Appendix 1 Responses from Renal Unit Clinical Directors in England
Renal Services
Freeman Hospital
Newcastle upon Tyne 12.8.14
Dear Graham
I am dismayed to read the proposed drastic reductions in tariff which seem to have no clinical rationale at all and will severely impact on the services we can provide.
We have forecast the impact of this (including Market Forces Factor) to be a loss of circa £837,000 to our annual renal unit income; clearly this will have an enormous effect on staffing levels and the service that we will then be able to provide, both for elective but also for emergency renal support. If renal unit and dialysis capacity and staffing are reduced, many other services (eg cardiac, vascular, transplant) will also be jeopardised by the absence of renal support when required.
There are several issues:
1. We as clinicians try hard to empower our patients to make decisions for their own care, assisted by all the information they require. Many elderly and frail patients on haemodialysis, who have had unsuccessful fistula formation attempts, then choose to dialyse on a neck line in full knowledge of the risks and benefits. It seems unfair that units should be penalised for this with an unrealistic and unachievable target of AVF versus tunnelled lines.
2. We are trying hard to take care closer to patients, both by outreach clinics and developing satellite dialysis units. In a large geographical area with a relatively small population, this cannot be done with reductions in tariffs as proposed. The satellite dialysis tariff will make a small and remote satellite unit in Alnwick (currently under construction by a private provider), dealing with elderly patients who may require admission to the main unit on occasion, financially unviable and our Trust will not be able to support such a loss long term. Furthermore, offering home care with assisted PD to frail and elderly patients who live a long way from Newcastle and cannot manage without support will also become unviable – how is this tariff reduction thought to promote patient choice and care close to home?
3. We have an excellent MDT including dieticians and specialist nurses who are heavily involved in follow up of our CKD patients and preparation for dialysis. The drastic reduction in OP follow up tariff for MDT clinics will jeopardise this, to the detriment of patient care.
I hope that you will be able to convince Monitor that review of these tariff proposals is required.
Best wishes
Alison
Dr A L Brown MA MD FRCP
Consultant Nephrologist and Head of Renal Services
Honorary Senior Clinical Lecturer
Freeman Road
High Heaton
Newcastle upon Tyne
NE7 7DN
*
Dear Dr Lipkin
Thank you for bringing this to my attention. I am told that our trust have responded to the document but it is the first that I am aware of it and no-one to date has shared what the response was. I share your concerns on all of your points.
£104 is less than we currently pay for haemodialysis sessions to our private providers.
The home therapies decrease is disappointing, as you say regarding, the drive for home therapy and the training and support both technical and nursing that patients require.
The reduction in follow up nephrology will cause a large drop in income.
Indeed the loss in income from the tariff changes are considerable. It does require a wholesale review of whether the service as stands is currently viable in my trust. Our “profit margin” for last couple of years has been in the region of 4-5%. Against this we were planning further expansion of home haemodialysis with increased technical and nursing support, refurbishment and enlargement of our main HD unit and a satellite to bring them up to NHS England specifications (and our HD population is still expanding). If the tariff is going to decrease in such a manner then I do not know where the money for refurbishment and enlargement will come from – even the private provider route looks very marginal on the tariffs suggested.
Do you know if anyone in the country will be able to offer a fully NHS England specification compliant service on such tariffs?
Dr David Warland
Consultant Nephrologist
Dorset County Hospital NHS Foundation Trust
01305 255269
From: Torpey, Nicholas [mailto:
Sent: 10 August 2014 15:17
To: Graham Lipkin
Subject: RE: Urgent- Renal tariffs proposed for 2015/16-needs response
Graham
This seems very disturbing. On reading the very lengthy Monitor documents, the principles on which they are operating seem clear but the detail and justification entirely absent. Have the various CRGs been involved? Monitor seem to be abandoning their assurance (in the Methodology Discussion Paper) that changes will be transparent, evidence-based, involve service providers, and that there will be an ‘Impact Assessment’. As far as I am aware the new tariffs have been proposed with no regard to any of the above!
From Addenbrooke’s point of view, the proposed changes would lead to financial pressures that we could not possibly compensate for. The main risks are:
1. Dialysis – the proposed changes will lead to a £1.5 million reduction in income. We are planning a new main dialysis unit to deal with an ever increasing dialysis population, outdated buildings and infrastructure, and inadequate facilities for an enlarging home therapies population.. In the long-term there will be cost savings, but initially cost pressures. A dramatic change to the tariff could not come at a worse time. We would likely be forced into drastic cost-cutting which will inevitably involve nursing staff, dieticians, pharmacists, social workers and psychologists – all supported through dialysis income, and all central to providing a patient-centered service.
2. Out-patients – most of a renal unit’s out patient activity comprises follow-up patients, not new patients. The change in tariff to favour the latter and penalize the former makes no sense at all. A particular concern is transplantation. All patients attending a transplant clinic are follow-up patients, and their care substantially more expensive than, for example, a general nephrology clinic. The tariff has to acknowledge such activity as CMV and BK virus monitoring and treatment, HLA antibody screening, excluded drugs (for example valganciclovir), and the complexity of many transplant recipients.
3. One part of the Monitor document seems to suggest that HRG for vascular access procedures will be abandoned?
4. I agree that allowing separate charging for acute dialysis is a positive development.
Nick
Nicholas Torpey
Consultant Nephrologist
Department of Renal Medicine, Box 118
Addenbrookes Hospital
Hills Road
Cambridge, CB2 2QQ
Hi Graham
Comment from our Trust.
