9 in 10 cases of liver disease are preventable. Policies are required to address the three preventable causes – excess alcohol consumption, obesity and viral hepatitis and crucially to ensure early detection of disease. If liver disease is detected early, the liver damage can be reversed and chronic liver disease can, therefore, be prevented.
The Government’s focus on prevention was made clear in November 2018 with the publication of their ‘vision’ document Prevention is better than cure. The full Green Paper ‘Advancing our health: prevention in the 2020s’ is available here. The approach is underpinned by the NHS Long term Plan.
What is a green paper?
Green Papers are consultation documents produced by the Government. In which they set out their proposals about an issue. The aim is to allow individuals and organisations to provide feedback on its policy or legislative proposals before firmer plans are put forward for legislation. It is the stage at which proposals are most likely to change so it is important for stakeholders like the British Liver Trust to comment on the proposals to try to influence future Government policy.
A green paper may lead to a white paper, which sets out proposals for legislative changes, which may be debated before a Bill is introduced.
What’s in the Prevention Green Paper?
The Prevention Green Paper set out how the government plans to embed the principle that ‘prevention is better than cure’ across wider society. This includes equipping people with the skills and knowledge to take better care of their health to prevent illness.
It is a very broad document covering ways to tackle ill health among the whole population. This includes addressing accidents, smoking, mental health, unhealthy eating and sexual health. It offers an opportunity for a shift of focus from cure to prevention.
While the green paper includes many positives for improving liver health, the British Liver Trust believes that there needs to be a broader commitment to tackling liver health and specifically more emphasis on tackling the growing problem of alcohol misuse.
The Green paper asks for responses on specific questions and free text answers are restricted to 250 words. We selected the questions that are relevant to liver disease and wrote a response. The answers below were submitted via an online portal.
1a) Which health and social care policies should be reviewed to improve the health of: people living in poorer communities, or excluded groups?
Liver disease disproportionately affects the poorest and most vulnerable in society. Those in deprived areas are up to six times more likely to die of liver disease than those in wealthier areas. It is the third most common cause of Years of Life Lost (YLL) in people of working age and the biggest cause of death in those aged 35-49. Three quarters of people are currently diagnosed at a late stage when there is little scope for treatment – yet 90% of these deaths are preventable. Policies are required to address the three preventable causes – excess alcohol consumption, obesity and viral hepatitis and crucially to ensure early detection of disease. If caught early, chronic liver disease can be prevented.
Targeted interventions should include commissioning of clear liver pathways in primary care including community screening for liver disease with liver fibrosis markers and a co-ordinated approach to case finding those with hepatitis B and C. This needs to be linked to improved access to weight management support (the key intervention to reduce mortality from NAFLD) and improved access to alcohol support services, currently only 7% of people drinking at harmful levels are in contact with treatment services.
Population approaches are also vital. These should include fiscal measures for reducing alcohol and unhealthy foods (e.g. MUP, increased alcohol duty, sugar tax); restrictions on the marketing and advertising of these products and better labelling and awareness campaigns so that consumers can make an informed choice.
2a) The NHS Health Check programme has achieved a lot. But uptake varies across the country, the risks identified in a check could be followed up more consistently by the NHS, and evidence is emerging that people could benefit from a more tailored service. There may also be a case for a particular focus on supporting people through key changes in their life, in particular thinking about future care needs and how they can remain healthy and active in older age. Do you have any ideas for how the NHS Health Checks programme could be improved?
The British Liver Trust and RCGP have recently submitted a jointly agreed case and rationale for liver disease to be included in the NHS Healthcheck to PHE. This case has been endorsed by the British Association for the Study of the Liver and the Society of Gastroenterology. The written response from PHE is positive but we have yet to hear about implementation.
The Healthcheck already assesses alcohol consumption and metabolic syndrome risk factors (the same risk factors for non-alcohol related fatty liver disease (NAFLD)) so the initial component can remain unaltered. However, a liver disease filter should then be added in for those at a high risk of alcohol related liver disease (ARLD) and NAFLD and these people should then enter clinical assessment. Assessment should follow NICE Guidance (fibroscan for ARLD and ELF or similar testing for NAFLD), but if these tests are not available, nationally agreed pathways should be followed which may include indirect fibrosis testing using Fib-4, AST:ALT ratio or NAFLD fibrosis score. Bearing in mind that NICE recommends that normal liver function tests should not be used to rule out liver disease, it is more useful to involve an objective assessment of liver fibrosis.
