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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1197-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE THE COMMITTEE OF PUBLIC ACCOUNTS
health services in
MR HUGH TAYLOR CB, DR WILL CAVENDISH, DR MARK PRUNTY AND DR BARBARA HAKIN
Evidence heard in Public Questions 1 - 96
USE OF THE TRANSCRIPT
Oral evidence Taken before the Committee of Public Accounts on Members present: Mr Edward Leigh, in the Chair Mr Richard Bacon Mr David Curry Mr Ian Davidson Mr Austin Mitchell Dr John Pugh Phil Wilson ________________ Mr Tim Burr, Comptroller and Auditor General, National Audit Office, gave evidence. Mr Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, gave evidence. REPORT BY THE COMPTROLLER AND AUDITOR GENERAL REDUCING ALCOHOL HARM: HEALTH SERVICES IN Examination of Witnesses Witnesses: Mr Hugh Taylor, Permanent Secretary, Department for Health, Dr Will Cavendish, Director Health and Well-Being , Department for Health, Dr Mark Prunty, Senior Medical Officer, Alcohol, Drugs and Tobacco Programme, and Dr Barbara Hakin, Chief Executive, East Midlands Strategic Health Authority, gave evidence. Q1 Chairman: Good afternoon; welcome to the Committee of Public Accounts. Today we are considering the Comptroller and Auditor General's Report on Reducing Alcohol Harm: health services in England for alcohol misuse; welcome back to Hugh Taylor who is Permanent Secretary to the Department of Health. Would you like to introduce your colleagues, please? Mr Taylor: Yes, could I introduce Dr Barbara Hakin, who is the Strategic
Health Authority Chief Executive for the Q2 Chairman: Thank you, Mr Taylor. Could you please look at paragraph 2.3 which tells us on page 17 that "PCTs found it difficult to provide us with details of their spending on services ..." How can we be confident that we know what is going on, that you know what is going on, that this is a priority when apparently PCTs have difficulty knowing how much they themselves are spending? Mr Taylor: It is clear that to address alcohol harm we expect PCTs to commission effectively based on an assessment of needs in their local populations in partnership with other local agencies, and resource planning and investment decisions should follow that. The situation is improving - there are some signs of progress, even since the NAO carried out its survey, but it is clear that the PCTs should have a stronger grip on resource planning than the survey results show, Q3 Chairman: You are going to now make sure they do that are you? Mr Taylor: Our priorities here are to make sure first of all that PCTs are doing what they should do, which is to assess the needs of their local populations and, second, we want to encourage them --- Q4 Chairman: Because 40% do not have a strategy, one-fifth do not know the level of harm in their areas - this is important stuff, you need to get a grip on them, do you not, and we need to know how much they are spending overall, what they are spending on individual services, what is the level of harm in their areas and they ought to have a strategy. That is something that your department can do, is it not? Mr Taylor: We certainly want them to carry out a proper needs assessment of their areas, they certainly should have and have now got access to better data to support them to do that than they have had in the past. Since last October local alcohol profiles have been published. Q5 Chairman: The answer to my question is yes. Mr Taylor: PCTs should be addressing this as an issue in the way that I have said. Q6 Chairman: Thank you very much. If we look at paragraph 22 in the summary on page 9 we see "The new PSA indicator on alcohol is a way of encouraging local NHS organisations to focus on alcohol harm." Great. However, we also read, "The adoption of the indicator locally is optional." Why is it optional and how can we be confident it is going to reduce the number of hospital admissions if this new target is optional? Mr Taylor: First of all we will measure the progress on the indicator against the performance of all PCTs and we will publish information on the progress of all PCTs. What we did with the introduction of the vital signs framework was to broaden our approach effectively away from top-down management to a stronger emphasis on PCTs looking out for their populations, and they were given a range of indicators rather similar to the system applying to local authorities which they could prioritise. As the Report confirms, 99 PCTs prioritised alcohol, 46 of the 50 areas with the biggest alcohol problems did so and we are encouraged by that as an indication of the seriousness with which the NHS is addressing the issue. We think it is important that PCTs should be allowed to set their own priorities in this area although all the evidence is that more and more of them are seeing this as a priority within their area. Q7 Chairman: Fair enough, but let us look at figure 7 which we find on page 19, which tells us - and we can see it for ourselves, it is very graphically there in that map, is it not - there is little correlation between the number of alcohol misusers