Stuck in the system

New treatment for hepatitis C has opened up massive opportunity for all-round health gains that we are just not taking, hears DDN.

We need to look at syndemics, said Charles Gore – when a set of linked health problems such as hepatitis C, drug and alcohol issues, mental health and homelessness interact to increase the person’s poor state of health and chances of disease. As chief executive of the Hepatitis C Trust and vice chair of the Hepatitis C Coalition, Gore was speaking to the Drugs, Alcohol and Justice Cross-Party Parliamentary Group about access to treatment.

Charles Gore: ‘Treating the prison population represents a huge opportunity… one area where you could send people out of prison better than they went in.’

In Scotland, treating people who injected drugs for hepatitis C had reduced death rates for this group by 50 per cent – ‘so treating hepatitis C might be a way of breaking this syndemic apart’, he said.

People who were treated were more motivated to address other factors, he explained, ‘so hep C treatment has a bigger effect than you might think’.

There had been ‘great breakthroughs’ in hep C drugs, which had a 95 per cent cure rate and were very tolerable to take (compared to previous treatment, which took a year and was ‘very unpleasant’) – ‘so we’re in a new era here’, he said.

In England there were around 160,000 people with hepatitis C, but a budget to treat only 10,000 of them. Treating all of them, at a cost of around £200m, would be ‘a lot of money – but not compared to other disease areas’.

The first year of new drugs had seen an 11 per cent decrease in mortality and a 50 per cent decrease in demand for liver transplants. ‘The gains in terms of health are enormous,’ said Gore.

The reasonably short course of eight to 12 weeks for the new treatment also meant there could be a big impact on treating people in prison.

Despite this, hep C testing and treatment levels in prison were low and prevention strategies ‘quite muddled and not homogenous across the prison estate’, failing to tackle the common transmission routes of shared needles, tattooing and sex.

In the community, there were wide variations in treatment strategy throughout the UK. In Wales, health boards had put money aside but could not find enough people to treat, while in England, a cap on numbers was stopping many people from accessing treatment. ‘Some areas of the country have massive waiting lists, but some are running out of people,’ said Gore. Financial incentives for finding and following up people after treatment also risked making low priority cases of those who were hard to follow up – ie the drug-using population.

The NHS was investigating procurement deals with pharmacies, and Gore explained that the Hepatitis C Trust had a preferred model of ‘one price for an unlimited amount of treatments, so there would be a great incentive to treat as many people as possible. At the moment, the system disincentivises treatment and the cap disincentivises testing.’

Treating the prison population represented a ‘huge opportunity’, Gore believed – ‘It’s one area where you could send people out of prison better than they went in.’ There were 10,000 people in prison with hepatitis C, and ‘if we took this population and treated them we could make a big difference’.

The current cap and rationing system did not prevent members of the population with advanced liver disease from being treated as a priority. The problem was for those who had to wait two years – ‘and this assumes you’re in services,’ he explained. ‘But you may be in prison. You may be a person who might not be in touch with services again, and when you do, you may have liver cancer.’ Prison might be the only chance you have to treat them, so we were missing a significant public health opportunity, he said.

Gore also underlined ‘the tremendous importance’ of linking with people who are released from prison, who might be part way through treatment. ‘If we concentrated on prisoners’ health, we would have a much better chance of improving their chances.’

The parliamentary group’s discussion reflected PHE and NHS England’s need to work together on a hep C prevention strategy, but there was concern that ‘fragmented commissioning’ was hampering efforts, with costs falling in different parts of the system and no ‘strategic flow’ between them.

‘There’s a lot of joining up to do,’ said Gore. ‘People who spend and people who gain are different people.’