1 Introduction

This report is intended for use by commissioners and providers involved in planning renal services over the next 10 years. Whilst the Kidney Alliance is unashamedly committed to the provision of excellent and equitable treatment of renal failure in the UK, great care has been taken to ensure that the recommendations contained in this document are realistic, evidence based wherever possible and achievable at acceptable cost. We recognise that the responsibility for achieving these aims will rest with providers and patients as well as commissioners. There is a need for improved efficiency of service delivery, comprehensive staff training and a commitment to continuous quality improvement as well as for increased funding.

Preparing this document, which we hope will lead the way towards a National Service Framework for Renal Services, has been necessary because the government has chosen, with good reason, to concentrate initially on the much bigger problems of cancer, cardiovascular disease, mental health, diabetes, elderly medicine and critical care. Its contents provide a challenge for everybody involved in renal service provision but we are convinced that implementation of the recommendations will lead to better, more equitable and more efficient patient care.

The first part of the document describes the current status of the service and important epidemiological and demographic factors which will influence planning and expenditure in the next decade. While much has been learned about the preservation of life in end stage renal failure (ESRF) by renal replacement therapy (RRT) since the 1960's, we still have inequitable access and unacceptable variations in clinical standards. We explore the reasons and build on the explanations to construct recommendations for the future.

The report then sets out the National Service Standards to which we would aspire in the modern NHS. These apply not only to patients already with ESRF but also to the attenuation of progression of renal diseases and the reduction of risk factors. The Standards also refer to the need to 'correct upwards' the numbers of patients in those areas of the country which have been historically poorly served where few patients are maintained by dialysis and transplantation compared to the rest of the UK and Europe.

The Structures which will be necessary to make the National Service Standards deliverable are then described. Regional responsibilities are spelt out. Special mention is made of the partnerships which will be required between Regional Specialised Commissioning Groups (RSCGs), Health Authorities, Primary Care Groups/Trusts and Provider Trusts. The report also details the information streams required to enable the Structures to deliver the Standards. Human Resources issues are also addressed. Finally, we outline a timetable for putting these Structures in place with defined responsibilities for each milestone. In adopting this approach, the Kidney Alliance recognises that much work will be needed in the key areas identified in the next few years with refinements which reflect the changes which will emerge as the NHS plan moves forward.

This Kidney Alliance initiative concentrates on ESRF, particularly dialysis, because this constitutes the largest workload in the renal service and the area probably most vulnerable to variations in quality. It also concentrates on the management of adults since we feel the management of children with renal disease will require specialist and focussed attention in a future initiative. We recognise that nephrology departments have wide-ranging responsibilities for all kidney disease which require close links with other specialities such as urology, diabetology, vascular surgery, radiology, cardiology and immuno-histopathology. Acute renal failure, although often reversible, is frequently associated with multiple organ failure and requires high dependency nursing and interface with intensive care. Although transplantation is carried out in relatively few centres the 'work up' and 'follow up' takes place in most renal units. The Kidney Alliance intends to make recommendations on the planning, commissioning and delivery of these services also as we move towards a definitive National Service Framework for Renal Medicine.