The latest clinical research, innovation and strategic thinking were highlighted at this year’s British Society of Gastroenterologists’ (BSG) conference, held in Liverpool. Clinicians, politicians and patients gathered at the annual meeting to discuss a wide range of issues – from the need for radical reform to reduce the burden of alcohol-related harm on the NHS; the future role of robot-assisted, incisionless surgery in gastroenterology; to the potential for improved models of service delivery aimed at ensuring quality care. Reflecting on recent progress achieved, under the guiding influence of the BSG, outgoing president, Professor Chris Hawkey cited a number of steps forward – including: the adoption of the National Liver Plan, launch of a national strategy for prevention and treatment of alcoholrelated illnesses, a relatively liberal ruling on anti-TNF agents in IBD, Government endorsement of IBD standards and establishment of a working party addressing needs for out of hours services for GI bleeding. However, Prof. Hawkey commented that the specialty of gastroenterology needs to “achieve more by doing less better”, pointing out that too much time is wasted on futile activity. “In order to deliver minimally intrusive, patient-focused care, one of the key goals must be to improve communication between primary and secondary care, through effective IT,” he commented, adding that there is a need to develop more coherent strategic planning to tackle key issues in gastroenterology and hepatology. In particular, the BSG is taking a strategic approach to addressing the burden of alcohol-related disease.
Alcohol strategy
Professor Jon Rhodes, the incoming president of the BSG, highlighted this as a priority issue for the society: “There has been a reluctance to get involved with patients with alcoholism and to shunt the problem elsewhere, but we need strong leadership and to take ownership. The strategy requires a multidisciplinary approach; the involvement of psychiatric services to deal with mental health issues; as well research into possible drug interventions aimed at improving abstinence,” he asserted. An important step, in his view, is the development of a new alcohol strategy report – launched at this year’s BSG conference. With as many as 40,000 deaths annually attributed to alcohol misuse, at a cost to the NHS of £2.7 bn, the BSG is calling for major reforms. The report, published by the BSG, the Alcohol Health Alliance UK and the British Association for Study of the Liver, sets out an evidence-based case for establishing a joint hospital and community outreach service, which together with a seven-day alcohol specialist nurse service, could result in a 5% reduction in alcohol related hospital admissions, with the potential for each district general hospital to save £1.6 m annually. Evidencing the need for action, the BSG pointed out that:
• In 2008, alcohol misuse cost the overall UK economy £25.1 bn1
• In England, the rate of liver cirrhosis mortality approximately trebled between 1970 and 1998. In the 35 to 44 years age group, the death rate increased eight-fold in men and almost seven-fold in women, while there was a four-fold increase in 25 to 34 year olds.2
• Around 35% of all A&E attendances and ambulance costs are alcoholrelated, including 70% to 80% at weekends.3
• There are over 125,000 facial injuries per year in Britain. In 61% of cases, either the assailant or victim has been drinking.4
The report draws on best practice across the UK to focus on new ways of addressing alcohol problems within hospitals and to intervene earlier in cases where alcohol misuse is implicated in patients presenting for different reasons. It calls for dedicated specialists to lead on alcohol in hospitals and to work with community partners to reduce alcohol harm and its cost to the NHS. The report also calls for a re-assessment of cost-effective alcohol treatments. Some 13% to 20% of all hospital admissions are alcohol-related. However, on average, PCTs only spend 0.1% of their budgets on alcohol services every year – the equivalent of around £197 per dependent drinker – whereas the amount spent annually on dependent drug users equates to £1,744. Lead author, Dr Kieran Moriarty pointed out that for every eight people who receive brief advice on alcohol consumption and harm, one will reduce their drinking to within lower risk levels. This compares to smokers, where only one in twenty will act on the advice given and suggests that brief interventions in alcohol are effective. A range of interventions can be made available, depending on the needs of individuals. The report specifically highlights the role of psychosocial treatments for dependent drinkers, finding that the public sector would save £5 for every £1 spent on treatment. Key recommendations from Meeting the challenge of improved quality of care and better use of resources included:
• A multidisciplinary “alcohol care team”, led by a consultant, who will also collaborate with public health, primary care Trusts, patient groups and key stakeholders.
• Co-ordinated policies on detection and management of alcohol-use disorders in accident and emergency departments and acute medical units, with access to brief interventions and appropriate services within 24 hours of diagnosis.
• A seven-day alcohol specialist nurse (ASN) service and alcohol link workers network.
• Liaison and addiction psychiatrists in alcohol working in the acute hospital.
• An assertive outreach alcohol service, including an emergency physician, acute physician, psychiatric crisis team member, alcohol specialist nurse, drug and alcohol action team member, hospital manager and primary care Trust alcohol commissioner, with links to local authority and social services
• Multidisciplinary, person-centred alcohol care, which is responsive to the needs and views of patients and their families.
• Integrated alcohol treatment pathways between primary and secondary care.
• Adequate provision of consultants in gastroenterology and hepatology.
• National indicators of quality, such as alcohol-related admissions, readmissions and deaths, against which hospitals can be audited.
• Integrated modular training in alcohol and addiction for alcohol specialist nurses and trainees in gastroenterology and hepatology, acute medicine, accident and emergency and psychiatry.
• Research into the prevention and treatment of alcohol-related disease.
