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<p>NHS England commissions dialysis services at a national level as a specialised
service, setting out what providers should have in place to deliver dialysis care,
including at home, as part of its remit to deliver specialised services. National
Commissioning supports equity of access to high quality dialysis care. The service
delivery contract sets out that the principle should be that home haemodialysis should
always be an option for patients and that solutions should be sought to overcoming
barriers that might prevent this. Decisions should be made on an individual basis
but in general, patients suitable for home haemodialysis will be those who:</p><p>-
have the ability and motivation to learn to carry out the process and the commitment
to maintain treatment;</p><p>- are stable on dialysis;</p><p>- are free of complications
and significant concomitant disease that would render home haemodialysis unsuitable
or unsafe;</p><p>- have good functioning vascular access;</p><p>- have a carer who
has (or carers who have) also made an informed decision to assist with the haemodialysis
unless the individual is able to manage on his or her own; and</p><p>- have suitable
space and facilities or an area that could be adapted within their home environment.</p><p><strong>
</strong></p><p>NHS England’s renal services specifications can be found at the following
link:</p><p> </p><p><a href="http://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-a/a06/"
target="_blank">www.england.nhs.uk/commissioning/spec-services/npc-crg/group-a/a06/</a></p><p>
</p><p>NHS England Specialised Services use the Renal Registry Annual Report and data
to support work with local dialysis services so they are aware where variation exists
so this can be considered and addressed.</p><p> </p><p>The Atlas of variation, published
by Public Health England in 2015, showed that for clinical commissioning groups (CCGs)
in England, the percentage of dialysis patients who were receiving dialysis in the
home (home haemodialysis and peritoneal dialysis combined) ranged from 4.1% to 44.0%
(10.6-fold variation). When the seven CCGs with the highest percentages and the seven
CCGs with the lowest percentages are excluded, the range is 7.6–33.7%, and the variation
is 4.4-fold. Variation by parliamentary constituency is not available.</p><p> </p><p>Reasons
for the degree of variation observed include differences in:</p><p> </p><p>- access
to, and timely assessment by, a specialist kidney unit – working with patients to
help them decide between treatments takes time, but in some areas 30% of patients
are not known to their kidney team for even 90 days before they start renal replacement
therapy;</p><p>- access to a multi-professional team, including staff who regularly
support patients undertaking home dialysis; and</p><p>- levels of support for people
undertaking home dialysis to help them maintain their independence, including access
to respite in-centre dialysis.</p><p> </p><p>The Atlas can be found at the following
link:</p><p> </p><p><a href="https://fingertips.phe.org.uk/profile/atlas-of-variation"
target="_blank">https://fingertips.phe.org.uk/profile/atlas-of-variation</a></p><p><strong>
</strong></p><p>According to the latest data from the UK Renal Registry (UKRR), there
were 1,195 patients receiving home dialysis in the United Kingdom in 2014, 1,175 patients
in 2015; and 1,256 patients in 2016. The UKRR collects, analyses and reports on data
from 71 adult and 13 paediatric renal centres. Participation is mandated in England,
via the national services specification published by NHS England.</p><p> </p><p>The
latest report from the UK Renal Registry can be found at the following link:</p><p>
</p><p><a href="http://www.renalreg.org/publications-reports/" target="_blank">www.renalreg.org/publications-reports/</a></p><p><strong>
</strong></p><p>No specific assessment of the cost to the National Health Service
of the provision of dialysis services in a patient’s home compared to a clinical setting
has been undertaken. In its assessment of the evidence regarding cost, the National
Institute for Health and Care Excellence (NICE) set out in its guideline, ‘Renal Replacement
Therapy and Conservative Management’, published in October 2018, that there is uncertainty
in current UK dialysis costs, but they may be lower at home. The committee acknowledged
that these treatments can have very different effects on lifestyle and recommended
patient choice. The NICE guideline can be found at the following link:</p><p><strong>
</strong></p><p><a href="http://www.nice.org.uk/guidance/ng107/resources/renal-replacement-therapy-and-conservative-management-pdf-66141542991301"
target="_blank">www.nice.org.uk/guidance/ng107/resources/renal-replacement-therapy-and-conservative-management-pdf-66141542991301</a></p><p><strong>
</strong></p><p>Regarding the benefits of home dialysis, there is good evidence that
home dialysis therapies offer advantages for suitable patients. The limitations of
thrice weekly standard in-centre haemodialysis have been recognised in recent years.
However, it is very difficult to separate the effect of different case mix, the most
up to date and comprehensive data does not show a survival difference between patients
who received more frequent versus thrice weekly (standard regimen) haemodialysis.</p><p>
</p><p>The advantage of self-care haemodialysis includes not only those related to
control and convenience but also the opportunity to conduct more frequent or longer
sessions to optimise health prospects. The introduction of smaller more portable haemodialysis
machines also provides opportunity for travel for employment or holidays. Furthermore,
these therapies are cost effective in the UK when compared with hospital treatments
and have been demonstrated to be safe. Information regarding a reduction in travel
times and reliance on other medicines is not available.</p><p> </p>
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