8 Appendices

Appendix V - FUTURE STAFFING REQUIREMENTS - PROFESSIONS ALLIED TO (PAM'S)
(Source: 1 Provision of Services for Adult Patients With Renal Disease in the UK; Royal College Of Physicians of London and the Renal Association, London 1991.
2 Renal Social Work Provision in the UK (draft). British Association of Social Workers, Renal Special Interest Group, June 2000.
3 Patient:Dietetic Staff Ratios in known Renal Centres in the UK. April 1999 update of 1996 Audit Report. British Dietetic Association, Renal Dialysis Group, 1999.)

DIETETICS
In 'Provision of Services for Adult Patients' (1991), the RCP/RA 'blue book', it was recommended that 2 dietitians, a Senior 1 with assistance from a Senior 2 would be required for a typical renal unit with 200 patients on dialysis and seeing 70 new patients a year, i.e. a patient:staff ratio of 100.

This Kidney Alliance document records the increase in acceptance and prevalence rates for RRT since 1991 with an increase in the mean age and co-morbidity burden of patients with ESRF. These changes place greater demands on dietetic services. We also record the need to comply strictly with adequacy standards for dialysis to prevent under-dialysis and malnutrition. Dietitians are necessarily involved in this work. Phosphate control, necessary to maintain bone health, has become more difficult in the modern era owing to shortened dialysis times and the dependence on less toxic but less effective phosphate binders.

The Renal Dialysis Group of the British Dietetic Association (BDA) carried out an audit of dietetic staffing in 1996 and updated this to include patient:staff ratios in 1999. This was presented at the BDA-RDG meeting in May 1999. 63 units were approached and 61 replied giving a response rate of 98%. The results were as follows:

This shows that the patient:staff ratio exceeds that recommended in 1991 when the workload per patient was undoubtedly less.

More worrying is the large variation in access to dietetics expertise throughout the country. The patient:staff ratio varied between 50 and 274:1, i.e. a >5 fold difference in workload. Clearly significant resource will have to be invested in recruitment of dietitians in order to bring the patient:staff ratio down to 100:1 which should be regarded as an absolute maximum to achieve adequate service provision.

SOCIAL WORK
The RCP/RA (1991) 'blue book' recorded that the British Association of Social Work and the North Western Regional Health Authority had reviewed workloads and had independently concluded that 1 WTE social worker was needed per 100 standard risk patients on dialysis. Taking into account the fact that high risk (frail, elderly, diabetic, blind) patients and those with special needs require additional time and recognising that they constituted about half the dialysis population, it was recommended that a unit with 200 dialysis patients and 600 associated transplant and pre-dialysis patients should have 3 WTE social workers. They should be employed at Level 3 due to the complex nature of the work .

The Renal Special Interest Group of the British Association of Social Work (BASW) has recently expressed concern about the great variation in provision of services to patients with ESRF throughout the UK.

In particular there are concerns about:

• The rights of patients and their carers to access the service
• The adequacy of service provision
• The variation in funding arrangements and contracts of employment
• The problems caused by short term contracts
• The lack of continuity of service provision
• The part played by charities in funding this essential NHS service

The RSIG of the BASW undertook a survey of renal units between June 1999 and May 2000. 95 units were surveyed and the response rate was 92%. The following information was collated:
Percentage of Renal Units

The sources of funding have become varied partly because units seeking social work services have accepted that Local Authorities may not be able to provide the comprehensive specialist provision they require.

The following is the current situation regarding funding:

Of the 76% of renal units with a Specialist Renal Social Work provision, 38% of posts are supported by charitable funds. These are all short term contracts often introduced as 'pump priming' posts which it is intended that Health or Local Authority will take up - a strategy which does not always materialise.

37% of posts are joint funded in some way, again often on a short term contractual basis with no clear responsibility for the continuation of service provision. 60% of posts are temporary.
Contracts of employment for renal social work are held by Local Authority 81%, Health Authority 15% and industry 3%.

In conclusion,
• The provision of renal social work in UK renal units is patchy and inadequate in some areas.
• Some renal units have no access to social work provision at all
• The large number of posts funded from charity is a cause for concern in this speciality which is of critical importance to the well-being and rehabilitation of patients with ESRF.
• BASW conclude that NHS resources should be made available to fund social work posts in the numbers that are required.
• BASW supports continuation of the arrangement where employment contracts are held by Local Authorities.

The Kidney Alliance notes that the current ratio of dialysis patients:staff of approximately 175:1 greatly exceeds the recommendations made in 1991 (RCP/RA) for a 70:1 ratio despite the increase in the proportion of patients requiring support. Elderly and disabled patients, in particular, will not be able to access the quality of service they require unless their poor staffing levels are reversed to approach towards the 70:1 patient:staff ratio.

Social work appears to be one of the most severely under-resourced areas in the renal service with staffing levels falling far short of those required to provide an adequate service. We cannot hope to achieve some of the key National Service Standards particularly NSS's 2, 5 and 6 detailed in this document unless there are more resources.

January 2001