Provision of Specialist Liver Services in EnglandRoger Williams, CBE, MD, FRCP, FRCS, FRCPE, FRACP, FACP (Hon)Director, th...
Abstract:Information on the current provision of specialist liver services in England – of majorimportance in the setting ...
The commissioning of specialised hospital services has, over the years, been the subjectof repeated reorganisation [1].   ...
have different administrative arrangements for specialised services were excluded fromthe survey.DESIGN AND RESULTS OF SUR...
also applies to facilities for liver transplantation, with the Northwest region, includingthe large urban conurbations of ...
hospitals providing limited hepatology services, only 2 had designated hepatologists andin 47 the workload was managed by ...
and 1 non-transplant centre having a larger number (Table 2).          An even smallerpercentage of the hospitals providin...
In answer to a question on ‘bottlenecks’ (data not tabulated) 18 of 34 liver centresconsidered that the number of outpatie...
DISCUSSION:Mortality from liver disease is increasing in the UK. In the year 2000 it killed moremen than Parkinson’s disea...
hepatologists, along with the virologists, needed for the ever expanding load of chronicHCV and HBV infections? In the sur...
those wanting to specialise in this area. Unfortunately this was not acceptable togovernment/ Department of Health and nei...
Bibliogaphy:1     Williams R. Direct and Indirect Constraints on Commissioning Specialist      Medical Care in “They’ve Ha...
Table 1: Staffing numbers for the 34 Hepatology centres, shownseparately for the 28 non-transplant and 6 transplant units ...
Table 2: Provision of dedicated Inpatient Beds and Outpatient Clinics inthe 28 non-transplant and 6 Transplant Centres (in...
Table 3: The commonest replies to the question “Do you have a wish listfor improving local Hepatology provision?” Numbers ...
Figure legend:Figure 1:    Location of the 34 hepatology centres in England identified in the             Survey          ...
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Provision of Specialist Liver Services in England

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Provision of Specialist Liver Services in England

  1. 1. Provision of Specialist Liver Services in EnglandRoger Williams, CBE, MD, FRCP, FRCS, FRCPE, FRACP, FACP (Hon)Director, the Institute of Hepatology, University College LondonKey Words:Staffing: Consultant Hepatologists: Specialist Nurses; Dedicated clinics; Radiology;Support facilities, Liver TransplantsWord Count: 3,384Correspondence:Professor Roger Williams, CBEDirector, the Institute of Hepatology69 – 75 Chenies MewsLondon, WC1E 6HXTel: 020 7679 6510Fax: 020 7380 0405Email: roger.williams@ucl.ac.uk The survey was carried out under the auspices of the Foundation for Liver Research and the British Liver TrustAcknowledgements:The tireless work of Ms Anne Gilbert with the questionnaire is gratefullyacknowledged, as is an educational grant from Schering Plough Ltd
  2. 2. Abstract:Information on the current provision of specialist liver services in England – of majorimportance in the setting up of commissioning contracts – was obtained by aquestionnaire survey. Thirty four liver centres were identified, including 6 centres forliver transplantation, and 49 other hospitals where some services were provided.Substantial deficiencies in staffing levels were recorded, particularly in consultanthepatologist posts and in specialist nurses. More specialist services for outpatients andmore clinics to bring down long waiting times were needed. The provision of alcoholservices was poor and radiological facilities were the commonest identified bottleneckin support services. Transplant centres had greatly superior staffing and facilities andcarried out a substantial amount of non-transplant work. The setting up of additionalcentres would add greatly to the overall provision of specialist liver care in the countryand recognition of hepatology as a distinct specialty is essential if the considerablyincreased burden of liver disease predicted for the next 20 years is to be met. --------------------------------------------------------- 2
