The lottery of primary care for liver disease

Abstract

Despite rising morbidity and mortality from liver disease in the UK, patient management approaches and adoption of evidence-based care pathways in primary care are highly variable between regions, according to findings from a survey of all Clinical Commissioning Groups (CCGs) in England and nearly all equivalent health boards or trusts across Wales, Scotland, and Northern Ireland. The burden of liver disease has long been underappreciated in the UK. The Lancet Standing Commission on Liver Disease in the UK, launched in 2014, highlighted the dramatic increase in deaths from liver disease since 1970 as a conspicuous exception to widespread improvements in other leading causes of morbidity and mortality, including stroke, cancer, and heart disease. Most deaths from liver disease are alcohol-related, and the increases in incidence track changes in alcohol consumption. Rising rates of obesity are also driving high rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, including in young adults. The identification and management of chronic disease is a fundamental mission of primary care. There has been a shift in the UK towards the use of nationally standardised, evidence-based care pathways for individuals living with chronic diseases, such as type 2 diabetes or cardiovascular disease. However, the development and adoption of pathways for identifying and managing patients with chronic liver diseases has lagged, a lack of attention reflected in the paucity of incentives for primary care providers. The Quality and Outcomes Framework, introduced in 2004 as a means to reimburse general practitioners (GPs) for good quality care, assesses indicators of clinical practice in 20 disease areas, such as the proportion of patients with diabetes and a history of cardiovascular disease being treated with statins. Strikingly, despite it being a leading cause of mortality in those under 65 years of age, there are no indicators relating to management of chronic liver disease. Against this backdrop, new research funded by the British Liver Trust has uncovered stark differences in the adoption and implementation of processes, guidelines, and tools for liver disease detection and management in primary care. 159 of 161 CCGs and health boards in the UK responded to the survey distributed between June and October, 2020; of these, 60% had no pathway in place for acting on abnormal liver blood tests, and 71% had no pathway for responding to liver disease more generally. Dishearteningly, given the remit of CCGs and health boards to commission effective care for individuals within their boundaries, only 35% reported monitoring local statistics on liver disease. The report also noted substantial variation among UK nations. For instance, all seven Welsh health boards reported using a liver blood test pathway and use of transient elastography to assess liver fibrosis. By contrast, eight (67%) of 12 Scottish health boards, just 49 (36%) of 135 CCGs in England, and no Northern Irish trusts had a liver blood test pathway, and transient elastography was used by only 26 (19%) English CCGs, seven (58%) health boards in Scotland, and no trusts in Northern Ireland. Proactive case-finding of individuals at high risk of liver disease, such as those with diabetes or harmful levels of alcohol consumption, was also starkly different between nations: six (86%) Welsh health boards did case-finding for individuals with at least one high-risk factor, compared with no Northern Irish trusts, one (8%) Scottish health board, and 35 (26%) English CCGs. The consistent lack of defined care pathways for managing liver disease in primary care is concerning. Yet the geographical disparities also illustrate the potential for strong policies at regional and local levels to influence patient management. In 2015, the Welsh Government published the Together For Health – Liver Disease Delivery Plan, which outlined priorities and specific actions for improving timely detection of liver disease and the provision of fast and effective care by 2020. On the basis of the new survey results, key recommendations—including improved assessment of people at high risk of disease, greater access to transient elastography, and implementation of nationally agreed care pathways for those with abnormal liver blood tests—seem well established at the health board level. There are also success stories from individual health boards and CCGs across the UK, such as the implementation of intelligent liver function testing and an automated diagnosis system for GPs in Tayside, credited with increasing liver disease diagnosis by 43%. The onus is now on policymakers and health commissioners in other regions to ensure that all patients with liver disease can expect the same standards of primary care, irrespective of the area they live in.