Kate Pitt, GP, writes about the growing rates of liver disease, how it disproportionately affects people experiencing homelessness, and shares a new resource developed to support frontline workers.
I was asked to deliver a teaching session about liver disease, so I asked my colleague for advice. She had many years of experience of frontline work in the homelessness sector. I knew that liver disease disproportionately affected people experiencing homelessness, and that she had worked with many people affected by it. I was struck by her response; she told me how frightening it could feel. My slides opened with a graph. She responded:
‘We (workers) don't need shocking by figures… we just want to know more about what to look for and what to do for people.’
She was acutely aware of the scale of the problem. She knew the causes, including higher rates of hepatitis C infection and harmful alcohol use. She had seen the complications and been at the bedside in hospital. She knew the barriers to accessing care, including the internalised stigma that many felt. She also knew that addressing the risk factors for liver disease could be complicated, by life circumstances, mental ill-health, cognitive problems, and the impact of trauma. I didn’t need to tell her that; she already had a deep understanding of the impact on individuals.
Despite the increasing rates of liver disease nationally, the public awareness and policy response is patchy. Another frontline worker colleague commented that liver disease: ‘doesn't have much public traction’. This is true and deeply unfair, not least because liver disease disproportionately affects people experiencing poverty and marginalised groups. I was surprised, as I was preparing for my teaching session, not to be able to find resources on liver disease catered for frontline homelessness sector workers. It highlighted the incredible and challenging job my colleagues did, and the opportunities to support them better.
A misplaced fatalism can affect people’s attitudes towards liver problems. I’ve encountered a perception that liver disease only gets worse, and not much can be done to help. This is not true. The risk of complications can be reduced and people can be helped. Even small changes make a difference. One example is a bedtime snack. People with cirrhosis are less able to store energy, and this can be a problem when they sleep. 50 g of carbohydrate, or a couple of slices of toast, before sleep can help this. Too often, healthcare appointments can feel rushed, and practical tips get lost or forgotten. Frontline workers help with communication, and trust matters. Frontline workers can be a key supportive relationship in people’s lives and encourage people to value themselves and their health.
The teaching session, and feedback from frontline workers and other clinicians, has led to a guidance document published on the Pathway website.
It includes tips on talking to people about their liver health, signs and symptoms of liver disease, common tests and medications, nutrition, cognition, palliative care, and looking after yourself. Links to further resources are included, including guidance from Homeless Link. I hope to develop it with ongoing feedback from frontline workers (see guide for link), to make it as practical and useful as possible, to support the vital work that they do.
Acknowledgement
This work was funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Kent, Surrey and Sussex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
