NHS Wales Liver Toolkit

A Case Study

The bespoke NHS Wales Liver Toolkit, is an exclusive education programme for NHS Wales that was adopted across all Health Boards and is formally endorsed by the British Liver Trust.
The outcomes from this case study:
A world first
Wales is the only country that deliver assertive fibrosis testing of a population basis worldwide.
The only country to provide education and support package
In addition, Wales is the only country to provide a specific education and support package underpinning this strategy.
Adopted by every practice in Wales
There is no geographical variation in coverage (North, South, East and West), nor variation in Deprivation Index based on GP postcode.
Delivering to the Welsh Government’s ‘A Healthier Wales strategy’
Of those patients, 90% surveyed said that the apps help them with self-management of their condition.

Background to the project:

The Liver Disease Implementation Group’s (LDIG) purpose is to continue to raise awareness of liver disease and, wherever possible, prevent it. However, data suggested that advanced liver disease is usually recognised very late and deaths from liver disease continue to rise. Consequently, a major part of the LDIG strategy is early detection.

To ensure that those affected by liver disease have timely access to high quality pathways of care, irrespective of where they live, LDIG piloted an early detection programme in ABUHB which proved successful. This programme guided healthcare professionals to have a more assertive approach to the management of abnormal liver blood tests, recognising advanced disease (including cirrhosis) at a much earlier stage.

But this was a local initiative showing success on a small scale; LDIG needed a way to disseminate this initial success across the rest of NHS Wales. The bespoke NHS Wales Liver Toolkit was developed and implemented in partnership with ICST, featuring a nationally agreed Abnormal Liver Blood

Test Clinical Pathway, and a programme of education and support, today used by tens of thousands of healthcare professionals across Wales.

The journey of success

Fail to prepare, prepare to fail
The early stages of the implementation process ensures that the product is prepared for the new environment, and that the environment is prepared to receive this product.
Customising the innovation for the environment
Although ICST’s toolkits are ‘ready to go’ for a general audience, there is a process to optimise the innovation for the environment in which it is being implemented. For example in NHS Wales, the guideline needed to be adapted to include a new ‘reflex fibrosis risk assessment’ protocol that was being implemented in digital healthcare systems across the country.
Establishing the teams
Identification of those who would be involved in the development of the innovations (the innovation team), the team who would oversee the governance of the process and content (the governance team) and the team that would oversee the implementation of the innovation into the system (the implementation team).
Alignment and awareness campaign
As part of ICST’s implementation methodology, the active alignment of key stakeholders, or people with influence in the system, is key to ensure that there are no barriers to implementation. In doing so, ICST supported NHS Wales to run awareness campaigns prior to the launch of the NHS Wales Liver Toolkit.
Testing the toolkit
A representative sample of users were recruited to test the toolkit and make sure it was real-world compliant. The feedback from this process highlighted a few areas of improvement that we addressed before proceeding with the formal launch.

Ongoing implementation success

Continuous optimisation of the toolkit
Throughout the implementation, ICST monitors the uptake and engagement of the innovation, as well as survey data and feedback from the audience. The findings from this help inform further development work, ensuring that the innovations continue to be optimised for the audience. One such finding, suggested that users preferred to use the clinical guideline as a physical copy, because it made quick reference during a short consultation much easier than accessing a digital version, so ICST organised with a local professional printing company to print thousands of guidelines, and copies were posted to every GP practice across Wales.
Active implementation work
During active implementation, ICST leads the implementation team towards implementation success, monitoring a whole range of proven implementation factors (we call them Enablers), to ensure that the value is realised for this implementation project.

Barriers overcome

Making the complex simple
Typically, the algorithms for interpreting liver blood tests are extremely complicated, which might explain why there is a lot of anxiety in interpreting these tests.
ICST work with our partners to make the complex simple, ensuring that the guidelines are as applicable to practice as possible.
Quick reference guidelines
Feedback from healthcare professionals suggested that they preferred having a physical copy of the Abnormal Liver Blood Test Pathway, for quick reference during consultations.
ICST printed thousands of guidelines, and copies were posted to every GP practice across Wales.
Endorsed by BLT and RCGP
The NHS Wales Liver Toolkit was endorsed by the British Liver Trust and the Royal College of GPs, as an important initiative towards reducing the mortality rates of liver disease.
ICST work closely with stakeholders who have influence in the system, and can influence the successful implementation.

“The All Wales Liver Pathway manages to differentiate between low and high risk of liver disease, a lot more succinctly than we might do otherwise. This will present a great tool for us to reference against, and for us to be embedding to this improved care.”


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"ICST supports the broader aspiration of the LDIG (and indeed of “A Healthier Wales”) in terms of providing care closer to home and providing more care in community or primary care settings. This is initially envisaged as an “outreach” model from secondary care given the historic lack of priority afforded to liver disease within healthcare services, primary care especially”


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For more information, check out the Liver Toolkit product page.