Appendix 1 Responses from Renal Unit Clinical
Directors in England
Renal Services
Freeman Hospital
Newcastle upon Tyne
12.8.14
Dear Graham
I am dismayed to read the proposed drastic reductions in tariff which seem to have no clinical
rationale at all and will severely impact on the services we can provide.
We have forecast the impact of this (including Market Forces Factor) to be a loss of circa £837,000
to our annual renal unit income; clearly this will have an enormous effect on staffing levels and the
service that we will then be able to provide, both for elective but also for emergency renal support.
If renal unit and dialysis capacity and staffing are reduced, many other services (eg cardiac, vascular,
transplant) will also be jeopardised by the absence of renal support when required.
There are several issues:
1. We as clinicians try hard to empower our patients to make decisions for their own care,
assisted by all the information they require. Many elderly and frail patients on
haemodialysis, who have had unsuccessful fistula formation attempts, then choose to
dialyse on a neck line in full knowledge of the risks and benefits. It seems unfair that units
should be penalised for this with an unrealistic and unachievable target of AVF versus
tunnelled lines.
2. We are trying hard to take care closer to patients, both by outreach clinics and developing
satellite dialysis units. In a large geographical area with a relatively small population, this
cannot be done with reductions in tariffs as proposed. The satellite dialysis tariff will make a
small and remote satellite unit in Alnwick (currently under construction by a private
provider), dealing with elderly patients who may require admission to the main unit on
occasion, financially unviable and our Trust will not be able to support such a loss long term.
Furthermore, offering home care with assisted PD to frail and elderly patients who live a
long way from Newcastle and cannot manage without support will also become unviable –
how is this tariff reduction thought to promote patient choice and care close to home?
3. We have an excellent MDT including dieticians and specialist nurses who are heavily
involved in follow up of our CKD patients and preparation for dialysis. The drastic reduction
in OP follow up tariff for MDT clinics will jeopardise this, to the detriment of patient care.
I hope that you will be able to convince Monitor that review of these tariff proposals is required.
Best wishes
Alison
Dr A L Brown MA MD FRCP
Consultant Nephrologist and Head of Renal Services
Honorary Senior Clinical Lecturer
Freeman Road
High Heaton
Newcastle upon Tyne
NE7 7DN

Alison.Brown5@nuth.nhs.uk
Dear Dr Lipkin
Thank you for bringing this to my attention. I am told that our trust have responded to the
document but it is the first that I am aware of it and no-one to date has shared what the response
was. I share your concerns on all of your points.
£104 is less than we currently pay for haemodialysis sessions to our private providers.
The home therapies decrease is disappointing, as you say regarding, the drive for home therapy and
the training and support both technical and nursing that patients require.
The reduction in follow up nephrology will cause a large drop in income.
Indeed the loss in income from the tariff changes are considerable. It does require a wholesale
review of whether the service as stands is currently viable in my trust. Our “profit margin” for last
couple of years has been in the region of 4-5%. Against this we were planning further expansion of
home haemodialysis with increased technical and nursing support, refurbishment and enlargement
of our main HD unit and a satellite to bring them up to NHS England specifications (and our HD
population is still expanding). If the tariff is going to decrease in such a manner then I do not know
where the money for refurbishment and enlargement will come from – even the private provider
route looks very marginal on the tariffs suggested.
Do you know if anyone in the country will be able to offer a fully NHS England specification
compliant service on such tariffs?
Dr David Warland
Consultant Nephrologist
Dorset County Hospital NHS Foundation Trust
01305 255269
From: Torpey, Nicholas [mailto:nicholas.torpey@addenbrookes.nhs.uk]
Sent: 10 August 2014 15:17
To: Graham Lipkin
Subject: RE: Urgent- Renal tariffs proposed for 2015/16-needs response
Graham
This seems very disturbing. On reading the very lengthy Monitor documents, the principles
on which they are operating seem clear but the detail and justification entirely absent. Have
the various CRGs been involved? Monitor seem to be abandoning their assurance (in the
Methodology Discussion Paper) that changes will be transparent, evidence-based, involve
service providers, and that there will be an ‘Impact Assessment’. As far as I am aware the
new tariffs have been proposed with no regard to any of the above!
