BTS 2013 Report – How will commissioning be different after April 2013 for kidney transplantation?

by Maria Dalby reporting on the presentation by Keith Rigg, Nottingham University Hospitals NHS Trust.   With effect from April 2013, kidney transplantation will be commissioned by the NHS Commissioning Board as a specialist service.

The Renal Transplant Clinical Reference Group (RTR CRG) was established in January 2012 and has to date developed a series of commissioning products. Keith Rigg, former president of the BTS and chairman of the RTR CRG outlined how the group will be implementing these products in the coming year, and highlighted plans for further developments including the introduction of Payment by Results in kidney transplantation.

 

Since its inception, the RTR CRG has endeavoured to engage with stakeholders in the kidney transplantation community and provide expert advice on service commissioning. All CRGs have been given similar work programmes. For RTR CRG, the initial work involved defining the scope and specification of the services to be commissioned, and proposing CQUIN and QIPP targets. The service specification work strand aimed to provide a clear description of the nature of the service and the required acceptable standards for its delivery. Whilst there are generally clear benefits to be realised, especially from a patients’ point of view, from having a single country-wide level of service regardless of geographic location, the RTR CRG realised at an early stage that in the case of  renal transplantation, individual centres have developed different ways of delivering service, both with respect to actual transplant procedure and to follow-up and repatriation, and the focus has therefore been on ‘what’ rather than ‘how’ in terms of service delivery.

 

Two CQUINs have been approved for kidney transplantation, namely limiting the cold ischaemia time for the first intended recipient to 12 hours for DCD and 18 hours for DBD, and increased use of the Renal PatientView portal. With regard to QIPP, Keith Rigg pointed out that although the abbreviation stands for Quality, Innovation, Productivity and Prevention, the principal focus is on productivity, which in reality means saving money. To this end, immunosuppression prescribing will be a target area for QIPPs, through secondary care prescribing and homecare delivery, national procurement, and generic prescription. The latter is likely to increase in the future to save costs, although Keith Rigg pointed out that depending on the impact of national procurement on the price of branded drugs, this is by no means a certainty. A further QIPP relates to working with NHSBT to maximise living donor transplantations.

 

The CRG work programme also includes innovation as a specific work strand. In specialist commissioning, 1% of the commissioning budget will be ‘top sliced’ for innovation, including new technologies, new drugs, and redesign of pathways. This funding is applied for through a three-stage process which closely resembles the Wellcome Trust application procedure.

 

From April 2013, NHSCB will commission all transplant-related care provided by adult specialist renal centres and transplant centres. Transplant commissioning begins when the patient has his/her first meeting with the transplant surgeon – the work-up prior to this point will be commissioned as renal dialysis services. An important difference from the previous model is that the strategic commissioning is done through the national operations directorate, with the strategy being implemented regionally – the role of the local area teams will be delivery of single national contracts rather than commissioning on the current sale.

 

Payment by results is a separate feature of the new commissioning system, which is currently being developed. A national tariff for kidney transplantation is expected to come into effect during 2015/16. A key part of this work is improving compliance with the mandatory Healthcare Resource Group (HRG) coding to ensure that not only the actual transplantation procedure is coded correctly – which is often not the case at present – but also the work-up and follow-up procedures which to a large extent are not coded at all in the present system.

 

Keith Rigg concluded that whilst many kidney transplant clinicians have been late in coming into the area of commissioning and may have preferred not to get involved, it is an important for everyone to engage with and not get left behind.