Thursday, 30 April 2009
The Kidney Care Specialised Commissioners Forum met recently and there was a lot of talk of CQUINs and QuIPs. CQUINs or the Commissioning for Quality and Innovation Framework aims to use payments to deliver real benefits for patients and improve quality. To quote from the Operating Framework “the aim of the CQUIN system is to support a shift towards the vision set out in High Quality Care for All of an NHS where quality is the organising principle”. For Acute and Foundation Trusts, the value of the CQUINs payment is to be 0.5% of total contract value and up to 25% of the scheme is allowed for improving data. Rob Lusardi (Assistant Director, West Midlands Specialised Commissioning Team (SCT)) gave a neat presentation on CQUINs for renal services. The West Midlands SCT have been working with their Kindey Care Network to develop and introduce quality improvement plans designed to support the renal units in submitting all the mandatory data of the National Renal Dataset. Getting robust, high quality data and turning that into information for patients, clinicians and commissioners is seen as a vital first stage in developing performance improvement targets for each provider unit for 2010/11.
If you haven’t already guessed it, QuIPs are Quality Improvement Plans.
Similar schemes are been considered and developed in other Strategic Health Authority and Specialised Commissioning Group areas. One of the great strengths of the kidney community is that colleagues in different parts of the country are happy to share their progress, methods and what worked and what didn’t work with others across the country.
I attach a link to the slides Rob showed at the Commissioning Event. I expect that many, perhaps even all, of the Kidney Care Networks and Specialised Commissioning Groups will want to consider how they can use these and other approaches set out in High Quality Care for All to ensure that quality is the organising principle for kidney care.
Tuesday, 28 April 2009
Matthew also raised the thorny issue of attribution of MRSA bacteraemias between the centres and their satellites. When Richard Fluck and our Kidney Care Healthcare Associated Infection Group discussed this with the Cleaner Hospitals Team and the Health Protection Agency, they decided that attribution should be linked with clinical governance and I am sure that’s correct. Medical governance is via the responsible renal consultant through the CEO of the Trusts. However, in commercially run satellites, the governance arrangements are shared – it’s a partnership. Contracts can’t specify the safety and clinical protocols that must be in place, even if they could, the risk would be fossilising of practice. Matthew’s point was that a Chlorhexadine concentration of 0.5% as skin preparation may not be sufficiently concentrated. We discussed the route cause analysis of the MRSA bacteraemias and agreed they should include and address the issue of variance in protocols between different settings. Patient safety being the overriding concern.
In my short visit I wasn’t able to see everything but 3 further initiatives stood out for me. Two that will directly and considerably improve patient experience and one change in practice that is already saving money that is being used to improve other aspects of quality of care for people with kidney disease at the Royal Liverpool Hospital. Eileen Newall (Holiday Dialysis Coordinator) has established a database of kidney units across the world that are suitable and willing to take UK patients. Eileen spends a considerable amount of time ensuring the database is up to date and her efforts have promoted an increase in uptake of dialysis away from the base unit, usually for holidays but sometimes for other reasons, in the patients on haemodialysis in Cheshire & Merseyside. In the region of 35-40% of dialysis patients in Liverpool now holiday abroad each year – a British Renal Society survey a few years ago showed that in most units less than 10% of people were actually getting away from base for up to or more than 2 weeks a year. This is a really valuable service and Eileen’s system is among one of the best that I have seen or heard about. Jonathan Davies (Lead Nurse) introduced me to one of the recent ABO incompatible transplant recipients who was doing really well and told me that his creatinine was below 100 and that Liverpool Football Club would win the Premiership. I wished him well with regard to transplant function! I also commented on how tidy the kidney unit looked, some VIP visits do lead to repainting of wards and other superficial and temporary changes but I don’t warrant such an approach. The tidiness resulted from the reduction of clutter and consumables by moving to each individual patient’s dialyser and canulation kit being pre-packaged resulting in a tremendous space saving, no boxes in the corridor (!) and a financial saving of around 12.5%.
Finally, I had the pleasure of sitting on the appointments committee for 2 new consultants. One of the those appointed, Dr Muhammed Ahmed will be developing the new service in Warrington and Dr Rema Saxena has been appointed to the Royal Liverpool Hospital and has a special interest in a conservative care programme pioneered by Dr Peter Williams who is now the Medical Director of the Trust.
