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-390525-161925Health Needs Assessment00Health Needs AssessmentChronic Liver Disease Gillian McLauchlan, Public Health Specialist, Public Health Directorate, Oldham Council November 2014-412757813040rightbottom00Contents PageAcknowledgements3Executive Summary41. Introduction72. Strategic Context 93. Liver Disease definition and pathophysiology 124. Main causal factors of Liver Disease 144.1 Alcohol 4.2Obesity4.3 Combinatory factor of Alcohol and Excess body weight 4.4 Hepatitis B and C5. Mortality from Liver Disease 276. Admissions from Liver Disease 347. Admissions attributable to the 3 main causal factors378. Patients perceptions and stories 419. Current chronic Liver Disease pathway and services in Oldham 46 10. Recommendations 6311. Priorities in Research68AcknowledgmentsI would like to thank the first and foremost the liver patients who shared their stories with me and Dr Lisa Wilkins -Consultant in Public Health Medicine, Oldham Council for her input and support. I also like to thank the following stakeholders for all their input: Dr Zuber Ahmed Clinical Director Elective Care, Oldham Clinical Commissioning Mr Alan Higgins Director of Public Health, Oldham Council Dr Vinay BothaConsultant of Communicable Disease, Public Health England Mr Phil Conley Health and Wellbeing Lead, Drugs and Alcohol, PHEMs Lynne Kendrick Specialist Liver Nurse, Pennine Acute TrustMs Rose WilsonSpecialist Liver Nurse, Pennine Acute Trust Ms Janet SewartHead of Service Drugs and Alcohol, Oldham Council Dr Keith JefferiesClinical Director, Oldham CCG Mr Richard KubiliusProcurement Manager, Oldham Council Dr Xola McFarlaneClinical Director for Gastroenterology, Pennine Acute Hospital Mr Graham Muslow Screening and Immunisation Coordinator, NHS England Ms Ellen CooperScreening Manager, NHS England Mr Alistair Rutherford Screening Coordinator, NHS England Ms Andrea Fallon Consultant of Public Health, Oldham Council Dr Andrew Vance GP, Royston Practice Dr Tom BarstamAccident and Emergency Consultant, Pennine Acute Hospital Mr Jay MurdockAlcohol Liaison Nurse, Pennine Acute Hospital Miss Koser Khan Public Health & Social Care Research & Engagement SpecialistMrs Bev Melia Specialist Palliative Care Lead, Pennine Care Foundation TrustExecutive Summary Liver disease is the fifth most common cause of death in the UK. It has direct healthcare costs that are currently in excess of ?0.5billon per annum and rising by 10% per year. Mortality rates of liver disease in the UK have risen sharply over the last 10-15 years, in contrast to declining rates of other major causes. Younger age groups are disproportionately affected, with the average age of liver related disease being 59 and falling. The North West region has the highest mortality rate of liver disease compared to other English regions. In 2010, North West liver disease mortality was nearly double that in 1995. Liver disease is largely preventable through tackling the 3 main causes: Alcohol, Obesity and Hepatitis B & C. According to the Chief Medical Officer’s 2012 report, from 2001 to 2012, the majority of premature mortality from liver disease in England and Wales was due to alcoholic liver disease (67%), though non-alcoholic fibrosis and cirrhosis of the liver (20%) and non-alcoholic fatty liver disease (4%) also made substantial contributions. The British Liver Trust estimates that around 2 million people in the UK have liver disease. Unfortunately, public awareness of liver disease is low and the disease has vague symptoms until liver damage is quite severe, so the majority of people are unaware of their condition and present at services in an advanced stage of disease. As a result liver disease is typically detected during tests for an unrelated illness or a medical check-up. The joint strategic health needs assessment for Chronic Liver Disease covers the prevention, identification, assessment, treatment and end of life aspects of Liver Disease and its 3 main risk factors. It:Identifies Oldham’s population needSummarises key national reports, guidelines and other evidence Identifies the key local stakeholders and current provision Gives two case histories of people who have liver disease Identifies gaps where the provision does not meet the needProvides evidence-based recommendations to enhance the current liver disease prevention, treatment and end of life care.The findings are that according to the Department of Health’s Call to Action for the average local authority with a population of around 350,000, 50 people will die from liver disease yearly. For Oldham; this equates 33 people dying before the age of 75 from liver disease. The actual numbers for Oldham are significantly higher, with 42 people dying prematurely from liver disease in 2012 and 55 in 2011. Oldham mortality rates from liver disease in those aged 75 have been declining over the last 3 years. It is now just below the North West average but still significantly higher than the England average. Downward mortality trajectories are seen in both males and females, with male mortality rates declining at a faster rate than females. This decreasing trend was also seen in Oldham’s mortality from liver disease considered preventable in those aged under 75. Again, this is in contrast to the increasing rates in the North West and England average. Oldham’s female mortality rates considered preventable are now the same as the England average having previously had rates higher than the North West average. These decreasing mortality rates need to be seen in the context of increasing North West and England rates. Unfortunately, this picture of decreasing rates was not echoed in hospital admissions of Oldham residents. Both emergency and non-emergency hospital admissions are increasing. In male non-emergency admissions with a primary diagnosis of liver disease increase by 43% from 2006/07 to 2013/14, whilst females increased by 92%. Emergency admissions with a primary diagnosis of liver disease in Oldham have also increased by 93% from 2006/07 to 2013/14. In 2013/14, 73% of emergency admissions with a primary diagnosis of liver disease were due to alcohol related liver disease. The number of emergency admissions with a primary diagnosis of alcoholic liver disease in Oldham have increased by 150% from about 40 to 100 admissions per year. However, it would appear that there has been a change in the way admissions have been coded. Over the same period of time, the number of emergency admissions with a secondary diagnosis of alcohol related liver disease has decreased. Overall, the number of emergency admissions, when primary and secondary admissions are taken together, show a fairly stable picture. A 128% increase was seen in non-emergency admission rate due to a diagnosis of non- alcoholic fatty liver disease.The prevalence rate of chronic hepatitis B infection is believed to be between 0.1% and 0.5% of the UK population; this equates to a prevalence of 225 - 450 persons for Oldham.Public Health England estimates that the total number of people in Oldham infected with HCV is 1,365. This is amounts to 0.6% of Oldham’s population, compared to 0.4% nationally. Of these, it is estimated that 1,010 (69%) will be RNA positive (i.e. have persistent infection) and be eligible for antiviral treatment.Stories from two Oldham patients with liver disease and their families revealed that they often feel unable to seek support due to the perceived stigma surrounding the disease; that it is all self-induced and alcohol related. This has left patients and their families feeling isolated. The needs assessment summarises the evidence base and sets out the current services in Oldham for the risk factors of liver disease and liver disease management, and stakeholders perceptions of the gaps in services. Key areas of concern included:Lack of public and professional awareness about liver disease and its risk factorsLack of coherent plans in Oldham to reduce obesity and excessive alcohol useLack of consistent screening for harmful alcohol use in primary care and other services High proportion of children born to hepatitis B positive mothers not having a full course of hepatitis B vaccination and poor data recording / fail safe mechanism to ensure that children do receive the vaccinationLow levels of hepatitis screening of users attending drug treatment programmes Very low levels of antiviral treatment for people with chronic hepatitis CMissed opportunities in primary care to identify liver disease at early stagesNeed to bench mark the PAHT alcohol liaison service against the National Confidential Enquiry into Patient Outcomes and Death report, Measuring the Unit, recommendationsNeed to strengthen links between the PAHT Nurse Led Liver Service and the Alcohol Liaison ServiceNeed to strength End of Life care for patients with liver diseaseNeed for a patient support groupGiven the preventable nature of liver disease and the increasing admissions, it is imperative that early identification and risk factor (obesity, alcohol misuse and blood borne viruses) modification of liver disease are given higher priority by the Oldham Health Economy. This requires the coordinated input from a range of health and social care professionals working in primary, community and secondary care settings, along with support from the voluntary sector and most importantly the patient and their families and carers. The needs assessment makes 17 recommendations that have been classified under commissioning responsibility and categorised under:Risk factor modification, liver awareness and early identification of liver diseaseTreatment of advance disease Section 1 - IntroductionAn estimated 2 million people in Britain have liver disease and every year over 4,000 people in the UK die from cirrhosis of the liver. Liver disease affects young and economically productive individuals. The average age of liver-related death is 59 years and falling. This is much younger than the average age of death for other major fatal diseases (Heart Disease 82, Respiratory Disease 83, Stroke 84 and Cancer 72 years). The National End of Life Care Network highlighted that in contrast to the other major causes of death, mortality from liver disease has risen sharply over the last 10-15 years, with a 25% increase in deaths seen between 2001 and 2009 The 2011 Chief Medical Officer Report noted that unlike comparable european countries where the number of people dying from liver disease is declining, the numbers of deaths is continuing to rise in the UK. Liver disease is now the fifth most common cause of preventable death in the UK It is largely preventable through tackling the 3 main causes - alcohol, obesity and hepatitis B & C. According to the Chief Medical Officer’s 2012 report, from 2001 to 2012, the majority of premature mortality from liver disease in England and Wales was due to alcoholic liver disease (67%), though non-alcoholic fibrosis and cirrhosis of the liver (20%) and non-alcoholic fatty liver disease (4%) also made substantial contributions. The incidence and mortality rate from primary liver cancer have increased nationally over the last decade but it still only makes up around 1% of all cancers. In 2009, there were over 3,000 new cases and nearly 3,000 deaths due to liver cancer.5Liver disease has often only vague symptoms until liver damage is quite severe. Early symptoms of liver disease are usually non-specific, including fatigue, nausea, vomiting, diarrhoea or abdominal pains. This results in the majority of patients with liver disease being unaware of their condition and presenting to primary care at an advanced stage of disease. Unfortunately, public awareness on liver disease is not high so most disease is being detected during tests for an unrelated illness or a medical check-up. Typically, patients are ill for 3-5 years before death but may experience many years of slowly eroding ability to work and function fully. Liver disease has a significant impact on the economy and is of high cost to the NHS. Direct healthcare costs of liver disease are currently in excess of ?0.5bn per annum and rising by 10% per year The NHS Hepatobiliary Service Specification states that there is an estimated 640,000 known liver patients in England as at 2009/10 with HES data showing that there were approximately 150,000 inpatients treated for liver disease at NHS Acute Trusts in 2009/10. Liver disease now accounts for almost 25% of outpatient referrals and 50% of inpatient admissions to Gastroenterology services.A range of methodologies have been used to ensure a robust overview is achieved. These include literature reviews, meetings and semi-structured interviews with stakeholders and service users. The NICE’s Health Needs Assessment: A Practical Guide was the framework used.This Joint Strategic Needs Assessment (JSNA) for liver disease will:Identify the population needSummarise key national reports, guidelines and other evidence Identify the key local stakeholders and current provision Give two case histories of people who have liver disease Identify gaps where the provision does not meet the needProvide evidence-based recommendations to enhance the current liver disease prevention, treatment and end of life care.Section 2 - Strategic Context 2.1 National Liver Disease Related Indicators CCG Indicator set for 2014/15 includes:Under 75 mortality from liver disease (joint with NHS Outcome 1.3 and Public Health Outcome Framework 4.06i)Emergency admissions for alcohol related liver disease (Domain 1) Alcohol specific admissions and readmissions (Domain 3)Public Health Outcomes Framework 2014/15In addition to the joint, CCG, NHS Outcome Framework and Public Health Outcome Framework indicator, the Public Health Outcome Framework has an outcome measure on liver disease that is preventable:Under 75 mortality rate from Liver Disease that is preventable (PHOF 4.06ii) Primary Care Quality Outcome Framework (QOF) Indicator for Liver DiseaseThere are currently no QOF indicators for liver disease. There is a QOF indicator for obesity registers and a number of the indicators require the practitioner to enquire about the person’s alcohol consumption (risk factor of liver disease). 