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5 Structures Necessary and Organisation of Services 5.1 Regional Framework 5.2 Partnerships 5.3 Responsibilities of Primary, Secondary and Tertiary Care 5.4 Local Management 5.5 Information Technology and Audit 5.6 Human Resources 5.6.1 NHS Workforce Planning Reforms 5.6.2 Future Staffing Requirements 5.7 Finance 5.8 Organisation of Services 5.8.1 Managed Clinical Networks and Shared Resources 5.8.2 Infrastructure of Renal Centres 5.8.3 The Private Finance Initiative (PFI) and Private Provision of Renal Services 5.8 Organisation of Services 5.8.1 Managed Clinical Networks and Shared Resources The 'managed clinical network' is a new paradigm for clinical care. The concept was introduced with respect to cancer services in the Scottish Acute Services Review (ref.87). It recommends the sharing of patients, expertise and resources rather than 'unidirectional centripetal flow' and connection and partnership rather than isolation and self sufficiency, on distribution of resources rather than centralisation. The important roles of nursing and allied professional staff are stressed. The concept may be applicable to renal services. While transplantation is the most obvious asset in renal medicine which must be shared, there are other areas of expertise which are not present in all hospitals which might be shared. Complex interventional radiology and some specialist urology services are other examples as is vascular and peritoneal access. Technical cover, for example, is well provided in some renal centres but is not available in others. Some centres have highly developed nursing education which is also a resource that can be shared. It may be possible for expertise in different dialysis modalities to be concentrated in particular units. Home haemodialysis centred in one facility serving a Region would be one example of this. There is already an example in London of a private sector establishment training patients from several NHS hospitals for home PD and home haemodialysis. It is conceivable that while a new haemodialysis facility was developing in one centre, peritoneal dialysis services could be supplied by another. Taking the managed clinical network approach may provide a more flexible template for commissioners grappling with the need to redress inequities rather than having to choose between the extremes of hub and spoke and autonomous renal centres. 
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