Risk management would include lifestyle advice (weight management support, brief alcohol intervention) and referral if necessary. People would then either be re-assessed in the 5-year rolling NHS health check programme or exit onto a Chronic Liver Disease register. It is easy to see how liver disease could fit into the NHS Healthcheck cycle remit.
Children who are obese or overweight are at a greatly increased risk of non-alcohol related fatty liver disease (NAFLD). The food that children choose and the amount that they eat is strongly influenced by marketing and advertising. We would like to see better labelling and health information on food so that parents can better assess the food they should buy for children. We think there should be a 9pm watershed on adverts for foods and drinks that are high in fat, salt and sugar. Government should also look at extending the ‘sugar tax’. Healthy food is more expensive so subsidies should be considered on fresh fruit and vegetables and other healthy food products.
5a) Support for individuals to achieve and maintain a healthier weight. How [other than a brief intervention and providing advice in primary care] can we help people reach and stay at a healthier weight?
Early diagnosis and/or awareness of liver disease can act as a motivator for people to lose weight. There is good evidence that losing weight (10% of body weight) can reverse the early stages of non-alcohol related fatty liver disease.
Integrated multidisciplinary approaches that address psychiatric needs and provide behavioural support for weight loss may help patients with NAFLD implement sustained lifestyle changes.
There should be restrictions imposed on the advertising and marketing of foods that are high in fat and sugar and better labelling on food products. Calories on alcohol products should be clearly displayed. The soft drinks levy (sugar tax) could be extended. Eating healthily is currently prohibitively expensive for many people and so measures should be brought in to make healthy foods such as fruit and vegetables be a cheaper option.
9a) Prevention in the NHS. Have you got examples or ideas for services or advice that could be delivered by community pharmacies to promote health?
Pharmacists should be equipped to provide information on the risk factors relating to liver disease and to provide brief interventions to those at risk. They may be ideally placed to identify those at risk and offer brief advice/intervention on both alcohol and weight loss.
It is likely that within the next few years the non-invasive technology to assess fibrosis (such as Fibroscan) will become more accessible so that it can be used in a pharmacy setting. Selected pharmacists could then become a routine part of community screening for liver disease.
There are highly effective curative treatments for Hepatitis C. Pharmacists could play a key role in the elimination of this disease by offering testing and referral.
13a) What is your priority for making England the best country in the world to grow old in, alongside the work of Public Health England and national partner organisations?
Liver disease kills young people. Preventing it and diagnosing it earlier would allow more people to enter old age. Addressing its risk factors, particularly alcohol and obesity would have a substantial beneficial effect in reduction in other significant co-morbid diseases such as cancer and musculoskeletal disorders which will improve health in older people.
Effective prevention for weight management and alcohol – the two leading causes of preventable liver disease need sustainable funding.
Public health grants need to be increased so that local authorities have the resources to address obesity and alcohol in their area. Local weight management and services that address alcohol should be made available.
Early interventions offering targeted support to individuals who are overweight need to be trialled and assessed for effectiveness.
Very little is currently offered to address the early signs of excess alcohol consumption. Early intervention programmes for people who are regularly drinking at a high level (over 30 units per week for women, 40 units for men) before they are severely alcohol dependent should be considered and assessed for their effectiveness.
18a) What other areas (in addition to those set out in this green paper) would you like future government policy on prevention to cover?
The British Liver Trust is excited to see this shift of focus from cure to prevention. 90% of liver disease is preventable. Deaths due to liver disease have increased by more than 400% since the 1970s. This is in stark to all the other main killer diseases such as heart disease and cancer which have seen great improvements in mortality rates, treatment and care. Liver disease is a major public health crisis and we believe a dedicated strategy to address liver disease is needed.
Although part of the increase in deaths is due to the rise in obesity, alcohol is still the leading cause of liver disease deaths in the UK. Public Health England has undertaken an evidence review and the British Liver Trust has contributed to several reports outlining what needs to be done including the Alcohol Charter (produced by the Drugs, Alcohol & Justice Cross-Party Parliamentary Group and All-Party Parliamentary Group on Alcohol Harm). We urgently need an integrated evidence-based alcohol strategy to reduce mortality, morbidity and the health inequalities caused by alcohol.