In Scotland, healthcare is a responsibility of the devolved Scottish Government (with the exception of regulation of most healthcare professionals, abortion, xenotransplantation, human fertilisation and embryology and the regulation of medicines). The Scottish Government receives a proportion of UK taxes determined by the UK parliament, but is then responsible for determining the proportion of its total budget used for health.
The Health Department distributes its budget to the 14 geographical NHS Boards on the basis of population, adjusted for age, gender, deprivation and rurality (see National Resource Allocation Committee). Separate funds are allocated to central organisations , including special NHS Boards (e.g. NHS Education for Scotland, the Scottish Ambulance Service and NHS Quality Improvement Scotland), and other important organisations such as the Scottish Medicines Consortium, the Chief Scientist's Office, the Information and Statistics Division and Health Scotland.
Each NHS Board is responsible for both the planning and provision of healthcare for its population, including primary and secondary care. There are also close interactions with local councils through Community Health Partnerships. The goal has been to create vertically integrated health care organisations based on cooperation rather than competition. The strategic focus for healthcare is provided by the Health Department and is primarily aimed at reduction of premature cardiovascular disease, cancer and social inequality.
General practitioners are funded in the same way as the rest of the UK, but with some differences relating to the enhanced services element of pay. There are no Primary Care Trusts, with NHS Boards fulfilling those functions.
In secondary care, hospitals are managed directly by the NHS Boards. Other than small amounts of funding transferred between Boards for cross-boundary activities, there is no element of funding following the patient, and no equivalent of Payment By Results. Tariffs are being developed, but the main function is to allow Boards to cross-charge each other and to facilitate benchmarking of services.
There is little, if any, formal renal policy produced by the Scottish Government. The Parliamentary Cross Party Group on Kidney Disease produced two reports in 2003-2004 and made 38 recommendations to Parliament. To date there has been no formal response from the Government.
The Quality Outcomes Framework applies in Scotland as in the rest of the UK. The results of the first year have been published. The prevalence of CKD was surprisingly low at 1.83% and varies remarkably by practice from 0.06% to 10.82%. Whilst ISD have attributed this variation to the availability of eGFR reporting, this seems an unlikely reason – eGFR reporting was universally available by 1st October 2006. Impressively, 98.9% of available points were obtained in the CKD domain.
The Scottish Renal Association is the professional multidisciplinary association representing renal doctors, nurses, AHPs and dialysis technologists. It meets biannually, with a three day general scientific meeting. Abstracts are published in the Scottish Medical Journal (freely available online).
The Scottish Renal Nurses Strategy Group aim to identify nursing priorities for renal services within Scotland, and to provide clear direction for nurses working within the specialty. They have recently produced recommendations on the care of vascular access.
The Scottish Renal Registry was founded under the auspices of the SRA in 1991, funded by grants from the NHS. In 1999, it became a part of (and is funded by) the Information and Statistics Division, but is still managed by a steering group appointed by the SRA. It receives data electronically from all renal units except one (which enters data manually). Data is shared with other registries including the UK Registry and the EDTA registry.
The Clinician And Laboratory Interface Committee (CALICO) is a joint initiative between the SRA/SRR and the Scottish section of the Association for Clinical Biochemistry. Initially formed to harmonise the implementation of eGFR reporting across Scotland, it is now examining other aspects of CKD such as proteinuria.
The Scottish Primary Care Collaborative is a Health Department initiative to improve the delivery of high quality care to the population. It has selected CKD as a major focus of its activity for 2008. It works with a number of primary care practices, and will suggest several measures of quality in the management of CKD. It provides education and support based on the Institute of Healthcare Improvement approach with numerous Plan-Do-Study-Act cycles. It has previously demonstrated a marked improvement in the management of diabetes and cardiovascular disease in participating practices using this approach.
NHS Quality Improvement Scotland is a special Health Board whose role is to provide guidance on effective clinical practice, set standards of care, monitor NHS practice against those standards and support service improvement. The SRA had previously performed peer reviews of the Scottish Renal Units. This activity was taken over by NHS QIS. A set of standards were published in 2002 and units reviewed against those standards in 2003-4. Further peer review has not been carried out.
The Scottish Medicines Consortium is part of QIS and reviews newly licenced drugs, and provides advice to NHS Boards on the appropriateness and cost-effectiveness of new medicines and formulations for use within NHS Scotland. Existing drugs are not reviewed. The SMC has a reputation for prompt decisions. Several drugs of relevance to nephrology have been reviewed, including cinacalcet and lanthanum.
The Scottish Intercollegiate Guidelines Network was formed by the Scottish Royal Colleges in 1993, but has since become a part of NHS QIS. It has an international reputation for producing rigorous and unbiased evidence-based clinical guidelines. It has produced several renal specific guidelines on haematuria, proteinuria and diabetic nephropathy. A new guideline on CKD is due for publication in 2008.
There are 10 renal units in Scotland and 19 satellite dialysis services. New main units are unlikely (indeed two are planned to merge), but satellites are expected to increase further in number. There are two units providing the surgical aspects of transplantation and one national paediatric renal unit. The challenge for Scottish nephrologists is to provide services to a population scattered across an area one third the size of England. More information about the individual units can be found on the Units pages.