2.2 National and Local Strategy ‘Living Well for Longer: A Call to Action to reduce avoidable premature mortality”In October?2010, the Government noted that there are two million people with or at risk of liver disease and that “Front-line clinicians and the NHS as a whole need support to tackle the complex causes of over 100 different types of liver disease”.Although the Government originally intended to publish a National Liver Disease Outcomes Strategy, this is no longer expected. Instead in March 2013, the Government issued ‘Living Well for Longer: A Call to Action’ to reduce avoidable premature mortality. This focuses on the 5 big killer diseases; one of which was liver disease. Of the 5 big killers it is only liver disease that does not have an underpinning national strategy and there are no specific recommendations on liver disease within the Living Well for Longer Call to Action. Chief Medical Officer’s Recommendation on Liver Disease NOTEREF _Ref398122234 \f \h \* MERGEFORMAT 3In the 2011 CMO’s report it recommended: Action on preventing, identifying and treating liver disease is a priority and needs to be included in local health and wellbeing strategies.Oldham’s Health and Wellbeing Strategy Tackling the main causal factors of liver disease (alcohol and obesity) is a priority within the Living, Learning and Working Well Theme of the Oldham Health and Wellbeing Strategy. The overall aim of the strategy is to achieve a shift in investment away from reactive crisis activity and towards planned activity that supports the prevention of ill health and early detection and intervention.Oldham Clinical Commissioning Group plans on a pageImplementation of this needs assessment recommendations is included in the CCG’s 2014/15 commissioning plan on a page for elective care.2.3 Oldham’s Population Liver disease disproportionately affects younger age groups; therefore it is important to understand the age profile of Oldham. Ethnicity profile in relation to Body Mass Index (BMI) cut offs is also of consequence because of an association between liver disease and obesity and the high Asian population in Oldham. The estimated population for Oldham based on the 2011 Census is 224,900 people. Females make up over half (51%) of Oldham’s population. Oldham has a higher proportion of younger people compared to England but a lower proportion of older people for both males and females. Oldham’s population has risen by 3.5% since 2001, which is considerably lower than the growth in the national population (7.9%). Oldham Population Projections Oldham’s population is projected to reach 237,000 people by 2021, a substantial 5.3% increase over the 2011 Census population estimate of 224,900. The main factors driving this population rise is increases in the 0-15 age range and the overs 65s. Ethnicity in Oldham’s PopulationThe size of Oldham’s minority ethnic population has increased from 13.9% in 2001 to 22.5% in 2011, a significantly greater change than nationally. The largest minority ethnic group in Oldham is Pakistani (10.1%) followed by Bangladeshi (7.3%) (Table one). Table 1 Ethnicity of Oldham by comparison of Greater Manchester, North West and England average, 2011Ethnic groupOldham(%)Greater Manchester (%)North West (%)England (%)White77.583.890.285.5Pakistani10.14.82.72.1Bangladeshi7.31.30.70.8Indian0.721.52.6Black (African/Caribbean)1.22.81.33.4Mixed1.82.31.62.2Other ethnic groups1.43.12.03.2All ethnic minorities (non-white)22.516.39.814Source: ONS Census 2011Projected Changes to Population EthnicityThe ethnic composition of Oldham’s population is forecasted to change over the next ten years, with further increases in the population with an Asian heritage (Chart 1). Chart 1 Forecast Changes to the Ethnic Composition of Oldham’s Population 2012-2022Source: Susan Lomax and Ludi Simpson, “Forecast updates for Oldham with an ethnic group dimension” University of Manchester, 2008Section 3 – Liver Disease definitions and pathophysiology 3.1 Definition The Public Health Outcome Framework and CCG Outcome Indicators definition of liver disease were used in this report. Table 2 provides a summary of the codes. Table 2: Definitions of Liver Disease Liver DiseaseICD10 CodesLiver diseaseK70* - K77Liver cancerC22*Other chronic liver diseaseI81, I85, T86.4 Viral liver diseaseB15*,B16*,B17*,B18*,B19*Definition of Liver Disease considered preventable Liver DiseaseICD10 Codes Alcoholic liver diseaseK70Chronic hepatitis, not elsewhere classifiedK73Fibrosis and cirrhosis of liverK74Liver cancerC22Viral liver diseaseB17.1; B18.2Note: * indicates the inclusion of 4-digit ICD-10 codesCaveats are needed for:The PHOF definition of liver disease considered preventable does not include Chronic Hepatitis B and Non alcoholic fatty liver disease. Discussions were had with Public Health England as the rationale of omission as locally these diseases would be considered preventable. Similar mortality indicators are published annually in the NHS IC Indicator Portal that uses a narrower definition of liver disease using just ICD-10 K70, K73 and K74. 3.1 Pathophysiology Preventable chronic liver disease follows a similar pathway involving chronic inflammation as illustrated by the following. Liver Insult → Liver Inflammation → Liver Fibrosis → CirrhosisLiver disease commences with insult (from various factors such as alcohol, virus or fat) which causes mild degrees of inflammation and repair. With repeated damage, the livers attempts to replace and repair damaged tissue lead to scarring (fibrosis). The scar tissue performs no function, and it can distort the liver's internal structure. When the scarring and distortion become widespread, cirrhosis develops. Once cirrhosis reaches a certain level, the liver gradually loses all its functions – commonly known as liver failure or end-stage liver disease. Liver transplant is the only hope for the long-term survival of a person with liver failure.3.2 Complications of Liver Disease Cirrhosis can remain compensated for many years prior to the development of a decompensating event. Decompensated cirrhosis is marked by the development of complications such as: ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension, hepatorenal syndrome. Ascites (accumulation of fluid in the abdominal cavity) is one of the most frequent complications of cirrhosis. Patients surviving an episode of acute variceal haemorrhage have a high risk of re-bleeding and death. There is an association between nutritional status and mortality. Protein energy malnutrition is found in 65–90% of patients with advanced liver disease and almost 100% of those awaiting transplant. Protein energy malnutrition before transplantation leads to higher rates of post-transplant complications Section 4 - Main Causal Factors of Liver Disease There are over 100 known forms of liver disease caused by a variety of factors; affecting everyone from infants to older adults. The four main causes of liver disease are alcohol, obesity and chronic hepatitis B and C infection. These are all preventable. 4.1 Social InequalitiesLiver disease, like cardiovascular disease, cancer and respiratory disease, must be seen in the context of tackling the underlying social determinants of health that drive health inequalities. Sir Michael Marmot’s review of health inequalities in England demonstrated a social gradient in health: the more socially deprived people are, the higher the chance of avoidable premature mortality. This is true for liver disease, with both men and women in the quintiles with the highest levels of deprivation having the highest rates of premature mortality from liver disease (Chart 2).Chart 2 – Liver Deaths per 10,0000 Population by Deprivation QuintileFig ONS under 75 DSR per 100,000 population.Research has consistently shown that whilst the number of people overall who engage in multiple risky health behaviours, such as excessive drinking, or smoking, or having a poor diet, has reduced, people from poorer backgrounds, and the most vulnerable are still more likely to undertake three or more of these behaviours. This is likely to lead to a much earlier onset of some of the major causes of early death, including liver disease. 4.2 Alcohol There is a strong relationship between population alcohol consumption and liver related deaths. From 2001 to 2012, two thirds of the premature mortality from liver disease in England and Wales was due to alcoholic liver disease (67%). Likewise, alcoholic liver disease was responsible for the majority of alcohol-related deaths. In 2012 it accounted for 63% (4,425) of alcohol related UK deaths, 18% higher than the number of deaths in 2002 (3,629). 31% of deaths from alcoholic liver disease in 2012 were among those aged 50-59 years. From 2002-2012, increasing deaths were seen in those aged 40 years and over but the biggest increase (33%) was seen among those in their 60s.Alcohol is the third biggest behavioural risk factor for disease and death in the UK after smoking and poor diet NOTEREF _Ref402953576 \f \h 1. According to the WHO report on alcohol, Europe was the region with the highest annual consumption of pure alcohol per capita, at 10.9 litres. The UK average was 13.8 litres of pure alcohol a year, with men consuming 18.9 litres and women consuming 8.5. UK rates of alcohol consumption have risen over the past 50 years, and in contrast to other EU countries, incidence of deaths due to liver disease is also increasing. 4.2.2 Alcohol Consumption in Oldham Table 3 describes the risk of drinking classifications as detailed in NICE guidelines. Table 3 Risk of Drinking ClassificationType of drinkingDefinitionEquivalent units – WomenEquivalent units - MenLower riskDrinking is unlikely to cause yourself or others significant risk of harm.Should not regularly drink more than 2-3 units of alcohol a dayAdult men should not regularly drink more than 3-4 units of alcohol a day.Increased riskDrinking above sensible limits but not yet experiencing harmDrinking more than 2 and 3 units of alcohol a day on a regular basis for women (15-35 units a week)Drinking more than 3 and 4 units of alcohol a day on a regular basis for men (22-50 units a week)Higher riskDrinking at levels that bring about significant harm to your physical and mental health and at levels that may be causing substantial harm to othersDrinking more than 6 units a day for women (35+ units per week)Drinking more than 8 units of alcohol a day for men (50+ units per week)Binge Drinking over twice the recommended daily guidelines in one drinking sessionDrinking over twice the recommended daily guidelines in one drinking session-Drinking over 6 unitsDrinking over twice the recommended daily guidelines in one drinking session-Drinking over 8 unitsCurrently, there are no direct measures of how many people in local areas are drinking alcohol and/or are drinking above the recommended limits. National survey data, demographic information and information on alcohol-related mortality and morbidity are used in combination to generate estimates for each local authority. Table 4 describes the percentage of the drinking population that these synthetic estimates consider engage in lower, increased, higher risk drinking or binge drinking in Oldham. Overall Oldham had similar levels of risk drinking as the North West and England. Oldham had a higher level of binge drinking than England but more abstainers than both the North West and England (Chart 5). Table 4 Mid 2009 Synthetic Estimate of the Percentage Within the Drinking Population (not including abstainers) Aged 16 Years and OverLocation % Engaging in lower risk drinking % Engaging in increased drinking % Engaging in higher risk drinking % Engage in binge drinking Oldham74.3119.446.2423.4North West73.5319.866.6123.3England73.2520.006.7520.1Source: Local Alcohol Profile 2014Table 5 Mid 2009 Synthetic Estimate of the Percentage Within the Total Population Aged 16 Years and Over who Report Abstaining from DrinkingOldham19.34North West15.38England16.53Source: Local Alcohol Profile 20144.2.3 Types of Alcoholic Liver DiseaseOne of the functions of the liver is to break down alcohol to allow it to be removed. Regular and heavy drinking over time can put a strain on the liver, leading to alcohol-related liver disease. There are several different stages and types of alcohol-related liver disease: Alcoholic cirrhosis of liver Alcoholic fatty liver Alcoholic fibrosis and sclerosis of liver Alcoholic hepatic failure Alcoholic hepatitis Alcoholic liver disease, unspecified Liver failure or decompensation occurs when the liver is so severely affected by alcoholic hepatitis or cirrhosis that it cannot carry out its normal functions. 4.3 Obesity The rising epidemic of obesity and obesity-related diseases in many post-industrialized countries has been accompanied by a rise in the prevalence of Non Alcoholic Fatty Liver Disease. Non-alcoholic fatty liver disease (NAFLD) spans a spectrum of liver diseases that ranges from simple steatosis of the liver to progressive inflammation and fibrosis, resulting in non-alcoholic steatosis and cirrhosis. The UK Chief Medical Officer’s Annual reports of 2011 NOTEREF _Ref398122234 \f \h 3 and 2012 NOTEREF _Ref398146482 \f \h 5 echoed these findings by stating that over the past couple of decades, it has become increasingly evident that non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are a major cause of liver disease in Western countries. The CMO estimated that 4% of the UK liver disease deaths are due to non-alcoholic fatty liver disease. It is estimated that over 66% of overweight people, and over 90% of obese people, have Non Alcoholic Fatty Liver Disease. There is increasing evidence that the prevalence of obesity and the progression of hepatic histological damage associated with Non Alcoholic Steatohepatitis (NASH) exhibit significant ethnic disparities. Despite a significantly lower body mass index and lower rates of obesity compared to other ethnic groups, people of Asian origin continue to demonstrate a significant prevalence of hypertension, diabetes, metabolic syndrome and NASH. Ethnic disparities in central adiposity and visceral fat distribution have been hypothesized to contribute to these ethnic disparities.Non Alcoholic Fatty Liver Disease is caused by accumulation of fat in cells inside the liver. Most people with NAFLD have a benign form known as steatosis. In a small proportion of people, this will progress to non-alcoholic steatohepatitis (NASH). NASH is virtually indistinguishable histologically from alcoholic steatohepatitis. NASH is closely associated with diabetes and there is also a strong correlation with the morbidity and mortality from cardiovascular disease. There is currently a lack of population-based studies, so it is unclear why some people progress from steatosis to non-alcoholic steatohepatitis. 4.3.1 Adult Obesity in the UK In 2012, the prevalence of overweight and obese persons (body mass index [BMI] ≥25 kg/m2) in the England had risen to 63.8%, with 25% of the adult UK population being obese (BMI ≥30 kg/m2). There is substantial variation in the distribution of obesity in England between socio-economic groups.The North West prevalence rate of adults classified as overweight and obese is 66%. In Oldham, the prevalence is greater at 69.6% - the highest in Greater Manchester (Table 6). One of the contributing factors to the increasing levels of obesity is that Oldham residents have lower physical activity and higher inactivity rates than the NW and England average. NOTEREF _Ref394741990 \f \h 28Table 6 Percentage of Population that are Classified Overweight or Obese Across the 10 Greater Manchester Local Authorities- 2012LocalityPercentage of population Oldham69.6Tameside69.2Rochdale68.6Bury68.2North West66.0Stockport65.9Wigan65.2England63.8Salford63.3Manchester62.7Bolton60.1Trafford59.2Source: Active People Survey; Sport England 4.3.2 BMI Cut offs for Different Ethnic Groups In recent years, there has been a growing debate as to whether there is a need to develop different BMI cut-off points for different ethnic groups. This is due to the increasing evidence that the associations between BMI, percentage of body fat, and body fat distribution differ across populations and that the health risks increase below the cut-off point of 25 kg/m2 (that defines overweight in the current WHO classification) in some populations. The WHO Expert Consultation concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMI's lower than the existing WHO cut-off point for overweight (= 25 kg/m2.). The Consultation recommended that the current WHO BMI cut-off points should be retained but the cut-off points of 23, 27.5, 32.5 and 37.5 kg/m2 were added as points for public health action. Considering 10.1% of Oldham’s population are of Pakistani and 7.3% Bangladeshi heritage, then potentially the proportion of the population that are classed as overweight or obese is greater than the recorded 69.9%. 