I suggested to Gordon Bell (Consultant Nephrologist & Clinical Director) and Talib Yaseem (Deputy CEO) that all these initiatives: reduced MRSA rates, increased fistula rates, better holiday dialysis arrangements and new and successful ABO compatible transplant programme and the cost saving approach to consumables allowing reinvestment elsewhere, should be put forward for innovation prizes, but being in Liverpool, and coming from Manchester, I had to caution about the unrealistic prospect of getting all 5 prizes in the one year – that would be the elusive quintuple.
Q: I have been asked to contact you regarding concerns over peritoneal dialysis contracting. following discussions of the North West Collaborative Procurement Hub. All the NW renal units work through the Procurement Hub with the aim of achieving the best results from contracting for dialysis consumables.
There have been major anxieties within units about the recent withdrawal of Gambro from the UK peritoneal dialysis market leaving only Baxter and Fresenius. I believe there is work ongoing moving towards national supply agreements and that the present round of negotiations are a “stop gap” measure.
It is clear the companies are under financial pressure and there may be pressure to increase prices either in contracts being discussed now or when next major renegotiations take place. However there is considerable disquiet from the represented renal units because of the move away from therapy costs to itemised fees. Although there are potential pros & cons to this for individual units depending on their usage the unbundling of holiday dialysis is a major issue. The price increases are coming through as increased payments for “extras” such as help in training patients and holiday dialysis.
Enquiries show that most units do not have a separate holiday dialysis budget line and that previously bundled holiday costs would largely come out of the “allowance” made through the contract with top ups coming from the general renal/dialysis budgets. The top up monies were relatively small so tended not to cause any problems so most PD patients would be supported for all their proposed holidays. If the cost of PD holiday dialysis is now clearly separated there is a major worry that there are no National guidelines on what a patient might reasonably expect. Managers and clinicians were agreed that this could cause a rift between the groups as managers became the arbiters of holiday allowance for individual patients, holidays would no longer be supported if financial pressures were high and the budget might disappear prior to the end of a financial year.
Although it is recognised that it will be up to units/regional procurement organisations to arrange for the best contract terms, the lack of a clear stance from the renal community on what patients can reasonably expect in terms of holiday support will hinder units in supporting their patients. As a major selling point of peritoneal dialysis is independence, the ability to travel and be independent of the hospital this could further erode the uptake of PD and ferment patient dissatisfaction in the prevalent population.
From a local regional level we are unclear if it is being flagged as a problem nationally although suspect it is happening nationwide. Clarification across the renal community of what are reasonable expectations regarding holidays for PD patients would we believe be a major benefit when financially strapped trusts pressure managers to save costs and there is no agreed protected budget provision. Dr David Lewis Clinical Director Salford Royal NHS Foundation Trust
A: David, thank you. These are serious concerns, particularly the risk of further restriction on the ability of people receiving dialysis to travel for holidays, work, family or all the other reasons we all value the basic human right of freedom of movement. You are not alone – others have raised similar concerns in other parts of the country including the West Midlands, London and South Central SHA.
I have therefore convened a short life working party to design a clinical peritoneal dialysis pathway, create a national service specification and develop a national template contract for procurement of services and supplies. Lindsey Barker (Consultant Nephrologist, Royal Berkshire FT) is chairing this group that will report to the NHS Kidney Care Programme Board later this year. The terms of reference are:
To maintain number of competitive providers in PD market
To maintain availability of the full range of PD products and services
To achieve national consistency in pricing across England
To achieve equity in patient access to all treatment modalities
To ensure that a full range of dialysis modalities is available from appropriate providers and is offered freely to patients
To inform development of Kidney Dialysis Tariff
To ensure effective communication with key stakeholders
To report appropriately to Kidney Care Programme Board
To develop Comunication Strategy to share outcomes
4. Patient-centred service
Ensure views of all stakeholders, including patients and carers, are considerd.
The group has representation from patients, nursing and medical experts, managers, procurement hubs, the national supply chain, the Department of Health and NHS Kidney Care.
