Steve Callaghan (left), Becky Hug, and Jane Cox explain how a new commissioning toolkit for hepatitis C was developed with the aim of improving services and outcomes
- It is estimated that 216,000 individuals are positive for hepatitis C:
- less than one-half of people have been diagnosed
- only 27,500 patients have received NICE-recommended treatment for this infection
- Liver disease is the only major cause of mortality and morbidity that is increasing in England, but decreasing across Europe
- Improvements in the identification and treatment of hepatitis C and appropriate commissioning of services are urgently needed
- The Hepatitis C Adult Services Commissioning Toolkit (available at: www.hcvaction.org.uk/commissioning) was developed with the aim of improving outcomes and reducing mortality from liver disease and hepatitis C
- The toolkit includes:
- an ABC commissioning for outcomes model
- an outcomes strategic map
- logic model examples
- an outcomes filter.
Current figures from the Health Protection Agency (HPA) estimate that there are around 216,000 people in the UK who are hepatitis C positive.1 In England, however, only 85,000 people have ever been diagnosed,2 and only 27,500 patients (less than one-third) have received NICE-recommended treatment for hepatitis C, which can clear the virus in approximately 72% of patients.1
The British Association for the Study of the Liver (BASL) and the British Society of Gastroenterology (BSG) (Liver Section) predict that the prevalence of chronic hepatitis C infection will double by 2020 unless healthcare commissioners and professionals identify and treat undiagnosed cases.3 It is also estimated that, in England alone,
15,840 individuals will be living with hepatitis C-related cirrhosis or hepato-cellular carcinoma by 2020,1 and that over 4200 people may need a liver transplant as a result of hepatitis C, if action is not taken.2 A key recommendation of the 2009 National Plan for Liver Services was to reduce the transmission of viral hepatitis.3
Patients who have a sustained viral response (SVR) following treatment for the hepatitis C virus are more than four times less likely to be hospitalised or die for a liver-related reason, than those patients who do not attain an SVR.4 Identification of people with hepatitis C is critical as the earlier the virus is detected, the more likely it is for treatment to cure the patient.3
Standards of care for hepatitis C
The staggering increase in premature deaths from liver disease in recent years, has been highlighted by both the Chief Medical Officer and the Secretary of State for Health,5,6 and it has emerged as a key theme from international comparisons. These show that liver disease is the only major cause of mortality and morbidity that is increasing in England, but decreasing across Europe.5
The 2008 All-Party Parliamentary Hepatology Group (APPHG) report into the state of healthcare provision concluded that services for hepatitis C across England are patchy, with only one-third of primary care trusts fully implementing the 2004 Hepatitis C Action Plan for England—inequalities in care and services are still unacceptable.7,8 Further audits in 2009 and 2010 by The Hepatitis C Trust and the APPHG have both reported continued failings to address care for people with hepatitis C, and recommended, among other proposals, a robust governance structure to oversee monitoring, benchmarking, and evaluation of actions by all levels of the NHS.9,10
The high numbers of undiagnosed individuals with hepatitis C and the shockingly low number of patients who have received treatment suggest that currently, comprehensive commissioning of effective hepatitis C care and services is not consistently implemented or linked to pathways of care, and that recommended NICE treatment is not provided consistently. A lack of progress in the identification and treatment of hepatitis C will have a significant impact on patients and healthcare services as liver transplants are in high demand and each procedure costs in excess of £50,000.11
It is no surprise therefore that the majority of the current documentation for commissioning in England highlights liver disease, and in particular hepatitis C, as key areas to focus on in order to:12-17
- achieve a healthy population
- reduce premature mortality
- reduced inequalities
- improve quality of life for people.
