This section provides links to national guidance and resources focusing on the management of liver disease

• NICE NG49 non-alcoholic fatty liver disease guidance (2016)
• NICE NG50 cirrhosis in over 16s guidance (2016)
• BSG LFT guidance 2017
• NICE PH43 hepatitis B and C testing guidance (2013)
• NICE CG165 hepatitis B (chronic): diagnosis and management (2013)
• SIGN 115 management of obesity guidance (2013)
• NICE CG189: obesity guidance (2014)
• NICE CG115: Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011)
• The Liver Disease Delivery Plan for Wales (2015).
• Lancet Commission: Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis (2014)
• Lancet Commission: Implementation of the Lancet Standing Commission on Liver Disease in the UK (2015)
• Lancet Commission: New metrics for the Lancet Standing Commission on Liver Disease in the UK (2016) 
• Caring for people with liver disease: a competency framework for nursing (revised edition 2015)
• Scottish Medicines Consortium
• WHO Hepatitis C fact sheet
• WHO Hepatitis B fact sheet
• Shooting Up: Infections among people who inject drugs in the UK
• Public Health England guidance and resources for GPs and patients: towards Hepatitis C elimination - patient re-engagement exercise

Recommended Read Codes for primary care

Read Codes for liver disease are suggested for both SystmOne and EMIS/Vision users. Good use of the Read codes will support effective audit.

• Liver investigations [PDF]
• Non-alcohol-related fatty liver disease [PDF]
• Alcohol-related liver disease [PDF]
• Other liver disease diagnoses [PDF]
• Viral hepatitis [PDF]

Review your practice - Ideas for audit and reflection?

These links contain ideas and suggestions to help you reflect on your clinical practice relating to liver disease. Are you equipped to identify patients with risk factors for liver disease and to help them reduce their risk? Are you equipped to identify and manage early liver disease?

• Practice checklist are all the right things in place for you to prevent and manage liver disease[DOC]
• Clinical audit ideas: identification and management of NAFLD [DOC]
• Clinical audit ideas: identifying and managing cirrhosis in primary care [DOC]
• Clinical audit ideas: reducing the risk of liver disease in those with high alcohol consumption[DOC]
• Clinical audit ideas: managing hepatitis C in primary care [DOC]
• Clinical audit ideas: managing hepatitis B in primary care [DOC]
• Personal reflections: managing neonatal jaundice [DOC]

This section contains articles and resources for primary care practitioners on liver disease, its impact, its risk factors and prevention, its early diagnosis and its management.

• Liver disease in the UK, an overview [PDF]
• Cirrhosis and its management in primary care [PDF]
• Non-alcohol-related fatty liver disease and its management [PDF]
• Alcohol-related liver disease and its management [PDF]
• Hepatitis B infection [PDF]
• Hepatitis C infection [PDF]
• PHE Patient re-engagement exercise for those who have been diagnosed with hepatitis C [PDF]
• Prolonged neonatal jaundice and its management [PDF]
• LFT blood testing and investigations in liver disease (summarising the British Society of Gastroenterology guidelines 2017) [PDF]
• Getting the most out of Liver Blood Tests [PDF]RCGP Annual Conference & Exhibition session slides

Resources are currently being developed for the following areas:

• Hepatocellular carcinoma
• End of life care in liver disease
• Care after a transplant
• Other viral hepatitis: A D and E
• Hepatic encephalopathy
• Hepatitis A and B immunisation
• Other liver diseases (including autoimmune and metabolic diseases)

Patient leaflets on different liver conditions

The British Liver Trust has a full range of leaflets on the whole range of liver diseases that can be downloaded for free. The full range of leaflets can be downloaded for free here or your patient can order a free hard copy by calling 01425 481320.The most popular leaflets include:

• Living with Liver disease
• Diet and Liver disease
• Alcohol and liver disease
• Non- alcohol related liver disease
• Different types of liver disease

Liver disease often has no symptoms in the early stages. The British Liver Trust has developed a range of materials covering the risk factors for liver disease and the signs and symptoms of liver disease. They are free to order and include posters and leaflets for display in GP surgeries

This section provides links to a range of organisations that work to prevent liver disease, to support those with liver disease, or provide resources and guidance to practitioners working with patients with liver disease.

