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Introduction Hepatocellular carcinoma (HCC) incidence is rising, yet early detection remains low. National Institute of Clinical Excellence recommends six-monthly ultrasound and alpha-fetoprotein (AFP) testing for high-risk patients. Patient engagement is key, as missed appointments waste resources and raise costs. This project explored patient and organisational factors limiting engagement with HCC surveillance in a district general hospital.Method Patients enrolled in a nurse-led HCC surveillance programme between January 2023 and December 2024 were included. Based on attendance at ultrasound, clinic, or blood test appointments, they were categorised as regular attenders (RA), or those who missed one (M1), two (M2), or three or more (M3) appointments. M2, M3 were termed frequent non-attenders (FNA). Ten patients from each category were interviewed in person or by telephone using a structured questionnaire. Data collected included demographics, occupation, social support, liver disease understanding, reasons for non-attendance, and suggestions for service improvement.Results Forty patients were interviewed, median age of 65.7 years, 24 (60%) male and 29 (72.5%) White British.Nineteen (47%) had metabolic dysfunction associated steatotic liver disease (MASLD) and nine (22%) had alcohol related liver disease (ArLD). In M3, five (50%) had viral hepatitis and in RA, three (30%) had autoimmune liver disease.Amongst 20 FNA, 9 (45%) engaged in manual or unstable work and 7 (35%) were unemployed/health-related absences. Whereas in RA (10), 9 (90%) were retired or in secure jobs. In FNA group (20), 5 (25%) lived alone or in supported accommodation, 1 (5%) had no fixed address, 13(65%) lived with family.Out of the forty patients interviewed, 18 (45%) identified early cancer detection as the reason for surveillance. Out of 30 non-attenders (M1,2,3), 11 (36.6%) reported poor understanding of liver disease, management, or purpose of surveillance as a key barrier. In RA, 10 (100%) reported liver disease understanding with only three (10%) non-attenders (M1,2,3) being unaware. Additional factors for non-attendance were comorbidities (9, 30%), mental health disorders (7, 23%), fear or avoidance (5, 17%), administrative errors (5, 17%) and transport issues (4, 13%). Patients suggested administrative improvements (7, 23.3%), timely letters, digital reminders, flexible scheduling and clearer communication (4, 13.3%) to enhance the service.Of the total study cohort, 24 patients (60%) were highly satisfied with the service, often citing direct phone access to the surveillance team as especially helpful.Conclusion Reasons for non-attendance in HCC surveillance is multifactorial. Enhancing patient education, communication, and individualised patient-centred support may improve engagement.