Tuesday, 19 January 2010

Twice weekly dialysis rears its ugly head again

I don’t know whether it’s the thought of the ghost of Christmas past or a Scrooge mentality, as is claimed to pervade football club boardrooms at this time of the year, that’s responsible or not but over the last few weeks several people have contacted me to enquire about the suggestion of adopting twice weekly haemodialysis as an efficiency measure. This is unacceptable and indeed as we move towards Payment by Results for dialysis the intention is to fund each dialysis session that patients receive.

The Renal Association Best Practice Guideline on haemodialysis makes it quite clear that haemodialysis should take place at least 3 times per week in nearly all patients with established renal failure. Reduction of dialysis frequency to twice weekly because of insufficient dialysis facilities is unacceptable.

Twice weekly haemodialysis has a small role:
  • In patients with significant residual renal function (usually at the start of a patient’s dialysis career)
  • As “palliative dialysis” usually in patients approaching end of life following the refocusing of the aims of treatment.

The dialysis prescription should be personalised to the individual’s needs. If individuals are to start on a twice weekly regime it’s important they know that an increase to thrice weekly is likely to be needed after a short while unless dialysis is being offered as part of end of life care.

I would strongly encourage clear unit policies and accurate documentation extending to individual patient care plans that take account of a full range of treatment options, including choice of treatment setting where clinically appropriate and in accordance with the patient’s wishes.

To be fair, one Clinical Director contacts me nearly every Christmas to enlist support to resist a push for providing less dialysis. In the bad old days of the 1980s and early 1990s, twice weekly dialysis was a scourge in several parts of the United Kingdom and I hope we have put that behind us for good. As we get over the bad weather and into the work of the year our focus does need to be on preparing for the harsher financial climate the NHS faces. No part of the system will be immune from the quality and productivity challenge, with the focus firmly on improving quality and efficiency simultaneously. The key challenge of delivering quality at lower costs can only be achieved locally. Frontline staff are in many ways the guardians of quality and have an essential role to play in ensuring high quality care and cost savings are delivered – that is not the code for twice weekly dialysis!

I have written out to commissioners, network leads and clinical directors to make these points and those of you with long memories will know I have actually blogged about this before.