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1
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
C
C
C
C
I
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
21
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