  3. 3. The commissioning of specialised hospital services has, over the years, been the subjectof repeated reorganisation [1]. Initially based on the Regional Health Authorities(“Regional Specialties”), their organisation in the early 1990’s was transferred to thethen newly established District Health Authorities. In 1997, following a number ofcritical reports, responsibility was given back to the regions with the establishment ofRegional Specialty Commissioning Groups (RSCGs). More recently, with the NHSPlan of 2001, the responsibility for commissioning was passed to the Primary CareTrusts (PCTs) with a performance management role being given to the Strategic HealthAuthorities. Commissioning was to be based on the ‘Definition Set’ for hepatologydrawn up by the RSCGs (Department of Health website, 2002). Set No.19 (adult)picked out the following areas as requiring specialised facilities and expertise:- complexhepatobiliary disorders; liver tumours; complications of cirrhosis; and viral hepatitis.However the funding of such specialised services within the new national tariff systembased on Health Resource Groups (HRG’s) is still to be decided as are systems for theaccreditation of such services. In the recent report of the main professional bodies inHepatology, entitled: “National Plan for Liver Services UK” [2] it is envisaged thatsome 10-15 hospital centres will provide specialised services through a series ofmanaged clinical networks. The necessity for an even distribution around the country isemphasized. New arrangements will have in addition to take into account the existenceof the separate, NSCAG-funded, centres for liver transplantation of which there are 6 inEngland and where because of the requirements of transplant patients, investigatoryfacilities and staffing have to-date been largely concentrated.The aim of the present Survey was to determine the staffing and facilities forhepatology patients currently in place through the country. Scotland and Wales which 3
  4. 4. have different administrative arrangements for specialised services were excluded fromthe survey.DESIGN AND RESULTS OF SURVEY:Members of the British Association for the Study of the Liver and of the Liver Sectionof the British Society of Gastroenterology, who would be expected to have apredominant interest in hepatology, were initially contacted to identify some 83hospitals where hepatology services were provided. Of these, 34 answered ‘yes’ to thequestion, ‘Do you run a Hepatology Centre?’ and this report is largely based on theinformation provided by these hospitals. Included in them are the 6 centres where livertransplantation is carried out, namely the Queen Elizabeth Hospital, Birmingham;King’s College Hospital and the Royal Free Hospital in London; Addenbrooke’sHospital, Cambridge; Royal Victoria Infirmary, Newcastle and St. Jamess Hospital,Leeds (paediatric programmes were excluded). The remaining 49 hospitals reported amore limited provision of hepatology services. The questionnaire comprised sectionson the population and PCTs served by the centre, the current levels of staffing withconsultants, junior staff and nurse specialists, and the availability of specialised supportfacilities. There were also questions on what were considered to have been successfuldevelopments during the past few years and what were considered currently to be themajor bottlenecks in providing an adequate service.1. Location and PCTs/population servedThe distribution of the 34 centres around England is shown in Figure 1. Although mostmajor cities have a liver centre either in a university hospital or a large DGH, these arenot evenly distributed in terms of population size or the number of PCTs served. This 4
  5. 5. also applies to facilities for liver transplantation, with the Northwest region, includingthe large urban conurbations of Manchester and Liverpool, and the Southwest Peninsulaextending up as far as the Midlands, notably lacking a unit. The median number ofPCTs served by the 28 non-transplant centres is 6, with a range of 1-14. There is also awide range for the draining populations recorded, with 6 at more than 1 million,including two with 4 and 7million. The remaining 22 centres serve between170-800,000 people with a median of 400,000. Each of the 6 transplant centres notedreferrals from all over the country, receiving patients from more than 50 PCTs (highest300) and with estimated draining populations of 3.5 - 9million. Breakdown of workload at the transplant centres, showed that substantial numbers of non-transplant caseswere seen by them amounting to an estimated 30-65% of their total referrals. The non-transplant centres recorded an average of around 50% of their patients coming from thesurrounding region and 50% locally generated. Three of the largest centres –Southampton, Sheffield and Manchester – emphasized the lack of funding for thetransplant cases referred back to them after transplantation despite the large amount ofwork generated by their continuing care.2. StaffingTwelve of the 28 non-transplant centres did not have a designated consultanthepatologist (Table 1). Of the other 16 centres, 15 had up to 3 hepatology consultantsand 1 more than 3. The majority of consultant staff working in these units weregastroenterologists (24 compared with 16 hepatologists) and in 11 units, generalphysicians also shared the workload. Quite a different picture was seen in the transplantcentres with all 6 having more than 1 hepatologist and 3 with more than 3, along withfewer consultants in gastroenterology and general medicine. In contrast, of the 49 5
