Doctors’ dilemmas

When I received the ELF test result, I phoned my GP’s surgery with the intention of arranging an appointment as soon as possible. I say, “my GP”, but I don’t have the luxury of a designated GP, so I hoped to see a doctor that Henry had recommended. Sadly, the modern NHS doesn’t work quite like that. Despotic receptionists have been replaced by equally authoritarian automated systems with recorded messages assuring the caller that, “Your call is very important to us” and, inevitably, “You are number .. in the queue and the estimated waiting time is .. minutes.” Eventually, I did get to speak to the “extremely experienced, highly trained member of staff” who was responsible for sorting the wheat from the chaff (a.k.a triage) that morning. It was clearly a mistake to mention that I’d arranged a private blood test.

At least I was granted a telephone call-back from the GP in two weeks’ time. And he was thoroughly pleasant on the phone, although he’d never heard of the ELF test. He had heard of Fibroscan, but he was clearly not about to refer me to Guys Hospital in London to confirm the ELF test findings. I mentioned my normal LFTs and he seemed happy with the idea of my abstaining for a month and then repeating the ELF test. AA wasn’t mentioned, thank goodness. There’s no ‘higher power’ for me.

I was left wondering what this GP would do faced with the average middle-aged, male or female patient who was drinking at risky levels. GPs don’t tend to use screening tools in consultations and they’re already bombarded with guidance and pathways from NICE (The National Institute for Health and Care Excellence) for this, that and the clinical other. Alcohol is the least of their worries.

There is one simple screening that GPs can do using a few routine blood test results, called the FIB-4. It looks daunting but it’s all done online with a few numbers.

My score was just above the cut-off of 1.45, which effectively excludes advanced fibrosis. That’s small comfort if your liver is already getting scarred asymptomatically. And most GPs won’t have heard of the FIB-4 either.

So what should GP’s be doing? Well, NICE now recommends that all persistently heavy drinkers should have a liver fibrosis assessment. But like my GP, most general practices don’t have access to Fibroscan because the machines are too damn expensive.

Mount something on wheels and throw in a maintenance contract and you’re looking at £80,000 minimum. The British Liver Trust did arrange some mobile road shows with Fibroscan-in-a-van, but that sensible initiative was short-lived. They really should try that at our local David Lloyd gym.

The NICE recommendation for screening heavy drinkers is currently unrealistic. 5% of males and 4% of adult females are estimated to be drinking at harmful levels. With an estimated adult UK population of about 54 million in 2018, this equates to 2.4 million people. Scanning just half of that number a year would require 250 scanners doing 25 scans a day, 5 days a week, all year. And at a cost of around £50 per scan, the cost to the NHS would be around £60 million per year.

Then there’s the ELF test: a simple blood test sent to a central lab with no operators of expensive machines – but at a cost of £100 (that’s the NHS price) per patient. And it would need to be repeated ad infinitum depending on the patient’s response to advice and the liver’s recovery.

It’s a tough one. I’m glad I’m not in my GP’s shoes – and that I’ve got the finances (and medical training) to organise (and interpret) self-testing. But what about my fellow 2.4 million heavy drinkers?

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