Q: Dear Donal, I speak as someone who would welcome a financial "grenade" to try to prove to our local surgeons and management that dialysis access is worth investing in. Nevertheless even as grenades go I feel that what is proposed and the way it is to be implemented will lead to serious unintended consequences.
In a unit such as ours where approximately 40 % of patients are on peritoneal dialysis and where we struggle to get more than 60% of haemodialysis patients dialysing via permanent vascular access (PVA) we will be heavily penalised by setting the "income neutral" rate for haemodialysis by PVA at 75% never mind 85%. There are three main reasons why we are different or lag behind depending on your point of view:
a) our access to surgical procedures and our surgical success rate are suboptimal.
b) many of our younger and fitter and therefore arguably "fit for a fistula" patients are on PD thus skewing our HD population as regards fistula suitability compared to other units who may have proportionately fewer patients on PD.
c) we have a very low catheter related bacteraemia rate, much lower than that reported for other units, where the need to avoid catheter based access is clearly more pressing. As a result of what they do and do not see many of our patients are simply unwilling to consent to a fistula procedure despite our genuine efforts to promote them. On the basis that "no decision about me, without me" is now one of our guideline principles and we are sometimes asking patients to endure a series of unsuccessful and mutilating operations I can not believe that the ultimate figure of 85% with a functioning fistula is anything like appropriate for our unit.
To impose this central target upon us, and let us be clear this is as much a target as any direct target imposed by New Labour, would leave me hopefully with a slightly more accessible, but perhaps no more successful, surgical vascular access service which is partly good, but, it also leaves me with the ethical conundrum of whether to accept a drop in funding or to coerce or corral patients into having fistulas done when that would not be their wish given a free and fully informed choice. I think our energies should be directed at promoting and incentivizing provider trusts to ensure that surgeons allocate sufficient time and resources to the often technically demanding discipline of vascular access surgery rather than to penalising dialysis units and ultimately the patients as well. Otherwise I shall have the New Year to look forward to discussing with my Trust which members of the multidisciplinary team we will be letting go in order to make ends meet.
The effects of this BPT implemented over this timescale really need to be thought through a little better and some "Localism" allowed to operate in the details of its implementation if we are to avoid causing a lot of distress to patients, at least here in Ipswich. Gerald R Glancey, Consultant Nephrologist
A: Dear Gerald, thank you very much for your letter of 24 December. I would like to say first of all that I very much appreciate your concerns about the introduction of Best Practice Tariff for dialysis and I would just like to take the opportunity to answer a few of your questions and hopefully address some of your concerns.
As you know, the introduction of best practice tariff for dialysis is part of a wider shift in the NHS towards rewarding quality in healthcare services and for providing financial incentives for commissioners and service providers to invest in services that result in better care for patients. At the same time, the NHS is facing an enormous productivity challenge to find savings in the order of £20 billion over the next five years to help resource services in the face of a very tight budget settlement. Unfortunately, this means that every trust will be faced with very difficult decisions about how best to allocate resources. The move towards a mandatory best practice tariff offers renal units a degree of financial security at this time of uncertainty – combining a clear signal of the renal community’s commitment towards better quality care at the same time as offering a stable, nationally mandated, financial settlement. Dialysis services have historically often been used to cross subsidise other areas of activity outwith renal units and any negative impacts on income resulting from tariff should be dealt with at trust level by keeping the income generated from tariff within renal units.
The 75% threshold for definitive dialysis access for 2011/2012 has been set with reference to the Renal Association Vascular Access Guidelines and the Joint Working Party Report on Vascular Access from the Renal Association, The Vascular Society of Great Britain and Ireland and the British Society of Interventional Radiology. The threshold has deliberately been set, following sense check, below their recommendations specifically to allow time for units more reliant on tunnelled lines to move towards the suggested 85% of prevalent dialysis patients dialysing through an arteriovenous fistula. Indeed, even at 85% the best practice tariff remains more conservative than the guidelines by its inclusion of grafts in the higher tariff rate, in recognition of the fact that a proportion of patients cannot have an arteriovenous fistula for technical reasons.
I acknowledge that your rates of vascular access bacteraemias are very low and feel that renal units generally have done fantastically well at improving infection control and reducing bacteraemias. Nonetheless, people with tunnelled vascular access remain at an increased risk of bacteraemias and infection related deaths compared to those with a fistula and so trying to minimise the use of intravenous catheters should remain a priority.
I think that the issue of informed consent that you raise is a vital one and the best practice tariff is in no way meant to be used as a way of limiting patient choice or of coercing patients into undergoing fistula procedures. However, the large variation in fistula use both nationally and internationally is more likely due to the availability and success of local vascular access services rather than reflecting fundamental differences in patient preference. I believe that fully informed consent for a dialysis access procedure could include information about all modalities of renal replacement therapy and conservative kidney care and should be undertaken using principles of shared decision making. Some patients having weighted the pros and cons for themselves, will undoubtedly prefer to have a tunnelled line instead of a fistula or graft but this is unlikely to be more than the 15-25% included in the tariff.
Thank you for highlighting the high proportion of patients choosing peritoneal dialysis in your unit. I have been very keen to promote home based dialysis therapies and unfortunately many units have been less successful at offering these to patients than you have. I understand the challenges that this will have in terms of potentially leading to an older, frailer and more co-morbid haemodialysis population. Some units have achieved both a high rate of PD and high fistula rate, but this can be challenging and may require the trust to invest in better vascular surgery services. In Salford we have always had a strong PD programme and like yourselves in Ipswich have previously had concerns regarding surgical capacity for vascular access. Locally we were able to improve our AVF rate for haemodialysis from 62% to 83% by addressing these concerns and using quality improvement methodology.
Finally, I would just like to conclude by saying that the intention of the best practice tariff is to encourage and provide financial support to locally led innovation in quality improvement. The price signal generated by the best practice element will be felt at trust level, and that signal should lead to an improvement in vascular access services for patients. I am very keen to help support renal units both with the introduction of tariff and with the undoubted
further challenges that will occur over the next few years. Please do let me know if I can help in any way or if you have any further questions or queries I can help with. Donal
PbR 2011/12 Road Testing letter 231210