Liver disease management as routine work in primary care: a qualitative interview study to guide implementation

Theme 1: Organisational barriers to care

Participants acknowledged that the two commonest causes of liver disease (ARLD and NAFLD) were ‘chronic’ in the sense that they required long-term management rather than acute treatment. Knowledge of the common preventable risk factors for liver disease was high. Despite this, the majority of participants shared the view that liver disease was not currently managed in the same standardised way as other long-term conditions within primary care. Reasons for this difference in approach to care for people at risk of liver disease were cited as primarily related to the organisational context and drivers of care, rather than individual clinical sense making.

To be considered a chronic disease in the primary care management context, it was felt that liver disease needed to be subject to protocols, with clear templates and guidelines. The primary care role was seen as being to implement and operationalise expertise brought together by others in clear guidelines, rather than to act independently to make clinical decisions outside of these protocols: ‘The difficulty that I certainly find is that I never know — there’s not a clear protocol. If you think like with diabetes you know what you have to achieve. You know what you’ve got to aim for your blood pressure, you know what your HbA1c should be, you know what urine sample should be, you know what the cholesterol should be, so there’s very clear guidelines. With livers I think there’s difficulty knowing when it’s considered abnormal enough for investigation, what you then do with the results. When do you refer for a fibro scan, when is a fibro scan result important enough to need — it’s a very woolly area which I think if it was clear guidelines that told you, ‘’This is when you do x, y, and z.’’ Again, I think it could fall into more of a streamlined chronic disease model.’(GP4, GP partner 18 years, cancer lead, list size = 9600 mixed/semi-urban)

The absence of QoF incentives for liver disease was highlighted. Participants pointed to the importance of systemic and IT changes that accompanied QoF, rather than financial incentives. These triggered processes for a comprehensive structured approach to management, and provided a prompt to remind them to take action in a given area: ‘I think QoF is useful for concentrating the mind. I think it’s never been a major driver in our practice. However, because the computer systems alerts and clever searches are often driven by QoF, I think things being on QoF benefit. So, for example, in diabetes when recording microalbuminurea came off QoF the figures dropped from 80% to 60% and I don’t think that’s anyone deliberately saying, ‘’Oh we’re not getting paid for this now so we’re not going to do it.’’ It’s about there weren’t alerts on the computers and everything else.’(GP5, GP partner 35 years, diabetes lead, list size = 9500 deprived/urban)

Theme 2: Liver disease as part of multimorbidity

Some participants felt that liver disease was too complex to fit into a more structured clinical management approach. This perception arose in part from the custom of considering all liver disease as a diagnostic conundrum based on abnormal liver blood tests. When liver disease was framed in this context, participants were unable to see the relevance of other protocolised long-term condition care. As a result, active management of liver disease was more likely to be neglected: ‘I think often a diagnosis as such of the liver disease is not made. So we get abnormal liver function tests for example and the response to that will quite often be simply to repeat the liver function tests after three months and then after six months and some people seem to get that continually and you look sort of two years down the line and they might not have had a liver screen done, so yeah I think it perhaps isn’t as well managed as some of the other conditions both in terms of the diagnosis but — and the response is often to repeat the blood tests rather than to necessarily get the patient in and ask about alcohol, lifestyle, check a BMI [body mass index] and those sorts of things.’(GP11, salaried GP 7 years, list size = 4000 mixed/rural)

Where participants considered the common lifestyle-related chronic liver diseases (NAFLD and ARLD) as separate from the other rare liver diseases, it was easier for them to see the sense in a more integrated, structured proactive approach. NAFLD and ARLD shared common risk factors with long-term conditions already being managed in primary care. This was seen as key by the majority of participants.

On a practical level it made sense to participants for liver disease to sit alongside other chronic diseases and be considered as part of multiple long-term condition care. Emphasising the impact that lifestyle advice could have on the liver, as well as other conditions, was perceived as helpful: ‘I think it’s almost easier in a way because you say there’s too much fat in your liver and I think people have a visual — can see that, can think what does that look like more easily than what does diabetes mean? Or what does high blood pressure mean? I think that’s a really strong image for patients and they can see they’re too fat and then there’s fat in their liver …’(GP7, salaried GP 6 years, list size = 10000 mixed/semi-urban)

