This case study features in the NHS Innovation Accelerator’s year three research report, Understanding how and why the NHS adopts innovation.
Liver disease is now the fifth largest killer in the UK. Currently, 50% of new diagnoses of liver cirrhosis occur only after emergency admission to hospital (Ratib et al, J Hep 2014). The Scarred Liver Pathway was developed to detect asymptomatic liver disease at an earlier stage when the disease could be reversed. The fibroscan (transient elastography) is an imaging-based tool that assesses the stiffness of the liver and can detect early stages of liver disease. In Nottinghamshire, NIA Fellow, Neil Guha, took a pathway that uses the fibroscan from secondary care and tested it in primary care with GP patients. The novelty of the pathway is based on targeting risk factors for liver disease and not simply implementing a technology in a different health care setting.
The early findings were very promising, but to move the development from a research project to a diagnostic tool integrated into primary and secondary care of liver disease, required the development and adoption of a complete scarred liver pathway.
Between 2014 and 2018, stakeholders from across the local health service worked together to iteratively develop the pathway that is now fully embedded in the liver disease treatment process in Nottinghamshire.
The Scarred Liver Pathway is an example of an innovation developed, tested, refined, spread and embedded within a local research and healthcare system.
In 2012, the NIA Fellow won a £30,000 research grant to conduct a pilot study in which a research fellow took a portable fibroscanner to GP clinics to diagnose early stage liver disease. The results were impressive but made clear that the diagnostic tool needed to be part of a complete pathway if it was to be widely adopted. In 2013 the development won a £100,000 NHS Innovation Challenge Prize that enabled two further pilot studies to be conducted, helping to build the evidence base for the effectiveness of the technique.
Research and development
This research work in Nottingham, co-led by the NIA Fellow, involved hepatology specialists at the hospital as well as GPs across the city, and triggered discussions about the importance of tackling the increasing mortality from liver disease and the promise of early diagnosis in primary care using fibroscan. Nottingham City CCG’s Clinical Chair became involved – prompted in part by the high costs investigating liver disease in the hospital – providing more focus on the work. A scarred liver project group was formed to explore the possibility of developing a pathway that the CCGs could fund.
During this process, the local Academic Health Science Network (AHSN) worked with the NIA Fellow to help create the conditions for the pathway to be developed. It provided funding, developed a robust analysis of the cost-benefits of the fibroscan, and created the necessary links with CCGs, secondary care, GP practices and other stakeholders for work to begin on pathway development.
The initial pathway went through 24 iterations until it reached its current form, where it is the established route for patients, and provided across four CCGs in Nottinghamshire. The work to construct and test the pathway involved many activities including:
- A programme of educational events to introduce GPs to the benefits and practices of fibroscan diagnosis
- Establishing a fibroscan day clinic in a Nottinghamshire hospital and staffing it with nurses who could conduct the scan and also offer lifestyle advice and signposting to patients at risk of developing liver disease
- Specifying a referral process for GPs that targeted patients at risk of developing liver disease who would most benefit from fibroscan diagnosis
- Embedding the referral and reporting process into the information systems used in GP practices and secondary care
- Establishing a tariff for the pathway so that its operation could become a sustainable way of delivering care
- Defining the pathways following fibroscan diagnosis: for patients with confirmed liver disease into secondary care treatment, and into lifestyle services when the disease had not yet developed
- Building and refining the evidence base as more patients progressed through the pathway
Working in partnership across organisational boundaries: The Scarred Liver Pathway changed where and when people were diagnosed and their subsequent treatment. It therefore needed GPs to embrace it as a different form of diagnosis; hospital services to be adjusted to absorb earlier referrals; and new tariffs agreed for it to be sustainable. Addressing these challenges involved the engagement of many people across primary and secondary care. An enabling team was created and sustained a development process capable of identifying and overcoming many impediments, such as system infrastructure.
System infrastructure: Via the AHSN’s support and nurturing of the pathway from a research project to a mature pathway, fully embedded across the geography.
Iteration of the pathway: The development mechanism adopted was an inclusive and iterative process in which successive versions of the pathway were tested. All stakeholders were able to give feedback and work through issues to produce the next iteration. Initially, for complex reasons, the investigation of liver disease in the hospital cost £900 per patient, and commissioners worked with the pathway designers until, in present arrangements, the agreed tariff is £40 per scan. This extensive stakeholder involvement presumably helped to build the next key enabler: champions.
Champions: There was sustained support and work by champions and enablers of many kinds. GPs who spread the word to others, liver specialists and nurses in secondary care who developed both the pathway and new parts of the service, and CCG commissioners who found ways to fund the pathway. One interviewee described the: “institutional pride” of having developed the Scarred Liver Pathway.
Tailoring the evidence base for the purchaser’s needs: Initially the evidence demonstrated long-term benefits of the pathway as fewer patients developed serious liver disease, whereas commissioners generally need to show return on investment over a shorter time frame. There was also a need to reduce the initial high costs of using fibroscan to allow widespread use so that the long-term benefits could be realised. The commissioners were closely involved in the design of the pathway meaning that the evidence they needed could be developed.
The pathway has been commissioned across four East Midlands CCGs because it has the potential to reduce a worrying trend towards higher levels of mortality from liver disease in Nottinghamshire.
More GP practices are joining and referring patients:
- The numbers of patients referred for a scan are now 338 per month (July 2018) compared to 58 in July 2016
- A total of 4,612 referrals over the two-year period
- Many patients have made significant lifestyle changes after visiting the day clinic for fibroscanning, and have thereby reduced their risk of developing liver disease
The development of the Scarred Liver Pathway is an example of the multi-partner, cross-NHS organisation engagement needed to transform a promising research project into an embedded, sustainable process delivering better patient outcomes. The change in diagnostic procedures in this case, had wide ramifications for the existing system for treating liver disease and all these implications had to be worked through before the benefits of the new procedure could be systematically realised.
The adoption journey is not over: the people who have championed this development have plans to disseminate it further and to develop its links to related pathways and services. For example, to the many lifestyle services that can support people at risk of developing liver disease.
1. Guru Aithal, Professor of Hepatology, University of Nottingham
2. Isobel Esberger, Specialty General Manager, Nottingham University Hospitals NHS Trust
3. Neil Guha, NIA Fellow, Clinical Associate Professor of Hepatology, University of Nottingham
4. Nick Hamilton, Operations Manager, East Midlands Academic Health Science Network
5. Rebecca Harris, Registrar in Gastroenterology, University of Nottingham
6. Jeanette Johnson, Matron in Ambulatory Care Pathway, Queens Medical Centre, Nottingham
7. Sonali Kinra, GP Advisor, Greater Nottingham Joint Commissioning Committee
8. Hugh Porter, GP and Clinical Chair, Nottingham City CCG
9. Emilie Wilkes, Consultant Hepatologist, Nottingham University Hospitals NHS Trust