IMPROVING DIALYSIS SERVICES FOR THE POPULATION OF WALES

IMPROVING CHRONIC DIALYSIS SERVICES FOR THE

ADULT POPULATION OF WALES

Foreword

Chronic Renal Disease is affecting a growing number of patients in Wales. Whilst the majority of these patients are managed within primary and secondary care, a small but significant proportion require Renal Replacement Therapy (RRT) as they develop End Stage Renal Failure.

For some patients, this can be achieved through Kidney transplantation. Recent developments such as the planned purpose-built Transplant Unit in Cardiff, the expansion of techniques to include Blood Incompatible Transplants and the potential of Presumed Consent will all increase this opportunity.

However, the greatest demand for RRT will come from older patients, increasingly with a number of co-morbidities, who are inappropriate to undertake a transplant. For these patients, the only alternatives are the different forms of dialysis.

Rates of incidence and prevalence of dialysis in Wales, whilst favourable in comparison with home nations, are significantly below the rest of the Western World. Demand for dialysis is universally accepted to be growing at around seven percent per annum, and is likely to continue to do so for at least the next ten to fifteen years.

In headline terms, the numbers of patients are relatively small; however the total cost of intervention for these patients is very high. For example, there were 961 patients receiving unit based haemodialysis in Wales as at the end of March 2008. This is expected to effectively double within ten years at an average cost of £35,000 per patient per annum.

In order to meet this demand, significant financial investment in workforce, procedure costs and capital development is needed. In recent years there has been an expansion in staffing infrastructure to facilitate this increased activity. This includes teams of specialist nursing staff to bridge the clinical corridor between community care and the hospital setting. Such investments will facilitate the management of this increased demand and optimise the opportunity to provide services closer to home.

The ability to develop services local to patients is important to patients given the burden of renal disease and the physical, emotional and mental demands of hospital based dialysis for many patients. The proposals also include improving staffing for areas such as clinical psychology, social work and patient advocates. This is in recognition of feedback from patients and their needs to adapt to a new life with dialysis.

The anticipated outcomes of such investment will include a significant increase in medical, specialist nursing and support staff for the delivery of dialysis (and it related general nephrology services). For example, the plan proposes the recruitment of nine additional Consultant Nephrologists, three Nurse Consultants and over 50 specialist nurses across Wales.

The plans also include the summary costs for the capital development of the six new satellite renal dialysis units across Wales. This was subject to an announcement by the Minister for Health and Social Services, Mrs Edwina Hart in November 2007. Whilst subject to detailed Business Justification Cases, the proposals indicate a capital cost of £16.6 million to provide an additional 99 stations across Wales, which represents nearly a 50% increase against the existing 200 stations.

This proposal details the requirements for development of the infrastructure across Wales, in order that dialysis services can be improved for the people of Wales.

Thank you to the members of the working group and wider renal community for their contribution to this review.

Professor John Williams

Renal Advisor, Wales

Stuart Davies

Health Commission Wales

Dr Kieron Donovan

Information Lead, Renal Advisory Group

Dr Richard Moore

South Wales Renal Network

Dr Peter Drew

North Wales Renal Network

David Heyburn

South Wales Renal Network

Nick Wilson

North Wales Renal Network

Summary

The prevalence of Chronic Kidney Disease (CKD) is approximately 5% of the population and this is expected to rise due to obesity, diabetes, coronary heart disease as well as the general aging of the population.

For a small but significant number of patients who go on to develop End Stage Renal Failure (ESRF) their only option is to undertake dialysis.

Growth in demand for dialysis is well understood and has been mapped and modelled closely for many years. It is accurately predicted that demand for Unit based Haemodialysis will grow by six to seven percent per annum.

Given this unavoidable growth in demand, it is necessary to increase the infrastructure to provide additional specialist staffing and dialysis stations through out the principality.

The proposals include developments for all dialysis modalities – Unit based Haemodialysis (UHD); Home Haemodialysis (HHD) and Peritoneal Dialysis (PD). This wider approach promotes the development of home therapies.

Unlike other parts of the UK and Western Europe, Wales has successfully maintained (and increased) its home therapy services. This plan looks to sustain and improve this situation further by developing the necessary staffing infrastructure to train, educate and deliver home therapies.

To do this, the proposal recommends establishing Community Specialist Renal Nursing Teams linked to each of the new satellite renal dialysis units (SRDUs). These teams will undertake functions such as anaemia management, vascular access management as well as providing a bridge between the community and hospital.

