1. Cheaper Kidney Care Vs. Redesigning kidney services to improve patient choice, shared decision making and deliver NHS costing savings

2. Impact of economic climate on pricing PD patient numbers have fallen consistently during a period of increased economic pressures without price increases Price decreases linked to initiatives to increase PD patient numbers have failed to drive growth in PD and have lead to regional price variations and differences in equity of access to advanced PD solutions List prices for Baxter PD solutions have not increased to reflect increased cost of manufacture and distribution Therapy prices include fluids, machines, Baxter and 3 rd party ancillary products, technical and customer service support The cost of APD to the NHS (staff, disposables and overheads) is still 35% less than in centre HD

3. Baxter’s response to the National PD tender Baxter’s response has been based on the tender specification and also the market evolution of Peritoneal Dialysis therapy in England over the past several years. – Over the past 5 years Baxter has endeavoured to hold or reduce prices whilst there has been a continual decline in the number of peritoneal dialysis patients. – Due to the high level of service support required to maintain patients at home we have been unable to leverage our costs and in real terms over the last 5 years we have experienced year on year increases in the costs of infrastructure and of the operation necessary to maintain a high level of patient and renal unit support. – Baxter’s response reflects what we believe is a fair cost of providing PD. Redesigning kidney services to improve patient choice, shared decision making and deliver NHS costing savings – what is the role of PD as a clinical and cost effective therapy?

4. “Shared decision making is the key to good outcomes for people with advanced kidney disease. The work of NHS Kidney Care is making that a reality for more people and my goal is that 100 percent of people have choice”. 1 Open patient choice should be a key step as part of shared decision making. If a patient chooses home therapies, focus on how to make that work, rather than on obstacles. 2 At least 50% of patients starting on dialysis will be eligible for home treatment, 60% of patients eligible for home treatment will choose a home treatment if they are given appropriate education. 3 Shared decision making: what does good look like? 1.Dr O’Donoghue PRESS RELEASE 24 May 2010 NHS Kidney Care welcomes Secretary of State’s commitment to home dialysis 2.Improving Choice for Kidney Patients: Five STEPS toolkit to Home Haemodialysis NHS Kidney Care February 2010 3.Renal Association Working Party on Peritoneal Dialysis Final Report 18.11.09 In the partnership or shared decision making approach, the practitioner genuinely does not disapprove of the decision the patient eventually chooses - it is the discussion that is important

5. 5 The patient pathway Established Renal Failure (ERF) Renal Replacement Therapy (RRT) Home Conservative Care In - centre PD HHD Transplant Benefits of PD as an initial modality? 1.Initial survival advantage 2.Preservation of vascular access 3.Preservation of RRF If PD is no longer possible, a switch to Home Haemodialysis (HHD) would be a logical treatment option for patients preferring home- based care

6. Costs and reimbursement The treatment of Established Renal Failure (ERF) is disproportionately costly using up to 2% of the NHS budget for less than 0.5% of the population 1. CodeDescriptionTariff (£) per session Tariff (£) per day LC01AHaemodialysis/Filtration on patient with Hepatitis B 19 years and over152 LC02AHaemodialysis/Filtration 19 years and over144 LC03APeritoneal Dialysis on patient with Hepatitis B 19 years and over 48 LC04APeritoneal Dialysis 19 years and over [1] 48 1. National Service Framework for Renal Services: Part One – Dialysis and Transplantation. Department of Health. 2004 2. Baboolal K et al The cost of renal dialysis in a UK setting—a multi centre study Nephrol Dial Transplant (2008) 23: 1982–1989 Annual cost of dialysis modalities 2 HD main unitHD SatelliteAPDCAPDHHD Annual cost of dialysis £35,000£32,500£21,600£15,500£20,700 Non-mandatory tariff 2010/11 Aim to move to a mandatory “best practice” tariff in 2011/12. Best Practice Tariffs are specifically priced and structured in order to promote quality of care and value for money Erythropoiesis Stimulating Agents (ESAs) and Patient Transport Services (PTS)/Healthcare Travel Scheme (HTCS) costs excluded

7. If just 30% of dialysis patients were treated at home it could save the NHS over £100 million Joseph, J and Laplante, S. NDT Plus (2010) 3 (suppl 3) iii91 (Sa182) Data projected forward to 2013 from 2008 Renal Registry Report

8. Increasing the number of dialysis patients treated at home from 15% in 2010 to 40% in 2014 could result in an annual cost saving of £12,459,644 in 2014 and cumulative cost savings of £31,370,101 over the 4 years Data on file using costs adapted from Baboolal K et al (2008) The cost of renal dialysis in a UK setting—a multicentre study Nephrol Dial Transplant 23: 1982–1989 Modelling the impact of dialysis modality mix on the cost to the Renal Unit of providing Renal Replacement Therapy (RRT) Using patient numbers and modality mix from Renal Units in London Home Dialysis Modality20102014 HHD1.2%10% CAPD5%11% APD8.8%19%

9. Impact of dialysis modality mix and reimbursement on Renal Unit contribution for provision of Renal Replacement Therapy Using patient numbers and modality mix from Renal Units in London Contribution under Best Practice Tariff Contribution under current reimbursement If there are no changes in modality mix over the next 5 years the introduction of the Best Practice Tariff may lead to substantial losses in contribution. Increasing the number of dialysis patients treated at home to 40% by 2014 could lead to a continuation of positive contribution for the Renal Unit Data on file using costs adapted from Baboolal K et al (2008) The cost of renal dialysis in a UK setting—a multicentre study Nephrol Dial Transplant 23: 1982–1989

10. Incentivising PD growth through Clinical KPI’s Clinical KPI’s developed by the Clinical Procurement team to support the PD commissioning pathway Sliding scale discount linked to quality Reported via monthly commissioners report National PD tender KPIMeasurement Incident take on to PD % of incident dialysis patients choosing PD Prevalent growth of PD programme % of patients remaining on PD at day 90 Demonstrate funding and infrastructure for aAPD

11. Commissioning for Quality and Innovation (CQUIN) targets: Incentivising home dialysis Example of a recent business case – Unit has CQUIN to grow PD patient numbers by 10 by end of 2011 – The PD service is run by one full time PD nurse (Band 7), resulting in a nurse to patient ratio of 1:33 – Risk of forfeiting associated CQUIN payment as current PD staffing levels insufficient to support growth in the PD programme – The National Renal Workforce Planning Group (2002) recommended 1 whole time equivalent per 20 community dialysis patients with a skill mix of 5 nurses: 1 HCA – Increasing % dialysis patients treated with PD from 16% to 26% would save the trust £230,639 – Following presentation of business care the trust identified budget to recruitment of one additional nurse to enable the PD programme to expand

12. PD patient numbers have fallen consistently during a period of increased economic pressures without price increases Price decreases linked to initiatives to increase PD patient numbers have failed to drive growth in PD PD offers a number of benefits as an initial modality? Initial survival advantage Preservation of vascular access Preservation of RRF If PD is no longer possible, a switch to Home Haemodialysis (HHD) would be a logical treatment option for patients preferring home- based care Incentivising PD growth Cost saving to the NHS Commissioning for Quality and Innovation (CQUIN) targets Clinical KPI’s linked to NPDT Excel model and App available to model local impact of modality mix and reimbursement Summary