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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 5.3 Responsibilities of Primary, Secondary and Tertiary Care Patients with ESRF usually have more frequent contact with dialysis units and transplant services than they do with general practitioners and primary care teams. This imposes a responsibility on all professionals to ensure that patients with ESRF get appropriate care for intercurrent illness and conditions which are not related, or only remotely related, to their renal disease. Renal physicians are not usually trained in primary care and often lack experience in the management of self-limiting illness as well as the breadth of generalist knowledge across other specialities. On the other hand, general practitioners may not immediately grasp the renal implications of occurrently disparate conditions and their management. They do, however, retain 24 hour responsibility for patients on their list unless the patient is actually in a secondary or tertiary treatment centre. There needs, therefore, to be an effective alliance between professionals to provide holistic care for patients. To place ESRF in perspective, it is instructive to illustrate the numbers of patients encountered. Assuming an RRT prevalence of 800 pmp is reached in the next few years, a PCT covering 100,000 population will have 80 on RRT with 12 new patients a year. Responsibilities of both renal teams and primary care teams • To provide effective, speedy two-way communication on all changes in treatment whether instituted by renal units or by primary care • To consult effectively regarding appropriate secondary care referrals to colleagues in other specialities • To ensure that each patient has an explicit understanding of who to consult when, about what Particular responsibilities of renal units • To keep general practitioners informed about plans for management of end stage renal failure of individual patients including the information that has been provided to patients and their families • To furnish appropriate protocols and specialist guidance, for example on erythropoietin prescribing • To keep general practitioners up to date regarding individual patient targets for blood pressure • To provide effective, immediate specialist consultation for the management of renal emergencies such as pulmonary oedema and for medical conditions with renal implications such as diarrhoea and vomiting which can result in electrolyte imbalance Responsibilities of general practitioners and primary care teams • To understand the implications of end stage renal failure for individual patients on their list • To appropriately flag electronic and manual records in order to maintain safe prescribing and safe health care for patients with ESRF • To consult appropriately with renal specialists when the management of intercurrent illness has renal implications It is suggested that it is good practice for local renal units to establish protocols with primary care which take account of features such as the local secondary care provision and the distance patients have to travel to renal units. Usually it will remain appropriate for patients to consult their general practitioner about conditions ranging from influenza to breast lumps and tertiary care should aim not to displace primary care from the important generalist roles. Best practice sees close co-operation between doctors and nurses at all care levels with consultation on appropriate referrals, for example, the renal physicians may know of rheumatologist colleagues with a specialist interest in the management of renal associated arthropathy. Communication is particularly important in two situations: a) where patients already have continuing, frequent involvement with a specialist unit. The prime example of this is diabetic patients with ESRF who will continue to need specialist diabetes team involvements b) patients who need specialist care requiring close co-operation with renal units. The prime example of this is obstetric care. Although it is rare for patients with ESRF to become pregnant they do so occasionally, particularly following transplantation and the management of pregnancy and delivery demands close co-operation between primary care, obstetric units and renal units.  |