4.7 Equity of Provision

4.7.1 Recent Expansion of Nephrology and Dialysis Services

The historical basis of inequities in provision of renal services is discussed in Section 2.2. In the late 1980's, it was recognised that significant decentralisation of dialysis services, particularly HD, would be necessary from the small number of units (<60) which were providing the service. A limited number of new autonomous (dialysis and inpatients) 'single handed' DGH units began to appear. Examples were in Carlisle, Ipswich, Bangor, Stevenage and Gloucester, typically areas where there had been poor RRT provision. Initial experience showed that a nephrologist working alone was unsustainable and junior staffing levels were inadequate. Securing satisfactory surgical support proved just as difficult as it was in the established centres.

By contrast, local recruitment of nursing staff and support workers was generally successful as was the ability to secure technical support, sometimes from commercial suppliers of dialysis and water treatment equipment. Most units found little difficulty linking to transplant centres, the number of local patients with functioning grafts eventually rising with the prevalence of dialysis. Few of the new units found it necessary to refer complex renal cases to the established centres, most being amenable to local management. The ability of the new DGH centres to become truly autonomous i.e. managing all cases of acute and chronic renal failure and all dialysis was aided by 'pairing' nephrologists and the improved distribution of urology, cardiac and radiology services which took place throughout the 1990's.

Appearing in much greater numbers than new autonomous units have been satellite units of the established centres in a 'hub and spoke' configuration. Typically, new consultants are appointed in the hub with 'outreach' responsibility for the satellite. Nurses and support workers are generally recruited and live locally. The majority of satellites (currently 82) do not have resident nephrologists nor local inpatient care although there are exceptions (ref.3). Patients requiring inpatient care are admitted to the hub which remains the referral centre for acute renal failure. Most satellite dialysis units have consultant led nephrology outpatient clinics on site or nearby which helps to improve local acceptance rates.

4.7.2 Future Configuration of Services

Traditionally the 'hub and spoke' has been regarded as the ideal service configuration with a typical hub (usually a transplant centre) covering two million population to provide transplantation and dialysis services through its satellites. New thinking is required given the likely reduction in the number of transplant centres and the burgeoning dialysis population. The potential weaknesses of the hub and spoke configuration, if too much resource is concentrated in the hub, include limited senior and junior medical presence, long travel distances for admissions and too many dialysis patients with intercurrent problems temporarily admitted to the hub. Continuing dialysis must take place in the hub which is usually under pressure from local dialysis demand. Excessive congestion in chronic dialysis units can be a disincentive to recruitment and retention of nurses.

Other less obvious weaknesses may be a lower rate of consultant expansion and less effective reversal of inequity of provision if satellites are developed in preference to autonomous centres. In the home counties which were served by London 'hubs' until 1990 dialysis prevalence rates were < 206 pmp (ref.20). A recent survey of Health Authorities in the old North Thames Region showed a variation in dialysis prevalence from 226 pmp in one HA served by a satellite dialysis unit (with 1.0 WTE nephrologists serving a population of 177,000) to 339 pmp in another HA with an autonomous unit (with 3.0 WTE nephrologists serving a population of 978,000).

Equity of access (1999 RRT prevalence 602 pmp) has been achieved in Northern Ireland through development, not of satellite units, but of subregional units. In this model, the subregional units are staffed by consultant nephrologists or physicians with an interest in nephrology. This allows a greater scope of local renal service to be provided, minimising travel inconvenience for patients. The service provided via subregional unit physicians includes local clinics (transplant review, CAPD, general nephrology), inpatient care and access to a nephrologist assessment for local general physicians. In this model, the only services not provided at subregional unit level are transplantation, peritoneal and vascular access surgery, interventional radiology techniques, CAPD training and tissue-typing (Doherty C - personal communication).

In Yorkshire, a policy whereby new satellites are developed into free standing units over a period of a few years has been successfully applied in York and Bradford. There are plans to expand this concept to other major towns. The two units within the Teaching Hospital in Leeds would not have been able to sustain an adequate service without these decentralising developments (Davison S - personal communication).

Therefore a balance has to be struck between the expansion of haemodialysis services by hub and spoke or by the creation of new autonomous units. This reflects the balance between the overall expenditure allocated to renal services, the need for a Consultant based service and to correct under-provision.

4.7.3 Filling in 'Blank Spots' in Service Provision

The first requirement is a population based 'gap' analysis where RRT stock can be compared to national norms taking into account local characteristics. Although this might appear straightforward, it may be difficult in practice due to the overlap of providers and HA's. Accurate assessment of transplant stock can also be difficult because of 'loyalty' of patients to the original transplanting centre after change of address. Unfortunately, UKTSSA patient data is not post-coded. Pooling provider based data which is usually more robust is an alternative strategy to identify areas with historically poor provision.

RSCGs have the opportunity to recruit medical, management and financial advice from 'Regional Interest Groups' (see Section 3) to produce an operational/ business plan for reversing the deficit. The options range from introducing satellites, doubling up single handed practices, converting satellites to autonomous units to the introduction of new autonomous units. In all cases, the Managed Clinical Network approach including 'borrowed' management expertise may prove helpful (see Section 5.8). Unless the rate of transplantation increases, approximately two thirds of patients accepted for RRT will be on dialysis. The transplantation rate varies markedly across the country and access to this, the optimal treatment for most patients with ESRF is thus inequitable. For those on long term dialysis, planning must be sensitive to patient and carer needs.

Link to National Service Standard 7