Memorandum by Alcohol Concern (WP 87)
ABOUT ALCOHOL
CONCERN
Alcohol Concern is the national voluntary agency
on alcohol misuse. Established in 1984 we seek to reduce the harm
caused by alcohol on individuals, families and society. Our work
spans the breadth of public policy impacted on by alcohol; we
run projects targeted at specific areas of policy and practice,
such as mental health and children and families and also provide
the most comprehensive information service in the country on alcohol-related
issues.
ALCOHOL AND
PUBLIC HEALTH
Tackling alcohol misuse remains a key challenge
for any coherent and proactive public health strategy. Alcohol
has been identified by the World Health Organisation[160]
as posing the third highest risk to health in developed countries;
For example, excessive alcohol consumption is a lifestyle risk
for coronary heart disease and stroke, whilst an estimated one-third
of psychiatric patients with serious mental illness have a substance
misuse problem. People with alcohol misuse problems tend to experience
poor health, present to a range of NHS services and costs at least
£1.7 billion in health spend each year; yet in the vast majority
of cases, the NHS fails to diagnose alcohol misuse and fails to
provide adequate treatment.
Alcohol contributes to such a wide range of
physical and psychological harms, that even modest improvements
in identification and treatment will help in meeting NHS targets.
For example National Service Framework targets on key issues such
as Coronary Heart Disease, Older People, Mental Health and Diabetes
are all related to alcohol misuse.
Over 8 million people in this country drink
at levels that put them at increased risk of harm but are not
chronic drinkers or alcohol dependent. These people are so numerous
that behaviour change in this group is even more essential to
public health targets than the much smaller number of people who
are alcohol dependent.
The publication of the Alcohol Harm Reduction
Strategy for England in March 2004 was an important first step
in tackling alcohol related harm in an holistic way. It was not
however underpinned by a strong public health perspective. Choosing
Health presented an ideal opportunity to build on the Alcohol
Harm Reduction Strategy, and we would endorse the comments by
the CMO in his annual report that it was
"an excellent opportunity to transform the
alcohol strategy from a framework for action into an action plan,
broadened and enhanced by other measures, to address what is a
very deep-seated problem with complex causes".
The central question of this submission from
Alcohol Concern is whether Choosing Health has fulfilled
these aspirations.
A public health approach to alcohol?
The World Health Organisation identifies three
main types of approaches to reducing alcohol related harm:
(a) Population-based policies that can shape
drinking behaviour across the whole population, eg taxation, availability
restrictions, minimum drinking age.
(b) Policies targeted at particular problems,
such as drink-driving or offences like sales to minors.
(c) Policies to help individual drinkers,
such as brief interventions or rehabilitation programmes.
A public health approach to alcohol should embrace
initiatives of known effectiveness from all of the above categories
and weave these into a coherent and strategic response.
When average alcohol consumption increases,
the number of people drinking at different degrees of severity
tends to increase proportionately. Put another way, if we see
a continued rise in average consumption, there is no evidence-based
and tested set of policies that will succeed in reducing hazardous
and harmful drinking. The most effective and cost effective approach
is therefore to decrease the overall level of alcohol consumption
in society through supply side controls such as taxation and licensing,
as described in the type "a" approaches. Unfortunately
many of these measures are politically unpalatable or (as in the
case of licensing) beset by complex political tradeoffs.
Alcohol Concern views it as a problematic that
the Government has failed to reflect the solid evidence base of
whole population approaches in its response to alcohol, but recognises
that many other excellent policies are being pursued.
Choosing Health could include many more
measures within the type "b" category, targeted at particular
problems. For example, reducing underage sales should help reduce
the number of young people developing alcohol problems. Reducing
the legal drink drive alcohol level would also save many lives
each year.
As well as trying to reduce overall levels of
consumption, it is important to respond to those who currently
drink at risky levels. This requires us to identify these individuals,
and provide an intervention for which there is an evidence base
of effectiveness; these are known in the research literature as
"brief interventions". We therefore welcome the inclusion
in Choosing Health of considerable interest in improving
identification and treatment and the range of type "c"
measures.
