Dinesh Liver Clinic Leicester“I think it would be interesting to see if they could extend it to other practices throughout the country, I think the more information you have the better chances you’ve got of diagnosing that particular disease and finding a cure if there is one somewhere down the track.”

Patient Dinesh from Leicester


EMAHSN’s Scarred Liver Project is implementing a community-based pathway focused on risk factors, integrated care across primary and secondary care and innovative diagnostic technologies (using a non-invasive procedure Fibroscan®). The pathway picks up patients much earlier, with the aim of halting the condition or dramatically improving patient outcomes.

Working in partnership with the NIHR Nottingham Digestive Diseases Biomedical Resarch Centre BRC, the pathway has been implemented in two sites across Nottingham and in an inner-city Leicester GP surgery.


The rise in cirrhosis mortality in England and Wales is the steepest in Europe, claiming 62,000 years of working life each annually. It is the third leading cause of premature death in the UK and the only one of the top five causes that is increasing. The majority of disease is lifestyle-related including excessive alcohol use, obesity and type 2 diabetes – and so is preventable. Early diagnosis is essential and current diagnostic algorithms are flawed in achieving this.

What’s the impact?

In total, during implementation in Nottingham, diagnosis more than doubled for cirrhosis:
  • 20,368 population analysed in Nottingham - 2,022 identified to be at risk
  • 25.6% (230) patients had signs of significant liver disease and 26 new cases of cirrhosis were identified – cases that would have otherwise gone undetected

Inner-city Leicester results:
  • 4,150 population analysed (focusing on obesity and alcohol risk factors) - 1,320 identified to be at risk
  • 720 patients scanned, all of whom received a lifestyle intervention to reduce their risk of developing liver disease83 patients had signs of significant liver disease and 13 were diagnosed with cirrhosis

Overall summary and other impacts:
  • EMAHSN has supported development of a commissioning case which has implemented risk-based stratification and Fibroscan® within the frontline liver disease pathway in South Nottinghamshire – covering four clinical commissioning groups
  • A health economics report concludes implementing the pathway provides better outcomes for patients with non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD), compared with standard care
  • Pathway costs are significantly within the NICE threshold of £20,000 per quality-adjusted life-year (QALY) at £2,138 per QALY for NAFLD and £6,537 per QALY for ALD
  • Attendance rates for scans in the community are 95% compared to 60% in hospital
  • More than 90% of patients stated that they would recommend the scan
  • The project’s success has contributed to the revision in July 2016 of NICE clinical guidance for liver cirrhosis (NG50) and NAFLD (NG49)

What’s next?
  • Promoting the pathway to other CCGs and supporting the development of further commissioning cases
  • Providing evaluation support for roll out in South Nottinghamshire, and ensuring patients scanned receive lifestyle advice and support
  • Securing primary and secondary care buy-in to implement within Chesterfield
  • There are 12 million people nationally at risk – the pathway will identify these people if scaled throughout England and Wales

Find out more by visiting our Liver project page.