In 2009, UnitedHealth UK was approached by NHS Bristol and the South West Specialised Commissioning Group to evaluate the provision of renal services for patients in Bristol. NHS Bristol and the South West Specialised Commissioning Group were keen to understand the reasons driving demand for renal services, as Bristol has a young population with low levels of diabetes, hypertension and cardiac disease.

Working to a tight framework, we were asked to develop a programme that would deliver the following objectives:

• Improve the health of renal patients in Bristol
• Identify and reduce financial inefficiencies
• Review existing pathway & forecast demand for renal services in Bristol
• Develop a robust business case for a new commissioning model

Our approach was to collect data on current performance and to compare this to a set of national benchmarks that we identified. This includes all the acute and specialised data as well as primary care activity (where available). Along side this approach all the national quality standards were summarised for example NICE guidelines and these were compared to existing performance.

For Global best practice an assessment of all standards, policies and guidelines was undertaken and then summarised. These were then compared to current performance for NHS Bristol.

Opportunities for driving financial and quality efficiencies were identified by undertaking a comparison between current service, UK national best practice and Global best practice.

• Identification of 10% saving within NHS Bristol’s renal spend
• Detailed recommendations were provided including:
  
  
  • Changes in acute commissioning that led to a 10% reduction in renal spend by contracting against national benchmark standards
  • Changed practice in primary care including contracts for PMS Practices that focus on disease measurements not currently collected
  • Contracting changes in Community Services that included new performance benchmarks for community matrons
  • Risk stratification measures to understand the population and target services appropriately, focusing on disease progression
  • Case management & telemedicine, including a disease specific management programme coordinated by a renal specialist nurse. This, we believe, will empower patients and support personal responsibility in care management, helping to reduce emergencies and disease progression
• We produced a business case outlining our findings and solutions including recommendations for tendering for a new service. This included a detailed analysis on current services, how they are provided and costed, and additionally how these support current disease management.
• Global best practice, including professional and clinical guidelines was used to build a model for a gap analysis with the existing service. This was used to identify opportunities for changes within the current system including contracting efficiencies, reducing the use of hospital services including emergency admissions, and a focus on disease management in primary care.
• A service specification was produced in preparation for a tendering process. This includes a detailed service and financial analysis for a nurse led telephone service. This focused on individuals with progressive chronic kidney disease (CKD) in stages 2 and 3 (as identified by our risk tool). This service could be funded by commissioning changes, and underpinned by best practice evidence of how to delay disease progression and reduce complications in disease management. This has enabled NHS Bristol to substantially improve service provision in renal care, commission for best practice outcomes and develop a new model of care that will produce significant long term health benefits in addition to savings for their internal programmes.

Additionally, in our review we also found very high levels of emergency admissions and outpatient follow up attendances amongst CKD patients. Also, in primary care higher than average numbers of patients were being excluded from QoF (Quality Outcome Framework) indicators.