From Addenbrooke’s point of view, the proposed changes would lead to financial pressures
that we could not possibly compensate for. The main risks are:
1. Dialysis – the proposed changes will lead to a £1.5 million reduction in income. We
are planning a new main dialysis unit to deal with an ever increasing dialysis
population, outdated buildings and infrastructure, and inadequate facilities for an
enlarging home therapies population.. In the long-term there will be cost savings, but
initially cost pressures. A dramatic change to the tariff could not come at a worse
time. We would likely be forced into drastic cost-cutting which will inevitably involve
nursing staff, dieticians, pharmacists, social workers and psychologists – all
supported through dialysis income, and all central to providing a patient-centered
service.
2. Out-patients – most of a renal unit’s out patient activity comprises follow-up patients,
not new patients. The change in tariff to favour the latter and penalize the former
makes no sense at all. A particular concern is transplantation. All patients attending a
transplant clinic are follow-up patients, and their care substantially more expensive
than, for example, a general nephrology clinic. The tariff has to acknowledge such
activity as CMV and BK virus monitoring and treatment, HLA antibody screening,
excluded drugs (for example valganciclovir), and the complexity of many transplant
recipients.
3. One part of the Monitor document seems to suggest that HRG for vascular access
procedures will be abandoned?
4. I agree that allowing separate charging for acute dialysis is a positive development.
Nick
Nicholas Torpey
Consultant Nephrologist
Department of Renal Medicine, Box 118
Addenbrookes Hospital
Hills Road
Cambridge, CB2 2QQ
Hi Graham
Comment from our Trust.
Steve
Dr Stephen H Morgan MD FRCP
Consultant Nephrologist and Clinical Lead for Renal Services
Basildon and Thurrock University Hospitals NHSFT
Essex SS16 5NL
Tel: 01268 394774
From: Ahad, Abdul
Sent: 08 August 2014 15:10
To: Magrath, Mark
Cc: Timpson, Emma; Ray, Andy
Subject: RE: Urgent- Renal tariffs proposed for 2015/16-needs response
Hi All,
No I was not aware of these price changes.
We would like to know what this significant tariff reduction is based on. I know Trusts were being
asked to make upto 4% gross savings, 1.5 % net after taking into consideration wage incremental
drift and other unavoidable costs, but this can not be based on reference costs submitted by NHS
Trusts, as that would imply there have been significant cost reductions in this area.
The tariff reduction of this percentage will have significant impact as the Trust can not make savings
of such a high percentage, which would mean that the Trust are being asked to do activity for which
it can not possibly cover its costs.
As stated above, the main question to Monitor would be, what the reductions are based on, as they
can not be based on reference costs submitted.
Regards
Abdul Ahad
Assistant Director of Finance
Dear Graham,
Thank you for forwarding this.
I agree that this is rather concerning reduction which will affect patient care and financial stability. Is
patient groups aware of the proposal and its potential effects.
We provide support services like specialist dieticians, pharmacists, specialist nurses (focussing on
CKD care, pre-dialysis care, community dialysis, line insertions, PDC insertions, anaemia
management), clinical psychologists. All of these services are funded from the Nephrology income
and if the income were to be reduced considerably then it’s likely that trust may have a different
view on these personnel.
The department provide specialist clinics like pre-dialysis, post-transplant follow up, haemodialysis
and peritoneal dialysis clinics, conservative management clinics, maternal medicine clinics, transition
clinics etc. The amount of work done by these clinics are not being reflected on the proposed tariff.
Any dilution of the work force in these clinics will have a direct impact on patient care. I do believe
(even though jury is out) the reduction in dialysis patients that we are seeing nationally and
internationally is due to the identification and management of CKD patients in these specialist
clinics.
I also do welcome tariff for dialysis in AKI patients but there’s still confusion regarding whether that
forms the part of HRG or not.
Thank you for leading on this and collating the info.
KR
Ani
Dr H Anijeet
Clinical Director and Consultant Nephrologist
Royal Liverpool University Hospital, Liverpool.