Furthermore, in the context of quality and the NHS Constitution there should be a greater focus on ensuring that all patients should (where appropriate) receive NICE-approved drugs.18,19
Hepatitis C Adult Services Commissioning Toolkit
In the context of the structural changes to NHS commissioning, The Hepatitis C Trust emphasised that care for people with hepatitis C must stay focused, commissioning of care and treatment needs improving, and support to the new emerging organisations requires enhancing.20 A cross-sector group of hepatitis C experts, including HCV Action members, developed The Hepatitis C Adult Services Commissioning Toolkit, with the aim of supporting clinical commissioning groups (CCGs), the NHS Commissioning Board, and local authorities in their plans to improve outcomes and reduce mortality from hepatitis C and liver disease.21 Commenting on the toolkit, Dr Charles Gore, Chief Executive of the Hepatitis C Trust said: ‘For too long, hepatitis C has been largely overlooked. The role of health commissioners is to place the patient at the centre of healthcare, and this toolkit will help them do exactly that. It offers clear guidelines to commissioners to ensure the effective treatment of those living with hepatitis C in their locality, and presents a huge opportunity given that the condition is treatable and curable. The onus on saving lives and confounding the appalling mortality predictions is now squarely on commissioners.22
The Hepatitis C Adult Services Commissioning Toolkit is available to download for free from the HCV Action website: www.hcvaction.org.uk/commissioning
The purpose of the toolkit is to ensure first and foremost that hepatitis C is included on the commissioning agenda. Therefore, it is designed to:
- help raise awareness and understanding of the scale of the problem
- support commissioners to answer key questions relating to hepatitis C
- help commissioners understand hepatitis C in the wider context
- provide templates to develop evidence-based services and monitor services.
It is called a ‘toolkit’ as it is a document that can be used, shared, and referenced by commissioners, and should be used as a catalyst to:
- support commissioners, commissioning organisations, and providers of hepatitis C services/care
- open dialogue about the breadth of issues affecting people with hepatitis C
- support commissioners to identify and commission NICE-recommended treatments/guidance
- develop pathways, redesign services, and focus on outcomes and communication
- integrate the NHS Outcomes Framework and other commissioning documents.
The toolkit provides commissioners with key questions that should be answered in order to gain an understanding of their local population: from assessing local needs (a link to HPA prevalence data is included), identifying evidence, reviewing service provision and current practice, through to understanding the key elements of the whole pathway for people with hepatitis C, while providing examples of quality and efficiency.21
The ABC commissioning for outcomes model
The cornerstone of the hepatitis C adult services commissioning toolkit is the ABC commissioning for outcomes model.23 This model is a method of achieving a comprehensive approach to commissioning that not only replicates the commissioning cycle, but also includes evidence-based practice, standards, guidelines (including NICE), quality, and outcomes in order to deliver meaningful and measurable changes in care for patients and clients. The ABC model was recognised by NICE as good commissioning practice and was awarded a ‘Highly Commended’ recommendation by NICE in 2011; and is hosted on the NICE shared-learning database.24
The ABC model for the toolkit on hepatitis C covers the following areas:21
- assessment of local needs for people with hepatitis C and the development of services in the area
- best evidence for the prevention, testing, treatment, and management of people with hepatitis C
- review of current practice
- development of outcomes to act as a driver to improve health
- formulation of an appropriate data set.
Outcomes strategic map
An outcomes strategic map was incorporated into the toolkit to support the commissioner with a strategic overview of the breadth of services for hepatitis C care.21,25 This particular map not only provides a strategic overview of hepatitis C, but supports the commissioner by highlighting the importance of interagency relationships in provision of services and the necessary outcomes (e.g. reduction in mortality for people with hepatitis C). The outcomes strategic map can also assist commissioners with strategic planning and prioritisation, be used to monitor and evaluate performance, identify change, and reflect the local health improvements that are required.21
The outcomes in the strategic map are the same as those published in a consultation document for specialised services (e.g. hepatobiliary and pancreas care), which identified four specific outcomes to improve care and treatment of hepatitis C:26
- improved and equitable access to specialist treatment, care, and prescription of antiviral medication
- increase in the number of patients achieving a SVR
- reduction in the number of related inpatient admissions
- reduction in related transplantation, liver cell cancer, and decompensated cirrhosis.