and the amount spent on specialist alcohol services across PCTs. This is rather worrying, is it not? You would expect that where the index of alcohol harm was most you would expect to get a lot more spending, but that does not necessarily follow. We also read in paragraph 2.4, just to push things along a bit - and we all know that alcohol abuse causes huge amounts of problems; our sister committee estimates it at £7.3 billion a year, this is the report out this week from the Home Affairs Committee - that £197 is spent per dependent drinker compared with £1,744 per drug user. Despite what you said in your last answer, which as always is very reassuring, they are doing the right thing, they are spending much less per dependent alcohol user than they are on drugs and services across the country are very patchy indeed and do not necessarily relate to where the most harm is. Mr Taylor: We certainly think there is scope for improvement in this area as a result of greater prioritisation at PCT level, there is no question about that. We think there is some evidence of progress in that respect as PCTs strengthen their commissioning capability, take joint needs assessment increasingly seriously and look out to their populations to look for where they can make the most effective interventions. We need to be a bit careful about drawing a tight correlation between level of spend and effectiveness of spend - I think the NAO Report itself provides some helpful caveats in that respect. What we should be looking for is progress on, for example, the key indicator which we have set in relation to hospitals and hospital admissions. Q8 Chairman: Yes, everything you are telling me is beautifully put, very reassuring, but you are not actually answering a single question I am putting to you. Mr Taylor: I think I am. Q9 Chairman: You are not actually, with respect. For instance, I gave you a fact, £197 is spent per dependent drinker compared with £1,744 per drug user; you refuse to acknowledge that. Mr Taylor: First of all it is apples and pears in the sense that treatment of people with drug problems is inherently more expensive than treatment of dependent people with alcohol abuse; it is partly to do with the nature of the treatment, it is partly to do with the rate at which people with acute drug problems present and so on, so it is apples and pears. That is not to say that we do not need a more sustained effort than we have got at the moment and a more systematic approach to dealing with alcohol abuse. Q10 Chairman: Why has there been a sudden burst of activity in 2008? A lot of these new initiatives started in 2003 but not much happened in the first few years, then suddenly - it is not because of the interest of this Committee and the NAO, is it, that we have had these new initiatives suddenly this year - for example, regional alcohol offices, supplementary guidance for PCTs, on-line training, information for drinkers, consultation on retailing code, a new Directed Enhanced Service, all in 2008? It is not because of the NAO is it? Mr Taylor: To be fair the first annex to the Report indicates that following the 2004 strategy there has been a pretty constant stream and a cumulative stream of initiatives from the department which have been aimed first of all at improving education and information in relation to alcohol generally, in relation to helping the environment in which people make choices about alcohol and in relation to supporting the NHS, for example, with advice on commissioning. That has undoubtedly gathered steam; I am sure the NAO survey was another stimulus but certainly the department has been pushing away at this agenda for some time. Can I also add that one of the things that has made a difference has been the new emphasis in the vital signs framework away from just setting single top down targets, but giving PCTs in effect more licence to set their own priorities. Q11 Chairman: I bet you if I asked people in this room to put up their hands and say what do you think is a sensible level of drinking they would probably say for a man 21 units a week - that is engraved on my consciousness, but that is wrong, is it not, because 13 years ago you changed your guidelines. If you look at page 23, figure 8, the guideline is no longer 21 units of alcohol per week, men should not regularly drink more than three or four units per day and women two or three units per day. Even the Daily Telegraph got it wrong, they said "The government recommends a limit of 14 units of alcohol a week for women and 21 for men" but that is not actually right, they have a daily limit now, do they not? Why have you had so much difficulty in getting your message across 13 years after you changed your guidelines? Mr Taylor: There has been some progress in getting this message across and some survey data does show that people think they know what the levels are. I am sure in some people's consciousness that still does relate to the weekly rate rather than the revised approach which we think is probably more balanced of the daily guidelines. That is why, frankly, we launched this big programme relating to know