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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 5.8.2 Infrastructure of Renal Centres Typically an autonomous renal centre has an inpatient nephrology ward, an outpatient haemodialysis unit and a CAPD unit. Outpatient facilities may be integral or shared with the main hospital. Dialysis Facilities In purely structural terms, it is not very expensive to create a new haemodialysis unit. Dialysis machines, once an expensive purchase can now be leased as can water treatment equipment. Conversion costs of existing buildings usually equate to £1K per sq m and a new build £1.5K per sq m. Typically, 4.5 patients with ESRF are managed by one haemodialysis station. Some units who use their facilities more intensively support over 6 patients per haemodialysis station. A 15-station haemodialysis unit will typically occupy 500 sq m, of which a third will be treatment area, a third will be office/outpatient/training area and a third will be for stores and technical support. Storage required for disposable dialysis equipment is often under estimated. A 15-station renal unit will often require 40 sq m and may require a similar space available in the main hospital. Large volumes of sterile fluid are delivered to renal units, usually once or twice weekly in large vehicles. There are important considerations in deciding the locations of renal units. The requirements for a satellite differ little but in some it is important to include integral outpatient facilities not only for review of dialysis patients but also for local nephrology referrals. Adequate waiting areas for patients and drivers are also necessary given that up to 50% of patients will be transport dependent. Since nurses and support workers tend to be recruited locally, education has to be decentralised from the 'hub' to some extent and there needs to be adequate training facilities. Quiet areas should be available for counselling and dietetics advice. Finally, satellites need to have good road communications and good parking facilities. A typical 15-station satellite unit will fully utilise 20 car parking places during the main part of the day. CAPD requires discrete training areas and areas for examination / intervention and for patient education. Approximately 30 sq m storage space is required for an average CAPD unit. A CAPD unit adjacent to a nephrology ward is a popular configuration because of the nursing cross cover which is possible for patients who are staying in hospital whilst undergoing training. Nephrology Beds The recent Royal College of Physicians review of workload and manpower (Appendix IV) based on data from South Wales, Yorkshire and Newcastle recommends that 36 nephrology beds are required for a team of 6 WTE consultant nephrologists covering a one million catchment population. A facility also functioning as a Regional Transplant Centre requires an extra 8 beds per million population. In October 1998, a Greater Manchester Renal Project was initiated to manage the change from 3 to 2 inpatient centres and development of the service across a conurbation comprising 13 DGH's and over 25 PCG's in 7 HA's. Detail work which was reported to the National Bed Enquiry recommended 50 nephrology beds and 6 high dependency nephrology beds for each 1.5m population base i.e. 37 beds per million catchment (O'Donoghue D - personal communication). Since approximately half the beds in a typical nephrology ward are occupied by dialysis patients with intercurrent problems, increases in these bed numbers need to be factored in as dialysis prevalence rates increase beyond current levels. Outpatient Facilities The Royal College of Physicians review 'Physicians Working for Patients' (Appendix IV) concluded that facilities for 1,800 new and 17,000 follow up consultations per year are required for a one million catchment area. The high number of follow ups results from the fact that the majority of patients diagnosed with renal disease are followed up 'for life'. The numbers include those approaching ESRF and those established on dialysis. Most renal facilities have two or three general nephrology clinics each week and increasingly nephrologists undertake outreach clinics where there are satellite dialysis facilities and often in DGH's where there are no dialysis facilities. Given the difficulties in expanding the geographical space available for clinics, it is worth considering clinic rooms integral to renal units when new autonomous centres or satellites are being designed. Increasingly, medical staff are joined by nurses and paramedical personnel in outpatient clinics.  |