The Lancet: British hospitals face serious shortage of liver specialists

November 19, 2015

Fewer than one in three hospitals employ a full-time doctor who specialises in liver medicine, according to a survey of 144 hospitals in the UK. The results - published as part of a new report examining progress since The Lancet Commission on Addressing Liver Disease in the UK was published in 2014 - suggest that staffing levels for liver specialists are worryingly low in some regions, and that patient outcomes may be suffering as a result.

"Although the total number of liver specialists in the UK has actually increased in recent years, they are concentrated in a small number of large specialist liver centres,"* says Professor Sir Roger Williams, the Commission's lead author, and Director of the Foundation for Liver Research in London, UK.

"The UK's specialist liver centres provide an excellent standard of care for their patients, but they aren't evenly distributed throughout the country. This results in a postcode lottery for patients with liver disease, who may not be able to access specialist care when they need it. We've seen very little progress on this problem since we first reported it last year, and the rising numbers of patients with liver problems in the UK means that we can't afford to ignore these shortcomings any longer."*

While the report finds that there has been some progress in improving staffing and standards of care for liver patients over the last year, poor patient outcomes in many areas of liver disease suggests that the UK still has much room for improvement. The report provides clear recommendations for how liver services should be structured in the UK, and suggests that all district hospitals should aim to have at least one full-time liver specialist.

A new area of concern highlighted by the report is the widespread lack of surveillance in the UK for detecting early liver cancer in patients with cirrhosis (scarring of the liver caused by long-term liver damage, which can be for a variety of reasons, including alcohol misuse, hepatitis C, or obesity-related liver disease). Nearly two thirds (60%) of liver cancer cases in the UK are not diagnosed until the cancer has reached an advanced stage, when it is incurable.

The report also highlights the continued need for stronger government leadership to tackle alcohol misuse and obesity, the two primary drivers of liver disease in the UK. Reiterating the findings of the 2014 Commission, the report authors again call for the government to re-instate the alcohol duty escalator and implement minimum alcohol pricing to curb rising drinking rates, and for effective policies to address the UK's rising rates of obesity.

"One of the most important challenges facing the NHS today is how we deal with rising obesity and excess alcohol consumption when such a high proportion of the population are affected. There is convincing evidence to suggest that measures such as minimum unit pricing for alcohol and curbing advertisement and promotional offers for high sugar products work to reduce consumption, but the current government appears to be ideologically opposed to measures like this, which will make tackling these problems difficult."*

Scotland and Wales are both singled out for making progress in terms of implementing national liver strategies and other measures to improve liver disease outcomes (including implementing minimum alcohol pricing, in the case of Scotland).

Other areas covered by the report include encouraging developments in the introduction of treatments for HCV (Hepatitis C virus), though this has been countered by a lack of progress in efforts to control Hepatitis B. The report notes that liver transplant services are now undergoing a comprehensive national review, as recommended in the last report, and that there have been some limited improvements in training for doctors and nurses.

Improving awareness of liver disease among both medical professionals and the public was one of the 2014 report's key recommendations, and the latest update finds that some progress has been made in this area, although many gaps remain - the damaging effects of obesity on the liver are poorly appreciated, for instance, and awareness of Hepatitis B and C remains low.

According to Professor Williams, "Over three quarters of liver disease cases are potentially preventable, yet the last three decades have seen a fourfold increase the number of people dying from this unpleasant and debilitating illness. Reducing obesity and alcohol misuse -responsible for the majority of liver deaths in this country - won't just reduce the number of people in the UK suffering from liver disease, but it will also hugely reduce the burden of heart disease and other related illnesses, so there are enormous and quite obvious benefits to acting on this problem now."*

* Quote direct from author and cannot be found in text of report

The Lancet

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