The “hub and spoke” model of liver transplant care that is used in some UK regions has been a concept over the past 10 years as described by John O’Grady in 2013^1.This sounds like a great idea on paper: you can see a patient as the hepatologist with chronic liver disease in clinic in a level 1 centre²; then one of the transplant hepatologists from the nearby liver transplant unit sees your patient in their peripheral clinic at your District General Hospital (DGH); assessment for liver transplantation then goes on from there. From the patient’s perspective, there is not this need to travel to the transplant centre which could be miles away from home. This seems good on paper, particularly in regions that do not have easy access to a transplant unit which coincide with a higher prevalence of liver disease (e.g. West of Scotland).

Does it actually make a difference? Tavabie et al sought to answer this question with their single centre, retrospective observational cohort recently published in Frontline Gastroenterology³. The authors examined whether outcomes are changed with HCC vs. chronic liver disease undergoing transplant assessment. This is particularly of relevance when considering where in the country these referrals may come from (sometimes many, many miles from home, as demonstrated by the map below (Figure 1).

Figure 1: Supra-regionally funded liver transplant centres in the United Kingdom⁴

The authors concluded that although transplant assessment outcomes are significantly improved for chronic liver disease with the use of satellite liver units, they do not demonstrate this for HCC. This may be somewhat surprising given HCC has more a defined pathway for referral that chronic liver disease. Furthermore, it is interesting to note that the authors of this paper found that patients living >60 minutes away from King’s College Hospital were more likely to be listed for transplant as this has not been demonstrated in previous studies. It is hard to know if this due to the way the satellite liver units are set up with Kings’ College Hospital and so it would be interesting to see if this is replicated at other transplant units around the country.

However, there are multiple barriers to overcome in order to facilitate these models. Firstly, you need the staffing. The most recent British Society of Gastroenterology (BSG) workforce report⁵ stated that we have 48% of unfilled consultant gastroenterology and hepatology posts. The authors of this report also state that 3.2 times the current number of those who identify as hepatology consultants is required in order for this model to be widely feasible. There is also considerable regional variation in where these consultants work currently and so if we want to try and improve equity for patients accessing “hub and spoke” care for transplant assessment, this needs to be addressed.

The British Association for the Study of the Liver (BASL) have reported that 25% of higher specialty trainees coming through specialist training should be hepatology-trained to help in the expansion of the hepatology workforce⁶. This potentially suggests we should be more optimistic about the future of UK hepatology services, until you look at what the theoretical ultimate destination of these trainees are. Li et al conducted a UK wide survey in 2022 to look at hepatology training in the UK and found that only 22.6% were aiming for DGH level hepatology as a consultant⁷.

For satellite liver transplant centres to work effectively, it does not just rely on a good service from the transplant centres but also from the local hepatologists who will ultimately look after patients until such a time comes that a transplant becomes a reality. This is particularly important whilst a pathway for referring these patients is not clearly defined and if we want to build a pan-UK network for these patients in the future.

References:

1. O’Grady JG. Network and satellite arrangements in liver disease. Frontline Gastroenterology. 2013; 4: 187-190.
2. BMJ Careers. The complete guide to becoming a hepatology doctor. https://www.bmj.com/careers/article/the-complete-guide-to-becoming-a-hepatology-doctor
3. Tavabie OD, Kronsten VT, Przemioslo R, et al. Satellite liver transplant centres significantly improve transplant assessment outcomes for patients with chronic liver disease but not hepatocellular carcinoma: a retrospective cohort study. Frontline Gastroenterology Published Online First: 18 January 2023. doi: 10.1136/flgastro-2022-102366.
4. Devlin J and O’Grady J. Indications for referral and assessment in adult liver transplantation: a clinical guideline. Gut. 1999; 45(Suppl VI): VI1-VI22.
5. Shamji S. British Society of Gastroenterology Workforce Report. 2022; https://www.bsg.org.uk/wp-content/uploads/2023/02/BSG-Workforce-Report-2022.pdf.
6. Cramp M and Newsome P. BSG/BASL Position Statement on Hepatology training. 2019. https://www.basl.org.uk/uploads/BASL-BSG%20Training%20Statement%202019.pdf.
7. Li W, Abbas N et al. UK national trainee survey of hepatology training, research and the future workforce. Frontline Gastroenterology. 2023; 0: 1-8.

Author: Gio Sheiybani (Trainee Associate Editor)

Twitter: @sheiybani

Declarations: I am a trainee associate editor for Frontline Gastroenterology