Transcript Setting up a Liver Service (a work in progress)

Setting up a Liver Service
Dr Allister J Grant
Leicester Liver Unit
Digestive Diseases Centre
University Hospitals Leicester NHS Trust
-a personal journey
Setting up aand
Liver Service
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)MWest Midlands SpR
• Liver experience
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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 deprivation.
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
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
population
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
BASL and BSG
-National Plan for Liver Services (May 2004)
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Consultant Hepatology cover 24/7. Each centre requires at least 2, ideally 4, hepatologists.
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Designated beds to accept liver emergencies.
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Liver pathology services, and access to investigational services
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Good cross sectional radiology (USS/CT MRI MRCP)
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Interventional radiologist and access to transjugular liver biopsies, TIPS, hepatic
angiography and embolisation.
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An experienced Hepatobiliary surgical service, access to good intensive care services, with
renal support on site including haemofiltration/dialysis.
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Facilities for multi-disciplinary meetings.
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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
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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
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
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
– A&E 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
Wellingborough
South Northamptonshire
Northampton
Kettering
East Northamptonshire
Daventry
Corby
Oadby and Wigston
NW Leicestershire
Melton
Hinckley and Bosworth
Harborough
Charnwood
Blaby
Rutland
Leicester
0.0
Adult Alcohol Related Deaths in
England and Wales
For
Men and Women 2001-2003
5.0
10.0
15.0
Deaths per 100 000 population
20.0
Diag Group
UHL Non-Elective Alcohol
Related Admissions
where treatment was
administered during patient
stay (Aug 2005 – Aug 2006)
25.0
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
• 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
DON’T give up!
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2007-8 Political landscape changes
Government and public focus on ASB due to alcohol
PCT re-focuses on Alcohol
PCT and UHL agree to 50:50 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 PCT’s agree to fund a further 3 Alcohol Liaison Workers
Viral Hepatitis Service
• HCV strategy for England, Hepatitis C Foundation, NICE
TA’s, 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
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 x2
• Community HCV Nurse- Bid to Regional Innovation
Fund (PCT, Primary care, Dawn Centre, UHL)
• Collective agreement
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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://hepatologist.eu