Service Change Proposal Proforma
1. Title of Proposal
Proposed Transfer of Cadaveric Renal Transplantation for North of Scotland Patients
from Aberdeen Royal Infirmary to Edinburgh Royal Infirmary.
2. Originator
Dr Nick Fluck, Head of Service for Renal Services
3. Sponsor
Dr Roelf Dijkhuizen, Medical Director
4. Background
4.1
Outline of the Service Currently Provided
Aberdeen Royal Infirmary currently offers cadaveric renal transplantation to the end stage
renal failure population in the North of Scotland. This includes patients from NHS
Grampian, Orkney, Shetland and Highland. With the imminent retirement of the lead
transplant surgeon at Aberdeen Royal Infirmary (transplant surgeon will cease to
undertake cadaveric renal transplants at Aberdeen Royal Infirmary in December 2003) it
is recognised that the cadaveric renal transplant program can no longer be provided
locally. The reasons for this are outlined in section 4.4 - key drivers for change.
Grampian patients considered for live related and unrelated renal transplantation are
initially evaluation in Aberdeen but are then referred to Edinburgh for full assessment and
subsequent transplantation.
4.2
Description of the Proposal
This paper sets out a proposed framework for providing a comprehensive renal
transplantation service outwith the Aberdeen Royal Infirmary. The current favoured option
would be to integrate services with the Edinburgh Royal Infirmary Transplant unit.
4.3
Activity
Year Total
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
33
19
23
35
21
21
11
31
20
14
15
11
Cadaveric Transplants
Grampian Patients in ARI
Inverness Patients in ARI
29
17
19
29
15
18
5
18
13
6
4
6
4
2
4
6
6
3
6
9
5
5
5
1
Live Transplants
Grampian Patient in Edinburgh Grampian Patients in Edinburgh
0
0
0
0
0
0
0
0
0
0
1
2
0
0
0
0
0
0
0
4
2
3
5
2
40
35
30
25
T ot al
Gr ampi an P at i ent s i n A RI
20
I nver ness P at i ent s i n A RI
Gr ampi an P at i ent i n E di nbur gh
Gr ampi an P at i ent s i n E di nbur gh
15
10
5
0
1990
1992
1994
1996
1998
2000
2002
2004
For service planning purposes a figure of 10 NHS Grampian and 5 NHS Highland
cadaveric transplants per annum has been used.
4.4
Key Drivers for Change

reducing number of cadaveric transplants being undertaken each year at Aberdeen
Royal Infirmary due to national shortage of cadaveric donors. This is set against a
requirement for renal transplant surgeons to undertake a critical mass of cases to
maintain clinical skills and expertise.

National shortage of renal transplant surgeons

Retirement of renal transplant surgeon at Aberdeen Royal Infirmary in December
2003. Requirement to make an urgent decision about the future planning of the
cadaveric renal transplant service for NHS Grampian patients. Arrangements need to
be put in place in advance of the renal transplant surgeon at Aberdeen Royal
Infirmary retiring in December 2003. This will allow Grampian patients to be assessed
by a new renal transplant team.
5. Aims and Objectives
The reasons for this service change are outlined in section 4.4 - key drivers for change.
Aim is to provide a proposed framework for providing a comprehensive renal
transplantation service outwith the Aberdeen Royal Infirmary
6. Link to strategy
Proposed strategy fits in with national guidance that renal transplant centres need to
undertake a critical mass of cases to maintain clinical skills and expertise.
7. Public Consultation and Involvement
Appendix One provides an overview of the process undertaken by NHS Grampian for
public consultation and involvement. It provides a summary of the feedback received from
members of the public in response to the proposed service change.
8. Timescales
Immediate decision required by NHS Grampian. There is an urgent requirement to put in
place arrangements to transfer the cadaveric renal transplant service for Grampian
patients from Aberdeen Royal Infirmary to Edinburgh Royal Infirmary in advance of the
renal transplant surgeon’s retiral date (December 2003).
9. Indicative Cost (estimated)
Enclosed below is a broad indication of the likely cost of transferring cadaveric transplant
services from Aberdeen Royal Infirmary to Edinburgh Royal Infirmary.
RENAL TRANSPLANTATION - TRANSFER TO
LOTHIAN
Note
Pre Transplant Assessment Clinics
Consultant
(i)
Transplant Co-ordinator
(ii)
Clinic Support
Patient Transport
(iii)
£'000
14
36
10
4
Transplantation
Cost of procedures at LUHT
15 cases @ £32k per case
Patient Transport
Backfill for SpR
(iv)
(v)
(vi)
480
6
16
Post Transplant
Patient Transport to ARI
(v)
4
570
(i) Assumed one session for pre dialysis and transplantation
(ii) If assessment indicates that co-ordinator is required then discussion
to be held with NSD central funding.
(iii) Cost for Grampian patients travelling to ARI Clinic for tx assessment
(iv) Cost for assumed 10 Grampian and 5 Highland cadaver transplant patients
Highland will reduce contract with GUHT accordingly.
Excludes costs of live transplant patients as all currently undertaken in Lothian.
(v) Grampian patients only
(vi) Assumes SpR's required to rotate to Edinburgh for transplantation experience
And locum brought in to backfill.
10. Risk Assessment

