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A friendly DALiC (Deprived Area Liver Clinic)

Scotland = "Sick Man of Europe". Liver = "thermometer of Public Health". Liver death = > 4x in the most deprived 10 %. A friendly DALiC improves this through equity of access and health knowledge & awareness.

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  • Proposal
  • 2022

Meet the team


  • D&G Dieticians
  • D&G nurses with interest in liver disease
  • D&G addiction team
  • D&G third sector organisations (e.g. WeAreWithYou Scotland), navigators, people with lived experience, buddies

What is the challenge your project is going to address and how does it connect to the theme?

Liver mortality is high in Dumfries & Galloway, especially in remote severely deprived areas like Stranraer. Difficult access to liver, mental, and physical health leads to disadvantage and delayed diagnosis.  Patient’s trust, health awareness and knowledge are low.

This project sets up a friendly DALiC (Deprived Area Liver Clinic) in a very deprived area, improving access to liver knowledge and health awareness. A lead hepatologist will supervise and train staff, leveraging a digital approach, maximizing knowledge sharing and improving access.  Moving knowledge, not people we use video communication, improving GP confidence, competence, and access for patents:
– Virtual education for GP and nursing staff in rural areas using current, challenging cases in structured sessions discussing and teaching, networking and sharing experience and knowledge.
– Virtual drop in liver clinics using ‘NHS Near Me’ to improve access, whereby community-based professionals facilitate consultant access in a timely fashion for those patients who most need it.

What does your project aim to achieve?

We improve inequities, liver disease, addiction and unhealthy lifestyles. We increase health and liver awareness, giving access to world class care, helping people by:
– in-person / virtual drop in access to a liver specialist for people with advanced liver disease including prevention of progression, risk management, and treatment.
– Support of lifestyle change, social prescribing, linking with local health / social care workers using shared digital tools (eg: Drink Free Days app), diagnosing & preventing liver disease progression by lifestyle adjustments for patient at an early stage.

After successful test of change we will roll out supervision and setup among other “DeepEnd practices” through teaching & training further GPs, extended MDT and discussion of patients. Referrals to specialist liver clinics & centres will be improved. We will increase health awareness among the population. We aim to have one GP with an interest and formal training in liver disease in each practice.

How will the project be delivered?

The senior hepatologist & lead QI has interest, experience & did research in liver disease, public health & inequities. Qualitative research and QI projects taught us that people from deprived areas with liver problems want to improve their health, but services are designed not to suit them, and are not accessible. The team includes primary care and community professionals who understand liver disease, addiction and mental health problems. Using a person-centred approach targets, outcomes and measures will be agreed with patients.

Data and current networks will be used to identify high risk groups and “host” practices. We will train local people in these areas by virtual education and knowledge sharing sessions & facilitated case-study training sessions (ECHO style).

Advanced assessment and early detection of liver disease in people including mobile fibroscans and specialist consultant led clinics will be done with world class quality. Expertise will be spread to further hubs with GPs and community specialists.

How is your project going to share learning?

Teaching sessions using remote / virtual methods runs through the core of this project with the lead being trained in high level communication via videoconferencing.

Outcome measures include the competence and confidence of the primary care teams involved, and GPs will be encouraged to take part in hosting and facilitating as the spread plan unfolds across the region.
Using virtual means to connect conversations, we will create a culture of organic sharing among peers in the community.  This will be fortified through the projects dedicated website as well as Quality Improvement related conferences. All interventions and engagement with the team will be documented to compare with numbers prior to the intervention, hard outcome data (hospitalisation for liver disease, re-admission rates after initial hospitalisation, liver transplant referrals / transplants and death from liver disease. These will be openly published together with tests of change.

How you can contribute

  • Sense check of the idea - put liver specialists where the need is rather than in "ivory towers"; moving knowledge not patients.
  • Community support for the multidisciplinary team from other addiction, psychiatric primary care teams with an interest in liver health.
  • Any ideas for engaging difficult people who don't usually engage with healthcare services is very much appreciated (overcoming the barriers of using technology).

Plan timeline

1 May 2022 Discussion with large practice(s) in most deprived decile area.
15 May 2022 contact with 3rd sector organisation for support (improvement of attendance)
15 May 2022 contact with persons with lived experience for co-creation of service
15 May 2022 job descriptions / advertisement for secondments to team
15 May 2022 training of link GP(s) in deprived practice
1 Aug 2022 Start of seconded nurses to support the team


  1. Hi Mathis and team

    It sounds like a great and much needed idea. I was wondering how it applies explicitly to the theme of Q Exchange 'Bringing together the worlds and methods of improvement and digital, to enable better outcomes and faster, more sustainable change.'?

    Digital innovations that enable more care at home can be transformative for people with long term health conditions, and much more proactive work is needed to ensure they don't widen inequalities by excluding people who experience digital exclusion. I think considering how this could be a focus of your work could strengthen the idea. There is idea and inspiration on the NHS Digital Playbooks Other members are also sharing their learning in the current Q Lab project and this online group

    In terms of tips for engaging people who are often under-represented or don't engage with healthcare services, there is some useful learning from previous Q Exchange-funded projects in this insight briefing, which may provide some useful inspiration for you

    Best of luck with developing the idea!


