The escalating cost of alcohol misuse, obesity and viral hepatitis

Liver disease has become one of the most common causes of premature death in the UK, with a cost not just in lives but also to health services and society.

As a contributor to The Lancet Commission on Liver Disease, an active researcher in liver disease and a physician who treats patients with liver disease, I am acutely aware of the intensity of the problem – and its potential to worsen.

As part of the Commission I played a role in a recent and pivotal report compiled by the Foundation for Liver Research – “Financial case for action on liver disease”.

The report takes three key themes of liver disease – alcohol misuse, obesity and viral hepatitis – and argues that focused investment in specific areas could result in the prevention of liver disease, fewer cases, and better quality of life for those who have liver disease.

While the report is national in its scope, its impact for us in the South West is significant – cases are on the increase across the peninsula, with hotspots in Plymouth, Cornwall and Torbay. According to figures from Public Health England, hospital admissions for liver disease are above average in those areas, together with the rate of hospital admissions for liver disease related to alcohol misuse.

In many cases liver disease is preventable – through lifestyle adjustments, immunisation and early diagnosis and treatment of viral hepatitis with improved testing. However, 62,000 years of working life are lost to liver disease each year with particular impact on the poorest in our society, contributing to a widening of socioeconomic health inequalities in the UK.

2016-17 saw the highest ever hepatitis C (HCV) treatment numbers in England, with 10,000 people receiving treatment. The total number of people chronically infected in the UK is estimated to be 216,000, but research suggests that as many as 86% could be unaware that they are infected and the true figure could be as high as 466,000.

Untreated, HCV can lead to major complications including cirrhosis, liver cancer and death from liver failure. It is distressing for patients and the management of HCV puts a significant burden on NHS services.

We are developing and implementing new drug treatments for HCV. In Devon, Cornwall and Somerset last year we treated 328 patients with newly-approved, directly-acting antiviral drugs for HCV infection. A further 31 were treated at the South West Liver Unit in Derriford Hospital, with newer drugs as part of clinical trials. All 31 clinical trial patients were cured of their HCV infection.

We are monitoring the 328 NHS England-funded cases but we anticipate that over 90% of those treated will be cured even though many of them had advanced liver disease including cirrhosis.

In the coming year we have approval to treat 399 cases of HCV infection across Devon, Cornwall and Somerset and in future years we expect that annual figure to rise. The new treatments are very safe, highly effective, well-tolerated and with very few side effects. The biggest challenge for the next few years will be identifying the as yet undiagnosed cases and ensuring they get access to the new treatments before their liver disease progresses to cirrhosis.

A planned hepatitis B vaccination programme for all babies born after 1st August 2017 has started, but additional measures are needed to protect against hepatitis B in other groups and to make sure those already infected get diagnosed and treated to improve outcomes for this with the condition.

In the report we recommended: the immunisation of everyone with risk factors for hepatitis B; the protection of harm reduction services, such as needle exchanges, and; improving access to hepatitis testing, diagnosis and treatment.

Alcohol misuse cost the NHS £3.5bn in 2009/10, equating to £120 for each taxpayer. Included in that figure are: £112m on GP appointments; £696m on attendance at A&E, and; £449m on ambulance services. This in addition to the related costs of unemployment and reduced productivity, and crime and disorder.

The report makes recommendations for reducing costs and improving lives, including: introducing a minimum unit price for alcohol; bringing back the alcohol duty escalator; a new higher duty band for cider; restricting trading hours of off and on-licences, and; tougher regulations for alcohol marketing and advertising.

Obesity is a national crisis covering all age groups, and it is a major contributor to liver disease. The direct cost to the NHS in England was £6.1bn in 2016, with an indirect cost to society of £5.6bn. Based on current trends the UK will face added health costs of £1.9-2bn each year from obesity-related diseases, with 48% of men and 43% of women obese by 2030.

Recommendations from the report suggested the following measures: further taxes on foods high in sugar, salt and fat; banning TV advertising for all junk food and sweets before the watershed; bringing in mandatory controls on supermarket price promotions for unhealthy food and drink, and; offering weight loss surgery to obese people with diabetes.

Advances in drug therapies are excellent news for those with HCV, but in order to tackle liver disease in general there will need to be a greater effort from policy makers, health delivery organisations, health care professionals and members of the public/patients, each working together to ensure that any measures introduced from the report are given the opportunity to work.