1. Renal Association, CD Forum, Guy’s, March 2010 Roger Greenwood Lister Renal Unit Stevenage, UK Home Dialysis – Operational and Financial Aspects

2. 15% HD Patients at Home is Realistic Greenwood vs Raftery Renal Association, CD Forum, March 08

3. Growth of the UK dialysis population 1982-2002

4. UK Renal Registry 9 th Annual Report 2006 Fig 17.5 Prevalent patients, percentage by each dialysis modality

5. Survival on RRT – Lister Renal Unit 1999

6. Utilometer Cost Utility Analysis, USA Bell et al. Med Decision Making,2001, 21, 288

7. “GFR” I II III IV V Dialysis Initiation Dialysis Patients Remain in Stage 4/5 CKD Residual Renal Function

8. Time Frequency Delivering More Dialysis by Increasing: Power

9. Impact of Power: HEMO Trial (USA 2002)

10. TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training materials. This document is not intended to replace the NxStage User’s Guide or cartridge Instructions for Use. NxStage® is a registered trademark of NxStage Medical, Inc. TM0065 Rev B Gotch, 1999 Impact of Frequency: Standard Kt/V (stdKt/V)

11. Day-of-Week, Association with Mortality DOPPS study, 1996-2004DOPPS study, 1996-2004 18,000 patients in USA and Europe18,000 patients in USA and Europe All had 2 consecutive days without dialysisAll had 2 consecutive days without dialysis Death significantly higher after ‘long break’Death significantly higher after ‘long break’ Death from cardiovascular eventDeath from cardiovascular event Zhang H et al, American Society of Nephrology, Philadelphia, Nov 2008

12. I II III IV V In Centre?Home HD x 3 HD x 4 HD x 6 Transplant ‘GFR’ Replacement Therapy

13. Home HD - Distribution of time & frequency Guys &St Thomas, London, 09

14. TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training materials. This document is not intended to replace the NxStage User’s Guide or cartridge Instructions for Use. NxStage® is a registered trademark of NxStage Medical, Inc. TM0065 Rev B Mobile HD Machines – At Last! Home Travel

15. TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training materials. This document is not intended to replace the NxStage User’s Guide or cartridge Instructions for Use. NxStage® is a registered trademark of NxStage Medical, Inc. TM0065 Rev B NxStage: Simple-to-use supplies Drop-in, disposable cartridge Disposable Purification Pack Disposable Dialysate Sack Portable Fluids Can we afford daily dialysis?

16. Purification Pack (good for 6-12 weeks) Water Sediment Filter UV LightCarbon Resin KDF Media Dual-bed Resin X3 Mixed-bed DI Resin Ultra- filter X2 Ultra- pure Water 0.2 micron filter Dialysate Sack Purification Pack Sensor 1Sensor 2

17. TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training materials. This document is not intended to replace the NxStage User’s Guide or cartridge Instructions for Use. NxStage® is a registered trademark of NxStage Medical, Inc. TM0065 Rev B Similarities APD and NxStage APDNxStage Mobile cycler ‘Fully saturated’ dialysate Healthy membrane Dwell time High blood flow Low dialysate flow* 115-140 L lactate/wk100-180 L lactate/wk 7 divided doses5/6 divided doses Daily disposables * Different from traditional HD

18. Dialysis Reference Costs, 16 NHS Trusts, 2008 £ Centre HD23,868 Home HD (3 X weekly)12,948 PD20,805 Home HD brings less income to the Trust NHS Kidney Care, PbR Working Group, 2008

19. Home Dialysis – Operational Aspects Promote frequent dialysis to optimise health prospects Self-care first policy Self-care first policy Dialysis initiation with APD, including late presenters Dialysis initiation with APD, including late presenters 4.5 sessions weekly using traditional machines 4.5 sessions weekly using traditional machines 5.5 sessions weekly NxStage 5.5 sessions weekly NxStage Expect significant demand for mobile machines Expect significant demand for mobile machines NxStage NxStage Quanta Quanta Deka (Baxter) Deka (Baxter)

20. EAST OF ENGLAND SCG – Strategy and Capacity Plan - 2008 Sites for New Renal Units Identified Expansion of HD Stations by PCT

21. Assumptions in EoE Strategy and Capacity Plan 5% annual growth in dialysis (NSF 2004/5) 5% annual growth in dialysis (NSF 2004/5) 2.4% annual growth in transplant procedures 2.4% annual growth in transplant procedures 3.8% annual growth in functioning transplants 3.8% annual growth in functioning transplants PD up to national average (10.7% RRT) by 2015 PD up to national average (10.7% RRT) by 2015 10% HD patients self-caring on Home HD by 2015 10% HD patients self-caring on Home HD by 2015

22. Business case to Board of E&N Herts NHS Trust Scenario 1Scenario 2 Total Dialysis Annual Growth 5% 10% HD Patients Self Caring by 2015 PD increase to 15% all dialysis by 2015 Total Dialysis Annual Growth 5% Limit Home HD to 5 Patients PD continues to decline (current 9.7%) Assume 50% HHD patients will choose NxStage

23. 4/094/104/114/124/134/144/15 HD (all)365378392406422439458 HD (Centre) - CHD364369375381389399412 Pts/CHD station65.95.85.65.45.25 Total CHD stations required61636568727782 CHD stations required in new units in Beds and Herts 2591419 Patients treated in new units 1028497197 Total staff req. for CHD 712.517.720.829.3 Home HD191725334046 % HD patients at home0.32.44.36.27.89.110 Total staff req for HHD12.32.5 344 PD38455260677481 % Total dialysis on PD9.4101112131415 Total staff req. for PD233.54.55.255.5 TOTAL DIALYSIS PATIENTS403423444466489513539 Projected Patients and Extra Staff Required from 2009 - 2015 Scenario 1: Aspire to EoE strategy to promote home therapies