British Liver Trust. The British Liver Trust is the leading UK liver disease charity, providing information and support for professionals, patients and carers; promoting prevention and early diagnosis of liver disease; funding and championing research; and campaigning for better services. In addition the Trust has an anonymous love your liver health screener that assesses the risks posed by alcohol, obesity and viral hepatitis and provides a print out of what you need to do and if need be what to discuss with your GP.

Children's Liver Disease Foundation. The CLDF is a UK-wide charity that provides support, information research funds and a voice for all those affected by childhood liver disease.

Yellow Alert. Yellow alert is CLDF's prolonged jaundice in newborn babies awareness campaign. Yellow Alert promotes the early diagnosis and appropriate referral for liver disease in newly born infants.

Alcohol Concern. Alcohol Concern's aims are to help people concerned about their drinking by providing information and guidance, and to help professionals through training, projects and research.

Drinkline. Drinkline provides a national helpline to offer help and signposting for callers worried about their drinking, support for the family and friends of people who are drinking and links to information and self-help materials.

Alcohol Health Alliance. The Alcohol Health Alliance brings together more than 40 organisations that have a shared interest in reducing the damage caused to health by alcohol. Members include medical royal colleges, charities, patient representatives and alcohol health campaigners. Its aims are to highlight the rising levels of alcohol-related harm; propose evidence-based solutions to address the harms; and encourage decision makers to take positive action.

Obesity Health Alliance. The Obesity Health Alliance is a coalition of over 30 organisations who have joined together to fight obesity. Members include medical royal colleges, charities, campaigners and professional associations. The alliance works together to influence Government policy on overweight and obesity.

Hepatitis C Trust. The Hepatitis C Trust is a national UK charity supporting those with hepatitis C infection. It is a patient-led and patient-run organisation and most of its board, staff, and volunteers either have hepatitis C or have had it and have cleared it after treatment.

Hepatitis B positive. This organisation provides information for the public on hepatitis B infection.

Hepatitis Scotland. Hepatitis Scotland provides training for non-statutory organisations, information and support for patient involvement for those with hepatitis B or C infection in Scotland, and resources for health professionals.

British Association for the Study of the Liver. BASL is a multidisciplinary association with 850 members from medical, nursing and research backgrounds. It aims to advance knowledge about liver biology and pathology; disseminate research findings and promote clinical care of liver disease.

British Society of Gastroenterology. The British Society of Gastroenterology promotes the practice and study of gastroenterology within the United Kingdom. It has over three thousand members including physicians, surgeons, pathologists, radiologists, scientists, nurses, dietitians, and others interested in the field. Internationally it is represented at World and European level.

PSC Support is the leading UK-based organisation for anyone affected by Primary Sclerosing Cholangitis (PSC). They offer advice for patients, family members, healthcare providers and researchers. The Primary Sclerosing Cholangitis Online Support Group is a group consisting of people with PSG and provides mutual support

Primary Care Society for Gastroenterology. The PCSG supports the practice of gastroenterology within primary care through providing guidelines, supporting research and educational events. Membership is free.

The RCGP is the professional membership body for family doctors in the UK and overseas. It is committed to improving patient care, clinical standards and GP training and offers resources for GPs in practice including CPD targeted towards liver disease.

If you have a liver problem yourself, or you are a health professional and one of your patients is worried about developing liver disease, has had an abnormal liver function test, has been diagnosed or is caring for a loved one with a liver condition or has questions about liver cancer, you will need access to jargon-free, patient-friendly, reliable information that has been checked by experts.

This section of the toolkit provides signposts to these resources. Much of the information is detailed and will useful for health care professionals as well as patients.

General Information

• British Liver Trust
• NHS Choices general information about liver disease

The British Liver Trust has a free patient helpline run by nurses with liver disease expertise.

