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Payment for Haemodialysis Treatment whilst away from Home Unit

Department of Health

TEMPORARY HAEMODIALYSIS AWAY FROM HOME

FUNDING ARRANGEMENTS FOR NHS PATIENTS RESIDENT IN ENGLAND:
A SUMMARY OF CURRENT GUIDANCE

People may travel for many reasons: for example to spend a few days with family or friends when there is a new baby or a bereavement; to receive, or provide, support following a hospital admission or illness; to take a holiday; to visit a client or attend a conference for work, or attend a course of education. People receiving haemodialysis treatment who wish to be away from home for more than a day or two will need treatment at their destination. It is made cleaan Part One of the National Service Framework for Renal Services that ‘For a variety of reasons - work, education, holidays, family visits - it is important that patients can dialyse away from home.’

Primary Care Trusts (PCTs) and NHS Trusts are encouraged to develop agreed local policies for temporary haemodialysis away from home, which will ensure equity while minimising the impact of renal failure on patients’ mobility. Such policies will need to operate within the framework of the arrangements summarised here.

People requiring such temporary haemodialysis treatment will need to arrange it before they travel. Patients considering a trip are advised to involve their home unit from an early stage, as their plans may be affected by advice from staff. However, it will vary from case to case how much help a patient needs with making the arrangements, and how much their unit is able to provide.

TEMPORARY HAEMODIALYSIS AWAY FROM HOME – WITHIN ENGLAND

1. The patient / the patient’s home unit will contact the dialysis unit providing NHS treatment in the area the patient wishes to visit, to ensure it is able to accept the patient for temporary treatment during the relevant period. The patient’s home unit will need to provide all necessary medical details, and agree funding. Units can also arrange temporary treatment for English patients in Wales, Scotland and Northern Ireland.

2. Funding is arranged on a unit-to-unit basis (not through the Out of Area Treatment (OAT) system). The charge quoted by the unit providing the temporary haemodialysis should reflect the costs actually incurred. The system of national tariffs for use in commissioning (Payment by Results) is currently being introduced in England: the tariffs are based on the reference costs collected from Trusts. Although the use of national tariffs in commissioning dialysis is not yet mandatory, the current indicative tariff can be used as a guide for charging; or alternatively the temporary unit’s reference costs for haemodialysis, adjusted for inflation.

Information about the national tariffs and reference costs can be found on the Department of Health website (at www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/FinanceAndPlanninq/NHSFinancialReforms/index.htm). The Payment by Results Core Tools 2004 includes the current indicative price in Appendix 9. The patient’s home unit will meet the cost of the temporary treatment, and any costs associated with keeping the patient’s place open for them on their return.

3. It is a fundamental principle that NHS treatment is provided to the patient free of charge. Specific legal provision has been made for certain exceptions, such as dental and prescription charges, but no charge can be made to patients for NHS dialysis while they are away from home, even if designated as an administrative charge or ‘top-up’ payment.

4. If no temporary treatment is available at a unit providing haemodialysis for NHS patients the home unit may, if it considers it appropriate, fund temporary haemodialysis for the patient at a private unit. Such funding can cover the cost of the haemodialysis treatment only, and not the cost of eg accommodation. However if a patient arranges private treatment without the prior agreement of their home unit, they will be responsible for the cost.

5. If a patient is eligible for hospital transport, and will need it for their temporary haemodialysis, the temporary unit should be notified in advance to allow time to arrange it.

6. The use of a standard form can help to facilitate the arrangement of temporary haemodialysis. One such form has been developed and piloted by the Renal Unit at Southend Hospital NHS Trust.

7. Those putting into effect PCTs’ and NHS Trusts’ policies on temporary haemodialysis away from home will need a process whereby individual cases, which may involve exceptional circumstances, can be considered on their merits.

TEMPORARY HAEMODIALYSIS AWAY FROM HOME – OVERSEAS

8. There are some countries in which, as a result of inter-governmental agreements, patients can obtain treatment from the health services of that country. However, this is not always provided on the same terms as NHS treatment in England.

Within the European Economic Area (EEA) and Switzerland

9. The European Economic Area (EEA)consists of the EU member states: Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Malta, Poland, Portugal, Romania, Slovenia, Slovakia, Spain, Sweden and the UK; plus Iceland, Liechtenstein and NorWay. Switzerland has agreed to operate the same arrangements as the EU countries.

10. UK residents visiting these countries can obtain any medical treatment which becomes necessary, including renal dialysis treatment, from the state healthcare system (though people who do not have UK, EU, EEA or Swiss nationality are not covered in Denmark, Leichtenstein, Norway or Switzerland. In Iceland, these people are covered for emergency treatment only). A new European Health Insurance Card has replaced the paper forms used to show entitlement to treatment, such as the E111 used by holidaymakers. This was introduced in the UK on 31 December 2005, and all other member states are also now issuing the European Health Insurance Card instead of the E111.

11. More information about entitlement, can be found on the Department of Health website at www.dh.gov.uk/travellers or in the leaflet Health Advice for Travellers, which is available from Post Offices.

12. Travellers needing dialysis treatment must arrange it in advance, at a unit which is part of the state healthcare system and/or provides treatment under the European Health Insurance Card arrangements.

13. The patient will be treated on the same basis as an ‘insured’ resident of the host country, and each country has its own rules: in some countries, the patient receives free treatment; in some, the patient has to pay part of the cost; in others, the patient pays the whole cost and can then claim a full or partial refund. For details, see our website www.dh.gov.uk/travellers or Health Advice for Travellers.

14. The patient’s home unit can help with making the arrangements, and provide medical details. However, it is not liable to pay any costs incurred for treatment obtained under European Health Insurance Card arrangements.