your units early this year - early indications are that that is having some effect. Other things which have changed of course are that overall the alcohol content of drinks has increased and glass size and so on has also increased in pubs so there has been some confusion in the public mind about units. Q12 Chairman: Can I stop you? This is very important because if you go into our pub now and loads of our children - my children are going to pubs - are being offered a large pub glass, 13%, a glass of red wine, that apparently is 2.3 units. If you have one large glass in a pub you immediately --- Mr Taylor: At 13% alcohol I think. Q13 Chairman: Yes, a glass of red wine, 13%, quite normal, you are immediately up to the limit for driving. Mr Taylor: Yes. Q14 Chairman: I am not sure again how many people in this room could immediately answer that question, and I think this is something perhaps where you should be more open with the public, that if you drink one large glass of red wine in the pub you are straight up to the limit. Mr Taylor: That has been very much the purpose of the campaign which we have been running, both through national campaigns and through local information. We are doing an evaluation at the moment of the immediate effects of that and provided we get the results through in time I could let the Committee have a note on how that is coming out. I expect that to show some overall improvement in public understanding of what the units are, but I am sure we have a long way to go on that. Q15 Chairman: What worries me - and this is for you now because we do not often get you, we often get Mr Nicholson who heads the health service, you are the Permanent Secretary and you are going to help us on lifestyle choices, public health choices - you are losing this battle are you not? The number of hospital admissions for alcohol has doubled over the last 30 years; are you losing this battle? Maybe it is a battle you cannot win, maybe it is something to do with society and it is just beyond your scope. Mr Taylor: I do not think we would take that view, we think that it is possible with effective marketing to increase public awareness of units and of what is safe and responsible drinking. We need to do that in co-operation with other key players, including those in industry and those retailing alcohol, so it has got to be part of a much wider approach so that information about this is more easily accessible to people who are drinking and they are drinking in an environment which is more supportive of them in that respect, and all those things come together. It is about in one sense education, enabling people to make healthy choices, but also putting them in an environment so that, for example, labelling on bottles of wine, on beer and in pubs is clearer and up to date. Q16 Chairman: It is a pity that having spent £7.3 billion on the new GP contract - we know a lot about that in this Committee and you know about it, you appeared - there is nothing we see in 3.17 on the Quality and Outcomes Framework for GPs on alcohol. That is my last question. Mr Taylor: As you know the department has just launched a Directed Enhanced Service which effectively has the same effect as the QOF in terms of incentivisation of GPs to support GP practices in better intervention and offering brief advice, and an £8 million commitment is part of that plan. Chairman: So you are fixing that; thank you very much. Richard Bacon. Q17 Mr Bacon: I am interested in your last answer because it says in the Report that three-quarters of attendances at accident and emergency in peak hours are alcohol-related. We know that a significant proportion of domestic violence is alcohol-related and if dealing with this were really a high priority you would not have thought at the last minute, after the GP contract had been negotiated, finalised and signed, oh, we had better get a bit of directed enhanced service which, as the Report says, you did in September 2008 because you were coming before the Committee of Public Accounts. It would have been integral in your thoughts and in your strategy from the word go when you were spending this £7 million or £8 million on the new GP contract, would it not? Mr Taylor: There have been lots of competing demands on the QOF structure with other clinical priorities being taken into account. I know when decisions on that have been made the potential of using QOF and DES for alcohol services has been considered and the honest answer must be that other things have been prioritised. However, it is important to say too that what we have seen over the last two to three years is a growing recognition of the potential harm that alcohol is doing and a growing consensus about effective ways of intervening to prevent it. I am not sure that we have been in as confident a position as all that until pretty recently. Q18 Mr Bacon: Alcohol has just got steadily cheaper, has it not? That is part of the problem. Mr Taylor: Certainly over time I am sure one of the factors - certainly international evidence suggests that the price of alcohol is one of the issues. Q19 Mr Bacon: This is a case for