Impact case study database

The iLFT approach provides a rapid, reliable means of identifying abnormal LFTs which require specialist follow-up, thus improving patient outcomes through timely intervention and NHS infrastructure through the exploitation and adaptation of existing clinical tools and processes. By identifying the highest priority patients it facilitates workload management in hepatology specialist services and builds the confidence of GPs in handling a previously complex and unwieldy diagnostic pathway. This has contributed to better diagnosis of liver disease, often at an early stage when lifestyle interventions are effective, with minimal workload implications for GPs and inconvenience to patients.

Benefits to patients and population health

In August 2018, NHS Tayside adopted iLFT as standard care accessible to all its GP practices. During its first year, iLFT generated >2000 diagnoses from 1824 samples with an abnormality in their initial LFTs [E1]. Compared with current real-world practice it did not increase overall GP workload; indeed, 21/23 GPs involved in the trial felt that iLFT reduced their workload. Since July 2020, NHS Tayside has performed Enhanced Liver Fibrosis testing, a further refinement of iLFT, on >500 patients; of these, 44% had a score which showed they could safely be managed in the community, thus reducing pressure on in-patient services [E2].

By testing all samples for viral hepatitis, iLFT made it possible to identify unsuspected carriers of hepatitis C and target them for treatment, preventing wider community transmission and contributing to the elimination of hepatitis C in Tayside by the end of 2019. Having become the first region in the world to effectively eradicate the virus, Tayside has already met the WHO target of eliminating hepatitis C as a public health threat by 2030 [E3].

National adoption in Scotland and the wider UK

Following the success of iLFT in Tayside the Scottish Access Collaborative (part of the Scottish Government’s Directorate for Health Performance and Delivery) recommended national roll-out [E4]. Implementation groups have been established in NHS Greater Glasgow and Clyde, Fife, Lothian and Lanarkshire; when roll-out is complete the service will be available to 1.6 million people. The Clinical Lead for the introduction of iLFTs in the Modern Patient Pathways Programme writes [E5]:

The introduction of iLFTs in Tayside resulted in the correct patients being seen by the correct staff, in the correct setting, at the correct time……The Scottish Government has adopted this as being an area where there is not only the potential for better patient management but also for significant financial benefit to the NHS.

The Lancet Commission for Liver Disease has recommended iLFT for implementation to reduce the burden of liver disease [E6] and it is now being adopted across the UK. North Cumbria Integrated Care NHS Foundation was the first to have a working system [E7] and iLFT is under consideration by the Wales Liver Disease Delivery Plan [E8].

Global recognition

In 2019 the Dillon team’s achievements in integrated clinical care were rewarded with the UNIVANTS Healthcare Excellence Award; this award recognises teams who collaborate across disciplines to transform healthcare delivery and patient lives, and involves a rigorous selection process conducted by seven leading international healthcare organizations including The International Federation of Clinical Chemistry and Laboratory Medicine [E9]. The iFLT has also won accolades for innovation from the British Society of Gastroenterology and the Royal Colleges of Physicians and Pathologists.

Benefit to GPs

One reason for the low follow-up rate for abnormal LFTs is that many GPs lack confidence in interpreting these findings and using them to inform referral decisions, partly because of the lack of a quantitative relationship between abnormal LFT findings and severity of disease: very high serum enzyme levels may resolve spontaneously whereas lower levels often persist and can lead to chronic liver disease. Referring everybody with an abnormal LFT is unnecessary and would overwhelm specialist hepatology services; by providing a rapid and reliable triage process, iLFT ensures that only those individuals requiring specialist services are referred.

Following roll-out of iLFT in Tayside, Dillon surveyed the views of 100 GPs, over a third of the workforce [E10]. The opinions expressed were overwhelmingly positive (Table 1).

Table 1: Outcomes of a survey of GP opinion on iLFT

The features most liked by respondents were the automatic calculation of fibrosis scores and information around referral criteria (80 respondents) and the reduction in number of consultations required before arriving at a diagnosis (77 respondents).

The benefits of iLFT to healthcare providers are succinctly summarized by North Cumbria Integrated Care NHS Foundation Trust [E7]:

The journey to date has been truly transformational, empowering primary care to have the confidence in managing low risk liver disease, expediting care for those with significant liver disease who truly need secondary care input and undoubtedly shortening the timescales in the assessment and management of liver disease across the health economy.