Offline: Failure, and why we should fear

Abstract

6 years. 6 years of trying to persuade politicians and policy makers that liver disease and its proximal determinants—obesity, alcohol, and hepatitis—should be taken more seriously. Did we succeed? The Lancet Commission into Liver Disease, chaired by the doyen of global hepatology, Professor Roger Williams, launched its final report last month in the austere yet hallowed rooms of the UK's Royal Society. I believe we made progress. The Commission provoked, incentivised, and stimulated evidence gathering that built and sharpened an argument for action. The Commission united what began as a fragmented response to the growing national burden of liver disease. 6 years ago, primary care, public health, and clinical services worked independently of one another. The Commission brought them together to forge a comprehensive strategy for change. And the Commission delivered awareness, attention, advocacy, and accountability—national liver disease profiles, the financial case for action on liver disease, and understanding the importance of living well for longer. These were surely tangible achievements. So why was the ambience at the gathering so sombre? It has taken me several weeks to try to understand. Roger Williams was blunt. We failed. We failed because there are still 1·2 million admissions to UK National Health Service (NHS) hospitals for alcohol-related illnesses. One in five patients drink harmful amounts of alcohol. One in ten are alcohol dependent. The total cost of alcohol-related ill health to the NHS is £3·5 billion annually. We failed because the continuing challenge of obesity has driven 4·7 million people into type 2 diabetes, at a further cost to the NHS of £6·1 billion. And we failed because specialist care for patients with liver disease remains appallingly inadequate. These are “unacceptable failures”. Should we not be hanging our heads in shame? Yes, but perhaps there are signs of hope. Karen Turner is Director of Prevention for NHS England. She pointed to a commitment in the latest NHS Long Term Plan to the creation of Alcohol Care Teams for hospitals with the highest rates of alcohol-dependence-related admissions. These teams could make a big difference. They will enable early intervention and access to comprehensive treatment for excessive alcohol use. They will educate staff about the dangers of alcohol. And they will reduce alcohol-related admissions and readmissions by identifying dependent drinkers and by engaging them in treatment. Even better, there will be additional money and services for the early identification and treatment of cirrhosis. But the truth still remains that the UK Government is unlikely to act at the root cause—the easy affordability of alcohol. Without tougher regulation of alcohol advertising, the implementation of a minimum unit price for alcohol, and controls over the place of sale of alcohol, there can be little prospect of making serious inroads into dangerous alcohol use. An even more important issue is obesity. There are few reasons to be hopeful when it comes to tackling today's epidemic of overnutrition. The most visible consequence of the obesity burden is a surge in cases of diabetes—there are 3·8 million people living with diabetes in the UK today, an intolerable pressure on society and the most serious challenge yet to the sustainability of the health system. Harry Rutter conjured up a formidable image. Envision the policies needed to quash obesity as being a 500-piece jigsaw puzzle. Today we have only 30 of those pieces in place. There must now be a direct attack on the commercial determinants of health. There must be a shift away from the individualising of risk. There must be an end to endless consultations, an end to short-term solutions, and an end to the moralising language of “sin taxes”. As Rachel Batterham emphasised, obesity is a disease, not a lifestyle choice. Obesity is a normal response to an abnormal environment. Unless we tackle that environment, we will continue to fail. So what should we conclude from this paradoxical mix of advances and disappointments? That unless countries follow the example of Singapore and implement whole-of-society approaches to urgent health predicaments—Singapore's “war on diabetes” being a shining example—there can be no hope for progress against obesity and its consequences. One feels forced to observe that in most western nations there is no prospect of such pan-society action. So yes, our Commission tried, but it did indeed fail. Yet honourably, I hope.