those patients who don’t need to be referred, those patients are at high risk of cardio vascular disease, those patients are already identified in Primary Care under the registered/registered hypertension registers and the like and Primary Care is already equipped with what they need to give them the appropriate treatment, so it’s not a new cohort of patients, a new way of looking at patients. Once that comes across people are very receptive to the whole process I think.

Inerviewer: And has the whole IT connection worked well?

Aled Phillips: Well we will wait and see. I think what we hear from Primary Care is we want it to be simple, we want it to be on the desktop and so what we’ve created is a fairly superficial looking document, all of the pathways on one page, it’s very simple to access and so we haven’t overburdened it with information, it’s not a textbook of nephrology in any way it very much is a flow of patients through it so we’ve kept it simple, listening to Primary Care saying we don’t it to be difficult, we want it to be easy to use, so hopefully it will be adopted and we will see its success because of its simplicity.

Inerviewer: And so hopefully your patients will be happier as a result? They will feel they are being treated more appropriately and quicker?

Aled Phillips: Well I think the outcome measurements, if you look at the impact of renal replacement therapy, these are patients who can’t work and they feel generally unwell so for any patients that we can delay the progression of their renal disease, keep them off dialysis, the benefit is huge and the impact for the individual patient is huge. So delaying all of that by seeing the right people at the right time is the key to all of this.