Secretary- 01517063512
Dear Graham
As a team we haven’t had time to go through the overall potential reduction in income which would
be consequent to the proposed tariff reductions
However, the loss of income would clearly affect the ability to accommodate the continued growth
in dialysis and nephrology activity, the tariff for HD below that we pay to our commercial partners
would make HD a loss leader for the service rather than a cash cow, the loss of outpatient tariff
would drive much nephrology and most dialysis and transplantation outpatient activity back into
primary care at a time when immunosuppression is being brought back to those who understand it
and can prescribe it safely. The vital multidisciplinary working in outpatients is threatened, the
complex clinic tail for these patients will be unaffordable. There is a perverse incentive for all CAPD
patients to be put on APD and all HD patients to be infected with a BBV!
Just my random thoughts but hope it helps
Best wishes
Tim
Leach Tim - Chief of Renal and Transplantation CSC [Tim.Leach@porthosp.nhs.uk]
_________________________________________________________________________________
Only comment is to absolutely agree with you!
I will get my finance team to add up the the total loss to our service, but clearly huge. Increase in BBV
helps very few units and PD will be approaching BAxter costs.
Apart from NHS England massive debt- how can they justify the size of reduction and the lack of
clinical engagement?
Barker Lindsey [Lindsey.Barker@royalberkshire.nhs.uk]
Consultant Nephrologist
Dear Graham
I quite agree, I think these "draconian'" tariff reductions without any basis as far as can be determined
and will push most units and eventually, with the overall tariff cuts, most hospitals into the red.
I'm on leave at the moment as is our dialysis matron and Business Manager, so I'm unable to give an
accurate financial return for Oxford by tomorrow, but:
1. I'm pretty sure that we will barely break even with the proposed haemodialysis tariffs and CAPD
and we are ALREADY making a loss on Assisted PD, and home haemodialysis for the few (but
increasing demand) on NextSatge 2. I quite agree with you about outpatients, the 45% increase in
new patients will be disastrously wiped out by the 34-40% reduction in follow-ups; virtually all of our
patients (and I suggest all of appropriately referred & followed) need follow up; as I say I'm on holiday
as are my senior management team but "back of a fag packet" calc. the ratio thinking about my own
clinics, is AT LEAST 10FU:1New including transplant patients and 5:1 excluding them (I do have a
heavy transplant workload). If anything like this tariff is forced on us I think it will encourage accepting
inappropriate New referrals e.g. The very elderly with creatinines in the low 100s (but with "CKD3"
without proteinuria), diabetics with micro/macro proteinuria but with normal or good and slowly
declining function with good blood pressure control on max ACEI etc etc-currently we are refusing
these C&B referrals,, writing back to the GPs with advice; clearly this will waste valuable NHS
resources.It may also risk discharge of patients who really ought to be followed with the risk that they
will return as "crash landers".
3. As you know the Service Spec for haemodialysis now requires monthly MDT appts, which will
drive up our follow-up requirement, for which we don't yet have capacity (one argument for more
consultants in Oxford) 4. The Engagement Overview that you sent refers to a Methodology
Discussion Paper
(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310128/NT1516MethodologyDiscussionPaper.pdf) that suggests that the tariff proposals will be Transparent,
Evidence-Based with Effective sector engagement and with Impact assessment of any proposed
changes. As far as I can see NONE of these have been met-who has been approached to help
provide data from our specialty for this exercise?
5. I also spotted in the EngagementNationalPrices document:
Existing currencies no longer eligible for 2015/14; QZ13A Vascular Access for Renal Replacement
Therapy with CC QZ13B Vascular Access for Renal Replacement Therapy without CC QZ14B
Vascular Access except for Renal Replacement Therapy without CC I'm not sure what this means;
how do they expect us to pay for this? Is there now an alternative means of remuneration?
I do hope that your response and perhaps Richard Fluck will have influence to delay imposition of
tariffs until we can have a properly informed and evidenced based review!
Best wishes
Phil
Dr Phil Mason
Consultant Nephrologist
Oxford Kidney Unit
The Churchill Hospital
Oxford, OX3 7LJ
Tel. 01865 225802
Fax 01865 225773
Hello Graham
This is appalling and looks to be a complete dis-incentive to provide either quality dialysis or indeed
follow up care.
