The future shape needs to have the right people in the right place at the right time - and the right information. The right people mean the people with the right skills and competence for that patient at that particular time. But information is crucial; evidence-based so we make the right decisions of how we manage a patient with chronic kidney disease.

Chronic kidney disease is common, it is not rare. Premature cardiovascular disease, heart disease, stroke, are major factors in chronic kidney disease. Those are diseases where we know we can make big impacts. We also know that the sort of treatments we use for cardiovascular disease slow down the developments of chronic kidney disease. The context of which we now think about the health service is determined by the policy that comes out from the Government, and perhaps the most important document that set us off on a new train was the NHS plan that describes how the services would change over time.

Another key document is Shifting the Balance of Power that has moved the power from the centre to primary care organisations. The core renal document is the National Service Framework, published in January of this year. Equally important are Saving Lives and Valuing Donors and the information strategy.

For people who are not at end stage renal failure, we can delay progression. A lot of that is in controlling blood pressure. If we are going to offer choice, we need capacity, and that means for haemodialysis vascular access. We have an over reliance on catheters compared to other countries. Regarding the National Service Framework document part 2, we know that diabetes is a cause of 20% of patients starting dialysis in the UK and diabetes worldwide is set to increase to 333 million by 2025.

In the U.K.chronic kidney disease is common. Why are we surprised? Because we’re thinking creatinine. We are surprised when we find out that someone with a relatively low creatinine has advanced renal failure. Because creatinine is a poor marker of kidney function and we should look at creatinine clearance or glomerular filtration rate (GFR). In patients under the age of 60 with unreferred chronic kidney disease, data from the USA show there’s a 34.5 times increase of death compared to the standardised mortality rate.

There is evidence in the large cardiovascular trials that chronic kidney disease is a marker for early cardiovascular death and also that chronic kidney disease is amenable to treatment in terms of that increased vascular risk. In data from the Hope Study which looked at the use of Ramipril, an ace inhibitor, and what they found in the people with normal serum creatinine is that the use of Ramipril is associated with a reduction in the cardiovascular events. For anybody with diabetes, heart failure, or hypertension there is a good reason to be on an ace inhibitor. Only 50% of people with diabetes were on an ace inhibitor, less than 50% in these other categories. So perversely, the high risk group, people with chronic kidney disease, do not receive the same quality of treatment as the general population.

Look at the overlap with coronary heart disease and its NSF, with more resources than our NSF. All need this type of treatment and a lot of therapies, such as treatment of heart failure, can be delivered in primary care. If we look at GFR we can detect people early. We need to link the implementation of diabetes and coronary heart disease and the renal NSF with chronic disease management. A lot of that is sharing IT systems.

It boils down to two things: the people and the information. We need to improve the morale of the staff in the NHS, and hopefully some of these initiatives, knowledge and skills framework and modernisation of medical careers etc, will improve staff morale. Actually the big thing that improves morale is when patients say, “That was a good job”.

Please note, this page is a summary of the full conference speech (click here for the full transcript).

Next >>Deborah Duval - Patient Speaker

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