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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. -a personal journey and a work in progress. Setting up a Liver Service. Dr Allister J Grant Leicester Liver Unit Digestive Diseases Centre

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Setting up a Liver Service

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

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

  3. 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

  4. 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.

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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!

  14. 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

  15. 2006- Alcohol Liaison Worker Business case • Reduction of number and length of detox (LOS) • Brief intervention (decreased admissions) • Education of staff • Cost/benefit analysis

  16. Adult Alcohol Related Deaths in England and Wales For Men and Women 2001-2003 UHL Non-Elective Alcohol Related Admissions where treatment was administered during patient stay (Aug 2005 – Aug 2006)

  17. 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

  18. DON’T 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 50:50 share in funding ALW

  19. Both PCT’s agree to fund a further 3 Alcohol Liaison Workers

  20. 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

  21. 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)

  22. 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)

  23. What do you need to develop a liver service?

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

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

  26. Thank you http://hepatologist.eu

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