Helpline: 0800 652 7330 (10am to 3pm Monday to Friday)

Liver Cancer Information

• British Liver Trust on liver cancer
• Liver Cancer leaflet free download
• Cancer Research UK  Liver cancer
• Macmillan Cancer Support Liver cancer

Hepatitis C Trust

The Hepatitis C Trust produces a range of materials and run a helpline on 0845 223 4424 or 020 7089 6221(10.30am to 4.30pm Monday to Friday). Alternatively, you can email helpline@hepctrust.org.uk

Patient leaflets on different liver conditions

The British Liver Trust has a full range of leaflets on the whole range of liver diseases that can be downloaded for free. The full range of leaflets can be downloaded for free here or your patient can order a free hard copy by calling 01425 481320.The most popular leaflets include:

• Public Health England information Hepatitis C and your liver
• Public Health England information on Hepatitis C for patients 
• Living with Liver disease
• Diet and Liver disease
• Alcohol and liver disease
• Non- alcohol related liver disease
• Different types of liver disease

Liver disease often has no symptoms in the early stages. The British Liver Trust has developed a range of materials covering the risk factors for liver disease and the signs and symptoms of liver disease. They are free to order and include posters and leaflets for display in GP surgeries

Children's Liver diseases

The Children's Liver Disease Foundation has a range of support information and offers support on the different types of liver disease affecting children.

There are also local support groups and support groups for rarer types of liver disease

Liver disease – examples of best practice in primary care

Many local teams have led innovative and exciting developments in the prevention and management of liver disease in their areas across the UK, some of these are listed below.

If you've been involved in innovative or best practice in the management of liver disease and you would like to share details of your project, please complete the pro forma and email it to jonathan.worsfold@britishlivertrust.org.uk

Areas of good practice for early detection include:

Camden and Islington

The Camden and Islington pathway consists of a two-step testing assessment for patients attending their GP with a new or established diagnosis of NAFLD. In the first step, all patients undergo a FIB-4 test. If the FIB-4 score falls below a certain level, patients are deemed to be at low risk of advanced fibrosis and are managed in primary care. If the FIB-4 score is considered high, patients are deemed to be at greater risk of advanced fibrosis and are referred to secondary care for specialist assessment. A further Enhanced Liver Fibrosis blood test can also be used to decide whether individuals can be managed in primary care or secondary care when it is not immediately clear from the FIB-4 test.

Patients managed in primary care receive treatment for cardiovascular risks and diabetes, receive annual liver function tests, and are re-assessed to gauge their risk of advanced fibrosis after three to five years.[i]

During the pathway’s pilot – between 2013 and 2016 – an 80% reduction in unnecessary referrals to secondary care was seen, saving £150,000. In addition, there was a five-fold increase in the detection of advanced fibrosis and three-fold increase in the detection of cirrhosis.[ii]^,[iii]

The pathway has been revised twice since its creation, most recently in 2019.[iv]

Dundee/Tayside

The intelligent Liver Function Testing pathway (iLFT) uses an automated, algorithm-based system to further investigate abnormal liver function test (LFT) results on initial blood samples from primary care.

GPs in Dundee can request an LFT via an electronic system, inputting information about a patient’s BMI, alcohol consumption and other risk factors. If an abnormal LFT result is found in the laboratory, a series of additional tests on the same sample are automatically run to find the cause and stage of fibrosis. The information automatically identifies the diagnosis; highlights whether a referral to a specialist is required; and provides a management plan, which includes lifestyle advice for NAFLD patients. This can be made available to GPs instantaneously to enable them to take action, and are also delivered electronically.[v]^,[vi]

The pathway, which was piloted from September 2015 to November 2016, saw a 43% increase in the number of liver disease patients diagnosed. It was found to save the NHS £3,216 per patient per lifetime, proving cost-effective.[vii] Since becoming fully operational across NHS Tayside’s primary care services in August 2018, iLFT has identified that 70% of patients could continue to be managed in primary care.[viii]^,[ix] The Scottish Government has identified the iLFT pathway as eligible for adoption across NHS Scotland through its Modern Outpatient Programme. The Tayside iLFT group are working with primary care services and laboratories to roll out the test.[x]

Nottinghamshire

In South Nottinghamshire, an integrated pathway has been established within the community, as part of the Scarred Liver Project, to identify patients with risk factors for liver disease. GPs can opportunistically refer at-risk patients for a FibroScan to test for liver scarring. Every patient, regardless of their test result, receives information on lifestyle interventions to maintain good liver health. Those with abnormal scan results are referred to a hepatologist for further review.[xi]

The pathway was piloted in 2014 and is now accessible to more than 100 GP practices serving a population of approximately 700,000 patients. The pathway is cost-effective, with the cost per quality-adjusted life-year (QALY) equating to £2,138 per patient diagnosed with NAFLD.