  6. 6. hospitals providing limited hepatology services, only 2 had designated hepatologists andin 47 the workload was managed by gastroenterologists with additional help fromgeneral physicians in 26. There was at least one Specialist Registrar, with oneexception, in each of the non-transplant centres (Table 1). Just over a half had 1-3 or >3posts and these numbers were reported by all the transplant centres. As to SHOs, allexcept 4 of the non-transplant units had a post with the majority having 1-3 and 4having >3. Few staff grade positions were in place. With respect to specialist nurses, 5of the 28 non-transplant units were without such a post for hepatitis. The remaining 23had between 1-3 posts. The transplant centres were the only units having >3 posts.Few specialist nurses for alcohol related disorders were in post; 20 centres had no suchpost and neither did 3 of the 6 transplant units. The provision of specialist nurses waseven less at the 49 hospitals providing limited services, with hepatitis and alcoholnurses in only 10 and 2 respectively.In the answers given to questions on the adequacy of provision of medical staffing, only10 of the 28 non-transplant and 3 of the 6 transplant centres recorded this as adequate orexcellent. For specialist hepatitis nurses, the corresponding figures were 5 and 1 for thenon-transplant and transplant centres respectively.3. Provision of inpatient beds and outpatient clinicsLack of dedicated hepatology beds was one of the most frequent answers given to thequestion on the major limitation to the development of the service. Only 12 of the 28centres recorded bed allocations as adequate with 4 of the transplant and 20 of the non-transplant centres describing provision as limited. Over half of the 28 non-transplantunits had no designated beds. The remainder had between 6-30 beds with 2 transplant 6
  7. 7. and 1 non-transplant centre having a larger number (Table 2). An even smallerpercentage of the hospitals providing limited services had designated beds:- 16 of the49.In answer to the question whether the present number of outpatient clinics adequatelyserved the population, 21 (17 non-transplant and 4 transplant) replied “no”. Thirteen ofthe non-transplant units were holding only 1-2 clinics a week (Table 2) and the waitingtime for a routine appointment was >20 weeks in 3 centres, and >10 weeks for 14centres. For urgent appointments, 11 of the centres were able to see a patient within 1-2weeks and 16 within 5 weeks, 3 centres having much longer waiting times (Table 2).For the hospitals providing limited services, the majority (30 of 49) had waiting times of10-20 weeks for non urgent cases.4. Wish-list for improved serviceThe commonest request was for additional staff, mainly specialist nurses in the livercentres and consultant hepatologists in the centres currently providing a limitedprovision of services. The need for more consultants in hepatobiliary surgery wasspecifically mentioned. Some specialist outpatient clinics had been set up includingone-stop investigation of jaundice and nurse-led venesection clinics forhaemochromatosis patients but the number of centres with them was small – 3 only ofthe 34 liver centres. The need for more specialist clinics for alcohol related disordersalso figured prominently on the wish-list. Similarly for HCV services only a few centreshad outreach clinics in the community and in prisons - 3 of 34 liver centres and 7 of 49providing limited services, and a number of hospitals in both groups expressedcontinued difficulty in the funding of HCV services (Table 3). 7