4.3.3 Childhood obesity In considering the future drivers of liver disease, consideration must be given to Oldham’s levels of overweight and obese children. The risk of obesity in adulthood and risk of future obesity-related ill health are greater as children get older. Studies tracking child obesity into adulthood have found that the probability of overweight and obese children becoming overweight or obese adults increases with age’’. Oldham has the second highest rate of obesity in children aged 4-5 years in Greater Manchester in 2012/13 (table 7). Table 7 Percentage of Obese children (4-5 years) and (10-11 year) Across Greater Manchester 2012/13 % of Obese Children EnglandBoltonBuryManchesterOldhamRochdaleSalfordStockportTamesideTraffordWigan4-5 years9.37.87.812.410.18.89.47.69.57.28.410-11 years18.920.119.424.119.420.721.317.219.018.819.0Source: Local Authority Child Health Profiles Public Health England Centre summary Greater Manchester - March 2014From 2006/07 to 2012/13 there has been an increase in the proportion of Oldham’s children aged 4-5 and 10-11 who are classed as overweight or obese (Charts 3 and 4). This is a cause for concern in relation to future liver disease and other morbidity and mortality. The National Child Measurement Programme has consistently shown a near linear relation between area-level deprivation and prevalence of obesity, with approximately double the prevalence in the most deprived decile relative to the least deprived decile. Table 8 describes the percentage of 4-5 year and 10-11 year aged children and deprivation by ward in Oldham, shows a more complex picture, although a double prevalence was noted between the most and least deprived wards.Chart 3 Trend over time percentage of 4-5 years classified as overweight or obese in Oldham compared with North West and England Source: Health and Social Care Information Centre, National Child Measurement ProgrammeChart 4 Trend over time percentage of 4-5 years classified as overweight or obese in Oldham compared with North West and England Source: Health and Social Care Information Centre, National Child Measurement ProgrammeTable 8 - Correlation between percentage of obese children at 4-5 and 10-11 years with Index of Multiple Deprivation (2009-12)Wards NameMultiple Deprivation Index (% of Rank)% Children obese aged 4-5 years% Children obese aged 10-11yearsAlexandra210.219.9Coldhurst214.222.6St Marys29.516.3Werneth49.920.5Hollinwood511.518.8Medlock Vale711.721.1Waterhead138.316.9St James1412.422.5Chadderton South1810.418.1Failsworth West2111.425Chadderton North268.415.2Chadderton Central279.616.6Failsworth East298.818.3Shaw297.315.5Royton South3811.819Royton North429.613.6Crompton498.617.9Saddleworth West and Lees508.818.6Saddleworth North756.315Saddleworth South834.310.6 Source: Health and Social Care Information Centre, National Child Measurement Programme4.4 Combinatory Factor of Alcohol and Excess Body Weight Increasing evidence’’’suggests excess body weight and alcohol consumption act together to increase the incidence of liver cirrhosis. The Million Women Study reported that women who were overweight or obese had a greater risk of liver cirrhosis than women in the ideal weight range (BMI between 22.5 and 25). The absolute risk of liver cirrhosis with increasing BMI was substantially greater for women who drank 150g or more of alcohol per week than for those who drank less than 70g a week NOTEREF _Ref394950005 \f \h 33 Raised BMI and alcohol consumption were also found to be associated with liver disease in two large prospective cohort studies of men in Scotland. The combination of a high BMI and alcohol consumption resulted in a greater risk of cirrhosis than would be expected from the additive effects of the two separate causal factors NOTEREF _Ref394950041 \f \h \* MERGEFORMAT 34.Similar findings have also been reported from other countries. For example, 2005–2008 NHANES cross sectional survey of adults in the United States suggests that the co-occurrence of obesity and excessive drinking may place adults at an increased risk of liver disease NOTEREF _Ref394950041 \f \h \* MERGEFORMAT 34 as did a study of older adults from the United States.Findings from a cohort study in China found that the risk of alcohol consumption and obesity together was far greater than the risk of either one on its own inducing liver disease NOTEREF _Ref394950202 \f \h \* MERGEFORMAT 35 The evidence highlights a multifaceted association between obesity and alcohol consumption, heavily influenced by individual characteristics including body weight, diet, genetic factors, as well as frequency, pattern, amount of consumption and types of drinks consumed. Lifestyle choices such as sedentary behaviour need to be taken into consideration. For example, alcohol is often a complement to sedentary activities such as watching television which may further promote weight gain.This increasing body of evidence needs to be taken into consideration when considering prevention and early interventions for liver disease. 4.5 Hepatitis B and CThe hepatitis B (HBV) and C viruses (HCV) are major causes of liver disease. Deaths certified as HCV-related end-stage liver disease or hepatocellular carcinoma in the UK have risen from 98 in 1996 to 323 in 20114.5.1 Hepatitis B Chronic hepatitis B is a spectrum of disease usually characterised by the presence of detectable hepatitis B surface antigen (HBsAg) in the blood or serum for longer than 6 months. In some people, chronic hepatitis B is inactive and does not present significant health problems while others it progresses to liver fibrosis, cirrhosis and hepatocellular carcinoma (HCC). The progression of liver disease is associated with hepatitis B virus (HBV) DNA levels in the blood. Without antiviral treatment, the 5-year cumulative incidence of cirrhosis ranges from 8 to 20%. People with cirrhosis face a significant risk of decompensated liver disease if they remain untreated. Five-year survival rates among people with untreated decompensated cirrhosis from hepatitis B can be as low as 15%. 4.5.2 Hepatitis B Transmission In the UK, the majority (95%) of new chronic hepatitis B infections occur in migrant populations, having been acquired perinatally in the country of birth. In highly endemic areas, HBV is most commonly spread from mother to child at birth, or from person to person in early childhood. Sexual transmission and the use of contaminated needles, especially among injecting drug users, are also major routes of infection. 4.5.3 Risk for Chronic DiseaseThe likelihood of a patient developing chronic hepatitis B infection is inversely related to age at the time of infection. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections: 80–90% of infants infected during the first year of life develop chronic infections;30–50%% of children infected before the age of 6 years develop chronic infections.In adults:<5% of otherwise healthy adults who are infected will develop chronic infection;15–25% of adults who become chronically infected during childhood die from hepatitis B-related liver cancer or cirrhosis.4.5.4 Vaccination A vaccine against hepatitis B has been available since 1982 and is 95% effective in preventing infection and its chronic consequences. All pregnant mothers in England are offered screening for hepatitis B and if the mother is infected, the child receives the hepatitis B vaccine at birth as this is the best way of protecting against a lifelong hepatitis B infection. The vaccine is also available to anyone who is at increased risk of Hepatitis B or its complications such as healthcare staff, people travelling to high risk countries and people who inject drugs. 4.5.5 Prevalence of Chronic Hepatitis B The UK falls into the lowest category of prevalence for HBV, as determined by the World Health Organisation. The prevalence rate is believed to be between 0.1% and 0.5% of the UK population; this equates to a prevalence of 225- 450 persons for Oldham. Only reports on Acute Hepatitis B are collated which does not give an indication of chronic hepatitis B. 4.5.6 Hepatitis C Hepatitis C is often asymptomatic, presenting with liver failure and cancer decades after infection. About 20% will develop overt hepatitis. About 80% of those exposed go on to develop chronic hepatitis. The rate of progression of the disease is slow but variable, usually taking about 20–50 years from the time of infection. About 30% of those who are infected develop cirrhosis within 20–30 years, and a small percentage of these people are at a high risk of developing hepatocellular carcinoma. A third may never progress to cirrhosis or will not progress for at least 50 years. Some people with end-stage liver disease or hepatocellular carcinoma may need liver transplantation NOTEREF _Ref403031636 \f \h 40. There is no vaccine for hepatitis C, but there are now very effective treatments which can cure up to 80% of those infected depending on the strain of the virus. Around 20% of those who are infected with hepatitis C clear the infection naturally during the acute phase (first six months) and do not develop a chronic infection requiring treatment.4.5.6 Transmission and at risk groupsPeople who inject drugs (PWID) and immigrant populations from countries with a moderate-to-high prevalence of hepatitis C virus (HCV) are the main risk groups. In England, a disproportionately large number of infections are seen in those of South Asian origin and in those of ‘other white’ backgrounds, the majority of whom were born outside the UK (particularly in Asia and Eastern Europe). Hepatitis C can only be transmitted through blood to blood contact with an infected person. Only in extremely rare cases can it be passed on through bodily fluids. In UK, the most common means of transmission is sharing equipment used for injecting drug use. 4.5.7 Burden of Disease NationallyThe prevalence of chronic hepatitis C infection in England is estimated by Public Health England to be around 0.4% of the population. The number of laboratory reports for hepatitis C in England increased by 73% between 2005 and 2012 (Table 9).Nationally the numbers of admissions and deaths from HCV-related end stage liver disease and hepatocellular carcinoma are both continuing to rise. Hospital admissions have risen from 612 in 1998 to 2268 in 2011, while deaths have risen from 98 in 1996 to 381 in 2011.43 Due to coding issues these are thought to be underestimates. An overall increase in registrations for liver transplants with a primary code of post-hepatitis C cirrhosis has been observed from 45 in 1996 to 124 in 2012.434.5.8 Burden of Disease LocallySimilar increases in the number of laboratory reports for hepatitis C have been seen across Greater Manchester as nationally. Oldham’s HCV reports, however, have remained consistent between 20 and 40 a year (Table 9, with the exception of a threefold increase in 2007. This increase was not sustained and is presumed to have been due to a drive in screening at that time. As the laboratory reports includes individuals with a positive test for hepatitis C antibody (a marker of past infection) as well as those with hepatitis C RNA (a marker of persistent infection), we are unable to determine the actual number of people who have persistent infection.Table 9 Laboratory Reports of Hepatitis C for 2005-2012 for Oldham, Greater Manchester, North West and England LocalityYear?20052006200720082009201020112012Oldham 28381282140281323Greater Manchester6085188388481,1891,0147901,072North West1,5031,3721,7451,6652,1481,8531,5491,832England 6,2956,9597,8038,3958,6467,8779,91210,866Source: PHE 2014Taking account of the estimated numbers of current and past injecting drug users and the size of the Asian population, Public Health England estimates that the total number of people in Oldham infected with HCV is 1,365 (table 10). This is amounts to 0.6% of Oldham’s population. Of these, it is estimated that 1,010 (69%) will be RNA positive (i.e. have persistent infection) and be eligible for antiviral treatment.Table 10 - Estimate HCV Prevalence by Local Authority in 2012Local Authority Estimated Total Infected PopulationManchester 4999Bolton 1835Rochdale 1493Oldham 1365Salford 1345Tameside 1147Stockport1135Trafford 891Bury 822Source: PHE 14 The prevalence of the different stages of HCV related liver disease has been estimated by PHE. By 2015, the proportion of people with moderate, cirrhotic or end stage liver disease due to hepatitis C is predicted to have increased compared to 2005 (Table 11). Table 11 Estimated Prevalence of Liver Disease from HCV in Oldham in 2005 and Forecasted for 2015 Proportion in disease state at 2005:Proportion in disease state at 2015Burden of Disease Number Proportion Number Proportion Total HCV infected 1365Number RNA positive 101069%Proportion with liver disease: Mild75574.7%55354.8%Moderate22922.9%32131.8%Cirrhotic202.0%323.2%End stage disease60.6%111.1%4.6 Risk Factors for Primary Liver DiseaseThe main preventable risk factors for primary liver cancer are hepatitis B and hepatitis C infection and harmful alcohol use. Individuals who smoke and have hepatitis B or C infection are at a higher risk.5 Prevention, early detection and treatment of both liver disease and liver cancer will help to reduce mortality due to liver cancer. 5Section 5 - Mortality from Liver DiseaseMortality from liver disease has been steadily increasing over the last 30 years in the UK and North West. According to the Department of Health’s Call to Action for the average local authority with a population of around 350,000, each year around 400 people die prematurely of cancer, 250 from heart disease and stroke, 100 people from respiratory disease and 50 people from liver disease. For Oldham; this equates 33 people dying before the age of 75 from liver disease to each year. The actual numbers for Oldham are significantly higher, with 42 people dying prematurely from liver disease in 2012 and 55 in 2011. 