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In depth – deep dives

Deep dives have already been undertaken for the following areas due to known clinical risks in NCL: Renal Dialysis, Liver Disease and Sickle Cell. A short summary of each deep dive is explained below.

Renal Dialysis

  • Current In-Centre Haemodialysis (ICHD) services are running at the 95% utilisation rate from 6am to 1am, 7 days per week.
  • Projections at 10 years, assuming a modest 1% growth is that NCL will need an additional 21 Stations by 2030.
  • London Kidney Network and NCL Renal Network are working with Royal Free London Hospital to clarify current utilisation and explore mitigations including increased Hypertension, Chronic Kidney Disease investment etc).
  • Planning is underway to confirm the date at which point current capacity is exceeded but most likely this will be within less than three years.
  • At present it is likely we will need to increase current capacity and work is required to understand the capital and revenue implications of this.

Renal Improvement Programme (2 Year Pilot)

  • In response to increased demand for Chronic Kidney Disease (CKD) and renal dialysis the NCL Renal Network have developed a programme to manage the number of patients needing renal services. Three areas of the end to end pathway have been identified:
  1. Primary Care (through Long Term Conditions Locally Commissioned Services LTC LCS)

In order to reduce our NCL population requiring CKD or more complex renal services, two searches have been created to:

    • Identify patients who are at risk of CKD and
    • Identify patients who have indicators suggestive of CKD but are not on the CKD Register
  1. Secondary Care (Royal Free)

Royal Free will be establishing a Renal Weight Loss Clinic (RWLC) to move patients from dialysis to the Renal transplantation list to improve patient quality of life.  A multi-disciplinary team (MDT) will also be implemented to support growing home haemodialysis and support the elderly and frail patients.

  1. Chronic Kidney Disease (CKD)

There is also another NCL workstream focused on the expansion of Community CKD Service to all five boroughs. The expansion of the service supports the reduction in health equalities evidenced through the high number of non-elective patients presenting in the Emergency Department. Analysis shows these patients were registered in Haringey and Enfield, and existing CKD services were established in Camden, Islington and Barnet only.

Liver disease

  • Liver Disease is growing at a rate of 20% per year with much of this driven by lifestyle factors (alcohol, smoking, obesity, drugs etc). This is placing increased pressure on Acute Services (including the need for transplants).
  • Both RightCare and Public Health England (PHE) flag we have high levels of preventable mortality arising because of Liver Disease (and related Liver Cancer).
  • Through the Inequalities Fund we already fund Lifestyle Hubs and we are seeking to see if we can extend these to cover the whole of NCL.
  • We have formed an NHS England funded Liver Network within NCL with a view to expand across London. The aim is to develop Liver Pathways with again developmental work in primary care as part of the LTC programme to identify and treat patients early and so avoid admissions to secondary care.
  • The Network also aims to link with outreach groups that can diagnose liver disease in at risk groups such as homeless, drugs and alcohol services.
  • Discussions are under way to develop sign posting services to appropriate clinics in secondary care in conjunction with appropriate testing via Community Diagnostic Hubs in NCL.
  • An assessment of capacity in Secondary care will also be undertaken and impacts of early detection, potential changes to Day care and use of ‘virtual wards’ will be reviewed to accommodate increased demand.

 

Sickle Cell Improvement Programme (2 Year Pilot)

  • In 2019, following the death of a 21-year-old Sickle Cell Patient in NCL and the subsequent inquest, an All Party Parliamentary Group produced ‘No One’s Listening’. To help address issues the NCL Sickle Cell proposal is split into the following two areas:
  1. Community Nursing Service

The aim is to introduce an integrated pathway to enhance out of hospital community support and build bridges of continuity of care. The service will utilise remote monitoring, virtual wards and enhanced preventative approaches to increase patient autonomy and confidence at each Specialist Haemoglobinopathy site (SHT).

  1. Hyper Acute Model Pathway (UEC Bypass, nationally funded)

This model ensure patients bypass the Emergency Department when safe to do so including Haematology specialist assessment/SDEC and direct admission to Speciality ward if clinically required and bed available. Aim is to reduce need for UEC and improve experience/bypass where needed. UCLH and Whittington Hospital maintain current HCC and SHT functions. Single Point of Access for advice and triage at Pilot Hyperacute Service site.