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Julie Cunningham

Commissioning Manager

Commissioning Business Services

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Hepatitis C Service Redesign Project

Scope of Project:

• Primary, community, secondary, tertiary services

• Testing, treatment, post treatment services• Adult services for Hepatitis C infection

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Local Authorities / Councillors

Directors of Public Health

Substance misuse

agenciesDrug users and user groups

SpecializeCommissioning

(SHA)DAAT

Managers

GM Public Health

Network

Project Group

Gastroenterology Consultants in local hospitals

Black and minority ethnic

voluntary agencies

HCV treatment

Consultants physiciansPatients

and Patient Group

Director of finance directors

of commissioning

Black minority

ethnic health groups

National charities Hep C

Trust/British Liver Trust

HCV Strategy Group

University

The Public

GP’s General

PCT CEO’s

Chairs / Boards

Substance misuse GP’s

Acute Trusts

NHS NW(SHA)

PCT’s

Local MP’s

Specialistnurses

Local Media

Virologists

Key Stakeholders

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Service Redesign ProcessAll HCV

treatment physicians

Gastro Consultants

in local hospitals

Patient Groups

LeadCommissioners

Lead DPH

GM Virologists

DPH’s

Directors of Finance

PCT CEO’s

Acute CEO’s

Directors of

operations

GM HCV Strategy Group

Project Board

Programme Manager

CBS

GM NHS Community

The Public

PEC Chairs/ Primary

Care Clinicians

Role Body Group

Lead / Assure

Design / Deliver

Check / Challenge / Oversee

Chase / Co-ordinate

Enable

Be aware

All HCV treatment

physicians

Gastro Consultants

in local hospitals

Patient Groups

LeadCommissioners

Lead DPH

GM Virologists

DPH’s

Directors of

Finance

PCT CEO’s

Acute CEO’s

Directors of

operations

GM HCV Strategy Group

Project Board

Programme Manager

CBS

GM NHS Community

The Public

PEC Chairs/ Primary

Care Clinicians

Key Roles in Service Redesign

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Stakeholder power / potential

Low Stake/ Importance High Stake / Importance

High Influence / Power Keep SatisfiedUseful for decision and

opinion formulation, brokering: mitigate impacts, defend against

Chief Executives of the

Association of Greater Manchester PCT’s

Directors of Public Health of the Association of Greater Manchester PCT’s

PIR Workshop members

Manage CloselyMost critical stakeholder

group: collaborate with

Project Group Strategy Group

Low Influence / Power Monitor (minimal effort)Least priority

stakeholder group: monitor or ignore

Keep InformedImportant stakeholder

group, in need of empowerment: involve, build capacity and secure interests

Support Group Forum Specialist Nurse Forum GM HCV S Subgroup

Members Wider health care

community DAAT managers Substance Misuse Service

Managers GP’s across Greater

Manchester

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I

C Consult with (before)

Inform (after)

DPH’s/PIR process PCT CEO’s

Acute CEO’s

Project BoardGMHCV

StrategyGroup

CBS, Commissioning and Finance Expertise

CBS Procurement

HCV treatment clinicians, virologists,

Specialist nurses, patient forum rep

External Advisory

Group

Recommendations

Assurance for provider selection

Clinical Assurance forHCV Care Pathway

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C

C

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Governance Structure for GMHCVS Service Redesign

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Stakeholder Consultation

Consulted with 163 people in total:• World hepatitis Day Event• GMHCVS Strategy and Project Groups• Patient Support Groups• BME patient group• Prison Group• Consultants Group• Specialist Nurse Group• Microbiology Group

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The overarching characteristics of an ideal Hepatitis C service

•Accessible•Multi Agency•Multi Disciplinary•Clear pathway •Multiple entry points•Chronic Disease Model•Achieve 18 week target•Evidence Based•Sustainable•Managed Clinical Network•Workforce development

•Conforms to Patient Charter, Race Equity Act•Support services•Safe •Effective•Cost-effective•Innovative•Patient Centered•Culturally sensitive•Good retention of workforce

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Characteristics of an ideal prison hepatitis C service

