Changes to Dialysis Commissioning

I’ve been contributing to this website for a year now and never in that time has there been a subject like the proposed changes to dialysis commissioning. Social media timelines have been full of the story and the lack of clear information has led to patients, who are quite rightly wary of changes to an important part of their lives, making up claims such as the introduction of a charging structure for patients undergoing dialysis. Before I get to the meat of this blog let me nail that particular rumour. I’ve read a lot on this topic throughout this week and even subjected myself to the blame-dodging knockabout of politics by watching this weeks Health Questions in the House of Commons and nowhere have I seen or heard any suggestion that patients are to be charged for dialysis.

On Thursday NHS England published a consultation document on changes to the commissioning of dialysis services. I thought this was rather odd because the decision to proceed with these changes has already been made and CCGs are scheduled to take over dialysis commissioning from April 2015. As with the recent announcement on changes to dialysis tariffs, NHS England has not given patients or their representative bodies such as The British Kidney Patient Association or The National Kidney Federation much time to respond to the consultation document. So much for Patient Involvement, something for which NHS England has already been rebuked. See here.

I thought I’d focus on the three reasons given to justify the decision to transfer commissioning responsibilty for dialysis from NHS England to local Clinical Commissioning Groups detailed on page 12 of the consultation.

Reason 1

Many patients on renal dialysis have co-morbidities such as diabetes where care is delivered on a primary care basis and/or where associated secondary care is commissioned by CCGs. Commissioning separately between NHS England and CCGs is a barrier to integrating services around people who need dialysis as well as non-specialised services.

In my experience, once a patient starts dialysis they automatically transfer to secondary care and those co-morbidities will be factored into their renal care. With all due respect to GPs, they do not have the depth of knowledge possessed by renal specialists to properly assess and treat those co-morbidities. Even to this day, years after my transplant, my GP still refers any changes to hypertension medication or diabetes control to my renal consultant and I don’t want that to change. There will always be a barrier to complete integration. There are myriad routes into end stage renal failure, a one size approach to this aspect of its treatment will not work.

Reason 2

The split of commissioning between CCGs and NHS England has created an artificial divide in the patient pathway that separates the commissioning responsibility for preventing and reducing the incidence of end stage renal failure and that for treating end stage renal failure. This is a barrier to investing more in preventing and reducing the incidence of end stage renal failure

The prevention of end stage renal failure is a laudable aim but this decision in isolation renders that aim unachievable. We will only see real progress in the prevention of end stage renal failure when public health policy addresses key issues such as the increase in the number of people diagnosed with type 2 diabetes, a leading cause of kidney failure. Perhaps if this government introduced legislation to reduce the amount of sugar in the nation’s food or re-introduced mandatory physical education into schools it would have a more meaningful effect than the change in which organisation pays for dialysis services.

Reason 3

CCGs already commission patient transport services – one of the biggest sources of complaint about access to dialysis services. Bringing responsibility for commissioning of these services together could enable significant improvement in the alignment of patient transport services with dialysis sessions.

So, by giving CCGs another commissioning responsibility, namely dialysis services, the problems associated with patient transport services, not all of which relate to dialysis patients, will magically improve. Where’s the evidence, where’s the logic for goodness sake?

All in all I’m not convinced by any of the the three reasons given and still think that the ultimate aim of the change to dialysis commissioning is driven by a desire to further privatise the NHS. None of the reasons survive the most casual of examinations, the absence of evidence is telling and most worryingly, NHS England has made another decision without reference to those most affected by it, the patients.


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