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Executive Summary
A
The Kidney Alliance, an umbrella body representing all organisations involved
in renal services, was formed in 1998 to bring together the voices of patients
and committed professionals. The Alliance has produced this document as
a forerunner to a National Service Framework for renal services. The driving
force has been the need to break away from the damaging culture of reactive
management, which has become the habitual manner by which the problems of
this rapidly growing service have been addressed, in favour of an approach
exemplified by shared ownership of the problems and solutions, responsible
investment and planned development. The document is intended for use by
commissioners and providers in planning renal services over the next ten
years. The initiative concentrates on end stage renal failure (ESRF), which
constitutes the largest workload in the renal service and is the area most
vulnerable to variations in quality. It also concentrates on the management
of adults recognising that the management of children with renal disease
will require further specialist attention.
B
The first part of the document describes the current status of the service
and the important epidemiological and demographic factors which will influence
planning and expenditure in the next decade. Together they constitute the
main justification for preparing this commissioning framework.
They are summarised as follows:
Increasing Acceptance rates in ESRF and Prevalence of RRT
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Acceptance rates for RRT are rising but there remain
geographical inequities.
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The low prevalence rates for RRT compared with Europe
reflect continuing difficulties in accessing the service rather than
negative attitudes to treating ESRF.
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Since acceptances exceed death rates, the numbers receiving
RRT (stock) will not plateau for at least 10 years.
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Since transplant rates are static the number of patients
on dialysis will continue to increase.
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Despite the success of transplantation and PD, HD remains
the default therapy for all ESRF and the proportion of dialysis patients
on HD will continue to increase.
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Current problems with the Renal Service
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The slow rate of HD decentralisation into
new autonomous centres and satellites has caused congestion in most
renal units often severe enough to compromise clinical care.
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Dysfunction in commissioning includes lack
of joint working between Health Authorities, a reluctance to accept
responsibility for purchasing and crisis management in place of forward
planning.
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Lack of a regional perspective on commissioning
perpetuates 'blank spots' in the UK which are still without autonomous
renal services or even satellite units.
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Difficulties in recruitment and retention
of nurses are exacerbated by poor working conditions resulting from
congestion and the associated compromises in quality.
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Consultant expansion has not kept pace
with the huge rise in RRT stock in the last ten years. The same is
true for dietetics, counselling, social work and pharmacy support.
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C
The document then identifies the building blocks, which are already in
place to support continuous quality improvement. Some of these are embodied
in new NHS initiatives but some are renal specific.
These include:
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The Renal Association's initiative in clinical
standards and audit. A third edition of the document 'Treatment of
Adult Patients with Renal Failure - Recommended Standards and Audit
Measures' is to be published in 2001.
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UK Renal Registry, which with its electronic
downloading of patient specific information, is the key to completing
a powerful audit loop with the standards initiative. The UK Renal
Registry now covers over 50% of the country and publishes an annual
report.
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D
Seven National Service Standards are then described which constitute the
core objectives of a strategic plan for renal services for the next decade.
Wherever possible, the evidence base for the recommendations is described.
Some recommendations reflect the enlightened level of expectation of patients
in a modern healthcare system. Other recommendations prescribe the developments
needed to reverse the inequities in access to therapy and in quality,
which have been characteristic of the UK renal service. These standards
could be the basis of performance targets within the new NHS Performance
Framework.
The seven National Service Standards are summarised
as follows:
National Service Standard 1
National Service Standard 2
National Service Standard 3
National Service Standard 4
National Service Standard 5
National Service Standard 6
National Service Standard 7
E
The document then describes how some
of the new NHS structures, particularly regional specialised commissioning
groups (RSCGs), can interface with consortia of Health Authorities and
new Primary Care Groups/Trusts to create a framework which will ensure
that the National Service Standards are deliverable. Also discussed is
the new thinking which will be necessary on the configuration of renal
facilities in order to ensure that there is equity of provision and adequate
rates of expansion of consultant nephrologists and other professional
groups.
F
The document then sets out a timeframe
for the framework to be put in place and for the delivery of the objectives
embodied in the National Service Standards. Since many of the recommended
structures flow with the stream of change already taking place in the
NHS, some of the timeframes are relatively short. This section also recommends
the agencies responsible for the achievement of each milestone. They are
summarised as follows:
REGIONAL
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| Milestones |
Responsibilities |
Timetable |
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| Commissioning structure
operational |
RSCG |
4/01 |
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Baseline assessment of needs/gap analysis
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RSCG |
4/01 |
| Regional Implementation
and Investment plan |
RSCG |
4/01 |
| Plan for Consultant
expansion |
RSCG |
4/01 |
| Establish monitoring
system |
RSCG |
4/02
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RSCG Priorities Reflected in Health Planning
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| Milestones |
Responsibilities |
Timetable |
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| HIMPs (Health Improvement
Programmes) |
HAs |
4/02 |
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PCIP's (Primary Care Investment Plans)
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PCG/Ts |
4/02 |
| SAFF's (Service
and Financial Frameworks) |
HA to PCT/Trust |
4/02 |
| Joint protocols
for referral of chronic renal failure |
PCT/Trusts |
4/02
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Costings
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| Milestones |
Responsibilities |
Timetable |
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| Agreement on template
for costing ESRF |
NHS Executive |
4/02 |
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Establish Benchmarking system for Trusts
(25% take up)
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RSCG |
4/02 |
Guidelines on the
responsibilities for prescribing erythropoietin and immunosuppressant
drugs
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RSCG |
4/02
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Information and Audit
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| Milestones |
Responsibilities |
Timetable |
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| Link all renal
facilities to National Renal Registry |
RSCG |
4/02 |
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RSCG reporting framework in place including
residence based acceptance and stock rates of RRT
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RSCG |
4/02 |
Audit information
not available from Renal Registry. Define Audit Plan
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RSCG |
4/02 |
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G
Finally, the appendices detail European
comparisons of acceptance and prevalence rates for renal replacement therapy
to illustrate the 'gap' which the UK faces to bring its renal services
up to European levels. The biggest challenge within this is the achievement
of appropriate staffing levels. These are discussed for a number of professional
groups in the appendices.
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