•Increased prevention, testing and treatment within prisons.•Fits in with prison regime•Equal to non-prison services•Hepatitis C virus expert group in each prison•Whole prison approach•Evidence based•Improved interface across prisons and from community to prison and prison to community

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Characteristics of an ideal Hepatitis C testing service

•Trained testers•Clear pathway•Accurate•Timely•Reduction in duplication•Screen at risk population•Rapid referral on for positive results•Discussion to accompany test

•Agreed process for testing•Info for patients in appropriate language

•Results available to treating centre•Offer test to family members•Use negative result as opportunity for Harm Reduction Advice

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Characteristics of an ideal Hepatitis C testing service for prisons

•Every prisoner should be tested unless they “opt out”•Offer during initial screening•Prisons should have specific performance indicators•Use health trainers•Ensure dried blood spot testing is available

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Characteristics of an ideal Hepatitis C assessment service

•Does not increase number of patient steps from diagnosis to treatment•Assessment by supervised trained Clinical Nurse Specialist•First referral to a treatment centre•All patients to receive agreed assessment•Referral onwards if specialist treatment plan needed•Specialist treatment centre to accept original tests•Agreed procedure for DNAs•Patient tracking function•Clear pathway•Referral criteria•Agreed procedure for “Watchful waiting” if treatment not yet appropriate

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Characteristics of an ideal Hepatitis C treatment service

•Experienced senior clinician•Full time nurse•Adequate administrative support•Standardised clinician-nurse-patient ratios according to National and local guidelines•Hepatitis C to be coded separately•Access to non-invasive fibrosis assessment•Rapid availability of blood results for treatment monitoring

•Workforce education and training at all levels•Accessible treatment•Treatment available from GPs•Good access to translation services•No waiting list•Career pathway for nurses•After hours nurse-led telephone support for patients on treatment•Dedicated treatment team

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Characteristics of an ideal Hepatitis C treatment service for prisons

•Full time treatment nurse•Sufficient administrative support•Consultant clinic in each prison every 6 – 8 weeks•Value for money

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Characteristics of an ideal Hepatitis C post treatment service •Chronic Hepatitis C team•Tracks patients including those leaving prison•Uses database•Multi Disciplinary Team approach•Specific remit•Clear pathway•Advanced Liver Disease Patients•Refer back to local provider

•Local referrer able to manage/refer complications•Unsuccessful treatment•Followed up by treatment centre•Access to new treatments when available•Patient at risk of re-infection•Refer to appropriate agency for support

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Characteristics of an ideal Hepatitis C support service

•Support, Information•Signposting•Help for carers•Expert Patient Programme•Resource Centre•Online Support•Advertise Hepatitis C Trust Helpline•Complementary therapies•Advocacy•Counselling •Not based in a drugs agency•Psychological support

•Family support•Buddying•Home visits•One – to – one support•Organised activities – e.g. exercise, speakers•Expert-led / peer-led group•Positive approach•Offers testing•Practical help that supports the patient throughout treatment.•Patient champions•Prison based

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Characteristics of an ideal Hepatitis C

Support Service for Asian People •Separate group for Asian people•Access to interpreters •Halal food•Travel expenses•Namaz (prayer place)•Childcare•Asian worker friendly•Local, e.g. Longsight or Ashton Town•Men and women separate •6 – 8 pm

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Baseline Data Reveiw

Paper data review

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Baseline Data Reveiw

Paper data review

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Baseline Data ReveiwCentral Manchester University

Hospital Foundation TrustPennine Acute Hospital Trust (at NMGH)

Total number of casenotes for March 2008

517This included clinic activity for Dr

Harry and Dr Prince

900This included clinic activity for the whole of

the Infectious Diseases Unit

Total number audited 130 150

Randomisation process Random sample created by selecting case notes in intermittent blocks of 5 throughout the list

Research Randomiser (Social Psychology Network)

Results Hepatitis C- 46Non Hepatitis C- 61Notes not available 23

Hepatitis C- 56Non Hepatitis C- 94

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Baseline Data Reveiw

At Wigan, Wrightington and Leigh NHS Foundation Trust there were a total of 11 patients seen in March 2008, all case notes were audited.

The numbers treated in the other 2 trusts were much larger (illustrated below), because of time constraints we randomised the case notes to be audited