1. Walking the walk or just talking the talk: how do we make progress?
Richard Fluck
Date: 16th March 2016

2. The strategic challenge
Numbers requiring RRT are growing
Population is older with more comorbidities
Home therapies are in decline – especially PD
Economic downturn has implications for healthcare expenditure
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3. UK Renal Registry 16th Annual Report
Figure 2.2. Growth in prevalent patients by treatment modality
at the end of each year 1997–2012
UK Renal Registry 16th Annual Report
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4. Falling PD UK Renal Registry 16th Annual Report
Figure 2.9. Modality changes in prevalent RRT patients from 1997–2012
UK Renal Registry 16th Annual Report
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5. Home Therapies Richard Fluck
Rise in home HD
Figure Detailed dialysis modality changes in prevalent RRT patients from 1997–2012
* Scottish centres excluded as information on satellite HD was not available
UK Renal Registry 16th Annual Report
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6. Variation UK Renal Registry 16th Annual Report
Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite
or home haemodialysis by centre on 31/12/2012
∗Scottish centres excluded as information on satellite HD was not available.
No centres in Northern Ireland have satellite dialysis units
UK Renal Registry 16th Annual Report
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7. Home Therapies Richard Fluck
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9. Home Therapies Richard Fluck
Ambitions
3. Self-management: All people with kidney disease are offered as much information as they would like in order to understand and manage their condition.
4. Person-centred care: Care is centred on the person, taking into account individual needs and preferences, quality of life, symptom burden and the presence of co-existing medical conditions.
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10. Home Therapies Richard Fluck
6. Preparation and Choice: All people approaching end-stage renal disease, or moving from one type of treatment for end-stage renal disease to another, understand and are given sufficient time and support to prepare for a treatment that is suitable for them, chosen from the full range of options.
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11. Home Therapies Richard Fluck
The House of Care
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12. Commissioning of RRT The base

13. Home Therapies Richard Fluck
Key principles
Ensure patient pathway integrity
Enable CCGs to better allocate their resources efficiently
Move to accountability linked to population outcomes
Improve financial incentives for commissioners and providers
Offer value across the system and to individuals
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14. But at all times our guiding principle will be: walk in the shoes of the people we serve. Think like a patient, act like a taxpayer
Simon Stevens, April 2014, Newcastle

15. Home Therapies Richard Fluck
Reimbursement
Short term
Mitigate short term issues
Long term
Process of internal and external consultation
Review of pricing engine
Challenge re reference costs
Renal specific – strategic review of reimbursement structure
Incentives?
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16. Service specifications
Modality specific
Clear pointers to shared care
CQUIN re shared care
Better metrics
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17. Home Therapies Richard Fluck
Specialised status
Advantages
High costs and complexity
Disadvantages
Reimbursement structure
One aspect of patient pathway
Collaborative solution
Reintegrate patient pathway
Plan A, B and C
Reestablish provider networks driven by peer review
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18. Patient participation The left hand wall

19. Home Therapies Richard Fluck
Engaging the patient on multiple levels
Carmen, Health Affairs Feb :232
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22. Integration Care delivery Location Dependent Independent Home AAPD
?AHHD PD
HHD (>4x week)
In-centre
HD (3x week)
Self care HD (3-7x week)

23. Skills, knowledge and confidence matrix
Education, self-awareness, changing beliefs about patient‘s role, self-management support, skills development
Skills, knowledge and confidence matrix
Interventions
High
(Clinician support for patient activation)
CSPAM scores
Changing beliefs about clinician’s role, leadership, skills training e.g. MI, communication, coaching
Low
Low
High
PAM scores (patient activation)
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24. Measurement and improvement: the ceiling

25. Home Therapies Richard Fluck
Data
Numbers
Organisational process
Outcomes
Clinical
Patient centred
Value
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26. Survival by Dialysis Modality—Who Cares?
All-cause patient mortality rates, overall and by modality,
US Renal Data System ESRD Database, Adjusted for age, sex,
race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis.
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CJASN 2016 ePub Martin B. Lee* and Joanne M. Bargman†

27. Home Therapies Richard Fluck
Value
The Renal Alliance: UKRR, PHE, CVIN, RightCare and Commissioning for value
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28. Home Therapies Richard Fluck
Recovery time after HD
Lindsay Clin J Am Soc Nephrol Sep;1(5):952-9.
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29. Home therapies: Patient Quality Markers - Restless legs and depression
Jaber Clin J Am Soc Nephrol 6: 1049–1056, 2011 (FREEDOM study group)
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30. The right hand wall: professionals

31. What do the professional stakeholders need to offer?
Leadership: vision, courage and commitment
Individual
Organisational
Expertise
Drive improvement – e.g. quality improvement
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32. Home Therapies Richard Fluck
Home therapies QI
KQuiP
Stakeholder led
RA, BRS, BKPA, NKF, KRUK, BTS
NHS England and home nations
Strategic alliance to foster QI
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33. Home Therapies Richard Fluck
Improving the pathway
Establish an MDT to assess new starters
Consider legibility
Shared decision making –
?Physician led PD insertion
Training
Late presentation
Perit Dial Int May-Jun; 33(3): 233–241.
Dialysis Measurement, Analysis and Reporting (DMAR: Oliver Medical Management, Toronto, ON, Canada)
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34. Home Therapies Richard Fluck
Home haemodialysis
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35. Home Therapies Richard Fluck
Summary
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36. Home Therapies Richard Fluck
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