joined-up governance with your colleagues in the Treasury is it? Mr Taylor: As you know decisions on tax, if that is where you are leading me, are very much a matter for the Chancellor and I am not going to tread into that territory. Q20 Mr Bacon: I would not dream of leading you there Mr Taylor. Could I ask you about the training of doctors? It says in 3.14 that fewer than half of the NAO sample of GPs felt that they had adequate training and you have provided £650,000 in 2008-09 for medical schools to develop training that is intended within ten years to produce 60,000 new doctors specifically trained to identify and advise or treat people who are drinking too much. Why does it take ten years to produce doctors who can help with alcohol? If three-quarters of attendances at A&E are alcohol-related the fact that you are prepared to sit back and have it take ten years and only put £650,000 into it does not, to be honest, sound like you are taking it seriously. Mr Taylor: If that were all we were doing it would be a fair criticism. Q21 Mr Bacon: Why does it take ten years? Why do you not say that by a certain date, 2010 or whatever it is, we will have done it? Mr Taylor: That is related to the introduction of a stronger emphasis on educating doctors in training in this area from the word go, and if course it takes a long time to train a doctor, so that is the core training which doctors are providing. Q22 Mr Bacon: It does not actually take ten years to train a GP does it? Mr Taylor: Not at all. Q23 Mr Bacon: How long does it take to train a GP from the moment they go to medical school until they qualify --- Dr Prunty: It is 60,000 over a ten year period that will be trained. Q24 Mr Bacon: Sorry, my question is how long does it take to train a GP from the moment they enter medical school as a fresh undergraduate until they can put up their hand and say I am a GP; what is that time interval, seven years? Dr Prunty: It takes in the order of eight or nine years depending on their training path. Q25 Mr Bacon: Yes, but it is not ten years, is it? Dr Prunty: The figures refers to the number of doctors who are in undergraduate training over the next ten years will be trained in this area, so it does not mean that the training will not take place in year one, two, three and four, but after the end of ten years all doctors in training will have received alcohol training. Q26 Mr Bacon: What is the total number of doctors who get trained in a ten year period? Dr Prunty: 60,000. Q27 Mr Bacon: It is 60,000, so it is all of them over that period. Dr Prunty: Yes. Mr Taylor: Can I just add to that? In addition to that core training one of the things we have been doing recently is to build effectively more learning capacity, education capacity, within our existing system. For example, we are about to launch in the jargon a new learning facility over the web which will enable all primary care practitioners - GPs, practice nurses and others - to get themselves trained up on best practice in relation to the use of brief intervention, one of the things that is mentioned in here, because that is obviously one of the concerns that has been expressed in the field, that people do feel under-developed in that area. Q28 Mr Bacon: That kind of brings me to my next point because the directed enhanced service which is screening of newly registered GP patients - this was the thing introduced in September 2008 to take account of the fact that there is nothing in the GP contract - only refers to newly registered patients; why not everyone? I mean, what is the turnover of the average GP surgery? If the average GP list is 1250 how long will that take in numbers of years completely to replace itself? Do any of the doctors know? Dr Hakin: It is hugely varied but it is a relatively small percentage. Q29 Mr Bacon: I would have thought so, yes. Dr Hakin: It is important to remember that as well as the directed enhanced service - which took a very considerable time to negotiate so it was not a last minute thing in September, that was when it was finalised and those services are an absolutely integral part of the contract, they are not an add-on, as Hugh said they are just an alternative to QOF - as well as that a significant number of PCTs are actually using another kind of enhanced service so we are already, because of the devolution of people's ability to do things, seeing PCTs across the country delivering local services and actually screening far more than the newly registered patients. In terms of what goes into the GP contract, as Hugh rightly pointed out, it is a question of prioritisation, there are competing priorities, heart disease, lung disease. Alcohol is of significant importance and we are working on how we might improve it. Q30 Mr Bacon: If you look at the bottom of page 27, note 23 "The average number of adults per GP list is 1250, so if all hazardous and harmful drinkers were the target, we could anticipate that each GP has about 325 patients drinking above the guidelines. Around 63% of adults visit their GP in a year so GPs could have the opportunity to identify over 200 patients per year" but