Back to the Future: Changes in the Dialysis Delivery Model in the UK

Abstract

The origins of dialysis in the United Kingdom (UK) predated the introduction of the National Health Service (NHS) in 1948 by a couple of years. The unique manner in which the NHS was formulated and developed has remained intimately linked to the delivery of dialysis therapy in the UK throughout the latter half of the twentieth century to the present. The power of the NHS is achieved through a closed managed healthcare system offering universal coverage, with care provided free at the point of delivery, underpinned by a registered population. Healthcare in England is delivered by the NHS and controlled by the Department of Health, which regulates 10 Strategic Health Authorities, geographical divisions essentially coterminous with government office regions with the exception of the southeast of England, which required further division to account for greater population. Strategic Health Authorities are responsible for the performance management of all NHS trusts within their region, including a number of NHS Primary Care Trusts, which total 152 across England. Primary Care Trusts are the principal fund holders in the NHS, accounting for 80% of the annual NHS budget, which is in excess of £100 billion. They are responsible for assessing local needs and commissioning healthcare services accordingly from a variety of providers, such as hospitals and general practitioners. Renal services in England (dialysis and transplantation) are commissioned through Specialised Commissioning Groups. These groups are aligned with Strategic Health Authorities and manage pooled budgets from corresponding Primary Care Trusts set aside for specialized services, such as dialysis and transplantation, to minimize the risks of individual Primary Care Trusts funding expensive services for a limited number of patients. There are 52 renal units in England serving approximately 51 million people, and the manner in which they were formed (described later) means an individual renal unit may serve a population that crosses Strategic Health Authority boundaries as well as several Primary Care Trusts. Delivery of desired care thus requires partnership between Strategic Health Authorities, Primary Care Trusts, and provider hospitals. The NHS has seen numerous structural reorganizations since its inception, particularly during the past 20 years, often as a result of new governments or changing sociopolitical climates. The ability to design and implement services for our patients has been directly affected by these changes.