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

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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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.

9. Cirrhosis clinic: Outcome – mortality rates

10. 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 £
Daycase admission to 10th Floor liver unit with LVP
£474.00
Cost-saving per case £
Amount saved in 2016 £
(46 x £2373)
Missed cases across the trust in 2016
(n = 6)
10 bed days
Missed cost savings in 2016 £
Potential for further cost savings
(extra 19 cases/yr) – 65 per year capacity £
Complications: 1 (admitted)
1 post-procedural bleed
Admissions from day-unit: 3
Post procedural Bleed
Hepatic hydrothorax
SBP
Mukherjee & Dhar 2017

11. 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

12. 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

13. 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.

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