SMMGP Clinical Update June 2008
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Hepatitis C - A Long Way Still to Go
Healthcare Commission/NTA improvement review results
Last year the HCC and the NTA improvement reviews looked at commissioning and harm reduction. The results have just been published. The results were broadly positive and no areas scored "weak" overall. The results for drug related deaths were particularly encouraging. However the weakest scoring area was that for needle exchange and blood borne virus screening, vaccination and treatment, which is a major cause for concern. There were some good scores for specialist and pharmacy needle exchanges, which is pleasing. Below are the main extracts relating to the shortfalls within this section. The full report can be read at www.nta.nhs.uk.
Vaccination for hepatitis B and testing and treatment for hepatitis C are not provided widely enough by local drug treatment systems. This is a clear national priority because of the scale of hepatitis C infection in England through injecting drug misuse, and also as hepatitis B is a disease which is preventable through vaccination programmes.
The weakest criterion for harm reduction was criterion 8, which relates to access to harm reduction services, including needle exchange, harm reduction interventions offered by services, and blood-borne virus vaccination and testing. Over half (51%) of local drug partnerships scored "fair" or "weak" for this criterion. The second weakest criterion related to whether harm reduction interventions were embedded in the whole system, with 33% of partnerships scoring "fair" or "weak".
There was a clear shortfall in the provision of out-of-hours needle exchange, with under half (44%) of local drug partnerships scoring "weak". Only 1.7% of partnerships opened most of their services after 7pm and only 21% opened most of their needle exchange services on Saturdays, with the percentage falling to 2% on Sundays. This clearly has access implications for service users who need injecting equipment during the evenings and at weekends.
Question 5 related to policies and service penetration around testing and vaccination for hepatitis B. Almost all (95.3%) local drug partnerships offered less than three-quarters (75%) of their service users a hepatitis B vaccination and 29% did not have a protocol relating to hepatitis B. The majority (70%) scored "fair" for this question and just over a quarter (26%) scored "weak".
Question 6 related to testing and treatment for hepatitis C. This is a clear national priority due to the scale of infection among injecting drug users. The scores for this question showed a national shortfall in testing and treatment provision - no local drug partnerships scored "excellent". The question asked what proportion of injecting service users had been tested for hepatitis C. The national mean for the percentage of injecting drug users that had been tested for hepatitis C was 21.5%. The vast majority (95.3%) of partnerships reported that less than 50% of their service users had a recorded test date for hepatitis C. This question also asked about hepatitis C testing and treatment protocols: 65.1% of partnerships reported that they had these in place.
All-Party Parliamentary Hepatology Group Report: Location, Location, Location: An Audit of Hepatitis C Healthcare in England. 2008 Audit of the Department of Health Hepatitis C Action Plan for England
House of commons 2008
This document demonstrates a considerable improvement on the previous report published in 2006 ("A matter of Chance") but it does also highlight the same shortfalls outlined above. Both reports were produced in order to audit the Hepatitis C action plan for England published in 2004. This was felt necessary due to anecdotal reports that it was not being implemented. The 2006 report found major deficiencies with only 8% of PCTs implementing the plan effectively. Therefore the audit was repeated 2 years later to see if there had been any improvement. Despite the improvement there are some pretty hard-hitting recommendations.
PCT Results 2008
Hepatitis C services across the country have improved but the improvements are patchy. Of responding PCTs still just a third are implementing the Action Plan effectively with half achieving only partial implementation.
- Unacceptably 15% of PCTs have demonstrated minimal or no implementation at all.
- Over half of PCTs have delayed treatment by more than three months, or do not monitor delays in treatment.
- 58% of PCTs used the Health Protection Agency commissioning template to estimate the prevalence of hepatitis C in their area, but only 22% of PCTs used the same template to estimate the number and cost of patients needing treatment for which it was designed.
NHS Hospital Trusts 2008
- 37 of the 63 (59%) responding NHS trusts reported that some of their patients had their treatment delayed for more than 3 months from their first hospital consultation.
- The waiting time from referral to a patient's first appointment with a consultant varied between 3 and 20 weeks. The waiting time between a recommendation of treatment and the first injection of interferon varied between 2 and 24 weeks.
- Less than two thirds (62%) of responding NHS Trusts are confident that they will have the infrastructure in place to ensure all hepatitis C patients can start treatment within 18 weeks by the December 2008 government deadline.
Conclusions and recommendations: There has been a marked improvement in hepatitis C services compared to the audit results in 2006. However, we are still a long way from effective country-wide implementation of the Hepatitis C Action Plan. Indeed the discrepancies between the best and worst performing PCTs are just as wide as before. Hepatitis C healthcare is still dependent on where you live. It is just as much "a matter of chance" as it was in 2006.
The Action Plan was launched over 3 years ago and we feel that its limited implementation indicates a fundamental inadequacy in the effectiveness of Action Plans that do not contain budgets, targets and timetables. With targets currently out of favour, the APPHG feel that issuing an Action Plan is not a suitable or workable lever to effect improvements in the devolved National Health Service. We believe the Department of Health should introduce a reform strategy for hepatitis C which relates to current NHS reforms, sets a clear direction for services, and requires providers to implement best practice at every stage of the patient pathway. Specifically, we call on the Secretary of State for Health to:
- Introduce a "World Class Commissioning pilot" in hepatitis C.
- Develop a good practice model for service organisation and delivery as part of a wider reform strategy for hepatitis C.
- Support the inclusion of hepatitis C case-finding in QOF (Quality & Outcomes Framework).
- Conduct a national audit of GP practice building on the model being piloted for cancer referral and diagnosis.
The two reports:
The Hepatitis C Trust
This is a fantastic campaigning organisation with an outstandingly informative web site. We recommend it to all members. It will keep you up to date with latest development and gives you the opportunity to get involved more directly if you wish. The sum themselves up, very modestly like this "a group of people with hepatitis C trying to help other people who are affected by hepatitis C." There is, of course, a bit more to it than that but that is the fundamental idea behind it.
A must to visit at www.hepctrust.org.uk.