Managing liver disease closer to home
SEL 20:20 innovation series
A new neighbourhood-based liver service in Lambeth is helping more people get specialist care in their local GP practice — rather than waiting for hospital appointments.
Consultant hepatologist Dr Terry Wong and GP Dr Jay Patel shared the success of the new model in a recent NHS South East London 20:20 Innovation Webinar.
Why change was needed
Liver disease is rising rapidly. It’s now one of the leading causes of death in people aged 35 to 50.
In south east London, we see higher rates of alcohol-related liver disease and non-alcoholic fatty liver disease (NAFLD), as well as hepatitis B and C. The demand for care keeps growing, but traditional hospital-based services haven’t kept pace.
Many people with stable long-term liver conditions were waiting six months or more for follow-up appointments. That’s too long — and in many cases, unnecessary.
A new approach: from hospital to neighbourhood
In 2023, Guy’s and St Thomas’ Hospital and the North Lambeth Primary Care Network (PCN) launched a pilot. The goal: shift routine hepatology care into the community.
Here’s how it works:
- Patients with stable liver conditions are reviewed and, where appropriate, discharged from hospital follow-up
- They are then cared for in local MDTs (multi-disciplinary teams) based in GP practices
- GPs have direct access to support from hepatology consultants and access to a community-based FibroScan
What’s different about this model?
- Integrated care: GPs, consultants and clinical nurse specialists work together to plan care
- Neighbourhood working: one MDT meets every week at Pavilion Medical Centre, Brixton
- Prevention-first: people at risk of liver disease are identified and assessed earlier
- Paperless and digital: the whole pathway is built around EMIS, with no paper referrals
This new way of working has already made a big difference:
- Over 50% of stable hepatology patients have been safely moved into community care
- Waiting lists for hospital appointments are shorter
- More people are being screened for liver fibrosis using simple tests and scans in GP surgeries
- Around 90% of referrals to hospital can now be avoided, freeing up capacity for more urgent cases
This approach is scalable and effective. It’s a learning opportunity for primary care and helps us give faster, more appropriate care for our patients.
It is also important it to align this work with NHS policy — including the 10 Year Health Plan, which focuses on moving care closer to home, and shifting from treatment to prevention.
What’s next?
There are now plans to expand the service across Lambeth, with one MDT in each of the five neighbourhoods. The team hopes to:
- Support more GPs to manage liver care confidently
- Make better use of existing community FibroScan capacity
- Offer quicker advice and diagnosis for patients with abnormal liver tests
The pilot was funded by Guy’s and St Thomas’ Charity. Discussions are now underway with NHS South East London to explore sustainable commissioning options as the model grows.
Want to get involved?
If you’re a GP, practice manager or clinician in south east London interested in developing a local liver pathway, get in touch with the ICS team at communications@selondonics.nhs.uk.