It is expected that these teams will link with primary care practitioners to support the local management of patients and where appropriate referral to general nephrology services.

Whilst maximising home therapies, many dialysis patients will have no other choice but to receive their treatment in an acute hospital setting due to progression of renal disease and / or co-morbidities. This will require an increase in medical staff to lead and co-ordinate their care. To achieve this, the plan has recommended the appointment of additional Consultant Nephrologist and Middle Grade doctor sessions. These posts will be appointed to the Renal Centres to ensure appropriate support and governance arrangements.

Following the announcement by the Minister for Health and Social Services in November 2007, current proposals include the indicative costs for the development of six new SRDUs across Wales in the following regions: Pembrokeshire, Baglan Bay, North Gwent, North Powys, Deeside and South Gwynedd. The capital programme for the development of these units is estimated to be £16.6 million. This will achieve a 50% increase in the number of dialysis stations in Wales by 2012. The agreed planning principle is to build larger units, with stations mothballed and commissioned as required – effectively future-proofing these facilities for approximately the next ten years.

The working group has also reviewed the costs for the different forms of dialysis modalities and agreed a unit price. This work has been heavily influenced by recent research undertaken across the UK looking at real ‘bottom up’ costs. To date, many of these costs have been hidden within other non-renal budgets or allocated to different commissioners. These prices now include all costs such as dialysis treatment, transport, vascular access and Erythropoietin Stimulating Agents (ESAs) with the exception of the discrete specialist staff separately identified.

Such an approach is comparable to the development of national tariffs currently being developed for renal services in England. This has a number of benefits including consistency, value for money and transparency.

A valuable benefit to such an approach is that this makes the ring-fencing of renal funding much easier to identify and be subsequently managed and utilised by the Renal Networks. This financial performance management by the Renal Networks is seen to be a key enabler in the future development of renal services.

Significant financial investment is required in workforce, procedure and capital costs order to meet the demand for dialysis in Wales. The estimated revenue cost of this proposal is £2.9 million in 2008/09 rising to £21 million and then £54 million by 2012 and 2018 respectively. During this same time period the patient stock will rise from 1270 to 1660 and then to 2300.

1. Why investment is needed

1.1. Chronic Kidney Disease (CKD) is estimated to affect 5% of the general population, with demand for Renal Replacement Therapy (RRT) growing annually by 5% and haemodialysis 7-8%.

1.2. There are a number of key factors that influence the need for renal replacement therapy, and in particular haemodialysis. These include age, gender, ethnicity, socioeconomic deprivation, diabetes, coronary heart disease and geographical accessibility:

1.3. Many of these factors – age, obesity-related diabetes and coronary heart disease are expected to increase and there is no indication that demand for RRT is likely to plateau in the next ten to fifteen years. The inclusion of community nursing teams and increased medical staffing will support primary care in the early diagnosis and subsequent management of renal disease. The inclusion of estimated Glomerular Filtration Rate (eGFR) and management of chronic kidney disease in the GP contract offers an effective collaborative model of care for renal patients that may in the future reduce demand for renal replacement therapy.

1.4. Demand for haemodialysis is further influenced by additional factors including:

· A significant proportion of patients present late with End Stage Renal Failure and the majority of these patients start on haemodialysis as default treatment;

· The majority of patients with failing transplants are usually managed by haemodialysis;

· 23% of peritoneal dialysis patients have to switch to haemodialysis after three to five years of treatment;

· Less than 50% of patients requiring renal replacement therapy are suitable for transplantation;

· Due to increasing age and co – morbidity of renal replacement therapy patients, neither peritoneal nor home haemodialysis is likely to offer a significant alternative to unit or satellite haemodialysis.

1.5. Information regarding the rates of therapy and international comparisons are detailed in section 4.3. This demonstrates that whilst incidence and prevalence in Wales is significantly lower than comparators in the developed nations, it continues to maintain a good ratio of home therapies to unit haemodialysis. The proposals contained within this document include options that will not only maintain this ratio but further increase and maximise home therapies.

1.6. There are a number of different dialysis modalities which can be divided into two specific groups – i. home therapies which include peritoneal dialysis and home haemodialysis and ii. hospital / unit-based haemodialysis:

1.6.1. Home Therapies

· Peritoneal Dialysis (PD)

Continuous Ambulatory Peritoneal Dialysis (CAPD) uses the patient’s abdominal cavity for dialysis. The cavity is filled with two to three litres of dialysis fluid, which is left in situ for approximately four hours to allow dialysis to occur. This fluid is then drained, and is replaced with fresh dialysis fluid. This process is undertaken four to fives times a day and is undertaken by the patient, carer / relative or nursing staff in some nursing homes.