Gwent 

In 2016, the Gwent AST Project (GAP) was commissioned as part of the Wales Liver Plan to pilot a pathway in primary care, aiming to improve the recognition of significant liver disease by automatically testing for the enzyme Aspartate transaminase (AST) as appropriate. The pathway automatically assesses and advises on whether to refer the patient for further assessment, which is done predominantly via FibroScan.

During the two-year pilot, 192 cases of advanced fibrosis were identified, and there has been an 81% increase in coded diagnoses of cirrhosis since its introduction. In addition, 50% of patients referred for Fibroscan via the pathway has probable NAFLD as the final diagnosis.

North East England

At Newcastle upon Tyne Hospitals NHS Foundation Trust a care bundle was developed by hepatologists, gastroenterologists, specialist dieticians and physiotherapists, to record key information on NAFLD follow-up patients.[xii] The care bundle was developed following a regional baseline audit which found variation in documentation and practice.

The bundle was introduced at the Foundation Trust in November 2018 and provides a short and structured checklist to facilitate the recording of anthropometry, metabolic risk factors, stage of liver fibrosis, lifestyle advice and weight reduction targets, metabolic risk factor management and specific NAFLD treatment. It incorporates key recommendations from EASL and NICE and includes advice on routine investigations and an NAFLD management algorithm.

Overall, there was significantly better documentation and implementation of most aspects of patient management when the bundle was used. This led to better management of metabolic risk factors, documenting of lifestyle advice and provision of patient information booklets on NAFLD.

Bolton

Teams in Bolton have created the ‘Bolton Alcohol Project’. They developed integrated and collaborative changes that led to:

• a primary care project that has been highly successful in identifying alcohol problems through screening with the AUDIT-C test and signposting patients to early interventions
• the creation of a consultant-led hospital based alcohol care team that has improved the care and reduced admissions for alcohol-related conditions

 Middlesbrough

Middlesbrough has developed a 'Live Well Centre'. The centre is a one-stop shop to support people in changing their lives for the better across a full spectrum of life issues. The project is specifically building in the identification of risk factors for liver disease together with signposting to further interventions as part of an opportunistic screening programme.

Southampton

The St Mary's Surgery in Southampton recognised that the patients in their large inner-city practice were likely to have a high prevalence of liver disease. Having been part of the ‘Locate’ project the practice worked with local liver specialists to improve their identification and management of liver disease through the development of local clinical pathways and through direct GP access to transient elastography (TE). They created a simple flagging system on their electronic patient records that identified those at risk so that they were routinely and systematically tested.

West Midlands

Recognising higher than average liver disease mortality in the region, together with high levels of health inequality, local PHE leads have brought together services and organisations to address the human and financial costs arising from this. Through local workshops and the creation of a local network, the region has put in place strategies to improve the early detection of liver disease and improve the patient experience.

Birmingham

The 'Liver Matters' project has worked across the Birmingham South Central CCG to enhance the quality of life for people with alcohol related liver disease and their carer(s) and families, providing information and advice, liaising with treatment services, expanding social networks, and supporting end of life care.

References 

[i] Srivastava, A., Gailer, R., Tanwar, S., Trembling, P., Parkes, J., Rodger, A., Suri, D., Thorburn, D., Sennett, K., Morgan, S., Tsochatzis, E.A., Rosenberg, W., Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease, Journal of Hepatology. March 2019. Available at: https://discovery.ucl.ac.uk/id/eprint/10072675/1/1-s2.0-S0168827819302272-main.pdf

[ii] NHS Camden, NAFL Camden, June 2019. Available at: https://www.basl.org.uk/uploads/NAFLD%20SIG/NAFl%20Camden.pdf Accessed on: 9 March 2021

