Q & A: Dialysis away from base (DAFB)

Q: Dear Donal, for some time there has been difficulty with funding of Dialysis Away From Base (DAFB) for patients from renal units within the NE, to the point where a certain degree of rationing of funding for DAFB takes place. With the constraints faced by renal units throughout the country due to the current financial climate, and with the imminent arrival of payment by results (PbR) for dialysis, funding for DAFB is becoming an increasingly important issue for both clinicians and patients. In the NE we are becoming increasingly concerned by a number of issues:

1. There is a lack of haemodialysis capacity within the NHS, so many patients have no alternative than to seek DAFB with a private provider.


2. The charges imposed by private providers are usually considerably more than the PbR tariff and some private providers require patients to supply their own dialysers, thereby adding further costs to the base unit.


3. Where capacity in the NHS exists to provide DAFB, NHS providers frequently charge considerably more than the PbR tariff.


4. The base unit will therefore lose out financially as they have to pick up the cost of the shortfall between the holiday DAFB cost and the PbR tariff.

The obvious answer to the problem of funding is to ask patients themselves to make up the shortfall between the holiday dialysis tariff and the PbR tariff. Such a move is likely to find opposition from patients and patient groups, and possibly, clinicians too. We would therefore like to ask for some clarification with regards to this subject, and perhaps make some suggestions for a more level playing field across England (if not the UK as a whole)

• Is guidance forthcoming from NHS Kidney Care and the Renal Association as to whether patients should be expected to pay for the shortfall between DAFB and PbR tariffs?


• If patients are expected to pay for some or the entire shortfall, is there any mechanism whereby patients can receive some financial support? (The concept of a “dialysis-leave budget”: if the patient uses up his or her budget, they then have to pay the extra cost).


• Can there be a national register as to what capacity exists within the NHS for DAFB, and what each unit currently charges for DAFB?


• For NHS units which have capacity to offer DAFB, should there be a national limit as to what is deemed to be an acceptable administration fee?


• Can assurance be given that patients dialysing via a central line will not be refused DAFB in another NHS unit, and that the cost for such patients will remain the PbR tariff plus reasonable administration fee?


• Can clarification be given as to who is responsible for supplying or paying for ESA’s, and that if dialysers are to be supplied by the base unit this cost is deducted from the DAFB cost? Dr Stephen Kardasz, Network Chair

A: Dear Steve, thanks for your question, it is important that patients can dialyse away from base. The introduction of a mandatory tariff should make it easier to arrange DAFB by providing a consistent basis for financial flows. The tariff prices and transitional arrangements apply equally for patients at or away from home. Patients’ requirements for DAFB will vary widely on a patient to patient basis. Patients who need time away for reasons of business, education, family emergencies, bereavement or other reasons should be able to arrange what they require.

The NHS is encouraged to develop agreed local policies for DAFB which will ensure equity while minimising the impact of renal failure on patients’ mobility and these policies need to operate within the framework of the DH guidance mentioned below.

Haemodialysis capacity is often a constraining factor which may limit where DAFB can be offered. The responsibility of the NHS for funding can include paying for dialysis (but not accommodation) privately if the NHS does not have the capacity locally. The charges imposed by private providers are usually considerably more than the PbR tariff. In addition, some private providers require patients to supply their own dialysers, thereby adding further costs to the base unit. Where the NHS is paying for DAFB from a private contractor there is no scope for exceeding the tariff price except where there is an existing contract at a higher price. When the contract is renewed this should be paid for at tariff price from 2012-13. To avoid destabilising existing arrangements, providers and commissioners are allowed to move 50% towards tariff in 2011-12. Detailed guidance on Payment by Results in 2011-12 can be found here. If dialysers are not included in the service provided, but are supplied by the home unit, the amount payable to the away unit would have to be reduced by the cost of these and the balance should be paid to the home unit. Where capacity in the NHS exists to provide DAFB NHS providers also frequently charge considerably more than the PbR tariff. There is no scope for NHS providers to charge additional fees over and above the tariff price.

The base unit will therefore lose out financially as they have to pick up the cost of the shortfall between the holiday DAFB cost and the PbR tariff. Funding arrangements for DAFB, prior to the introduction of tariff for dialysis, has been on a unit-to-unit basis. The home unit agreed the funding level with the away unit and paid accordingly from the block contract it received from the Specialised Commissioning Group or Primary Care Trust. From April 2011, dialysis will be paid for by session. As with other services within the scope of PbR, commissioners will contract for dialysis, making monthly instalments against the contract value, adjusted for actual levels. The arrangement for DAFB will be to follow that already used elsewhere in PbR for Non-Contract Activity where providers will invoice the responsible Specialised Commissioning Group or PCT on a monthly basis for the DAFB activity provided.

With regard to guidance, Department of Health guidance revised in 2007 states that funding for temporary dialysis in England should be provided by the referring unit and this remained the case until the end of March 2011. As mentioned above, from 1 April 2011 this will be paid for by the relevant Specialised Commissioning Group or PCT. Top-up fees cannot be imposed on the patient under any circumstances as the rules about NHS services being free at the point of delivery apply. For the same reasons patients cannot be charged for the costs of drugs. However, if a patient arranges private treatment without getting approval from their home unit (or possibly specialised commissioner – dependent on the policy locally) the patient will be responsible for the full costs of the dialysis.

As mentioned above, there are no circumstances in which a patient can be asked to pay top-up fees for services provided by, or on behalf of, the NHS except where this is provided for in regulations.