What on earth do they think they’re doing? I completely agree it will have an awful effect on our
budget.
We are one of the few departments in this Trust that is within budget but there is no hope of
remaining so with these tariffs.
Is there anything we can do? Anyone they will listen to? The drop in income will be vast.
Does Richard Fluck, Nesta Hawker, other ‘renal bigwigs’ know about these numbers?
Thanks for letting me know, and scaring me
Fiona
Dallas Fiona (RNL) North Cumbria University Hospitals [Fiona.Dallas@ncuh.nhs.uk]
Consultant Nephrologist-Clinical Lead
Dear Graham
SUSSEX RESPONSE
Thanks for alerting everyone
The HD tariffs (line and definitive access) will mean that contracts currently in place with
commercial HD providers will be unsustainable. SKU have 2 commercial satellites currently
with just 100 pts This is scheduled to increase with new build completion in 12/14. We are
also under pressure to vacate an NHS location in West Sussex with commercial provision
one option to maintain capacity)
In the short term we could increase twilight shifts in our central HD unit. This will increase
transport costs (CCG spend) and patient dissatisfaction.
Introducing financial disincentives to home therapies in a capital-starved world with
unsustainably low centre HD tariffs is incomprehensible. Sussex CRGs spend circa £2-3M on
transport
Please let me know if you need more detail. Our commercial partners are not likely to want
their prices revealed but I am sure we can think of a way around that if needs be.
I have forwarded to our income team to establish the net effect of all of the changes
proposed.
I am not sure who has constructed this proposal and how NCD/CRGs/SCNs have
contributed/modified/guided the proposals
BW
Ed
Kingdon, Edward [Edward.Kingdon@bsuh.nhs.uk]
Clinical lead Brighton
____________________________________________________________________________
Dear Graham
Thank you for drawing this to my attention.
Having run through a few calculations I estimate that implementation of the draft tariff as it stands
would result in a reduction of over 10% in my department’s total income. We have already been
cutting year on year and options for further efficiency savings are very limited – in reality this sort of
cut would inevitably result in us having to cut frontline clinical services. As you have already
identified it is particularly perverse to cut so sharply in home therapies when the thrust of practice in
recent years has been towards expanding home treatment, particularly home HD and assisted
APD. For a small home HD program such as ours this sort of cut may well make the service nonviable.
I have raised this with my Trust’s finance department as I suspect the Trust will want to respond
directly to Monitor.
I am sure that a strong co-ordinated response from the Renal Association as well would be helpful.
Ian
Dr Ian Stott
Consultant Nephrologist
Doncaster and Bassetlaw Department of Renal Medicine
Doncaster Royal Infirmary
Ian Stott [Ian.Stott@dbh.nhs.uk
Thanks for this Graham. Agree a co-ordinated and robust response is required. Thank you for leading
on this.
My brief comments are as follows:
1.
These proposals amount in aggregate to a @13% reduction in tariff for renal services.
2. Hospitals running specialist services such as renal require price stability in order to make
effective long term investment decisions. In addition many organisations have entered long term
contracts involving 3rd party suppliers based on existing tariff levels. These may be loss making under
the proposed tariff.
3. We understand the need to re-align tariffs. However in this case the scale of reduction and the
associated timetable are destabilising financially for individual services and provider organisations.
For example the planned income for my renal service in this year is £40m – a 13% income reduction
equates to £5.2m. This is not a manageable loss.
4. From a patient care perspective these proposals, if implemented, will limit choice, which
Payment by Results was intended to support.
5.
The application of an ‘efficiency factor’ ignores the fact that QCIP schemes next year already
require a 5.6% reduction in expenditure in my renal unit. It is not possible to have a sustainable
service in which costs are being cut year-on-year (more than 15% in the 3 years), and payments
for services are also being severely reduced.
6. The cut in follow up tariff is particularly severe and will impact particularly badly on dialysis and
transplant units who by their nature are obliged to follow patients for life and do not have the
option of discharge to GP follow up. This must be reconsidered.
7. We recommend that renal elements of the proposal are reviewed and altered to avoid
unintended detrimental impact on patients and their providers.
