Download 5. Providing (Holiday) Temporary haemodialysis away

Specialised Services Policy:
(Holiday) Haemodialysis Haemodialysis Away From Base
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Executive Lead:
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Manager, Welsh Renal Clinical Network
Director of Finance
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Version: Consultation draft
Specialised Services Policy: (Holiday) Haemodialysis Away from Base
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Document History
Revision History
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Summary of Changes
0.1
Draft for consultation
Updated
to version
no.:
Date of next revision
Consultation
Name
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Date of
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Version
No.
Policy Statement
Background
Welsh residents who are routinely having unit
haemodialysis (UHD) may seek to do so for
short spells of care away from their normal base
and the cost of that care will be met by WHSSC.
This can be made necessary by unplanned
health or social events as well as planned events
such as holidays.
Non-Welsh residents may seek to come to Wales
on a planned basis and require dialysis whilst
temporarily resident or on leave. It is the policy
of the Welsh Renal Clinical Network to plan to
enable all units to have sufficient capacity to
enable this service to be offered although
continuation of routine care for local residents
will remain the priority. A charge to meet the
cost of the care will be made by the unit
haemodialysis provider for patients not
registered with a Welsh GP.
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Summary of
Access Criteria
For Welsh patients to be dialysed in Wales no
internal charging mechanism is required. This
will be managed through the Long Term
Agreements between the Welsh Provider Health
Boards and WHSSC/WRCN.
This means that there is no requirement for prior
approval for a Welsh patient going elsewhere in
Wales for holiday haemodialysis.
The application of this policy is for haemodialysis
patients who are registered with a Welsh GP.
Funding for Haemodialysis Away From Base is
available for locations where there are national
reciprocal funding arrangements and these are
identified within the policy.
Any requests for outside of this area will need to
be considered on an individual / exceptional
basis as part of WHSSC’s IPFR process.
Responsibilities
Patients or representative
The individual patients and families will be
responsible for initially identifying locations and
preferred unit for treatment.
The patient must try and give sufficient notice to
allow all arrangements to be made where
possible:
 Within Wales and the UK, minimum of six
weeks’ notice should be given wherever
possible.
 Outside of the UK, three months notice
should be given as a minimum to enable
the necessary clinical information and
tests.
Emergencies and urgent ‘short notice’ events will
be managed as quickly as possible.
Referrers
2 Inform the patient that this treatment is not
routinely funded outside the criteria in this
policy; and
3 Refer via the agreed pathway i.e. the Holiday
Dialysis Request Form, or an IPFR request
where there are unusual circumstances which
must be submitted to WHSSC IPFR team for
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processing.
The administration of the funding application and
the sharing of relevant clinical information
between units will be the responsibility of the
patient’s normal renal service provider.
WHSSC
The IPFR team will acknowledge receipt and
respond to routine applications using the agreed
checklist.
Complex or unusual requests will require
consideration at WHSSC IPFR panel
WHSSC will respond in time to enable the
referrer and patient to make their arrangements.
Routine applications will be reviewed and
decided upon within two weeks. Complex cases
will require longer, and minimum of four weeks
to enable discussion at monthly IPFR meetings.
WRCN
The WRCN will be responsible for reviewing this
policy and its implementation across Wales.
The WRCN will oversee the approval process for
funding for Welsh patients requiring DAFB within
Wales are within the countries covered by the
policy, advising on both routine and unusual
applications.
Work with providers in Wales as part of capacity
management to secure where appropriate,
capacity for holiday dialysis.
Other key
issues
Routine provision of haemodialysis to the local
population is the absolute priority. Whilst
recognising the importance and value of holiday
dialysis, access to a specific location or session
cannot be guaranteed.
Rarely, it may also be appropriate to advise a
patient that a period of suspension from the
renal transplant waiting list is necessary to
ensure the patient is not incubating blood borne
virus infections that would be accelerated by the
immunosuppression required for renal
transplantation.
Any absence over a month will require a clinical
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hand over of responsibility for care.
If a patient is away for a prolonged time from
their usual renal dialysis unit then they may not
be able to resume their original renal dialysis
slot on their return.
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Table of Contents
1. Aim.....................................................................................7
2. Scope..................................................................................7
2.1
Patient Group ................................................................7
3. Access Criteria .....................................................................8
3.1
3.2
3.3.
3.4
3.5
3.6
Countries covered by the policy .......................................8
Other Factors for consideration ...................................... 10
Exclusions ................................................................... 10
Exceptions................................................................... 10
Responsibilities ............................................................ 10
Individuals studying / working away from Wales .............. 11
4. Short notice requests ......................................................... 11
4.1
Emergencies ................................................................ 11
5. Providing (Holiday) Temporary haemodialysis away from base . 12
6. Putting Things Right: Raising a Concern ................................ 13
7. Equality Impact and Assessment .......................................... 13
8. Further Information ............................................................ 14
Appendix - Summary guide ..................................................... 15
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1. Aim
1.1
Introduction
Haemodialysis is the main dialysis modality used for patients with
End Stage Renal Disease. Typically this is undertaken during three
4 hour sessions a week either at home or at a haemodialysis unit.
This policy is for the planning of temporary haemodialysis Away
From Base (known as “Holiday Dialysis”). The policy applies to
residents registered to a GP in Wales.
The purpose of this document is to:

