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Setting up a Liver Service


Setting up a Liver Service Dr Allister J Grant Leicester Liver Unit Digestive Diseases Centre University Hospitals Leicester NHS Trust Your personal skills Leadership ... – PowerPoint PPT presentation

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Title: Setting up a Liver Service

Setting up a Liver Service
  • Dr Allister J Grant
  • Leicester Liver Unit
  • Digestive Diseases Centre
  • University Hospitals Leicester NHS Trust

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Setting up a Liver Service
-a personal journey and a work in progress
  • Dr Allister J Grant
  • Leicester Liver Unit
  • Digestive Diseases Centre
  • University Hospitals Leicester NHS Trust

My Background
  • CCST in Gastroenterology and G(I)M-
  • West Midlands SpR
  • Liver experience
  • General Gastro Training
  • Birmingham Liver Transplant Unit
  • 18 months as a Clinical SpR
  • 1 year as a DDF (Core) Research Fellow
  • 3 years as a MRC Clinical research Fellow
  • PhD
  • 2004 Appointed in Leicester

Leicester Demographics
  • Life expectancy on average is 2 to 6 years lower
    than the rest of the country.
  • 39 from the black and minority ethnic
    backgrounds (12 England 9 East Midlands).
    Predominantly south Asian (30).
  • Half the population is under 29
  • Joint strategic needs assessment (March 2009)
    half the population is highly disadvantaged.
  • 20th out of 152 local authority areas in terms of

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Liver related health problems
  • Alcohol
  • In 2009 the Leicester alcohol-related admissions
    / 100,000
  • Men 673 (national average 397)
  • Women 270 (national average 188)
  • Deaths due to alcohol were also significantly
    higher than the national average.
  • Viral Hepatitis
  • NASH

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Liver related health problems
  • Alcohol
  • Viral Hepatitis
  • Large South Asian community (at risk population
    400,000)- 5-9 of Pakistani community
  • IVDU
  • Local prison, YOI, Cat B, Cat C and Cat D
  • NASH

Liver related health problems
  • Alcohol
  • Viral Hepatitis
  • NASH
  • High levels of deprivation
  • 27 of adults are obese
  • High levels of diabetes in the South Asian

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Definition Set 19
  • The DoH published (December 2001) the definition
    for Specialised Hepatology Services
  • 1. Specialised services for the treatment of
    patients with viral hepatitis
  • 2. Specialised services for patients with acute
    liver failure and advanced complications of
  • 3. Specialised services for patients with benign
    and malignant liver tumours and cancer of the
    intra-and extra-hepatic biliary tree (including
  • 4. Specialised hepatobiliary and pancreatic
    surgery services

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BASL and BSG-National Plan for Liver Services
(May 2004)
  • Consultant Hepatology cover 24/7. Each centre
    requires at least 2, ideally 4, hepatologists.
  • Designated beds to accept liver emergencies.
  • Liver pathology services, and access to
    investigational services
  • Good cross sectional radiology (USS/CT MRI MRCP)
  • Interventional radiologist and access to
    transjugular liver biopsies, TIPS, hepatic
    angiography and embolisation.
  • An experienced Hepatobiliary surgical service,
    access to good intensive care services, with
    renal support on site including
  • Facilities for multi-disciplinary meetings.
  • Each centre should develop the role of
    Specialist Nurses and be able to collect data on
    clinical outcomes from the liver centre

Leicester in 2005
  • Hepatology being done by all Gastroenterologists
  • Infectious Diseases Unit treating 10 HCV
  • Interventional radiology for TIPS, TJLBx, PTC etc
  • Large and busy Regional HPB service
  • Dedicated Liver Pathologists
  • Regional Dialysis Unit

The Vision
  • Develop a Regional Liver Centre
  • Excellent Hepatology Service-
  • pathways/ protocols/guidelines/shared care with
    Transplant Unit
  • Hepatology Colleagues
  • Alcohol Liaison Service
  • Develop the Viral Hepatitis Service
  • Liver HDU with adequate nursing complement
  • 24/7 GI Bleed rota Management of Gastric Varices
  • 24/7 Hepatology cover

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What was the process?
  • Identify each of the individual parts of the
    service that need development
  • Is it possible? Staff? Space?
  • Understand the bigger picture
  • Political, national, local
  • Find Allies
  • Colleagues, Service Manager, Public Health, PCT

What was the process?
  • Gather evidence of need
  • National Guidance, Surveys, Audit, Literature,
    Demographics, Benchmarking
  • Co-write the business case
  • Frame the benefits analysis
  • Finance is best guided by clinicians and executed
    by Managers
  • If you're unsuccessful Persist and Be Creative!