8.
At the very least, these changes must be phased in allow a managed run down of hospital
services. I doubt the commissioners would look kindly upon my request if I asked for an
immediate extra £5-6m income at 6 months’ notice, and slipped it out at the beginning of the
holiday season.
Happy to help if needed.
BW
Dr Peter Andrews | Consultant Nephrologist & Clinical Director
SW Thames Renal & Transplantation Unit | Epsom and St Helier University Hospitals NHS Trust
T: 020 8296 2526 (sec) | E: peter.andrews@esth.nhs.uk | W: www.epsom-sthelier.nhs.uk/renal
From: Kingston Richard (EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST)
[mailto:richard.kingston@nhs.net]
Sent: 06 August 2014 16:54
To: Graham Lipkin
Subject: RE: Urgent- Renal tariffs proposed for 2015/16-needs response
Dear Graham
Thank you for sending this through – clearly some cause for concern.
The increase in first visit is great and I presume the MDT tariff change reflects the idea of
encouraging an initial all-encompassing clinic visit followed by single professional visits thereafter – I
am not sure if you move from gen neph to a pre-dialysis clinic whether this first pre-dialysis clinic
visit, which may well be MDT, can count as a first attendance?
I completely agree with your comments on the dialysis tariff changes – this will discourage home
therapies and Assisted APD will cease to exist – it is already reimbursed at a tariff that doesn’t cover
cost.
Being expected to continue to provide haemodialysis with a reduction in tariff of 13% will be
challenging – patients are older and have more co-morbidities than before . This also fails to take
into account inflation of approx. 2%. All units have been working hard over the last several years to
keep costs down and identify savings – to now impose a further cut in income is going to have
significant impact on quality of service delivery – it would be very useful to know what the basis for
this reduction is – has there been an updated reference cost exercise? Does this take into account
the National Service specifications produced by the CRG? If there were other options to having
dialysis for our patients then incentivising this by cutting tariff might be the way to go but for a large
proportion of our patients there is no alternative and they will now receive a less good service as
units struggle to make cost savings.
I wonder if it is time for the differential between lines and fistula/graft to be reviewed – this has
been subject to great debate at the CRG and the reduction in line infections etc. perhaps makes this
an irrelevance. Patients are choosing to dialyse with lines and for many of the older population this
is entirely reasonable and of lower risk than forming an AVF etc.
With best wishes
Richard
Graham
Thanks for circulating this, I hadn’t seen it – it is utterly depressing.
I am very supportive of the introduction of an unbundled tariff for dialysis for AKI although it’s
difficult to comment on this without an idea of the tariff price.
The rest of the changes will I agree be very destabilising. I think NUH is probably ahead of the curve
in terms of patient level costing models – all of our pathology, pharmacy, nursing, estates charges,
radiology (including interventional radiology) are recorded down to patient level data. For us as a
speciality the financial picture has changed over the past few years with an increase in fixed costs
(mainly estates particularly electricity and heating costs for dialysis units) and a reduction in income.
Over the past few years the drive to increase transplantation and (I hope) the work we have done to
reduce progression/ ensure we have good conservative care programmes in place has led to a
reduction in the size of the dialysis programme and an expanded pool of transplant patients – whilst
that is good for the patients and commissioners it has led to a financially adverse situation. Based on
our PLICS data we loose money on a significant proportion of the inpatient workload. NUH has
recently had McKinseys in doing work at speciality level looking at costs – there weren’t any real
opportunities they came up with so I think we are running a financially efficient service – as a whole
nephrology and transplant surgery made a loss last year – the loss for nephrology was much higher
than for transplant. Clearly everyone expects the year on year efficiency savings but I struggle to see
how we could pull this amount of money out of the system without some fairly radical changes (such
as reducing the number of satellite units, sweating assets with 3 session days 6 days per week and
increasing travel times for patients)
In terms of specific issues:
1. I haven’t read all the accompanying material but I can’t at first glance see any reason for the
disproportionate reduction in renal tariff (apart from perhaps that specialised
commissioning is bust and renal services amount for a significant proportion of their budget)
2. The reduction in PD and HHD tariff disincentives any move to increase home based therapies
particularly if it makes the margins on in centre dialysis worse (less patients, similar fixed
costs)
3. The BPT does incentivise fistula access but every unit will have some patients where
catheter access is needed – in Nottingham we have run catheter rates of approx. 10% for a
number of years now and struggle to reduce this mainly as we have a 7% rate of permanent
lines. The line tariff will be well below what we are charged by independent providers (our
current Diaverum cost per treatment is £124.50 – this is for a 40 patient unit).