  8. 8. In answer to a question on ‘bottlenecks’ (data not tabulated) 18 of 34 liver centresconsidered that the number of outpatient clinics was inadequate for the needs of thelocal population with less than a third expressing satisfaction with the currentarrangements and current waiting times for appointments. Of the 49 limited providers,29 felt the number of clinics did not adequately serve their population, 17 did and 3 didnot comment.Although pathology services were described as excellent/adequate by the majority ofcentres, radiology facilities were recorded as limited in a quarter of the centres as wellas in 2 transplant centres. This is in keeping with replies to the wish-list question forimproving services, which included better radiological services and specific mention ofthe need for TIPSS, ultrasound guided liver biopsies and other procedures carried out byradiologists (Table 3).The majority of the liver centres recorded good links with the HDU/ITU (21 of 34 and26 of 49 centres respectively) and a need for more ITU beds figured only on the wish-list of the liver transplant centres. The majority of the liver centres as well as thelimited providers had integrated links with oncology services - 24 and 31 respectively.The successful development of links with Hepatobiliary services was mentioned by only5 units. A number of the centres particularly the limited providers, commented on theneed for better links with the transplant centres. Amongst the administrative issuesraised (data not tabulated), the commonest were funding provision for referred casesand difficulties arising because of the lack of recognition of Hepatology as a clinicalspecialty. 8
  9. 9. DISCUSSION:Mortality from liver disease is increasing in the UK. In the year 2000 it killed moremen than Parkinson’s disease and more women than cancer of the cervix. Death ratesfrom alcoholic liver disease have doubled in the past 10 years and as pointed out by theCMO in his Report for 2000, men in the 40-60yrs working age group are mainlyaffected. Because of the long natural history of hepatitis C infections, the number ofcases of chronic liver disease from this cause is expected to treble by 2020. Only43,000 out of an estimated total number of 720,000 cases of HCV infection in the UK,are as yet diagnosed. Around 6,000 persons with hepatitis B positivity are estimated tobe coming into the country each year through legal immigration alone and there is likelyto be a similar number who are HCV positive. Consequent on the rise in cirrhosisprevalence, primary hepatocellular cancer is also increasing in frequency, as is that ofthe other primary liver tumour - cholangiocarcinoma. Fifty percent of the 30,000 caseswith colo-rectal carcinoma seen each year, will have liver metastases, one fifth of whomwould be suitable for resectional surgery. Steato-hepatitis as a result of rising levels ofobesity and diabetes in the population is being referred to in the USA as the ‘newepidemic of cirrhosis’. Advances in therapy are nevertheless encouraging. Thusantiviral therapy is successful in a substantial percentage of cases of chronic HCV andHBV infection. Complications of cirrhosis are better treated and more effective formsof liver support devices are currently under clinical trial. On the horizon are excitingdevelopments in the transplantation of isolated hepatocytes for genetic disorders.But are there the expert staff and facilities in place to manage all this? The liversurgeons required for the hepatic resections already referred to - are few in number, asare oncologists specialising in liver tumours. And where too are the trained consultant 9
  10. 10. hepatologists, along with the virologists, needed for the ever expanding load of chronicHCV and HBV infections? In the survey report entitled “Hepatitis C in the UK: Areview of prevalence and service delivery” [3] only 40% of the consultants provided afully comprehensive service and even amongst the latter group, a quarter did not haveaccess to in-house liver histopathology and 29% were without nurse counsellingservices.The results of the present survey show all too clearly that very few of the 28 non-transplant liver centres identified in England are currently providing a full range of liverservices. Deficiencies in staffing at all levels are staggering. Nearly a third of thecentres do not have a single consultant hepatologist in post. A surprising number donot have even one specialist hepatitis nurse and the provision of specialist staff foralcohol related disorders is dismally low. The failure to provide dedicated liver beds forhepatology services and insufficient outpatient clinics, with unacceptable waiting timesfor appointments contribute to major limitations in service provision. The lack ofsufficient expansion in the support departments – particularly in radiology - is a furtherlimitation. The apparent paucity of links with hepatobiliary services merits comment inthe light of the emphasis placed on combined development of specialised liver andhepatobiliary services in the document “National Plan for Liver Services UK” [2]already referred to.The question then has to be addressed as to how staffing levels and expertise are to beimproved with all the current manpower shortages in the NHS. SpRs ingastroenterology currently have only a limited exposure to hepatology training andbecause of this the SAC recommended the introduction of an additional 6th year for 10