The logic model27 has been incorporated into the toolkit to enable commissioners to develop service specifications for people with hepatitis C. The original concept of the logic model was adapted by Callaghan and Perigo, who synthesised the elements of quality, process, evidence, outcomes, guidelines, and standards within the logic model, to assist commissioners and providers to:28
- link health outcomes to:
- the commissioning process
- a strategy (national and local)
- understand the long-term effects of interventions
- clearly identify what the intended outcomes should be
- support the measurement and
design/re-design of pathways
- develop a synopsis prior to a full service specification.
Adaption of the original logic model in this way provides clinical clarity for both providers and commissioners of hepatitis C on:
- who they should be caring for
- what the evidence-based interventions are
- evidence that the intervention has taken place
- an understanding on how to measure the intervention
- an understanding of the long-term effects of the intervention.
There are three examples of logic models in the toolkit that relate to hepatitis C services. The logic model example for the needle and syringe programme and opioid substitute therapy service has been developed from NICE guidance.29 It may be worth considering people who successfully complete the needle and syringe programme as ideal candidates for NICE-recommended treatment of hepatitis C.
As a result of the structural changes in the NHS, commissioners should be aware that hepatitis C services in the future will be commissioned by:
- CCGs (identification and treatment of non-complex hepatitis C)
- local area teams (complex hepatitis C and prison health)
- health and wellbeing boards (awareness of hepatitis C).
The Hepatitis C Adult Services Commissioning Toolkit should be used as a vehicle to embrace and link these three responsible commissioning organisations together, improve communication, and provide lead commissioners with the tools for effective ‘whole system’ commissioning for people with hepatitis C. Effective and comprehensive use of the toolkit should be the first step in tackling this growing disease.20
- This commissioning toolkit represents a novel and easy to use resource for commissioning hepatitis C services
- It accurately describes the fragmentation of responsibilities among different agencies
- CCGs should look to work with health and wellbeing boards and public health and specialist commissioning colleagues to forge local commissioning strategies for hepatitis C
- This strategy should identify gaps in service provision and prioritise investment in the most effective interventions to prevent hepatitis C-related morbidity
- CCGs should benchmark their performance in mortality rates related to liver disease in people aged under 75 years against the NHS Outcomes Framework, and consider including improvement against this as part of a quality premium if performance is below national standards
- GP awareness programmes to increase testing for hepatitis C in at-risk individuals should be considered by CCGs.
CCG=clinical commissioning group
- Health Protection Agency. Hepatitis C in the UK 2012. London: HPA, 2012. Available at: www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317135237627
- Health Protection Agency. Hepatitis C in the UK 2011. London: HPA, 2011. Available at: www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfections/HepatitisCInTheUK/1107HepCintheUK2011report/
- The British Association for the Study of the Liver (BASL), the British Society of Gastroenterology (BSG) (Liver Section). A time to act: improving liver health and outcomes in liver disease. The national plan for liver services UK. 2009. London: BASL, BSG, 2009. Available at: www.bsg.org.uk/attachments/1004_National%20Liver%20Plan%202009.pdf
- Innes H, Hutchinson S, Allen S et al on behalf of the Hepatitis C Clinical Database Monitoring Committee. Excess liver-related morbidity of chronic hepatitis C patients, who achieve a sustained viral response, and are discharged from care. Hepatology 2011; 54: 1547–1558.
- Department of Health. Annual report of the Chief Medical Officer. London: DH, 2012. Available at: www.dh.gov.uk/health/2012/11/cmo-annual-report/
- Politics.co.uk website. Jeremy Hunt speech in full. www.politics.co.uk/comment-analysis/2012/10/09/jeremy-hunt-speech-in-full (accessed 30 January 2013).
- The All-Party Parliamentary Hepatology Group. Location, location, location. An audit of hepatitis C healthcare in England. An All-Party Parliamentary Hepatology Group Report, 2008. Available at: www.hepctrust.org.uk/Resources/HepC%20New/Hep%20C%20Resources/Reports/Locationlocationlocation.pdf
- Department of Health. Hepatitis C action plan for England. London: DH, General Health Protection, 2004.
