2 The Case for a Commissioning Framework

2.1 Acceptance and Prevalence Rates in Renal Replacement Therapy (RRT)
2.2 Historical Basis of Inequity and Congestion
2.3 Current Problems in the Renal Service

2.3 Current Problems in the Renal Service

2.3.1 Crisis in Haemodialysis Provision

Services are under intense pressure despite an expansion of satellites from 36 units in 1993 to over 80 now. In a recent survey of provider trusts which achieved >90% response rate (Greenwood R, on behalf of the Kidney Alliance 99/00) 31 out of 56 autonomous centres (55%) reported their dialysis programmes as 'tight, bordering on clinical compromise.' 22 units (39%) reported 'severe congestion resulting in clinical compromise' with 12% centres admitting that thresholds for acceptance had changed with fewer ESRF patients being accepted than in the past. 38% of centres said that more patients than ideal were treated by CAPD with 21% units admitting that CAPD was the only treatment option for new ESRF patients because of exhaustion of HD capacity.

The results showed that the majority of RRT programmes are finding it increasingly difficult to meet the growth in demand. However, another finding was the variation in circumstances. While some units were developing and had the opportunity to meet projected growth others were severely compromised by a lack of capacity and had no obvious way of meeting the problem.

2.3.2 Geographical Areas of Under provision

Given a lack of incentives to decentralise and the difficulty of accessing capital in the NHS it is not surprising that few new autonomous centres (dialysis, inpatient care, local nephrologists) have appeared. Confining expertise and manpower to large metropolitan centres often forces patients to travel many miles to access inpatient care, consultant and paramedical expertise.

It was first shown in 1987 that the chances of receiving dialysis diminish the further patients live from renal centres (ref.18,19). The London Implementation Group in 1992 showed prevalence rates for dialysis in some parts of the home counties were less than 120 patients pmp while in some of the Thames regions rates were approaching 300 patients pmp. Perhaps even more alarming was the number of patients with functioning grafts at less than 70 pmp in certain parts of Bedfordshire, Essex, Kent and Sussex compared with prevalences exceeding 200 pmp in more central areas in London (ref.20). Data collated in 1991/3 for the 'National Renal Review' which was published by the Department of Health in 1996 (ref.21) showed similar large variations with fourfold differences in stock and threefold differences for acceptance rates in different areas of the Country.

Among Health Authorities in the Eastern Region, dialysis stock rates currently range between 226 and 339 pmp. In Greater Manchester, in 1999/00, the acceptance rate of new RRT patients ranged from 34 to 98 giving an RRT prevalence of 215 versus 319 pmp in contiguous districts
(O’Donoghue D - personal communication).

There remain a number of large towns in the UK currently without any dialysis service, e.g. Luton and Colchester. Within Greater Manchester, 5 large towns with large district hospitals i.e. Oldham, Bury, Bolton, Wigan and Trafford have no dialysis facilities. There are still several counties in the UK without autonomous renal services, e.g. Buckinghamshire, Bedfordshire and Cheshire.

2.3.3 Commissioning Difficulties

Linked with the problems of equity are difficulties in the commissioning of RRT. This requires specialist knowledge and an understanding of the issues facing these services. However, individual health authorities often only commission a proportion of the total renal package and may not develop specialist skills or establish constructive relationships with renal service providers. Rapid turnover of health authority (HA) staff who rarely retain responsibility for a particular area for more than a year or two is a further confounding factor.

The Kidney Alliance survey of provider Trusts showed that only 19 of 55 (35%) believed that their commissioners showed an understanding of the planning issues and only 16 (29%) felt that purchasers understood the financial pressures they were facing. The responses to the survey pointed to 6 main issues:

• A lack of joint working and co-ordination between Health Authorities
• A reluctance to accept responsibility for the commissioning of these specialist services
• Uncertainty over funding responsibilities and obligations
• Crisis management as opposed to forward planning
• A general lack of understanding of the issues facing renal services
• Poor access to capital to allow expansion of the haemodialysis base

The commissioning of renal services is currently being reorganised. Renal and supporting nephrology services have been recognised as specialised services which are provided by hospitals to populations larger than that of a single HA. They have therefore been adopted into the remit of Regional Specialised Commissioning Groups (RSCGs). In essence, the strategic plans for the service and the subsequent implementation and investment plans will need to be agreed by a group of HA and Primary Care Trust (PCT) commissioners rather than a single HA/PCT.

2.3.4 Human Resources

Difficulties in maintaining and developing the renal workforce is another obstacle to progress.

Despite many technical innovations the practice of dialysis is particularly labour intensive with high skill levels required of nurses who, in relation to number of patients, are fewer in number than in the past. Increasingly tasks are being carried out by non-registered practitioners. They in turn must attain high levels of clinical and technical skills which requires substantial investment in education and training. The pressure in the service was reflected in the survey of renal units carried out for the Kidney Alliance in Dec 99/Jan 00. Only 4 of the 55 services stated that recruitment and retention of nurses was not a major problem. Similarly, only nine of the respondents described nursing morale as high whilst 22 described it as poor.

Equally important is the poor rate of Consultant expansion in the last ten years. Although a problem across all medical and surgical specialities, the impact in nephrology is amplified by the huge expansion of RRT stock. (See Section 5.6.2).

Paramedical specialities including social work, dietetics and pharmacy support have all too often been regarded as added luxuries rather than essential components of the multidisciplinary team in workforce planning in provider Trusts. (See Section 5.6.2).

Technical support is an essential component of the service. For home HD patients, although now fewer than in the past, it is common for their most regular contact to be with technical staff. Recruitment and training have been made more difficult in recent years following the disappearance of many of the medical physics departments in NHS hospitals with which technicians were often affiliated. The requirement for more stringent technical standards including water quality calls for urgent reinvestment in the technical service. (See Section 5.6.2).