Units will only be able to charge tariff price (from April 2012) and from April 2011 they have to move 50% towards tariff price from their existing price in 2010/11. Units may wish to decide locally to develop a register but we have no plans to set one up nationally at present. You may be interested in the Dialysis Freedom website as an example of information that is already available nationally.

With regard to patients dialysing via a central line and assurances that they will not be refused DAFB in another NHS unit, it is not possible to charge an administration fee at present. Units should offer dialysis where there is a clinical need and where they have the capacity regardless of the means of access the patient has. In the same way as for patients dialysing in their home unit, those dialysing away from base via a line should be paid for at the rate for those using a line.

Finally, ESAs are currently excluded from the tariff price (we will be exploring whether it will be possible to include them in the future). Specialised Commissioning Groups or PCTs should pay for these on top of the tariff and patients cannot be charged a top-up fee for their cost. Specialised commissioners will need to consider paying the home or away from base unit for dialysers and where the home unit supplies these, the cost should be deducted from the tariff price paid to the away unit.

During 2011/12 we will be assessing the impact on dialysis away from base on the introduction of a tariff for dialysis to see if any changes need to be made to next year’s guidance. I hope this is helpful, Donal.

Department of Health : DAFB Q & A

Manchester team wins top trophy

Dr Sandip Mitra and the team at Manchester Royal Infirmary scooped this year’s NICE shared learning award for their work in transforming home haemodialysis services in Manchester. Many of you reading this blog will know that the Manchester home haemodialysis team have developed an innovative approach to engaging with people who have chronic kidney disease and have a novel approach to dialysis delivery which has empowered patients and enabled many to now perform haemodialysis independently at home, avoiding the need for regular visits to the hospital for treatment.

Patient feedback has been extremely positive. One patient said “when I was faced with hospital dialysis, I lost a lot of self esteem, felt low and lost interest in a lot of things – it was like a downward spiral. Home dialysis has suddenly made me feel more interested, happier and relaxed”.

As well as being of benefit to patients, it has also generated financial savings, with costs up to 40% lower than hospital care. More than 175 patients so far have been trained in this programme to be independent on home haemodialysis, with increasing numbers joining every day.

Professor Sir Michael Rawlins (Chairman, NICE) praised the high quality of all the submissions for the Shared Learning Awards this year and commented on the Manchester home haemodialysis team’s approach as “an example of the extraordinary things that people do in the NHS”.

There are lots of excellent case studies and tools so support home therapies available from NHS Kidney Care and Sandip, along with Alastair Hutchison, Ken Farrington, Roger Greenwood and Diane Comer, run a regular home dialysis symposium; the 4th annual conference is on 29-30 September at The Lowry Hotel, Manchester. If you want your haemodialysis services transformed, that’s the place to go.

Well done Sandip and team.

How safe are your clinical systems?

The knowledge that clinical systems can cause harm is not new, but the size of this problem has not previously been established systematically. This Health Foundation report therefore provides groundbreaking evidence of the extent to which important clinical systems and processes fail and the potential these failings have to harm patients.

“Rather than being the instigators of an accident, operators tend to be inheritors of system defects …. their part is usually that of adding the final garnish to a lethal brew using ingredients that have already been long in the cooking” (James Reason, 1990).

A significant proportion of the liability failures identified in the research were associated with risks to patient safety. For example, the report identified that 15% of outpatients’ appointments were affected by missing clinical information. In 20% of these cases the doctors involved judged the patients to be exposed to risk. A fully reliable systems function as intended under expected conditions. The clinical systems for which reliability could be assessed in the study had an average failure rate of 13-19%. That would not compare favourably to any 21st century process, let alone the airline industry! There was significant variation between organisations in reliability ranging from 63% of equipment available in one organisation, to 96% for availability of clinical information in another Acute Trust in the study.

Across the range of systems and organisations studied unreliability was usually a result of the same factors. These included: a lack of feedback mechanisms for both individuals and systems; poor communication; and widespread acceptance on the part of clinical staff that systems are going to be unreliable BOLDand that this is not their responsibilityBOLD.

The variation between and within organisations suggests that it is possible to create systems that have higher reliability – that requires clinical leadership. The importance of leadership comes out loud and clear from the review of the National Patient Safety Agency report on the patient safety first campaign which used social marketing principles to mobilise the NHS staff resulting in an increase from 18% to 61% of Acute Trusts having patient safety and quality as their first agenda item. The campaign promoted 5 interventions: leadership; deterioration; critical care; perioperative care; and high risk medicine. All of these would be useful in making a step change to the recognition and outcomes in acute kidney injury.

I would add a sixth vein – to move from a blame culture to a culture of learning from failure. A knowledge system like the NHS will only provide the care we want if its components are learning organisations. The ingrained attitude that all failures are bad often means organisations don’t learn from them. All staff need to feel safe admitting to and reporting failures. Creating that environment takes strong leadership.

NICE pathways

To support the implementation of the NICE Quality Standards for chronic kidney disease a “nice” pathway approach to the implementation guidance and quality standards has been produced.

It is just a simple way to access the standards and the key recommendations of NICE Clinical Guideline 73 on chronic kidney disease as well as providing links for patients and the public to information about CKD, drug treatments and even surgery. Wouldn’t it be great if it could link into GP systems and even provide the opportunity for local audit?

Further work is now starting to link the CKD Quality Standards into the commissioning outcomes framework and commissioning guidance that is being developed to strengthen implementation and drive quality improvement forward.