Domain 2Enhancing quality of life for people with long-term conditionsEffectivenessDomain 3Helping people to recover from episodes of ill health or following injuryDomain 4Ensuring people have a positive experience of careExperienceDomain 5Treating and caring for people in a safe environment and protecting them from avoidable harmSafety

health and social care professionals to make decisions about care based on the latest evidence and best practice
patients to understand what service they can expect from their health and social care providers
NHS trusts to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide
commissioners to be confident that the services they are providing are high quality and cost-effective

NICE published its quality standards for chronic kidney disease in 2011 (Table 1.2).

In addition to informing commissioning decisions, quality standards can also be aligned with the NHS funding system to encourage providers to follow best practice. In 2011, a best practice tariff for renal dialysis was introduced, paying significantly more for dialysis sessions that are delivered through definitive access (arteriovenous fistula or graft) than for those that are not. This is known to be better for patients because the faster flow rates result in more effective and efficient dialysis and it is much safer because of the reduced risk of infection. The level of the tariff was set so that providers with 75% (increased yearly by 5% to meet the Renal Association clinical guidelines of 85%) of their patients on definitive access would receive the same level of funding as under the previous system. In addition to rewarding services that do better than this, the tariff also provided a strong lever for those that were below this level to bring their services in line with best clinical guidance.

Table 1.2 NICE quality standards for chronic kidney disease.

National Institute for Health and Clinical Excellence (2011) ‘Chronic Kidney Disease quality standard’. London: NICE. Available from www.nice.org.uk. Reproduced with permission.

1	People with risk factors for CKD are offered testing, and people with CKD are correctly identified.
2	People with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance.
3	People with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD.
4	People with CKD are assessed for cardiovascular risk.
5	People with higher levels of proteinuria, and people with diabetes and microalbuminuria, are enabled to safely maintain their systolic blood pressure within a target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
6	People with CKD are assessed for disease progression.
7	People with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function.
8	People with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance.
9	People with progressive CKD whose eGFR is less than 20 mL/min/1.73 m², and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options.
10	People with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
11	People with CKD are supported to receive a pre-emptive kidney transplant before they need dialysis, if they are medically suitable.
12	People with CKD on dialysis are supported to receive a kidney transplant, if they are medically suitable.
13	People with established kidney failure start dialysis with a functioning arteriovenous fistula or peritoneal dialysis catheter in situ.
14	People on long-term dialysis receive the best possible therapy, incorporating regular and frequent application of dialysis and ideally home-based or self-care dialysis.
15	People with CKD receiving haemodialysis or training for home therapies who are eligible for transport have access to an effective and efficient transport service.

A similar tariff for multi-professional outpatient clinics encourages providers to offer patients with complex needs appointments with a multi-professional team (for example, a doctor and a psychologist or social worker) so that patients are given more choice and control and are able to move to their chosen treatment pathway more quickly. In facilitating support for patient choice and engagement as described in the White Paper, the NHS requires better systems that make it easier for different professionals and services to work more collaboratively together, providing more coordinated and seamless pathways of care. In addition to commissioning more integrated services, commissioners are also able to incentivise providers to deliver services in new ways through the Commissioning for Quality and Innovation (CQUIN) payment framework. This enables commissioners to make a percentage of payments to providers contingent on achieving locally agreed quality improvement goals.

The structure of commissioning is also changing. The Health and Social Care Act paves the way for the introduction of clinical commissioning groups (CCGs), consortia of GP practices that work together to commission services for their local populations. While some elements of kidney care, for example dialysis and transplantation, will be commissioned at a national level, CCGs will be responsible for local services to identify and manage CKD in the community. As member organisations, they will be able to engage with their member GPs on improving standards and sharing good practice; and with their population-based approach they are best placed to look at the most appropriate approaches to the prediction and prevention of CKD and proactive targeted interventions for their patients.

At the time of writing the Department of Health is consulting on a cardiovascular disease outcomes strategy. One of the main aims of this is to better integrate care across a range of associated chronic conditions including CKD, hypertension and diabetes.