Special thanks go to Katharine Caddick and Katie Ramos, whose leadership and commitment guided the project to completion.
A message from the editors
Foreword - Katharine Caddick
“It is my privilege to introduce this updated edition of Caring for People with Liver Disease: A Competence Framework for Nursing. Building on the strong foundations of earlier versions, this edition reflects the increasing complexity of hepatology and the growing demand for highly skilled nursing care across the UK.”
The rising burden of liver disease
Liver disease is the only major cause of death in the UK that continues to rise year on year. In 2023, over 12,300 people died from liver disease—more than 60% in working-age adults (45–64 years). Mortality has quadrupled over 50 years, disproportionately affecting deprived communities where stigma and limited healthcare access remain barriers to care. Liver cancer, particularly hepatocellular carcinoma (HCC), is the fastest-rising cause of cancer-related death, with over 6,200 diagnoses annually. Yet only 20% are detected early, making robust surveillance and early detection strategies critical. The NHS 10-Year Health Plan (Fit for the Future, 2025) calls for a shift from treatment to prevention, embedding care in communities and harnessing digital innovation to reduce inequalities. Liver disease must be a priority within this transformation. National developments
One significant step forward has been NHS England’s Community Liver Health Check programme, using mobile FibroScan units to screen high-risk groups. Findings show that 1 in 10 people screened have advanced liver disease requiring urgent follow-up. To align with the national goal of diagnosing 75% of cancers at stages I–II by 2028, liver services must embed equitable surveillance pathways within Community Diagnostic Centres, strengthen early detection, and reduce regional variation in outcomes. This requires integrated care models that bring together primary, specialist, and community services with social care and allied health professionals—ensuring wraparound support for patients at risk. Tackling inequality and stigma Health inequalities remain stark: liver disease mortality is five times higher in the most deprived areas. Nearly three-quarters of people with liver disease report experiencing stigma, with a third saying it prevented them from seeking care. The adoption of non-judgemental, person-centred terminology—such as “metabolic dysfunction-associated steatotic liver disease (MASLD)”—is an important step in reducing stigma and supporting more compassionate, inclusive care. Nurses are uniquely placed to lead this cultural shift. Professionalism, nursing identity, and evolving roles The Nursing and Midwifery Council (NMC) makes clear that professionalism is non-negotiable. It safeguards trust, equity, and quality of care, and must be visible at every level of practice. Hepatology services increasingly rely on Clinical Nurse Specialists, Advanced Practitioners, and Consultant Nurses, who now lead clinics, manage surveillance pathways, conduct complex assessments, and contribute to education and research. This framework is designed to strengthen these roles by embedding professionalism, leadership, and clinical competence. Liver transplantation: A life-saving intervention – Katie Ramos Liver transplantation has been a cornerstone of advanced hepatology since the first UK transplant in 1968 at Addenbrooke’s Hospital, Cambridge. Today, almost 1,000 transplants are performed annually across just seven UK centres. Outcomes continue to improve, with risk-adjusted survival rates of 93.5% at one year and 82.3% at five years (NHSBT, 2024). With over 12,000 liver recipients requiring lifelong specialist care, it is clear that this burden cannot be shouldered by transplant centres alone. Education and upskilling of nurses across the UK is essential to ensuring high-quality care regardless of proximity to specialist centres. This competency framework supports transplant nursing across the entire patient journey—from assessment and preparation to immediate post-operative care and long-term follow-up. Looking ahead: A future-ready framework This 4th edition arrives at a critical juncture. Hepatology is a rapidly evolving specialty, and the demands on services are growing. Nurses are at the forefront—identifying disease early, coordinating care, leading services, and shaping policy. As Florence Nightingale once wrote: “Rather ten times die in the surf, heralding the way to a new world, than stand idly on the shore.” This framework is more than a document. It is a call to action: to raise the profile of liver health, strengthen the workforce, and ensure that every patient receives care that is skilled, compassionate, and equitable. The fourth edition of the Competency Framework for Nurses in Liver Disease and Transplantation has been produced as the result of dedicated collaboration from hepatology nurses nationwide. Their insight, energy, and commitment have shaped a framework that is both clinically relevant and practically applicable. Gratitude is also extended to those who reviewed and refined the work, ensuring its accuracy and utility. To the nurses leading liver care across the UK—we salute you.