5.1 Under 75 Directly Standardized Mortality Rate from Liver Disease for OldhamIn the mid 2000’s, Oldham’s direct standardized mortality rate (DSR) from liver disease for the under 75s was approximately double the English average (Chart 5). Rates have, however, been declining over the last 3 years to below the North West average but still significantly higher than the average rate for England. In 2010, Oldham’s nurse led liver service was created which may have led to improvements in care of people with advance liver disease and a reduction in mortality.Chart 5 Under 75 Mortality Rate from Liver Disease (persons) in Oldham Compared with North West and England from 2000-2012Source: Public Health England (2014)The directly age and sex standardised mortality rate from liver disease for all ages in Oldham has also been decreasing but still remain higher than the English average (Table 12). Table 12 ONS Directly Age and Sex Standardised Mortality Rate (DSR) per 100,000 for 2009-12 from Liver Disease for All AgesLocality 2009201020112012TrajectoryOldham 24.66Missing data25.9119.87↓Greater Manchester 21.2822.5622.9123.96↑England 13.9615.1815.6115.40↓Source: HSCIC 2013 - GP registered population counts from NHAIS (Exeter), the Primary Care Mortality Database (PCMD) and ONS mid-year England population estimates5.1.1 Ward level data There is a wide variation in Oldham’s ward level directly standardised mortality rate from liver disease in under 75 years (Chart 13). Saddleworth North had a DSR of 12.38 which is below the England average. Coldhurst had the highest DSR with 48.52 which is well above Greater Manchester and England averages. Caution needs to be taken when interpreting this data as these are only a small number of deaths per ward. Indeed, none of the wards had a statistically significantly different rate of liver deaths compared to Oldham as a whole.Table 13 Under 75 DSR from Liver Disease for Oldham (person), 2007-2011AreaNo.DSR per 100,000Lower CIUpper CIAlexandra1427.5114.9546.26Chadderton Central813.865.9227.39Chadderton North1729.1016.7446.88Chadderton South2136.6622.6256.14Coldhurst2048.5229.3075.40Crompton1217.298.6730.58Failsworth East1729.6917.1147.79Failsworth West1321.0811.0236.36Hollinwood917.618.0333.43Medlock Vale1631.5317.9751.26Royton North1117.548.4031.92Royton South1219.389.8334.13Saddleworth North812.385.1424.72Saddleworth South913.786.1726.37Saddleworth West and Lees1727.2315.8143.65Shaw915.737.0330.11St James'1425.5113.8342.96St Mary's819.578.3038.79Waterhead1526.2014.5943.30Werneth1536.0720.0659.65Oldham26523.8421.0426.91Source: PCMF Annual extract5.1.2 Comparison with Greater Manchester boroughs Across the 10 Greater Manchester boroughs, it is only Oldham and Salford that have a mortality rate lower than 2001-03 rates. Seven of Greater Manchester borough’s mortality rates have an upward trajectory in contrast to Oldham (Table 14) Table 14 Comparing Oldham with 10 Local Authorities of similar deprivation, similar patterns emerged with 8 on upward trajectory except Oldham and St Helen’s. 5.2 Under 75 Directly Standardized Mortality Rate from Liver Disease Considered PreventableThe mortality rates from liver disease considered preventable for males (Chart 6), follows the same trend as the under 75 mortality rate for all liver disease (Chart 5). The Oldham rate starts considerably higher than the rate seen for England and the North West in 2001-2003 but decreases in recent years brings it to just below the NW rate.Chart 6 Under 75 Male Mortality Rate from Liver Disease Considered Preventable, 2001-2012The trends for females is different (Chart 7).In 2001-03 preventable liver disease mortality rates were similar in Oldham to the England average, from which over a 6 year period rose to rates above North West and England average. Since peaking in 2006-08, there has been a marked decline to 2010-12 having rates yet again similar to the England average. It is appreciated that the numbers are small; therefore the margin of error is greater. Chart 7-Under 75 Female Mortality Rate from Liver Disease Considered Preventable, 2001-125.3 Years Life Lost Chart 8 shows liver disease compared to the other to the other major killers. Chart 8 Years of Life Lost for Selected Conditions in Oldham, Persons Under 75 DSR per 10, 000, 2010-2012Although the DSR for liver disease mortality for women is now similar to England, the years of life lost is a lot higher suggesting that women dying from liver disease in Oldham are doing so at a younger age than they do in England as a whole (Chart 9). Whereas for men, the DSR is higher but YLL lower suggesting men are older in Oldham at time of death (Chart 10). Chart 9Chart 10 5.4 Mortality by Causal FactorsNationally and in the North West, in both men and women, alcoholic liver disease is the commonest cause of liver disease (all ages).2 Fatty Liver Disease accounted for twice as many liver related deaths in women (12.9%) as men (6.1%) nationally. The proportion of deaths due to fatty liver is higher in the northwest, with a lower proportion of alcohol related deaths compared to nationally. Viral liver disease only accounts for 1.6% of female and 2.2% of male liver related deaths nationally, with similar rates in the North West.Mortality from primary liver cancer accounts for less than 1% of all cancer deaths and 20.1% male and 6.5% of female liver related deaths nationally. Compared to England, the DSR for primary liver cancer in men is slightly higher but as a percentage of all liver deaths it is lower. For women the DSR is over 3 times as high as in England and accounts for 15.4% of liver related deaths.Age-standardised Mortality Rates (per 100,000) of Liver Disease in England, 2001–09AlcoholicliverdiseaseFatty liverdiseasePrimary livercancerOtherchronic liverdiseasePancreatitisLFTs orjaundiceViral liverdiseaseAll liverdiseaseDSR%DSR%DSR%DSR%DSR%DSR%DSRMalesNorth West14.948.92.27.25.317.44.916.12.78.90.51.630.5England 10.144.11.46.14.620.14.017.52.310.00.52.222.9FemalesNorth West 8.045.71.37.42.715.43.318.92.011.40.21.117.5England 4.838.71.612.90.86.52.318.52.621.00.21.612.4Source: National End of Life Care Intelligence Network (2012) Deaths from liver Disease: Implications for End of Life Care in EnglandUsing the death certificates for Oldham Residents from 2006-13, table 15 shows liver disease in Oldham is driven predominately by alcohol. The top 8 liver disease categories below account for 92.8% of liver related deaths, of which 61.7% were alcohol related. Some of the other and unspecified cirrhosis liver deaths may also have been alcohol related, just not coded as such. X has been allocated where the number of deaths were under 5. Table 15 Underlying Cause of Death Attributable to Liver Disease in Oldham, 2006-14Liver Disease DescriptionTotalProportion of DeathsAlcoholic liver disease, unspecified 9526.4Other and unspecified cirrhosis of liver 7821.6Alcoholic hepatic failure ? 7119.67Alcoholic cirrhosis of liver ? 4512.47Fatty (change of) liver, not elsewhere classified 154.15Alcoholic fatty liver ? 123.32Liver disease, unspecified 0113.04Hepatic failure, unspecified ? 82.21Alcoholic hepatitis ? XAlcoholic fibrosis and sclerosis of liver XToxic liver disease with hepatitis, not elsewhere classified XAcute and subacute hepatic failure ? XChronic hepatic failure ? XChronic active hepatitis, not elsewhere classified XPrimary biliary cirrhosis ? XAbscess of liver ? XAutoimmune hepatitis ? XPortal hypertension ? XHepatorenal syndrome ? XOther specified diseases of liver ? X?361Source: HSCIC Deaths by diagnosis for all agesThe ONS definition of liver conditions uses the ICD 10 Codes 70-77, which excludes viral hepatitis. Considering the total number of deaths with an underlying cause of viral hepatitis for England and Wales is small (Table 16), the number of deaths due to viral hepatitis in Oldham will be very small. It would appear many of the deaths are coded as viral hepatitis, rather than specifying which virus was the cause.Table 16 – All Age Deaths with an Underlying Cause of Viral Hepatitis, England and Wales , 2012 ICD CodeICD descriptionGenderNumberB15-B19 Viral hepatitis M139? ? F94B18 Chronic viral hepatitis M125? ? F83B18.1 Chronic viral hepatitis B without delta agent M11? F1B18.2 Chronic viral hepatitis C M112? ? F82B18.8Other chronic viral hepatitisM1??F-B18.9 Chronic viral hepatitis, unspecified M1? ? F-B19 Unspecified viral hepatitis M2? ? F3B19.9 Unspecified viral hepatitis without comaM2? F3ONS: Deaths -All age for England and Wales 2012Section 6 - Admissions Emergency and non-emergency hospital admissions with a diagnosis of liver disease in Oldham residents have been increasing. 6.1 Non-emergency admissions – primary diagnosis Both male and female non-emergency admissions with a primary diagnosis of liver disease have increased from 2006/07 to 2013/14 (Chart 11). Male admissions saw a 43% increase whilst females increased by 92%. In terms of actual numbers, both genders increased by 31-35 admissions. Chart 116.2 Non-emergency admissions – secondary diagnosisMale admissions with a secondary diagnosis of liver disease have increased by 158% and female admissions by 125% (Chart 12). This may reflect improvements in coding of comorbidities when patients are admitted for other reasons, for example, for elective surgery.Chart 12 Non-Emergency Admissions with a 1st to 6th Secondary Diagnosis of Liver Disease by Gender for Oldham Residents, 2006/07 -2013/14 6.2 Emergency admissionsProvisional HSCIC national and local data for emergency admissions per 100,000 of the adult population between April 2013 and March 2014 shows that nationally, hospitals admitted 10,500 cases of alcohol-related liver disease - equating to just over 200 admissions a week. Areas of the North West and North East of England have the highest rate of emergency hospital admissions for alcohol-related liver disease in the country, with Greater Manchester a rate of 45.8 admissions per 100,000 of the population (1,010 admissions in total - or just over 19 per week on average). Emergency admissions with a primary diagnosis of liver disease in Oldham have increased by 92.9% from 2006/07 to 2013/14 (Chart 13), from about 70 to 149 admissions per year. In 2013/14, 73.3% of emergency admissions with a primary diagnosis of liver disease were due to alcohol related liver disease. Chart 13 Emergency Admissions with a Primary Diagnosis of Liver Disease for Oldham Residents, 2006-20146.3 Admissions by Gender and Age In line with the young age of death from liver disease, chart 14 shows the 50-54 year age band had the highest total and male number of emergency admissions from liver disease in Oldham. The 45-49 year group was the second highest proportion for all. Female emergency admissions follow slightly different trend - 40-44 being the age group with the highest proportion of admissions. The female and male admissions follow a similar distribution curve but the highest female admissions are noted approximately 10 year prior the male. This needs to be taken into consideration when creating and implementing early intervention and prevention campaigns.Chart 14HES: 2014Non-emergency admissions with a primary diagnosis of liver disease showed the highest admission rates in males age 60-64 and females is 45-49 (Chart 15).Chart 15 Section 7 - Admissions Attributable to the 3 Main Causal Factors7.1 Alcohol Related Liver Disease Admissions 7.1.1 Emergency Admissions due to Alcoholic Liver DiseaseEmergency admissions with a primary diagnosis of alcoholic liver disease in Oldham have increased by 150% between 2006/07 and 2013/14 from about 40 to 100 admissions per year. (Chart 16) .Chart 16 Emergency Admissions with a Primary Diagnosis of Alcohol Related Liver Disease from 2006-07 to 2013-14However, it would appear that there has been a change in the way admissions have been coded. Over the same period of time, the number of emergency admissions with a secondary diagnosis of alcohol related liver disease has decreased. Overall, the number of emergency admissions, when primary and secondary admissions are taken together, show a fairly stable picture (Chart 17). Chart 17This does not take account of the alcohol related attendance in Accident and Emergency. Unfortunately attendance data could not be ascertained but in discussions with clinicians it was considered 90% of liver disease related A&E attendances were not admitted but referred back to primary care. A proportion of these may subsequently be admitted as non-emergency admissions. 7.1.2 Gender and Age of Alcohol Related Admissions Alcohol related emergency admission rates are highest in 50-54 and 45-49 age groups for men (Chart 18). Females again showed the same distribution but with a younger age peak with the highest rates in the 40-44 and 45-49 categories echoing the pattern for all emergency admissions due to liver disease. Chart 18 Age and Gender Profile of Emergency Admissions with a Diagnosis of Alcohol Related Liver Disease from 2006-20147.1.3 Non -Emergency Admissions due to Alcoholic Liver DiseaseThe number of non-emergency admissions showed a big increase between 2012/13 and 2014/15, from around 15 admissions per year to nearly 50 (Chart 19) .This is likely to reflect a true increase as increases were also seen in secondary diagnosis fields. These timings fit with the development of the nurse led liver service and improvements in care moving to a more proactive management model.Chart 19The non-emergency admissions predominately were liver related, such as oesophageal varies and ascites. However, they do include some non-related liver problems such as births where chronic hepatitis C was detected. 7.2 Obesity Related Liver Disease North West hospital admissions rates for men for Non Alcoholic Fatty Liver Disease have more than doubled from 14.1 per 100,000 population (95% CI 12.9 - 15.4) in 2005/06 to 36.9 per 100,000 population (95% CI 34.9 - 38.9) in 2010/11. Female rates have increased three fold over the same time period from 10.9 per 100,000 population (95% CI 9.9 - 12.0) to 31.9 per 100,000 population (95% CI 30.1 - 33.8). Similar increases have been seen in Oldham; a 128% increase in non-emergency admission rate due to Non Alcoholic Fatty Liver Disease (Chart 20). This again may relate to the establishment of the nurse lead liver unit and more precise coding of admissions. Chart 20 HES 2014Chart 21 shows an upward trajectory of emergency admissions non-alcoholic fatty liver disease of fatty liver a after a dip in 2009/10.Chart 21It is probable that there may be more fatty livers but that they have been coded under different diagnosis codes, such as ICD 10 K liver disease other specified. It is the perhaps the combination of obesity and alcohol that is driving admissions. 