Liver services at ICHNT Dr Ameet Dhar PhD FRCP Consultant Hepatologist and Head of Speciality for Liver Imperial College Healthcare NHS Trust

Liver Services: Current Service Structure of current service Services available Referral pathways

Liver Services: Current Service Lead provider for liver services in NWL. See over 2000 new patients per year and > 10,000 follow appointments Over 1000 patients admitted under our care per year.

Liver Services: Current Service Provide liver services across 4 sites within the trust 4 full-time clinical consultants with 3 less than full-time clinical consultants 3 academic consultants providing 0.7 WTE clinical activity. SITE Inpatient care General Hepatology clinics / week Specialist clinics Ambulatory care unit ST MARYS (main site) Douglas Ward 10 per week (all include access to real time fibroscan) - Cirrhosis (x4 per wk) - NAFLD (x2 per wk) - Alcohol (x1 per wk) - HCV and HBV (x3 per wk) - Transplant (x1 per wk) - Acute liver injury (x1 ) - PBC & Autoimmune (x1) - Viral Family & Pregnancy 10th Floor QEQM: - Paracentesis - Liver Biopsy - Venesection - Clinical Trials - Fibroscan Lists HAMMERSMITH Outreach 3 per week - Pregnancy (QCH) - HCC (x1 per week) - CHARING CROSS 2 per week ST. CHARLES 1 per week

Summary of referral pathway Consultant to Consultant referrals Ambulatory care (clinical day unit) ERS Referral General Hepatology OPD Clinic GP referral Specialist Liver clinic CCG commissioned Referral guidelines if applicable Real time fibroscan at SMH site in OPD

Liver Services: Speciality Services Cirrhosis clinics (x4 per wk) : Dr Dhar (Lead), Dr Manousou, Dr Lewis, Dr Selvapatt NAFLD clinics (x2 per wk): Dr Manousou (Lead), Dr Yee (Endocrine and Diabetes) Alcohol Liver disease (x2 per wk): Dr Lewis (Lead), Dr Vergis, James Lovendoski HCV and HBV (x3 per wk): Professor Brown (Lead), Dr Smith, Dr Lemione Transplant (x1 per wk): Dr Dhar (Lead) Acute liver injury (x1 per wk ): Dr Possamai, Dr Dhar PBC & Autoimmune (x1 per wk): Dr Smith Pregnancy and Liver Disease (non- viral) (once per month): Dr Smith Viral Family & Pregnancy (twice per month): Professor Brown - HCC clinic (x1 per wk) : Professor Khan

Cirrhosis clinic: Current Service October 2013: Pre-OLT clinic 2008: cirrhosis clinic Pre-cirrhosis clinic 2017: current status No dedicated service Clinic Clinic (AD) Clinic & Vasc disorder (AD) Cirrhosis MDT Pre OLT (AD) Pre OLT (AD) Alc cirrhosis service (BC) Clinic (PM) Nurse led education (HM) Clinic (NS) HPS/PPS MDT with Pulm HT HH Clinic (HL): Palliation

Cirrhosis clinic: Current Service Referrals – decompensated CLD / variant syndrome patients / HPS& PPS patients vascular disorders of the liver. Referrals from ward or general Hepatology/ Gastroenterology OP Referrals from other specialities (oncology / HIV / haematology) No direct GP referrals at present Cirrhosis clinics acts as a feeder to Pre OLT clinic.

Cirrhosis clinic: Outcome – mortality rates

Value of Ambulatory Care: Cost-benefit analysis of LVP on the 10th Floor 46 procedures 2016 via 10th floor clinical unit. Admission via Accident & Emergency with overnight stay in acute medical bed for LVP £2847.00 Daycase admission to 10th Floor liver unit with LVP £474.00 Cost-saving per case £2373.00 Amount saved in 2016 £109158.00 (46 x £2373) Missed cases across the trust in 2016 (n = 6) 10 bed days Missed cost savings in 2016 £28470.00 Potential for further cost savings (extra 19 cases/yr) – 65 per year capacity £45087.00 Complications: 1 (admitted) 1 post-procedural bleed Admissions from day-unit: 3 Post procedural Bleed Hepatic hydrothorax SBP Mukherjee & Dhar 2017

NAFLD: Current Service Dedicated NAFLD clinic twice weekly (Dr Manousou and Dr Yee) Referrals from general Hepatology/ Gastroenterology OP/ Endocrine / Obesity Service No direct GP referrals at present Joint clinic with Endrocrine/ Diabetes, with access to dietician. Pathway with obesity services

ALD: Current Service Dedicated ALD liver clinic once per week (Dr Lewis and Dr Vergis) Dedicated alcohol and addiction specialist nurse Access to real time fibroscan Outpatient detoxifcation regimen in ALD patients

Fibroscan Service One of the largest providers in the UK (>3000 fibroscans per year) Real time in clinic and dedicated elective lists (nurse led) Access to CAP and LSM with XL probes for raised BMI patients Hepatology New Appointment Real Time Fibroscan Intervention / Discharge to GP Process completed in 1 day Real time fibroscan pathway: Avoids unnecessary follow ups Patients - fewer days lost at work Benefits for CCGs - reduces appointment costs, release of appointments to see more appropriate patients Implementing real time fibroscan service, identified cost savings to commissioners.

Other services / useful contacts GP email helpline: hepatologyadvice.imperial@nhs.net Secretary: 02033126254 (Maureen Allen – lead secretary) Hepatology Registrar – Bleep 1316 via Switchboard (9am-5pm) GI bleed Registrar covering St. Marys – via Switchboard (5pm-9am).