Sustainable Health and Green Care Donal O’Donoghue National Clinical Director for Kidney Care Green Nephrology Summit London Wednesday 26 th September 2012 Working for Better Kidney Care

Environmentally sustainable health and social care: scoping review Naylor and Appleby, March 2012 “Some service areas are already leading the way. For example, Green Nephrology includes a network which brings together clinicians, patients, renal technicians and industry partners.”

“Quality is the only organising principle of the NHS” Sustainable Patient Centred Equitable Efficient Effective Timely Safe

Vascular Disease – One Event Leads to Another (REACH Registry) Original Event = Stroke MI Risk 2-3 x greater risk Stroke Risk 9 x greater risk Original Condition = PAD MI Risk 4 x greater risk Stroke Risk 2-3 x greater risk Original Event = MI MI Risk 5-7 x greater risk Stroke Risk 3-4 x greater risk Diabetes (type 2) Because of the increased risk associated with diabetes, it should be considered a cardiovascular risk equivalent to a non-diabetic patient with previous MI CKD MI Risk 2 x greater risk Stroke risk Up 50%

Disuse-Disability Spiral Painter (1996)

10% of our wealth is spent on health

Waste Value Waste

Value in Health Care (Porter M: NEJM 363:2477, 2010, Lee: NEJM:363:2481, 2010) “Value should always be defined around the consumer… and the creation of the value for patients should determine the rewards for all other actors in the system.”

Value in Health Care (Porter M: NEJM 363:2477, 2010, Lee: NEJM:363:2481, 2010) “Measurement of value is challenging…the critical first step is measurement. Provider organisations need to capture data on outcomes that matter to patients and carers.”

Results of Public Opinion Survey: Source: Ipsos MORI

Data from Canadian, UK and ANZDATA Renal Registries Trends in Late Referral by Year Late referral defined as ≤3 months before RRT start

Prevalent patients by treatment Demand for renal replacement therapy continues to increase RRT incident rates but incident rates appear to be reaching a plateau or falling

Percent distribution at initiation by eGFR The mean eGFR at initiation of RRT in 2009 in the UK was 8.6 The mean eGFR at initiation of RRT in 2008 in the US was 11.1 The mean eGFR at initiation of RRT is rising

Shared Decision Making: The care team communicates to the patient personalised information about the options, outcomes, probabilities and scientific uncertainties of the various treatments. “is a fundamental part of care planning and promotes the best choice in what otherwise can be a complex and overwhelming situation.” The patient communicates his or her values and relative importance he or she places on the potential benefits and harms.

Patient Decision Aids

Aerobic Exercise Training: Haemodialysis bed cycle ergometer training

Environmentally sustainable health and social care: scoping review – Naylor and Appleby, March % of transport emissions in the UK are estimated to be accounted for by healthcare facilities

Environmentally sustainable health and social care: scoping review – Naylor and Appleby, March % of transport emissions in the UK are estimated to be accounted for by healthcare facilities Ingredients in a steak and kidney pie served in one hospital had travelled a total of 31,000km

Motivate and inspire … Influence key levers and mechanisms to support uptake … Legislation, Inspection, Incentives Performance management of new Commissioning Consortia through the Outcomes Framework National clinical audit Education/ accreditation/ CPD e.g. via Royal Colleges and professional bodies Workforce development Promoting evidence into practice – guidelines Developing the evidence base Patient stories

“Often change need not be cajoled or coerced. Instead it can be unleashed.” Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution Press; Washington, D.C