Published: 02/09/2004, Volume II4, No. 5921 Page
Patient demand is set to increase following a new government campaign warning people of the dangers of hepatitis C. Ann Dix reports on one area of the UK that is better prepared than most
The HIV public health campaign of the 1980s sent shock waves through a generation. This autumn will see the launch of another major government health campaign warning people at risk that they may be infected with hepatitis C.
However, on this occasion the government's desire to avoid mass panic is likely to result in a softly-softly approach, focusing on the treatment available for the disease rather than its potential consequences.
Hepatitis C is a potentially fatal virus, but because symptoms take so long to appear, as many as 90 per cent of sufferers do not realise they are infected ('All at C', HSJ, 1 July 2004, pages 28-29).
The Department of Health released its action plan on hepatitis C this July, two years after the launch of its national strategy. The plan lays out what the NHS needs to do to implement the strategy. This includes improving surveillance and research, increasing awareness, reducing undiagnosed infections, prevention, and ensuring high-quality services for assessment and treatment that are co-ordinated and accessible everywhere. It was accompanied by an awareness campaign for primary care professionals which includes advice on identifying at-risk patients.
While the action plan has been welcomed by professionals and patients, it has also been criticised for its lack of teeth. Chief executive of the Hepatitis C Trust Charles Gore saystargets are needed.He fears PCTs will not make hepatitis C a priority until their hand is forced by an increased demand for services. The extent of this demand will depend on the strength of the public awareness campaign. Again, he says, the government has set no targets for how many people should be treated and how long they should wait for it.
The Hepatitis C Trust is so concerned that the campaign might not be hard-hitting enough that it is considering one of its own: 'Then they [PCTs] will have to respond. If patients do not get satisfaction we'll take up their case and we will make PCTs' lives hell, ' says Mr Gore.
This month the Hepatitis C Trust will also be launching its own targets, which it will use to monitor progress. The targets will be for the NHS to diagnose 20,000 new cases (10 per cent of the estimated 200,000 undiagnosed infections), treat 5,000 of these and reduce waiting times from recommendation of treatment to no more than 17 weeks - all within a year.
But while the NHS is generally ill-equipped to cope with a deluge of patients coming for testing, some trusts are ahead of the game. The South West, for example, is more prepared than most.
Plymouth launched its own viral hepatitis strategy in April. Commissioned by the Drug and Alcohol Action Team (DAAT), the strategy includes a patient pathway and action plan, and was drawn up by the Eddystone Trust in consultation with various agencies, to develop the city's response to hepatitis A, B and C.
The Eddystone Trust is an independent agency, providing information and support for anyone concerned about HIV or hepatitis C. Director Mike Taylor says one aim was to gain a better understanding of what was already being done. For example: 'the availability of testing for hepatitis C; who is providing it, how and what support they are offering patients. A lot of work is being done by drugs teams in isolation.'
Dr Matthew Cramp, consultant hepatologist at Derriford Hospital, Plymouth, said the strategy would bring together local initiatives on hepatitis C and help secure long-term funding: 'The problem is that hepatitis C has not been on the funding agenda, ' he says.
A managed clinical care network for hepatology was set up last year with the specialist commissioning team from the strategic health authority whose work programme includes viral hepatitis. The network is establishing links with all the DAATs in Devon and Cornwall to produce a strategy for diagnosis and referral of hepatitis C cases. It is also helping to coordinate disparate primary care services, such as drug rehabilitation and treatment services, and GPs with special interests, to give appropriate testing.
He adds that there is also work to reduce waiting times from 16 weeks to two to three weeks between referral and being seen in secondary care: this is seen as a major cause of people failing to attend clinics.
'A lot of people diagnosed with hepatitis C do not make it to secondary care because of difficulty in accessing services, ' he says. 'Most are intravenous drug users who live at mobile or temporary addresses.'
Plymouth Hospitals trust also employs a blood-borne virus nurse who goes out to all drug rehabilitation centres in Plymouth and whose remit includes pre- and post-test counselling for people with hepatitis C.
Dr Cramp says another problem with testing is that there are not the physical facilities in primary care to do it.He is looking to set up a mobile testing unit, possibly with the help of pharmaceutical company funding.
Bristol already has a mobile viral hepatitis service that targets at-risk groups who might not otherwise access services, such as prostitutes and drug users.
Nigel O'Malley, hepatitis support worker with Community Action Around Alcohol, explains that it is a nurse-led service, providing testing and pre- and posttest counselling, vaccination for hepatitis B, wound care, health promotion and a needle exchange. It also helps people access primary, secondary and tertiary services.
'People get referred straight from the van, ' he says.
Bristol also has its own hepatitis strategy and action plan. 'The strategy pulls together existing agencies and services using existing models of care and gives everyone clear aims and objectives, ' says Mr O'Malley.
He is now piloting a community-integrated care pathway for hepatitis which, he says, covers the full package, from diagnosis and treatment to support, housing and benefits.
Five months into the pilot, he says clients are already getting a better service. For example, they now give benefits and housing advice on site.
'The service is now so much clearer and transparent for everyone, ' he says. 'If you want to refer someone on, you can see what happens next and what they will access, and the client can sit down and make a choice.'
1.Hepatitis C Action Plan for England 2004. www. dh. gov. uk
2. Hepatitis C Strategy for England 2002.www. dh. gov. uk
Hepatitis C Action Plan for England 2004. www. dh. gov. uk
To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com