Wednesday, 25 November 2009

Q & A: Developing future kidney services

Q: I am writing from a large hospital without a renal unit, offering general nephrology and liaison with critical care for acute RRT. I work with a renal unit in a neighbouring town which provides end-stage RRT.

Over several years there have been initiatives to develop a more extensive service on site, to support our tertiary services as well as the local ESRF population but each one has foundered through a combination of inertia, funding and local politics.

Until recently there seemed to be some light in the tunnel of joint working but once again we seem to going back to square one in justifying a service based on site here - rather than one provided here by visiting clinicians from the renal unit based elsewhere, without an inpatient presence.

I would be very grateful if you could give me a steer on the national situation - I've have looked at various documents (and have even tried to play with MORRIS) but I can't find any hard information. Senior management have referred to a national strategy, from which they have the idea that there will be 30 new units some time soon? Is there any initiative at SHA level which supports local provision?

A: Many thanks for your email of 16 November about developing kidney services. It’s a timely letter as NHS Kidney Care have just produced a guide to “Achieving Autonomy for Kidney Services”. It’s a 7-step toolkit and was featured in the HSJ a few weeks ago.

You will be well aware of the history of renal medicine in the UK – from a slow start, interrupted by the Hepatitis B outbreaks, to the majority of teaching hospitals and then, in the 1980s, services becoming established in some of the bigger district hospitals. There has been little growth in the number of units over the last 15 years. The focus has been largely on satellite dialysis provision. It’s a highly unusual model of care, I think it is salutary to consider that in England with 50 million people we have 52 units and in the other home countries there are 26 units serving a population of 10 million. Nor is there a geographic explanation for the highly concentrated nature of kidney services in England. Now that kidney services have expanded to interact more closely with primary care in the management of early kidney disease which is recognised to affect in the region of 10% of the adult population, and with the focus on conservative care for those who elect not to have dialysis where getting local care in the community is often the preferred option, it’s perhaps timely to ask the question do we need bigger central kidney units or a more dispersed model of care providing more local support to both primary, secondary and tertiary care. The recent publication of the NCEPOD report on acute kidney injury also highlights the uneven spread of kidney services and recommends the development of on site renal services to support colleagues in acute medicine, critical care and other specialties looking after the acutely unwell where AKI is a frequent occurrence and of course to provide replacement therapy in the minority of AKI patients who need dialysis.

Conversely I am sure that one size does not fit all and planning does need to be done at a local level. I don’t see renal centres developing in every acute hospital. I have speculated that perhaps we should be moving towards 85 centre in England. I suspect I was quoted saying that in the HSJ and that’s maybe where your senior team got the number of an additional 30. However, there are a number of organisational, commissioning and professional challenges in developing new services as we know from the recent experience of places like Doncaster, North Hampton, Aintree and Worcester. “Achieving Autonomy for Kidney Services” draws on this experience to identify the various steps, tasks required and partnerships to be put in place and as well risks that must be managed. Of course now the focus is definitely on quality and productivity, but the need for kidney services in only going to grow and it may be that more units rather than just bigger units are both better value for money and the cheaper option.

I hope you find the 7-steps toolkit of interest. I am of course happy to discuss in more detail at a mutually convenient time. With best wishes, Donal.

Related blogs:
Establishing new kidney units