  11. 11. those wanting to specialise in this area. Unfortunately this was not acceptable togovernment/ Department of Health and neither so far is the recognition of hepatology asa distinct sub-speciality of gastroenterology. The latter is essential if all the newresearch and knowledge in this field is to be brought into the NHS. The considerablecosts of specialised liver work underlies the need for appropriate funding andaccreditation of standards within the new tariff structure. PCTs need to be providedwith full knowledge of what is available. What also has to be taken into account, aspointed out by one of the respondents to the survey, is the current dependency ofhepatology services on academic rather than NHS sources in many of the centres in ourmajor cities.It is apparent too from this survey that non-transplant liver cases referred to thetransplant centres benefit greatly in terms of investigatory facilities and availability ofexpert staff. Increasing the number of transplant centres in the country would be oneway of enhancing the level of provision of liver services generally. Furthermore, largeareas of the country are without a transplant centre at present, notably the Northwest,(including Manchester and Liverpool) and the Southwest peninsula. It has beenestimated that a patient living in Leeds is four times more likely to be referred for a livertransplant than if their home is in Cornwall. Some years ago an imaginative proposalwas put forward for an additional centre serving the West Country, centred on Oxfordand including the cities of Plymouth, Bristol and Southampton and with a fullyintegrated network of medical and surgical hepatology. It is to be hoped that thefindings of this survey will inform and stimulate further debate on an appropriateorganisational pattern as well as funding for specialist services in hepatology includingliver transplantation. 11
  12. 12. Bibliogaphy:1 Williams R. Direct and Indirect Constraints on Commissioning Specialist Medical Care in “They’ve Had a Good Innings: Can the NHS Cope with an Ageing Population?” Ed. David G Green and Benedict Irvine, CIVITAS: the Institute for the Study of Civil Society.2 Moore K, Thursz M, Mirza DF. National Plan for Liver Services – Specialised Services for Hepatology, Hepatobiliary and Pancreatic Surgery. 2003. Report prepared for the British Association for the Study of the Liver.3 Parkes J, Roderick, P, Bennett Lloyd B, Rosenberg W. Hepatitis C in the United Kingdom: A review of prevalence and service delivery. 2003. Report prepared for the British Association for the Study of the Liver. 12
  13. 13. Table 1: Staffing numbers for the 34 Hepatology centres, shownseparately for the 28 non-transplant and 6 transplant units (in brackets) Number of Units With >3 1-3 1 Without Consultants• Hepatology 1 (3) 7 (3) 8 (0) 12 (0)• Gastroenterology 9 (1) 13 (3) 2 (0) 5 (2)• General Physician 7 (1) 2 (1) 2 (0) 18 (3) Junior Medical Staff• Specialist Registrar 3 (3) 10 (3) 12 (0) 1 (0)• SHO 4 (1) 9 (4) 12 (1) 4 (1)• Staff Grade 0 (0) 4 (1) 9 (2) 21 (3) Specialist Nurses• Hepatitis 0 (2) 7 (3) 16 (1) 5 (0)• Alcohol 0 (0) 7 (1) 7 (3) 20 (3)• Other 1 (1) 7 (1) 3 (2) 19 (2) 13
  14. 14. Table 2: Provision of dedicated Inpatient Beds and Outpatient Clinics inthe 28 non-transplant and 6 Transplant Centres (in brackets) along withWaiting Times for Routine and Urgent Clinic Appointments > 30 beds 6-30 beds 1-6 beds Without• Inpatient Beds 1 (2) 9 (3) 3 (1) 15 (0) > 5 clinics/wk 3-5 clinics/wk 1-2 clinics/wk Without• Outpatient 5 (4) 10 (1) 13 (1) 0 (0) Clinics > 20 weeks 10-20 weeks 5-10 weeks < 5 weeks• Waiting times: Routine 3 (0) 14 (3) 9 (3) 0 (0) > 10 weeks 5-10 weeks 2-5 weeks < 2weeks Urgent 1 (0) 2 (0) 16 (2) 11 (4) 14
  15. 15. Table 3: The commonest replies to the question “Do you have a wish listfor improving local Hepatology provision?” Numbers given for the 34Liver Centres and 49 providing a limited range of services Centres Liver (and transplant) Limited ProvidersAdditional Specialist Nurses 11 (0) 20More Consultant Staff 3 (2) 10Setting up of Alcohol Service 4 (2) 7More Specialist Clinics 2 (0) 6Funding for HCV Services 4 (1) 7Better Radiological Service 2 (4) 1Facilities for TIPPS/Liver Biopsy 3 (0) 2Protected Inpatient Beds 4 (3) 2Increase in ICU/HDU Beds 0 (2) 1Better links with Transplant Centres 2 (-) 5 15
  16. 16. Figure legend:Figure 1: Location of the 34 hepatology centres in England identified in the Survey Available at the following link: http://www.bsg.org.uk/pdf_word_docs/hepservices.ppt 16

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