A public health approach to alcohol should include
a co-ordinated range of measures covering supply side controls,
initiatives to target specific behaviours and the identification
and treatment of individuals who drink excessively. The combination
of measures should bring about a shift in cultural norms (the
assumptions and expectations around drinking including when and
how much is drunk) and downward pressure on the overall level
of alcohol consumption as well as a reduction in risk behaviour.
VISIBILITY OF
ALCOHOL WITHIN
CHOOSING HEALTH
Our first concern was whether alcohol would
be given a level of attention within the document that reflects
its importance as a determinant of ill health. On balance we are
pleased with the level of inclusion, and commend the Government
for their apparent shift in thinking in the last two years (all
too often, alcohol is underplayed to the point of invisibility).
This visibility is vital to encourage local planners, clinicians
and commissioners to take alcohol seriously and develop innovative
and local solutions. We would argue that the overall level of
attention to alcohol should be increased, but it is important
to acknowledge the progress made.
Recommendation
— It is essential that Choosing
Health maintains or increases the visibility of alcohol as
a determinant of ill health alongside smoking and obesity.
ROLE OF
THE ALCOHOL
INDUSTRY
Alcohol Concern has always advocated a partnership
approach to tackling alcohol misuse, and that this should include
the Alcohol Industry. We are however profoundly concerned about
the role of an industry funded lobby organisation "The Portman
Group" proposed in Choosing Health.
The alcohol industry is in the business of selling
alcohol and has legal responsibilities to maximise shareholder
value. This will in general be achieved by selling more alcohol.
This legitimate business activity brings harm as well as benefit
to society, and therefore represents a clear conflict of interest
in running campaigns to reduce consumption of alcohol (an inevitable
corroraly of trying to reduce alcohol misuse).
The Portman Group has a part to play in tackling
alcohol misuse, as industry representatives they should be instrumental
in bringing the alcohol industry into line with their social and
legal obligations; the high proportion of licensed premises that
promote irresponsible drinking and continue to sell alcohol to
children, suggests there is much work to be done.
We urge the Government to work on public education
with experts from across the medical, alcohol policy and research
community. The industry should be included, but as a partner not
a leader. Such work should be evidence based and free from (or
at very least counter balance) the competing interests of the
alcohol industry. The Royal Colleges, Alcohol Concern and other
bodies are keen to work in such a collaborative fashion and have
no difficulty of sharing the table with industry.
We urge the Government to abandon any bilateral
approach to Public Health with industry, and adopt a more inclusive
approach.
Recommendation
— That the Government establish an
advisory panel including the Royal Colleges, Alcohol Concern,
researchers and representatives from the alcohol industry, to
lead on or oversee campaigns aimed to reduce alcohol misuse.
— Industry representatives should include
on trade and off trade as well as producers.
SUPPORT FOR
SPECIALIST TREATMENT
The funding and coordination of alcohol treatment
services in this country is in a parlous state. They receive one
tenth the funding of drugs services despite five times as many
people dying from alcohol than drugs, in many areas no individual
has responsibility for commissioning these services and there
is no national system of performance management, monitoring or
planning.
We warmly welcome many of the proposals in Choosing
Health that support the role of treatment services. Although
there is much repetition from the alcohol strategy, this is not
in itself a bad thing and in some areas offers stronger (or at
least clarified) commitment to turning proposals into an actual
programme of improvement.
One section of Choosing Health refers
to additional funding provided through pooled treatment budgets.
We have clarified with the DoH that the funds are not intended
(nor of sufficient size) to invest in provision of treatment per
se, and will instead go toward improving commissioning. This section
needs clarification as it raises false hope for new funding. A
better approach still would be for the Government to make a reasonable
and realistic investment in alcohol treatment services and indicate
in how the "planned programme of improvement" will be
resourced.
The National Treatment Agency for Substance
Misuse has been tasked with developing a Models of Care framework
for alcohol, along the lines of the existing framework for drugs.
The drugs document is described as "having the status of
a national service framework" and has played a major role
in the strategic development of drug treatment services. It did
however focus largely on the specialist treatment services.
Models of Care for Alcohol must have a wider
remit than the drugs document, and set out the nature and structure
of interventions across non-specialist as well as specialist services.