In some patients this process can be semi-automated to take place over night and is known as Automated Peritoneal Dialysis (APD)

· Home Haemodialysis (HHD)

Haemodialysis involves using a machine to pump blood from the patients’ circulation (via a fistula, graft or tunnelled line) through an artificial kidney in which dialysis takes place. Patients using this form of dialysis must be capable, stable and have good support from relatives, friends or nursing staff. They must also have reliable vascular access. Dialysis is conventionally undertaken three times a week for three to five hours each time. In addition it should be recognised that there is a move to extend the number of dialysis sessions to a daily dialysis programme (two to four hours each day) with a significant improvement in clinical outcome.

This is an important point as clinical advice is shifting and it can be expected that developments such as daily or nocturnal home haemodialysis become standard clinical practice and optimal treatment plans. This will be monitored by the Renal Networks, and if appropriate amended via annual revisions.

1.6.2. Unit based Haemodialysis

· Unit Haemodialysis (UHD)

The process is the same as HHD, but these more dependent and unstable patients (e.g. elderly / co-morbidities) require greater nursing and medical assistance and therefore receive their treatment at a dialysis unit three times a week.

1.7. Development and investment in the three modalities needs to be regarded as complementary. Disproportionate investment in UHD to the detriment of home therapies will further increase the demand on UHD. The Dialysis Plan for Wales is based on improving and increasing access to all dialysis options. A set of planning assumptions are to be found in section 4.3.

1.8. The most significant factor in developing home therapies is providing the clinical staff to train and educate patients and carers and where appropriate, deliver the treatment. Within the staffing requirements is the inclusion of Specialist Community Renal Nursing Teams. These teams will have a wide function including anaemia and vascular access management, home therapies and linking with primary and acute care settings to manage patients in the most appropriate setting and guide referrals.

1.9. Current Rates of Dialysis

The Renal Advisory Group undertakes six-monthly audits collecting number of patients by modality. The most recent available data is taken from the October 2007 audit returns.

Table 1. Number of patients by modality (October 2007)

Modality

South East

Mid & West

N Wales

Wales

UHD

451

296

210

957

HHD

28

16

9

53

PD

163

76

92

331

Dialysis

642

388

311

1341

2. Priorities for investment

2.1. The following clinical areas are the agreed priorities for investment:

Phase 1

· A first phase of capital development enabling six new satellite renal dialysis units (SRDUs) across Wales;

· Investment in community specialist nursing teams;

· Investment in medical staffing infrastructure;

Phase 2

· Investment in vascular access services;

· Increased investment in teaching and training for home therapies;

· Increased investment in patient support services;

Phase 3

· Enhanced investment in community renal teams;

· Second wave investment in the existing Renal Centres.

Phase one

2.2. First commitment is to the development of the six new SRDUs across Wales. Planning work undertaken by the Renal Advisory Group (RAG) has advised that satellite capacity should be established in the following geographical locations: Pembrokeshire; Baglan Bay; North Gwent; Powys; Deeside; and South Gwynedd.

2.3. These areas were identified following assessment by the Renal Advisory Group in collaboration will local renal services. Determining factors included:

· Unmet need with prevalence lower than the national average;

· Demand and capacity imbalance at existing renal centres;

· Opportunity to improve access by reducing travel times as set out in the NSF;

· Too few ‘fit for purpose’ dialysis stations to meet existing and predicted need.

2.4. To support these developments, recruitment of key staff will also be required in phase 1. This will include Consultant Nephrologist and Middle Grade sessions to provide clinical leadership for the growing dialysis and general nephrology services.

2.5. Sessional allocation of medical staff will be reviewed by the implementation process and related to workload and service developments.

2.6. Dialysis services are increasingly nurse-led and delivered. To develop this model of care, the plan proposed the appointment of a Nurse Consultant for each region. This post will lead the recruitment, training and education for dialysis nursing staff in each region. They will be responsible for developing the nursing model of care including the proposed home and community renal nursing teams.

2.7. It is intended that each satellite unit will host a community renal nursing team. This team will provide a ‘clinical corridor’ for patients between community, primary care and renal replacement therapy, and will enable the assessment and education of patient’s at the most appropriate location whether this is hospital, GP practise or patients home.

