Campaign for equity of tariffs for remote consultations
This is just a short brief to let you know about the ongoing work the UK Green Nephrology group has been undertaking on tariffs for remote clinic consultations.
Many renal units operate over wide geographical areas, providing specialist services for populations far beyond their own hospital’s immediate catchment area. Intuitively, for such a results-driven specialty, the concept of remote clinic consultations – either by phone or video-link - ticks many boxes in the sustainability agenda whilst also carrying the potential to deliver care close to home without the associated carbon impact of staff travel. Recognising this, a small number of initiatives have, indeed, sprung up around the UK but it is worthwhile trying to understand why the technology has not taken off more than it already has.
Firstly, there is the technology – video-links are not universally available and would require provision either via a local facility (e.g. GP practice) or through individual provision of hardware. There will be a trade-off between travel and technology costs whose balance, at this stage, is still not clear. The question does need to be raised, however, about whether video-linking does not simply represent the Emperor’s new clothes and whether a phone consultation would not suffice.
The second potential barrier to uptake is administrative – who coordinates the consultation, the availability of bloods and BP check? Informal feedback from our scoping exercise (see below), has indicated that this might best be renal-led, particularly if large numbers of different GP practices are involved.
Next is defining the target patient population – to achieve a meaningful carbon impact, visits that would have happened anyway should be replaced by a remote consultation. This probably precludes many with more modest CKD who are increasingly managed solely by primary care. Inter-digitation of remote and face-to-face consultations might, however, work for those in pre-dialysis or transplant clinics. Patient and staff acceptability are clearly needed to sustain these initiatives.
The above barriers do not seem insurmountable but it is the final hurdle of tariff that, we feel, places any new initiative immediately on the back foot. We are aware of local agreements for remote consultations being negotiated with commissioners but remuneration falls far short of the national tariff for on-site clinic visits. Rather than considering whole system costs, the combination of this disparity and the parochial incentives of the NHS internal market actually drives face-to-face consultations despite potentially negative impacts on patient, system and climate.
With this in mind, the UK Green Nephrology group have been undertaking a scoping exercise to help inform a campaign for parity of national tariffs. Clear indications of whole system costs, patient acceptability, outcome equivalence and carbon impact would, we feel, be needed to inform a successful bid. Working through the Association of Renal Managers (via Leo Bailey), as well as through our own individual contacts, we have identified a variety of initiatives around the country but, at this stage, there is still insufficient information that would help build a watertight argument – with some major project work due to report in the near future, the group are continuing to monitor the national experience whilst also seeking corroboration from non-renal work that might already be in place.We’ll shortly be publishing a template to keep track of the various developments and the outcomes they will generate. We’ll keep the Green Nephrology community posted but if you are involved in any initiatives that you can share with us – or if you have any comments on the above – it would be good to hear from you.
Suren Kanagasundaram (nephrologist, Newcastle)