7.3 Hepatitis related Liver Disease Admissions Over the last three years there has been between 56 and 86 non-emergency admissions in Oldham with a primary diagnosis of chronic viral hepatitis (Table 17). Table 17 Non- Emergency Admissions with Primary Diagnosis of Chronic Viral Hepatitis, Oldham residents, 2006/07-2013/14Non- Emergency Admissions with Primary Diagnosis of Chronic Viral Hepatitis 06-0707-0808-0909-1010-1111-1212-1313-14Chronic active hepatitis, not elsewhere classified 1Chronic hepatitis, unspecified 23131222Chronic viral hepatitis B with delta-agent 1Chronic viral hepatitis B without delta-agent 47112322141719Chronic viral hepatitis C 3271425248704635Grand Total3881567971866556Source HES 2014 7.3.1 Non-Emergency Admissions with a Diagnosis of Chronic Hepatitis BAs Hepatitis B admissions seemed to be on an upward trajectory, all diagnoses were examined to investigate if this was due to coding changes. Chart 18 shows the upward trajectory of non-emergency admissions with a primary diagnosis to secondary 5th diagnosis related to Chronic hepatitis B. Caution must be taken of potential bias due to the small numbers. Table 18 Non-Emergency Total Admissions with Diagnosis of Chronic Viral Hepatitis B, 2006-07 to 2013-14?Diagnosis 06/0707/0808/0909/1010/1111/1212/1313/14Total Admissions with diagnosis of Chronic Viral Hepatitis B 519214434324741HES 20147.3.2 Emergency Admissions with a Diagnosis of Chronic Hepatitis BThe numbers of acute admissions (primary and secondary diagnosis) due to hepatitis B are small and no pattern can be detected in number of admission each year (Table 19). Table 19 - Emergency Total Admissions with Diagnosis of Chronic Viral Hepatitis B, 2006-07 to 2013-14Diagnosis 06/0707/0808/0909/1010/1111/1212/1313/14Total admissions with diagnosis of Chronic Viral Hepatitis B 7911061225HES 20147.3.3 Admissions from Hepatitis C Chart 22 – Non Emergency Admissions with Diagnosis of Hepatitis C, 2006-07 to 2013-14Since 2008/09, total non-emergency admissions of hepatitis C have remained fairly constant (Chart 22) but emergency admissions have increased. The opposite trend to hepatitis B (Chart 23).Chart 23 – Non Emergency Admissions with Diagnosis of Hepatitis C, 2006-07 to 2013-14Section 8 - Patient Perceptions and Stories The hepatology literature largely focuses on the clinical complications of liver disease and treatment options that may improve both prognosis and quality of life. However, there are also a plethora of complex physical, psychological, social, and family problems that are the norm in advanced liver disease. Understanding and addressing the wider illness experience of these patients and families is crucial to providing care and preventing liver disease. Many research papers and reports such as The British Society of Gastroenterology’s Management of patients with Chronic Liver Disease NOTEREF _Ref403043800 \f \h 4, Burham and Vaughn-Sandler highlight that a stigma and lack of awareness was a key factor in how patients perceived prevention, risks, causes, and treatment. Vaughan-Sandler’s study highlighted that “Perceived stigma is common among patients with cirrhosis, and is associated with adverse attitudes and behaviours such as decreased healthcare-seeking behaviour. Healthcare providers need to be aware of these perceptions and their potential impact on patients' interaction with the medical system”.The studies found that lack of awareness and understanding of liver disease was not only common among the public but also common within healthcare workers and liver disease specialist healthcare professionals. The feelings of stigma and lack of public and healthcare professional awareness were echoed in the two Oldham patient stories collected for the Needs Assessment. The names of the patients and staff have been changed to protect confidentiality. Lesley’s Story Lesley was a professional man who had an active life and loved sailing, living in Oldham and the Lakes. He was a well man and had not visited his GP for over 20 years. In the spring of 2013, Lesley accompanied his wife to her GP for blood tests and they agreed that it would be a good idea for him to have some routine bloods taken as a kind of check-up. Surprising, his results showed elevated Bilirubin levels. He was told by a locum GP to stop drinking and further investigations were needed. He attended Kendal Hospital for an ultrasound scan. He was informed that “he had fluid on him and that a report would go back to his GP”. Lesley and his wife felt unsure of his diagnosis but thought he was ok. Within 10 days, he was lifeless, couldn’t walk, passing blood in his stool and was in a very confused state. He attended the Royal Oldham Hospital Accident and Emergency and was admitted onto the Medical Assessment Unit. Prior to his admission onto MAU, he was cared for by a bank nurse who said to Lesley’s wife “how long has he had dementia”. This caused distress to the family. At 4am, his wife was told “he is going to die”. Further investigations took place and a perforated ulcer was detected. Lesley was moved to High Dependency ward where staff explained Lesley’s diagnosis and management to him and his wife. The operation was a success and he moved onto X2 Gastro Ward under the care of Dr Jones. Lesley and his wife felt supported by the staff particularly from Claire the liver specialist nurses. Claire took time to explain his condition which was Chronic Liver Disease with Hepatic Encephopathy, the anatomy and function of the liver, and his medication. Lesley was told that he should not drink any alcohol. Prior to getting ill, Lesley would drink red wine most nights. At diagnosis, he was 17 ? stone and now is 11 stone.Lesley can no longer work and is unable to do most activities without assistant. He is currently an outpatient, being seen predominately by the liver specialist nurses. He is occasionally admitted to the Royal Oldham Hospital when his Hepatic Encephalopathy reaches a critical level. Lesley has now been referred to Leeds Transplant service and is awaiting a donor liver. Lesley’s condition has been immensely stressful and upsetting for the family, but they have found Claire and her colleague supportive, approachable and caring which has been enormously comforting for Lesley and his family. Lesley’s family spoke of their feelings of shame and stigma attached to liver disease and its perceived association with dependent drinkers. The family felt unable to discuss Lesley’s condition except with very close friends which added to the stress of supporting Lesley. They felt talking to other families and patients of liver disease would help them on their journey. Since speaking to Lesley, he has now been put in touch with another patient who has successfully had a transplant. They also felt greater awareness is needed on the risks of liver disease associated with drinking and obesity. Mary’s storyMary was a high achieving A student with lots of interests. At 16, she embarked on a relationship with a man some years older, secured work in sports and left home. This propelled her into a new and adult world assuming many responsibilities which she felt made her grow up very quickly. She started to become conscious of her appearance and became anorexic. She used ‘Alco pops’ as a way to relax her into eating. By 18, she was engaged and had moved to a different city away from her family and network of friends. She had 2 sports related jobs and started a 3rd job in a nightclub. She drank alcohol as a way to give her confidence and gain weight. She changed from Alco pops to drinking wine. “I was trying desperately to be confident and to cope with this adult world; I found that in the bottom of a bottle. Drinking was used in my family to celebrate and commiserate, like so many”Mary eventually left her partner. She moved city and started dancing in a nightclub. The club had long opening hours and a culture of starting the shift with a drink, whatever time. Mary was part of the team and joined in. Throughout her shift, she would be bought drinks which again she used as a confidence boost. Her drinking had increased moving from wine to vodka. “It crept in and was never a conscious decision.”Eventually Mary returned home to her family and got a job. She was drinking secretly, which carried on for approximately 3 years; by the end drinking 1 litre of vodka a day. Mary’s health started to suffer. “I was ill with stomach complaints and ended up in and out hospital after falling over”.Often she ended up on ward G2 and MAU, she praised the nurses but felt there was an underlying frustration from the nurses due to denial around her drinking. In 2011, her health deteriorated, feeling ill with and without drink. She was frequently vomiting, and was suffering from weight loss and depression. She felt unable to leave the house, therefore could no longer work. “I knew I had no life and realised if I carried on I would die.”After a GP appointment explaining the situation she was referred to ADS. She was seen immediately and offered a place in Chapman Barker unit for detox and then in Turning point for rehabilitation. In 2012, she entered a 3 week detox which she admits “I was very scared” and after that, she went to Turning point where she remained for 7 months. “They were fantastic; they helped me get back into education and get a flat”.She has subsequently trained as a peer mentor and volunteer for them as she feels“I would like to help people like me; you need be ready, otherwise you won’t manage”.She feels lucky about her rehab and detox especially as she has heard people struggle to get a 3 month rehab place. As she was getting back on her feet, her health was deteriorating, being firstly diagnosed with peripheral neuropathy then chronic liver failure. She was on and off G2 with pain and sickness. She praised all the staff especially the nurses. Claire is fantastic. She really explains things”. There was only one occasion when she ended up on an assessment ward as couldn’t get on G2. She was in a confused state, but felt the nurses on the assessment ward had limited understanding and awareness on liver complications. As Mary had been 2 years alcohol free, she was recommended for a transplant. She was told her chance of lasting a year was 40% without the transplant and with the transplant 95%. The staff on G2 helped her get ready for her transplant. On 23rd April, this year Mary got the new liver and is embarking on her new life. She learnt all about her new medication and is out-patient of Leeds. She currently has weekly check-ups and receiving her medication. Her GP is not active in her care. She said “I have been given a second chance and I am so lucky. I wake up every morning and think I am alive”. Mary feels there is not enough awareness/knowledge on liver disease for the public but also for staff on general wards after her experience. She also feels there is a stigma around liver and drinking. “It’s important to show the other side of drinking not just one night… I was yellow, thin, ill, being sick. I love seeing my eyes bright and white- ‘I looked like Bart Simpson’. I want to scream it from the roof tops. You can’t see what state your liver is in… there is all this stuff for stroke, heart attacks. The thing is everyone drinks, that’s what everyone does. The stigma is the alcoholic and the automatic assumption- problem with the liver alcohol”.Speaking about her care, Mary and her family felt supported through this journey.“I have been given information all the way along to help me recover. If I was feeling ill I would contact Claire. ‘I like her and trust her’. She understands my condition and then it automatically became less scary and I had more control. The nurses talks to me not at me. They were good with my mum too, explaining things. I was looked after with respect, no-one ever blamed me. I have worked hard -I took a wrong turn but I am on the right path again. Claire was great so supportive to me and my mum that was when my life turned around”.Section 9. Chronic Liver Disease Pathway and Current Services in Oldham 9.1 Risk Factor ModificationAs the main causes of liver disease are all preventable, firstly the services and pathways to reduce the incidence of the key risk factors of alcohol misuse, obesity and hepatitis B and C infection will be discussed 9.1.1 Alcohol Evidence Base There is a number of NICE guidance for alcohol use disorders such as:CG100: Diagnosis and clinical management of alcohol-related physical complicationsCG115: Diagnosis, assessment and management of harmful drinking and alcohol dependencePH24Preventing harmful drinking. NICE guidance (PH24) recommends that healthcare professionals should use a certified questionnaire (e.g. Audit) to ask their adult and teenage patients about their alcohol intake, for example during new patient registrations, when screening for unrelated health conditions, when treating minor injuries, and when advising patients about medication or sexual health. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report, Measuring the Unit, found that hospitals are missing opportunities to intervene early in the care of people with alcohol-related illness. Box 1 summarises their recommendations. -2857690170Box 1 Summary of Measuring the Unit RecommendationsAll patients presenting to hospital services should be screened for alcohol misuse. An alcohol history indicating the number of units drunk weekly, drinking patterns, recent drinking behaviour, time of last drink, indicators of dependence and risk of withdrawal should be documented. All patients presenting to acute services with a history of potentially harmful drinking, should be referred to alcohol support services for a comprehensive physical and mental assessment. The referral and outcomes should be documented in the notes and communicated to the patient’s general practitioner. Each hospital should have a 7-day Alcohol Specialist Nurse Service, with a skill mix of liver specialist and psychiatry liaison nurses to provide comprehensive physical and mental assessments, Brief Interventions and access to services within 24 hours of admissionA multidisciplinary Alcohol Care Team, led by a consultant with dedicated sessions, should be established in each acute hospital and integrated across primary and secondary care. 00Box 1 Summary of Measuring the Unit RecommendationsAll patients presenting to hospital services should be screened for alcohol misuse. An alcohol history indicating the number of units drunk weekly, drinking patterns, recent drinking behaviour, time of last drink, indicators of dependence and risk of withdrawal should be documented. All patients presenting to acute services with a history of potentially harmful drinking, should be referred to alcohol support services for a comprehensive physical and mental assessment. The referral and outcomes should be documented in the notes and communicated to the patient’s general practitioner. Each hospital should have a 7-day Alcohol Specialist Nurse Service, with a skill mix of liver specialist and psychiatry liaison nurses to provide comprehensive physical and mental assessments, Brief Interventions and access to services within 24 hours of admissionA multidisciplinary Alcohol Care Team, led by a consultant with dedicated sessions, should be established in each acute hospital and integrated across primary and secondary care. Current Alcohol ServicesLocal authorities have the commissioning responsibility for drug and alcohol misuse services. The Oldham Drug and Alcohol Commissioning Strategy 2011 – 2014 noted that alcohol treatment and prevention has been historically underfunded and funded from a variety of funding streams. There are a number of services in Oldham working towards reducing alcohol-related harm such as Addiction Dependency Solutions (ADS) and OASIS (young people’s alcohol and substance intervention service), which focus predominately on treatment and risk reduction. Oldham Council commissioned services are currently being redesigned, shifting the focus towards prevention and early intervention (model 1).A new alcohol strategy for Oldham, following the format of the Greater Manchester Strategy, is also under development. This will focus on reducing alcohol related health harms, alcohol related crime, anti-social behaviour, domestic abuse and the establishment of a diverse, vibrant and safe night-time economy.106680012954001971675262255Recovery from dependenceSpecialist services00Recovery from dependenceSpecialist servicesModel 12019300172720Targets those most at risk Targeted interventions00Targets those most at risk Targeted interventions2314575355602019300409575Lowering Risk0Lowering Risk180022546355CCG Commissioned ServicesAn innovation funding bid established the Royton Cluster’s Early Intervention Alcohol Service pilot; covering 5 GP practices. The pilot commenced in April 2014 and targets individuals in the increasing and high risk drinkers’ category, who are at highest risk of alcohol-related harm and alcohol-attributable hospital admissions. The aim is to raise awareness of the health impact of increased alcohol consumption, change behaviour and to reduce its detrimental impact. Individuals who are defined as increasing and high risk drinkers are invited for an initial 20 minute session with an assigned alcohol counsellor and subscribed to the Breaking Free Online treatment and recovery programme. Six weeks following the initial session, individuals are invited back for a follow-up appointment to assess their drinking behaviour and whether medical and/or psychosocial support should be offered. Oldham Clinical Commissioning Group (CCG) collaboratively commission with Manchester, Rochdale and Bury CCGs, Pennine Acute Hospital NHS Trust (PAHT) to deliver an Alcohol Liaison Service. This comprises of a small team providing strategic direction and training across the Trust with Royal Oldham Hospital having 2 band five nurses and 1 band three assistant providing frontline support and advice. Stakeholder’s Perspectives Discussions with primary care and other stakeholders suggested that use of the audit screening tool was not occurring in systematic way across the borough. The innovation funding bid for the Royton Cluster pilot acknowledged that there is currently a gap of health care provision for people who are at risk of the effects of hazardous drinking in Oldham The Alcohol Liaison Service recognised that historically their work has focused on Accident and Emergency departments and pathways with other services needed to be strengthened. Both the alcohol and liver nurses recognised that to ensure appropriate patient care and support, relationships and referral pathways between the services need to be strengthened. This work has started with the lead alcohol liaison nurse and liver nurses working with the Clinical Lead in Gastroenterology to benchmark PAHT services against recommendations in the Measuring the Unit report. 