2.8. The Community Renal Team will also provide a local contingency in supporting the SRDU’s which due to geographical considerations, are to be managed operationally as if autonomous units from the main renal centres.

2.9. The specialist nursing staff will also have a role in educating and assisting patients in deciding the most appropriate form of dialysis.

Phase two

2.10. The second phase of developments will look to improve access to home therapies such as home haemodialysis and peritoneal dialysis. Such schemes require an enhancement in the staffing infrastructure to support patient education, training and choice and to maintain patients’ confidence and competence.

2.11. Requirements include centre-based training and education staff, training facilities, and community based staff to further expand the remit and output of the community renal teams.

2.12. Good dialysis access is paramount to improved morbidity and mortality and this is the underlying objective of the Renal NSF Standard relating to 80% of prevalent haemodialysis patients receiving dialysis through permanent vascular access. Whilst each region in Wales has different needs it is recommended that an initial appointment in each region for an additional Consultant Vascular Surgeon and Radiologist be undertaken.

2.13. This service is to be supported by Vascular Access Nurses (in phases 1 and 3)

Phase three

2.14. This stage will focus on refurbishment and expansion of the existing Renal Centres and will include improved inpatient facilities for both acute and chronic renal failure patients.

2.15. Additional staffing including expansion of community nursing teams will be required to provide the infrastructure to support the growing numbers of patients.

3. Financial Implications

3.1. In order to increase dialysis capacity, significant investment is required to develop both home therapies and unit-based haemodialysis.

3.2. A summary of revenue and capital costs are attached as appendices (separate excel spreadsheets).

3.3. Staffing costs

Staff costs have been obtained from current agenda for change and medical workforce guidance and reflect average costs to take account of recruitment points.

These consist of specialist staff that are not included in the costs associated with dialysis. These are key stepped costs in workforce infrastructure to enable the undertaking of the increased levels of activity and to support service change with an increasing emphasis on primary care and home therapies.

Table 2. Resource implications – workforce

Year

Additional staff costs

Cumulative staff costs

Proposed additional investment

Phase one

2008/09

£553,000

{1 wte Consultant Nephrologist; 1 wte Middle Grade; 1 wte Nurse Consultant; 5 wte Renal Specialist Nursing Team)

2009/10

£1,584,000

£2,137,000

{3 wte Consultant Nephrologist; 3 wte Middle Grade; 2 wte Nurse Consultant; 15 wte Renal Specialist Nursing Team}

2010/11

£956,000

£3,093,000

{2 wte Consultant Nephrologist; 2 wte Middle Grade; 10 wte Renal Specialist Nursing Team}

2011/12

£300,000

£3,393,000

5 wte Clinical Psychologists

Phase 2

2012/13

£914,000

£4,307,000

Region 1 {1 wte Consultant Vascular Surgeon; 1 wte Consultant Radiologist; Home Therapies Specialist Nursing Team; 3 wte Social Workers (one for each region); 3 wte Patient Advocate (one for each region)}

2013/14

£798,000

£5,105,000

Region 2 {1 wte Consultant Vascular Surgeon; 1 wte Consultant Radiologist; Home Therapies Specialist Nursing Team; 3 wte Social Workers – Satellite Units (one for each region)}

2014/15

£794000

£5,899,000

Region 3 {1 wte Consultant Vascular Surgeon; 1 wte Consultant Radiologist; Home Therapies Specialist Nursing Team; 3 wte Social Workers (one for each region)}

Phase 3

2015/16

£288,000

£6,187,000

{3 wte Vascular Access Nurse (one per region); 3 wte Anaemia Nurse (one per region)}

2016/17

£480,000

£6,667,000

3 wte Consultant Nephrologist (one per region)

2017/18

£250,000

£6,917,000

5 wte Social Worker

3.4. Procedure costs

A costing model has been developed for the purpose of this work to predict future growth and associated costs. Procedure costs have been identified from some recent work undertaken by the a collaborative of renal services and authored by Dr Keshwar Baboolal et al - The cost of renal dialysis in a UK setting – a multicentre study (2008). This provides a comprehensive look at costs associated with the different modalities of dialysis and provides an average cost.

This paper has used these average costs to predict the financial requirements for dialysis services over the coming ten years. In headline terms, these seem higher than normal, however for the first time this process brings together all the elements required for dialysis patients that would otherwise be allocated out to different commissioners under different discrete budgets, with the exception of the specialist staff identified in Table 2. The costs reflected are therefore the only cost to be sought with each patient and includes elements such as transport, vascular access and Erythropoietin Stimulating Agents (ESAs).

