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From the time haemodialysis started to become available in the mid 1960’s, technical support was needed to allow treatments to take place. This was not only for the maintenance of the equipment, but also to give direct support in preparing and operating the equipment. The personnel involved in this support were often part of Medical Physics and Clinical Engineering departments but, by the end of the decade, as renal units were becoming more established, dedicated technical teams were being formed to support the treatment programmes. Indeed, the technical team at Leeds General Infirmary worked with Dr Frank Parsons to build their own system.
(Dr Parsons was to later become the first president of the Association of Renal Technicians (ART)
As the availability of equipment expanded with Lucas, Cambridge Instruments and Dylade all manufacturing in the UK, technicians started to become more involved in the wider aspects of how equipment was chosen and developed although technically minded nephrologists leading the innovations in renal treatment were still key to these advances. While British companies were still manufacturing dialysis equipment, input from NHS technicians was actively sought and particularly with the development of the Lucas Mk II and Dylade D2 machines which were introduced in the mid 1970’s. Towards the end of this period companies like Gambro, Cobe and then Fresenius by buying out Dylade, were starting to get a bigger share of the UK market. Although these companies sought input from NHS staff, the driving forces were international markets rather than the relatively small UK market.
This was also a period when the emerging technical aspects of equipment were very important. Reliability, ease of maintenance and improving patient safety were the big considerations and technicians were key in driving equipment selection even though nephrologists were generally the final decision makers. Over time the decision making has moved more to useability; reliability, ease of maintenance and patient safety are taken for granted and it is the user/patient interface which is the more important. There are also cases, sadly, where financial business cases have taken precedence over technical and user input.
During the 1970’s, technical teams, in conjunction with the Department of Health and Social Security (DHSS, to later become the DoH) became more involved in equipment safety and the potential for improved equipment contributing to better treatments of patients with Renal failure. In 1973, Henry Robinson from the DHSS, organised a symposium for haemodialysis technicians at the Hospital Engineering Training Centre at Falfield, Gloucestershire.
This was attended by 42 hospital technicians as well as 7 representatives from the DHSS. Over two days papers were presented on equipment maintenance, various safety considerations, and evaluations of new equipment becoming available. The presenters included Graham Harston from Sheffield and Alan Siviter from Birmingham who were both going to become very involved with the development of specialist renal technicians.
Following the success of the 1973 symposium, a further meeting was held at Falfield in 1974; this time with nearly 60 attendees. The papers this time also included one on the history of dialysis prior to 1969 and several on water quality for haemodialysis, still a hot topic today. Dr Des Oliver from Oxford was one of the guest speakers.
In 1975, a third symposium was held; this time at St Ann’s Hotel in Buxton. Again, it was mainly organised by the DHSS but it was the first time that consideration was given to forming an
The ART was formed after this meeting with Alan Siviter (above) from Queen Elizabeth Hospital in Birmingham the main driving force and remaining chairman for a number of years until being succeeded by Colin Aldridge from St. Bartholomew’s Hospital in 1988.
The first ART symposium was held at Keele University in 1976. This was the first of a string of meetings held at university venues culminating in a run of meetings at Warwick University. In 1983, the RCN Dialysis and Transplantation Nurses Forum joined ART in organising the meetings although the nature of the papers presented remained mainly technical.
Following the success of these meetings and pressure from manufacturers sponsoring the meetings, the format was opened out to a wider multidisciplinary group and the first British Renal Symposium was held in 1990. These meetings became more successful than ever but the technical input started to decline and ART’s involvement slowly became less relevant. It also led to a financial crisis for the Association which had previously been supported by the income from the annual meetings.
Cliff Harvey from the Royal Free held ART together when Colin Aldridge became involved with the technical section of EDTNA and in 1995 Gordon Farquhar from Norwich started the job of successfully rebuilding the Association.
This resulted in the reintroduction of an annual meeting in the year 2000 which was a success. The meeting has become more popular as the years go by and is still going in 2024. A key feature of the exhibitions has been current equipment shown by manufacturers but also an historic exhibition of some of the equipment stored by ART as a museum opportunity.
Gordon also stood down as chair in 2000 to be replaced by Andy Mosson (Oxford), then David Gandy (Guys), and currently Roger Moore (Wolverhampton).
The purpose of the renal technical meetings and the creation of ART was to provide a forum where knowledge could be shared nationally. In the early years of haemodialysis this was very important as new ideas were continually being developed.
One item of interest at ART meetings was the variety of ways in which home dialysis was delivered and many of the symposia included papers about the techniques used in different units. These were often the installation of a portakabin in the patient’s garden to create a medical environment for dialysis – very different from the minimal approach taken now which in many instances relies on technical innovation to make something fit the home.
In the seventies and eighties, when the majority of patients treated themselves at home, there was an opportunity for holiday dialysis; not, as now, provided in dialysis units but relying on self care. The patient charity organisations of many dialysis units funded holiday sites which would typically be a portakabin in a suitable location kitted out by the unit technicians in the same way as their home dialysis systems. Home patients could then make a booking to use these sites to treat themselves on holiday. Some sites were quite ambitious, St. Thomas’ Hospital had a site on the Isle of Wight, Guy’s had one on the Channel Islands, and Oxford had one in France – I’m certain there were many more just as interesting.