2006- Alcohol Liaison Worker
  • National Alcohol strategy, ANARP
  • Medical consultant colleagues
  • Service Manager
  • Evidence of the benefit of ALW
  • Evidence of the scale of the problem
  • AE and Hospital Admission data

2006- Alcohol Liaison Worker
  • Business case
  • Reduction of number and length of detox (LOS)
  • Brief intervention (decreased admissions)
  • Education of staff
  • Cost/benefit analysis

Adult Alcohol Related Deaths in England and
Wales For Men and Women 2001-2003
Diag Group Consultant Episode Count Occupied Bed Days
Alcohol Intoxication 410 291
Alcohol Withdrawal 195 483
Alcoholic Liver Disease 179 1298
Cirrhosis due to Alcohol 63 754
Alcohol Withdrawal Fits 56 119
Alcoholic Hepatitis 25 274
DTs 14 66
Total 942 3285
UHL Non-Elective Alcohol Related Admissions
where treatment was administered during patient
stay (Aug 2005 Aug 2006)
  • 1373 ED attendances at 86.95 (average ED
    attendance rate for 2005/06) 119,382 total
  • 3285 occupied bed days at 220.34 (average bed
    day rate for specialty 300 General Medicine for
    2005/06) 723,817 total cost
  • Total cost 843,199
  • Estimate that the employment of an ALW would
    prevent 10-15 of ED attendances / occupied bed
  • This would result in a total cost saving of
    between 84,320 and 126,480
  • The cost of employing an ALW in UHL at Agenda
    for Change Band 7 37,758, inclusive of

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DONT give up!
  • 2007-8 Political landscape changes
  • Government and public focus on ASB due to
  • PCT re-focuses on Alcohol
  • PCT and UHL agree to 5050 share in funding ALW

Measure Baseline 08/09 Target year 1 Target year 2 Target year 3
Raised profile Strategically re Alcohol Harm reduction Some engagement city wide within planning groups Demonstrable evidence within planning and development strategies of Alcohol Harm reduction targets Improved National indicator data across City Wide partners in relation to alcohol Alcohol harm reduction to be included in the annual planning cycle for City Wide services
NI 39 Alcohol-related harm hospital admission rates 2776 cases per 100,000 (currently 2392 cases per 100,000) 2970 cases per 100,000 Rate of increase 10 3118 cases per 100,000 Rate of increase 5 Still to be set
Both PCTs agree to fund a further 3 Alcohol
Liaison Workers
Viral Hepatitis Service
  • HCV strategy for England, Hepatitis C Foundation,
    NICE TAs, 18 weeks RTT
  • 4 ID Consultants and 2 Hepatologists with common
  • With Public Health (HPA) developed a Local HCV
    Strategy Group, Offender Health Viral Hepatitis
    Group, Regional Group,
  • EMSCG Advisory Group with EM Guidelines

Viral Hepatitis Service
  • Audit of Non referral of HCVAb to Clinic
  • Identified an unmet need
  • Questionnaire to non referrers
  • Identified reasons for non referral
  • New Referral pathways from Prisons, Primary care,
    Homeless centre
  • Increase the HCT budget (100,000 to 1,000,000)

Viral Hepatitis Service
  • HCV Outreach service (for Prisons)- unsuccessful
  • Community HCV Nurse- Bid to Regional Innovation
    Fund (PCT, Primary care, Dawn Centre, UHL)
  • Collective agreement
  • Management Protocols for Hepatitis Clinic
  • MDT after each clinic
  • One stop clinic
  • Fibroscan (charitable funds bid)

What do you need to develop a liver service?
You need
  • Understanding of NHS and political imperatives
  • Backing of Colleagues/Managers
  • Understanding of the local processes (mentoring)
  • Evidence to support need for change

Your personal skills
  • Leadership skills
  • Communicate your vision
  • Build relationships
  • Team working
  • Change management
  • Time management (Job planning)
  • Perseverance

Thank you http//
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