Dr Jez Thompson is the RCGP’s liver disease clinical champion. The condition, according to the British Liver Trust, is the only major disease that continues to increase year-on-year. As NHS financial costs relating to liver disease mount, Jez discusses how primary care can get better at identifying the condition earlier and tells how his own work is successfully spreading best practice
You’ve worked extensively as a GP with a special interest in the area of liver disease. Was it a natural progression to then become the RCGP’s clinical champion?
In 30 years as a GP I’ve worked with large numbers of patients with liver problems – mostly through hepatitis C and alcohol abuse as well as others with hepatitis B. Through this work I’ve been connected with the RCGP substance abuse health unit – working with them on their training courses. They have a hepatitis B and C certificate training course for GPs and they have an alcohol certificate, too, which I’ve been involved in developing.
It’s through those links that I first heard about the champion role coming up. I feel very committed to the issue of liver disease. I guess what people need to be aware of is that liver disease is one of the top 10 causes of death in the UK and it’s the only major cause of death where the incidence continues to grow.
It’s really important to understand that 90% of liver disease is preventable – but people don´t know they have it until they have serostis – at which time the opportunity is gone for prevention. It stops being a treatable disease at that point, unfortunately; it can be controlled but not treated.
The work is half a day a week for three years. Given this timeframe, how do you prioritise spreading news and resources relating to liver disease to practices?
There’s a fleet of e-modules that GPs can take and there’s soon to be a liver disease toolkit that they can access online. We are planning to hold regional and national training days but, given the scope of my role, I think it’s better to provide such materials in a user-friendly way rather than just have me deliver presentations to healthcare professionals.
I also manage to engage at a national, strategic level in the management of liver disease. For example, I have links with The Lancet‘s standing commission on liver disease and I’ve written for them too.
What are some of the key issues relating to the prevention, treatment and diagnoses of liver disease in primary care?
Due to the fact that liver disease presents late I think there’s enough evidence to suggest that we, in primary care, can get better at identifying the risk factors of the condition and putting in prevention strategies earlier.
There are three main liver disease categories; fatty liver disease, associated with obesity and metabolic syndrome, alcohol-related liver disease and chronic hepatitis – hepatitis B and hepatitis C.
If you go through those one-by-one I think we have to get better at identifying those who are obese – but not just identification; we should be opening up a dialogue with patients. There’s quite a lot of evidence that says GPs are reluctant to discuss these matters with patients out of concern that they’ll damage their relationship. They also worry that the resources aren’t available in the event that they do end up having such a conversation.
Similarly, for alcohol-related liver disease, there’s an abundance of evidence that shows GPs aren’t great at asking people if they drink and, if they do, there may not be good resources to refer them to for the necessary support they need.
For hepatitis B and hepatitis C, probably 50% of people with the condition don’t know they have it because they aren’t being tested and, if they do have it, they aren’t very good at visiting a liver specialist.
All this means that there’s a whole ocean of morbidity across the country that’s not being addressed, whether that’s obesity, alcohol-related or hepatitis.
What can be done to improve practice work and what role does public health play in all of this?
I’d like to see GPs more confident about asking essential questions and more confident that they have the resources to make interventions that can make a difference. The more structured help becomes the easier it is to identify, for example, who needs hepatitis B or hepatitis C tests.
When it comes to discussing drinking, drug use, sexual orientation and ethnic background, these are conversations that aren’t comfortable to address. I think the issue of smoking has been dealt with; thirty years ago GPs were relatively reluctant to challenge patients about their smoking but that’s no longer the case. I think, perhaps, talking about a patient’s sexual orientation, or whether they have sex with a member of the same sex, are seen as very private discussions.
In terms of public health, GPs see individuals and can only do so much; we can only be effective if there’s a sugar tax or an obesity tax or minimum unit pricing for alcohol. Thank goodness all children are now immunised against hepatitis B!
Which initiatives are having a significant impact on prevention across the whole spectrum of liver disease?
I think there’s some really exciting stuff happening and, on a national level, Wales has a national liver strategy that is doing fantastic things across the country. There are a number of local research projects in Southampton and Lancashire that have been doing great things at a CCG level.
One of the things I’ve been doing is bringing together all these examples of best practice – asking those involved in the projects to summarise them on a side of A4 paper – and this will then be published online, allowing people to see what is being done in those localities. What tends to happen is you get some real enthusiasts who are doing great local or regional work but that information isn’t spread across the board. Again, I’m not doing all the work but rather shining a spotlight on what others are doing well.
Which one example, from either Southampton or Lancashire, stands out?
In an area of Lancashire they’ve incentivised GPs to screen for alcohol use using the AUDIT C test before moving on to a full AUDIT test. It involves three screening questions to ask people about their alcohol use and the uptake in screening for alcohol use has been phenomenal. The scheme has also ensured that interventions are available to provide those who have been drinking too much to get the treatment they need.
How can pathways be improved between primary and secondary care to better support liver disease care?
We have just completed a GP survey and approximately nine out of 10 GPs said that there wasn’t a local referral pathway or, if there was, it wasn’t embedded; so either pathways aren’t in place or they aren’t fully embedded. So, one of the aims we have – as well as supporting commissioners – is to create those pathways because it’s crucial that the right people with liver disease are referred to secondary care and that those who can be managed in primary care are managed in primary care because, with the increasing prevalence of liver disease, I think secondary care would find it very difficult to cope if we referred everybody that we were worried about.
Unlike most diseases, you can get clusters of specific types of liver disease in particular areas of the country. If, for example, you are living in an area in the West Midlands that has a really high South Asian population then you are going to have a large number of people with hepatitis B whereas, where I work in Middlesbrough, there’s a lot of alcohol-induced problems, so we get alcohol-related liver disease. The systems we put in place need to reflect and respond to these geographical needs and differences.
Finally, what can be done to ensure care delivery is less variable than it is at present?
We really need to invest in local solutions that are reflective of the needs of respective populations.