Monday, 13 October 2008

Radical social movement in Manchester

A Home Haemodialysis Symposium in Manchester on 2 and 3 October 2008 was oversubscribed – 20 or 30 people were turned away. The lucky 200 heard about the experience of home haemodialysis from Canada, Finland and several centres in the UK. Dr Martin Wilkie (Consultant Renal Physician, Sheffield Kidney Institute) gave a great talk on the future of Peritoneal Dialysis (PD). That was the only exclusive peritoneal dialysis talk but the concept of an integrated service – offering choice, training support for the optimal replacement therapy option, or conservative kidney care underpinned the philosophy of the whole faculty and delegates. I spoke about commissioning flexible dialysis provision - and commissioning is an important lever for change. The power of the people however is an even greater lever. As a kidney care community we have moved a long way since 2002 and the NICE health technology assessment guideline suggested that up to 15% of dialysis patients would benefit from home haemodialysis. Some of you will remember that there was a strong negative reaction to that recommendation – this was “pie in the sky” was a frequently heard comment. The fact the costing model used in 2002 was seriously flawed added to the scepticism, indeed cynicism, about the figure of 15%.

Dr Sandip Mitra (Consultant Renal Physician) and colleagues Manchester Royal Infirmary now have 15% of all haemodialysis patients on home haemodialysis!! Dr Cormac Breen (Consultant Renal Physician) and the team Guy’s & St Thomas’ have gone from 3% and falling to 7% and growing and are aiming at 10% within the next year or so. Derby have the same goal. At Guy’s people on home haemodialysis agree their hours and care plan with the community dialysis team – some are still on 3 x 4 hours per week, far more on 5 or 6 times per week, some on 2 hours daily and some on daily nocturnal.

Costs of home dialysis are less than hospital based – no travel costs and much less staff costs. Of course dialysing 6 or 7 times per week does use more consumables and costs more than 3 times per week home haemodialysis – a small sum in the scale of things. How have these units achieved that shift from in-centre to home treatment? Not rocket science, not financial investment, not a miracle: no they have achieved it by designing their service around the needs and choices of people approaching or on dialysis. But redesigning the service alone would not achieve similar results – in addition to designing around patient preferences these teams have moved their model of delivery from a reactive to a proactive managed care model. Planning for the population, using Registry and other demographic data and most importantly of all care planning for the individual is the key to success.

In the words of a Manchester Royal Infirmary patient “dialysis at home was safe, machine problems were rare, the community support was excellent, and the delivery of supplies well managed”.