they are only doing 66. This new scheme, which is at the point of contact with the patient, is only targeting newly registered patients. I know from electoral rolls that urban and rural turnover is very different, but if in an urban area you can get 15% or more turnover of an electoral roll I am sure it is the same with GPs. That would leave, even in the most concentrated areas, 85% of the available possible cohort not being touched by this enhanced provision. Dr Hakin: That is right and again we are working to look at the contribution in the future to increase it, but as I say other priorities such as smoking and vascular disease all have to be taken into account. There is huge range of priorities. Q31 Mr Bacon: I know that there is a huge range of priorities, but I go back to the point I made at the beginning. Three-quarters of all attendances at accident and emergency are alcohol-related. I forget what figure it is for domestic violence, but it is very high just as an absurdly high proportion of crime - it is 71% of violent crime - relates to funding a drug habit. It is very, very concentrated around alcohol, the attendances, and we know the pressure on A&E, it is absolutely enormous. Surely this would be a relatively small investment to get this right. You sound like you are admitting that you are ignoring 85% and just doing what you can after the event. Dr Hakin: We are completely committed, in the whole of the GP contract, to
ensuring that everything we put into it is cost-effective, and it is only
recently that we have had more certainty about the brief interventions, so for
this particular occasion we had other priorities but I am sure there will be
discussions in the future about extending that.
As I say, if you just look at Q32 Mr Bacon: The evidence at 3.16 suggests that some of the brief interventions are both ineffective and expensive. Can you distinguish what are the factors that make for an effective and economical brief intervention rather than one that is expensive and not that effective? Mr Taylor: One of the things that we are doing there is a research programme that is referred to in the NAO Report called SIPS which is looking at the way brief interventions are done across 53 sites and we are doing some analysis of what turn out to be the best and most cost-effective ways of doing that. While the overall methodology of brief interventions is well evidenced and well documented, both in this country and abroad, there are still lessons to be learned about the best ways to do it. Q33 Mr Bacon: I am running out of time but I have two quick questions, one about glasses, the size in which alcohol is sold; that is a statutory matter is it not, whether it is sold by a pint or a half pint and the size measure in which spirits are sold? There was talk of moving to the Australian system where you have something larger than a half but less than a full pint, and presumably it is the same for wine glasses and the size in which they are sold in licensed premises is controlled by law is it not? Dr Cavendish: That is largely a matter for DIUS. Q34 Mr Bacon: For DIUS? Dr Cavendish: They lead on weights and measures and it is a weights and measures issue as I understand it. Q35 Mr Bacon: Presumably you could be liaising with your colleagues in whoever it is - it might be HMRC, I do not know - to influence what is the statutory size at which alcohol is sold. The Chairman referred to this large glass of wine; you could be influencing that through your public health role. Dr Cavendish: What we are consulting on at the moment is whether we need to take action to expand the range of choice available to people. In the mandatory consultation that closed last month we posed the question of whether we should make sure that there was a range of choices available on glass size, exactly so that people could get a smaller size if they wanted to, because there was some evidence that people could not. They wanted to go in, have a small glass of wine and they were refused service; that is something we think we should probably take action on, but the consultation closed last month and we are considering it at the moment. Q36 Mr Bacon: Finally, the best place to look surely is where things are going well and on page 28 it gives an example at Liverpool and at St Mary's Hospital, Paddington, of where things are going well. Why do you think it is that there are so few examples of good practice? Dr Cavendish: We could multiply more examples of good practice. There are some that are emerging across the country, including in your own area, so I do not think we are short potentially of examples of good practice. The argument in the Report, which we have to accept, is that that good practice is not being followed through systematically. Chairman: Thank you very much; Mr Ian Davidson. Q37 Mr Davidson: Can I ask whether or not we are essentially losing the battle against alcohol abuse? Are things getting better or worse? Mr Taylor: Measured by the indicator which we have set ourselves as the key indicator to measure future progress, at the moment things are getting worse. In other words, the number