9.1.2 Obesity Prevention and ManagementEvidence Base There is a plethora of guidance and evidence on obesity prevention and management such as Foresight report on obesity, Cochrane reviews and PHE online tools. NICE has created a number of guidance documents on different aspects such as:CG43Obesity PH47Managing overweight and obesity among children and young people: lifestyle weight management servicesIPG432 Laparoscopic gastric plication for the treatment of severe obesityPH2Four commonly used methods to increase physical activityPH42 Obesity – working with local communitiesPH13Promoting physical activity in the workplacePH46 Assessing body mass index and waist circumference thresholds for intervening to prevent ill health and premature death among adults from black, Asian and other minority ethnic groups in the UK.Oldham’s childhood obesity strategy ends in 2015. There are currently no action plans in place for Adults or Children obesity but work in the Local Authority has commenced on their creation. Current Services in Oldham The commissioning of obesity prevention and management cuts across the commissioning landscape with:Local Authorities retaining primary commissioning responsibility for tiers 1 and 2, including population level interventions to encourage healthy eating and physical activity, as well as lifestyle related weight management? servicesClinical Commissioning Groups (CCGs) having primary commissioning responsibility for tier 3, clinician-led specialist multidisciplinary teamsNHS England retaining primary commissioning responsibility for tier 4 services, including bariatric surgery, but with the transfer of all but the most complex adult bariatric surgery to local commissioning once the predicted increase in volume of tier 4 activity has been realised and once locally commissioned tier 3 services are shown to be functioning well.Tier 1 and 2 ServicesPennine Care NHS Foundation Trust is the current main provider of Health Improvement Services for Oldham. They deliver a range physical activity and weight management services (box 2). They also provide community nutrition and dietetics services. 2857519685Box 2 - Weight Management Services Provided by Pennine Care NHS Foundation TrustChildren’s Weight Management and physical Activity - FRESH For children aged up to 13 years and their families.Aims to encourage people to make healthy improvements to their lives, in terms of diet and exercise, which will help to tackle unhealthy weight gain. Its ethos is to encourage healthy habits for the whole family. There are 3 programmes aimed at different aged children and their families 0-4, 4-7 and 7-13 years. Each session lasting 90 minutes. Adults -Why weightEight-week ‘Why Weight’ course is aimed at men and women aged 18 and above who are above their ideal weight, or who just feel unhappy with the way they look Includes guidance around healthy recipes, portion sizes and being more active. Men -Lose your spare tyre 10-week ‘Lose Your Spare Tyre’ programmes aimed at men. 020000Box 2 - Weight Management Services Provided by Pennine Care NHS Foundation TrustChildren’s Weight Management and physical Activity - FRESH For children aged up to 13 years and their families.Aims to encourage people to make healthy improvements to their lives, in terms of diet and exercise, which will help to tackle unhealthy weight gain. Its ethos is to encourage healthy habits for the whole family. There are 3 programmes aimed at different aged children and their families 0-4, 4-7 and 7-13 years. Each session lasting 90 minutes. Adults -Why weightEight-week ‘Why Weight’ course is aimed at men and women aged 18 and above who are above their ideal weight, or who just feel unhappy with the way they look Includes guidance around healthy recipes, portion sizes and being more active. Men -Lose your spare tyre 10-week ‘Lose Your Spare Tyre’ programmes aimed at men. CCG Commissioned Tier 3 - Specialist Adult Weight Management ServiceManchester, Oldham and Salford CCGs collaboratively commission ABL Health Ltd in partnership with More Life and North West Centre for Eating Disorders to deliver Specialist Adult Weight Management Services (SWMS). The contract is for 3 years (from 1 October 2011 to 30 September 2014). The purpose of the Specialist Weight Management Service is to provide evidence based and quality of interventions for the management of adults (18 years and over) who are severely obese (BMI 40+), obese with severe co- morbidities (BMI 35+), maternal obesity (BMI 30) and individuals who are eligible for bariatric surgery. The service targets and supports approximately 1400 people per year across the three localities, which equates to approximately 250 Oldham residents. ABH has named the service Choose to Change. It states on its web site that after completing the programme, patients can access the ‘Moving Forward’ Programme. A further 18 months of follow up sessions, newsletters and continuing support. It is unclear whether Oldham residents can access this support as there is no contract in place for provision with Oldham CCG. No performance data could be accessed. Tier 4 - Bariatric PatientsThe approved providers for bariatric surgery for Oldham are Salford Royal and Countess of Chester. All patients that meet the priority criteria for bariatric surgery must attend the required pre bariatric surgery education sessions held by the specialist weight management service within the 6 months of treatment. It appears that referrals from this service will be from the respective CCGs Individual Application of Funding process for bariatric surgery. This service needs to be seen in the context of draft guidance by NICE stated increasing numbers of people should be eligible for bariatric surgery.Stakeholders PerspectivesThe increasing prevalence of obesity and a lack of action plans for Oldham on obesity were cited by stakeholders as an area of concern. This was against a backdrop of stakeholders stating that there was a strong likelihood that Tier 1 and 2 services would be re-commissioned and the contract for tier 3 was near completion. The measure-ability of some outcome measures in the tier 3 service was also raised. 9.1.3 Hepatitis B and C9.1.3.1 Testing and immunisation for Hepatitis B and CEvidence Base The early diagnosis of hepatitis C virus (HCV) infection is crucial to prevent further transmission in high-risk groups and to allow clinicians to make a rapid decision about treatment. NICE guidance PH43 - Hepatitis B and C: Ways to promote and offer testing to people at increased risk of infection provides recommendations on:Awareness-raising among the general population and among people at increased risk of hepatitis B and C infectionDeveloping the knowledge and skills of healthcare professionals and others providing services for people at increased risk of hepatitis B or C infectionTesting for hepatitis B and C in primary care, prisons and youth offender institutions, immigration removal centres, drugs services and in genitourinary medicine and sexual health clinicsContact tracingCommissioning hepatitis B and C testing and treatment servicesLaboratory services for hepatitis B and C testing.Regarding settings for testing Martin et al found HCV dried blood spot testing increases case-finding in addiction services and is cost effective. In addition, Sharp et al found that in Primary Care, hepatitis B and HIV testing occurs more frequently than HCV testing. Barriers cited included not questioning patients about risk factors, competing priorities, the chaotic lifestyle of people who inject drugs, difficulty extracting information from computerised records, and forgetting to address HCV. Sharp recommended computer prompts and GP education on whom to test are warranted. Ensuring that country of origin and drug use is included on the new-patient questionnaire was also cited to aid case-finding for HCV.The NICE guidance on hepatitis testing also details recommendations on providing and auditing neonatal hepatitis B vaccination. All pregnant mothers in England are offered screening for hepatitis B. As per the immunisation Green Nook, the infants born to hepatitis B surface antigen (HBsAg) positive mothers should receive four doses of hepatitis B vaccine (initial dose at birth with, further doses at one and two months of age and a fourth dose at one year of age). Other people who should be offered immunisation for hepatitis B include individuals at high risk of exposure to the virus or complications of the disease because of their lifestyle, occupation or other factors. Immediate post-exposure vaccination is used to prevent infection (box three). There is no vaccine for hepatitis Ccenter0Box 3 - Green Book recommendations for at risk groups who should be offered hepatitis B vaccinationPre-exposure immunisationIntravenous drug users and those who are likely to ‘progress’ to injecting, non-injecting users who are living with current injectors, sexual partners of injecting users, children of injectors.Individuals who change sexual partners frequentlyClose family contacts of a case or individual with chronic hepatitis B infectionFamilies adopting children from countries with a high or intermediate prevalence of hepatitis BFoster carersIndividuals receiving regular blood or blood products and their CarersPatients with chronic renal failurePatients with chronic liver disease of whatever causeInmates of custodial institutionsIndividuals in residential accommodation for those with learning DifficultiesPeople travelling to or going to reside in areas of high or intermediate prevalenceIndividuals at occupational riskThose at risk of Occupational exposure:Healthcare workers in the UK and overseas Staff of residential and other accommodation for those with learning difficulties: Morticians and embalmersAll prison service staff who are in regular contact with prisonersMaybe considered for Police and fire and rescue services.Post-exposure immunisationBabies born to mothers who are chronically infected with HBV or to mothers who have had acute hepatitis B during pregnancyAny individual potentially exposed to hepatitis B-infected blood or body fluids Any sexual partner of individuals suffering from acute hepatitis BPersons who are accidentally inoculated or contaminated with blood from a known HBsAg-positive person.00Box 3 - Green Book recommendations for at risk groups who should be offered hepatitis B vaccinationPre-exposure immunisationIntravenous drug users and those who are likely to ‘progress’ to injecting, non-injecting users who are living with current injectors, sexual partners of injecting users, children of injectors.Individuals who change sexual partners frequentlyClose family contacts of a case or individual with chronic hepatitis B infectionFamilies adopting children from countries with a high or intermediate prevalence of hepatitis BFoster carersIndividuals receiving regular blood or blood products and their CarersPatients with chronic renal failurePatients with chronic liver disease of whatever causeInmates of custodial institutionsIndividuals in residential accommodation for those with learning DifficultiesPeople travelling to or going to reside in areas of high or intermediate prevalenceIndividuals at occupational riskThose at risk of Occupational exposure:Healthcare workers in the UK and overseas Staff of residential and other accommodation for those with learning difficulties: Morticians and embalmersAll prison service staff who are in regular contact with prisonersMaybe considered for Police and fire and rescue services.Post-exposure immunisationBabies born to mothers who are chronically infected with HBV or to mothers who have had acute hepatitis B during pregnancyAny individual potentially exposed to hepatitis B-infected blood or body fluids Any sexual partner of individuals suffering from acute hepatitis BPersons who are accidentally inoculated or contaminated with blood from a known HBsAg-positive person.Population vaccination coverage - Hepatitis B (2 years old)Period Sig Count Value Lower CI Upper CI North West England 2010/11 31 49.2* 37.3 61.2 - - 2011/12 28 46.7* 34.6 59.1 - - 2012/13 24 40.7* 29.1 53.4 - - Source: Cover of Vaccination Evaluated Rapidly (COVER) data collected by Public Health England (formerly by the Health Protection Agency). Available from The Health and Social Care Information Centre (HSCIC).Current Services Chart 24 describes the numbers of individuals tested for hepatitis C by service across the North West. Drug services in Oldham currently test for HCV. Chart 24Source: PHE 2014 The 2014 PHE Liver Disease Profile shows that in Oldham in 2012/13, of drug users in their most recent treatment episode in a structured drug treatment programme:259 (55.8%) people, who currently, or have previously injected drugs, had a hepatitis C test. This is significantly lower than the national rate of 70%.Only 3 (10%) of eligible persons completed a course of hepatitis B vaccination. This compares to 17.3% nationally. The Liver Disease Profile also showed that only 40.7% (24) of children whose mothers were hepatitis B positive had received the complete course (4 doses) of hepatitis B vaccine by the age of 24 months in 2012/13. Further analysis of this data (Table 20) shows high rates of nil and missing data, suggesting the lack of a robust integrated screening, immunisation and reporting pathway. Table 20 Percentage of Children in Oldham who Received All Doses of Hepatitis B Vaccination by 12 and 24 months, 2010-2014Quarter% of Children received all doses by 12 months% of Children received all doses by 24 months?Hep B Denominator% received Hep B Hep B Denominator% received Hep BJan – March 20141210013100Oct- Dec 20131110018100July - Sept 2013missing datamissing datamissing datamissing data April- June 20130000Jan - March 2013101001070Oct- Dec 20121681.31442.9July - Sept 20120000April- June 201210701315Jan - March 20121369944.4Oct-Dec 2011 8751258July - Sept 201113611553April - June 20119771362Jan - March 20115801443Oct - Dec 2010missing datamissing datamissing datamissing data July - Sept 201011631266April - June 2010missing datamissing datamissing datamissing data Source: PHE Quarterly COVER report 2014Stakeholder PerspectivesStakeholders felt that the Greater Manchester Hepatitis C strategy had lost its momentum after the programme manager’s post was lost in the NHS reorganisation. Stakeholders suggested that testing for Hepatitis B and C was not occurring in NICE recommended sites systematically throughout the borough. Stakeholders were keen to ensure that testing of HCV was part of any new drug service specifications. The flow of clinical data between maternity services, primary care and child health records was raised as a concern and something that needed improving. The notion of women fully understanding ‘informed consent’ for screening programmes and the importance of completing the immunisation schedule was also raised. 