The key outputs will be a nationally agreed pathway and detailed service specification that I hope will be a valuable resource for commissioners and procurement teams as well as clinicians and patients. The pathway will span modality discussions/choice of treatment, catheter placement and training, treatment regimes while on peritoneal dialysis through to change of modality or withdrawal from replacement therapy. It will include aspects of patient experience including dialysis away from home. Donal
Friday, 24 April 2009
It provides a simple and easy to understand guide for people making advanced care plans for their future. I think it will prove to be relevant to family members and informal carers. I anticipate that kidney care professionals will find this booklet a useful support tool when approaching the often difficult situation of discussing advanced care planning with people who have advanced chronic kidney disease.
The initial print run will provide booklets free of charge and it is available to download from the website. If you wish to receive booklets for your service please complete the request form.
Sarah Fatchett, Director of Operations, PTS
A: The risk of cross-infection from an MRSA colonised or infected patient to others in an ambulance is minimal. Good infection control practice and routine cleaning should suffice to prevent cross-infection.
The guidelines for MRSA in healthcare facilities does include sections on patient movement, cleaning and decontamination and other measures to minimise the risk of spread to other areas. This includes a section on transportation (page 7, second column).
Tuesday, 21 April 2009
When I visit kidney units and meet people from both the kidney community and others who care for people with kidney disease I am struck by the quality, talent and values of our people – not just NHS staff, social care staff, volunteers and others from the third sector. “High Quality Care for All” set out to foster and recognise leadership for quality and a new NHS leadership award scheme has been set up with 7 categories:
- The NHS Leader of the Year
- The NHS Mentor of the Year
- The NHS Partner of the Year
- The NHS Quality Champion of the Year
- The NHS Change Leader of the Year
- The NHS Innovator of the Year
- The NHS Award for Inspiration
I particularly liked the quote from Mark Ogden (Finance Director for NHS North West), who I had the pleasure of working with when he was Finance Director of Salford Royal, “to deliver our ambitions for the NHS, it needs more than just leadership from the top. It’s the leadership that takes place in the informal settings, like wards, theatres, community teams, small offices and conversations with colleagues which we have each day that will make the real difference”.
Making a nomination is not a complicated process. All you need to do is write a 250 word citation and I would strongly urge you to nominate colleagues who you feel have made a special contribution to safety, patient experience and outcomes.
Thursday, 16 April 2009
The National Institute for Health and Clinical Excellence is scoping out health technology appraisals on both belatacept and everolimus for the prevention of rejection in kidney transplantation. Belatacept is a protein drug which has in clinical trials been compared to ciclosporin or tacrolimus to prevent organ rejection and everolimus is a “anti-fibrotic” drug, an analogue of sirolimus. Everolimus is intended for use in combination with ciclosporin and corticosteroids and as a substitute for other anti-proliferative agents.
The questions for consultation are:
- Have the most appropriate comparators for belatacept for renal transplantation been included in the scope?
- Are there any subgroups of patients in whom the technology is expected to be more clinically effective and cost effective or other groups that should be examined separately?
- Are there any issues that require special attention in light of the duty to have due regard to the need to eliminate unlawful discrimination and promote equality?NICE intends to appraise this technology through its Single Technology Appraisal (STA) Process. We welcome comments on the appropriateness of appraising this topic through this process. (Information on the Institute’s Technology Appraisal processes is available here
One of the holy grails of kidney medicine is portable dialysis. Peritoneal dialysis offers that option and it’s surprising to me to see that modality continues to attract fewer patients, proportionally, year on year. Haemodialysis is of course much less portable and we know the shocking figures regarding the number of people on dialysis in England who have holidays or other breaks away from home and their dialysis unit each year – less than 10%! Home haemodialysis using traditional equipment and water purification systems has lots of advantages – less dietary and fluid restriction, less drug burden, feeling better and better survival. One of the problems of home haemodialysis is however, the size of the kit and particularly the water treatment unit – depending on individuals’ housing circumstances that can be a reason not to choose this option. I am therefore pleased to see that the National Institute for Health and Clinical Excellence is scoping a health technology assessment to appraise the clinical and cost effectiveness of a tap water haemodialysis system for home haemodialysis.
The PureFlow SL (NxStage Medical Inc) is an integral portable water purification system which uses domestic tap water which is passed through a series of carbon filters to produce very pure (‘ultrapure’) water. The PureFlow SL system is used in conjunction with a portable home haemodialysis device called NxStage System One. Drainage of used dialysate occurs through an under sink connection. If a patient needs to be mobile (i.e. away from the home) the System One cycler can be removed from the top of the PureFlow SL unit and used with bagged fluids instead.