of hospital admissions --- Q38 Mr Davidson: I just want you to be clear, things are getting worse. Can I just clarify then, compared to as it were the battle against smoking, are things getting better in relation to smoking abuse? Mr Taylor: Yes. Q39 Mr Davidson: So there is a contrast. To what do you ascribe the fact that you are doing better against smoking and worse against alcohol? Mr Taylor: First of all the public health messages on smoking are more straightforward and more simple because in essence they are do not do it and any smoking harms you. Q40 Mr Davidson: I understand that. Mr Taylor: Alcohol is a fundamentally more complex message because at certain levels it does not harm you. The other thing is unquestionably that smoking has been shown conclusively, if we can get you to stop smoking, to have the biggest single impact of any public health measure. We have been at it for longer, we have learned more about how to do it in overall public health terms. Q41 Mr Davidson: Is it mainly then a question of information? It is an information battle rather than anything else. Mr Taylor: It is three things: it is information and education, it is getting the right environment where people are making those choices properly and, thirdly, it is about better service provision, and one of the things we have succeeded in doing with smoking to some extent is getting effective - although I think it is a simpler task - local interventions on, for example, smoking cessation services. It is not just one thing. Q42 Mr Davidson: I understand that. We have had a letter in from the BMA - usually when they send us stuff it is all self-serving but this time it is relating more to the general issues that we are dealing with. Do you agree with their analysis about how to tackle alcohol abuse? They are mentioning higher tax and I think there is a clear correlation between price and consumption, is there not? They mention irresponsible promotions and the display of standard labelling - is there a consensus between yourselves and the BMA on that? Mr Taylor: Certainly in the latter area which is around the area of labelling, of promotion, of the retail environment, there is a very strong consensus. As you know we have been consulting --- Q43 Mr Davidson: What about the question of price? I understand that it is not for you to decide what the tax level should be, but do you agree with their analysis that higher price would discourage consumption? Mr Taylor: The international evidence suggests there is a correlation between price and consumption. Q44 Mr Davidson: In terms of your relationship with the drinks industry I wonder about the extent to which you are handicapped by the fact that the drinks industry is simply too powerful both economically and politically to allow you to do the sorts of things that you might want as compared to smoking where the industry was less powerful. Could you comment on that? Mr Taylor: It is important that we work together with industry on this and there have definitely been some encouraging signs. They themselves have put up some money to work on better education and programmes on sensible drinking and so on. Q45 Mr Davidson: Sorry, how much have they put up? Mr Taylor: It is £12 million over three years. Q46 Mr Davidson: How much is their turnover per year? Mr Taylor: They make a lot of money. Q47 Mr Davidson: So as a percentage it is infinitesimal. Mr Taylor: We, as you know, have worked closely with them on a voluntary code in relation to retailing practice and we published a report in July having had a survey done by KPMG which, frankly, was disappointing in relation to how that voluntary code is working, which is why we are now consulting. Q48 Mr Davidson: Disappointing - sorry, can I just clarify, disappointing means that they were not doing it. As I understand it the figure was that only 3% used the labelling scheme in its entirety, that was the voluntary agreement, and I would say that only 3% is disappointing and I would have thought another way of saying it is that they were not abiding by it. Mr Taylor: There was some indication, for example, that well over 50% were including information on units. Q49 Mr Davidson: Yes, they were doing something but they were not actually doing what they had agreed, is that correct? What they agreed was the full monty so only 3% of the labels had on them what they had voluntarily agreed to put on them. Mr Taylor: Just in relation to the labelling exercise, strictly speaking the time period over which we asked them to comply with our suggestions on labelling has not yet finished, that exercise has still some time to run and that is clearly a problem. In relation to other examples of retailing which is to do with promotion and the way licensed premises are managed, staff trained and so on, which are all features of a voluntary code, again the KPMG report found instances where that clearly was not being followed which is why we are now consulting on the mandatory code. Q50 Mr Davidson: We have disappointment there at 3% but what sort of percentage have we got there that are not following it? Mr Taylor: I am sorry, can