Steve
Dr Stephen H Morgan MD FRCP
Consultant Nephrologist and Clinical Lead for Renal Services
Basildon and Thurrock University Hospitals NHSFT
Essex SS16 5NL
Tel: 01268 394774
From: Ahad, Abdul
Sent: 08 August 2014 15:10
To: Magrath, Mark
Cc: Timpson, Emma; Ray, Andy
Subject: RE: Urgent- Renal tariffs proposed for 2015/16-needs response
Hi All,
No I was not aware of these price changes.
We would like to know what this significant tariff reduction is based on. I know Trusts were being asked to make upto 4% gross savings, 1.5 % net after taking into consideration wage incremental drift and other unavoidable costs, but this can not be based on reference costs submitted by NHS Trusts, as that would imply there have been significant cost reductions in this area.
The tariff reduction of this percentage will have significant impact as the Trust can not make savings of such a high percentage, which would mean that the Trust are being asked to do activity for which it can not possibly cover its costs.
As stated above, the main question to Monitor would be, what the reductions are based on, as they can not be based on reference costs submitted.
Regards
Abdul Ahad
Assistant Director of Finance
Dear Graham,
Thank you for forwarding this.
I agree that this is rather concerning reduction which will affect patient care and financial stability. Is patient groups aware of the proposal and its potential effects.
We provide support services like specialist dieticians, pharmacists, specialist nurses (focussing on CKD care, pre-dialysis care, community dialysis, line insertions, PDC insertions, anaemia management), clinical psychologists. All of these services are funded from the Nephrology income and if the income were to be reduced considerably then it’s likely that trust may have a different view on these personnel.
The department provide specialist clinics like pre-dialysis, post-transplant follow up, haemodialysis and peritoneal dialysis clinics, conservative management clinics, maternal medicine clinics, transition clinics etc. The amount of work done by these clinics are not being reflected on the proposed tariff. Any dilution of the work force in these clinics will have a direct impact on patient care. I do believe (even though jury is out) the reduction in dialysis patients that we are seeing nationally and internationally is due to the identification and management of CKD patients in these specialist clinics.
I also do welcome tariff for dialysis in AKI patients but there’s still confusion regarding whether that forms the part of HRG or not.
Thank you for leading on this and collating the info.
KR
Ani
Dr H Anijeet
Clinical Director and Consultant Nephrologist
Royal Liverpool University Hospital, Liverpool.
Secretary- 01517063512
Dear Graham
As a team we haven’t had time to go through the overall potential reduction in income which would be consequent to the proposed tariff reductions
However, the loss of income would clearly affect the ability to accommodate the continued growth in dialysis and nephrology activity, the tariff for HD below that we pay to our commercial partners would make HD a loss leader for the service rather than a cash cow, the loss of outpatient tariff would drive much nephrology and most dialysis and transplantation outpatient activity back into primary care at a time when immunosuppression is being brought back to those who understand it and can prescribe it safely. The vital multidisciplinary working in outpatients is threatened, the complex clinic tail for these patients will be unaffordable. There is a perverse incentive for all CAPD patients to be put on APD and all HD patients to be infected with a BBV!
Just my random thoughts but hope it helps
Best wishes
Tim
Leach Tim - Chief of Renal and Transplantation CSC [
______
Only comment is to absolutely agree with you!
I will get my finance team to add up the the total loss to our service, but clearly huge. Increase in BBV helps very few units and PD will be approaching BAxter costs.
Apart from NHS England massive debt- how can they justify the size of reduction and the lack of clinical engagement?
Barker Lindsey [
Consultant Nephrologist
Dear Graham
I quite agree, I think these "draconian'" tariff reductions without any basis as far as can be determined and will push most units and eventually, with the overall tariff cuts, most hospitals into the red.
I'm on leave at the moment as is our dialysis matron and Business Manager, so I'm unable to give an accurate financial return for Oxford by tomorrow, but:
1. I'm pretty sure that we will barely break even with the proposed haemodialysis tariffs and CAPD and we are ALREADY making a loss on Assisted PD, and home haemodialysis for the few (but increasing demand) on NextSatge 2. I quite agree with you about outpatients, the 45% increase in new patients will be disastrously wiped out by the 34-40% reduction in follow-ups; virtually all of our patients (and I suggest all of appropriately referred & followed) need follow up; as I say I'm on holiday as are my senior management team but "back of a fag packet" calc. the ratio thinking about my own clinics, is AT LEAST 10FU:1New including transplant patients and 5:1 excluding them (I do have a heavy transplant workload). If anything like this tariff is forced on us I think it will encourage accepting inappropriate New referrals e.g. The very elderly with creatinines in the low 100s (but with "CKD3" without proteinuria), diabetics with micro/macro proteinuria but with normal or good and slowly declining function with good blood pressure control on max ACEI etc etc-currently we are refusing these C&B referrals,, writing back to the GPs with advice; clearly this will waste valuable NHS resources.It may also risk discharge of patients who really ought to be followed with the risk that they will return as "crash landers".
3. As you know the Service Spec for haemodialysis now requires monthly MDT appts, which will drive up our follow-up requirement, for which we don't yet have capacity (one argument for more consultants in Oxford) 4. The Engagement Overview that you sent refers to a Methodology Discussion Paper (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310128/NT15-16MethodologyDiscussionPaper.pdf) that suggests that the tariff proposals will be Transparent, Evidence-Based with Effective sector engagement and with Impact assessment of any proposed changes. As far as I can see NONE of these have been met-who has been approached to help provide data from our specialty for this exercise?
5. I also spotted in the EngagementNationalPrices document:
Existing currencies no longer eligible for 2015/14; QZ13A Vascular Access for Renal Replacement Therapy with CC QZ13B Vascular Access for Renal Replacement Therapy without CC QZ14B Vascular Access except for Renal Replacement Therapy without CC I'm not sure what this means; how do they expect us to pay for this? Is there now an alternative means of remuneration?