The questions for consultation are:
- Which haemodialysis systems used for home haemodialysis should be included as comparators in the appraisal?
- Are there any subgroups of patients in whom the technology is expected to be more clinically effective and cost effective or other groups that should be examined separately
- Are there any issues that require special attention in light of the duty to have due regard to the need to eliminate unlawful discrimination and promote equality?
NICE intends to appraise this technology through its Multiple Technology Appraisal (MTA) Process. We welcome comments on the appropriateness of appraising this topic through this process. (Information on the Institute’s Technology Appraisal processes is available here
This looks like progress towards the introduction of some of the new haemodialysis technology that we have read about, seen on UTube or seen in action in North America.
Wednesday, 15 April 2009
Overall, over 60 per cent of patients have said that transport services met their needs. This is a good starting point, but there’s still much to do. In particular it identifies that patients are having to wait for dialysis once their transport has taken them to hospital, and that many patients using their own cars have to pay for parking.
Transport to and from haemodialysis is a major part of the experience of care. The action learning sets sponsored as part of the NSF by the Department of Health set a travel time of 30 minutes. According to the survey, 33 per cent of patients in England had to travel over 30 minutes to their dialysis which indicates that in most units action is needed to achieve this standard.
I am told by the project team that detailed results will be released in summer. This will be through an online system that will allow units to undertake detailed analysis, giving them some really rich and valuable data. The NHS Information Centre will also be releasing a national report on the patient transport results at that time.
I hope to see these results used to bring about positive changes, for instance to help set endorsed national standards for patient transport services. I also think the survey results will be invaluable for the renal community. I would now like to see everyone working locally to make sure it is used to drive improvements to services.
Patient transport survey results launched - for action
Use NHS iView to get the most out of the Patient Transport results
Tuesday, 14 April 2009
The award was made at the National Kidney Foundation’s Spring clinical meeting in Nashville in March. I knew I was in Tennessee because Elvis met me at the airport. He had arrived on an internal flight from Memphis and I have to say looked better than me after my transatlantic journey.
Seriously. It was a real honour to receive the medal at the President’s dinner hosted by Bryan Becker. I was pleased to be able to publicly thank the National Kidney Foundation for supporting the KDOQI and now the KDIQO initiatives that have given us definitions and the classification system for chronic kidney disease that we can now use across the world. The shared language has created a global understanding and helped demystify kidney disease. The structures, underlying principles and values of our National Health Service have since enabled the early identification of over one million people with previously unrecognised kidney disease. A remarkable achievement – but not a time to rest, we still have to identify the missing millions and have to turn visibility of kidney disease into health gain and a preventative dividend. So lots to do.
The only downside was spraining my ankle running in the gym – the family are convinced that I did it line dancing. I know I shouldn’t have packed those check shirts!
Monday, 6 April 2009
In addition to the kidney community, this brought together representatives and key opinion leaders from diabetes, cancer, muscular skeletal conditions, infection prevention and most importantly, patients and their experience.
The kidney – healthcare associated infection story goes back decades of course. To the Hepatitis B outbreaks of the late 1960s and early 1970s. More recently it has linked with the preparation and choice agenda and the push for improvements in vascular access for haemodialysis.
Ginny Edwards (Head of Targeted Support in the HCAI and Cleaner Hospitals Division at the Department of Health) gave an overview of progress to date – emphasising the improvements but also the need not to be complacent.
From the kidney team, Roger Greenwood (Consultant Renal Physician, Lister Hospital, Stevenage) highlighted the central role of nursing staff in infection control and explained the importance of vascular access. Fiona Loud (Chair of the Kidney Alliance), explained the feelings and concerns of service users. The anxiety poor environments cause and the need for honestly and transparency in discussions between staff and patients. Richard Fluck (Consultant Renal Physician, Derby City Hospital and Department of Health Renal HCAI lead) provided the data, a 62% reduction in MRSA bloodstream infection in the last 3 years but still an 800 times higher risk of MRSA in those dialysing via a line. The variance between units demands more attention and action to drive up quality further. Tim Statham (CEO, National Kidney Federation) spoke eloquently about the role of the public in promoting a zero tolerance to infection and to breaches of infection control measures. It is difficult for a patient to stop nurse and even more difficult to stop a doctor or professor to point out that their hands need to be washed. But such an intervention should be met with thanks for pointing it out, because it’s an important break in protocol, rather than smiles or resentment. Clearly it would be even better if patients, relatives and the public don’t need to police infection control!!