Set out the circumstances under which patients registered
with a Welsh GP will be able to access temporary Dialysis
Away From Base (DAFB or Holiday Dialysis) services;

Clarify the referral process; and

Define the criteria that patients must meet in order to access
treatment.
And

Provide guidance to units in Wales in providing (Holiday)
Temporary haemodialysis away from base to both Welsh and
non-Welsh residents.
1.2 Relationship with other Policies and Service
Specifications
This document should be read in conjunction with the following
documents:

All Wales Policy: Making Decisions on Individual Patient
Funding Requests (IPFR).
2. Scope
1. Purpose
2.1
Patient Group
All patients registered with a Welsh GP who are undertaking
haemodialysis either at home or at a haemodialysis unit.
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3. Access Criteria
3.1
Countries covered by the policy
Patients will not be expected to pay for DAFB within the United
Kingdom (UK). If a patient is planning to go abroad there are
different arrangements as to whether patients will need to pay
which depends on the country. In line with the national guidance
the NHS will not refund travel or accommodation costs connected to
renal dialysis treatment abroad.
Member States of the European Economic Area and
Switzerland
The European Economic Area (EEA) is a free trade zone between
countries of the European Union (EU), Iceland, Norway and
Liechtenstein. The regulations on access to healthcare in the EEA
also apply to Switzerland.
The European Health Insurance Card (EHIC) replaced the old E111
in 2006. The EHIC permits access to state healthcare at reduced
cost and sometimes free of charge. It covers treatment that is
needed to allow continuation of stay until planned return. It also
covers treatment of pre-existing medical conditions. It does not
cover elective treatment.
Any person who is ordinarily resident in the UK, and is of British,
other EU/EEA or Swiss nationality, is eligible for an EHIC.
Application is available online and is free of charge via the official
EHIC application form. Possession of an EHIC is a requirement to be
able to receive “all necessary state funded treatment” free of
charge.
A European Health Insurance Card will be required. These can be
obtained via https://www.gov.uk/european-health-insurance-card.
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, Lichtenstein and Norway. Switzerland has agreed to
operate the same arrangements as the EU countries.
Within the European Economic Area (EEA):
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
State sector providers: Within the EEA patients can use
their EHIC card if the provider is within the state sector. The
EHIC will entitle the patient to renal dialysis for free or at a
reduced cost, but the patient will need to make arrangements
directly with the provider in advance of their visit. Patients
should take this opportunity to find out what contribution (if
any) is required under the health system of the country they
are visiting.
Patients must have a valid passport and EHIC card.

