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Public Private Partnerships for Satellite Dialysis

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Dr Nick Richards

What I would like to do is share with you our experiences with public private partnerships for satellite dialysis over the last 7 to 8 years. Firstly some history - back in the early 1990's we had rapidly expanding dialysis population. We had hopeless under-provision of haemodialysis facilities, we had about 19 hospital haemodialysis stations and they were all full. About a third of our patients were dialysing twice a week which was wholly inadequate. We had far too many patients on CAPD, and we had the wrong patients on CAPD, and we were unable to offer patients any sort of choice. In 1990 to 1993 we had 300 patients, then in three years it grew to 400 patients. We were growing at about 10 per cent a year, but we had no increase in facilities. We discussed this with our commissioners and the Regionalised Specialist Services Agency and they agreed we needed to set up some dialysis units because many of our patients were travelling more than 100 miles in a round trip three times a week, but of course there was no money. They suggested we explored funding opportunities with the private sector for two units originally, one down in Hereford, and one in the West of Birmingham. This was a very lengthy process, which took around two years. We developed a specification for what we wanted, which was for the provider to come along and design the units for us, to build them, to staff them, and to run them. We wanted the staff to include the nurses, the technical staff, the dieticians, and the social workers, and these units were to be nurse run. So we wanted them to do all this, but we said we couldn't guarantee any patients. We did not want to be tied down to any particular equipment manufacturer. We wanted them to do all the routine screening for us as well.

We eventually let the contract to National Medical Care which were an American Company who where then the biggest provider of dialysis in the world. They were subsequently taken over by Fresenius in 1997, and our initial contract was for seven years. We decided we wanted the units to be built near where the patients are, we did not think they needed to be built in hospitals, and so they were built in business parks. The first one opened in 1994 down in Hereford, it was 10 stations originally, then expanded to 13, the following year we opened one in central Birmingham, which had 21 stations which expanded to 31 pretty rapidly. We have gone on from there, opening a unit in the West of Birmingham with 31 stations, this was not in a business park but was in a converted Chip Fryer factory. We then opened two units, the last two being on hospital sites, the first in Kidderminster in February of last year (2002) with 13 stations, and lastly the City Hospital at 12 Stations. By now seven years have gone by, and the contract has come round again, and we have given it back to Fresenius again, apart from the Kidderminster Unit, which is run by Baxter.

What we set out to do was to select patients on where they lived, so we are trying to provide dialysis adjacent to where they lived, so geography was the most important criteria. We wanted to really try to include everyone, so we would take patients for their first dialysis with temporary lines, if they had blood borne viruses such as hepatitis, we would take holiday patients, other units' patients, and CAPD arresters. So there was no absolute exclusions, and there are still not any.

There are not many differences in the last seven years as to the difference in ages between the satellite unit and the base unit. When set out we decided we wanted to treat what we thought was proper, so patients should have three times a week dialysis. for around a minimum of four hours. We said we would re-use our dialysers on grounds of cost, as it was cheaper. We would use low flux dialysers, because they were cheaper, but we would use compatible membranes and we would monitor the whole process to make sure we were delivering the right sort of quality, or at least as good as what they got in the hospital.

So over the course of 13 years, back in 1990 we had 19 dialysis stations, we have now got 120. That's a massive increase! I don't think an increase in that size has been seen elsewhere.

So what I am going to tell you about now is the effect of increasing the capacity by that amount has had on things like the numbers of patients being treated, has it altered the way we practise, what has it done to patients in terms of how often are patients are admitted and how long do they stay in, and is the quality all right? When we started to do this, the first thing the commissioners (the people who are paying us) said we were creating renal failure. We were opening all these dialysis units, and patients were appearing and it was all our fault, and it was of course costing them a fortune. I tried to argue that in fact we had opened these units because the patients were there. Back in 1990 we were treating around 100 new patients a year, this has steadily increased over the years to around 200. I do not know if we are creating them or just finding them. The number of patients when we started off was 100 patients, now we have 800 patients on dialysis.

If we look at the take-on rate, the Renal Association says you should take on 80 new patients per million of the population per year for Caucasian patients, and about 240 per million of the population in the ethnic minorities. Back in 1991 we taking on around 100 new patients per million of the population per year. This has grown dramatically, we at our peak are now taking on about 180 new patients per million of the population. This is far and away above the level we are supposed to be taking on according to the guidelines, but there is no doubt these patients exist, and we are treating them. So I suggest the guidelines are probably wrong! These are levels that are seen in mainland Europe and in the United States. Many other parts of the UK are down a little.

