Wednesday, 14 July 2010

Q & A: Home dialysis start-up costs

Q: Dear Donal, the perennial question relating to the provision of home haemodialysis is; “what further resources do we have at our disposal to facilitate the choice of the patient?”

About a quarter of the patients that we have in training for home haemodialysis at present do not have a suitable room for conversion and we therefore have to look at how we can provided accommodation through the provision of a porta cabin in their garden at a cost of around £12,000 per installation.

I understand that the mandatory tariff for home HD may be set in such a way as to incentivise home therapies which is to be welcomed. However as you know one of the sticking points to setting up a home programme is accessing funding to cover start up costs.

Whilst we have a modest budget to convert homes, and these conversions are not extravagant, the cost of providing one cabin is the equivalent of providing home conversions for 4 patients. I am in the process of speaking to PCTs to see if they would be able to contribute to the cost of providing cabins. In the recent past I have been successful in securing funding but the criteria for supporting such applications seems to be inconsistent across PCTs. One may argue that the cost of covering all types of installation should be affordable from the current tariff.

I am obviously aware that new technology is on the market that requires minimum work to the patient’s home for it to be installed and I await the report of the experience that SRFT and the Lister in the use of this equipment and its operational costs.

I am advised by Dr Sandip Mitra that funding to cover start up cost is available; where this is being held I do not know hence my email. Can you advise if Sandip’s assumptions are correct?

In my efforts to secure funds from the PCTs I argue that it will effectively cost them more to keep a patient on maintenance haemodialysis Vs home HD. My worry at the moment is that a tariff to incentives home therapies could be counter productive if that tariff is higher than hospital/satellite tariff. It would make any future bids to PCTs futile I think.

Given the financial climate that we find ourselves in at present will patient choice be sacrificed in an effort to deliver a more financially viable service?

I look forward to hearing your thoughts on the matter. With kind regards, Ken Collins, Directorate Manager, Central Manchester University Hospitals NHS Foundation Trust

A: Dear Ken, thank you for your recent email. As you know better than most, this is an important part of the process for establishing people on home haemodialysis and frequently discussed at our home therapies road shows.

At present, the non-mandatory tariff suggests a sessional price for haemodialysis, irrespective of the setting and the intention is for this price to be fully inclusive, including set-up costs. The non-mandatory tariff was introduced in consultation with the Payment by Results (PbR) team, who were clear that tariffs are fully inclusive and mindful of the desire to incentivise home therapies. As a result, there are no separate funding sources for set-up costs within the dialysis tariff.

Owing to the visibility of set-up costs, providers are concerned that suitable patients may not receive home conversions. However, no patient should fail to receive home therapy on this basis. The challenge for provider units is to demonstrate the importance of home therapies for individual patients and the costs benefits across the whole pathway of dialysis provision. Highlighting the patient benefits, such as improved quality of life, reduction in medications and hospital transport, alongside the unit benefits of reduction in hospital admissions and the need for investment in expanding capacity provision, should be persuasive.

To minimise the effort for requests on a case-by-case basis, we would advocate commissioners, providers, patients and PCT representatives agreeing collectively on the types and timings of home conversions for all patients. This may involve less costly home conversions, or newer technologies, or assistance from disability allowances or housing associations.

Such approaches are all the more relevant in the current financial climate, as we strive for all renal patients to have genuine choice of their preferred form of renal replacement therapy as clinically appropriate. I would be very interested to hear your thoughts and potential solutions regarding this important issue. Please do not hesitate to contact me if you wish to discuss this matter further. Kind regards, Donal