Delay in assessing Grampian patients for renal cadaveric transplants if an agreement
has not been reached to transfer the service to Edinburgh Royal Infirmary. The
opportunity cost would be NHS Grampian patients missing out on a cadaveric renal
transplant, which is qualitatively better for the patient and far more cost effective than
maintaining patients on hospital haemodialysis

National shortage of renal transplant surgeons – High likelyhood that NHS Grampian
would be unable to attract a suitably trained renal transplant surgeon due to limited
number of cadaveric transplants being undertaken locally and the lack of a live
related and unrelated renal transplantation service in the North of Scotland.

The cost of maintaining a renal cadaveric transplant service in Grampian would be
significant in comparison to transferring the service to Edinburgh Royal Infirmary
where economies of scale around fixed costs will be far greater.
11. Workforce/Staff Development

Pre-Transplant Assessment Clinic - Patients will reach this clinic through direct
referral from their specific renal consultant. This should follow a defined structured
format with reference to unit-based protocols. The clinic will offer recipient
assessment for all forms of renal transplantation (cadaveric, living donor and
kidney/pancreas). Potential living donors will also be evaluated. Re-assessment of
patients already on the transplant waiting list would be carried out in this clinic. The
clinic will be based in the Aberdeen Royal Infirmary and would be staffed by
transplant surgeons from the Edinburgh transplant unit together with an Aberdeen
based recipient renal transplant co-ordinator. Additional supporting clinic staff would
also be required.
A similar clinic based in Dundee manages to assess around 5-6 patients per session
(Typical case mix, 1 potential Living donor/recipient pair, 2 new patients and 2-3 listed
follow-up patients). This requires 2 transplant surgeons from the base unit and 1
transplant co-ordinator from the local unit. The current demand from the Aberdeen
patient population would support a clinic every 2 weeks. Re-evaluation of currently
wait-listed patients before transfer to the Edinburgh list would require a more intense
clinic schedule, perhaps weekly.

Information Management - It is vital that up to date comprehensive patient
information is available to the Edinburgh transplant team. Co-ordination of data
should be managed by the Aberdeen recipient transplant co-ordinator in collaboration
with their Edinburgh counterparts. Investment in IT infrastructure may be required to
make existing database system fit for purpose.

Transplantation and post operative care - following transplantation patients will be
cared for in the Edinburgh unit until fit for in patient transfer back to the Aberdeen
Renal Unit. This would usually be no earlier than post op day 5 and most often
between 1 and 2 weeks after surgery.
Once in Aberdeen post op surgical problems will all be initially discussed with the
Edinburgh transplant surgeons and the patient returned if required. If urgent
intervention is required precluding transfer then designated support needs to be
arranged with a group of local surgeons, most probably a subset of the vascular
team. Biopsy decisions and treatment of acute rejection will be handled by the
Aberdeen renal team with histology assessed by the local renal pathology team.

SpR Support to Renal Service delivery within ARI - the transfer of renal
transplantation away from Aberdeen Royal Infirmary will impact on current and future
Nephrology Specialist Registrar experience. There are currently 3 SpR posts and 1
lecturer position with SpR status. It is likely that each trainee will need to spend at
least 2 months in the Edinburgh Royal Infirmary transplant unit during the latter phase
of their training. This will have significant direct costs and indirect ones relating to
support of the renal service in Aberdeen Royal Infirmary. These are included in
section 8 – indicative costs.

Renal Transplant Outpatient care - All post transplant outpatient follow up would
remain in the current Aberdeen transplant clinics. Specific late surgical issues relating
to the transplant will be initially discussed with the Edinburgh transplant team.
12. Option Appraisal
Option 1 - Transfer Cadaveric Renal Transplant Service from Aberdeen Royal Infirmary
to Edinburgh Royal Infirmary.
Option 2 - Maintain Cadaveric Renal Transplant Service at Aberdeen Royal Infirmary
Section 10 - Risk Assessment, sets out why option 1 is the preferred option. Option two is
not clinically viable due to the imminent retirement of the renal transplant surgeon at
Aberdeen Royal Infirmary, the national shortage of renal transplant surgeons and the
requirement for renal transplant surgeons to undertake a critical mass of cases to
maintain clinical skills and expertise.
Appendix One
Public Consultation and Involvement
Introduction
NHS Grampian is committed to underpinning any service change with the
principles and values of Patient Focus and Public Involvement (PFPI).
A public involvement plan was prepared to support this proposal, as follows:
Stage 1





informing all stakeholders of the current and impending position, and what
NHS Grampian believes is the best way forward and why
engaging with them, offering the opportunity to give their views and
suggestions on the proposed way forward
responding to the above, plus any queries or particular concerns
feeding in all contributions to the NHS Board
feeding back the final proposal, the views and decision of the Board
Stage 2


working in partnership with renal patients and their families to design the
future service
ongoing dialogue with patients and families, as part of continual learning
and improving of all services
Process
A consultation paper, with covering letter, was sent to the following
stakeholders:






