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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 5.6 Human Resources 5.6.1 NHS Workforce Planning Reforms Medical Staffing Consultants are supported by either non-career staff (Associate Specialists, Staff Grades) or career grades (Specialist Registrars, Senior House Officers and pre registration House Officers). The majority of those in training grades will also have duties in general medicine in addition to their commitment to the renal service. There is a commitment to training Specialist Registrars who are expected to attend an academic programme for half a day per week as well as training both within the hospital and outside to fulfil the requirements of the Specialist Advisory Committee (SAC) in general medicine and renal medicine. Each SpR has regular appraisal and assessment with a trainer as well as a record of in-training assessment (RITA) and a penultimate year assessment. All these commitments take registrars and consultants away from clinical service. The way in which career grade doctors are funded and how their numbers are set are detailed in Appendix III. The pressures for more consultants in renal medicine are intense for the following reasons: • Increased numbers of patients on RRT and increased acceptance rates in ESRF • Reduction in hours worked by all grades of staff as a result of European working time directives • An increasing requirement for continuous medical education, training and assessment of junior staff, audit and managerial duties These changes have exacerbated chronic understaffing. Planning for medical staffing is national with the Specialist Advisory Workforce Group (SWAG) taking advice from the Royal College of Physicians and Renal Association on future workforce requirements in nephrology. Predictions of need up to 10 years in the future allow determination of the number of trainees who should be recruited into the speciality each year. The weakness in this system is that there is no means of requiring Trusts to employ the number of nephrologists required. This has resulted in imbalances with an apparent over provision of trained nephrologists for the posts available. SWAG have responded by reducing the numbers of trainees to match the number of posts which Trusts can or will afford rather than the numbers needed. This problem may be solved if budgets for renal services are held or at least carefully directed by Regional Planning Groups. One suggestion which has been made to deal with the increasing clinical workload in nephrology is the establishment of a new Sub-Consultant grade. While this grade may be suitable for a few doctors who for a variety of reasons have been unable to become fully trained in nephrology and gain the Certificate of Completion of Specialist Training (CCST), it is not appropriate for fully trained nephrologists. Furthermore the establishment of such posts would move us away from the current aim of a consultant based service. Consultant Numbers 10 years ago it was estimated that there were a quarter the number of nephrologists in the UK compared to France and one sixth compared to Italy on a population basis (ref.2). The recommendations made at the time by a working party of the Royal College of Physicians/Renal Association that there should be 4 whole time equivalent (WTE) nephrologists per million catchment is now out of date for the reasons stated above. The Royal College of Physicians (London) taking advice from a joint Renal Association/RCP Committee recently reviewed manpower needs for nephrology (Wilkinson R - personal communication). The figures are derived from independent estimates for a catchment population of one million provided by physicians in South Wales, Yorkshire and Newcastle and are based on analysis of the work programme in all areas of the renal service (for detailed breakdown see Appendix IV). It is estimated that for a population of 1 million, 65 consultant notional half days (NHD's) are required for direct patient care and 29 NHD's for supporting activities making a total of 94 NHD's per week. This workload would be satisfied by 9.4 WTE nephrologists. If trainees compromise 27% (an approximate average) of the total workforce and there is an Associate Specialist and a Staff Grade then this figure can be reduced to 6.1 WTE per million population. This gives a current need of 316 WTE consultants in nephrology for England and Wales. At the moment there are 164 WTE nephrologists which is roughly equal to the number judged to be necessary for the service ten years ago. With the expected rate of increase in workload, the requirement is estimated to be 390 WTE in 2006 and 439 in 2010. A survey by the RCP showed that 60% of nephrologists also provide a service in acute general medicine (GIM) and that on average they spend 30% of their time in general medical duties. 1 WTE in nephrology requires 1.4 physicians in post in these circumstances. The growth rate in consultant numbers of 11.3% per annum over the next four years is required to achieve these recommendations. The growth rate in consultant numbers of 11.3% per annum over the next four years is required to achieve these recommendations. Nursing The role of the nurse within the multi-professional team is pivotal. The scope and content of renal nursing is shaped by many factors but at present difficulty in recruitment and retention of qualified nurses poses a particular problem. In a recent survey carried out on behalf of the Kidney Alliance (Keogh A - personal communication) renal units reported that 26% of all posts for qualified nurses were vacant. In 41% of the units this was causing problems in delivery of service and in a further 38% it had some impact on the service. As satellite units increase in number and size nurses must identify the skill mix required to deliver