Specialised Commissioning of Kidney Transplantation

Keith RiggChair, Renal Transplant CRG

1. Introduction2. What has been done?3. What is coming?

1. Introduction

Specialised Commissioning

• Where does it fit into NHS England?– Alongside commissioning of primary care,

offender healthcare and aspects of armed forces healthcare

• What is included?– Prescribed services meeting defined criteria

• Budget of £13.8 billion pa (14% NHS budget)• Six national Programmes of Care

Operating model for specialist commissioning

• Single ‘do once’ function at national level

• Strategic interpretation at a regional level

• Provider/commissioning interface at Area Team level

Where do the Clinical Reference Groups (CRGs) fit in?

Roles of CRG

• Specialised advice and guidance• Developing national service level strategy• Developing and providing assurance of

commissioning products• Evolving performance management role

Specialised Commissioning Taskforce

• Established April 2014• Improve how NHSE commissions specialised

services and to put commissioning arrangements on a stronger long term footing

• Seven work streams• Priorities– Deliver balanced financial plan– Reducing unwarranted variation & improving

quality– Strengthening commissioning infrastructure

2. What has been done?

What has been done?

• Service specification• Commissioning policies• CQUIN• Quality measures and dashboard• 5 year strategy• Collaborative working• Business as usual

Service Specifications

• Clear description of what a service is and the acceptable standards that need to be in place for delivery

• Benefits of country wide single service specification

• Recognise different ways of service delivery and interface with RDI CRG

• Concentrate on the ‘what’ not the ‘how’

Commissioning Policies

Current• Reimbursement of

expenses for living kidney donors

Consulting• Eculizumab for the

treatment of refractory antibody mediated rejection post kidney transplant

• Bortezomib for the treatment of refractory antibody mediated rejection post kidney transplant

CQUINs 2013/14

• Cold ischaemia time–DCD <12 hours–DBD <18 hours

• Increase use of Renal Patient View

Quality Measures

• NHS England/NHSBT agreement• Kidney Centre Specific reports– Robust data– Validated by centres– Available to units, commissioners, patients

• Purpose to reduce unwarranted variation and improve quality

RTR Dashboard

• Access to renal transplant– Median waiting time– DBD Organ Decline rates – standard & extended– % of living donor transplants that are pre-emptive

• Transplant outcomes– 1 & 5 year graft and patient survival rates for

deceased and living donor transplantation

Five Year Strategy

• Improving the deceased donor transplant patient pathway - from assessment to transplantation

• Living Donor Kidney Transplantation• Improving the deceased donor transplant

patient pathway - from assessment to transplantation

• Improving the effectiveness of kidney transplant follow-up

Collaborative Working

• Renal Dialysis CRG• NHS England/NHSBT• National Services Division, Scotland

Business as Usual

• Advice and Guidance – Local Area Teams– Clinicians– Patient Groups– IFRs– Drug issues

• NICE stakeholder• Performance management

3. What is coming?

What is coming?

• National Tariff• QIPP• Future commissioning models• Peer Review• Managing capacity

What is the Renal Transplant Currency?

Different ways of working

• Work-up – what, who, where?• Maintenance on list – what, who, where?• Transplant procedure• Follow-up – what, who, where?• Repatriation – who, when, where?

Need a single model of currency and costing that will capture different ways of working

Currency development

• Workshop January 2013• Mandated currency from April 2013• Four pilot networks – Effectiveness of recording currencies– Case mix audit undertaken – variation in investigations and

frequency • Workshop October 2013– Currencies best recorded through adapted clinic outcome

form – Broad agreement reached on pathway in terms of currency

and tariffs to be utilised

Next Steps

• Initial finance workshop June 2014

• Costings being modelled to currencies

• Shadow tariff 2015/16• National tariff 2016/17

QIPP 2013/14

• Immunosuppression prescribing– Secondary care prescribing & Homecare delivery– National Procurement– Push towards increased used of generic brands

• Pre-emptive living donor transplantation– Linked to NHSBT LDKT strategy

QIPP 2015/16

• Clinically led QIPP programme to produce 3% savings - £420 million

• CRGs working with area teams• Dilemma for transplantation – increased

activity vs savings– Increasing transplantation– Reducing unwarranted variation

Future Commissioning Models

• National specialised commissioning• Co-commissioning with CCGs• Commissioning by CCGs

Peer Review

Key aims• Quality assurance of a service• Enable quality improvement of a service

Why consider peer review?

Benefits• Recognise and share

good practice• Identify and act on

reasons for non-standard variation

• Increase public and commissioner confidence

Disbenefits• Increased regulatory

burden• Negative perception• Time and resource

required

Activity and Capacity

• 2007/08-2013/14: 47% increase in the number of new transplants performed per year

• 2008-2013: 31% and 40% increase in the number of functioning transplants in transplant centres and specialist renal centres respectively