4. The outpatient tarfiff reduction doesn’t recognise the chronic nature of the speciality and
the need for regular long term follow up (which I think is becoming a greater requirement
with more elderly, dependent patients with complex health care needs and worsening
access to primary care services)
Happy to contribute anymore info if that would help.
Regards
Simon
Dr Simon Roe Consultant Nephrologist / Head of Service, Nottingham Renal and Transplant Unit, City Hospital
Campus, Hucknall Road, Nottingham, NG5 1PB
Response to proposed best practice tariffs for renal services 2015/16 on behalf of Bartshealth NHS
Trust.
We were surprised and disappointed to see the proposed BPTs for renal services proposed by
Monitor for the financial year 2015/16.
Since BPTs for renal services were first introduced over 3 years ago they have been reduced each
year in real terms by 3-5%. Thus has been done by a combination of 3-4% per annum efficiency
savings and no uplift for inflation. This has occurred at a time when inflation in the NHS has ranged
from 3.5-5%. This has resulted in severe cost pressures for renal units and a struggle to maintain
access to treatment and quality standards in the services we provide.
The proposals for 2015/16 are both surprising and extremely disappointing. It is proposed that the
main income streams for renal units i.e. maintenance dialysis be downsized by 13%. In the narrative
that accompanies the spreadsheet, no evidence is provided to explain this swingeing cut and I would
be surprised if such evidence exists.
The main costs incurred in dialysis are as follows;
1. Dialysis consumables.
2. Staff pay.
3. Plant and buildings. (Transport is an exclusion from the tariff)
1. Dialysis Consumables.
We and most other NHS Trusts have gone out to competitive tender for our dialysis consumables for
more than a dozen years and the evidence is that this is now a very competitive market place. We
achieved very substantial savings in the early competitive tenders but savings in recent rounds have
been much more modest or even non existent which suggests that this market is competitive and
margins are low. We know of no evidence from ourselves or other units that prices have fallen in the
past year or that further price cuts are to be expected in the near future.
2. Staff Pay.
Despite 3 or in the case of doctors 4 years of no or very modest annual increases in pay, there is still
upward pressure on pay budgets in most clinical services and this includes renal services. This is due
to the banding structures in Agenda for Change and Medical and Dental pay, in that the system of
annual increments ensures that the pay bill rises year on year unless there is very high turnover with
replacement of senior staff with junior staff and in practice this never happens to such an extent
that it keeps pay costs static. There is therefore no evidence that pay costs are reducing and some
evidence that they are increasing to a modest degree.
Plant and Buildings.
In the case of dialysis this includes water treatment plants, dialysis machines and buildings. In the
case of water treatment plants, these have been going out to tender for the past 15 years and once
again the market is very competitive with several suppliers. In the case of dialysis machines whether
purchased or leased the situation is similar with a very competitive market place and many
suppliers. We know of no evidence that prices have fallen substantially in the recent past or that a
substantial price cut is imminent.
In the case of buildings once again there is no evidence that the cost per square metre has gone
down recently or that a price reduction is in prospect. On the contrary in those Trusts with a recent
PFI new build (such as ourselves), these costs per square metre have risen substantially over the
recent past and Trusts have little control over them.
On a more detailed note we fail to understand how there can be such a drastic cut to the CAPD tariff
and an increase to the APD tariff. Is this an attempt to discourage CAPD since it would be difficult to
provide quality treatment on CAPD at this tariff?