15. Patients who arrange to be treated in a private unit outside the European Health Insurance Card arrangements will normally be responsible for meeting the whole cost of their treatment.

Australia

16. Australia is the only country outside the EEA and Switzerland in which renal dialysis is covered by a reciprocal healthcare agreement. Treatment must be arranged in advance, at a state facility. Costs are met by the Australian Medicare system.

Outside the EEA and Australia

17. Patients visiting any country other than those in the EEA, Switzerland or Australia are responsible for meeting the whole cost of their dialysis treatment.

The Risk of Infection

18. The nature of dialysis treatment makes patients vulnerable to contracting blood-borne viral infections such as HIV, hepatitis Band hepatitis C. There is a very low rate of such infections among patients in UK dialysis units, and the high level of infection control procedures means the risk of transmission is minimised.

19. In some countries, the risks are much higher, because the infections are more common, facilities are more limited, or infection control measures are not so strict.

20. Patients planning to travel abroad will need advice about these risks from their home unit, and patients visiting high risk areas will need to be made aware of the precautions which might be required on their return, such as testing, monitoring or dialysing in isolation for some weeks. As not all units have isolation facilities, this might involve travel to another unit.

The funding of referrals for treatment overseas

21. In the past, the NHS could seek authorisation from the Department of Health to fund referrals for treatment overseas, if that treatment met certain criteria. One of the criteria was that the treatment concerned was not available within the UK or the EEA, so this arrangement did not cover routine dialysis for patients who had gone abroad for a visit.

22. Since November 2002, the NHS has not had to seek authorisation for such referrals, but the criteria remain unchanged. Details were issued in the Chief Executive Bulletin of 14 November 2002, and can be found on the Department of Health website at www.dh.qov.uk/en/Policyandguidance/International/index.htm.

23. NHS bodies who receive funding requests for temporary dialysis overseas will want to take into consideration not only the criteria for referrals outside the UK and EEA, but also their position with regard to clinical negligence liability.

SOME ILLUSTRATIVE EXAMPLES

24. A patient wishing to travel to an English resort: the patient / patient’s home unit will make arrangements with the unit at the resort, and treatment will be funded on a unit-to-unit basis. NB Units in popular holiday destinations get more requests for temporary haemodialysis than they can accommodate, especially at peak times. If no treatment is available at a unit that treats NHS patients in the area, the home unit may, if it considers it appropriate, fund treatment at a private unit (but cannot pay for any other costs eg accommodation).

25. A patient wishing to travel to Wales: although healthcare in Wales is the responsibility of the Welsh Assembly, the unit-to-unit arrangements apply throughout the UK. The patient / the patient’s home unit will therefore make arrangements with the Welsh unit, and the treatment will be funded as at the English resort, above. (It is the same for Scotland and Northern Ireland.)

26. A patient wishing to travel to the Channel Islands: the Channel Islands are a dependency of the British Crown, not part of the UK, so the home unit cannot fund haemodialysis on a unit-to-unit basis; nor are they covered by European Health Insurance Card arrangements; and the UK’s reciprocal healthcare agreement with the Channel Islands does not include renal dialysis. The patient will therefore have to meet the cost of haemodialysis treatment there. (It is the same for the Isle of Man.)

27. A patient wishing to travel to Greece: as Greece is in the EEA, treatment is available under the European Health Insurance Card arrangements. If treatment is agreed under these arrangements but takes place ata unit which charges-more than the state rate, the patient will have to pay the excess (see paragraphs 9-15 above, and Health Advice for Travellers).

28. A patient wishing to travel to Spain: Spain is in the EEA,so the patient/ patient’s home unit will contact the Spanish state unit at the patient’s destination, to make arrangements under the European Health Insurance Card arrangements. Under Spanish procedure, the Spanish health authorities will issue form P1O, confirming the details of the agreed treatment. The patient / patient’s home unit is advised to obtain the P1O from the Spanish unit before the visit. The European Health Insurance Card will then be accepted to cover the cost of treatment up to the state rate, though if treatment takes place at a unit which charges more than the state rate, the patient will have to pay the excess.

29. A patient wishing to travel to Turkey: Turkey is not in the EEA, and has no reciprocal healthcare agreement with the UK, so the patient will have to meet the cost of haemodialysis treatment there.

30. A patient wishing to travel to Australia: renal dialysis at a state facility is covered by the UK’s reciprocal healthcare agreement with Australia, but needs to be arranged in advance. The cost will be met by the Australian Medicare scheme.

31. A patient wishing to travel to New Zealand: unlike Australia, New Zealand does not have a reciprocal healthcare agreement with the UK, which includes renal dialysis. The patient will therefore have to meet the cost of haemodialysis treatment there.

32. A patient wishing to travel to the USA: there is no reciprocal healthcare agreement between the UK and the USA. The patient will therefore have to meet the cost of haemodialysis treatment there. (It is the same for Canada, Mexico and South America.)

33. A patient wishing to travel to India or Pakistan: the case is the same as for the USA. The UK has no reciprocal healthcare agreement with India or with Pakistan, so the patient will have to meet the cost of haemodialysis treatment there.

34. A patient wishing to travel to the Caribbean: the islands in the Caribbean either have no reciprocal healthcare agreement with the UK, or an agreement which does not include renal dialysis, so the patient will have to meet the cost of haemodialysis treatment there.

The great majority of countries worldwide have no healthcare agreement with the UK, including those in the Middle East, Africa, most of Asia and South America; or agreements which do not cover renal dialysis treatment, including many republics of the former USSR. Patients visiting them will have to meet the cost of haemodialysis treatment there.

For further details, see ‘Health Advice for Travellers’(www.dh.gov.uk/travellers).

Last updated June 2007

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