[iii] Srivastava, A., Gailer, R., Tanwar, S., Trembling, P., Parkes, J., Rodger, A., Suri, D., Thorburn, D., Sennett, K., Morgan, S., Tsochatzis, E.A., Rosenberg, W., Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease, Journal of Hepatology. March 2019. Available at: https://discovery.ucl.ac.uk/id/eprint/10072675/1/1-s2.0-S0168827819302272-main.pdf

[iv] NHS North Central London, Adult Abnormal Liver Function Tests Guidance, February 2019. Available at: https://gps.northcentrallondonccg.nhs.uk/pathways/liver-function-tests-1 Accessed on: 9 March 2021

[v] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19-Research-Article-iLFT.pdf

[vi] Royal College of General Practitioners, Recommendations for commissioning bodies to improve the early detection of chronic liver disease in UK primary care. Available at: https://www.rcgp.org.uk/clinical-and-research/resources/a-to-z-clinical-resources/recommendations-for-commissioning-bodies-to-improve-the-early-detection-of-chronic-liver-disease.aspx Accessed on: 8 March 2021

[vii] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19-Research-Article-iLFT.pdf

[viii] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19-Research-Article-iLFT.pdf

[ix] Scottish Government, Demand optimisation in laboratory medicine: phase two report. November 2019. Available at: https://www.gov.scot/publications/demand-optimisation-laboratory-medicine-phase-ii-report/pages/6/

[x] Scottish Government, Demand optimisation in laboratory medicine: phase two report. November 2019. Available at: https://www.gov.scot/publications/demand-optimisation-laboratory-medicine-phase-ii-report/pages/6/

[xi] The Scarred Liver Project, Detecting liver disease in the community. Available at: https://www.scarredliverproject.org.uk/#top Accessed on: 9 March 2021

[xii] Neilson, L., Macdougall, L., Lee, P., Hardy, T., Beaton, D., Chandrapalan, S., Ebraheem, A., Hussien, M., Galbraith, S., Looi, S., Oxenburgh, S., Phaw, N., Taylor, W., Haigh, L., Hallsworth, K., Mansour, D., Dyson, J., Masson, S., Anstee, Q. and McPherson, S. Implementation of a care bundle improves the management of patients with non-alcoholic fatty liver disease, Frontline Gastroenterology. January 2021. Available at: https://fg.bmj.com/content/early/2021/01/03/flgastro-2020-101480

Patient leaflets on different liver conditions

The British Liver Trust has a full range of leaflets on the whole range of liver diseases that can be downloaded for free. The full range of leaflets can be downloaded for free here or your patient can order a free hard copy by calling 01425 481320.The most popular leaflets include:

• Living with Liver disease
• Diet and Liver disease
• Alcohol and liver disease
• Non- alcohol related liver disease
• Different types of liver disease

Liver disease often has no symptoms in the early stages. The British Liver Trust has developed a range of materials covering the risk factors for liver disease and the signs and symptoms of liver disease. They are free to order and include posters and leaflets for display in GP surgeries

This section provides links to resources specifically aimed at commissioners.

A financial case for action on liver disease has been developed by the Foundation for Liver Research and this report has been endorsed by the lancet commission on liver disease.

Scotland

There is public health information for Scotland relating to:

• Chronic liver disease
• Liver disease mortality 
• Chronic liver disease morbidity

Wales

There is information on the prevalence of a range of liver diseases in Wales.

England

In England NICE has produced a quality standard for the management of liver disease . This quality standard covers identifying, assessing and managing chronic liver disease in children, young people and adults, and cirrhosis in young people and adults. It describes high-quality care in priority areas for improvement.

NHS England has published a policy statement on the management of chronic Hepatitis C in patients with cirrhosis.

The Foundation for Liver Research has compiled customised liver disease profiles for each of the 533 parliamentary constituencies in England:

• Profiles for constituencies with names beginning a-s
• Profiles for constituencies with names beginning t-z 

Public Health England has developed an atlas that shows variation in healthcare for people with liver disease England

As part of RCGP/British Liver partnership, our Clinical Champion has written a number of articles and also presented at the RCGP main conference. Some of the articles are below:

Detecting liver disease in primary care: are we ready for change?

How can primary care enhance end-of-life care for liver disease?

Championing change in liver disease in primary care

PBC: In Practice

Guideline of the month: Abnormal LFTs