The Joint Hepatology/Path-2-Recovery (local drug and alcohol addiction service) Clinic: improving access to holistic healthcare for vulnerable, socially deprived adults with alcohol-related liver disease, in Bedford Borough and Central Bedfordshire Councils.

Author:

Jay Patel, Consultant Hepatologist, Bedfordshire Hospitals NHS Foundation Trust

Acknowledgements:

Anna Woodford, Physical Health and Hospital Liaison Lead, Path To Recovery (P2R), East London NHS Foundation Trust

What were the challenges to your service and why did you need to change? 

1. The under-diagnosis of chronic liver disease in patients in the community with severe alcohol dependency is a challenge faced by many district general hospitals, none so other than Bedford Hospital. A contributor to this, for example, was the lack of a direct interface between the local drug and alcohol service (Path 2 Recovery Bedford Borough, P2R) and Bedford hospital (East of England) to refer patients at the highest-risk for developing cirrhosis (or undiagnosed) for clinical assessment (2023).
2. Did-Not-Attend (DNA) rates for patients with underlying concern for alcohol-related liver disease were higher than any other suspected cause of chronic liver disease, and an attempt to improve these rates was required. 
3. Providing holistic care for patients with severe alcohol dependency was non-existent in 2023. There was no alcohol liaison service accessible to the hospital, and advice from clinicians towards tackling patients with alcohol dependency was very limited and time restricted. Wrap-around care was required to remove barriers faced by many of these vulnerable patients, related to their accommodation, finances and cost-of-living, and in doing so allow patients the opportunity to overcome their addiction.

How did you overcome the challenges? 

A direct relationship was required with P2R. I established verbal and face-face communication with the P2R team, through contacting a senior P2R specialist nurse Anna Woodford. Insight was gained towards the organisational structure of P2R and the diligent, often unrecognised work they achieve in the community setting.

A business case was then produced and approved for a hospital-based clinic, exclusively for the review of vulnerable, alcohol-dependent patients deemed high risk of developing or having undiagnosed chronic liver disease. P2R were able to determine risk factors for chronic liver disease through their initial contact with the patient, which involved obtaining a clinical history, completing blood tests and conducting a fibroscan. 

The clinic had a multidisciplinary format involving a Consultant Hepatologist and a P2R addiction nurse specialist. Social/support workers and carers were actively encouraged to attend the clinic. With the patient already establishing an initial rapport with P2R nurse specialists, it allowed a reassuring face for these patients in the clinic setting. 

As of January 2025, fifteen clinics have been completed (since August 2023), with an average of seven patients reviewed per clinic. The aim had been for conducting one clinic per month, but this was not always achievable due to NHS service commitments, in particular ward-consultant duties. New patients were offered 30 minutes, and follow-up patients were offered 15-20 minutes, although overall timing remained flexible, dependent on the patient clinical status. 

What were the outcomes? 

Below are outcomes that have been tabulated. 

Positive outcomes included a low DNA rate (6/110 patients), detection of cirrhosis (15 patients/88), and detection of Hepatocellular carcinoma (2/88 patients, both patients of which have received treatment at a tertiary centre and without distant metastatic disease).

What were the learning points and how can this influence other teams? 

Establishing communication with the local drug and alcohol service and developing a joint clinic that harbours a multi-disciplinary approach may have appeared a simplistic concept in relation to service development, but nevertheless helped to remove barriers at patient, clinician and organisational levels for reviewing patients with chronic alcohol use disorders.

Almost all district general hospitals within the East of England deanery, and geographically beyond, do not offer an approach that integrates a hospital-based clinic that primarily supports an alcohol-dependent patient from a physical health, social, financial, criminal justice, and emotional perspective. Quicker access to treatment to the most vulnerable was achieved, and supported the delivery of holistic care that the NHS strives upon as a clear quality standard of care. Feedback from patients has been significantly positive, through commending the opportunity to debunk the stigma associated with alcoholism and the opportunity to discuss their wellbeing in a non-judgemental environment, both of which were factors that prevented DNA.

The clinic provided a wonderful opportunity to understand how the local drug and alcohol addiction services operate, including an insight into the subsection teams that manage safeguarding, rough- sleepers, criminal justice and physical health. Furthermore, it developed a robust referral pathway to support the community service to highlight vulnerable patients, with the ease of access and without prejudice. Active discussion with local drug and alcohol addiction services is often not explored by district general Hepatologists, despite being key clinicians in challenging the increasing NHS burden related to alcohol-related liver disease.

The success of the multi-disciplinary clinic and the garnered strength in relationship between hospital and community alcohol services was recognised as a strong contributory factor to the development of an in-house hospital alcohol liaison service (Monday-Friday), supported by senior practitioners. This was a service development project I had been actively pursuing since 2020 at Bedford Hospital, but restricted due to Trust finances. This service will be funded by P2R, and commences from March 2025.

Implementing a care-model such as the above is an achievable strategy for any hospital looking to strive towards developing a service that caters towards alcohol use disorder and alcohol-associated liver disease.

I would like to extend my gratitude to the P2R team and in particular Anna Woodford, for the significant contribution they have provided towards tackling liver-related health. I have applied for this award more to recognise their hard work, dedication and commitment to treating the most vulnerable patients within our community.