9.1.3.2 Treatment of Hepatitis B and CTreatment of Hepatitis BAccording to NICE’s Hepatitis B (chronic): Diagnosis and management of chronic hepatitis B in children, young people and adults guidance, the goal of treatment for chronic hepatitis B is to prevent cirrhosis, hepatocellular carcinoma (liver cancer) and liver failure. Antiviral therapy such as interferon alfa and nucleotide analogues suppresses HBV replication and decreases hepatic inflammation and fibrosis, thereby reducing the likelihood of serious clinical disease. The complexity of treatment is which patients need immediate treatment and what sequence and combination of drug regimens should be used, and which patients can be monitored and delay treatment. Although currently available treatment is effective in suppressing HBV replication, it fails to eradicate the virus necessitating long treatment duration and perhaps lifelong treatment.Treatment of Hepatitis CNICE clinical guidelines for the management of hepatitis C are under development. A number of NICE technology appraisals recommend the use of pegylated interferon in combination with a range of antiviral agents such as ribavirin, boceprevir and telaprevir NOTEREF _Ref402773770 \h Error! Bookmark not defined.’. The drug combination and duration of use is determined by the stage of disease, genotype of the virus and response to therapy. As study by Public Health England suggests that only 3% of those chronically infected with HCV accessed treatment each year. In 2011, 1,039 people in the North West were prescribed pegylated interferon. This is an estimated 3.8% of the eligible population (Chart 25).Chart 25 Estimated numbers of HCV-positive patients receiving combined therapy based on national supply of, residents of the North West region, 2006-2011Source: PHE Hepatitis C Commissioning ToolThe treatment of hepatitis B and C falls within the NHS England commissioning specification for infectious diseases. The management of complex hepatitis C also falls within the NHSE specification for hepatobiliary and pancreatic disease NOTEREF _Ref402789150 \f \h Error! Bookmark not defined.. 9.2 Liver Disease Specific Prevention Awareness Evidence Base The British Society of Gastroenterologist’s suggests that population awareness campaigns/interventions would increase public understanding of liver disease and its many causes. It can help to motivate behaviour change, reduce the stigma attached to liver disease due to the general perception that all liver disease is self-induced and alcohol related and improve patient outcomes.Current Situation for OldhamCurrently there is no ‘specific’ liver disease prevention work occurring in Oldham. There is some prevention work happening on the risk factors of liver disease. Stakeholder PerspectivesThere was recognition amongst stakeholders (both service providers and patients) that liver disease prevention was essential to decrease mortality and mortality. All stated that there was limited public awareness on the disease which appeared to fuel misconceptions and stigma. The liver nurses were keen to support prevention but were currently unable to due to capacity. 9.3 Early Identification of Liver DiseaseEvidence Base The British Society of Gastroenterologists - Management of patients with Chronic Liver Diseases recommends that commissioners should require that all new patients registered at a general practice should undergo health screening for liver disease. This should include; Assess alcohol intake (AUDIT, an alcohol questionnaire)Assess risk of viral hepatitis (race, travel, intravenous drug use, blood transfusion, family history)Assess BMI, and presence of diabetes as risk factors for fatty liver diseaseMeasure liver function tests (ideally ALT and AST, gamma – GT) as part of screeningThis is reinforced in Aqua’s Chronic Liver Disease Care in the North West of England report which recognised that early identification and treatment of liver disease could delay progression to fibrosis and cirrhosis, reduce the risk of complications such as ascites and liver cancer and ultimately save lives. This will reduce costs to the NHS and improve quality of life for those with liver disease. Although according to the CMO’s report, the proportion of deaths due to non-alcohol fatty liver disease is smaller than that of alcoholic liver disease research highlights that while non-hepatologists appreciate the seriousness of Non-Alcoholic Fatty Liver Disease they appear to underestimate its prevalence. This is particularly among their own patients despite known risk factors. This has implications for targeting 'at-risk' populations and the appropriate referral of patients. Current Services There is currently no enhanced local service for early identification of liver disease or any QOF indicators for liver disease. Primary care currently diagnoses and manages patients with early onset liver disease and refers to secondary care where appropriate. Stakeholder Perspectives According to the British Society of Gastroenterologists, nationally it is recognised that systematic identification and risk stratification of people at risk of liver disease is not occurring. It appears from discussions with stakeholders that this is also true for Oldham. It was felt that primary care has a pivotal role in the early diagnosis of liver disease and across the pathway. Stakeholders/evidence base suggest that a greater use of the NHS 40+ health check including AUDIT and the Southampton traffic light system is needed. It appeared there was a lack of knowledge and awareness of the nurse led liver service which could support primary care. 9.4 Treatment of Advanced Liver Disease Evidence Base The British of Gastroenterologists - Management of patients with Chronic Liver Diseases recommend that: Commissioners should require that all patients with decompensated liver disease are seen by a specialist trained in the management of liver disease within 24 hours if not responding to outpatient treatmentPatients with stable, compensated cirrhosis can have their surveillance (Hepatocellular carcinoma, portal hypertension, enemas for hepatic encephalopathy, monitoring of electrolytes and LFTs) performed within primary care if the requisite expertise is present. In this setting there should be ready access to a specialist in secondary care trained in liver diseaseVirtual clinics under guidance of liver specialistPalliative care for patients with end stage liver disease not suitable for liver transplantation Desirable recommendation is Patient held record and development of shared specialist recordsCurrent ServicesBoth primary care and secondary care manage patients with chronic liver disease. The complications result in admissions and attendance in secondary care, predominately in Royal Oldham Hospital. This includes management of ascites and monitoring of electrolytes, hepatic encephalopathy, variceal bleeding and hepatocellular carcinoma. Surveillance in patients with cirrhosis for hepatocellular carcinoma, portal hypertension and osteoporosis is also within secondary care, led by Dr Xola McFarlane Director for Gastroenterology. Fundamental to the treatment and care of advanced liver disease is the Nurse Led Liver Service. This service was originally established through staffing changes to the gastroenterology department. The service is now carrying out proactive and reactive work. The service is staffed by 2 nurses. The team has:Developed a hand-held summary note which promotes self-care/management for patients and enables patients to track levels such as bilirubin and liver function. Provides ongoing advice and support for patients regarding the management of the complications of chronic liver diseaseUndertake insertion of drains for ascetic taps - A recent audit noted this reduced the length of stay by approximately 4 days and the number of day cases Provides a Jaundice Service – investigation and management of patients with a bilirubin above 50 of unknown origin. Patients are referred by GPs. Audit has demonstrated a reduction in length of stay from 12.7 to 2 days. Tertiary liver care is commissioned by NHS England, within the service specification for Hepatobiliary and Pancreatic Disease (Box 4) NOTEREF _Ref403046672 \f \h 7 -38100152400Box 4 - Key Elements of the NHSE Service Specification for Hepatobillary and Pancreatic DiseaseTreatments offered include medical, surgical or interventional radiology management of acute and chronic liver failure and diseases requiring complex multidisciplinary interventions. This includes:acute liver failurecomplicated chronic liver diseasecomplicated viral hepatitisprimary cancers of the liver and biliary treesecondary liver tumoursnon-cancer related complex hepatobiliary surgerypancreatic cancer including neuroendocrine tumours and cystic neoplasmsbenign pancreatic disease including acute and chronic pancreatitis.liver and pancreatic transplant services (where designated or referral to a such a centre where not)00Box 4 - Key Elements of the NHSE Service Specification for Hepatobillary and Pancreatic DiseaseTreatments offered include medical, surgical or interventional radiology management of acute and chronic liver failure and diseases requiring complex multidisciplinary interventions. This includes:acute liver failurecomplicated chronic liver diseasecomplicated viral hepatitisprimary cancers of the liver and biliary treesecondary liver tumoursnon-cancer related complex hepatobiliary surgerypancreatic cancer including neuroendocrine tumours and cystic neoplasmsbenign pancreatic disease including acute and chronic pancreatitis.liver and pancreatic transplant services (where designated or referral to a such a centre where not)Stakeholder Perspectives The two patients interviewed for the needs assessment, spoke very highly of the PAHT liver nurses; which is reflected in this statement:“Claire was great so supportive to me and my mum that was when my life turned around. They explained everything - 5 times if needs be”. They were wonderful”.The team are enthusiastic and very willing to do more to meet the unmet need but are currently limited by capacity and no budget. They recognise more work was needed on:Awareness raising among the public and healthcare professionals. Promoting the service to primary careEnd of life care for people with liver diseasePatient support groups The team recognised that patients suffer from the stigma associated with liver disease and many had emotional journey towards transplantation which would benefit from a support group. This need for peer support came up in the patient stories. Discussions with urgent care highlighted a small cohort of liver patients are attending Accident and Emergency on a regular basis. It appeared that these patient’s conditions were manageable so admission was not necessary but they had high and complex needs. Patients were perceived to be between the revolving door of primary care and secondary care. Discussions also focussed on patients presenting too late and in some cases dying in Accident and Emergency. It was recognised that more support was needed for primary care to identify and support patients. 9.5 Liver Transplant EvidenceOnce cirrhosis reaches a certain level, the liver gradually loses all its functions – commonly known as liver failure or end-stage liver disease. Liver transplant is the only hope for the long-term survival of a person with liver failure. NICE IPG 194 provides guidance on living-donor liver transplantation. Those patients who have been assessed and deemed unsuitable for transplant are a group with urgent need for palliative care review; studies have concluded that their expected survival may be 2-3 months . Current ServicesOldham residents are usually referred to the Leeds Transplant Centre; but occasionally Birmingham. This is commissioned by NHSE.Stakeholder Perspectives From the patient stories, it was evident that having a transplant is very traumatic; with anxiety linked to anticipation as well as feelings of guilt regarding the death of the donor. They spoke of the benefits of speaking to a fellow patient post-transplant to discuss their anxieties and feeling. Currently there is no patient support group; the liver specialist nurses stated that the creation of such a group it would benefit all patients deal with their condition, associated stigma and pre-transplant.9.6 End of LifeEvidence BaseGetting it Right: Improving End of Life Care for People Living with Liver Disease 2013 states that for patients with liver disease, care at the end of life poses additional and particular challenges. This is mainly due to the patient population being typically younger and the trajectory of the disease more uncertain than other potentially terminal diseases. The fluctuating course of liver disease makes identification and management of the end of life period challenging. Patients may benefit from both active medical management and palliative and supportive care at the same time. Murray et al concluded that identifying the terminal phase of liver disease can be particularly difficult. Deteriorating health is not always a ‘one-way street’ and an episode of decline may reverse, either spontaneously or with medical treatment. Many patients with advanced liver disease experience repeated episodes of deterioration (‘decompensation’) when one or more symptoms (such as ascites, oedema, encephalopathy, jaundice, bleeding) become more limiting and the patient’s ability to function declines. There is the added complexity of liver transplantation. According to Getting it Right, the majority of patients listed for liver transplantation have unresolved symptoms and 20% of patients on the waiting list die before an organ becomes available. The wait for transplantation can generate additional social and psychological difficulties for patients and those close to them. It also found end of life care provision was limited compared to other fields such as cancer care. It found that although liver doctors have developed several predictive models of death and seem to recognise very well the signs leading up to the end phase of life, surprisingly few have developed programmes to help those patients or their families either to appreciate this or to navigate the realities and hurdles of their final months of life. Box 5 describes the Getting it right 6 steps recommendations to end of life care:center0Box 5 Getting it Right 6 Steps RecommendationsDiscussions as end of life approaches – some prognostic indicators or clinical triggers for liver disease have been identified.Assessment, care planning and review – there is a need to identify healthcare professionals who, with appropriate training, could discuss prognosis and future care preferences with patients who have advanced liver disease.Co-ordination of care – an identified healthcare professional needs to coordinate care to minimise duplication and ensure information is shared promptly