Wednesday, 19 May 2010

Q & A: Transplant work up costs

Q: Dear Donal, I would be grateful for guidance on this which has some bearing on the (otherwise welcome) recent proposals for more explicit remuneration of dialysis services. There is a potential serious funding shortfall likely to occur in non-transplanting renal centres, who currently bear the cost of transplant work up and follow up from savings from the HD budget. I have discussed this at a Renal Advisory Group meeting and our colleague Catherine Turner is planning to bring this up at a national level in due course as well. Having emailed a couple of dozen colleagues around the country, it seems nobody has a simple or workable solution, and the worry is that in a cash-strapped economy patient feed through into transplantation services will be threatened. Thanks, Paul Warwicker, Renal CD. Lister Renal Units

A: Dear Paul, thanks for your email, I awaited issue of the final Guidance on PbR for 2010-11 before responding. You will no doubt have seen that and “Developing robust reference costs for kidney transplantation in adults” and the FAQs, available on the NHS Kidney Care website, which have been produced to help support the introduction of the non-mandatory tariff for dialysis.

Quite a lot of work has been done to improve the reference cost returns for kidney transplantation and to produce a specification template, which has been agreed with all the transplanting teams so that a complete picture of costs is available. The intention is to bring kidney transplantation into PbR probably in a non-mandatory fashion akin to dialysis this coming year, from April 2011. This has now been published. Part of that exercise involves specifying the various components of transplant work-up some of which of course can be more easily done for the potential recipient at the non-transplant centre. A number of these such as outpatient visits and cardiological investigations would I think already be within other tariffs but there will no doubt be other elements that are currently “bundled” with the current funding arrangements for transplantation. These do vary between centres and specialist commissioning groups.

We have also begun some early discussions about a potential best practice tariff for kidney transplantation considering elements such as timely transplant listing, laparoscopic live donation and shorter cold ischaemic times. I should emphasise that these discussions are at an early stage. You will also appreciate that patient level costing isn’t available from most Trusts yet and work still remains to be done on the kidney transplant pathway specification, coding, data capture and counting challenges before we are able to move to robust PbR type contracting arrangements.

Practicing in a non-transplanting centre and having, until I took up my national post, been clinical director, I do appreciate the challenges the historic and diverse commissioning arrangements pose. The overarching principle must remain that all individuals likely to benefit from a kidney transplant are supported in making choices at an early stage, listed promptly and managed so as to achieve the best possible quality of life (NSF Standard 5). To achieve this the local contracting arrangements should take account of the shared model of transplant pathway care and guard against perverse incentives or distortion of clinical need. I think your document “Funding for Transplant Service in non Transplanting Centres – a discussion document” will support such an approach locally and I know that Catherine Turner (Senior Commissioning Manager/Renal, East of England Specialised Commissioning Group) is keen to promote equitable arrangements locally that will support a nationally consistent approach. Thank you for writing and I hope this is helpful. Donal.