Response to Monitor on Draft Proposed National Tariffs 2015/16 for Renal
Services from the Renal Association
This response from the Renal Association (RA) includes comments received from Clinical Directors
(CDs) of English Renal Units. The Renal Association is the Specialist Professional Society of UK
Nephrologists & incorporates the Renal Clinical Directors Group & the UK Renal Registry. The Renal
Unit CDs have asked the RA to collate their responses for Monitor. These individual responses are
attached (Appendix). We comment solely on adult tariffs, a separate response has been submitted by
the British Association of Paediatric Nephrology. The Renal Association recognises the difficult
financial position which the NHS faces and the requirement of ‘Maintaining financial discipline
while promoting high quality care in tough conditions’. Monitor’s Tariff document became known
to the RA only 1 week ago.
Comments on Sections of the Spreadsheet:
1.
2.
3.
4.
Service
Spreadsheet Tab
Line/Row
Nephrology OP
Adult Renal dialysis,
AKI tariff
Tariff for acute dialysis
OP attendances
55
BPT Sheet
20-42
APC
Referred to in supporting documents
Assessment used
‘Modelled’
PbR methodology.
No Tariff found
Comments:
These tariff proposals have very disturbing implications for the delivery of services to patients with
kidney disease in England. Supporting Documents accompanying Monitor’s tariff proposals identify a
target cost reduction across NHS services of 3-5%. The huge reduction in tariff proposed across renal
services of circa 13% is wholly disproportionate & unjustified in the documents. Proposed tariffs will
result in perverse incentives counter to the current direction of good clinical care and of patient
choice. We present evidence that the proposed tariffs would lead to destabilisation of Renal Unit
finances and have a major adverse impact on service delivery and care of patients with kidney
disease. We ask for these proposed tariffs to be actively reviewed in a transparent and evidencebased process. We ask for the evidence on which these Tariff proposals were based. We offer
support of the Renal Association in working with Monitor.
1. Process
We have major concerns about the process with which renal service tariffs were developed.
Using Monitors own criteria above, we find them wanting. Monitor describes the development of
the proposed draft tariff document as being transparent, evidence-based, utilising effective sector
engagement and with impact assessment on clinical services.
a. Sector Engagement: The proposed tariffs were published on the Web in mid July. No
notification of publication was given to Renal Units, or to our knowledge, Trusts, the Renal
CRG or the National Clinical Director. Sector engagement was therefore absent. It is wholly
unacceptable to develop tariffs in a vacuum from the clinical or NHS organisational structure
for renal services. It is purely by chance that those responsible for delivery of services for
patients have had an opportunity to comment.
b. Transparency & Methodology. The methodology section describes use of 2011/12
reference costs, ‘modelling’ or PbR tariffs in setting these changes. It is however far from
transparent as to how these proposed tariffs were reached. We wonder if the reference costs
we misinterpreted or misunderstood as they do not reflect those described by CDs of Renal
units in England. We therefore challenge the evidence base, transparency & methodology on
which Tariffs were developed.
c. Impact Assessment: Renal Unit Clinical Directors & their finance managers identify that the
proposed tariffs will compromise the financial viability of Trust’s Renal services and therefore
the ability to deliver high quality services by renal units. As such it is difficult in the extreme to
see how Monitor has performed an impact assessment which is fit for purpose in this area.
2. Proposed Treatment Tariffs
a. Dialysis for AKI. This new Tariff is very welcome but does not compensate for the loss in
Renal Unit income proposed elsewhere. Furthermore, we can find no actual tariff listedhave we missed it? All Renal Units currently provide dialysis and clinical care for patients
with AKI without reimbursement. This happens when AKI occurs during another speciality
IP episode (eg following cardiac surgery, general surgery, non renal transplantation,
critical care episode, Oncology etc.) The patient is, not under primary renal care but
consumes considerable renal resource. Although in relative terms these numbers are
small, the costs incurred currently are at the expense of other patient activity. We request
this tariff be unbundled and will reflect the true cost of this service delivery. The RA will be
pleased to assist in discussion on the level of tariff.
b. Unbundling of radiology tariffs. (Unbundled Services, Line 1-75). This is supported in
large part by the Renal Association.
c.
Adult Chronic Renal Dialysis (Best Practice tariff, line 20-42). Changes are summarised
below.
Adult Chronic Renal
Haemodialysis
2014/15 (£)
(per Session)
2015/16 (£)
(Per Session)
% Change
Lines on
BPT/HRG
(LD01A-8A)
Line
119
104
-13
20-32
Fistula/graft
150
130
-13
20-32
Line
143
150
+5
20-32
Fistula/graft
178
186
+5
20-32
-13
33-35
Hospital and Satellite
Patients with Blood
borne virus
Home HD
Line
Per Week
449
390
Fistula/graft
449
390
-13
33-35
d. Hospital and satellite based adult haemodialysis.
 We understand the desire to re-align tariffs but a 13% cut in hospital and satellitedelivered haemodialysis is a swinging reduction for Renal Units. Responses from Clinical
Directors indicate that this cannot be accommodated without endangering the viability of
renal services (see attachments). It must also be remembered that CIPs have already
been applied year on year since 2011/12 amounting to >10% reduction in reimbursement.
 The majority of Renal Units have fixed long running contracts with 3rd party private
dialysis providers for a proportion of their HD patients (including the old DH N16 contracts
which are fixed with 3rd party providers at a level above the proposed tariff). Reference
cost data & renal CD responses indicate that a 13% drop in tariff to £104 (patients
dialysing on a line) is below the 3rd party contract price paid by many Units. These
services would therefore run at a loss to Trusts & lead to an inevitable reduction in level
of service. It risks a return to adverse patient outcomes seen in earlier days of dialysis
delivery. Safe delivery of a quality chronic haemodialysis session requires not only the
dialysis itself but also includes the MDT input, medical, dietetic, social work, psychology,
coordinators and transport. This is not covered by these private provider contracts & this
may not be clear from reference costs. We are willing to clarify with you these reference
cost issues.
 Current BPT correctly incentivises dialysis accessed through a fistula or graft. The scale
of a 13% reduction in HD Tariff for Dialysis delivered by a fistula or graft will potentially
push renal services to be delivered at a loss. Whilst there is agreement that HD via a
fistula/graft has clinical advantages, some patients, often co morbid or elderly patients
choose to dialyse on a line. The current BPT target of 80-85% fistula/graft access is
increasingly felt inappropriate/ unrealistic by many clinicians. Proposed tariff may well
provide perverse financial incentives for Units to ‘push against’ choice of some patients.
 Several CDs identify that reduction in tariff may prevent much needed planned unit
infrastructure development/expansion. This identifies the fine balance that exists in
maintaining renal unit financial viability and a drastic reduction in tariff in one area may
lead to unintended consequences in other areas of renal units’ services.
 Haemodialysis of BBV positive patients. These patients do require substantial additional
infrastructure/staffing to provide adequate patient care and safety of other patients and of
staff. A proposed increased tariff of 5% for these patients is realistic & welcome.
However, these patients account for less than 5% of all dialysis patients. This increased
tariff is required and will in no way offset the reduced tariff for non BBV-infected patients.
Home Therapies (Home haemodialysis and Peritoneal Dialysis)
A significant proportion of patients choose dialysis therapies at home achieved by peritoneal dialysis
and home haemodialysis. This is in line with informed patient choice and NICE guidance for both
Home Haemodialysis and Peritoneal Dialysis. Patient choice is appropriately supported in developing
these areas by the Clinical Service Specifications. In addition home therapies have significant health
economic benefits. Draconian reductions in Tariff of between 13 and 18% are proposed which will put
at real risk this clinical direction.

