Specialised Commissioning of
Kidney Transplantation
Keith Rigg
Chair, Renal Transplant CRG
1. Introduction
2. What has been done?
3. What is coming?
1. Introduction
Specialised Commissioning
• Where does it fit into NHS England?
– Alongside commissioning of primary care,
offender healthcare and aspects of armed forces
healthcare
• What is included?
– Prescribed services meeting defined criteria
• Budget of £13.8 billion pa (14% NHS budget)
• Six national Programmes of Care
Operating model for specialist
commissioning
• Single ‘do once’ function at
national level
• Strategic interpretation at a
regional level
• Provider/commissioning
interface at Area Team level
Where do the Clinical Reference
Groups (CRGs) fit in?
Roles of CRG
• Specialised advice and guidance
• Developing national service level strategy
• Developing and providing assurance of
commissioning products
• Evolving performance management role
Specialised Commissioning Taskforce
• Established April 2014
• Improve how NHSE commissions specialised
services and to put commissioning arrangements
on a stronger long term footing
• Seven work streams
• Priorities
– Deliver balanced financial plan
– Reducing unwarranted variation & improving quality
– Strengthening commissioning infrastructure
2. What has been done?
What has been done?
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Service specification
Commissioning policies
CQUIN
Quality measures and dashboard
5 year strategy
Collaborative working
Business as usual
Service Specifications
• Clear description of what a service is and the
acceptable standards that need to be in place
for delivery
• Benefits of country wide single service
specification
• Recognise different ways of service delivery
and interface with RDI CRG
• Concentrate on the ‘what’ not the ‘how’
Commissioning Policies
Current
• Reimbursement of
expenses for living
kidney donors
Consulting
• Eculizumab for the
treatment of refractory
antibody mediated
rejection post kidney
transplant
• Bortezomib for the
treatment of refractory
antibody mediated
rejection post kidney
transplant
CQUINs 2013/14
• Cold ischaemia time
– DCD <12 hours
– DBD <18 hours
• Increase use of Renal Patient View
Quality Measures
• NHS England/NHSBT agreement
• Kidney Centre Specific reports
– Robust data
– Validated by centres
– Available to units, commissioners, patients
• Purpose to reduce unwarranted variation and
improve quality
RTR Dashboard
• Access to renal transplant
– Median waiting time
– DBD Organ Decline rates – standard & extended
– % of living donor transplants that are pre-emptive
• Transplant outcomes
– 1 & 5 year graft and patient survival rates for
deceased and living donor transplantation
Five Year Strategy
• Improving the deceased donor transplant
patient pathway - from assessment to
transplantation
• Living Donor Kidney Transplantation
• Improving the deceased donor transplant
patient pathway - from assessment to
transplantation
• Improving the effectiveness of kidney
transplant follow-up
Collaborative Working
• Renal Dialysis CRG
• NHS England/NHSBT
• National Services Division, Scotland
Business as Usual
• Advice and Guidance
– Local Area Teams
– Clinicians
– Patient Groups
– IFRs
– Drug issues
• NICE stakeholder
• Performance management
3. What is coming?
What is coming?
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National Tariff
QIPP
Future commissioning models
Peer Review
Managing capacity
What is the Renal Transplant
Currency?
Different ways of working
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Work-up – what, who, where?
Maintenance on list – what, who, where?
Transplant procedure
Follow-up – what, who, where?
Repatriation – who, when, where?
Need a single model of currency and costing that
will capture different ways of working
Currency development
• Workshop January 2013
• Mandated currency from April 2013
• Four pilot networks
– Effectiveness of recording currencies
– Case mix audit undertaken – variation in investigations and
frequency
• Workshop October 2013
– Currencies best recorded through adapted clinic outcome
form
– Broad agreement reached on pathway in terms of currency
and tariffs to be utilised
Next Steps
• Initial finance workshop
June 2014
• Costings being
modelled to currencies
• Shadow tariff 2015/16
• National tariff 2016/17
QIPP 2013/14
• Immunosuppression prescribing
– Secondary care prescribing & Homecare delivery
– National Procurement
– Push towards increased used of generic brands
• Pre-emptive living donor transplantation
– Linked to NHSBT LDKT strategy
QIPP 2015/16
• Clinically led QIPP programme to produce 3%
savings - £420 million
• CRGs working with area teams
• Dilemma for transplantation – increased
activity vs savings
– Increasing transplantation
– Reducing unwarranted variation
Future Commissioning Models
• National specialised commissioning
• Co-commissioning with CCGs
• Commissioning by CCGs
Peer Review
Key aims
• Quality assurance of a service
• Enable quality improvement of a service
Why consider peer review?
Benefits
Disbenefits
• Recognise and share
good practice
• Identify and act on
reasons for nonstandard variation
• Increase public and
commissioner
confidence
• Increased regulatory
burden
• Negative perception
• Time and resource
required
Activity and Capacity
• 2007/08-2013/14: 47% increase in the
number of new transplants performed
per year
• 2008-2013: 31% and 40% increase in the
number of functioning transplants in
transplant centres and specialist renal
centres respectively