The Lancet Commissions 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 Roger Williams, Richard Aspinall, Mark Bellis, Ginette Camps-Walsh, Matthew Cramp, Anil Dhawan, James Ferguson, Dan Forton, Graham Foster, Sir Ian Gilmore, Matthew Hickman, Mark Hudson, Deirdre Kelly, Andrew Langford, Martin Lombard, Louise Longworth, Natasha Martin, Kieran Moriarty, Philip Newsome, John O’Grady, Rachel Pryke, Harry Rutter, Stephen Ryder, Nick Sheron, Tom Smith Executive summary increasing every year as a result of immigration from Lancet 2014; 384: 1953–97 Liver disease in the UK stands out as the one glaring countries with a high prevalence of hepatitis B and Published Online exception to the vast improvements made during the hepatitis C infections. November 27, 2014 past 30 years in health and life expectancy for chronic Costs to the UK’s National Health Service are equally http://dx.doi.org/10.1016/ S0140-6736(14)61838-9 disorders such as stroke, heart disease, and many staggering, with estimates of £3·5 billion per year for For The Lancet Liver Commission cancers. Mortality rates have increased 400% since 1970, alcohol-related health problems and £5·5 billion per infographic see http://www. and in people younger than 65 years have risen by year for the consequences of obesity. Obesity costs are thelancet.com/commissions/ almost fi ve-times. Liver disease constitutes the third almost certainly an underestimate now that the disorder crisis-of-liver-disease-in-the-UK commonest cause of premature death in the UK and the is recognised as an important factor in several common Foundation for Liver Research, 1 London, UK rate of increase of liver disease is substantially higher in cancers, including breast cancer and colon cancer. (Prof R Williams MD); Queen the UK than other countries in western Europe. More Obesity is a factor in metabolic disorders—the basis of Alexandra Hospital, than 1 million admissions to hospital per year are the diabetes, hypertension, cardiac diseases, and strokes. Portsmouth, UK result of alcohol-related disorders, and both the number Furthermore, the poorest and most susceptible in society (R Aspinall MBChB); College of of admissions and the increase in mortality closely have the highest incidence of liver disorders, making Health and Behavioural Sciences, Bangor University, UK parallel the rise in alcohol consumption in the UK liver disease a major issue for health inequalities. (Prof M Bellis DSc); Medical during the past three decades. The new epidemic of Of particular concern is the 2013 National Confi dential Marketing Consultants, Oxford, obesity is equally preventable. Of the 25% of the Enquiry into Patient Outcome and Death (NCEPOD) UK (G Camps-Walsh DMS); population now categorised as obese, most will have report,2 which showed that the care of patients acutely Plymouth Hospitals NHS Trust, Plymouth, UK non-alcoholic fatty liver disease many (up to 1 in 20 of sick with liver disease dying in hospital was judged to be (Prof M Cramp MD); Plymouth the UK population) will have ongoing infl ammation and good in less than half of patients; other unacceptable University Peninsula Schools of scarring that fi nally leads to cirrhosis. Of those patients fi ndings were the inadequate facilities and lack of Medicine and Dentistry, with cirrhosis, 5–10% will get liver cancer. This expertise of those caring for patients. Also, it is Plymouth, UK (Prof M Cramp); King’s College Hospital, increasing burden of liver disease is added to by chronic increasingly evident that defi ciencies exist in primary London, UK (Prof A Dhawan MD, viral hepatitis; annual deaths from hepatitis C have care, which has crucial opportunities for early diagnosis Prof J O’Grady MD); Queen almost quadrupled since 1996 and about 75% of people and prevention of progressive disease. Elizabeth Hospital, infected are estimated to be still unrecognised. The The aim of this Commission is to provide the strongest Birmingham, UK (J Ferguson MD); St George’s same applies to chronic hepatitis B infection, in which evidence base through involvement of experts from a wide Hospital, London, UK progression to cirrhosis and liver cancer also happens. cross-section of disciplines, making fi rm recommendations (D Forton PhD); Queen Mary’s The number of silently infected individuals in the UK is to reduce the unacceptable premature mortality and University, London, UK www.thelancet.com Vol 384 November 29, 2014 1953 The Lancet Commissions Introduction Key messages: Ten key recommendations This Commission was set up after the meeting (Addressing 1 Strengthen detection of early liver disease and its treatment by improving the level of the Crisis in Liver Disease in the UK: alcohol, viral hepatitis expertise and facilities in primary care and obesity) by the Foundation for Liver Research to 2 Improve support services in the community setting for screening of high-risk patients highlight the serious situation emerging with respect to 3 Establish liver units in district