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2 Specialties Renal medicineTable 1 Variation in RRT : renal WTE ratio in 2010Area Mean RRT : renal WTE ratio Individual unit RRT : renal WTE ratio rangeUK 110 25–211England 117 25–211Wales 116 62–196Northern Ireland 63 32–112Scotland 89 62–127RRT = renal replacement therapy; WTE = whole-time equivalent.party report The changing face of renal medicine in theUK: the future of the specialty. 32 On the basis of currentpatterns of work, with support from NCCG doctors,junior doctors, nurses and staff from other professionsallied to medicine, it is recommended that one WTErenal physician is required for every 100 RRT patients orfor every 75 RRT patients for an ‘average’ physician withGIM responsibilities. This resulted in a projectedworkforce requirement of 570 WTEs by 2010. In fact,the 2002 projection is similar to a more up-to-dateprojection (taken from actual numbers of patients onRRT on the Renal Registry in 2008) of 53,000 patientsin 2010 (which would require 530 WTEs) and the actualend-2010 figure of 50,965 RRT patients requiring510 WTEs. This number is slightly lower becausethe rate of increase has slowed down from theaverage annual increase of 5% between 2000 and2006. The actual current averages fall short of this butthere is considerable regional and unit variation(Table 1).These projections assume that the balance betweencommitment to renal medicine and GIM and the extentof part-time working will remain the same. This ispossibly not a valid assumption, as increasing numbersof renal physicians are dropping GIM and the numberof doctors planning to work less than full time isincreasing. In addition, the median contracted timeworked by consultant renal physicians currently isequivalent to 11.5 programmed activities (PAs) perweek. To achieve 10 PAs per consultant would need 109more posts.The currency for estimating workforce requirements asdescribed (one WTE renal physician renal physician forevery 100 RRT patients) broadly assumes that thesenumbers will effectively cover the range of outpatientand inpatient work of a ‘typical’ renal physician. It alsotakes into account the service contribution of traineesand NCCGs and the demands of general medicine,academic commitments and less-than-full-timeworking for personal reasons. Furthermore, there is avision for many more independent renal units,especially in England and Wales, and provision ofadvice and care of patients with AKI in our hospitals, asemphasised in the NCEPOD report from 2009. 8Predicting workforce requirements is challenging at thetime of writing because of uncertainty about the impactof changing practice (eg increasing use of specialistnurses) and changes in the detection and referral ofpatients with CKD to renal units and the increasinginvolvement of the specialty in improving the provisionand quality of care of patients with AKI. A repeat censusof all UK renal units and review of the estimate of therequired ratio of renal physicians to numbers of patientson RRT are in progress.9 Key points for commissioners1 Chronic kidney disease often coexists with otherchronic diseases, especially diabetes mellitus andcardiovascular diseases.2 Although patients with established renal failurecan be kept alive by dialysis or kidneytransplantation, mortality rates are as high as forsome malignant diseases: well-defined carepathways for end-of-life care are an important partof kidney services.3 There is a need for seamless commissioning of thewhole patient pathway, from early chronic kidneydisease right through to treatment by renalreplacement therapy and end-of-life care.4 For patients without major comorbidity, kidneytransplantation offers the best survival and qualityof life: pre-emptive kidney transplantation from aliving kidney donor is optimal.C○ Royal College of Physicians 2013 221
Consultant physicians working with patients5 Funding for additional treatment to allow patientsto undergo ABO- and HLA-incompatibletransplantation will generate cost savings withintwo to three years but not within the same financialyear.6 Variations in the use of home haemodialysis andperitoneal dialysis, and of maximal conservativecare for patients with significant comorbidity,appear to be driven more by clinicians’ preferencesand biases than by those of patients; promotion ofshared decision-making will likely reduce thisvariation, as will the provision of formalmultidisciplinary clinics for patients approachingestablished renal failure.7 The UK Renal Registry provides high-qualityprofessionally led audits of the quality of care ofpatients with established renal failure, and isdeveloping plans to extend its work to patients withacute kidney injury, advanced kidney disease, andconservative care: it is also piloting measurement ofthe quality of shared decision-making, quality oflife, and patient experience. Dissatisfaction withtransport for dialysis is one of the most frequentcauses of poor experience.8 Managed renal networks have played an importantrole in promoting high-quality care. There is aparticular need to define clear clinical pathways forthe management of patients developing acutekidney injury in hospitals without an on-site renalservice.9 There are major opportunities for reducing bothfiscal cost and the carbon footprint of kidney care,for instance by development of phone clinics andvirtual consultations between GPs andnephrologists. The current ‘payment by activity’funding arrangements provide a disincentive tosuch new pathways.10 The ratio of new to follow-up outpatient visits willnecessarily be lower than for many specialties dueto the large number of patients with chronicdisease (including those on dialysis and those withfunctioning kidney transplants) who requireregular specialist follow-up.References1 Gilg J, Castledine C, Fogarty D. UK Renal Registry 14thAnnual Report: Chapter 1. UK RRT incidence in 2010:national and centre-specific analyses. Nephron Clin Pract2012;120(suppl 1):c1–27.2 Castledine C, Casula A, Fogarty D. UK Renal Registry14th Annual Report: Chapter 2. UK RRT prevalence in2010: national and centre-specific analyses. Nephron ClinPract 2012;120(suppl 1):c29–54.3 Royal College of Physicians. Chronic kidney disease inadults: UK guidelines for identification, management andreferral. London: RCP, 2006.4 National Institute for Health and Care Excellence. Earlyidentification and management of chronic kidney disease inadults in primary and secondary care. London: NICE,2010. www.nice.org.uk/CG73 [Accessed 25 April 2013].5 Renal Association. Renal patient view. London: RenalAssociation, 2010. www.renal.org/rpv [Accessed 25 April2013].6 Winearls CG, Fluck R, Mitchell DC, et al. Theorganisation and delivery of the vascular access service formaintenance haemodialysis patients. Reportofajointworking party. London: Renal Association, VascularSociety of Great Britain and Ireland and British Societyof Interventional Radiology, 2006.7 Figueiredo A, Goh BL, Jenkins S, et al. Clinical practiceguidelines for peritoneal access. Perit Dial Int2010;30:424–9.8 National Confidential Enquiry into Patient Outcome andDeath. Acute kidney injury: adding insult to injury.London: NCEPOD, 2009. www.ncepod.org.uk/2009aki.htm [Accessed 25 April 2013].9 Federation of the Royal Colleges of Physicians of the UK.Census of consultant physicians and medical registrars inthe UK, 2011: data and commentary. London: RCP,2013.10 Department of Health. National service framework forrenal services: part one – dialysis and transplantation.London: DH, 2004. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Renal/DH 4102636 [Accessed 25April 2013].11 Department of Health. National service framework forrenal services: part two – chronic kidney disease, acute renalfailure and end of life care. London: DH, 2006. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Renal/DH 4102636 [Accessed 25 April 2013].12 Renal Association. Clinical practice guidelines committee.Petersfield: Renal Association, 2010. www.renal.org/Clinical/GuidelinesSection/Guidelines.aspx [Accessed 25April 2013].13 Department of Health. Main renal unit. Health BuildingNote 07-02. London: Stationery Office, 2008.14 Department of Health. Good practice guidelines for renaldialysis/transplantation units: prevention and control ofblood-borne virus infection. Recommendations of aworking group convened by the Public Health LaboratoryService (PHLS) on behalf of the DH. London: DH, 2002.15 British Transplantation Society and the RenalAssociation. United Kingdom guidelines for living donor222 C○ Royal College of Physicians 2013
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