Dr Moriarty commented: “We strongly support the Chief Medical Officer’s calls for a substantial increase in the effective cost of alcohol, but we recognise that such preventive measures may take 10 years to impact on the scale of the problem. In the meantime, it will grow at an increasing rate. “We therefore need to urgently re-evaluate practical measures, which can be implemented to improve detection in primary care and ensure appropriate management of patients with alcohol problems in secondary care. We can then implement an alcohol pathway to facilitate rapid but appropriate discharge, followed by the right levels of support in the community.” Professor Ian Gilmore, chair of Alcohol Health Alliance and president of the Royal College of Physicians, said: “Education of the public about alcohol and alcoholrelated problems is essential for our long-term health, but it will take many years to have a major impact. Therefore, we need to evaluate the treatment services that are currently in place, if we are to ever address the effects of Britain’s alcohol epidemic on our hospitals and on the health of our nation. “The recommendations outlined in the report set out how to achieve tangible results for patients, through effective team working and clinical leadership, while helping to save the NHS money. Through simple service redesign, highly cost-effective alcohol treatment can help mitigate against the most serious cases.”
Quality
Also high on the agenda was the issue of quality in gastroenterology services. Former Parliamentary Under-Secretary of State at the Department of Health and pioneering surgeon, Lord Darzi, discussed the steps needed to ensure quality improvement in the current financial climate, while offering some predictions on the role of innovation in advancing surgery in the future. “Measuring quality is nothing new to gastroenterologists, who have considerable experience of measuring quality in relation to outcomes, but it is also crucial to measure quality in relation to safety and patient experience indicators,” he commented. PROMs (patient reported outcome measures) will provide a useful tool, in his view, along with the new system of rewarding quality through the “commissioning of quality and innovation payment” or “CQUIN” in driving quality improvements. The CQUIN payment framework makes a proportion of providers’ income conditional on quality and innovation. He pointed out that the tariff will be increased to 6% in the next year – at the Imperial College Healthcare NHS Trust, for example, this figure is the equivalent of around £38 m. “This is a significant amount of money to ensure the Trust board focuses on quality,” he commented, adding that regulation should be used to ensure that the minimum core standards are adhered to. However, in his view regulation is “not the way forward to drive quality improvement”. “Quality improvement is a professional, local issue – whereas regulation is a national issue,” he asserted. He outlined the key components of the “quality continuum” as:
• Define.
• Measure.
• Publish.
• Improve.
• Reward.
• Regulate.
• Innovate.
He acknowledged there would be challenges ahead in light of the financial pressures being faced within the NHS, but warned: “The worst thing the NHS could do in a recession is to lose its talent, to cut back on technology and adopt a ‘bunker’ mentality.” He added that the key to survival in tough economic times would be to ensure that innovation is made a priority. He commented that, over the last few decades, there have been significant advances in terms of technology and process innovation – especially in the area of gastroenterology – which have led to improvements in both access and quality of care, while reducing costs. This has been particularly evident in the move from open to laparoscopic surgery. However, in his view, there is potential to advance this further through the move to incisionless surgery in the future. Lord Darzi predicted that the majority of operations will become minimally invasive or incisionless within the next few decades and surgeons will increasingly use laparoscopic surgery, image-guided procedures and virtual reality, to carry out complex procedures. Future techniques highlighted in his presentation included:
Motion compensation: Advances in robotic surgery include the use of technology that incorporates “motion compensation” to compensate for the movement of soft tissue – which is especially important in heart surgery, for example. The technology developed by Prof. Darzi and Guang-Zhong Yang, a computer scientist at Imperial, involves using cameras to track how a surgeon’s eyes refocus on “fixation points”. Using the changes to the eye as focus shifts, scientists can determine “depth perception” and the precise dimensions of the moving organ. Research at Imperial has demonstrated that eye gaze derived from binocular eye tracking can be effectively used to recover 3D motion and deformation of the soft tissue. “The way I explain the principle behind the technology is that when you are driving on the motorway, the car next to you can appear static as it is travelling at the same speed as you. Ultimately, the system stabilises the image to make surgery easier,” said Prof. Darzi, adding that motion compensation technologies will also have a significant impact on radiotherapy applications in the future.
Augmented reality: Surgeons can superimpose scans of the patient’s body, taken before an operation onto visuals seen by the surgeon to “see through tissue” to the organs behind. This helps the surgeon to navigate around the body, providing important additional detail on the location of internal structures.
Force constraint: New robots can be used in surgery that have constraints on their movements so that if a surgeon tries to cut somewhere that could cause danger to the patient, the robot will stop. Lord Darzi commented: “Laparoscopic surgery is not an end point rather it is a transitional phase between the radical approach of open surgery and the emerging forms of non-invasive image guided procedures. We are now seeing technological advances such as laparoscopic surgery, telepresence, virtual reality, digital imaging and networking all coming together. We are fast reaching the point where more operations will be incisionless than actually using incisions.” “As hospitals across the country are increasing the use of robotics to remotely operate their tools, this is a different but incredibly important skill that surgeons will need to learn. As Lord Darzi’s pioneering work has shown the potential impact for patients with gastrointestinal disease is phenomenal,” commented Prof. Rhodes.
References
1 NHS Information Centre. 2009: Statistics on Alcohol: England. 2 The Annual Report of the Chief Medical Officer of the Department of Health, 2001. 3 Prime Minister’s Strategy Unit (2003). Strategy Unit alcohol harm reduction project; interim analytical report. London: cabinet Office. 4 Home Office Policy and Reducing Crime Unit (1999). Alcohol and Crime: Taking Stock, Crime Reduction Research Series Paper no3, Home Office, London.