    1. Thanks Jo for your kind words and links which I had a look at (some again). To have digital as a main focus and this to work I feel that it will need to be very much patient driven and I think I need to run this past one of our people with lived experience. I can imagine that something like a "virtual ward" could work giving the people signing up to this could feel that somebody (who they also have personal contact with and is available through other means) is looking after them and can check on them. What do you think? Would you be happy to have a chat about ideas?

      Thank you very much again, kind regards,

  2. Hello Mathis. This seems a very worthwhile proposal, and combines improving access, offering training, and utilising equipment not usually available locally. The buddy system seems to have much to commend it.  I like the co-production with people with lived experience, and assume that they will also be part of the evaluation of the service.   All the best with developing this idea.

    1. Thanks Helen for your kind words. Yes, we will have people with lived experience help evaluate the service (and I am sure they will want to be involved). This is for qualitative aspects of the service. However, I am hopeful that after some time we will also be able to also see an improvement in hard endpoints including earlier detection of liver disease and narrowing the gap in liver mortality between the most deprived people and the rest of the population with regards to liver disease.

  3. Hi Mathis,  I like the different approaches the project proposes to use, especially the combination of training for staff and increasing health awareness in hard to reach groups.

    It would be great if you could elaborate bit more on how expertise from the digital and improvement worlds will come together for sustainable change through this project.

    1. Thanks Beth,
      This is probably the toughest question so far despite the fact that I am very comfortable in both quality improvement and digital worlds. The reason is probably because (in my experience so far with practices in deprived areas) any change / offer / attention is already a significant improvement because liver disease has been / is? often regarded as complicated and an ivory tower specialty? Also, the patients are not really early adopters of digital technology (many of my patients often can't make sure that their phone is charged) and during the pandemic suffered significantly from the lack of human connections...

      Re: digital: from a related Quality Improvement project (see ALFA nurses project) we have experience in working with and analysing routinely collected hospital data with regards to admissions, re-admissions and their hospital coding - going back some years from a Scotland wide research study). We will use similar searches to monitor outcome (see comment below on Dimple's question).
      Another digital idea (almost no brainer) will be to have a database of all liver patients in the deprived area. With the Covid-19 pandemic and the necessity to be able to identify people at risk virtually over night we have learnt of the importance of databases anyway. This will allow a detailed picture of the types / prevalences in liver disease in the area.
      Examples of digital in teaching: I have (this week for the first time) used a digital whiteboard in GP education and I will improve my technology and skill to use this more effectively. Another one is a regular educational e-mail including external links for useful free education material and uploaded talks to the teams managing the people on a daily basis.
      Examples of digital in patient engagement: In our work with these people we have found that the main thing will be to use whatever platform it is they are used to on an individual basis. At the moment for example we find that using WhatsApp works best for communication because many of our patients, even when there is no credit on a phone know where free wifi hotspots are to use. Even if the patients don't reply, the teams sees at least whether they are alive (two ticks when the message was seen).
      We will continue to reflect / improve / refine our approach using digital means as much as possible. Any other digital ideas are very welcome.

  4. What an innovative idea which truly aims to look at equity of access/support for people. The IQILS (improving quality in liver services) accreditation programme has a standard related to upskilling and providing training for people who are involved in liver care.

    It would be good to understand what your evaluation/success measures may be.

    I'd be happy to help raise awareness of this initiative!

    1. Thanks Dimple,

      Yes, I am very aware of and involved in IQLS, for several reasons the driver for accepting the standards because of commissioning does not work here in Scotland (but as specialty advisor for the Scottish CMO (liver) I relentlessly try to get these accepted and rolled out).

      Evaluation for success will be in different ways:
      - GP confidence / knowledge about liver disease
      - development of and adherence to a pathway for liver referrals
      - appropriate referrals from GPs to the liver clinic (all cirrhotics should be referred).
      - percentage of patients with known liver disease engaging in the service
      - longer term outcome: earlier referral (at present a large proportion of patients with liver disease do not get referred to see a liver specialist before their death from liver disease or get referred in the last year of their life when it is often too late). Equity in access to referral for liver transplant and liver cancer treatment. Mortality from liver disease of the people in the very deprived area (narrowing the gap in mortality between the most deprived people and the least deprived people which is currently more than 4 times as high, higher than in any other disease I am aware of).

  5. This is a great idea. As a GP having worked in various socioeconomic areas assessing abnormal LFTs can be a challenge and knowing when to or not refer. Making expert advice more assessable to these patients (who may miss secondary care appointments) seems like a good idea.

    1. Thanks Kirsten,

      Yes, Thanks for your comment. I have already started spreading knowledge and expertise throughout the catchment area of the hospital. The idea of this is providing a much closer link with individual case discussions of patients to upskill all GPs in the deprived area(s) to become GPs with an interest in liver disease (of which there are per population many fewer than in England / Wales).

    2. Thanks Kirsten,

      You are right, abnormal liver biochemistry can be difficult to interpret (I don't like the word LFTs because most of the tests don't have anything to do with function and some tests reflecting function are not routinely part of liver blood tests). The liver is just a bit more complex than other organs. To prevent missing appointments I hope to engage with patients with lived experience / charities to have a buddy system to get them to attend (see also my ALFA nurses idea). Any other ideas from your experience? Thank you very much again, kind regards,


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