you remember? Dr Cavendish: I did not quite catch the question. Q51 Mr Davidson: This is in reference to the point about them not following the voluntary code. Dr Cavendish: There are two different reports. There is one report that was following the question of whether the alcohol industry was --- Q52 Mr Davidson: That is the 3% one. Dr Cavendish: That is 3% in full compliance. Around two-thirds are putting unit labelling on their bottles and cans but only 3% are doing it in the entirety. There was a separate report on the social responsibility code that the alcohol industry pulled together in 2005; that was not a representative sample, KPMG looked at some clubs and pubs and some retailers. Q53 Mr Davidson: What were the results? Dr Cavendish: As the Permanent Secretary said they were frustrating. Some were doing great practice, often the larger ones ---- Q54 Mr Davidson: That is generally not a good thing, is it? I just want to be clear. Dr Cavendish: I cannot give you a number. Q55 Mr Davidson: But you must say it is unsatisfactory. Dr Cavendish: Yes. Q56 Mr Davidson: Can I just clarify one point that you are making there about the labelling. You are arguing in the industry's defence that they were putting something on it to do with units but only 3% were doing the whole thing. If they were actually putting something on about units surely at the same time as they did that they could have put everything that they had already agreed to on it, so why would they strike a voluntary code and then not actually abide by it. I could understand if there was an issue about it takes a while to get the labels printed and everything else, but if they have changed to put something on it why did they not change it to put everything that they actually agreed on it unless they are bad people? Dr Cavendish: We are looking for a majority of the alcohol industry to be in compliance with the agreement on labelling by the end of this year. We will then do some research on whether that is the case or not and we will take a decision - indeed, we put this in the consultation in July - in March next year of whether we will move to a mandatory position or not. Q57 Mr Davidson: That is not actually answering what I am asking. What I am trying to identify is the extent to which the industry are genuinely committed to this voluntary approach, and it seems to me that if they have made some change to include information about units, but they have not actually done the complete change to what was voluntarily agreed, that is an indication of bad faith is it not? Dr Cavendish: Sections of the industry have complied more strongly, others have not. Q58 Mr Davidson: Can you tell us who has not complied? Dr Cavendish: Some of the major companies. Q59 Mr Davidson: Can you tell us the names? Mr Lawrence: We can provide the list; it was published at the time. Q60 Mr Davidson: Can you just give us one of the bad names then - can you remember any of them? Dr Cavendish: We have an issue with Diageo - and we could again find some more background on their position and our position on why they seem unwilling to comply with the voluntary position. Indeed, some companies have asked for mandatory labelling because they believe a level playing field would be the appropriate position to take. Q61 Mr Davidson: It would be very helpful if you told us who were the laggards who are behaving badly and who were adopting a more constructive position and we actually had it in writing. Could we have it reasonably quickly because sometimes it takes us a long, long time to get information out of departments and even if you cannot produce everything that we want from this Committee, maybe you will let us have that early in order that we can do with it as we see fit. Coming on to the question of joined-up government some would say how appropriate is it and what sort of message does it send out when alcohol abusers can get enhanced benefits through the benefit system? Is that not something that sends out entirely the wrong signal? Mr Taylor: I am not quite sure where that argument would take you. Do you mean people who have been convicted? Q62 Mr Davidson: No, people in my constituency have indicated their unhappiness about the fact that alcohol abusers get additional money through the benefits system and they think that that actually rewards bad behaviour. Is that something that you agree with? Mr Taylor: I just am not sure that I am aware of the situation in which people would be getting extra benefits. Q63 Mr Davidson: You are not aware of it - surely you must speak to the other departments. Mr Taylor: Yes. Q64 Mr Davidson: Surely if another department dealing with benefits was undertaking a course of action which was undermining the message you were seeking to project you would want to comment to them on that. Mr Taylor: If that were the case. Q65 Mr Davidson: Have you commented on this at all if you are not even aware of it? Mr Taylor: I have to say that the issue and the way that you have expressed it, that there may be perverse incentives which are supporting people who are alcohol misusers, then that would be something that