clinical management where medicine meets management

Published: 04/03/2004, Volume II4, No. 5895 Page 28 29

Without action to curb the impending epidemic in liver disease, hospitals will be overburdened. Mark Thursz and Kevin Moore outline a national strategy to tackle the problem

The incidence of liver disease in the UK is increasing to epidemic proportions. There has been an explosion of hepatitis C carriers: people who contracted the disease in the 1970s and are now developing cirrhosis, liver cancer and liver failure.

There is also an eight-fold increase in alcoholic liver disease in young people and a marked increase in primary liver or biliary cancers. These are placing an increasing burden on hospitals.

Unless we act now to curb this epidemic, there will be a predicted 500 per cent increase in the need for liver transplantation in the next six to 10 years, and a similar escalation in the incidence of liver cancer.

To put the numbers in perspective, hepatitis C affects 0.7 per cent of the UK population, but in London and other large cities the incidence is nearer 1 per cent, or 10, 000 people per million of the population. Between 50 to 80 per cent of these people could be cured with the new treatments available. But while these problems have been recognised by chief medical officer Professor Sir Liam Donaldson and the Department of Health, there is still no coherent strategy for UK liver services to deal with this impending crisis.

The DoH is expected to publish an action plan for hepatitis C later this year that will force commissioners to consider their delivery strategy for hepatitis C patients in the 21st century Other countries have taken the problem more seriously and recognise the effectiveness of treating the hepatitis C virus at an early stage to prevent morbidity and mortality. In Italy, France and Germany, 16-20 hepatitis C virus patients have been treated for every one patient in the UK. In this country only a minority of infected people have been identified, yet services are overwhelmed.

The lack of a national service framework for liver disease has seriously disadvantaged liver patients. The cost of implementing existing NSFs has been so high that further frameworks are unlikely to be announced. The anticipated hepatitis C action plan and the long-awaited alcohol strategy should encourage improvements in service delivery, but will not address the issues facing hepatology and hepatobiliary surgery services as a whole.

UK liver services have evolved in the past 50 years through the gradual seeding of gastroenterology departments with physicians interested in hepatology.

Development has therefore been haphazard, with some areas of the country, such as the south-west peninsula or Wales, being poorly served.

Problems with the delivery and development of liver services were recognised by the DoH in 2001 with the publication of the specialised services national definition set. This identified which liver services should be commissioned, including management of viral hepatitis, complications of liver disease, treatment of hepatobiliary-pancreatic tumours and surgery. The other important components were the criteria for designating units as hepatology or hepatopancreaticobiliary surgery centres.However, the need for a national plan became evident two years ago when it was clear the specialist commissioning process was failing to prioritise liver services.

Specialist groups, including the British Association for Study of the Liver, the British Society of Gastroenterology liver section and the Association of Upper Gastrointestinal Surgeons, decided to join with patients and patient support groups to plan how liver services should be organised. The result is a national plan for liver services, currently in draft form, to be published in the next few months and circulated to all primary care trusts (see box).

Building from the criteria for liver centres in the service definition set, the plan outlines the organisation of liver services around 20 to25 clinical networks.

A key element, as with NSFs, is the setting of standards. There is already an international portfolio of evidence-based guidelines developed by hepatology and HPB clinicians.

The development of networks is intended to strengthen and lead to the development of closer integration and co-operation between units, with the standards acting as a stimulus for units in poorly served areas to develop services to enable designation as liver and HPB centres.Wherever possible, each network will develop or embrace existing clinical care pathways.

Where no guidelines exist, work will be done to develop a concise set of treatment pathways to encompass the existing practice of UK hepatologists or HPB surgeons so that data on clinical effectiveness can be compared.

Many of the changes require local organisational changes rather than the purchase of new services.

However, a few areas will need an expansion of liver services to serve the local population, and these will have cost implications. The ability to deliver services effectively will lead to increased use and increased costs.

But much of this will be offset by the improved efficacy oftreatments and decreased bed occupancy in non-specialist units.

Potentially, the most important component of the plan is to develop systems to monitor clinical effectiveness of treatments. These need not be extravagantly expensive to develop, particularly as there is a prototype for managing hepatitis C in operation in Gloucester and other trusts in the South West.

Early implementation of IT systems to support liver services would provide answers to key questions posed by commissioners. For example, how many patients within a particular area have been treated for hepatitis C, how many were cured, and what was the true cost of treatment?

Is treatment of hepatitis C cost effective? We think so. It costs£30,000 to cure one patient of hepatitis C and prevent cirrhosis and liver cancer. This compares with£180,000 to prevent one cardiac event when treating patients with clopidogrel in the primary prophylaxis for angina.However, it is easy to get lost in the world of health economics, when the only currency should be 'lives saved' rather than cost per cure.

The national plan for liver services provides a framework for the planning, commissioning, organisation and delivery of liver services. Unless the DoH backs it, or develops its own strategy, it will be up to strategic health authorities, PCTs and specialist commissioning groups to decide whether to leave liver services going their own way, or to work with the profession in providing a high-quality service that ensures equity in the delivery of liver services.

Further information

Specialised services national definition set www. doh. gov. uk/specialisedservicesdefinitions/19hepat. htm

Mark Thursz is a consultant hepatologist at St Mary's Hospital, London, and secretary of the British Association for Study of the Liver (m. thursz@imperial. ac. uk).Kevin Moore is professor of hepatology at the Royal Free and University College Medical School, University College London.

Liver services: what's in the national plan

Advice for commissioners on the most appropriate clinical arrangements for hepatology and hepatic, pancreatic and biliary surgery services.

A set of clinical standards and guidelines against which local services can be monitored and assessed.

An outline of structures for the reorganisation of liver and hepatopancreaticobiliary surgery services building on the existing network model.This will require the development of 20-25 managed clinical networks, the basic structure of which already exists.

A framework that will ensure equitable access to high-quality, cost-effective management of liver and HPB disease.

Key points

There have been massive increases in the incidence of liver diseases in the UK, reaching epidemic levels.

The development of liver services has been haphazard and there is no national service framework for liver disease, endangering patients.

Specialist groups have formulated a national plan setting standards and guidelines.