National Institute for Health and Clinical Excellence (NICE)
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The Scarred Liver Project: A new diagnostic pathway to detect chronic liver disease

Blog posted by: Neil Guha, clinical associate professor in hepatology, Nottingham University Hospitals NHS Trust, 08 May 2019.

Shared Learning Award 2019 finalist

A major challenge in the NHS is how we identify individuals who have progressed to significant liver disease. Symptoms occur late in patients and routine tests are not sufficiently robust. Liver disease is the third leading cause of premature mortality in the UK with 50% of patients being first diagnosed with cirrhosis following an emergency admission.

With our project we decided to challenge in Nottinghamshire the traditional route to referral for liver disease.

Our pathway incorporated NICE guidelines for the identification of chronic liver disease and it provided GPs in primary care with the opportunity to directly access specialist tests for liver scarring such as a liver scan, usually available only in hospital settings. 

The implementation faced challenges regarding the short-term investment needed to change clinical practices versus the long-term cost-effectiveness it can achieve. Our pathway is cost-effective compared to current standard of care and is within the NICE threshold.

The pathway has been commissioned in Nottinghamshire since 2016. Over 3,000 patients have received a brief lifestyle intervention and we found significant liver disease in up to one in five of those attending for a liver scan. Patient feedback has been excellent, with over 90% expressing a high degree of satisfaction.  

A major part of our success can be attributed to having prior face-to-face discussions with clinical commissioners. Our referral pathway attends to the evidence while it accounts for the financial constraints faced by primary and secondary care.

We are currently working with other primary and secondary care centres outside Nottingham, including Chesterfield Hospital and Lakeside Healthcare, to adopt and spread the pathway with attention to the specific needs of that area.

Further details of our work are available at


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