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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 2.2 Historical Basis of Inequity and Congestion In the 1960's and 1970's, dialysis units and transplant units were established mainly in teaching hospitals. There was little incentive to decentralise and there remained fewer than 60 renal units up to the end of the 1980's. One consequence was that home haemodialysis rather than 'centre' dialysis became the main treatment modality. The need for training resulted in the selection of the relatively young and fit for long term treatment. In contrast there were several hundred units in each of Germany, France and Italy which were established as haemodialysis treatment centres, home haemodialysis being much less developed. As attitudes to age and co-morbidity became more liberal, European units expanded to absorb large numbers of the relatively old and infirm whereas UK units were unable to do this. As a result acceptance and prevalence rates at the end of the 1970's were markedly inferior to that in most other developed countries. On a population basis only a quarter the number of Consultant Nephrologists were employed compared to those other large European countries (ref.17). The introduction of CAPD in 1980/81 was timely, its simplicity allowing more patients to be treated at home, with minimal capital outlay. Dialysis thereafter expanded rapidly with little increase in the numbers of renal units or haemodialysis stations. By contrast CAPD was greeted with less enthusiasm in the rest of Europe. Eventually though, problems with peritonitis and the recognition that CAPD could be inefficient when patients' natural renal function diminished led to significant numbers of CAPD patients requiring HD as a fallback. This, along with the decline of home haemodialysis and further liberalisation of acceptance of the elderly onto treatment were the main drivers to the congestion which has been experienced by most British renal units in recent years. It is regrettable that many patients are still channelled into CAPD or forced to remain on it inappropriately due to lack of HD spaces (see Section 2.3.1). The expansion of HD facilities in the last 10 years has only partially depressurised the over-inflated CAPD programme. Whilst new satellites (usually without local nephrologists or in-patient facilities) of the main tertiary centres have been the main mode of expansion, few new autonomous units (usually two or more nephrologists and in-patient care) have emerged (ref.3). The number of nephrologists remains relatively few compared to other European countries.  |