My involvement in the development of ways of treating liver patients goes back much further than this specific project and I wanted to outline a bit of background, to help understand the project and what we are trying to achieve.
So, what exactly is ‘it’, all about? In simple terms this is about improving the approach to patients with long term liver disease (or ‘chronic’ liver disease). I’ve been involved in the treatment of patients with liver conditions virtually my whole career since qualifying in 1992. A huge amount has changed over these nearly three decades, in terms of the scientific understanding of liver diseases, the treatments available and the types of disease which have become more predominant. At the same time though, liver disease has not really permeated into the public consciousness in the same way as other conditions, such as heart disease and cancer. Liver diseases don’t come with the same political impact, and many clinicians would consider the whole speciality under-funded.
One of the key consequences of the general lack of awareness of liver diseases is that patients present with their problems very late, with complications, and often irreversible health issues. The lack of awareness is compounded by the fact that chronic liver disease often has no symptoms at all. People aren’t going to their doctor saying ‘I have a liver problem’ or ‘there is a pain in my liver’ – they simply wouldn’t know without specialist tests. At the same time, most chronic liver diseases are silently following a similar pattern (although at different speeds). Damage, or inflammation in the liver causes scarring. This scarring builds up over time (often years, to decades) eventually leading to distortion of the structure of the liver and (mostly) irreversible damage. The liver becomes nodular – a condition known as cirrhosis. This in itself is problematic. The general population tends to associate cirrhosis with drinking too much alcohol, and liver diseases are often categorized as being somehow the patients’ own fault. In many cases though nothing could be further from the truth.
Cirrhosis isn’t, though, the end of the journey. People can live with cirrhosis for many years but ultimately there is a high risk of liver failure, liver cancer and other complications. It is only at that stage that many patients are actually diagnosed – and by that time it is usually too late to change the outcome.
Liver specialists have known for some time that there needs to be improvement in identifying patients who have liver disease. There is a huge amount of research published in this area already, and many innovative ideas and systems have been, or are being, developed. Processes for diagnosing patients with liver disease, and referring on those with a need for specialist intervention have been designed and refined over many years.
A key moment for us locally was about four years ago, when a group of interested clinicians met to see exactly what we could do to improve things in our areas. My colleagues (Rudi Matull and Jim Gotto, both Consultants in Gastroenterology and Liver Disease) had already developed a clear and effective diagnosis and referral pathway – essentially a flowchart for any doctor to follow when presented with a patient with possible liver problems, and the relevant tests and clinics were all in place. Despite this work patients were still not being identified properly. With David James (Consultant Chemical Pathologist) from our local blood testing laboratory we started looking at how we could improve the situation.
A key moment for me was when I understood the size of the problem. In Somerset (population 500,000) around 18,000 liver blood tests were done by GPs every month, and around 2000 of these were abnormal. The majority of these were unique patients. Whilst many of these didn’t need immediate intervention, and month by month some of the ‘2000 new’ would already have been flagged up previously, there was still a huge gap to overcome. At best we would see 25-30 new liver patients per month in our specialist clinics between us. Clearly the scale of the problem needed a new approach, and the first steps towards a ‘Somerset Liver Improvement Programme’ began. SLIP will be covered in my next blog.
Dr Tim Jobson