It should, for example cover interventions in A&E and Primary
Care.
Whilst Choosing Health reiterates commitment
to the delivery of Models of Care for Alcohol, this would be more
effective if it was clearer how the document sat within the NHS
Plan and National Service Frameworks. It recommends that ".
. . alcohol services—benefit fully from the same drive for
modernisation and improvement that exists across the rest of the
NHS". This will only be achieved if Models of Care reflects
that standards based approach used across the National Service
Frameworks.
One benefit of NTA involvement in alcohol would
be that the existing investment in the drugs infrastructure (workforce
planning, information management and commissioning structures)
could be quickly extended to support the alcohol sector. New money
for alcohol services should therefore result in a relatively quick
impact on the ground, with relatively small amounts needing to
be diverted to building infrastructure.
Choosing Health explicitly mentions the
role of the voluntary sector in the delivery of alcohol treatment.
This is to be welcomed. A key challenge facing this sector is
the slow implementation of the recommendations of the Treasury
review of the role of the voluntary sector in delivery of public
services, in particular full cost recovery.
The prison alcohol strategy is referenced in
the white paper, and has now been published. It remains aspirational
and to be delivered "within existing resources", which
means on the ground that nothing changes.
Recommendations
— The Models of Care for Alcohol Misusers
should have the status of a National Service Framework and include
standards linked to the NHS plan.
— Investment in commissioning through
pooled treatment budgets needs clarification.
— Significant new investment is needed
in alcohol treatment services, and Choosing Health should
commit to such spending.
— Choosing Health should reference
the Treasury review of the role of the voluntary sector and recommend
the implementation of its findings.
— The prison alcohol strategy could
be referenced with recommendations that it is adequately resourced.
BUILDING LINKS
TO OTHER
POLICY AREAS
A key plank in improving public health is to
ensure that there are links between the public health and other
policy agendas and this is of particular importance if we are
genuinely to shift the culture of drinking in the UK.
A key gap in the public health white paper was
the lack of proposals to push the identification of alcohol problems
into settings other than health. The identification/brief intervention
initiatives proposed for the NHS would have equal effectiveness
in other settings across social care and criminal justice. The
task is to identify places where hazardous and harmful drinkers
come into contact with professionals. These can be described as
"capture points", and exist way beyond healthcare settings
(for example criminal justice, education and social care). An
example of this activity is to skill up custody officers to identify
people who may have alcohol misuse problems and refer them for
brief interventions at local alcohol treatment services.
These other policy areas need workforce-planning
strategies to ensure that staff are trained in identification,
minimal intervention and referral of people with alcohol problems.
This could be achieved by a commitment to include basic Drug and
Alcohol National Occupational Standards competencies into the
emerging national occupational standards for these fields.
There are other areas of alcohol policy that
would yield marked public health gains yet are not mentioned in
the strategy. Some of these are covered in these recommendations:
Recommendations
— Increased reference to the role of
other social care, criminal justice and housing sectors in delivery
of public health goals around alcohol.
— Specifically, to state that the DANOS
competencies for the identification, brief interventions and referral
on will be included in the occupational standards for these sectors.
— For the legal drink drive limit to
be reduced to the European consensus of 50mg/ml.
— For effective enforcement of underage
sales policy (a key supply side control).
IMPACTING THE
OVERALL CONSUMPTION
OF ALCOHOL
Over the last 50 years, the per capita consumption
in the UK has risen by a little over 100%. This is seen as the
result of increased accessibility including affordability (price
in real terms), the proliferation of bars, clubs, pubs and off
licensed premises and the relaxation of licensing laws.
The evidence base overwhelmingly links increased
per capita consumption with increases in diseases linked to long
term heavy drinking, accidents as a result of being drunk, crime,
violence and suicide. The recent publication from the Academy
of Medical Sciences[161]
cites numerous examples of research from Europe, Canada and the
UK to conclude that per capita consumption stands out as a crucial
determinant of how many people will drink heavily and as an indicator
of alcohol related harm more broadly. Yet both the Alcohol Strategy
2004 and the Public Health White Paper avoided this approach as
a basis for formulating policy.