Richard Furminger, one of the technicians in St. Leonard’s Hospital, East London, was involved in converting an old ambulance for mobile dialysis.
A Cambridge Instruments MkV machine was built into the ambulance to achieve this.
There was also opportunities to use specialist portable systems. The Redy machine, developed in the USA used a sorbent system to recirculate the used dialysate to minimise the requirement for a water supply. In this country, the dialysis technicians in Sheffield developed their own suitcase machine which could use large cans to handle the water and waste dialysate.
Other information shared by ART involved safety standards. Standards were being developed in USA, Europe and by the DHSS in the UK. These involved both electrical safety and defining necessary safety monitoring of the prepared dialysate and the extracorporeal blood circuit. Discrepancies between American and British requirements certainly caused headaches for manufacturers. Over the years the standards have become internationally agreed and, in the UK, adopted by the British Standards Institution (BSI). ART have had an input route into these standards and still have members sitting on the relevant BSI committees. There was some responsibility laid on unit technicians to ensure equipment complied with these standards but that was eventually superceded by type testing performed by BSI – the latter a little more consistent than the former!
Technical training has also been a key theme of the ART symposia. This has slowly evolved from merely sharing information to the development of prescribed training scheme. The training programme is also now available as part of a Clinical Engineering degree to give renal technologists a solid foundation of renal knowledge. Along the way there have been those who doubted the need for this education; my answer has always been “It has taken me forty years to pick up this knowledge, often incorrectly or misinformed, we now have the opportunity to impart knowledge much more quickly and accurately”
There are many people who have been involved in the training scheme and several deserve a mention. Ray James developed a European curriculum which was the basis for the British curriculum developed mainly by him, David Gandy and Ian Morgan. These three, with Maurice Harrington and Lizzie Lindley, worked with Bradford University to create the degree module and David, Andy Mosson and Peter Jones worked it into a vocational programme which could be delivered in Renal Units. There are many others to whom apologies are due for not getting a mention.
During the last twenty years or so, ART have become very involved in other organisations to develop the professionalism of Renal Technologists. It was becoming apparent in the late 1990’s that the DoH would proceed to formalise many of the support professions working in the NHS. ART were very keen not to be sidelined in this process and as a first step ART contacted the body representing Clinical Physiologists who were seen as a similar grouping to Renal Technicians. After attending several meetings with the physiologists, which included introduction to the NHS Chief Scientist, it was concluded that the direct patient related work of the physiologists was not the best fit with renal technicians and that the Institute for Physics and Engineering in Medicine (IPEM) was a more fitting partner. Successful talks with IPEM led to the signing of a formal affiliation agreement.
Under the auspices of Professor Sue Hill, a new Chief Scientist at the DoH, groupings of Healthcare Scientists were being recognised which included Renal Technologists (a posh new name, no longer ‘technicians’) and the DoH hosted meetings of the leaders of these professions to consider education and professional standards already applying to other State Registered Professionals.
Part of this process included a reception at 10 Downing Street hosted by Tony Blair to recognise the work of Healthcare Scientists.
ART had been discussing the issues of registration of Renal Technologists with IPEM, who already held the Statutory Register of Clinical Scientists, and was considering creating a register of Clinical Technologists as a prerequisite for forming a statutory register. After further discussion, IPEM and ART, along with IHEEM (The Institute of Healthcare Engineering and Estate Management) agreed to create the Voluntary Register of Clinical Technologists (see: therct.org.uk) with a view to achieving statutory registration. In 2004 the Health Professions Council (HPC) agreed to the statutory registration of clinical technologists along with a number of other professions (including Clinical Physiologists). Preparations continued with the HPC but in 2007, after the actions of Harold Shipman, central government decided to review the registration situation and decided to not create any new registers but to rely entirely on voluntary registration! The Register of Clinical Technologists is accredited by the Professional Standards Authority but despite much lobbying by the affected professions, individual registration still remains voluntary.
In the last sixty years haemodialysis has moved from being an experimental treatment to become a mainstream treatment for patients with renal failure. Renal Technologists have had to change to meet the demands as the therapy has evolved. The first clinical engineers had to cope with all the unknowns of the new treatment and were often working with handmade devices and simple control systems, using their own initiative to make the systems do what was needed. The modern Renal Technologist has less scope to adapt the therapy but needs to be highly trained and competent to work on complex computerised equipment and capable of meeting the demands set by the large number of treatments being carried out.
The first treatments required a minimum of water purification – a water softener at most. Because of the porosity of modern dialysis membranes, to prevent harmful contaminants entering the blood stream, renal units now require huge amounts of highly purified water for dialysate preparation. Besides the understanding of electronics and hydraulic pressure and flow relationships, the renal technologist of the 2020’s also needs to be an expert in large scale water purification.
Renal technologists are the classic Jack of All Trades but also Master of All!
Author – Andy Mosson
First posted 22 October 2024
Last Updated on October 21, 2024 by John Feehally