Based on the above analysis, we fail to see how Monitor can propose such swingeing tariff
reductions on our main income streams and they do not provide any justification for these cuts. The
only conclusion to be drawn is that they are purely driven by a requirement to cut the costs of
specialist services and the cuts are being applied in a non evidence based way, in areas where
perhaps the political fallout will be felt least. There is a substantial risk that these proposals will
reduce access and quality for patients. The tariff for haemodialysis with at central line at
£104/session is barely affordable by Trusts unless a substantial “efficiency” is introduced such as
shortening dialysis sessions and fitting it 4 shifts per day on the same fixed cost base. This of course
would be a major reduction in quality of treatment for the patient. The other “efficiency” would be
to direct onto supportive care those frail elderly patients who are unlikely to consent to or have a
successful arterio-venous fistula and so avoid dialysis of these patients at an unaffordable tariff.
Is the real agenda rationing by the back door?
We welcome the modest increase in out patient tariffs but once again there is a mistaken approach
in that the dogma regarding new to follow-up ratios would completely distort the priorities of renal
services. The majority of new patients seen in renal clinics are seen once or at most twice and
discharged and many have got marginal indications for referral in the first place. On the contrary,
those that are seen in follow up clinics often have serious systemic disease or have progressive renal
failure and benefit from specialist monitoring. A tariff cut for these patients of 34-40% is frankly
absurd and completely inexplicable.
We sincerely hope that Monitor will re-visit these proposals in response to this consultation
exercise.
Martin Raftery
Consultant Nephrologist; Barts health NHS Trust.
Reply to proposed reduction in tariff for in-centre haemodialysis 2015-2016
Dr Clara Day. Lead Consultant for Haemodialysis. Queen Elizabeth Hospital Birmingham
The renal community are fully aware of the need to reduce cost within the NHS and also that renal
dialysis consumes a significant proportion of the health budget. However, the cuts in tariff for
haemodialysis proposed for 2015-2016 are completely unmanageable and destabilising. They would
inevitably lead to a decrease in the quality of the service that could be provided to an extremely comorbid group of patients.
1. Most renal units are fully cognisant of the sessional cost of the dialysis treatment itself;
these are made up of the cost of consumables and staffing. Most dialysis units will have
procurement contracts in place, either as an individual unit, or as group of units, to reduce
consumable costs to low levels. There are now very small margins of saving to be made with
regards to dialysis consumable. Nursing staffing is to be provided as per National Renal
Workforce Planning Group guidelines (2002) which state that:
a. Staff should reflect cohort co-morbidity but should as a minimum be at 1 staff member to 4
patient ratio with a 70:30 split of qualified versus non-qualified nursing staff. In the past
decade the co-morbidity of the in-centre dialysis population has increased meaning that this
ratio is a bare minimum now for most units to provide safe care and many feel more staff
than this are required.
b. Nursing staff should be employed as 1 to 4.5 WTE per patients within the dialysis unit to
ensure safe cover for leave and training.
2. The care of the dialysis patient, and thus the dialysis tariff, does not simply include the
dialysis session. NHS England specifications state, quite correctly, that the in centre
haemodialysis patient should be provided with holistic, multi-disciplinary care. Such patients
are often unable to work because of their illness and its treatment, and over 30% have coincident depression. Psychosocial support is thus crucial. In addition, specialist nursing care
is required for anaemia and vascular access management as well as ensuring provision of a
strong professional development leadership. The latter is particularly important to ensure
that nurses are confident, skilled communicators and are able to support the specified
shared and self-care initiatives. Tailored dietetic support is vital and ongoing nephrological
care, ideally provided by skilled dialysis doctors, is also necessary. Haemodialysis patients
often have multi-morbidity and find access to primary care difficult thus requiring skilled and
time-consuming medical case management by the nephrologists. Skilled technical services
are also required to maintain dialysis machines and water purification equipment. All of
these services must also be provided by the haemodialysis tariff.
3. Equity of care is specified, particularly relating to the need to have satellite dialysis units
located to reduce time of travel to a maximum of 30 minutes. This requires capital
investment that will need to be reflected in the tariff income.
4. Many units already work in partnership with independent providers to help drive down costs
by deriving benefits from outsourcing capital expenditure and employing staff on non-NHS
terms and conditions. Contracts will usually contain a fixed cost per treatment for the
lifetime of the provision. Such sudden reduction may well destabilise such contracts and are
in danger of precipitating a situation where independent providers are no longer able to
operate within the UK causing many renal units very significant difficulty.