24. 4/094/104/114/124/134/144/15 HD (all) 365387410435461487516 HD (Centre) - CHD364382405430456482511 Pts/CHD station65.95.85.65.45.25 Total CHD stations required616570778493102 CHD stations reqd in new units in Beds and Herts 2714213038 Patients treated in new units 64077116154196 Total staff req. for CHD 316.322.63545.360 Home HD 1555555 % HD patients at home 0.31.31.21.1 11 Total staff req. for HHD 0.25 0.3 0.25 PD 38353230272523 % Total dialysis on PD 9.48.37.26.45.54.94.3 Total staff req. for PD 2221.751.51.41.25 TOTAL DIALYSIS PATIENTS 403423444466489513539 Projected Patients and Extra Staff Required from 2009 - 2015 Scenario 2: Current trends in dialysis case mix continue

25. Cumulative (extra) costs by year 2015/16 Scenario 1 – 10% HHDScenario 2 – Mainly CHD Pay 1,254,486 2,037,096 Consumables 1,093,293 502,730 Machine Lease Costs 175,478 112,893 Home Conversion 118,688 2,000 Pathology Savings -34,200 -3,040 Pharmacy Savings -79,639 18,011 Travel Savings -44,000 5,500 Holiday Dialysis Saving -56,700 -5,040 Total Non-Pay 1,172,919 633,054 Total Revenue Costs 2,427,404 2,670,150 GBP *before depreciation and capital charges

26. Cumulative (extra) costs by year 2015/16 Scenario 1 – 10% HHDScenario 2 – Mainly CHD Pay 1,254,486 2,037,096 Total Non-Pay 1,172,919 633,054 Revenue Costs (excl) 2,427,404 2,670,150 New Dialysis Centres Depreciation over 40 yr 200,000 450,000 Capital Charges (3.5%) 280,000 630,000 Total Revenue (incl) 2,907,404 3,750,150 Capital Build (new centres) 2,000,000 6,000,000 GBP

27. Reimbursement (PbR), NHS Kidney Care, June 2009 Hospital HD£28,860 Satellite HD£22,152 Home HD (4X weekly)£17,264 CAPD£18,980 APD£21,900 All HD LC02A£23,868 All PD LC04A£20,805 But: Self –Care at home brings less income to the Trust Need to test whether Trust can afford a home dialysis programme by feeding these reimbursement rates into the model

28. Cumulative (extra) costs by year 2015/16 Scenario 1 – 10% HHD Scenario 2 – Mainly CHD Compare Scenarios 1 and 2 Extra Revenue (expenditure) 2,907,404 3,750,150 842,746 Income (PbR) 12,907,400 13,369,500 462,100 Effective Savings to Trust 380,646 Capital Build (new centres) 2,000,000 6,000,000 4,000,000

29. Business Case – bottom line Self-Care will result in costs savings of £842,746 p.a. by 2015 Self-Care will create a revenue deficit of £462,100 Current PbR tariffs likely to dampen the enthusiasm Denoument: Challenge traditional funding model Patient advocacy - Kidney Alliance, NKF Work with SCGs, NHS Kidney Care, PbR team at NHS Pull levers - Payment for Performance, Patient Choice

30. Kidney Alliance, 09/10 Mission Statement re Home Therapies World Kidney Day, March 2009 –Home HD featured in Commons Terrace reception Questions in Commons, Lords, through 09/10 Patient presence in SCG Strategy meetings

31. DH, Payment by Results, Draft Guidance, December 2010 Paras 283-292: Renal Non-Mandatory Prices for 2010/11 £ £ Centre HD144 session22,464annum Home HD 144 session33,696 annum CAPD/APD48 day17,520annum....this recommendation is intended to incentivise an increase in provision of home dialysis options.......sessional payment since patients may dialyse 4 or 5 session a week.......we encourage commissioners, where there are low levels of provision, to work with their providers to create effective choices… DH PbR Team 17 th Dec 2009

32. Kidney Alliance Response to PbR Consultation, Jan 10 Plea for a soft landing for some Trusts Don’t over-incentivise HHD, suggest parity with CHD Clarify tariff includes home conversion costs Address Assisted PD (aAPD) Clarify drug in(ex)clusions – anaemia, bone-mineral-metab ‘Unbundling’ exposes Conservative Mgnt, Pre-Dial, Transp w/u, f/u ‘Unbundling’ exposes dietetics, SW and counselling

33. Commissioning for Quality and Innovation (CQUIN)...CQUIN monies linked to this indicator will be at risk of being withdrawn if non-submission of data or failure to achieve interim targets... EoE SCG 15 th Feb 2010 CQUIN part of ‘Payment for Performance’ scheme Proportion of provider income conditional on agreed goals Worth 0.5% contract value in 09/10 rising to 1.5% in 10/11 EoE Renal CQUIN for 2010/11 ‘Providers in EoE to achieve a 10% Home HD rate by April 2015’

34. Summary Rejuvenation of interest in Home HD (HHD)Rejuvenation of interest in Home HD (HHD) HHD chief aim is to deliver more (frequent) dialysisHHD chief aim is to deliver more (frequent) dialysis Mobile machines will be in demandMobile machines will be in demand HHD insufficiently incentivised with traditional reimbursementHHD insufficiently incentivised with traditional reimbursement PbR rates recently proposed will incentivise HHDPbR rates recently proposed will incentivise HHD HHD can also be incentivised through Payment by PerformanceHHD can also be incentivised through Payment by Performance At least 2 English regions have adopted HHD for their renal CQUINAt least 2 English regions have adopted HHD for their renal CQUIN