In 2011, Neil Guha and Guru Aithal, two hepatologists at Nottingham University Hospitals and the National Institute for Health Research’s Nottingham Digestive Diseases Research Unit, saw an opportunity to reverse this trend. Sitting in the hospital was a new piece of equipment, a fibroscanner, which held the key to faster diagnosis and earlier intervention. An adapted ultrasound scanner, it sends a sheer wave across the liver, and the speed at which the wave comes back indicates the liver’s stiffness and how much scarring is present. It provides a more accurate diagnosis of liver disease than blood tests, and a quicker, less invasive test than a surgical biopsy. But it was being used in the hospital primarily to monitor patients with advanced cirrhosis rather than to identify early signs of liver disease at a time when the damage could still be reversed.
In 2011, Neil and Guru led a pilot to assess the benefits of more proactive testing for liver disease, working with a single GP practice in Nottingham. They screened the entire practice list for risk factors such as excessive alcohol consumption and type 2 diabetes and offered all patients with significant risk factors a fibroscan in the community. The results were dramatic: a 100 per cent increase in the number of patients diagnosed with cirrhosis and a substantial increase in detection of liver disease at an early stage, where lifestyle changes could still be effective.
From 2013, the East Midlands AHSN joined forces with the Digestive Diseases Research Unit to support further testing and implementation of the model. They ran three more pilots with GP practices at selected sites in Nottingham and Leicester. Over two and a half years, they screened approximately 25,000 patients on GPs’ lists, carried out almost 3,000 fibroscans, and identified 300 new patients with significant liver disease, along with 40 new patients with cirrhosis.
At the same time, the AHSN and the Digestive Diseases Research Unit were building the evidence base for commissioners and providers on the costs and benefits of the new pathway. One recently published article in the British Medical Journal summarises the effectiveness of the new pathway, including the assessment of risk factors and use of fibroscans, in identifying new patients with liver disease and cirrhosis. A second paper estimates the costs per quality-adjusted life-year (QALY) of the new intervention at £2,138 for patients with non-alcohol fatty liver disease and £6,537 for patients with alcoholic liver disease. The National Institute for Health and Care Excellence (NICE) recommends that the NHS should invest in treatments that cost up to £20,000 to £30,000 per QALY.
With such compelling evidence, the priority for the project team was to ensure sustainable implementation of the new pathway across Nottinghamshire. The team persuaded four CCGs in central and southern Nottinghamshire to commission the pathway on an ongoing basis. However, this raised substantial new challenges. The project team did not have the resources for risk stratification of patients from hundreds of GP practices across Nottinghamshire. The small team of hepatologists at Nottingham University Hospitals NHS Trust would struggle to cope with an exponential increase in the number of patients requiring treatment for liver disease.
The response to these challenges was to make substantial further changes to the roles of hospital consultants and general practitioners in delivering the pathway. Neil and Guru are spending an increasing proportion of their time attending meetings with GP practices to win their support for the new model and to train GPs to administer parts of the pathway. GPs now make the initial assessment of which patients on their lists are at risk of liver disease and send these patients to hospital for fibroscans when particular conditions are met, including patients’ willingness to consider lifestyle changes. The GPs receive the results of the tests, make their own diagnosis on the basis of them, and decide which patients to refer to the hospital team and which patients to treat in the community.
The need for continual adaptation has been a consistent theme throughout the project. When fibroscanners first arrived, hospital consultants used them as an adjunct to existing diagnostics and treatment pathways. As they started to use fibroscanners for early detection, they needed to develop new diagnostic pathways. As this increased the number of diagnosed patients, they needed to make further changes to the roles of hospital and primary care teams.
This process of adaptation is far from over. The team are currently considering how they can implement the new pathway in areas supported by smaller hospitals without their own liver specialists. They are developing rapid behavioural interventions to encourage patients to make lifestyle changes. And they are working with drug and alcohol teams on the use of fibroscanners in longer term programmes for people with alcohol dependency. One consequence of this constant adaptation is that the evidence base needs to evolve too. Rather than simply providing proof of concept, the team need to continually test the impact of small-scale refinements of the model. They are currently evaluating the implementation process and the impact of giving patients advice on lifestyle changes after the scans.
Another consistent theme is the need for boots on the ground to support the adoption of new care pathways. These are not ‘plug-and-play’ technologies but complex programmes to win over colleagues and to train and support staff in new treatments. Interviewees highlighted the critical importance of funding for senior hospital consultants to act as clinical champions for the innovation, and for these to work in close partnership with GP opinion leaders to gain traction in primary care.
This process is far from over. Even in Nottinghamshire, there are clinical commissioning groups that have not adopted the new pathway, typically because they have limited capacity to manage service change, other priorities for their communities, and such severe funding constraints that they are focused exclusively on short-term cost reduction rather than longer term improvements in population health. According to Nick Hamilton, a project manager in the East Midlands AHSN, ‘We push on open doors. But we don’t try to force the pathway on commissioners who have other priorities.’
Ensuring adoption across the whole of England, something which would save thousands of lives at a low cost, would be a major endeavour. Success so far has depended on leapfrogging from one small pot of innovation funding to the next. At present, it is unclear whether the team will continue to receive funding beyond the end of 2017. It is working on web-based resources so that commissioners and providers can learn about and adopt the tool on their own in future.