Rethinking Funding in Healthcare

Last week, I attended a meeting of key providers of kidney disease care in England. This meeting looked to feedback to the government on what has worked so far in caring for patients and families living with kidney disease and what has not. It looked to bring our heads together to improve services across all aspects of kidney disease. As I sat through the main talk from a representative from NHS England, I couldn't help but see how healthcare is a vast industry worldwide. It employs the largest swathe of any population and consequently demands as much, if not more, resources for oiling the cogs of its ever-turning wheels. In a nutshell, healthcare gives as much as it takes. The conversation then shifts to how we can fund healthcare in the prevailing dynamic economic vicissitudes. This question is not just pertinent to the United Kingdom. It applies to all healthcare systems from the Icelandic occiput to the rudimentary tail of Antarctica.  Healthcare funding needs to be as efficient as it is effective. We must recognize our limited resources hence aim to maximize our outcomes. Allow me to share some ideas on how we can reimagine our quest for funding, home and away.

1) Integration of services

There is inter-causality of almost all chronic diseases known to man. The most interesting, if not tragic factor is that they almost always end with chronic kidney disease. The two main causes of chronic kidney disease in the world are diabetes and hypertension.  As such, coming up with strategies for the three specialties to work together is key. I must applaud various groups in England and Wales who came up with the idea of a cardiorenal metabolic syndrome group. This means that heart failure, diabetic, and renal practitioners can finally sit in one room and holistically look at the patient in front of them.

I say this because the three diseases tend to follow each other (not always) in the same patient. When we seek funding, selling the idea of three diseases in one will attract more resources as opposed to separating the three into individual silos. This does not eliminate any of the three specialties but gives them a modality to work in which allows constant direct interactions. At the same time, we must understand the chronicity of kidney disease. As such, we have patients who opt not to have dialysis and others for whom dialysis or kidney transplants are not viable treatment options.

These patients end up either forgotten in most countries or just shoved onto dialysis machines anyway which greatly diminishes their quality of life and heralds an untimely, unplanned death. The concept of conservative management of kidney disease must have emerged from this very concept.

That notwithstanding, we have already established supportive care services that we can plug into the kidney community. Cancer services have long existed and given us a large number of conservative care models. Liaising with them and introducing our supportive care expert teams to work with them on the care of a terminally ill patient who has end-stage kidney disease is a plus. It not only helps us maximize available resources but also provides more focused care for the patients and their families.

While we are on this topic of focused care, I draw your attention to the various departments that care for a patient who has kidney disease. Their general practitioner (GP), the physiotherapist, the dietitian among other members of other departments. We need to tee off these departments through a multidisciplinary meeting to offer focused patient care. After all, holistic care is the tenet of nursing as a profession. We can argue that we do not have time for extra meetings but this is how we save that patient from unnecessary admissions to the hospital and fractured advice on their care. We have Microsoft Teams, Zoom, and Google Meet among other resources we could utilize to touch base and see how best we can offer our services to that one patient.  You will be surprised what such an MDT could accomplish.

2) Public Health Messaging

When you hear the words 'high blood pressure' and its side effects, stroke will be your main concern. I have lost count of the number of times my patients on dialysis have mentioned that they lived with high blood pressure for years and nobody mentioned that they were at an increased risk for having chronic kidney disease. Most of them never had a simple urinary protein check done. This underpins the fact that we have a long way to go as far as kidney disease awareness goes.

We seem to know everything in our professional quarters while the people who need the information we have know little, if anything,  about kidney disease. A quintessential rain in the ocean. When I look at our public health messages on prime-time television,  the public is told about dementia and cancers of various forms and absolutely nothing about kidney disease. I am not diminishing the campaigns against dementia and cancer, far from it! I am amplifying the fact that we are largely silent about kidney disease, ignoring the knowledge gap that we already know exists among members of the public.

We need to specifically fund talks on kidney disease. I want a talk show and an interview with a kidney nurse on a breakfast show. I want to see kidney disease incorporated in prime time watch and other watershed moments. We need to talk about this. We cannot continue regurgitating our knowledge to one another while those who truly need it are starving.

3) Private partnerships

Every country has its formula for public-private partnerships in healthcare. The United Kingdom is not an exemption. I used to think that the NHS provided all services as a public healthcare system but I came to learn it outsources several of these to private providers. On the other hand, while cutting costs to the NHS, sometimes quality is compromised and it is the patients that suffer. I have witnessed a few examples like lack of snacks for patients on dialysis, delays for patients who need transport to and from dialysis centers, dialysis needles that are not sharp enough, lack of blankets for patients to cover themselves with while on dialysis and I could go on! I have unfortunately observed things I wish I had not.

Partnerships with the private sector must be through open tender systems. We must rely on proven track records of quality dialysis care for example before we offer contracts to the applicants.  In addition, contracts need to have wiggle room for the NHS to walk away from if quality is compromised. The only way to address quality concerns is to speak to patients themselves and the nurses on the shop floor. This is how you partner and maintain quality at the same time.

4) The 'Is it Beneficial?' Test

In Rotary, we have the Four Way Test. It asks us to measure everything we say or do against four parameters. Is it the truth? Is it fair to all concerned? Is it beneficial to all concerned? Will it bring goodwill and friendship? If whatever I want to do or say fails any of the Four Way tests, then I keep it to myself. The NHS must adopt one of the Four Ways which is "Is it Beneficial?" I say this about the several managerial posts within NHS ranks. Too many managers and sub-managers and fewer and fewer nurses on the shop floor.

Is it beneficial to have five managers within a department of less than fifty nurses for example? What are they managing? Don’t we need more nurses on the floor where direct patient care is being compromised by unsafe staffing levels? For a healthcare system decrying short staffing, we need to retain managerial positions which are must-haves not nice to have. This frees up the budget to take nurses back to school for renal courses or even buy more resources for the team.

Speaking of benefits, it is not beneficial to truncate the renal specialty into tiny little subspecialties and limit horizontal movements to any of them. We need to allow nurses to rotate in all renal areas and let them find their true calling. I will tell you for free that nurses do not leave bad jobs, they leave bad management. When you clip their wings through suffocating red tape and unnecessary hoops they have to jump through, then you lose them. And this is not beneficial. I find it utterly non-beneficial that a nurse who works in a hemodialysis unit has to apply afresh for a job in a renal ward and vice versa. How little do we then think of our ability to train nurses in a wholesome manner within a specialty?

Understandably, nothing is cast in stone and these ideas are suggestions, not rules. Everything will change depending on the geographical and geopolitical circumstances.  Yet we cannot deny that the application cuts across the board. Though everyone wants a stake in the profitable healthcare industry, we all have a role to play to not only seek more funding but also make existing funding models make sense.