Health PolicyDisease burden and costs from excess alcohol consumption, obesity, and viral hepatitis: fourth report of the Lancet Standing Commission on Liver Disease in the UK
Introduction
This fourth report of the Lancet Commission1 on Liver Disease in the UK provides up-to-date evidence on the harm being done to the nation's health by excess alcohol consumption, obesity, and viral hepatitis and the continuing failure to introduce effective measures of control.2, 3 Lifestyle issues, as well as smoking, have a major part in exacerbating poor health with age and have been implicated in 30% of dementia cases.4 Public Health England's 2nd Atlas of Variation in NHS Diagnostic Services in England5 shows that the previous steady increase in overall life expectancy has stalled and that the gap between healthy and overall life expectancy is now 16·1 years for men and 19·0 years for women. With 10 million adults regularly drinking more than 14 units of alcohol each week—the upper limit of safe drinking for men set by the Chief Medical Officer6—the extent of the resulting morbidity and mortality is not surprising, particularly with the added effects of obesity and smoking, which frequently occur together with high alcohol consumption. The Atlas5 also describes the poor provision of health services, including deficiencies in provision of diagnostic tests for liver disease, in certain regions of the country, which occurs alongside poverty and social inequality.
An important initiative of the Commission in 2017 has been to bring together costs resulting from alcohol, obesity, and viral hepatitis infection and the escalation of health-care costs that is anticipated on the basis of current trends. In their report,7 the Foundation for Liver Research predict that the National Health Service (NHS) will incur £17 billion in costs related to alcohol misuse over the next 5 years. Failure to take action on adult obesity alone could result in an additional £1·9–2·0 billion in costs each year.
Briefly mentioned in this report, but of considerable relevance to the Commission's recommendations, are the sustainability and transformation plans (STPs) of NHS England and the development of accountable care systems. Only six of the 44 provisional STP sites have plans that mention liver disease specifically, although some do mention action on alcohol. How closely these new arrangements reflect Public Health England's best practice guidance8 will need careful examination.
Section snippets
Recommendation 1: improving expertise and facilities in primary care to strengthen detection of early disease and its treatment, and screening of high-risk patients in the community (metrics 1.1–1.5)
The Royal College of General Practitioners (RCGP) Research and Surveillance Centre has access to anonymised data from more than 2 million primary care clinical records.9 The figures for the past year are alarming: of 1 595 450 adult patients in the RCGP Research and Surveillance Centre database of primary care clinical records, only 421 785 (26·44%) had body-mass index (BMI) readings, 281 309 (17·63%) had records of alcohol consumption, and 48 880 (3·06%) had received an alcohol use disorders
Recommendation 2: establishment of acute liver services in district general hospitals linked with 30 regional specialist centres for more complex investigations and treatment, and increased provision of medical and nursing training in hepatology (metrics 2.1–2.6)
Follow-up metric data on provision of liver services in hospitals will not be available until the next survey of hospitals is done in 2018. Information is available in the STPs about possible hospital reconfigurations and how these will link to the recommended regional centres for specialist liver work and the operational delivery networks set up to deliver the anti-HCV drugs.
After a pilot study, the Royal College of Physicians officially launched its new exemplar liver accreditation
Recommendation 3: a national review of liver transplantation to ensure better access for patients and to increase capacity (metrics 3.1–3.5)
1003 liver transplantations were done in 2016 (children included), which is a substantial increase from previous years, although still fewer than the number of new registrants added to the waiting list (1169 new registrants added to the 600 pre-existing registrants, with 72 patients on the waiting list dying and 168 being removed because of sickness). Although 95–100% of patients survive elective transplantation, 5 year survival rates vary considerably between transplantation centres. The
Recommendation 4: specialist paediatric services and continuity of care in transition arrangements for children with liver disease reaching adult life (metrics 1.6 and 4.1–4.3)
Table 3 shows data on the number of children born with persistent conjugated jaundice lasting longer than 14 days (in babies born at term) or 21 days (in babies born preterm) who were referred to the three national paediatric liver units between 2012 and 2017. Most babies diagnosed with extrahepatic biliary atresia were referred before age 56 days, but the range was wide (0–242 days) and 56 children were seen after that time, too late for a benefit to be obtained from early surgery.15 This
Alcohol policy, consumption, and use disorders
In England, 595 131 adults with alcohol dependency are in need of specialist alcohol treatment. Of these, an estimated 173 399 have dependency of moderate severity and 107 979 have severe dependency. 57% of adults with alcohol dependency in 2014 wanted to reduce their alcohol consumption.17 According to the Adult Psychiatric Morbidity Survey in 2014,18 7·1 million (16·6%) adults in England were consuming alcohol at hazardous levels (>14 units per week) and a further 813 000 (1·9%) at harmful
Prevalence of child and adult obesity
New data have been added for each of the metrics in this section. Figures for the number of individuals with a BMI of 30 kg/m2 or greater in England, Wales, Scotland, and Northern Ireland— derived from the Health Survey for England35 and equivalent surveys in the other three countries36, 37, 38—show a trend of increasing prevalence of obesity in adults. The prevalence of obesity in the Welsh Health Survey was lower than the prevalence in the other surveys, which might reflect use of
Number of HCV-infected patients treated with direct-acting antiviral therapies
The effectiveness, ease of use, and overall safety of new direct-acting antiviral drugs against HCV infection have enabled progress to be made in the UK towards the goal of elimination of this infection and reduction of the associated burden of liver disease. NHS England data show that the 22 HCV operational delivery networks treated 9440 cases between April, 2016, and March, 2017,53 and plans are now in place to treat 12 500 cases in 2017–18. An interim analysis of sustained virological
Public health campaigns and patient representation
Ongoing health campaigns include the Children's Liver Disease Foundation Yellow Alert,59 which aims to highlight the signs and symptoms of neonatal liver disease to prompt early diagnosis. Over the past 5 years, 14 000 protocol packs have been distributed to health-care professionals, with an additional 35 000 being downloaded from the foundation's website. The British Liver Trust's Love Your Liver campaign60 comprises an easy to use screen for the three preventable lifestyle causes of liver
Scotland
Later this year, the Scottish Government will publish an update of its alcohol strategy to improve early identification of liver damage and to focus treatment services more effectively on those at greatest risk. A programme of research has been commissioned to establish the effect of implementing minimum unit pricing, subject to the decision of The Supreme Court. With about 80% of the estimated number of cases of HCV infection having been diagnosed, bringing the remaining cases to treatment
Conclusion
The further increase in disease burden from excess alcohol consumption, obesity, and viral hepatitis reported in this fourth annual report of the Lancet Commission1 on Liver Disease in the UK is unacceptable because so little is being done to avert it. All of the measures proposed by the Commission were carefully considered, in particular the minimum unit pricing and sugar levy, which would target people at most risk of serious disease and improve their chances of good quality of life. With the
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2022, Contemporary Clinical TrialsCitation Excerpt :Alcohol use problems, ranging from unhealthy alcohol use, i.e., drinking over the recommended safe limits, to alcohol use disorders (AUDs), are associated with serious medical conditions [1–3] and increased healthcare utilization and costs [4,5].