A new approach to end stage liver disease using the United Kingdom model. End stage liver disease is the final common pathway of chronic liver injury. It has a wide spectrum of liver function and therefore, can vary greatly in the clinical presentations of the affected patients. Clinical examination is the key to diagnosing end stage liver disease, although many of the complications are not recognised until it is advanced. Liver biopsy is often delayed because of the complications, which include haemorrhage, infection and bile leak, and it may not be possible to perform during life, in which case, the liver function may deteriorate during the delay. In recent years the United Kingdom has had a significant change in its model of service delivery, and this article highlights these developments and compares them to overseas models. This change in the model of service delivery ensures an increasing number of patients undergo liver biopsy while they are being assessed for transplant, and it is likely that this strategy will reduce the need for liver transplantation in the future. This article discusses the potential barriers to implementing a biopsy programme in many countries. The authors have proposed a strategy to deal with the current barriers in countries such as Malaysia.