Addressing liver disease in the UK: A blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis

Abstract

Liver disease in the UK stands out as the one glaring exception to the vast improvements made during the past 30 years in health and life expectancy for chronic disorders such as stroke, heart disease, and many cancers. Mortality rates have increased 400% since 1970, and in people younger than 65 years have risen by almost fi ve-times. Liver disease constitutes the third commonest cause of premature death in the UK and the rate of increase of liver disease is substantially higher in the UK than other countries in western Europe. More than 1 million admissions to hospital per year are the result of alcohol-related disorders, and both the number of admissions and the increase in mortality closely parallel the rise in alcohol consumption in the UK during the past three decades. The new epidemic of obesity is equally preventable. Of the 25% of the population now categorised as obese, most will have non-alcoholic fatty liver disease many (up to 1 in 20 of the UK population) will have ongoing infl ammation and scarring that fi nally leads to cirrhosis. Of those patients with cirrhosis, 5-10% will get liver cancer. This increasing burden of liver disease is added to by chronic viral hepatitis; annual deaths from hepatitis C have almost quadrupled since 1996 and about 75% of people infected are estimated to be still unrecognised. The same applies to chronic hepatitis B infection, in which progression to cirrhosis and liver cancer also happens. The number of silently infected individuals in the UK is increasing every year as a result of immigration from countries with a high prevalence of hepatitis B and hepatitis C infections. Costs to the UK's National Health Service are equally staggering, with estimates of £3.5 billion per year for alcohol-related health problems and £5.5 billion per year for the consequences of obesity. Obesity costs are almost certainly an underestimate now that the disorder is recognised as an important factor in several common cancers, including breast cancer and colon cancer.1 Obesity is a factor in metabolic disorders-the basis of diabetes, hypertension, cardiac diseases, and strokes. Furthermore, the poorest and most susceptible in society have the highest incidence of liver disorders, making liver disease a major issue for health inequalities. Of particular concern is the 2013 National Confi dential Enquiry into Patient Outcome and Death (NCEPOD) report,2 which showed that the care of patients acutely sick with liver disease dying in hospital was judged to be good in less than half of patients; other unacceptable fi ndings were the inadequate facilities and lack of expertise of those caring for patients. Also, it is increasingly evident that defi ciencies exist in primary care, which has crucial opportunities for early diagnosis and prevention of progressive disease. The aim of this Commission is to provide the strongest evidence base through involvement of experts from a wide cross-section of disciplines, making fi rm recommendations to reduce the unacceptable premature mortality and dsease burden from avoidable causes and to improve the standard of care for patients with liver disease in hospital. From the substantial number of recommendations given in our Commission, we selected those that will have the greatest eff ect and that need urgent implementation. Although the recommendations are based mostly on data from England, they have wider application to the UK as a whole, and are in accord with the present strategy for health-care policy by the Scottish Health Boards, the Health Department of Wales, and the Department of Health and Social Services in Northern Ireland. Our ten key recommendations are based on the strong evidence base and are in line with reports in 2014 of several other enquiries, including from the 2014 All Party Parliamentary Group on Hepatology3 and the All Party Parliamentary Group on alochol misuse. Results showing the value of a minimum unit price policy in targeting heavy drinkers were published in The Lancet in May, 2014, and the European Observatory on Health Polcy, together with the Department of Health and NHS England, has drawn attention to four areas of premature mortality, including liver disease, in which the UK lags behind other European countries. Such stark contrasts with our European neighbours are unacceptable and in this Commission we give clear, evidence-based policy proposals for the UK Government to use in closing the gap in liver disease.