Continuous Peritoneal Dialysis. The proposed reduction in tariff for treatment by
peritoneal dialysis of 18% is extremely difficult to understand in light of the strategic
commissioning direction. Attached responses from Renal Units indicate that this will put



units at risk of being financially unviable, limit patient choice and potentially undo many
years of strategic work to increase home therapy treatments. Is this justified by evidence?
Automated Peritoneal Dialysis. The UK Renal Registry reports an equal split in
automated vs continuous peritoneal dialysis treatments. The 4% increase in APD Tariff
does not compensate for the reduction in CAPD Tariff. We would like to see the evidence
base on which these proposals are made?
Assisted APD. Assisted APD has enabled a small number of patients to receive home
dialysis. It is seen as clinically effective and preferred by suitable patients. The impetus of
the last years has been to enable this relatively recently introduced treatment modality. It
is therefore incomprehensible to us that funding for this therapy should be reduced by 6%
without evidence.
Home Haemodialysis: Home haemodialysis enables highly effective, cost effective
treatment. National commissioning and clinical policy as well as NICE guidance and
Clinical Service Specifications have supported the expansion of this treatment modality.
There is widespread variability in availability of this modality and Trusts have invested in
the infrastructure required to deliver an effective service. There is evidence from the
UKRR that this is leading to a welcome change in practice for suitable patients. Again an
18% reduction in Tariff is diffuclt to understand and requires justification.
Renal Outpatient Tariffs


Current renal OP services necessarily differ in respect of new to follow up OP ratios from
those seen in many other areas of medicine. This reflects the highly specialist nature
required for follow up required by patients who have advanced CKD, those on dialysis
and those treated by kidney transplantation. In addition renal services care for a
disproportionate number of patients with rare diseases which require specialist follow up.
The need to expertly address the requirements of patients with rare diseases is identified
the DH strategy document for Rare Disease Services 2013.
We welcome the increase in first single and multi-professional OP attendance. However,
the reduction in tariff for follow up attendance and the severe tariff reduction in follow-up
multi-professional OP attendance is of great concern. Patients treated by dialysis, those
approaching dialysis, patients who choose a conservative (non dialysis) care strategy to
their disease, those with complex rare diseases and those transitioning from paediatric to
adult care substantially benefit from nursing, dietetic, social work, psychologist input in a
MDT environment. We have severe concerns about the impact of a 40% tariff reduction
for those requiring MDT follow up. This will by no means cover the costs of MDT input
and we request these are reviewed.
Impatient AKI and CKD Tariffs (APC line 852-)

AKI as a cause of admission or acquired during a hospital admission is a key area of
focus in clinical care improvement at present. AKI is associated with a marked increase in
hospital costs and adverse clinical outcomes. Substantial renal service input is consumed
in care of these patients. It is at present not clear whether the tariffs proposed reflect true
costs. We would be interested in the reference cost data used to generate this.
Summary
The Renal Association and Clinicians recognise the financial challenges faced by the NHS. However,
with little evidence presented by monitor we challenge the process used to derive these changes. The
reasons for substantial and disproportionate tariff reductions proposed for renal services especially for
some dialysis therapies are not transparent and we are not presented with the evidence base. We
believe these tariff reductions to be extremely destructive to renal services and patient care and
choice. We request that these Tariffs be substantially revised.
Graham Lipkin
Clinical Vice President Renal Association
Consultant Nephrologist