by Es Will
Contents
Much history of renal specialty interest is centred on early developments, beyond living memory. Twentieth century events, of course, are still part of a survivor’s experience, which creates some hesitation in laying it out. However, despite the hazard of generalising from anecdote, it seems worth exploring the arc of development of the specialty in the last five decades of the century. That was, after all, when the fundamentals of maintaining Nephrology in the NHS were established.
It was apparent by the end of the 1970s that it was common for renal units to be a cockpit in which many consultants were struggling for influence and control. The early NHS model, of consultant appointments by regional health authorities, rather than by their institutions, committed incumbents to practice for the local community and regional populations. In-patient beds were designated on appointment but the coherence of most medical specialties, with an accepted routine of sharing acute medicine, was loose. University departments, as in the USA, carried an established internal hierarchy, which gave a clear status to clinical academics. Otherwise, local consultant influence on medical policy and development depended on seniority by longevity and personal characteristics, ultimately enacted in the professional Cogwheel system. The balance of supervisory prerogatives was contingent, not predetermined.
The NHS provision of maintenance haemodialysis for renal failure, a centrally funded initiative delegated to regions in the years after 1966, depended on the near coterminous appointment of a series of renal consultants. It created a cohort of foundation nephrologists, synchronising the clock that ticked on their careers. They were expected to set up units from scratch, in a variety of existing local infrastructures. They were often obliged to transform otherwise redundant healthcare spaces. Thankfully, they were in an energetic, heroic mould, inevitably idiosyncratic in their rather isolated practice. They had a social role to engage with local populations for fund raising, initially for research and then for equipment, and mobilise charitable and voluntary sources for unit support. The backdrop of encouraging renal donation for transplantation was a parallel mission. The scale, complexity and development of renal units imposed a significant and changing management burden on consultants.
Dialysis patient populations grew apace and that demanded additional trained senior manpower, which, as ever in the NHS, was slow to be funded and variable, region by region. Middle grade staff, notionally in training, filled any gaps in supervision and took extensive responsibility for clinical management. The appointment of more consultants was inevitable, although the chosen single-handed period was discretionary and variable in each case. That incumbent prerogative determined the quality and expectations of the subsequent succession.
The foundation cohort became faced with acquiring more up to date colleagues, who were variably expectant of shared responsibility, consistent with their commitment to covering the acute, chronic and training renal services. The certain likelihood of those potential bargains was not recognised centrally, but dealt with piecemeal at regional and hospital levels, with each incumbent determining a tolerable onward course for the unit and themselves. The timing was at their discretion and suitable, congenial candidates could often be accommodated. However, the implicit model, aping the honorary status of pre-NHS specialists in assumptions of independent practice, was carried over as an implicit part of the system.
The founder generation, the first of trained Nephrologists, had acquired influence, not only locally, but also in professional organisations. The consequences of a new colleague for local private practice were uncertain, although probably less than for other medical specialties. However, the specialty tradition, of active research in post, meant that new appointments might be significant for personal academic aspirations and the potential for merit awards.
The dominance of founders was the more marked because decisions, clinical and administrative, had had to be incisive, in the absence of other sources of expertise and as an economy of means. More theoretically, the suggestion of dialysis as an implicit ritual (see previous essay on ‘Units’) leaves open an interpretation of single senior staff as equivalent to a high priest, producing an unformulated acknowledgment that might earn from unit staff and patients. It is easy to understand the feeling of ownership that would come from these incidental attributes, combined with the conscious effort of having created and sustained a renal unit for a decade or more. Existing hospital administrators and senior unit staff were likely to feel a natural inclination of sympathy for an incumbent, whom they had seen striving and knew well. The need for expansion of unit capacity and changes in technique also put pressure on leadership, where forging new unit entities demanded a vision that could be subject to dispute.
What is more, in metropolitan areas, the politics of renal investment often involved strong defensive policies in dealing with other candidate centres. Some Unit incumbents were engaged constantly in sustaining their current investment and share of the growing demand for renal replacement.
There were some practical pros and cons of consultant dislocation. It was sometimes necessary to dissuade staff actively from enshrining senior personal preferences in routine procedures, to sustain unit coherence and avoid mischance. The differential encouragement of policies, like influenza vaccination, and technical enthusiasms was a hazard. Other staff might become aware of how to promote their view of uncertain patient management, by presentation to the consultant believed to be of similar opinion.
However, on the positive side, the possibility of a patient choice of sympathetic consultant accompaniment was created in some settings, either permanent or temporary, according to their perceived need. No doubt there were many shades of these opportunities from discord.
If there was anything but informal organisational responses to this widespread predicament it was not evident. Consultant partnerships were seen as too intimate to direct, and no model based on counselling was introduced, although apposite. There was consideration by incumbents and appointment committees of just what might work out well, but motives were not easy to know, and subsequent adjustments of influence were unpredictable. The tradition of the semi-honorary independent status of senior staff, and perhaps the limited awareness of human psychology in the UK of the time, meant that poor relationships were allowed simply to develop and then fester, regardless of rights and wrongs.
In the early 1980s an informal review suggested that up to half of all UK renal units could be considered to have uncomfortable or poorly functioning consultant co-operation. Much of that was covert, for obvious reasons. At the extreme, there developed alternate, single, management intervals, in others the colleagues accepted separation of responsibility by sub-specialty interest or experience. There was a wide range of solutions depending on the capacity/reputation of the founder and the recruited colleague. Whilst in the USA movement between institutions was a routine part of career progression, in the UK it was frowned upon and in one case, prior to legal constraint, formally prevented. There was actually no relocation escape from founder preferences.
The tensions persisted until some voluntary relaxation of control by incumbents or the formal declaration of a Unit Clinical Director, as Trusts became more imitative of corporations. Such appointments could both clarify and aggravate working relationships. This scenario, which in hindsight can be seen as predictable, was largely unmanaged until the mortality or retirement of incumbents, or the appointment of more colleagues. The much later major enlargement of senior staff numbers, in place of trainees, changed the intra-unit supervision towards shared arrangements and rotation, for good or ill.
This historical sequence was phasic because of the coterminous appointments of the 1960s and early 70s. It demonstrated the penetration and consequences of such coherent initiatives in a large organisation. Whether a greater, modern awareness of personal/group psychology and management strategies would have resulted in less conflict and alienation remains to be seen. In retrospect the avoidance of responsibility for the maintenance dialysis initiative by the NHS centre came to allow, inadvertently, a variably incoherent and dislocated peripheral supervisory infrastructure in a number of renal units. There were serial consequences from the NHS regional initiative, enacted through professional traditions to create invidious challenges for individual incumbents.
The traditional model of consultant status was dependent on goodwill and patronage, not necessarily on fairness or compromise. That was overtaken ultimately in the pursuit of a corporate NHS, which has put all the players on a different spot and successfully subverted traditional consultant practice! The 1990s expectation that Trust Medical Directors would manage individual consultant aspirations actively and generously was largely disappointed, as the new Boards were vested with corporate identity. The step from administration and senior staff committee prerogatives to Hospital Board was a usurpation far greater than anticipated at the time.
Author – Es Will
Last Updated on December 1, 2024 by John Feehally