Setting up a Liver Service

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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

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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

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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
  deprivation.

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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

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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
  population

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Definition Set 19
http//www.specialisedcommissioning.nhs.uk

• 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
  cirrhosis
• 3. Specialised services for patients with benign
  and malignant liver tumours and cancer of the
  intra-and extra-hepatic biliary tree (including
  pancreas)
• 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
  haemofiltration/dialysis.
• 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

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Leicester in 2005

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

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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

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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!

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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

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2006- Alcohol Liaison Worker

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

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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)
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• 1373 ED attendances at 86.95 (average ED
  attendance rate for 2005/06) 119,382 total
  cost
• 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
  days
• 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
  on-costs

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DONT give up!

• 2007-8 Political landscape changes
• Government and public focus on ASB due to
  alcohol
• 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
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Both PCTs agree to fund a further 3 Alcohol
Liaison Workers
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Viral Hepatitis Service

• HCV strategy for England, Hepatitis C Foundation,
  NICE TAs, 18 weeks RTT
• 4 ID Consultants and 2 Hepatologists with common
  goals
• With Public Health (HPA) developed a Local HCV
  Strategy Group, Offender Health Viral Hepatitis
  Group, Regional Group,
• EMSCG Advisory Group with EM Guidelines

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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)

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Viral Hepatitis Service

• HCV Outreach service (for Prisons)- unsuccessful
  x2
• 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)

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What do you need to develop a liver service?
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You need

• Understanding of NHS and political imperatives
• Backing of Colleagues/Managers
• Understanding of the local processes (mentoring)
• Evidence to support need for change

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Your personal skills

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

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Thank you http//hepatologist.eu