5. In-centre haemodialysis is a ‘best practice tariff’ with differential payment for dialysis for the
preferred option of permanent vascular access (AV fistula or graft) versus the less preferred
dialysis catheter. It is widely acknowledged that such permanent vascular access is
preferable for long term patient outcomes in most patient groups and thus as a driver for
practice change, the best practice tariff, is a reasonable option. It is however, felt by many
units, that the tariff structure requiring 85% of patients to receive dialysis through
permanent vascular access is over ambitious, unachievable by many and does not include
the patient’s right to choose. However, the proposed changes in the tariff do not seem to
reflect any change in the differential with a 13%+ drop in both categories.
6. The increase in the tariff for dialysis of patients with blood borne virus is appreciated as care
is more complicated, particularly with regards to blood monitoring. However, I am unsure
how costing models have allowed such a significant reduction in tariff for the uninfected
dialysis patients vs an increase in the tariff for the infected patient.
In summary, the care of the in-centre haemodialysis patient requires a highly skilled, multidisciplinary team in a purpose designed, locally available facility. Costly technical infrastructure
needs to be provided along with necessary sessional consumables. Many units struggle already to
provide such care within the tariff envelope and the proposed reduction will simply lead to a marked
reduction in the quality of care that this highly co-morbid group of patients receive. This will
inevitably lead to more costly hospital admissions. Such proposed cuts are ill-thought through at
best and seem to bare no relation to the costs incurred in providing quality care as per national
specifications for this group.
Proposed change in tariff for home haemodialysis for 2015-2016
Dr Clara Day. Consultant Lead for Haemodialysis, Queen Elizabeth Hospital Birmingham.
There has been over the last few years, quite correctly, a national drive to increase the proportion of
patients performing haemodialysis at home. The reasons for this include:
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Better quality of life in those in control of their own treatment
The ability to be able to perform differing dialysis regimes at home, whether more frequent
or more prolonged, which are associated with better long term patient outcomes than
regimes possible in renal units
Economic advantages of less infrastructure and lower nursing ratios
The tariff for home haemodialysis, when first established, was intended as an incentive to facilitate
transfer of patients to this treatment modality. However, providing home haemodialysis is not very
significantly cheaper than provision of in-centre haemodialysis.
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Each patient needs their own machine, chair and reverse osmosis unit. These are obviously
shared in-centre and this is therefore a cost pressure
Home adaptations are required to allow dialysis at home and this is included within the
tariff. Sophisticated adaptations are now rare but adaptations are required in all cases to
allow plumbing and machine placement.
Training patients and carers to perform haemodialysis at home is time and resource
consuming. One to one nurse training is required to ensure safe and confident technique.
This period of time is included within the current tariff.
In order to maintain patients at home, and thus prevent technique failure, skilled senior
nursing staff are required. The ‘typical’ home haemodialysis profile as a young, stable
patient no longer exists with the modality quite correctly offered to all who are clinically
suitable. The change in this population needs confident, highly skilled and very available
nursing care.
Skilled technical support is required with 24 hr call out availability to aid patients with
machine problems and ensure strict water governance policies are followed.
Home haemodialysis needs considerable input from experienced nephrologists. There is
additional risk associated with performing haemodialysis at home as opposed to in-centre.
Nephrological leadership is required to ensure all standards are met and to help maintain an
increasingly complex group of patients on their renal replacement therapy modality of
choice.
We are being encouraged to consider newer, purpose-designed home haemodialysis
machines which are easier to use, smaller and portable. These devices are often more
expensive to use but may allow more patients to dialyse at home because of their better
usability.
The proposed substantial reduction in the home haemodialysis tariff will have a significantly
negative effect on home haemodialysis in this country. Trusts will no longer be able to afford to offer
what is felt to be ‘gold standard’ increased frequency/more prolonged dialysis therapy which
improves patient survival. It also embraces all national policies about patient involvement in
management of chronic illness. This will have a very significant effect on both patient quality and
indeed quantity of life and goes against all national drives for increasing this treatment modality.