Shetland, Orkney and Highland NHS Boards for distribution to their staff,
MSPs, Health Council, GPs, interest groups etc
Patients on the ARI renal transplant waiting list (individual letters)
Grampian GPs
Grampian Local Health Council
Grampian MSPs and MPs
National and local interest organisations (Grampian Kidney Patients
Association, Scottish Federation of Kidney Patients Associations, National
Kidney Federation, UK Transplant)
A news release was sent to all NE media outlets, and placed on the NHS
Grampian intranet for staff.
A public notice was placed in the Press and Journal.
Consultation
Views were sought on the proposal that:


NHS Grampian enter into discussions with NHS Lothian on extending the
already-established arrangement with the Edinburgh Transplant Unit to
provide all kidney transplant operations for patients from Grampian,
Orkney and Shetland.
the Aberdeen renal team works with patients, families, and other
interested groups to design the future service, so that we best meet the
needs of local patients, including practical arrangements and follow-up.
Consultees were asked:



what do you believe to be the best way forward?
do you agree that NHS Grampian should discuss extending the current
arrangement with the Edinburgh Transplant Unit?
do you have any particular suggestions, views or issues?
We acknowledged all contributions, and responded to specific queries and
requests for clarification.
Responses
A total of 17 responses have been received, from:
7 members of the public, patients and relatives
1 Grampian GP
3 Grampian MSPs
1 Grampian Local Health Council
Grampian Kidney Patients Association (GKPA)
Orkney Kidney Patients Association (OKPA)
Scottish Federation of Kidney Patients Associations
National Kidney Federation
UK Transplant
All responses are available in full for Board Members.
1. Patients/relatives/members of public
Main views
Disappointment at the scarcity of suitable donor organs, and the need for
stronger efforts to encourage people to be donors.
The dramatic improvement in quality of life that patients experience after
receiving a new kidney.
Aberdeen is most convenient, but reluctant acceptance of the present
situation, and that ‘centres of excellence’ do make sense.
Importance of maximising pre- and post care in the familiar surroundings and
staff at ARI.
Support of family is vital during this time (and for family to support each other).
Praise for the Aberdeen team from those who had received kidneys at ARI.
Praise for the Edinburgh service from a patient who had received kidney there
(living donation).
Issues
Strain on patient’s family, and difficulty of supporting each other at a distance.
Financial cost of partner’s travel and accommodation in Edinburgh, and
childcare arrangements.
Not knowing the Edinburgh staff, and being in unfamiliar surroundings.
Might follow-up at ARI also disappear in time?
Logistical problems, will there be sufficient time to get down to Edinburgh so
that a kidney is not wasted?
The disappointment of travelling to Edinburgh, to discover - at the last
moment - that the kidney is unsuitable.
Suggestions
Aberdeen could concentrate its resources on vital aftercare.
An Edinburgh surgeon could travel to Aberdeen regularly to meet patients and
possibly also do transplants.
An offer from Grampian Local Health Council to work with patients to design
the new service.
2. Responses from MSPs
All three MSPs are supportive of the proposal, while also raising issues
relevant to their constituents (including transport, accommodation and followup), and a number of queries which have been responded to.
3. Responses from organisations and interest groups
Grampian Kidney Patients Association circulated a questionnaire to its
members and submitted a collation of individual responses. There was a 5:1
ratio in favouring of retaining service in Aberdeen. Ease of access for family
was the main reason. Main issue with Edinburgh was time and cost of travel
and accommodation. Also concern that renal services at ARI could be
downgraded if transplant service moves.
Orkney Kidney Patients Association supports the proposal, acknowledging the
superb previous service at ARI, while realising that the decline in transplant
numbers means that surgical standards cannot be maintained. OKPA also
raises issues relating to transport, inpatient care and follow-up for Orkney
patients.
Grampian Local Health Council supports the proposal, welcomes the active
involvement of patients in developing the new service, and offers to assist
with this. The Health Council raises the issue of arrangements for family
members, and the costs of transport and accommodation.
The Scottish Federation of Kidney Patient Associations concurs with the
proposal, while raising the issue of accommodation for next-of-kin and the
importance of their support in the recovery process.
The National Kidney Federation supports the general philosophy of trying to
keep transplant units open, and is pressing for an increase in the number of
surgeons and medical staff to ensure that these units remain operating.
UK Transplant supports the proposal to transfer the service from Aberdeen to
Edinburgh, citing national standards that transplant units should generally
serve a population of at least two million.