Care of patients with Gastrointestinal Disorders: A Strategy for the Future 14th March 2006

1. British Society of Gastroenterology Care of patients with Gastrointestinal Disorders: A Strategy for the Future14th March 2006

2. British Society of GastroenterologyLaunch of Strategy Document Professor Elwyn Elias President of the BSGWelcome

3. British Society of GastroenterologyLaunch of Strategy Document Dr Mike HellierChair, BSG Strategy GroupWhat is Gastroenterology?

4. Gastroenterology is:- Oesophagus Stomach Liver / Pancreas Bowel CANCER GI Cancer is the commonest cause of cancer death

5. Gastroenterology is:- Hepatitis Cirrhosis Alcoholic liver disease Gallstones JAUNDICE Liver disease kills more women than Ca cervix

6. Gastroenterology is:- BLEEDING FROM THE BOWEL Acute GI bleeding has 10% mortality rate

7. Gastroenterology is:- Acid reflux Dyspepsia Ulcers INDIGESTION 20 – 40% of population affected

8. Gastroenterology is:- Infective Ulcerative Colitis Crohn’s Irritable BowelSyndrome (IBS) DIARRHOEA 10 – 20% of population affected by IBS

9. © Anatomy of the gastrointestinal tract

10. Gastrointestinal Disorders Constitute a huge burden of disease to society

11. Gastrointestinal Disorders COST SOCIETY: £7.18 Billion in non NHS costs £1.4 Billion in NHS costs A HUGE EXPENSE

12. British Society of GastroenterologyLaunch of Strategy Document The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders A review of the evidencehttp://www.medicine.swan.ac.uk/giservicesreview Professor John WilliamsGastroenterology services in the UK

13. Topics covered • Burden of disease • Incidence; mortality; morbidity; quality of life; geographical variation; socio-economic factors; costs to society • Current service provision • Organisation; workforce; primary care activity; inpatients; procedures; voluntary sector; costs • Problems with current provision • Access; inequalities; waiting lists; patient safety; information to patients and practitioners; complications of care • Other drivers for change • Guidelines; changing incidence; screening and prevention; genetics; quality assessment

14. Delivery of services for patients with gastroenterological and hepatic disorders Developments in service delivery Patient perspectives Economic burden of GI disease Cost effectiveness of GI services Information and IT infrastructure Topics covered

15. Methods • Systematic review of the literature, supplemented by additional papers on incidence, mortality and morbidity (997 references examined; 936 used) • Interrogation of routine data sources (Hospital episode statistics; Office of National Statistics; Office of Population Census and Surveys) • Critical analysis of the evidence found • Grading of the evidence as appropriate, based on NICE approach • Discussion of key issues with service users • Wide dissemination to seek feedback, and any additional material • Final revision of the document, with conclusions

16. Rising incidence of... Cancer (oesophageal and colorectal) Liver disease (hepatitis C; cirrhosis; alcoholic liver disease; non alcoholic fatty liver disease) Barretts oesophagus; pancreatitis; gallstones; upper gastro-intestinal haemorrhage; diverticular disease; coeliac disease; irritable bowel syndrome Considerable impact on quality of life A flavour of the findings…

17. Gastrointestinal Disorders in Primary Care For every 9 patients who consult their GP, one will have a gastrointestinal problem Source: OPCS 3rd and 4th National Morbidity Surveys

18. Secondary Care Admissions Percentage of hospital admissions for major disease groups,England, 1998/99-2001/02: based on Finished Consultant Episodes Source: Department of Health Hospital Episode Statistics

19. Hospital bed occupancy for gastrointestinal procedures Total number of bed days for main surgical and endoscopic procedures by OPCS-4 chapter in England, 2000/01 Source: Department of Health Hospital Episode Statistics

20. Mortality from gastrointestinal disorders All ages Mortality rates (per 100,000) for major diseasegroups, England & Wales, 2000: people of all ages Source: ONS (2001)

21. Mortality from gastrointestinal disordersin the potentially working population Mortality rates (per 100,000) for major disease groups, England & Wales, 2000: people aged 15-64 Source: ONS (2001)

22. Gastrointestinal cancer Percentage of cancer deaths, according to site of cancer: England & Wales, 2000 Source: ONS (2001)

23. Costs to society of gastrointestinal and hepatic disorders in 2004 • Workforce • 150,000 person years of working age lost per annum from premature death (cost £3.2b pa) • 1.7% of long-term sickness absence (£1.05b pa) • 20% of short-term sickness absence (£2.9b pa) • Hospital costs in England £1.44b pa • Total NHS costs in England £2.4b pa Source: Lewison G Gastroenterology in the UK: the burden of disease. Wellcome Trust 1997.