So what about the treatment modality and the hospitalisation rates? Well as we started out we had too many patients on CAPD, and they were the wrong patients. What immediately happened when we started to open these units was our number of CAPD patients fell dramatically, over about three years from about 300 down to 150. It has stayed at 150 ever since. When we were looking at the number of admissions the patients were having, the number of admissions per patient per month over period has halved. Not only has the number of admissions halved, but the number of in patient days per patient per month has also halved for CAPD patients. What we think has happened is that initially patients were being admitted frequently and they were staying in hospital a long time because they were unwell on their CAPD. Once the people who shouldn't be on CAPD had moved on to Haemodialysis, those that were left were supposed to be on CAPD and therefore spent less time in hospital and had fewer admissions.

In terms of new treatment, initial treatment, for people first starting dialysis, back in 1993 we had no choice at all. If you had renal failure, you had CAPD, because we did not have any haemodialysis. Or very little. So 70% of our new patients started on peritoneal dialysis. With opening these new units introducing patient's choice, we now see that's fallen dramatically. Now 20 per cent of new patients start on peritoneal dialysis, and 80 per cent start on haemodialysis. In our pre-dialysis service, it is the CAPD nurses who offer our patients the choice. So it is not me, who knows nothing about PD. It is our PD nurses offering the choice. If we look at the other choices of dialysis on a graph, our CAPD programme climbing and when our satellite programme started and our CAPD programme declined, and we see a massive increase in satellite dialysis. We are approaching 400 patients now, with around 200 patients on hospital dialysis. We were very relieved when we opened our satellites, all these patients moved out, everybody back at base breathed a sigh of relieve. Of course the first thing that happened was the satellite patients were admitted, as they were unwell, which put extra pressure on the hospital unit because we had filled all the slots there. That created a bit of disquiet. To begin with about 20 per cent of our satellite patients were being admitted every month. As the years have gone by, now about 5 to 7 per cent of our satellite patients are admitted every month. So they are spending much more time at home and out of hospital.

Now quality was always going to be very important for us. When we set up these units we set up a quality insurance system. All the units have what is called ISO accreditation, which is an international standard for accreditation around management and clinical systems. We review every clinic and all its patients every month. This takes the form of multidisciplinary meeting involving consultants, nurses from both the satellite and from hospitals, dieticians and social workers, and the technical staff. The sort of thing we look at is what we call the clinical variances, i.e. something that has happened that should not have happened, and is there a trend? We look at the water quality, we look at every patient's results, and do they conform to the Renal Association standards? We look at our hepatitis immunisation programme; transplant listing, access problems, and diet problems, and their social work problems. What has happened in terms of the results we have achieved over the years, and this is the proportion of patients that have adequate dialysis as defined by the Renal Association, what we see is that largely is a year on year increase in our performance against the standard, but interestingly the biggest increase was in the hospital unit. We think that this was because those patients who were being under dialysed now have adequate dialysis and therefore their results have improved. There is now no difference in terms of adequacy of dialysis between the base and the satellites. The same is true of haemoglobin. This is the proportion of patients where the haemoglobin is greater than 10, again a steady increase in most of the satellites, and no real difference between the satellites and the base unit. If you look at the overall performance against all the standards, in the satellite units and the base there has been steady improvement most years.

When we first started out we thought we should like to ask the patients if they liked it. This is not very fair, because they are going to say their facilities are more superior because the Queen Elizabeth's Unit is a portakabin and these were brand new. It still is a portakabin at the QE. If you were travelling 100 miles and you now travel three obviously your travelling time is going to be less, and it is going to be more convenient. Therefore you will be more satisfied. It was quite good it came out that way because patients could have been very dissatisfied with it all. The other thing that worried us is if we tie ourselves into a contract with a private provider, will nothing change? Will there be no development and that isn't what has happened. So we have had a number of cost neutral service developments that means I have had not to pay, that the company has. So we no longer reuse our dialysers, we have now 100 per cent what's called high flux dialysis which is much more efficient. We have seen new types of dialysers being introduced and IT systems have been introduced into the units, and we have seen funding for clinical staff. There have also been some developments which we have had to pay for, haemodiafiltration is a newer type of dialysis which again is more efficient, and a thing called Lipoprotein Adsorption ,which is a new specialised sort of treatment, which we managed to introduce.

So that in summary, I think that the benefits of the public private partnership has been a very rapid expansion in haemodialysis capacity, in the absence of any capital money to do it. We have now got a number of units, which are sited much closer to where patients live, and they are of a very high quality. We have seen some cost neutral service developments and this programme has allowed improvements to occur back in the hospital unit. So the impact I think in conclusion, we have seen a massive increase in dialysis capacity. I'm not sure if I have created renal failure? Or just treated the patients who have just turned up? We have occasionally seen an increased pressure on our hospital facilities, but we have seen a marked reduction in admission rates for the satellite patients, who are now spending less days in hospital per year. We have improved the quality of dialysis. We have dramatically increased the number of renal nurses, we had 19 stations and enough nurses to look after them. Now we have 120 stations, and nurses to man them all. We may not employ them all, but they are all trained nurses. So overall I think this programme has been a fairly significant benefit for patients.

Thank you very much!

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