Table 3. Resource implications – procedures

Year

Additional procedure costs

Cumulative procedure costs

Predicted annual additional patient numbers

UHD

HHD

PD

Phase one

2008/09

£2,308,200

58

7

5

2009/10

£2,458,882

£4,767,083

62

8

5

2010/11

£2,620,975

£7,388,058

65

10

5

2011/12

£2,795,528

£10,183,586

69

11

5

Phase 2

2012/13

£2,983,705

£13,167,292

74

13

5

2013/14

£3,065,565

£16,232,857

78

6

11

2014/15

£3,243,740

£19476,598

83

6

11

Phase 3

2015/16

£3,432,432

£22,909,030

88

7

11

2016/17

£3,632,268

£26,541,299

93

7

12

2017/18

£3,843,911

£30,385,211

98

7

12

2018/19

£4,068,064

£34,453,275

104

8

12

3.5. Capital costs

3.5.1. Satellite Renal Dialysis Units

Capital costs for the development of six Satellite Renal Dialysis Units (SRDU’) have been estimated using previous work undertaken for the Renal Advisory Group.

The capital costs and charges have been taken from the recent development in Carmarthen and are based on a number of assumptions:

· A conventional brick build to the specifications set in the Health Building Note (HBN) 53 ‘A satellite Haemodialysis Unit’;

· That the scheme is for a renal unit and does not include additional space or storeys for other services;

· Capital charge will be 7% of the capital build.

It is recognised that significant capital costs are required to develop the six SRDUs and therefore the Renal Networks and the Renal Advisory Group will complete a prioritisation process that will assist the implementation and delivery based on objective criteria.

The Pembrokeshire scheme is currently subject to an existing Business Justification Case which has a separate Addendum submitted by the South Wales Renal Network to utilise a demountable temporary dialysis unit.

The phasing of the developments has been suggested below following a limited review of criteria for priority. This is to be revisited on a larger basis using weighted-benefit criteria and a larger group of stakeholders and may therefore be subject to change.

Table 4. Resource implications – capital investment for satellite renal dialysis units.

Year

Additional capital costs

Annual capital charges (7%)

Proposed additional investment

2009/10

£3.28m

£229,600

21-station unit in Pembrokeshire

2010/11

£2.56m

£179,200

12-station unit in North Powys

2010/11

£3.28m

£229,600

21-station unit in North Gwent

2010/11

£3.28m

£229,600

21-station unit in Baglan Bay

2011/12

£2.56m

£179,200

12-station unit in South Gwynedd

2011/12

£2.56m

£179,200

12-station unit in Deeside

3.5.2. Replacement of existing Units

Whilst recognising that the strategic priority is to establish new satellite renal dialysis units a number of existing facilities require either replacement or refurbishment.

Existing satellite facilities such as those in Merthyr Tydfil, Newport and Aberystwyth are subject to issues such as:

· Health & Safety e.g. leaking roofs and breaking floors;

· Infection Control e.g. Proximity of stations and risk of blood spillage;

· Capacity shortfalls e.g. Original lifespan of facilities exceeded.

Year

Additional capital costs

Annual capital charges (7%)

Proposed additional investment

2010/10

£4 m

£280,000

Replacement of facility at Prince Charles Hospital: 30-station unit to replace existing 14 station unit. Would future proof for over ten years and probably longer with other regional developments. Valleys have one of the highest prevalence of renal disease anywhere in the UK and this is likely to continue.

2010/11

£4 m

£280,000

Replacement and relocation of the facility currently based at the Cardiff Royal Infirmary site: 30-station unit to replace existing 15 station unit. Would future proof for over ten years and probably longer with other regional developments.

Other areas will also require refurbishment and potentially replacement but will need a different model of approach. For example, there is little opportunity to refurbish and expand the existing unit in Newport. With developments proposed by Gwent clinical futures it may be that a more appropriate approach would be to consider a greater number of smaller units in Gwent as spokes to Newport and Abergavenny.

Both Renal Centres in Cardiff and Swansea will require refurbishment. This will need to be carefully planned and phased to minimise service disruption and link with increases in satellite capacity. The same is true for both Renal Centres in Bangor and Wrexham and these will need closer review before appropriate timescales and details can be submitted and included in future versions of this plan.

