Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK

Summary

This final report of the Lancet Commission into liver disease in the UK stresses the continuing increase in burden of liver disease from excess alcohol consumption and obesity, with high levels of hospital admissions which are worsening in deprived areas. Only with comprehensive food and alcohol strategies based on fiscal and regulatory measures (including a minimum unit price for alcohol, the alcohol duty escalator, and an extension of the sugar levy on food content) can the disease burden be curtailed. Following introduction of minimum unit pricing in Scotland, alcohol sales fell by 3%, with the greatest effect on heavy drinkers of low-cost alcohol products. We also discuss the major contribution of obesity and alcohol to the ten most common cancers as well as measures outlined by the departing Chief Medical Officer to combat rising levels of obesity—the highest of any country in the west. Mortality of severely ill patients with liver disease in district general hospitals is unacceptably high, indicating the need to develop a masterplan for improving hospital care. We propose a plan based around specialist hospital centres that are linked to district general hospitals by operational delivery networks. This plan has received strong backing from the British Association for Study of the Liver and British Society of Gastroenterology, but is held up at NHS England. The value of so-called day-case care bundles to reduce high hospital readmission rates with greater care in the community is described, along with examples of locally derived schemes for the early detection of disease and, in particular, schemes to allow general practitioners to refer patients directly for elastography assessment. New funding arrangements for general practitioners will be required if these proposals are to be taken up more widely around the country. Understanding of the harm to health from lifestyle causes among the general population is low, with a poor knowledge of alcohol consumption and dietary guidelines. The Lancet Commission has serious doubts about whether the initiatives described in the Prevention Green Paper, with the onus placed on the individual based on the use of information technology and the latest in behavioural science, will be effective. We call for greater coordination between official and non-official bodies that have highlighted the unacceptable disease burden from liver disease in England in order to present a single, strong voice to the higher echelons of government.

Introduction

In 2018's report, we wrote optimistically of a gathering momentum to address liver disease in the UK, and to some extent this has continued. However, this final report of the Lancet Commission is mainly concerned with a series of ongoing failures in terms of the continuing harmful effects on health resulting from lifestyle causes. The broadcaster Adrian Chiles, who had learnt of the dangers of heavy drinking before it was too late for him personally, has been powerful in advocacy and was instrumental in the BBC Panorama programme in June, 2019, directed at the lobbying power of the drinks industry and its influence on UK Government policy. Sadly, the past 12 months have seen no progress in institution of the regulatory and fiscal measures that are the only proven way of controlling overall alcohol consumption. The government's published Prevention Green Paper, entitled “Advancing our health: prevention in the 2020s”,¹ while acknowledging the extraordinarily high numbers of people who are overweight or obese in the population, focuses mainly on tackling childhood obesity. Furthermore, for adults with obesity, the main funding commitment is for diabetes. The UK has the highest rate of obesity of any major nation in western Europe, and according to the latest report² by the Organisation for Economic Cooperation and Development, conditions fuelled by excess bodyweight soak up more than 8% of health expenditure in the UK, while cutting life expectancy by an average of 2·7 years.

National Health Service England (NHSE) has announced new funding for alcohol care teams in hospitals³ that have the highest levels of admissions due to alcohol dependency, but with one in five patients in UK hospitals consuming alcohol at a harmful level and one in ten alcohol dependent,¹ many more hospitals will need to be included in the scheme.

Provision of adequate care and facilities continues to lag behind the continuing rise in hospital admissions of severely ill patients with liver disease, and mortality figures can only be described as unacceptable. Further work in 2019 has gone into developing a hospital masterplan based on networks of district general hospitals linked to specialist liver centres. But, as indicated in this section of our report, the proposals are held up awaiting endorsement by NHSE. Screening for early liver disease with transient elastography by general practitioners is worthwhile for detection of previously undiagnosed cases of cirrhosis at a stage when treatment measures can be effective. However, severe cuts in community alcohol and addiction services, as a result of the reductions in public health spending, are likely to add to the difficulties.

A worrying new finding relates to the occurrence of neurocognitive impairment in infants and children with liver disease, raising issues over meaningful life outcomes. Also new to the Commission's work this year, and described in detail in this report, is a ComRes poll on public awareness of liver disease. The one encouraging event in recent months was a National Institute for Health Research broad call for research projects of a translational nature in liver disease, encompassing many of the recommendations made by the Commission.