In the late 1990s there was increasing concern at the chronic underinvestment in renal services across the whole of Greater Manchester, as well as the lack of coordination in the service development. Three renal units had been long established – at Manchester Royal Infirmary (MRI) in central Manchester, at Withington Hospital in South Manchester, and at Salford in the north west of the conurbation.

MRI had started first based on the academic department of medicine chaired successively by two nephrophiles of the pre-dialysis era – Sir Robert Platt and Sir Douglas Black.  Black in the 1970s was a highly influential figure in Manchester medicine and was not an enthusiast for chronic dialysis. He encouraged instead a focus at MRI  on establishing a regional transplant unit (with an eventual catchment population of 4.5 million) , with the limited dialysis facilities there necessary to support the transplant programme. Black promoted the establishment of the maintenance dialysis unit at Withington. Read more about the beginnings of nephrology in Manchester – a piece by Netar Mallick ready soon)) . A CRF Committee was established (chaired first by Netar Mallick (MRI) then by Peter Ackrill (Withington) which made recommendations for service development resulting in a third unit being established at Hope Hospital, Salford. This was followed in the 1980s by a unit at Preston which  began to take over responsibility for kidney care in the northern half of the northwest region as far as Cumbria.

Despite those efforts, the growth in consultant nephrologist numbers in the northwest was remarkably slow throughout the 1980s and 1990s, as it was elsewhere in the UK. By 1997 there were still only ten consultant nephrologists in total leading care in the three units in Greater Manchester, and the workload of all clinical staff was formidable. A significant under provision of HD facilities meant that more than 50% of all dialysis patients at MRI and Salford were on peritoneal dialysis, whereas at Withington more than 90% were HD, reflecting in part the long established and very large home HD programme at Withington. There were also some geographically anomalous relationships between the three centres and the district hospitals across the region, based on relationships established in the early days of nephrology in the region; examples being that the Withington unit in the south was providing outpatient nephrology clinics in Lancaster, despite the Preston development, and in Rochdale to the north east.  Patients from those areas requiring in-patient care were still travelling to Withington.

The need for a strategic review of this unsatisfactory situation was accepted by the Greater Manchester Health Authority, and in 1997  a proposal emerged for the reduction of three units to two, based at MRI and Salford) with a coherent plan for future service development as a managed clinical network. Whichever of the three units had been recommended for closure, there was inevitably going to be disappointment, especially among staff,  some of whom had worked in one unit for twenty years or more. The choice that the two major units would be MRI and Salford was indeed challenged and went to the Secretary of State for Health for review and final approval in 1997.

A three year implementation programme began in 1998. Donal O’Donoghue (Salford) was chosen by the consultant staff of all three units to be its Clinical Lead, and Jenny Scott (an experienced renal commissioner) was appointed as  Programme Director.

Watch a presentation by Jenny Scott about the programme, which she gave at a meeting to honour Donal O’Donoghue after his unexpected early death.

Although this retrospective review indicates the overall success of this transformation project and offers it as an exemplar of what is achievable within a disparate kidney care community, it is important not to understate the challenges.  The leadership of the project was undoubtedly seen by some staff in other units as favouring Salford; O’Donoghue was an established Salford consultant, and Scott had been the renal directorate manager at Salford as well as having past experience as a specialised renal commissioner. Scott had offices at both MRI and Salford to try to highlight her commitment across the patch, but nevertheless recalls herself being described unfavourably as ‘Donal’s lackey’.

The programme included workstreams for consolidation (of the three main units into two), strategic planning (of new dialysis capacity),  outpatient planning, and workforce planning. One example of the challenge of consolidation was ensuring adequate preparations at MRI for the absorption of the Withington patients; not only would the routine outpatient treatment of 180 HD patients be transferred to MRI, the MRI unit also had to be ready for the substantial call on in-patient facilities which is required by HD patients.

The eventual result was the Greater Manchester Renal Managed Clinical Network, the first of its kind in England (see map).

The network emphasised empowerment of DGHs through partnership, rather than a more traditional ‘hub and spoke’ which was perceived to be based on central control.  The network also required consistency of clinical standards which was expected to lead to improved patient outcomes.   Existing anomalies in patient flows based on historical links were rationalised, and proposals for new units (the first in Bolton and Wigan) were approved.

Some acrimony had to be overcome, and this was aided by an extensive public consultation, promoting the case that the proposed changes would improve patient access to care, and improve the quality of that care. Close partnership with patient representatives is recalled by Jenny Scott as a key to success, mainly through partnership with the North West Kidney Patients Association, and its leader Dennis Crane. Patients representing each modality of RRT also became part of the discussion and decision making processes.

This tra. Jenny Scott recalls that the case of need they were able to   build thronsformation project was funded for three years by the Greater Manchester Health Authority, but thereafter development proposals had to make their way through the existing specialist commissioning processesugh the transformation project and the consensus support for changes greatly enhanced their ability to get positive responses from commissioners.

Last Updated on June 26, 2023 by John Feehally