between healthcare providers.High quality care in different settings – each patient will need identified contacts for palliative care advice and liver advice both in and out of hours.Care in the last days of life – patients with advanced liver disease can have complex medical needs and may require frequent medical attention as death approaches, highlighting the need for care planning and review of preferred place of death as illness progresses.Care after death – bereaved relatives of liver disease patients can have complex psycho-social needs both before and after the patient’s death needing support00Box 5 Getting it Right 6 Steps RecommendationsDiscussions as end of life approaches – some prognostic indicators or clinical triggers for liver disease have been identified.Assessment, care planning and review – there is a need to identify healthcare professionals who, with appropriate training, could discuss prognosis and future care preferences with patients who have advanced liver disease.Co-ordination of care – an identified healthcare professional needs to coordinate care to minimise duplication and ensure information is shared promptly between healthcare providers.High quality care in different settings – each patient will need identified contacts for palliative care advice and liver advice both in and out of hours.Care in the last days of life – patients with advanced liver disease can have complex medical needs and may require frequent medical attention as death approaches, highlighting the need for care planning and review of preferred place of death as illness progresses.Care after death – bereaved relatives of liver disease patients can have complex psycho-social needs both before and after the patient’s death needing supportIn 2012, The National End of Life Care Intelligence Network published a report into deaths from liver disease and the implications for end of life care in England NOTEREF _Ref403046892 \f \h 2. It highlighted over two thirds of people whose death had an underlying cause of liver disease died in hospital, compared to a little over half of all recorded deaths from any cause. This was true of Oldham where less than 20% of patients with liver disease recorded on their death certificates are dying in their own home. GPs are required to maintain a register of all patients in need of palliative care and support. GPs also have a responsibility to have regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. NICE have proposed the development of 2 end of life care indicators which will be part of the Clinical Commissioning Group Outcomes Indicator Set.Current ServicesPennine Care NHS Foundation Trust is the lead provider of all end of life care in the borough. There is a multi-disciplinary Specialist Palliative Care team that supports patients with complex palliative and terminal care needs, and their carers, to enable patients to die in their preferred place free from pain and other unwanted symptoms. They work closely with other healthcare professionals such as GPs, District Nurses, Consultants and Social workers to assess people’s needs and provide specialist support where required. They also provide education, training, advice and support to other professionals on symptom control and end of life care.Stakeholder’s Perspectives The palliative care team currently report that receive very few referrals for patients with liver disease. It is appreciated that recognising when it is appropriate to introduce elements of end of life care will vary with patient, clinician and disease factors but end of life care needs to be considered within the broader spectrum of ‘overall care’ for individuals living with liver diseases. The need for closer working between the nurse led liver service and palliative care team was recognised and that being placed on the transplant waiting list needs to prompt rather than preclude consideration of the need for supportive and palliative care. Section 10 RecommendationsGiven the preventable nature of liver disease and the increasing admissions, it is imperative that early identification and risk factor modification of liver disease are given higher priority by the Oldham Health Economy. This requires the coordinated input from a range of health and social care professionals working in primary, community and secondary care settings, along with support from the voluntary sector and most importantly the patient and their families and carers. The following 17 recommendations have been classified under commissioning responsibility and categorised under:Risk factor modification, liver awareness and early identification of liver diseaseTreatment of advanced diseaseRisk Factor Modification, Liver Disease Awareness & Early Identification of Liver DiseaseClinical Commissioning Group and Local Authority Joint responsibility A liver disease public awareness campaign for Oldham residents is needed which tackles stigma; increases knowledge of the risk factors, early symptoms of liver disease and the benefits of early intervention; and where to get help and support. By tackling 2 of the 3 main causal factors of liver disease (obesity and alcohol misuse) the campaign would also contribute to decreases in other morbidities such as stroke, coronary heart disease and diabetes. The campaign should link with, and expand, current work on reducing harm from alcohol and obesity.Targeted prevention work and awareness raising should be prioritised with: Children and young people – due to the long lead time to the development of liver disease, this presents opportunities to tackle and reduce risk factorsAreas of high deprivation - due to the strong association with deprivation and increased prevalence of causal factors Women - due to the increasing prevalence, and young age of onset, The CCG and Council should jointly review the potential to add in liver disease awareness and testing in to NHS Health Checks.Local Authority Responsibility The new Oldham Alcohol Strategy should:Make links between the liver disease public awareness campaign and the alcohol strategy.Include enhanced case finding in primary care of people who are drinking above the recommended levels of alcohol and early interventions for alcohol misuse within the primary care setting.Drug service specifications, and monitoring, need to ensure that the services:follow NICE recommendations on the testing of drug users for blood borne virusesthat clients are offered hepatitis B vaccination in line with national guidancethat clients who are found to be infected with hepatitis are referred on for assessment and treatment where clinically indicated.An Obesity Plan is needed to tackle the increasing rates of overweight and obesity in the Oldham. This will reduce not only people at risk from liver disease but also contribute to a reduction in hypertension, type 2 diabetes, musculoskeletal disease, stroke and coronary heart disease, among other conditions. Local Authority, Public Health England and Clinical Commissioning Group responsibility Improvements and fail-safe measures are needed to the Hepatitis B screening and immunisation pathways to ensure all affected mothers are identified and 100% of new-borns at risk receive all doses of the immunisation schedule.Clinical Commissioning Group responsibilities Liver disease education and training should be included in the primary care education programme for practice nurses and GPsEducation should include information on:Risk factorsSteps primary care can take to increase identification of people at risk (e.g. screening for alcohol misuse, hepatitis B and C) and support they can provide to help people minimise their risks e.g. weight management, alcohol reduction, hepatitis B vaccinationEarly identification of people with liver diseaseManagement of liver diseaseLocal servicesThe PAHT liver nurses would be in an ideal position to support this training but their capacity needs to be taken into consideration. The CCG’s CPD Apply allocation should be explored as a training mechanism to further increase workforce awareness and education on liver disease. Maximize opportunities within primary care to identify patents with risk factors for liver disease and the early identification of liver disease. Support the early implementation of interventions to help minimise the person’s risk within primary care.Use the new contractual requirement for all GP practices to identify newly registered patients aged 16 or over who are drinking alcohol at increased or higher risk levels, to support primary care practices to systematically use the Audit tool and the Southampton Traffic light tool and also raise awareness on the link between alcohol and liver disease. Develop recommendations, and a common clinical system template, for new patient registrations that incorporates the recommendations of the British Society of Gastroenterologists that all new patients registered at a general practice should undergo health screening for liver disease. This should include: Assess alcohol intake (AUDIT, an alcohol questionnaire)Assess risk of viral hepatitis (race, travel, intravenous drug use, blood transfusion, family history)Assess Body Mass Index, and presence of diabetes as risk factors for fatty liver diseaseMeasure liver function Review whether primary care staff are following the NICE recommendations for screening for hepatitis B and C and administration of hepatitis B immunisations. Determine barriers if it is confirmed that screening and immunisation recommendations are not being followed. Consider the introduction of computer prompts in primary care to consider hepatitis B and C testing in high risk patients.Consider EQALS indicators (locally enhanced service payment) to promote risk assessment and early recognition of liver disease to minimise late diagnosis. This should include improvements of coding of liver disease, specifically non- alcohol fatty liver disease and compliance with NICE guidance on Hepatitis B and C testing in primary care. Making Every Contact Count in all commissioned services needs to be explored as a lever to raise awareness of the risk factors for liver disease and the early identification of liver disease in patients. Existing training and referral pathways will need to be examined to ensure staff are supported in their discussions on liver disease. Staff skills in brief interventions and motivational interviewing will also be key in helping to support behaviour change.To ensure that patients who are identified as having chronic hepatitis B and hepatitis C infections are referred on to specialist services for appropriate assessment and where clinically indicated antiviral treatment and follow up. NHSE ResponsibilitiesNHSE should commission adequate capacity within their Infectious Disease contracts to cope with an increase in referrals of patients identified as having chronic hepatitis B or C who require specialist assessment and antiviral treatment. Joint Clinical Commissioning and Pennine Acute Hospitals NHS Trust ResponsibilitiesLinks between the Alcohol Liaison Service and the Liver Nurses need to be strengthened to support the early intervention in people with liver disease and to help support those whose liver disease is due to alcohol to stop drinking. The recommendations of the National Confidential Enquiry into Patient Outcomes and Death report, Measuring the Unit, regarding the opportunities to intervene early in the care of people with alcohol-related illness should be implemented.These include: All patients presenting to hospital services should be screened for alcohol misuse. All patients presenting to acute services with a history of potentially harmful drinking, should be referred to alcohol support services for a comprehensive physical and mental assessment. Each hospital should have a 7-day Alcohol Specialist Nurse Service, with a skill mix of liver specialist and psychiatry liaison nurses to provide comprehensive physical and mental assessments, Brief Interventions and access to services within 24 hours of admissionA multidisciplinary Alcohol Care Team, led by a consultant with dedicated sessions, should be established in each acute hospital and integrated across primary and secondary care. Treatment of Advanced DiseaseClinical Commissioning Group responsibility To review and develop the liver disease care pathway including:Reviewing the capacity and remit of the Nurse Led Liver service at Pennine Acute Trust, considering whether the remit could be extended to include: Supporting the development of a patient support group – this would provide peer support but also would be a forum to promote self-management. Primary care outreach work including seeing patients in the community and supporting primary care educationPublic awarenessLiaison with A&E and support to patients currently having frequent A&E attendancesEnhancing links between A&E, Alcohol Liaison Service, Liver Services, Gastroenterology and End of Life Care Services.Development of Liver Disease End of Life Pathways using the 6 steps detailed in the NHS Liver Care – Getting it right as a guide. This includes:Clinicians and health professionals in Oldham using the ‘surprise question as a prompt to ask themselves ‘Would I be surprised if this patient were to die within the next 12 months?’ or ‘…the next week?’ Referral pathways and referrals into the palliative care team need to be improved to adequately support patients and their families. Improved integration of active treatment of medical crises whilst preparing the patients, those close to them for the possibility of death. Proactive engagement with those declined a transplant who have advanced progressive disease.Promotion in primary care to increase awareness of the liver and jaundice servicesPrimary care responsibility Patients with Liver Disease nearing the end of life should be included on primary care end of life register.Priorities for ResearchAlongside the recommendations, the Health Needs Assessment for Chronic Liver Disease has identified 7 priority areas for research using Viergever et al checklist for health research priority setting. The priorities aim to ensure that public health and clinical practice is knowledge and evidence informed. The priorities aim to gain an understanding of:What is the progression of Non Alcoholic fatty liver disease and the relationships with obesity specifically identifying why some people progress from steatosis to non- alcoholic steatohepatitis? What is the multifaceted association between obesity and alcohol consumption, at a UK and local level as a driver of increased liver disease?What is the role gender plays in the onset and progression of liver diseaseWhat are the effectiveness and components of complex interventions tackling multiple factors in delivering improved health outcomes – specifically investigating the interventions in primary careWhat is the effectiveness of liver disease awareness campaign to deliver outcomes on:?Increased early intervention ?Reduced stigma ?Decreased mortality rates?Decreased hospital admissions What is the effectiveness and efficacy of liver disease education for healthcare staff on delivering outcomes such as:?Increased awareness of causal factors and liver disease?Increased early intervention ?Decrease in mortality ?Decrease in admissions (emergency and non- emergency)What impact does increased knowledge and awareness of hepatitis B and C among the general public have on the uptake of testing and treatment? ................
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