- The Hepatitis C Trust. Hepatitis C: out of control. An audit of strategic health authority hepatitis C governance. London: The Hepatitis C Trust, 2009. Available at: www.hepctrust.org.uk/Resources/HepC%20New/Hep%20C%20Resources/Reports/Out%20of%20control.pdf
- The All-Party Parliamentary Hepatology Group. In the dark: an audit of hospital hepatitis C services. London: APPHG, 2010. Available at: www.hepctrust.org.uk/Resources/HepC%20New/Hep%20C%20Resources/Reports/inthedark.pdf
- Specialised Commissioning Team NHS West Midlands. Organs for transplants: an analysis of the current costs of the NHS transplant programme; the cost of alternative medical treatments, and the impact of increasing organ donation. Birmingham: NHS Midlands and East Specialised Commissioning Group, 2010. Available at: www.wmsc.nhs.uk/uploaded_media/OfT%20Economics%20paper%20October%202010%20(final%20draft).pdf
- Department of Health. The NHS outcomes framework 2013/14 : technical appendix. London: DH, 2012. Available at: www.dh.gov.uk/health/2012/11/nhs-outcomes-framework/
- Department of Health. Healthy lives, healthy people: improving outcomes and supporting transparency. Part 1: a public health outcomes framework for England, 2013–2016. London: DH, 2012. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358
- NHS Commissioning Board. Everyone counts: planning for patients 2013/14. Leeds: NHSCB, 2012. Available at: www.commissioningboard.nhs.uk/everyonecounts
- NHS Commissioning Board. Manual for prescribed specialised services. NHSCB, 2012. Available at: www.commissioningboard.nhs.uk/resources/spec-comm-resources
- Department of Health. The mandate: a mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. London: DH, 2012. Available at:
- NHS Commissioning Board. CCG outcomes indicator set 2013/14: technical guidance. Leeds: NHSCB, 2012. Available at: www.commissioningboard.nhs.uk/ccg-ois/
- National Quality Board. Quality in the new health system. Maintaining quality and improving quality from April 2013. A draft report from the National Quality Board. National Quality Board, 2012. Available at: www.wp.dh.gov.uk/publications/files/2012/08/nqb-quality-draft.pdf
- NHS. The NHS Constitution: the NHS belongs to us all. London: NHS, 2012. Available at: www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overview.aspx
- Hepatitis C Trust. Hepatitis C: out of control. Hepatitis C Trust, 2009. Available at: www.hepctrust.org.uk/News_Resources/news/2009/July/Out+of+Control+Spiralling+Number+of+Deadly+Hepatitis
- HCV Action. Hepatitis C adult services commissioning toolkit. HCV Action, 2012. Available at: www.hcvaction.org.uk/commissioning
- Hepatitis C Trust. Update from the Hepatitis C Trust. Issue 12, November 2012. Available at: www.hepctrust.org.uk/Resources/HepC%20New/The%20Trust/Trust%20Updates/Issue%2012%20for%20PDF.pdf
- Callaghan S, Perigo G. ABC commissioning for outcomes model: can it be used for any service? Guidelines in Practice 2011; 14 (1): 27–34.
- National Institute for Health and Care Excellence website. Shared learning database. www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=384
- Perigo G, Callaghan S. The outcome strategic map can support the commissioning process. Guidelines in Practice 2011; 14 (2): 46–50.
- NHS Commissioning Board. 2012/13 NHS standard contract for acute, ambulance, community and mental health and learning disabilities (multilateral): hepatobiliary and pancreas (version 1.1). NHSCB. Available at: www.engage.commissioningboard.nhs.uk/consultation/ssc-area-a/
- W. K. Kellogg Foundation website. Logic model development guide. Michigan: W.K. Kellogg Foundation, 2004. Available at: www.wkkf.org (accessed 14 January 2013).
- Perigo G, Callaghan S. Commissioning for outcomes: a resource guide for commissioners of health and social care. 2011. Available at: www.fadelibrary.org.uk/wp/downloads/?did=306
- National Institute for Health and Care Excellence Guidance. Needle and syringe programmes. Public Health Guidance 18. London: NICE, 2009. Available at: www.nice.org.uk/guidance/ph18 G