by Es Will
Contents
The piecemeal establishment of UK renal units over four decades created a notional archipelago of kidney specialty islands in the ocean of NHS secondary care. Each renal island reflected their origins, supervision, special local circumstances and clinical interests in a range of idiosyncratic, strong, clinical and managerial cultures. Their various challenges were managed through the local improvisations that were characteristic of NHS secondary care departments before, and after, the reorganisation upheavals of the 1990s. The island metaphor fits the playful suggestion of the first renal Czar, Donal O’Donoghue (D O’D), that an Ethnography of the specialty might be useful, as a prelude to the greater uniformity of policy and practice that he aspired to create through the Renal National Service Framework (R-NSF) of the early millennium. An Ethnography?
The academic sub-discipline of Ethnography was hatched from an immersion (we would now say ‘embedding’) of anthropologists in the native societies of the Pacific Ocean in the early 20th century, which was designed to produce a detailed description of their attitudes, behaviours and conventions. A comprehensive synthesis of each island culture could then be attempted. The iconic pioneers were Malinowski and Mead.
The renal specialty situation in the late 20th century was almost the reverse of those intentions. Leaders of the discipline promoted two high-level hypotheses of clinical effectiveness in nephrology, in style and process, research and routine, which they wished to see implemented. The methods appealed to logic and clinical motivation. They consolidated the informal, inherited approaches of clinicians by general structural suggestions. They promised greater uniformity in the cultures of the specialty. The NHS appeared to offer an excellent context for such reorientation.1-3 Expert supervision was embedded through the leadership of the R-NSF by a clinician (D O’D) and the enrolment of allied health professionals (PAMS) as agents in the processes of change. Nephrological culture was to be globally revamped, without prior preparation at unit level, a reverse ethnography! The plausibility was irresistible. What could go wrong?
The two imported cultural comets of the 1990s were Evidence-based Medicine (EBM) from Canada and Continuous Quality Improvement (CQI) from the USA, both bearing a tail of novel methodologies.1 For example, the introduction of Bayesian Statistics was an attractive come-on to thoughtful clinical scientists, a glister in the tail of EBM. Several contexts made UK Nephrology especially suitable as a substrate for these two approaches. Existing NHS uniformities suggested an infrastructure for CQI, in particular, and that offered an effector arm for EBM. The established renal PAMs were a corps waiting for direction and contribution, as a prelude to their greater professional recognition. Perhaps the UK specialty tradition of professional hierarchy was a significant, unamerican, dissonance, but dialysis in particular had always carried a presumption of multidisciplinary engagement, albeit under conventions of medical supervision.
Such general assumptions (aka ‘common knowledge’) concealed the idiosyncrasies of everyday renal unit operation, although comprehensive generic explanations and implementation procedures were developed for the two new ideas.4 It seems obvious that changes could have been tailored to each unit if their detailed culture had been known. In the event, the introduction and development of the hypotheses was left largely to local players, who promptly contrived a blizzard of uncoordinated, illustrative projects, reflecting their personnel and interests.5-7 The range of practical issues was rather narrow, like patient autonomy and transport.
A strong clinical tradition of individual patient management, and the gradual, universal, movement towards ‘personalised’ medicine, rather conflicted with the general (guideline-based) implications of both theories. Subsequently that has demanded a reconciliation with the large-scale studies that were necessary to enlarge the Evidence base and define physiological optimisations, like blood pressure control. That task is continuing and controversial.8-10
What was unfolding, in retrospect, was the increasing capacity of the specialty to manage both patients and facilities in a more informed, quantitative, context. The specialty was ‘tooling up’ but begged an overall shape! The clinical IT coming out of the 1980s offered better information flows and situational awareness to professionals. Efforts to define necessary dialysis dose (Kt/V urea) brought greater confidence and control of late-stage renal disease. Renal anaemia became directly manageable, if not entirely prescriptive. Above all, the establishment of the UK Renal Registry (1995) brought the activity of the many centres together, allowing national comparative audit and open clinical performance within a national epidemiological framework.1 A provisional commonwealth of the archipelago was enacted, albeit largely focussed on secondary laboratory-derived indicators and dependent on local buy-in.
The scope of nephrological practice was also clarified through the import of two other new terminologies and definitions. A more graduated approach to acute renal disturbance (AKI) and chronic disease (CKD) brought a welcome re-examination of the specialty task. Predicted functional deterioration through eGFR and the amelioration by blood pressure control in Diabetic Nephropathy, for example, created both an awareness of disease progression and served as an early rehearsal of effective means to intervene.11,12
Proactive renal transplantation also represented an increasing pre-emptive capacity to transform previously inevitable renal and health outcomes.
These high-level, theoretical, reconstructions penetrated variably to unit level. The task of undertaking detailed description of six dozen renal unit cultures was not envisaged formally as a project. Impeccable, or at least good enough, clinical practice standards were assumed in both medical and PAMs practitioners, notwithstanding the necessary scale of improvement in unit processes and function that was in prospect. It was left to unit level to assess audit results, for example, a narrow, self-derived, ethnography? The sensitive issue of unit independence was more than fully respected in the new mechanisms of practice.
The original R-NSF aspirations were much more ambitious than had been realised, a forgivable optimism. An explicit attempt at unit ethnography might have exposed that more clearly, but at least a start had been made.
Ultimately, repeated, detailed re-investigation of unit practices and outcomes were found to be desirable under a different guise (as, for example, through the GIRFT initiative), and further nation-wide specialty improvement programmes have followed.13,14 It seems that unit ethnographies can be compiled inadvertently through repeated surveys, an intuitive group spreading of the considerable but necessary effort and expense.