When participants considered embedding liver disease within existing structures for managing multimorbidity, they claimed that this would help to contain the workload. This was crucial when considering taking on new pathways of care: ‘No, I think it would be quite easily encompassed in the screening because obviously we’re doing bloods anyway so potentially we’ll be looking at adding in a couple more bloods and obviously we’d be looking at patient’s BMI and other sort of risk factors so I don’t think potentially it would make a huge difference in the workload …’(Nurse [N]3, practice nurse 6 years, list size = 3500 mixed/rural)

Theme 3: Seeing value by professional role

The perceived value of identifying and managing liver disease seemed to relate to professional role. Nurses’ positive approach to prevention and lifestyle interventions as treatment contrasted with the views expressed by some of the GPs. Doctors were more likely to link the value of liver disease management to the expectation of more ‘medical’ treatment. This tension led to some GPs struggling to identify their role within liver disease management and assuming, incorrectly, that other team members would not see beyond traditional doctor/patient expectations of a ‘treatment’: ‘I guess the reason is because I don’t perceive an active treatment or benefit from monitoring. You know, they come back, and their ALT [alanine transaminase] is a bit worse next year. What am I going to do? Speak to them again and say, ‘’You didn’t really try hard enough with your diet? Are you still eating too much sugar?’’ or ‘’I think you’re lying to me about alcohol.’’ I don’t know. Awkward, awkward conversations’.(GP2, GP partner, 21 years list size = 11500 mixed/urban)

In contrast, the nurse participants felt that a liver pathway in chronic disease management would fit well into their current ways of working. They saw this as an extension of their established roles and expressed a willingness to be involved: ‘I think if you can explain the fatty liver as a disease and what’s causing it and why they need to change their lifestyle they’re much more likely to engage with that. In a similar way to high blood pressure and diabetes, if you can really explain the relationships between these things and potentially they then see the results, so it’s actually really satisfying for people if they can actually reduce their BMI and their liver function gets better for example or their HbA1c comes down, they can actually see that effort paying off …’(N3, practice nurse 6 years, list size = 3500 mixed/rural)

Theme 4: Facilitators of change in liver disease care

Education, legitimisation, and a local champion were seen as key facilitators to changing liver disease care in the community. Education gave practitioners confidence and allowed them to see the value of the intervention. This was noted as particularly important for the nurse participants to have effective and informed discussions with patients, despite not having been prioritised in any practice nursing curricula: ‘We talk about alcohol and diet and things like that and it would be good to have some information to talk about liver disease for these certain patients so we can prevent things like that at first point instead of managing the condition later but no, we definitely don’t really talk about anything like that to be honest. I’ve seen it on patients’ notes but not been trained on it or anything. No.’(Healthcare assistant [HCA]1, healthcare assistant 6 years, list size = 5000 mixed/urban)

Prioritisation of a condition for inclusion in the QoF legitimised its importance and the need to change practice in that area. Participants gave this more weight than local pathways, as there was a perception that decisions made at national level had been through rigorous processes with more robust clinical reasoning from central decision makers. Such legitimisation was felt to be crucial to developing a common understanding among the whole practice team: ‘Well, I think the whole point of it is its quality isn’t it? It’s not just the payment for it, it’s also that it’s seen at a national level that it’s important enough to go onto QoF. I think also in terms of getting practice managers engaged in the process as well and having it more as a wider team. I think if you were going to put this down as a diagnosis you’d want to retrospectively perhaps look at your patients to make sure you had everybody who had fatty liver disease on the register. It’s far easier to do that if you’ve got the practice management team on board and QoF definitely helps with that …’(GP11, salaried GP 7 years, list size = 4000 mixed/rural)

Participants stated that the importance they would attach to making liver disease a priority would also be enhanced by local colleagues within commissioning and secondary care. Someone championing change in an area of practice could make a lasting difference, and if this came from an ‘expert’ that was further evidence of the value of change: ‘I think something like this which is probably quite a large-scale change in how we do things, I think probably we’d need somebody dedicated from the secondary care like gastroenterology setting who would actually perhaps work with some GPs who are particularly interested in the subject and develop a protocol between primary and secondary care that could be sent out to practices and adopted from there.’(GP4, GP partner 18 years, cancer lead, list size = 9600 mixed/semi-urban)

Interpreting the findings using NPT

Although the themes were not constrained by NPT, as this action-based theory of implementation was used to guide the study process, in a second analysis step the themes were interpreted with reference to NPT. Table 2 summarises the themes presented and how primarily the first two constructs of NPT, coherence, and cognitive participation, can be used to help interpret these themes and provide a focus towards the work that individuals and organisations would need to do to enable chronic liver disease management to become a normalised part of long-term condition care.