Liver disease is the fifth largest cause of death in the UK. The majority of treatable liver disease is undiagnosed and untreated.
Brownlow Health and two other practices in inner city Liverpool (Vauxhall Primary Health Care and Marybone) run a neighbourhood wide hepatitis C treatment service in primary care. This is the first primary care-led treatment service nationally.
The service started over two years ago when the neighbourhood was awarded PBC efficiency savings. The neighbouhood agreed to invest in an innovative post encouraging patients to be assessed and, if appropriate, treated for hepatitis C.
The three neighbourhood practices have approximately 40,000 patients between them and a high drug user and homeless population. Hepatitis C prevalence was high, but patients did not engage with secondary care services.
Aims and objectives
Vulnerable patients who are at most risk of hepatitis C are least likely to attend treatment and comply with care in a hospital setting. This project aimed to:
- Improve quality of life for patients with hepatitis C
- Reduce referrals to secondary care for treatment, thus reducing waiting times for other patients with liver disease
- Address poor attendance for assessment in secondary care through the provision of a community based assessment and work up, including patient engagement, before referral for treatment.
- Increase number of patients who complete treatment
- Early diagnosis and treatment
- Treat patients in primary care where appropriate
- Improve public health by reducing prevalence of hepatitis C
How we did it
Engagement and agreement with local primary and secondary care providers at local level were key. We established a joint steering group, including representatives form primary and secondary care.
We developed a business case to present to commissioners to secure the necessary funding, this included a full cost-benefit analysis.
We also developed robust shared clinical governance procedures to ensure safe, high quality care. This has been a major achievement and required agreement from a range of governance organisations, including pharmacology.
We recruited and trained a lead nurse to establish the service. As part of this we developed honorary contracts to enable the primary care nurse to work in secondary care one session per week to develop her skills and confidence.
We also had to establish inclusion criteria for patients suitable for community assessment and treatment.
Year one and two was primarily spent searching practice clinical systems to identify at risk patients and assessing, engaging and referring appropriate patients for treatment in secondary care. Once our confidence developed and the pathways were robust we started treating patients in 2010.
A big challenge for the nurse has been learning to communicate and effectively engage with vulnerable, hard-to-reach patients who have often been living at the margins of society. This group of people who are most at risk of liver disease will often never engage with secondary care with its requirements to attend appointments and conform to treatment regimens that they can perceive as unrealistic.
The challenges of working with these patients require considerable support. Brownlow has provided this support within general practice with its outreach team of nurses and GPs who have considerable commitment and expertise in the management of vulnerable, chaotic people.
Creating a communication solution that worked across primary and secondary care to enable virtual clinical supervision and consultations where appropriate is also a big challenge. We are working with PCT IT managers to look at EMIS Web as a solution.
Funding for drug therapies
Funding for drug therapies in primary care was a huge problem. We knew early on that treatment in primary care would be possible, but although we had funding for the nurse we had no funding for drug therapies. There were no savings to be made from secondary care either; these were new patients we were identifying as suitable for treatment.
We were fortunate that Liverpool PCT acknowledged that these patients needed treatment funding and the cost of treating them in secondary care would have been significantly more. Therefore our drug budget has been increased to include hepatitis C treatment.
We now have an agreement with our secondary care trust where we have an account with their pharmacy department. Our lead GP is a prescriber in the hospital system and the hospital pharmacy delivers the drugs on a weekly basis to us. We’re hoping the nurse specialist will become a prescriber in the near future too.
Clinical supervision by secondary care consultants has continued and is essential. Without secondary care passion and support this project would not have succeeded.
Case for change
We have proved primary care treatment of hepatitis C is possible. We know patients want to be treated in primary care and we know it is more cost effective.
At present only one neighbourhood in Liverpool has access to this service. Brownlow Health plans to submit a case for change to commissioners and public health within the next few months, with a view to the commissioners considering a city wide service. This case for change will:
- Highlight the potential savings for commissioners in moving this service into primary care
- Explain the impact the service will have on the commissioning outcome framework. For example the outcome framework’s first domain is to reduce liver mortality - our case for change will describe how this service will support the domain.
- Highlight the influence this service will have on the CCG priorities, for example reducing health inequalities by engaging with and supporting vulnerable patients to be treated.
|Liverpool primary care treatment of hepatitis C|
- Dr Diane Exley is a GP, Jayne Wilkie is a nurse and Tina Atkins is management partner at Brownlow Health in Liverpool.