24. Service provision • There is strong evidence for a shift towards greater self-management by patients with chronic inflammatory bowel disease (level of evidence: 1) • But such patients need support (eg education; rapid access to specialist services when needed) • We found no research into the clinical or cost effectiveness of diagnosis and treatment centres • Nurses can perform diagnostic endoscopy safely and effectively, but are not more cost effective than doctors (1)

25. In hospital, patients with GI and liver disorders should be looked after by specialists (2+) Complex surgery for GI and hepatobiliary cancer should be performed by specialists who operate on larger numbers (2+) There is insufficient evidence to support the greater concentration of services in tertiary centres without further research into the clinical and cost benefits, and disbenefits to other services Specialisation

26. Clinical Research • Much data is available on burden of disease • There is a lack of high quality research relating to the organisation and cost effectiveness of services, but plenty of opinion • Much more research is needed, to inform policy, service delivery and organisation • A more strategic approach to the co-ordination and funding of research in gastroenterology is needed (as for cancer, heart disease, elderly etc) • The UK Clinical Research Collaboration is potentially a major opportunity

27. British Society of GastroenterologyLaunch of Strategy Document The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders: a review of the evidence http://www.medicine.swan.ac.uk/giservicesreview Gastroenterology Services in the UK

28. Thanks to Those who did the work: Faiz Ali; Ivy Cheung; David Cohen; Gaynor Demery; Richard Driscoll; Adrian Edwards; Margot Greer; Mike Hellier; Hayley Hutchings; Barry Ip; Mirella Longo; Stephen Roberts; Ian Russell; Helen Snooks; Judy Williams; Giles Croft; Ian Frayling; Alistair McIntyre; Roland Valori; Anne Williams Many other colleagues who gave us comments and further information, and the service users who discussed our findings The British Society of Gastroenterology for funding

29. British Society of GastroenterologyLaunch of Strategy Document Professor Alastair WatsonRoyal Liverpool University HospitalGI Cancer

30. 21% of all new cancers in the UK are gastrointestinal Cancer Research UK

31. 24% of all cancer deaths in the UK are gastrointestinal

32. Comparison of survival from colon cancer Late diagnosis when the disease is incurable. Gut 2005;54:268-273

33. British Society of GastroenterologyLaunch of Strategy Document Professor Elwyn EliasPresident of the BSGLiver Disease

34. Overweight and Obesity - Obesity Trends Prevalence among U.S. Adults of a Metabolic Syndrome Associated with Obesity(Findings from the Third NHANES Survey) The Centers for Disease Control and Prevention (CDC) estimated that as many as 47 million Americans may exhibit a cluster of medical conditions (a "metabolic syndrome") characterised by insulin resistance and the presence of obesity, abdominal fat, high blood sugar and triglycerides, high blood cholesterol, and high blood pressure BSG Strategy: Liver Disease

35. Hospitalisation for NAFLD Courtesy of Dr P Roderick

36. Nash & Cryptogenic Cirrhosis Caldwell SH et al Hepatology 1999; 29 : 664

37. Mortality trends from liver diseasein England Wales 1950-2000

38. Alcohol consumption 1900-2000

39. Mortality from Alcoholic liver disease in males. England & Wales 1960-2000

40. Mortality from Alcoholic liver disease in females. England & Wales 1950-2000

41. Hospitalisation rates for alcoholic liver disease 1988-2002 Courtesy of Dr P Roderick

42. Mortality from Hepatitis C England & Wales

43. Hepatitis C in EnglandThe First Health Protection Agency Annual Report 2005

44. Age specific rates of Laboratory notificationsHepatitis C in England & Wales

45. Hepatitis C in EnglandThe First Health Protection Agency Annual Report 2005

46. Hepatitis C in EnglandThe First Health Protection Agency Annual Report 2005

47. Hepato-cellular cancer mortality in malesEngland & Wales 1960-2000

48. Chronic liver disease: Patients listed for transplantation 2000-2 Data from UK Transplant

49. Total number of liver transplants in UK by year Data from UK Transplant

50. Percentage of total liver transplants that were less than whole grafts Data from UK Transplant