3.5.3. Options for Rapid increase in Unit Haemodialysis Capacity

The renal Networks have been exploring with third parties opportunities to provide flexible provision of haemodialysis capacity including mobile and demountable units.

Such units present a number of opportunities including:

· Contingency in the event of major incidents or problems with existing facilities;

· Provision of interim capacity in advance of permanent facilities;

· Improve access to small, geographically separate communities as an alternative to larger units. Such an approach may be more appropriate for areas such as rural Wales – Powys and West Coastal Wales.

Such an approach has already been utilised by the South Wales Renal Network in respect of the Pembrokeshire dialysis facility. This has involved the provision of a six station demountable unit on site at the Withybush Hospital in advance of the permanent facility. Such a development will enable the early provision of local services for the population of Pembrokeshire.

Similar opportunities exist for other schemes including Baglan Bay, Welshpool and possibly South Gwynedd by utilising contract variations for existing services and establishing demountable / temporary units in advance of permanent facilities. Costs of such facilities have not been built into this plan but with some re-working of the advance recruitment, procedure costs and additional capital for infrastructure costs to prepare sites such schemes are highly feasible.

4. Supporting information

4.1. Workforce implications

4.1.1. Services for patients with renal disease involve a multidisciplinary workforce of medical, nursing, technical and other professional staff.

4.1.2. The majority of patients with CKD can be managed

effectively in the community. To support and encourage this arrangement, it is proposed to develop and enhance where already in place, Community Specialist Renal Nursing Teams.

4.1.3. The majority of staff including dialysis nursing, technical support and professions such as pharmacy, general radiology and hotel support staff are included within the unit cost of each dialysis modality.

4.1.4. Specific specialist roles such as medical staff, community nursing and support staff such as social workers and patient advocates are identified separately.

Medical Workforce

4.1.5. In phase 1, there is the need to provide additional medical staffing, both Consultant Nephrologists and Middle Grades. This investment will provide appropriate medical leadership and governance to the SRDUs. It will also enable increased access to general nephrology for local population via outpatient services. This will ultimately assist the early detection, management and delay in renal disease progression. As such, this investment should also be regarded as providing a level of secondary prevention.

4.1.6. Phase 2 focuses medical staffing developments on vascular access. By increasing regional capacity with additional vascular surgeons and consultant radiologists with an interest in vascular access, the necessary infrastructure will be in place to provide timely and appropriate vascular access for the growing numbers of patients. This area of service will be reviewed over the course of 2008/09 by the Renal Networks of Wales following an initial report to the Renal Advisory Group in January 2008. It can be expected therefore that these requirements may be subject to revisions and so should be seen as a minimum requirement.

4.1.7. Phase 3 increases the numbers of regional Consultant Nephrologists and introduces the post of Renal Nurse Consultant to provide local leadership and specialist skills. This post will be invaluable in pulling together the enhanced Renal Nursing Teams and enabling region-wide standards of service delivery and quality.

Nursing workforce

4.1.8. Phase 1 introduces the development of Community Specialist Renal Nursing Teams. Over the subsequent phases these teams and their parent Renal Centres are enhanced with additional nursing staff to meet the growing need for home therapies and vascular access.

Other professional staff

4.1.9. In phases 1 and 2 see the introduction of clinical psychology, social workers and patient advocates. The client patient groups tend to have significant social needs as well, associated with age, co-morbidities, and these specialist staff are highly regarded as essential in providing high quality care and good outcomes. Such posts have been recently recommended in a report by the Institute for Improvement and Innovation: ‘Preparing for End Stage Renal Disease’.

Patient Advocates are highly regarded and can be of immense value to new and existing patients. Research demonstrates that where available, they assist patients in the psychological and emotional challenges that come with initiating and where necessary changing dialysis.

4.2. Concept of service model

4.2.1. It is proposed to maintain the current hub and spoke arrangement for the provision of dialysis across Wales. The future growth of renal services will require this to be reviewed, with the need for a designation process of Renal Centres, Subsidiary and Satellite Units.

4.2.2. The Costed Plan introduces a relatively new concept of community renal nursing teams. Currently some staff associated with home dialysis, vascular access and anaemia management provide services to patients in the community setting. The proposals are to expand this concept further by establishing teams of specialist nursing staff to support discrete localities.

4.2.3. Functions of these teams could include:

· Support primary care practitioners in locally managing CKD patients where referral to secondary or tertiary care is not appropriate;

· Support the referral pathway from primary care to general nephrology. Evidence exists to support this role. In such event it is predicted that initially referrals and subsequent demand for RRT will increase but longer-term will challenge the gradient of growth;

· Patient education and training to support RRT services.

