Elsevier

The Lancet

Volume 384, Issue 9958, 29 November–5 December 2014, Pages 1953-1997
The Lancet

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

https://doi.org/10.1016/S0140-6736(14)61838-9Get rights and content

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Executive summary

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 five-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

Extent of liver disease in the UK

In the past few decades vast improvements have been made in health, and death rates have decreased for almost all diseases. In some areas (eg, cardiac disease), in which large health resources have been invested, the decrease in mortality has been substantial. Liver disease is the exception; standardised mortality rates have increased 400% since 1970, and in patients younger than 65 years have increased by almost 500% (figure 1). Most patients die in working age (18–65 years) and as a result,

Postcode lottery of specialist services and centres

In-hospital mortality rates for cirrhosis and liver failure vary across the country, with some acute trusts consistently reporting mortality rates of more than double those of the better centres (figure 5). The All Party Parliamentary Hepatology Group (APPHG) noted “grave concerns about patchy service provision across the country, the late diagnosis of patients and a lack of the necessary central drive and prioritisation”.3 There was concern and disappointment that despite the commitment

How to improve hospital care and reduce premature mortality

The high mortality rates from cirrhosis and the inadequate care provided in hospitals for patients dying from alcohol-related diseases, graphically show the deficiencies in the present provision of hospital liver services in England. These deficiencies could be assumed to apply to the full range of causes of chronic liver disease in patients admitted to hospital. In the NCEPOD analysis,2 73% of patients who died from chronic liver disease had been admitted via the emergency department, and only

Obesity and non-alcoholic fatty liver disease

Understanding of non-alcoholic fatty liver disease is still at an early stage and has only started to gain broad professional recognition. Furthermore, only a small proportion of the general public know that being overweight or obese increases the risk of developing liver disease, and that there is much to learn about the natural history and effective treatments for this disease. Nevertheless, much can be done to minimise the resulting effects of fatty liver disease, taking into account the

Engagement of primary care in detection and management of liver disease

Knowledge and awareness of liver disease in primary care is low with an absence of adequate diagnostic methods and training in the diagnosis and management of the early stages of liver disease. About three-quarters of people with cirrhosis are not detected until they present to hospital with end-stage liver disease, by which time morbidity and mortality is high and the scope for intervention is substantially reduced (figure 14). Despite the long natural history, often decades, of almost all

Screening at risk populations

Early detection of liver disease in general practice by screening programmes can only be justified if it leads to effective treatment or intervention. The value of detecting hepatitis B and C infections cannot be questioned, with the availability of new highly effective treatment regimens that can prevent progression to severe liver disease and in the case of viral hepatitis C, eradicate the infection. Although evidence is scarce for the effectiveness of preventive or treatment options in

Management in paediatric care

Management of paediatric liver disease in the UK, including hepatobiliary surgery and transplantation, is centralised to three national centres, leading to internationally recognised outcomes and high value educational programmes. Children with liver disease are now surviving with a good quality life into adulthood, which will increase the burden for adult providers who will need to become familiar with childhood onset of liver disease.150 Progress still needs to be made in increasing public

Economic assessment

The economic costs of liver disease encompass the NHS spend, the cost to society (in terms of lost productive output), and the opportunity cost of failing to address and manage risk factors for advanced stages of this disorder.

On the basis of Hospital Episode Statistics, the costs of admissions and outpatient attendances for people with a primary diagnosis of liver disease were about £270 million in 2012–13 in secondary care alone (Longworth L, unpublished). In 2008, the latest breakdown of

New commissioning arrangements and the public interface

To address the high and increasing incidence of liver disorders in the UK, a range of activities is needed at different levels that require concerted action from national and local government, the NHS—starting with primary care—through to Public Health England, and from professional and patient organisations, all working in alliance. A result from the Health and Social Care Act of 2012, has been to make it difficult to create a national plan because of the philosophy that local commissioners

Overall conclusions and key recommendations

In the UK, the present numbers of premature mortality and overall poor standards of care being afforded to patients with liver disorders are unacceptable.

Our ten key recommendations represent the most important of each listed in this Commission. We believe that these ten recommendations will have the greatest effect on reducing the burden of liver disease in the UK and should be given the greatest priority in implementation.

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