Instead the Government's current approach is
focussed on changing the behaviour of specific groups of problem
drinkers. Whilst many of the policies that are proposed are excellent,
they are a inadequate response to the steadily increasing problem
of excessive alcohol consumption. In addition to a targeted approach
there is a need to policies related to reducing the overall level
of national drinking if we are to see a sustainable improvement
to public health in the long term.
We would particularly highlight a failure of
joined up government, the development of the Licensing Act without
significant regard for public health. The licensing regime in
this country is one of the prime means available for the Government
to control the availability of alcohol, yet the opportunity to
coordinate these reforms with the alcohol strategy was missed.
Many of the reforms proposed in the Act are positive (such as
increased democratic accountability of licensing decisions) so
we would not argue for the whole act to be scrapped, but in its
present form may worsen public health.
Recommendations
— If alcohol consumption or alcohol
misuse continues to rise, moderate increases in the price of alcohol
should be considered. This is a valuable tool that is recommended
by the World Health Organisation as effective.
— The Licensing Act and guidance that
supports implementation urgently needs review. The Act should
have at its heart a consideration for public health.
— Moderation of average alcohol consumption
should be an accepted and acceptable target for government, and
reflected in a range of policy initiatives.
— We welcome the revision of Ofcom
guidelines on the broadcast advertising of alcohol and are pleased
that this was seen as relevant for inclusion.
— We support the calls from the RCP
for an end to broadcast advertising of alcohol before 9 pm.
BUILDING CULTURE
CHANGE IN
THE NHS
The NHS is one of the largest employers in the
country and does not have a coherent workplace alcohol policy.
If we are interested in changing the culture of the NHS in its
approach to alcohol, a good place to start would be to look at
the drinking culture of the NHS. NHS physicians would find the
necessary shift in role legitimacy easier to navigate if their
own places of work had less conflicted approaches to drinking.
It should for example be unacceptable for medical school bars
to offer subsidised alcohol and run drink promotions that the
rest of the alcohol industry is under pressure to stop.
One of the problems identified with the alcohol
strategy was the lack of clear teeth or commitments to bring about
culture shift within the NHS. The white paper builds usefully
on the alcohol strategy, for example promising: "guidance
and training to ensure all health professionals are able to identify
alcohol problems early". There is a broad commitment for
the NHS to have conversations "linking health improvement
advice to clinical care". If we succeed in getting health
professionals trained in screening and minimal/brief intervention,
there are real opportunities to help the millions of hazardous
drinkers who present to the NHS but do not need referral to specialist
services.
The white paper is however a little weak on
the specifics of implementation. We look forward, for example
to seeing greater detail on how the training is to be delivered.
Primary care is the ideal setting for identification,
brief intervention and referral of alcohol misusers. Models of
Care for Alcohol Misusers is considering how this activity might
be structured, but there is not yet an appropriate set of levers
to ensure this gets implemented across primary care. Screening
needs to take place in every surgery, not just a handful, and
the nGMS contract represented was a missed opportunity to create
an incentive structure (similar to smoking cessation) to get GPs
involved in early identification work.
Recommendations
— There should be an NHS wide workplace
alcohol strategy, and review of how as an employer the NHS can
set the standard by example on how to move away from a culture
of heavy drinking.
— A more concrete delivery plan is
provided for alcohol in primary care.
— A more concrete delivery plan for
the training of NHS staff is needed.
— The review of the nGMS contract and
Quality in Outcomes Framework should consider how screening and
brief interventions can be encouraged in primary care.
CONCLUSIONS
Alcohol Concern welcomed the inclusion of Alcohol
in the public health white paper, and recognises that the level
of inclusion on alcohol is an important step forwards. There are
however a number of shortcomings that should be addressed as a
matter of urgency; in other areas there are comparatively minor
revisions that would ensure that Choosing Health has a
greater impact to the reduction of alcohol related harm in this
country.
January 2005
160 World Health Organisation: Global Status Report:
Alcohol Policy (2004). Back
161
Academy of medical science: Calling Time-The nations drinking
as a major health issue (2004). Back
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