There were interesting observations from our colleagues in other disciplines including the psychological impact of HCAI which Joerg Huber (Principle Lecturer, Roehampton University) noted had been studied in diabetic foot disease. Given the use of lines and the neutropenia, low white count, in cancer, it is perhaps surprising that HCAI have had a relatively low profile in cancer care, Ian Beaumont (Campaigns Director, Bowel Cancer UK) commented.
David Jenkins (Medical Microbiologist and Lead for Infection Control at the University of Leicester Hospitals) gave a detailed account of measures taken systematically to reduce all HCAI across his organisation. He commented on the surveillance measures that were brought in on the day of this meeting (link to Q & A about infection control- chris winearls). There were a range of other interesting, some surprising and, at times, challenging statements from the invited guests and audience.
Returning for a moment to the G20, regulation does have a part to play and of course the Care Quality Commission came into operation on 1 April 2009 but as with banking, regulation alone is unlikely to solve our HCAI problems.
Nigel Edwards (Director of Policy at the NHS Confederation) pointed out that “shooting the CEO” pour encourager l’autres is not a tried and tested technique to win wars or manage healthcare organisations. A detailed systematic approach to understanding the problems and drivers of infection coupled with ownership and responsibility for HCAI by the individual clinical teams does however work. Lots of nods from the kidney team.
If the lessons we have learned by stepping up and tackling the problems through research, audit, sharing best practice, working with our patient groups and providing accurate data so that HCAI can be part of the annual quality report in every kidney unit can help other areas of clinical care to frame their approach then we should share our knowledge. But we must remember why we have made such progress – we tolerated infection; and we must not be complacent – kidney patients are still very much at risk of infection.
Nick Bosanquet, (Professor of Health Policy, Imperial College, London), concluded proceedings drawing parallels between the various clinical areas. Nick highlighted and congratulated the approach that kidney services working with kidney patients had taken and Nick will be be part of the team writing up the proceedings. I will bring you up to date with that and any suggestions that flow in my blog when the report is available.
Something of interest that I have come across recently was an item featured on HealthExec TV by North East Essex Provider Services. They have developed an electronic patient questionnaire able to capture feedback of patient experience in real time. Part of it relates to whether the patient had observed the healthcare staff handwashing. Take a look at the demonstration video on the HealthExec TV website at
A: Dear Chris, thank you for your email of 2 March concerning MRSA screening and decolonisation. MRSA is as you know a serious and significant problem in the dialysis population and renal medicine is listed as one of the high risk areas in the MRSA screening – operational guidance. Good progress is being made in reducing MRSA blood stream infections in renal services by a combination of general measures and improvement in vascular access, much of the later based on the innovative approach you have taken in Oxford coupled with the implementation of the professional societies guidance on vascular access.
FAQs on the DH website include guidance on how to treat dialysis patients – they should be screened on admission to the dialysis programme and then at regular intervals thereafter. The FAQs acknowledged that some patients, such as renal patients will be tested more than once.
Renal is not exempt from the general screening policy for admissions. In other words, just as a surgical case is to be screened, so should all elective renal admissions. My interpretation is that out-patient procedures such as out-patient intravenous iron infusions are excluded.
The guidance note justifies the screening/decolonisation by citing the high risk of infections, but I am not aware of a detailed evident base for screening within the speciality of nephrology.
There is one study that supports this approach - Nasal carriage of MRSA; the prevalence, patients at risk and the effect of elimination on outcomes among out-clinic haemodialysis patients. European Journal of Medical Research 2007, July 26; 12/7): 284-8; Lederer SR, Riedelsdorf I, Schiffl H.
I understand that some UK groups are now studying the effect of screening and decolonisation for the dialysis population and I hope that will provide a better evidence base for the effectiveness of decolonisation within our speciality in due course.
