Liver Disease: The NHS Atlas of Variation in Healthcare for People with Liver Disease








Liver Disease – a growing epidemic

Premature death from chronic liver disease is rising, largely as a result of lifestyle issues such as alcohol, drug-taking and obesity. There is significant local variation in these mortality rates, with deprivation a key factor.

During 1993-2010, there was an 88% rise in England in age-standardised mortality rate from chronic liver disease.

In 2011, the Department of Health estimated the cost of alcohol misuse to the NHS was £3.5bn. Over 24% of the population (33% of men, 16% of women) consume alcohol in a way that is potentially or actually harmful. In England, alcohol dependence affects 1m people aged 16-64 years. It is estimated that as few as 6% of these receive treatment.

Up to 10-20% of the population are potentially at some risk of developing some liver damage, while 600,000-700,000 individuals actually have a significant degree of damage.

Exposing variation

The NHS Atlas of Variation in Healthcare for People with Liver Disease uses data sets in the form of maps to reveal the extent of variations in services and outcomes.

This Atlas reveals widespread variation:

  • in the prevalence of risk factors for liver disease, including Hepatitis infection, obesity and alcohol abuse
  • in emergency admissions and routine treatments and operations
  • in the expenditure on liver disease services accross the NHS
“More than anything else, we hope that patients, service providers, commissioners, monitors of public health and others will use the maps to ask questions in their localities.  If questions lead to dialogue and a focus on data, information and outcomes, we may gain a better understanding of the reasons for variation. If we can achieve that, we may be closer to discovering what may need to be done to address any unwarranted variation.”

Professor Martin Lombard



We wholeheartedly welcome the NHS Atlas of Variation in Healthcare for People with Liver Disease.

We hear first-hand through our helplines and in forums and networks how variations in liver services affect patients across England:  there is variation in when and how people are diagnosed, the information they receive on diagnosis, access to treatments, the support they are offered, their experiences with doctors and nurses, in hospitals and during end-of-life care

Although we recognise that there will always be some warranted variation in service models, depending on the demographics and prevalence of liver disease in each locality, all patients need to receive the same high quality of care, access to expertise, procedures and treatments, and should be assured of the same outcomes irrespective of where they live in accordance with the NHS constitution which declares that the NHS should provide a comprehensive service available to all”  

The publication of the NHS Atlas of Variation for People with Liver Disease is a good start in providing area-specific comparative disease data to highlight where variation exists and where commissioners and providers need to focus attention to eliminate waste and increase value.  We look forward to working with the National Clinical Director for Liver Disease, the NHS Commissioning Board, Public Health England, clinical commissioning groups, local authorities and the Care Quality Commission to reduce unwarranted variation and improve the quality and outcomes of care.  Only then will people with liver disease have the knowledge they need to make truly informed choices.”

Catherine Arkley, Chief Executive, Children’s Liver Disease Foundation

Charles Gore, Chief Executive, The Hepatitis C Trust

Andrew Langford, Chief Executive, British Liver Trust

Maps matter…

Maps of variation in healthcare matter because they can help us to understand that different resources or solutions may be required in different areas but they also serve as a powerful orientation tool, comparator, and benchmark for where we stand amongst our peers.  They can help us to pinpoint areas where variation in outcomes may require a more detailed examination or a different solution.

The central message of the NHS Atlas of Variation in Healthcare is that it is possible to achieve better outcomes for patients. Although data may be open to more than one interpretation, the power of the Atlas lies not in the answers it provides but in the questions it raises. When looking at local data, clinicians, service providers and commissioners need to ask whether the outcomes they are achieving for patients are as good as those achieved by the best.

The Liver Disease Atlas has been prepared in partnership with:



In addition, over 24 other organisations contributed to the publication of this Atlas and 12 organisations provided case studies of good practice and innovations.