effective care. A National Strategy is needed. In 1998 a nursing development group was established to standardise nursing skill mix and to provide guidelines. The four key elements to its work are: • Organisation of patient care • Competence and development • Education • Recruitment and retention This work, which has the support of the Department of Health, is ongoing and its preliminary recommendations are expected shortly. Meanwhile, 'bottom-up' five year workforce plans from Trusts, feed up to education consortia, which then aggregate plans from Trusts and other employers such as nursing homes and private hospitals. The consortia commission training on the basis of these plans (see Appendix III). Progress is urgently needed since previous structures have failed to delivery a uniform approach to workforce planning and there are marked differences in the skill mix ratio of registered nurses (RN's) and Health Care Assistants (HCA's). In the Eastern Region for example, the mix ranges from 30:70 to 70:30. Professions Allied to Medicine (PAM's) Dietetics In 'Provision of Services for Adult Patients' (1991), the RCP/RA 'blue book' (ref.2), it was recommended that 2 dietitians, a Senior I with assistance from a Senior 2 would be required for a typical renal unit with 200 patients on dialysis and seeing 70 new patients each year i.e. a dialysis patient: staff ratio of 100. Since that time there have been significant increases in acceptance and prevalence rates for RRT with an increase in the mean age and co-morbidity of patients with ESRF. Dietitians have also become involved in new areas including monitoring the adequacy of dialysis to prevent malnutrition. The Renal Dialysis Group of the British Dietetic Association (BDA) have recently completed an updated audit of staffing levels (1999). The results are detailed in Appendix V. The survey show that the patient:staff ratio currently averages 128:1 which greatly exceeds the ratio recommended in 1991 where the workload per patient was less. More worrying is the large variation in access to dietetics expertise throughout the country. The dialysis patient:staff ratio varies between 50 and 274:1, i.e. a >5-fold difference in workload. A survey carried out by the same group in 1999/00 of Trusts advertising renal dietetics vacancies demonstrated lower than usual numbers of applications with frequent acceptance of lower grades who would subsequently require training (Wells L - personal communication). More work is needed in the context of the new NHS initiatives on workforce planning to better define the needs of the service and to define mechanisms by which appropriate levels of staff can be achieved. Social Work/Counselling In 1991 the 'blue book' 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 i.e. a dialysis patient:staff ratio of 70:1. Since that time, there has been great increase in the numbers of elderly and disabled in the RRT population who now require support to ensure an adequate quality of life, access to assessment for available resources and empowerment to make the best possible choices in terms of treatment options. In addition, counselling roles have been taken on by social workers without any formal recognition of time necessary to satisfy the most basic needs of the service. The Renal Special Interest Group of the British Association of Social Work (BASW) recently surveyed the position and the results are detailed in Appendix V. While 76% of renal units had a social work service, the remainder had no specialist renal social work service and 10% of units had no social work provision at all. Perhaps more worrying was the finding that out of the 76% of renal units with a specialist renal social work provision, 38% of posts were supported by charities. It was noted that all were short term contracts designed as 'pump priming' schemes which it was intended that Health or Local Authority would take up - a strategy which does not always materialise. The ratio of dialysis patient:staff of approximately 175:1 greatly exceeds the recommendations made in 1991. Social work appears to be one of the most severely under-resourced areas of the renal service, the staffing levels falling far short of those required to provide an adequate service. Elderly, disabled patients, in particular, will not be able to access this vital service unless more resources are made available and the replacement of charitable funding by substantive NHS funding proceeds. It is important to define service needs accurately in the context of the new workforce planning initiatives. This is work which should be carried out urgently. The analysis in Appendix V constitutes a good basis for this work. Pharmacy The UK Renal Pharmacy Group (RPG) are currently developing a best practice standards document, to include minimum standards of service and minimum staffing levels required for different sized renal units. In 1999 the RPG conducted an analysis of pharmacist staffing levels in renal units. This suggested that the average unit (200 patients) needed 0.5 WTE for pharmaceutical care planning services, 1.0 WTE if providing a transplant service and 1.5 WTE for business service, e.g. commissioning services. Technical Support Services Technical support services are as important as they have ever been within the service on account of more stringent quality standards and the renewed interest in home haemodialysis. The critical importance of this highly specialised area was underlined by a study by the Institute of Manpower Studies in 1992 (ref.86). Graduate training schemes for Clinical Technologists of the future are currently being developed by the Institute of Physics and Engineering in Medicine (IPEM). IPEM recognise the specialist nature of renal technology and are working with the Association of Renal Technicians (ART) to produce a suitable scheme.  |