Debra Mundle (Satellite Unit Matron), and Nick Gadd (Deputy Divisional Director for Managed Networks) met me and, with Simon Steddon (Clinical Director for Kidney & Urology Services), showed me the main dialysis area where I was able to chat with a number of patients. They mentioned that it was quieter, less “clinical” and easier to get to and park. Alan Williams (Charge Nurse), showed me the patient resource room and David Gandy (Chief Renal Technician), tried to explain the intricacies of the water treatment plant to me. I didn’t like to admit that physics had never been one of my very strong points so I was starting from a low base but left considerably more knowledgeable about water quality. There is no waiting room as people don’t wait for dialysis now! Now that’s clearly a good thing. A couple of patients did mention the risk of a loss of camaraderie amongst the patients now they are in better facilities and don’t have to wait as a group. That’s a tricky one. Sense of community is very important for many people with advanced kidney disease. Some units do have formal service user groups and I know of several kidney teams that have regular social events such as an annual dialysis dinner, summer Balls and Christmas parties.
Locally dialysis units do of course reduce travel times, improve patient experience and in addition reduce the carbon footprint associated with dialysis services. But I was not going to the Tunbridge Wells Satellite Dialysis Unit. The not so old Pembury Hospital Satellite Dialysis Unit, a portacabin style structure that was opened in 1966 and had been in the grounds of a local hospital was closed earlier this year; and yes, Tunbridge Wells kidney treatment centre does contain a “satellite dialysis unit” – bigger, better, brighter and quieter than the old unit. John Scoble (Consultant Kidney Doctor), did look a few years younger and the machines in the new centre are slicker than those in the photograph that was on show of the opening of Pembury, but the big change that struck me was the move from delivering satellite dialysis at a distance to providing a locally responsive service. The kidney centre also contains a training area for home dialysis and a self care section on the first floor quite separate from the main dialysis unit on the ground floor and clinic rooms for consultation with nursing, medical and surgical staff.
Cormac Breen (Consultant Kidney Doctor) showed me the Guys renal IT system working fast and comprehensively and that enables patients across the whole kidney care pathway to be safely, effectively and efficiently managed in the High Street in Tunbridge Wells as well at Guys tower at London Bridge. Soon venous imaging and Doppler studies will be available on site – so decisions about vascular access can be made locally. The centre offers a range of services including dialysis, transplant follow-up, chronic kidney disease assessment, conservative kidney care management and dietetics.
It was therefore a great pleasure to open the centre with Mike Rusbridge (Mayor of Tunbridge Wells). The team have made a film of building the new centre, leaving the old unit and the scramble that was opening day. It’s fun, it would make you smile and I think it embarrassed Debra but what it shows is a multi-disciplinary team working together across the boundaries that can sometimes slow us down or stop us, it shows a commitment to high quality care and a clinical vision based on the needs of local people with kidney disease. The centre is building relationships with local GPs and community services. Also, as a result of the medical presence on site in the High Street most days, the link with Kent & Sussex Hospital for education, acute kidney injury management, access to local services and joint management when inter-current illnesses develop in people with chronic kidney disease is actually stronger, more responsive and more personalised to the individuals’ needs than when a nephrologist visits the hospital for their weekly clinic.
Wednesday, 1 April 2009
People with advanced kidney disease should not have to travel long distances to receive IV iron as an outpatient or a day case in hospital setting. “A guide to the administration of intravenous iron for people with anaemia of chronic kidney disease (CKD) in a non acute hospital setting” sets out this intention, and highlights that, where appropriate, specialist services should be transferred to a community setting; administration of IV iron is an ideal example. The CKD Forum and ANSA are leading the way in developing partnerships with primary care so that services can be delivered safely and effectively closer to patients’ homes.
Many of the 1 in 10 people affected by kidney disease in England, are elderly and most have other associated conditions – particularly vascular disease. Historically people with kidney disease were referred to specialist services but it is increasingly clear that primary care has a major part to play in care planning with people affected by kidney disease and that services can easily be provided in alternative settings such as day hospitals, community hospitals, GP surgeries and of course patients’ own homes.
Project lead Karen Jenkins (Consultant Nurse, East Kent) with contributions from Lesley Bennett (Senior Anaemia & Renal Patient Support Nurse Manager, Oxford), Sharon Benton (Anaemia Nurse Specialist, Cornwall), Laura Corner (CKD Nurse Practitioner, Liverpool), Jane Higginson (Practice Nurse Manager, Oldham), Dr Ian Wilkinson (GP, Oldham) have produced guidance which provides us all with an opportunity to take a further step in providing fair, personalised, effective and safe care for our patients. Implementation will demonstrate that the NHS is a system of care, where primary and secondary care are partners and where quality is the organising principle.