“Our GP practice was doing a research project with Queen’s Medical Centre. They did a Fibroscan in the community and I found out I had cirrhosis of the liver. I’m a teetotaller, so it was the last thing I thought I was going to get. If I don’t change my lifestyle, my cirrhosis would get worse. Hopefully the change in lifestyle will put the cirrhosis on a more even keel.”
Martin, Service User
Overview

The Scarred Liver Project implemented an adult liver disease stratification pathway focused on lifestyle-related risk factors across a number of different care settings. This combined proactive identification of patients at risk of chronic liver disease with use of mobile, non-invasive point of care diagnostic tests to detect liver disease earlier. This provided a more integrated pathway between primary and secondary care.

The Fibroscan® device enables healthcare professionals to offer more accessible and non-invasive diagnostic testing for early stage liver disease and associated scarring (fibrosis) with a near-instant result. Enhanced detection of early stage liver disease and associated lifestyle-related risk provides opportunities for behavioural interventions to facilitate prevention and self-management before the condition becomes chronic and outcomes significantly worsen. Fibroscan® also reduces the need for clinically intrusive and costly liver biopsies.

Through implementing a system of rapid localised diagnosis supporting future prevention and improved management, the project aimed to support an overall reversal in premature mortality from liver disease in the East Midlands and across the country.

What was the problem?

Liver disease is the third leading cause of premature mortality in England and whilst mortality due to other diseases in this category are declining, liver disease continues to increase. Liver disease is responsible for 62,000 years of working life lost per year and the average age of death of those with liver disease is currently 59 years. 90% of liver disease in the UK is due to alcohol, obesity and viral hepatitis and is therefore preventable. 75% of those with liver disease are diagnosed in a hospital or emergency setting, when the disease is already well-advanced. By this time, treatment options are limited.

Earlier detection and better treatment is critical in order to:

  • Identify patients earlier – enabling more impactful interventions
  • Diagnose patients closer to home in a community/primary care setting using less invasive procedures than a surgical biopsy
  • Assess patient risk, undertaking stratification at the point of care and where appropriate offer patients a brief intervention to promote lifestyle changes.
Actions taken

The East Midlands AHSN, working in partnership with the NIHR Nottingham Digestive Diseases Centre Biomedical Research Unit, has supported implementation of the innovation at sites across Nottingham and Derbyshire.

The East Midlands AHSN supported this project since 2013 and assisted implementation of the pathway across multiple settings with differing socio-economic characteristics – providing specialist expertise to support adoption and spread of the pathway into clinical practice. This includes health economics and translational research expertise, which has informed the development of commissioning cases with local Clinical Commissioning Groups (CCGs). The Scarred Liver Project won a 2013 NHS Innovation Challenge Prize which funded this pilot scheme.

The pathway, which used non-invasive point of care diagnostic tests (Fibroscan®), has supported identification of patients at a much earlier stage, with the ultimate aim of halting the condition or dramatically improving patient outcomes (in comparison to current processes, which often lead to patients not being identified early enough for effective treatment). The pathway change has undergone a full health economic evaluation and attracted interest from regional CCGs, which included the East Midlands AHSN facilitating the redesign of the adult liver disease stratification pathway in one locality.

The pathway across Nottingham and Nottinghamshire is now an established clinical approach and has been commissioned across Greater Nottingham and Nottingham City Integrated Care Partnerships. It is expected that this will me mirrored across Mid-Nottinghamshire in line with the emerging Integrated Care System. In 2019 the Scarred Liver Project was successful in securing additional funding via Innovate UK to undertake research and implement a community hub approach for liver diagnostic approaches in partnership with The University of Manchester and supported by the East Midlands AHSN.

Impacts / outcomes

Overall the project has been successful in the implementation of Fibroscan® in previously unexplored pathways and accessing new networks. The project has achieved significant levels of activity within the East Midlands

The pathway is now accessible to more than 100 GPs in the East Midlands, serving a population of approximately 700,000 people.

Additional benefits were also highlighted as part of research undertaken following brief intervention offered post- Fibroscan®.

Research following intervention suggests that Fibroscan® triggers a recognition about the need to change lifestyle behaviour, with 32% of patients (who consented to be followed up, had baseline data and were contactable) losing at least 5% of their baseline body weight and 29% reducing their alcohol intake by 10%.

Lifestyle behaviour impacts include:

  • Reduced alcohol use – A statistically significant reduction in alcohol use was reported from baseline to three and 12 months, with alcohol use reducing by an average of 10 units per week across the sample.
  • Weight loss – A statistically significant reduction in weight was observed from baseline to three and 12 months, with an average of 1.1kg and 1.6kg of weight lost at three and 12 months, respectively.

Decreased Emergency Department admissions – There was a 36% reduction in attendance at the Emergency Department and an 88% reduction in hospital admission.

The project has received a range of recognition, including:

  • NHS Innovation Accelerator (2018) scarred liver is listed as one of 37 evidence-based innovations
  • NICE Guidance submission for ‘Cirrhosis in over 16s: assessment and management (NG50)’ ready for publication
  • The Royal College of General Practitioners (RCGP) have listed the pathway as an example of innovative care
  • The British Liver Trust invited Dr Neil Guha (Scarred Liver Project Clinical Lead and Consultant Hepatologist, Nottingham University Hospitals NHS Trust) to join a national committee to look at commissioning
  • The King’s Fund have included the Scarred Liver Project as one of eight projects selected across the whole AHSN network on a report about innovation with Dr Guha being invited to write a guest blog.
Plans for the future

The project has now concluded. However through a successful bid with Innovate UK further work is underway to develop a similar community hub approach in Manchester in collaboration with The University of Manchester.

The pathway established and commissioned in Nottinghamshire will continue and is expected to be adopted across the whole Integrated Care System (ICS) footprint and single commissioning structure.

Contacts

Project contact for further information

Dara Coppel

Head of Innovation Programme Delivery

East Midlands AHSN

dara.coppel@nottingham.ac.uk

Media contact for further information

Chris Taylor, East Midlands Academic Health Science Network
E: chris.taylor@nottingham.ac.uk

Programme duration

2013 – present.