4.2.4. The impact of these community teams will need to be carefully monitored. Pilots of similar approaches around the UK suggest that they will over time, improve appropriate referral rates to general nephrology, tackle unmet need related to renal disease in primary care, and contribute to the earlier detection and management of CKD, and as a result potentially reduce the longer-term demand for RRT.

4.3. Planning Assumptions

There is a common hierarchy to the provision of renal replacement therapy which represents evidence on clinical and cost effectiveness within the general patient population:

1. Transplantation;

2. Peritoneal dialysis;

3. Home haemodialysis; and

4. Unit based haemodialysis

To support the development of this costed plan, a simple excel model has been created to predict growth in patient numbers. The model is prevalence based, and uses agreed growth functions to estimate the number of patients by dialysis modality. These are then multiplied by the agreed Tariff to provide a predicted activity cost.

A key planning assumption has been the growth in demand for unit haemodialysis. To date, growth has been closer to 7%, with some local variation. However the model underpinning the Costed Dialysis Plan is predicting a growth gradient of 6%. This deliberate choice has been made using the following rationale:

· Strategic intent to significantly increase transplantation – new transplant unit in South Wales; Recommendations and action plan from the Organ Donor Task force and development of Antibody Incompatible Transplants;

· Wales has good examples of promoting home therapies, and whilst there are recognised limitations, there is room for further growth and promotion;

· The continued expansion of medical management for patients who do not require or would not benefit from, renal replacement therapy.

The table below summarises the main planning assumptions used by the group to prepare this costed plan.

Table 5. Agreed planning assumptions for dialysis services in Wales

Area

Planning Assumption

Clinical

Prevalence of renal replacement therapy

This is currently 447 per million population (pmp). This is expected to increase by 5% per annum:

2011 = 517 pmp

2014 = 599 pmp

2017 = 693 pmp

Unit Haemodialysis

Annual growth of 6%.

Home Haemodialysis

Annual growth of 15% up to 2012 to reflect RAG framework target of doubling home haemodialysis. Unlikely to be sustainable from this point due to increased transplantation rates.

Drop to 6% per annum from 2012.

Target is to increase patient stock and then maintain.

Peritoneal Dialysis

Up to 2012 annual growth of 1.5%. Target is to double this growth as a response to early detection, reduced ‘crash landers’ (who require default UHD) and development of Assisted PD.

Medical Management

Current services are at different stages of developing medical management care pathways for patients not suitable for conventional renal replacement therapy. Given such variation, the model at present does not account for growth in this area but future versions will be subject to in-year work that will inform this area of clinical practice.

Shift Pattern

Two shifts per day, six days per week

Patients travelling time to UHD

Achieve maximum of 30 minutes travelling time to dialysis unit for all UHD patients

Home Haemodialysis

Meet NICE requirements that all clinically suitable patients are offered choice of having home haemodialysis

Establishing Renal Access

At least 80% prevalent haemodialysis patients are receiving dialysis using arterio-venous fistula / grafts where this is clinically appropriate

Vascular Access

70% Day Case rates

15% Re-do

Financial

UHD cost per patient per annum

£35,000

Based on 150 sessions per annum:

HHD cost per patient per annum

£25,000

Based on 150 sessions per annum:

PD cost per patient

£18,000 (based on 66:34 split between CAPD:APD)

CAPD cost per patient per annum

£16,000

APD cost per patient per annum

£21,000

Transplantation

The planning for increases in dialysis are built on the assumption that transplant activity will increase as set out in the phases of the development of the new Transplant Unit in Cardiff. If this is not realised, the cost and growth in dialysis will be significantly higher than predicted and future versions will be revised accordingly

Capital Charges

These have been estimated using previous schemes and will need to be subject to refined work with individual BJCs. Clearly the sum of the capital charges is significant, and the Networks have prompted a debate that as a National programme, the associated capital charges should be funded centrally.

4.4. Planning process

The diagram below summarises the key documents and processes for co-ordinating and delivering the capital schemes. This Costed Plan will provide the strategic vision and framework for all dialysis services. The implementation of the individual schemes will be pulled together under the umbrella of a Strategic Outline Plan (SOP) for Dialysis Facilities. Each individual scheme will be subject to a Business Justification Case linked to the SOP.