Subsequent to clinical IT being developed according to specialty, and then found wanting for general application in secondary care, it became very apparent that renal services could not develop without collaboration with other medical specialties. The decades-long struggle to ensure the availability of adequate facilities for renal replacement, and the focus on disease-based research, had meant, arguably, some commonly accepted voids in medical care and nephrological research. That was to have been expected in the elderly, with a de facto age ceiling (>60 years) and diabetic nephropathy untreated until after 1980, but less obviously so for mental health and symptom control. Those areas have been receiving greater attention in the past two decades through the recruitment of other specialty expertise.
The rational principles of the 1990s raised hopes of widespread improvements in practice. The slow progress might be explained by an excess of delegation to the uncharacterised island unit cultures, but that was only part of the poorly recognised challenges of clinical ‘change management’. A subverting, common feature has been the uncertainty of benefit from hard to formulate rational hypotheses and the trade-offs that become obliged by a resource- limited NHS.
The uncertainty of improvement initiatives has become expressed in quite opposite academic approaches. On the one hand, clinical specialty practice can be seen as highly complex and unpredictable. Specialties are then defined as Complex Adaptive Systems, able to resist or divert change (see box). 15 Alternatively, frustrating uncertainty may be tamed through a yet more vigorous and comprehensively informed Implementation Science.16
These are perhaps the modern equivalent of the historical conflict between the medieval Franciscan and Dominican Religious Orders, whose philosophies delimited a spectrum running from the recognition of a multi-dimensional humanity to an intolerant religious literalism and rigidity. Holistic, humane, cushioning was contrasted with direct, severe, responses by the energetic and impatient. The Cathars of SW France felt the heat of that difference keenly.17 There is nothing new in the extremes of intuitive preferences!
Complexity theory (CT) is the study of how large systems, containing a variety of elements prone to unpredictable, non-linear interactions, come to reorganise and adapt to changing circumstances. A complete description of the micro-interactions of system components cannot be anticipated, although a detailed understanding of them can inform change. A clinical specialty can be seen as a ‘complex system’ in these terms.15
Implementation science (IS) is the close study of formal strategies and tactics to steer the uptake of evidence-based practice and research into routine use. The aspiration is towards generalisable models that will bring what is current consensus into the clinic. The systematic design of interventions acknowledges the need to create buy-in and a suitable context. An element of evaluation is central to the philosophy. The approach is based on the hypothesis that comprehensive analysis and energetic, focussed action will improve the penetration of best practice. 16
It is apparent that EBM and CQI will be components of any IS approach in medicine. While Complex solutions can be characterised but are uncertain, Implementation solutions are expected to be scrupulously designed and specified.
The cultural sequence in Nephrology has also rehearsed a surprising progression from a Palliative towards a Preventive capacity – the specialty has been moving from the back to the front foot, with increasing understanding, control and effectiveness. That aligns comfortably with current NHS/political policy. The remarkable progress in pharmacological agents to mitigate renal deterioration in CKD was not predicted. It is being validated by drawing on the experience of now familiar scientific study methodologies, like RCTs, developed to address the validation of past, largely palliative, treatments.
There has been a kind of democratisation of aetiology, where the disorders that prompted early, sustained, scientific effort to understand the kidney, like glomerulonephritis, are now exceptional, minority players. There is reason to believe that modern investigatory techniques will progressively improve understanding of those non-metabolic diseases that are now described as ‘rare’. However, in the modern epidemiology of renal disorder greater patient numbers derive from metabolic and vascular causes. The overlap of vascular, diabetic and renal disorders has been recognised, with a major enlargement of interdisciplinary cooperation as the current consensus. That late convergence is consistent with the premature, calcific vascular disease that was recognised very early as the major non-renal complication that limited survival on dialysis.
Critical specialty developments are enacted over decades and so the Timelines based solely on new events do not convey well the slow, overlapping, cultural changes that have occurred. Staggered parallel lines would perhaps do that rather better, although few maturing developments have an offset, such as general acceptance, that is as clear as any introduction.
A detailed knowledge of the ethnological idiosyncrasies of UK renal units might have usefully informed and accelerated the brokerage of clarifying hypotheses (EBM/CQI) in renal specialty culture after the millennium, but the parochial, informal, efforts were incomplete. Indeed, the history of UK renal culture was a kind of reverse ethnography, with the attempted imposition of high-level hypotheses on renal unit cultures that were assumed to be largely uniform. At least six theoretical realignments for changing those traditional cultures have been made, as clinicians have become more aware and informed of their task and context. Unit ethnographies have been slowly compiled but the shift towards the prevention of renal disorder and broader medical specialty linkages are still occurring in the setting of a heterogenous localism.13 Further national initiatives seem inevitable. The current recommendations are more detailed than in the past and take advantage of a modern expression of ideals in organisation and process.14,18 Just how effectively the post-millennial multi-consultant units are able to respond, compared to what we may call the baronial past, has yet to be formally explored.
The renal island pattern would seem to be typical of established NHS specialty departmental cultures. Whilst mitigated by an awareness of complexity and the rigours of implementation science, it presents a systematic problem for attempts to rationalise UK secondary healthcare. To nearly torture the metaphor, the brokerage of consensus processes and standards into unit cultures is not half as congenial as the experience of Captain Cook’s crews in Tahiti.
Last Updated on October 24, 2025 by John Feehally