Managing Dialysis Patients Ineligible for NHS Treatment. Paul Warwicker Lister Renal Unit

Transcription

1 Managing Dialysis Patients Ineligible for NHS Treatment Paul Warwicker Lister Renal Unit

2 Nye Bevan Rejoice at the opportunity to practice a civilised principle One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill informed and some of it deliberately mischievous... The whole agitation has a nasty taste.

3 Case History 1 Mrs A 2009/10 Declined a regular slot on HD (family unwilling or unable to meet her NHS costs) Over several months 8 emergency admissions to hospitals in our area, usually at night, usually in extremis, frequently requiring haemofiltration on ITU Annualised costs to NHS in excess of 90K Following lobbying of our local MP (Barbara Follett), Andy Burnham and Ann Keen patient given a regular slot. Doing well, still awaiting decision from Home Office

4 Case History 2 Mrs K 47 year old from Republic of Djibouti. Resident at Yarl s Wood Detention Centre. Presented soon after Mrs A. Given a slot on programme. Several weeks into treatment, intercepted by Home Office officials and forcibly repatriated to Djibouti. 1 renal unit in Djibouti access severely restricted and expensive

5 The UK Estimated 500, ,000 refused asylum seekers in UK (British Red Cross/ Oxford Uni) What is the entitlement to healthcare throughout the asylum process? Charges Access to dialysis

6 DH Guidance Charges for treatment Any person who has made an application for asylum (or an application for leave to remain under Article 3 of the ECHR on protection from serious harm grounds) which has not yet been determined, including all appeals, is exempt from charge for all hospital treatment, including dialysis. They should be subject to the same waiting lists as everyone else; based on clinical need

7 DH Guidance Charges for treatment Failed asylum seekers, and those making applications to remain as residents may not be exempt from charges until they have been accepted or accumulated 12 months lawful residence whilst awaiting a decision

8 DH Guidance immediately necessary and urgent treatment Anyone who a clinician considers to be in need of immediately necessary treatment must receive it regardless of charges, and it is usually inappropriate or impossible to request charges before treatment. Therefore the payment is arranged after treatment and if the person cannot pay then the debt is written off. Only when the clinician considers the treatment to be non urgent should it be denied if the patient does not pay in advance.

9 The white paper The white paper will force increasing commercialisation and competition. Vulnerable members of society will be the first to feel the pinch (YPHR)

10 The US 11 million undocumented residents in US 6000 have ESRD 400,000 US citizens undergo regular HD Annual cost of HD is $72K per annum for eligible, and $200K per annum for undocumented emergency treated patients.

11 The US model COBRA passed in 1986 explicitly prohibits the use of federal funds for covering undocumented residents for non emergency services such as dialysis Some states (California and Massachusetts) use State allocated Medicaid or local taxes to fund thrice weekly HD for ineligible patients. Most dont. NEJM 364;23 Raghavan R. & Nuila R. Survivors Dialysis, Immigration and US Law

12 The US Model The patients sits in a special row of dialysis patients in ER, waiting for their blood results. The line begins to swell at 6am Attend every 2 days Only receives HD if potassium is greater than 6 Diaz Ruiz didn t want to talk about money as he received dialysis at UMC Thursday. I only want to live, he wept.

13 The Lister Used to be relatively straight forward to establish HD treatment. Introduction of tariff HD and widespread utilisation of NHS numbers have exposed these patients. Tried US model of emergency HD proved to be logistic headache lack of space, lack of staff, capacity constraints. Proved much cheaper, much simpler (and more humane) to offer a regular slot.

14 Currently In the last year alone we have 4 ineligible patients 2 are dialysing, 1 is poised to start and 1 has voluntarily returned home (Morocco) Potential cost to Trust - 100K per annum No ineligible patient has ever paid for treatment charging is a red herring Trust can write off the debt but will not be reimbursed by the PCTs Context: 4.2% reduction in dialysis tariff (approx 7% with inflation cut in dialysis income), 6-7% annualised CIPs, our Trust has announced 20% reduction on consultant FTEs over the next year

15 Summary Basic humanity - We need a consensus statement concerning the obligation of Trusts to provide planned renal replacement therapy to all ineligible patients pending immigration status decisions. Dialysis is an emergency treatment. Recognition The costs of these patients should be bourn centrally or the financial pressure on Trusts will lead to obfuscation regarding treatment and threaten the financial viability of renal services Audit (anonymised) The number of patients and approach to treatment