Why should liver disease be a priority for public health?
Liver disease is a growing public health burden; premature mortality has risen, the condition is frequently identified late, and it disproportionately impacts people living in more deprived communities.
In England, the under-75 mortality rate from liver disease increased by 42% between 2001 and 2023, taking the number of annual premature deaths to 10,858¹
The 2025 Chief Medical Officer report on health trends and variation in England also concluded that premature mortality from liver disease has steadily risen, reflecting trends in alcohol consumption and obesity.²
Liver cancer adds to this burden. A UK-wide analysis of adults aged 35 to 69 found rising liver cancer incidence and mortality in both men and women between 1993 and 2018, despite substantial reductions in mortality from most other cancers.³
Why is liver disease often identified late?
Most types of liver disease do not cause symptoms during their early stages. People can therefore live with progressive liver damage without realising that anything is wrong.
This means patients may remain outside established liver pathways despite having risk factors or previous test results that warrant further assessment. They may only become visible to specialist services following the development of advanced fibrosis, cirrhosis, liver cancer or an acute hospital admission.
Late identification narrows the opportunity for preventative intervention. It can also create avoidable pressure on hepatology teams, diagnostic services, liver cancer surveillance pathways, emergency departments and inpatient care.
Current pathways frequently depend on symptoms, individual test results, coded diagnoses or referrals. These routes remain essential, but they fail to identify everyone who is developing liver disease, particularly when relevant information is distributed across years of routine clinical data and multiple care settings.
Why is liver disease a health inequalities issue?
The effects of liver disease are not evenly distributed.
Alcohol harm, obesity, metabolic risk and viral hepatitis are influenced by wider social and economic conditions. Communities experiencing greater deprivation also experience substantially worse liver disease outcomes.
In England, the premature mortality rate from alcohol-related liver disease was 4.6 times higher in the most deprived areas than in the least deprived areas. For mortality attributed to non-alcoholic liver disease, the difference was 6.4-fold.¹
Traditional identification routes can reinforce these inequalities when they depend on people recognising symptoms, attending routine appointments or already being known to a specialist service. Those at greatest risk may also be among the least likely to be identified through established pathways.
A population health approach must therefore look beyond patients who are already visible to liver services.
Why is earlier identification a public health opportunity?
Up to 90% of liver disease is associated with potentially preventable or treatable risk factors, principally alcohol, obesity and hepatitis B and C.⁴
Earlier identification can create opportunities for interventions such as:
- alcohol support and treatment
- lifestyle and weight-management services
- metabolic risk management
- hepatitis B and C testing and treatment
- non-invasive liver screening
- fibrosis assessment
- surveillance and specialist referral where appropriate
The appropriate intervention will depend on the person’s risk, clinical history and diagnostic results. Case-finding is not a diagnosis and should not replace clinical review. Its purpose is to identify people who may benefit from further assessment through a clinically governed pathway.
How can existing NHS data help anticipate population need?
The NHS already holds large volumes of routinely collected information, including blood-test results recorded over many years.
Viewed individually, a single test may provide limited insight. Viewed longitudinally, test results can reveal persistent abnormalities, changes over time or combinations of findings that may justify further clinical review.
Using this information for proactive case-finding can give health systems a clearer view of:
- how potential risk is distributed across the population
- which groups may be underserved by current pathways
- how many people may require further assessment
- where diagnostic demand may emerge
- how community and specialist capacity should be planned
This enables public health teams and NHS leaders to move beyond estimates of disease prevalence and towards the identification of specific cohorts who may benefit from an intervention.
How does hepatoSIGHT® support population-level case-finding?
hepatoSIGHT is a case-finding search engine that analyses historic NHS blood-test results to help clinical teams identify people who may be at risk of metabolic and chronic liver disease.
The system provides a longitudinal view of patient test results and enables clinicians to apply clinically defined and configurable criteria according to local priorities.
This can help health systems identify cohorts who may require further investigation and connect them with locally agreed pathways. Depending on the clinical objective, this could include repeat blood testing, viral hepatitis testing, non-invasive screening, transient elastography, digital lifestyle support or specialist review.
hepatoSIGHT supports the identification and prioritisation stage. Its impact depends on the clinical pathway around it, including governance, diagnostic capacity, follow-up and access to appropriate treatment.
Does proactive case-finding increase demand?
Proactive case-finding may create additional planned demand for assessment and diagnostic services in the short term. Public health and NHS leaders should acknowledge this and build it into pathway, workforce and capacity planning.
However, this is different from waiting for people to present later with advanced disease, complications or emergency care needs.
Earlier identification allows systems to manage demand more deliberately. It can help prioritise patients according to risk, direct people to the most appropriate setting and focus specialist capacity on those most likely to benefit.
NICE has similarly emphasised that expanding liver fibrosis assessment outside specialist care must be supported by clear pathways explaining what should happen following each result. It also notes that earlier testing may increase referrals while enabling more people who need specialist care to access it.⁵
The objective is to precisely identify the right patients earlier and ensure they enter an effective pathway that prevents advanced disease.
What should public health leaders consider?
A population-level liver disease strategy should address four connected questions:
What is the likely level of unmet need?
- How many people may be living with unidentified liver risk or disease within the local population?
Where are the inequalities?
- Which communities are least likely to be identified through existing pathways, and how does this align with local deprivation and risk-factor data?
What happens after identification?
- Which tests, interventions and referral routes will be available to people identified through case-finding?
Does the system have sufficient capacity?
- How should primary care, community diagnostics and specialist services work together to manage planned demand?
Health systems are likely to encounter many of these patients eventually. The public health opportunity is to identify them before avoidable disease progression, rather than waiting until they present with advanced liver disease, liver cancer or an emergency admission.
Using existing data more effectively can help health systems act sooner, target resources more precisely and build liver pathways around anticipated population need rather than late presentation.
References
- Office for Health Improvement and Disparities. Liver disease profile, December 2024 update.
- Department of Health and Social Care. Health trends and variation in England, 2025: a Chief Medical Officer report. See section 2.32, “Liver disease: premature mortality”.
- Shelton J, Zotow E, Smith L, et al. 25 year trends in cancer incidence and mortality among adults aged 35–69 years in the UK, 1993–2018. BMJ. 2024;384.
- Office for Health Improvement and Disparities. Liver disease profile.
- National Institute for Health and Care Excellence. FibroScan for assessing liver fibrosis and cirrhosis outside secondary and specialist care. HTG682.