Private sector providers: If there is no space available or
no local state provider, then NHS Wales will fund unit
haemodialysis at an independent / private sector provider.
Outside of Member States of the European Economic Area
and Switzerland
Reciprocal / bilateral agreements
There are other countries and territories outside of the EEA where
there is some form of reciprocal arrangement which is variable in
cover.
Patients visiting any of these countries should be able to access
renal dialysis for free or at a reduced cost. Again, patients must
make arrangements for the renal dialysis directly with the provider,
in advance of treatment.
Different countries require different proofs of identity and/or
residency. Further information about which countries the UK has
reciprocal healthcare agreements with and how to access treatment
in those countries can be found here:
http://www.nhs.uk/NHSEngland/Healthcareabroad/countryguide/No
nEEAcountries/Pages/Non-EEAcountries.aspx
Other countries
Patients will have to fund their own renal dialysis if travelling to a
country, outside of the EEA with which the UK has no reciprocal
agreement. Reimbursement is not available in these circumstances.
Patients may be able to apply for funding via the IPFR process on an
exceptional basis for payment of any renal dialysis outside of the
EEA or reciprocal countries. An example of an exceptional case
would be a patient who is to receive NHS funded care in a nonreciprocal country and will require renal dialysis during their stay
whilst they receive this treatment.
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3.2
Other Factors for consideration
Duration
Up to four weeks maximum away from base in one period will be
routinely agreed. Greater durations will require further
consideration to ensure that the clinical management of an
individual is clear and that matters such as Transplant Waiting List
status are clarified.
Financial limits
Charges associated with (holiday) haemodialysis have remained
relatively unchanged over the past three years both within and
outside of Wales.
At present, there is no cap placed on sessional price due to variation
in prices dependent upon location. However, charges above £250
per session will be scrutinised to seek assurance that more
affordable options are not available.
3.3. Exclusions
This policy is only for adults registered with a Welsh GP.
3.4
Exceptions
If the patient does not meet the criteria for treatment, but the
referring clinician believes that there are exceptional grounds for
treatment an Individual Patient Funding Request (IPFR) can be
made to WHSSC under the All Wales Policy for Making Decisions on
Individual Patient Funding Requests (IPFR).
If the patient wishes to be referred to a provider out of the agreed
pathway, an IPFR should be submitted.
3.5
Responsibilities
The patient / family / carer will:

Identify the location and preferred unit;

Initiate contact with the preferred unit to determine if space is
available for desired times;

Advise their home unit of availability.
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The referring (Welsh) unit will:

Inform the patient that this treatment is not routinely funded
outside the criteria in this policy;

Discuss the DAFB unit’s service with the patient;

Advise the patient of any risks including discussion about
emergencies and transplant status whilst away;

Confirm that there is the need for a funding agreement with
WHSSC for the treatment;

Submit a Holiday Dialysis request form or an IPFR request;

Where possible, there should be a period of at least six weeks
between the date of application and holiday.
All referrals must be made with a completed Holiday Dialysis
form (Annex X) which must be authorised by the patient’s
regular Consultant Nephrologist.

The WHSSC IPFR Team will:

Acknowledge receipt of application;

Routine applications compliant with the national policy will be
approved using the agreed checklist;

Unusual / complex cases to be discussed with WRCN Manager
for advice and guidance;

Processing of applications will be done in a timely manner to
avoid delay.
3.6
Individuals studying / working away from Wales
There will be some individuals who through the circumstances of
work or education will need semi-permanent but flexible
arrangements e.g. Term time haemodialysis in England or dialysis
near location of employment Monday to Friday. This will require an
application via the IPFR process and will need to include a clear
explanation on governance and responsibilities.
4. Short notice requests
4.1
Emergencies
It is understood that emergencies happen which may mean little
notice. In such circumstances, the policy can be applied
retrospectively.
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Examples


Delay in return journey due to unforeseen circumstances
means that additional haemodialysis is required.
Unforeseen family emergency requires urgent travel.
In these circumstances, the Welsh haemodialysis unit will liaise with
WHSSC on your behalf.
5. Providing (Holiday) Temporary haemodialysis away from
base
Where possible, units should look to offer temporary haemodialysis
to Welsh and non-Welsh patients. However, providing routine
chronic and acute haemodialysis to local residents remains the
priority and units should monitor capacity plans regularly.
Holiday dialysis should only be offered when there is sufficient
capacity in any given period and cancellation once booked should be
avoided wherever possible.
Blocks of greater than two weeks should not be routinely approved
as part of holiday haemodialysis. This is to allow access to the
facility for as many patients as possible who are seeking holiday
haemodialysis, particularly during popular periods.
Holiday and second homes
There will be circumstances where some patients who are nonWelsh residents have holiday homes and who will seek to undertake
haemodialysis at a Welsh Unit.
It is recommended that each process is reviewed on individual merit
but this should have some structure and agreed frequency. The
practicalities of providing ad hoc chronic dialysis for non-permanent
residents, if not planned, presents significant challenges for units.
It is proposed that routinely, such patients will only be allowed four
weeks in a 12 month period. This is to allow fair access to other
visitors.
Turning up for dialysis without prior agreement could cause
confusion around care and treatment management and must be
avoided wherever possible. In such circumstances, emergency
treatment will be provided and the patient advised to return to base
unit.
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6. Putting Things Right: Raising a Concern
Whilst every effort has been made to ensure that decisions made
under this policy are robust and appropriate for the patient group, it
is acknowledged that there may be occasions when the patient or
their representative are not happy with decisions made or the
treatment provided. The patient or their representative should be
guided by the clinician, or the member of NHS staff with whom the
concern is raised, to the appropriate arrangements for management
of their concern:

When a patient or their representative is unhappy with the
decision that the patient does not meet the criteria for
treatment further information can be provided demonstrating
exceptionality. The request will then be considered by the All
Wales IPFR Panel.

If the patient or their representative is not happy with the
decision of the All Wales IPFR Panel the patient and/or their
representative has a right to ask for this decision to be
reviewed. The grounds for the review, which are detailed in
the All Wales Policy: Making Decisions on Individual Patient
Funding Requests (IPFR), must be clearly stated. The review
should be undertaken, by the patient's Local Health Board;

When a patient or their representative is unhappy with the
care provided during the treatment or the clinical decision to
withdraw treatment provided under this policy, the patient
and/or their representative should be guided to the LHB for
NHS Putting Things Right. For services provided outside NHS
Wales the patient or their representative should be guided to
the NHS Trust Concerns Procedure, with a copy of the concern
being sent to WHSSC.
7. Equality Impact and Assessment
The Equality Impact Assessment (EQIA) process has been
developed to help promote fair and equal treatment in the delivery
of health services. It aims to enable Welsh Health Specialised
Services Committee to identify and eliminate detrimental treatment
caused by the adverse impact of health service policies upon groups
and individuals for reasons of race, gender re-assignment,
disability, sex, sexual orientation, age, religion and belief, marriage
and civil partnership, pregnancy and maternity and language
(welsh).
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The EqIA for this policy has concluded that there is no impact on
access on the grounds of the Equality Act (2010). A copy of the
impact assessment can be made available upon request.
8. Further Information
The Welsh Kidney Patients Association provides useful guidance and
advice on holiday dialysis and this can be sourced via the following
website:
http://www.wkpa.org.uk/holidayfacilities.html
The National Kidney Federation provides useful guidance on holiday
dialysis and this can be sourced via the following website:
http://www.kidney.org.uk/help-and-info/holidays/holidays-tips-hdhol
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Appendix - Summary guide
1. For haemodialysis patients registered with Welsh GP
Patient to identify location and unit. The NHS will then complete
the necessary applications and paperwork including tests, etc.
Within Wales
Duration allowed - More than four weeks / 12 sessions in one block
will require confirmation of clinical responsibility and whether this
transfers to new unit (temporarily).
Notice - Six weeks minimum (unless emergency)
Funding - Completely funded via the Welsh Renal Clinical Network
Outside of Wales
Duration allowed - More than four weeks / 13 sessions in one block
will require confirmation of clinical responsibility and whether this
transfers to new unit (temporarily).
Notice - Three months minimum (unless emergency)
Funding - Will depend on location:



Within European Economic Area and Switzerland – Fully
funded via Welsh Renal Clinical Network;
Where there are bilateral / reciprocal arrangements outside of
the EEA and Switzerland, funding can very from no support to
all funded via WRCN (e.g. Australia);
For all other countries, cost is fully with patient.
2. For patients not registered with Welsh GP wanting
(holiday) haemodialysis away from base in Wales
Duration - Routinely up to two weeks will be offered in a single
period. More than this will need to be carefully considered so as i.
not to jeopardise routine provision and ii. prevent other holiday
patients.
Frequency - not more than four weeks in a 12 month period in the
same location to allow opportunity for other visitors.
Funding - Will depend upon the individual’s residency whether this
is paid for by their health service or whether this is a direct
transaction between the individual and the Welsh dialysis provider.
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Approval of funding by patients health service will be required
before attendance to holiday dialysis unit.
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