Tuesday, 28 April 2009

Q & A: Peritoneal Dialysis contracting & holiday entitlements

Q: I have been asked to contact you regarding concerns over peritoneal dialysis contracting. following discussions of the North West Collaborative Procurement Hub. All the NW renal units work through the Procurement Hub with the aim of achieving the best results from contracting for dialysis consumables.

There have been major anxieties within units about the recent withdrawal of Gambro from the UK peritoneal dialysis market leaving only Baxter and Fresenius. I believe there is work ongoing moving towards national supply agreements and that the present round of negotiations are a “stop gap” measure.

It is clear the companies are under financial pressure and there may be pressure to increase prices either in contracts being discussed now or when next major renegotiations take place. However there is considerable disquiet from the represented renal units because of the move away from therapy costs to itemised fees. Although there are potential pros & cons to this for individual units depending on their usage the unbundling of holiday dialysis is a major issue. The price increases are coming through as increased payments for “extras” such as help in training patients and holiday dialysis.

Enquiries show that most units do not have a separate holiday dialysis budget line and that previously bundled holiday costs would largely come out of the “allowance” made through the contract with top ups coming from the general renal/dialysis budgets. The top up monies were relatively small so tended not to cause any problems so most PD patients would be supported for all their proposed holidays. If the cost of PD holiday dialysis is now clearly separated there is a major worry that there are no National guidelines on what a patient might reasonably expect. Managers and clinicians were agreed that this could cause a rift between the groups as managers became the arbiters of holiday allowance for individual patients, holidays would no longer be supported if financial pressures were high and the budget might disappear prior to the end of a financial year.

Although it is recognised that it will be up to units/regional procurement organisations to arrange for the best contract terms, the lack of a clear stance from the renal community on what patients can reasonably expect in terms of holiday support will hinder units in supporting their patients. As a major selling point of peritoneal dialysis is independence, the ability to travel and be independent of the hospital this could further erode the uptake of PD and ferment patient dissatisfaction in the prevalent population.

From a local regional level we are unclear if it is being flagged as a problem nationally although suspect it is happening nationwide. Clarification across the renal community of what are reasonable expectations regarding holidays for PD patients would we believe be a major benefit when financially strapped trusts pressure managers to save costs and there is no agreed protected budget provision. Dr David Lewis Clinical Director Salford Royal NHS Foundation Trust

A: David, thank you. These are serious concerns, particularly the risk of further restriction on the ability of people receiving dialysis to travel for holidays, work, family or all the other reasons we all value the basic human right of freedom of movement. You are not alone – others have raised similar concerns in other parts of the country including the West Midlands, London and South Central SHA.

I have therefore convened a short life working party to design a clinical peritoneal dialysis pathway, create a national service specification and develop a national template contract for procurement of services and supplies. Lindsey Barker (Consultant Nephrologist, Royal Berkshire FT) is chairing this group that will report to the NHS Kidney Care Programme Board later this year. The terms of reference are:

1. Strategic
To maintain number of competitive providers in PD market
To maintain availability of the full range of PD products and services
To achieve national consistency in pricing across England
To achieve equity in patient access to all treatment modalities

2. Commissioning
To ensure that a full range of dialysis modalities is available from appropriate providers and is offered freely to patients
To inform development of Kidney Dialysis Tariff

3. Communication
To ensure effective communication with key stakeholders
To report appropriately to Kidney Care Programme Board
To develop Comunication Strategy to share outcomes

4. Patient-centred service
Ensure views of all stakeholders, including patients and carers, are considerd.

The group has representation from patients, nursing and medical experts, managers, procurement hubs, the national supply chain, the Department of Health and NHS Kidney Care.

The key outputs will be a nationally agreed pathway and detailed service specification that I hope will be a valuable resource for commissioners and procurement teams as well as clinicians and patients. The pathway will span modality discussions/choice of treatment, catheter placement and training, treatment regimes while on peritoneal dialysis through to change of modality or withdrawal from replacement therapy. It will include aspects of patient experience including dialysis away from home. Donal