This Review, in addressing the unacceptably high mortality of patients with liver disease admitted to acute hospitals, reinforces the need for integrated clinical services. The masterplan described is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospitals—a pattern of care similar to that successfully introduced for stroke services. The plan includes the establishment of a lead and deputy lead clinician in each acute hospital, preferably a hepatologist or gastroenterologist with a special interest in liver disease, who will have prime responsibility for organising the care of admitted patients with liver disease on a 24/7 basis. Essential for the plan is greater access to intensive care units and high-dependency units, in line with the reconfiguration of emergency care due to the COVID-19 pandemic. This Review strongly recommends full implementation of alcohol care teams in hospitals and improved working links with acute medical services. We also endorse recommendations from paediatric liver services to improve overall survival figures by diagnosing biliary atresia earlier based on stool colour charts and better caring for patients with impaired cognitive ability and developmental mental health problems. Pilot studies of earlier diagnosis have shown encouraging progress, with 5–6% of previously undiagnosed cases of severe fibrosis or cirrhosis identified through use of a portable FibroScan in primary care. Similar approaches to the detection of early asymptomatic disease are described in accounts from the devolved nations, and the potential of digital technology in improving the value of clinical consultation and screening programmes in primary care is highlighted. The striking contribution of comorbidities, particularly obesity and diabetes (with excess alcohol consumption known to be a major factor in obesity), to mortality in COVID-19 reinforces the need for fiscal and other long delayed regulatory measures to reduce the prevalence of obesity. These measures include the food sugar levy and the introduction of the minimum unit price policy to reduce alcohol consumption. Improving public health, this Review emphasises, will not only mitigate the severity of further waves of COVID-19, but is crucial to reducing the unacceptable burden from liver disease in the UK.
Bibliographical noteFunding Information:
RLB declares personal fees from NovoNordisk, Pfizer, ViiV, International Medical Press, and Boehringer Ingelheim, and consultancy and grant support from NovoNordisk, outside the submitted work. MA declares grants from GSK/Takeda and personal fees from Intercept, outside the submitted work. GF declares consulting and speaker fees from AbbVie, Bristol Myers Squibb, Gilead, GSK, and MSD, outside the submitted work. RA declares personal fees from Norgine UK, Intercept Pharmaceuticals, and Novartis UK, outside the submitted work. All other authors declare no competing interests.
We thank all those who attended meetings of the working groups of the Commission, including Mark Hudson (Freeman Hospital, Newcastle, UK); Camille Manceau and Mark Tyrell (Echosens, Paris, France); Jonny Greenberg, Riddhi Thakrar, and Thomas Stephens (Incisive Health, London, UK); John Wass (Department of Endocrinology, Churchill Hospital, Oxford, UK); Pamela Healy and Vanessa Hebditch (British Liver Trust, Bournemouth, UK); Jyotsna Vohra (Cancer Research UK, London, UK); Alison Taylor (Children's Liver Disease Foundation, Birmingham, UK); Ian Gee (Worcestershire Acute Hospital, Worcester, UK); Matthew Cramp (Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK); Mead Mathews (St Mary's Surgery, Southampton, UK); Helen Jarvis (Newcastle University, Newcastle, UK, and The Royal College of General Practitioners, London, UK); Annie McCloud (Kent and Medway NHS and Social Care Partnership, Gillingham, UK); Martin McKee (London School of Hygiene & Tropical Medicine, London, UK); Joanne Morling (Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK); Michael Goldacre (Unit of Health-Care Epidemiology, Nuffield Department of Population Health, University of Oxford, Oxford, UK); Peter Rice (Scottish Health Action on Alcohol Problems, Edinburgh, UK); Robyn Burton (Public Health England, Leeds, UK); Guruprasad Aithal (Nottingham Digestive Diseases Centre and the National Institute for Health Research [NIHR] Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK); and Tamara Pinedo (Royal College of Emergency Medicine, London, UK). We thank Norgine for their unrestricted grant to the Foundation for Liver Research (London, UK), which has enabled the Commission to work with Incisive Health (London, UK) in bringing the work of the Commission to the attention of the UK Government. CD was partly funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK, and by the NIHR Collaboration for Leadership in Applied Health Research and Care South London, now recommissioned as the NIHR Applied Research Collaboration South London, and receives funding from an NIHR senior investigator award. The views expressed in this Review are those of the authors and not necessarily those of the Medical Research Council, the NHS, the NIHR, or the UK Government's Department of Health and Social Care.
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