CCG Commissioning of Dialysis – An opportunity for positive change

From 1st April 2015 Commissioning of Renal Services will move from NHS England Specialist Commissioning, to Clinical Commissioning Groups.  The National Kidney Foundation lobbied against the move, as I am sure, did other groups and commercial organisations. This is something that has been on the cards for a long time.  With a growing elderly, ethnically diverse, and diabetic population, it was inevitable that the required planning population of 1 million people for Specialist Commissioning, would no longer be necessary for provision of services for patients with reduced kidney function.
There are always concerns about transitions within any part of healthcare, whether they be commissioning, procurement or provision of services, but as populations and their needs change, then healthcare must adapt to meet these needs. With the introduction of Health and Wellbeing Boards, and Integrated Commissioning, this could spell a new era of patient choice and flexibility of provision.
In all matters of healthcare, the cost of treatment is always a consideration when caring for patients, I know this is an unpopular statement, but let’s face it, no one will get a silver dressing on a wound unless it really needs it.  Over the years that I have worked with Specialist Renal Commissioners, Procurement Managers, Consultants and Nurses, and whenever discussing the use of home dialysis, the cost was always compared to in-centre or satellite provision without taking into account the savings on transport. Why? Because this was a different budget, and usually the responsibility of the CCG, whereas dialysis was commissioned by the LAT.
So what? If you have ever been to a dialysis unit, you will recognise this description.
An elderly, frail, person on a bed. Not wishing to make eye contact. Often covering their face. Not wanting to eat, but looking very underweight. The staff don’t expect the patient to be with them for long……..the patient hopes that to be the case.
This patient is the exception.  There are patients in the unit, chatting to the staff and each other, reading books or watching TV, some are working on laptops. It’s not how they want to spending their time, but it is necessary to maintain their health and wellbeing so they make the best of it.
Let’s return to the elderly patient, I’ll call her Ethel, though she is just as likely to be Albert or Ahmed.  Ethel came for dialysis in an ambulance, manned by 2 staff, and will return in another.  She will do this 3 times each week.  When she is at home she needs help to wash and dress, and on dialysis days her care worker has to arrive at 6am to help her get ready (Social Services are charged a higher rate for the early call by the care provider), because she feels rushed, she doesn’t want breakfast, so goes without.  The ambulance arrives to take her to the dialysis unit, sometimes at the expected time.  If Ethel arrives on time for her slot, then she will be taken to a bed and “hooked up” to a dialysis machine for about 4 hours. Ethel doesn’t leave the house much (except for dialysis), she doesn’t like crowds, or strangers. She forgot her glasses in the rush to be ready, so can’t read or watch the TV.  She’s worried about the cat. She’s offered a sandwich and a cup of tea, she nibbles the sandwich, and sips at the tea. After her session of treatment finishes, Ethel is taken to the waiting area, for her ambulance. It’s a busy day, the ambulance arrives after 2 hours. When Ethel gets home she’s too tired to eat.  Her care worker arrives not long after she gets home.  Ethel is helped into bed.
If the full cost of Ethel’s treatment were taken into account, it would be cost-effective for her to dialyse at home. The cost of a 2 man ambulance, 6 trips per week, additional cost of homecare unsociable hours, and even the additional nutritional supplements she may need, could be balanced against the cost of a dialysis machine at home.  A truly integrated service would train Ethel’s care worker to assist her dialysis, the social care provider who be paid a higher rate for this, and the care worker gains experience and opportunity to expand their skills. Family are trained every day to support patients to dialyse at home, so why not care workers?
There are also opportunities for community dialysis, small numbers of beds closer to home, patients performing their own dialysis overnight, booking their slots on-line and fitting around work commitments.
Yes, change is scary, but it can also be good.