Figure 1. Planning process for capital schemes

4.5. International comparisons

The information in the table below has been sourced from a central database (USRDS) which acts as a single source for all registered national registries (this incorporates over 40 countries across the World).

The critical points to highlight are:

· Prevalence is significantly lower than other western and developed nations;

· Ratio of home therapies to hospital therapies is very good although it is acknowledged in work previously undertaken by the RAG, this could be expanded further, particularly HHD;

· Incidence and prevalence are likely to continue to increase annually, and international comparisons and modelling suggest that total numbers are to increase by approximately 7% per annum for the foreseeable future and at least next ten to fifteen years.

Country

Incidence

Prevalence

UHD

HHD

PD

pmp

pmp

%

%

%

UK

110

700

75

3

22

Wales

129

720

74

1.5

24.5

Spain

125

950

90

0

10

Italy

160

1050

88

0.3

11.7

Germany

195

1000

94

1

5

Sweden

122

800

75

3

22

Japan

265

1850

97

0.1

2.9

USA

345

1550

91.9

0.6

7.5

4.6. Working Group and consultation

4.6.1. Improving Dialysis Services for the Population of Wales Working Group

The following individuals provided the core information, editorial and administrative activity in producing this costed plan.

Member

Organisation

Professor John Williams

Lead Renal Advisor for Wales and Vice-Chair of the Renal Advisory Group

Dr Kieron Donovan

Consultant Nephrologist and Information Lead for the Renal Advisory Group

Dr Richard Moore

Lead Nephrologist for the South Wales Renal Network

Dr Peter Drew

Lead Nephrologist for the North Wales Renal Network

David Heyburn

Network Manager for the South Wales Renal Network

Nick Wilson

Network Manager for the North Wales Renal Network

Stuart Davies

Interim Chief Executive for Health Commission Wales

4.6.2. Wider consultation

The contents of this paper have been shared with the wider renal community including the Renal Networks and their respective Network Boards and patient group representatives including Kidney Wales Foundation and the Welsh Kidney Patients Association.

5. Monitoring, annual review and implementation

5.1. Monitoring and annual review

It is critical that this proposal is monitored and reviewed on a regular basis to ensure accuracy and validity. The process will be co-ordinated by the Renal Advisory Group with direct operational responsibility of the Renal Networks.

The costed plan will be monitored annually and will be a core part of the Networks internal performance governance arrangements linked to the monthly and annual audit and contract returns from service providers.

Following agreement on version 1, a version control system will be put in place and the costed plan will be available on the internet sites of the Renal Networks.

The Renal Networks in collaboration with the Renal Advisory Group will be monitoring renal services via a Self Assessment Audit Tool (SAAT) annually. This will develop to include a process by which patients will have a means to assess the standard of their care matched against the standards and quality set out in the Renal NSF.

5.2. Implementation

An implementation plan has been drafted to support this costed dialysis plan. The implementation requires careful management to ensure objective resource-allocation and prioritisation, consistency and achievement of objectives.

A draft of the implementation plan is attached as Appendix 5.

6. Resource Allocation for 2008/09

Allocation of resources for 2008/09 has been undertaken in advance of this work and as such there is a clear difference between the predicted need and the allocated sum.

In summary, Health Commission Wales has received an allocation of £2.5 million whilst this costed plan indicates a requirement of £2.9 million. In the absence of the difference, the Renal Networks have been instructed by HCW to agree a process of allocating the £2.5 million to renal services across Wales. This has presented a significant challenge to the renal community. It has only been achieved through the delayed recruitment of medical and nursing staff until later in 2008/09 and a earlier directed emphasis on home therapies.

The proposed allocations are provided in Appendix 6.

Whilst accepting this short-term disruption from the plan, it is critical that future allocations include the full year effect of this year’s investment and the necessary funding levels to enable the predicted growth in procedures and key staff for future years.

7. Attachments

Appendix 1 - Summary of procedure revenue requirements (excel spreadsheet)

Appendix 2 – Detail of workforce requirements (excel spreadsheet)

Appendix 3 – Summary of Capital requirements (excel spreadsheet)

Appendix 4 – Summary of financial costs for proposal (excel spreadsheet)

Appendix 5 – Draft Implementation Plan (Word document)

Appendix 6 – Resource Allocation for 2008/09 (Word document)

Costed Dialysis Plan

Individual Existing Units Business Justification Cases

Strategic Outline Programme

Individual SRDU Business Justification Cases

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CONFIDENTIAL – NOT FOR CIRCULATION - Version 1.0 – May 2008