general hospitals to be linked with 30 specialist centres liver disease in the UK. Held on July 15, 2013, the meeting regionally distributed, for availability of highly specialised investigations and was timely because it was a few weeks after the report treatment Hospital Deaths from Alcohol-related Disease was released 4 A national review of liver transplantation services to ensure better access for patients by the National Confi dential Enquiry into Patient in specifi c areas of the country; provide suffi cient capacity for the anticipated increase Outcome and Death (NCEPOD) containing alarming in availabilty of donor organs statistics, including care being rated as less than good for 5 Strengthen continuity of care in transition arrangements for the increasing number of more than half of patients with liver disease. UK children with liver disease surviving into adult life Government ministers had also announced in July, 2013, 6 Implement a minimum price per unit, health warnings on alcohol packaging, and that they were not proceeding with the minimum unit restriction of alcohol advertising and alcohol sales price proposal for targeting heavy drinkers, which was 7 Promotion of healthy lifestyles to reduce obesity in the country and its results on the cornerstone of their previously published alcohol health; governmental regulations to reduce sugar content in food and drink; use of strategy to bring down levels of overall alcohol new diagnostic pathways to identify people with non-alcoholic fatty liver disease consumption in the country. However, the present 8 Eradication of infections from chronic hepatitis C virus in the UK by 2030 using Secretary of State for Health, Jeremy Hunt, had antiviral drugs; reduce the burden of hepatitis B virus; target high-risk groups for these announced a campaign to reduce levels of premature viruses, including immigrant communities; use of a universal six-in-one vaccination mortality in the country, of which liver disease was listed for infants for hepatitis B third of the so-called Big Five causes 9 Increase provision of medical and nursing training in hepatology and wider In his mandate to the Commission, Richard Horton, educational opportunities for health-care professionals to increase the number of editor of The Lancet, stressed the need for the doctors and nurses in hospitals and primary care recommendations to be evidence-based and scientifi cally 10 Increase awareness of liver disease in the general population with a national campaign focused. He suggested the inclusion of experts from led by National Health Service (NHS) England; clinical commissioning groups increase a wide cross-section of disciplines and said that awareness in area health teams economic considerations were crucial bearing in mind the fi nancial pressures on the UK’s National Health Service (NHS). (Prof G Foster FRCP); University disease burden from avoidable causes and to improve the Our Commission describes the extent of the problem of Liverpool, Liverpool, UK standard of care for patients with liver disease in hospital. of liver disease in terms of mortality rates, numbers of (Prof Sir I Gilmore MD); From the substantial number of recommendations given hospital admissions, the present defi ciencies both in University of Bristol, Bristol, UK (Prof M Hickman PhD, in our Commission, we selected those that will have the hospital and primary care settings, and the association N Martin DPhil); Freeman greatest eff ect and that need urgent implementation. between the burden of liver disease and social Hospital, Newcastle, UK Although the recommendations are based mostly on data deprivation in the UK. We provide a blueprint for (M Hudson FRCP); Birmingham Children’s Hospital, from England, they have wider application to the UK as a improving hospital care, with accreditation at Birmingham, UK whole, and are in accord with the present strategy for two levels—acute district general hospital liver units (Prof D Kelly MD); British Liver health-care policy by the Scottish Health Boards, the providing 7-day acute services for emergency care and Trust, Ringwood, UK Health Department of Wales, and the Department of regional specialist centres—that would be responsible (A Langford PhD); Royal Liverpool and Broadgreen Health and Social Services in Northern Ireland. for more specialised investigations and care including University Hospitals NHS Trust, Our ten key recommendations are based on the strong liver transplantation. Liverpool, UK evidence base and are in line with reports in 2014 of We report about the rapidly rising levels of obesity in the (Prof M Lombard MD); Brunel several other enquiries, including from the 2014 All country, and the results in terms of non-alcoholic fatty liver University, Uxbridge, UK 3 (L Longworth PhD); Royal Bolton Party Parliamentary Group on Hepatology and the All disease and the continuing high burden of alcoholic liver Hospital, Bolton, UK (K Moriarty Party Parliamentary Group on alochol misuse.