I would want to follow through, but that has not been raised as an issue. Q66 Mr Davidson: It has been raised now. The final point that I wanted to ask about relates to the point that was made by one of my colleagues about glasses. I understand of course the point about glasses in pubs but one of my members of staff actually raised with me the fact that Habitat and Debenhams and the like are now moving towards much larger glasses, more fashionable, larger glasses so that by the time you have filled one of those you have almost taken half a bottle of wine. Have you been speaking to people in the glassware industry as well as those who are actually in pubs because pubs have tended to sharpen up their act a bit and are much more responsible than they were and drinking at home is now much more of a problem. People are much more likely to drink more if the glasses they are using, particularly for wine and spirits, are themselves larger. Is there anything that you are doing in that regard? Mr Taylor: Our discussions have focused primarily around the way in which alcohol is dispensed rather than glasses sold, but I will follow that up. I am not aware of us being involved in any such discussions. Mr Davidson: Thank you. Chairman: Thank you, Mr Davidson. Listening it strikes me that perhaps a supplementary hearing where the chief executive of Diageo might be summoned to this Committee might concentrate his mind, so we might think about that. Mr Pugh. Q67 Dr Pugh: The figure given in the NAO Report says that £217 million is spent on alcohol services by PCTs. Am I right in assuming that the bulk if not all of that £270 million is spent on dealing with people who have acute alcohol dependency issues rather than on health promotion and stuff like that? Mr Taylor: That would be accurate. Q68 Dr Pugh: Are we aware how much of that money - and my principal line of questioning is concerned really with the severely dependent - is spent in the private sector commissioning rehab and the like? Mr Taylor: I do not have that specific figure in my head for the private sector. I know that a lot of the service provision in that area is provided by the third sector, by the voluntary sector. Q69 Dr Pugh: The voluntary and private sector, but you have no idea how much we are actually spending with organisations outside the NHS. Mr Taylor: I have a figure in my mind of about 50% but it may be more than that. A significant proportion of specialist services in that area are provided by the third sector. Q70 Dr Pugh: The fact that these services exist does not necessarily mean that they work; have you commissioned any research into which of the variety of the voluntary sector or private sector or public sector providers actually do the job of rehab best? We are all probably aware of acquaintances and the like, people who go off to rehab, come back and find themselves not much better but the person who provides the rehab financially benefits, if I can put it like that, and there is a lack of integration sometimes, a lack of follow-through. In terms of looking at what we call the patient pathway here can we differentiate between simply going through the motions and actually effective practice? Mr Taylor: There is evidence on best practice in this area as in other areas and effectively that surrounds stepped progress so that you need measured interventions at each step. It is a chronic relapsing condition, problems with severe alcohol, so it is not inherently surprising that some people who go through it --- Q71 Dr Pugh: There is not a high success rate, we understand that. Mr Taylor: Overall it is demonstrated that a combination of therapy, cognitive behaviour type treatment services, supplemented in some cases by detox-like facilities --- Q72 Dr Pugh: What I am aware of is piecemeal across the country there are different regimes in place; this Report makes it clear that there are different regimes in different places but I have not seen any sort of consistent spreading of best practice or even any real rating of how efficacious any of these regimes are; have you any sort of data that would help here? Mr Taylor: We have some data which was produced for the study which we published in 2005 which looked at the evidence base for interventions, and some of that of course relates to how well the interventions are delivered on the ground, so it is one thing to describe them, the other is to see how they are delivered. When I talk to the specialists about this they will say the evidence of what works is there, the question is getting people to go out and do it - commission it effectively and then deliver it. Q73 Dr Pugh: It is effective commissioning really that it is all about, is it not? My concern is that as you go to the GP with a problem, the GP does something in referring you to rehab so he thinks he has done something, the rehab people then do something, the person is then returned to the community and the problem then replicates itself. That must be happening pretty frequently. Mr Taylor: Certainly the evidence as I understand it suggests that at each step in that process what you want is a properly worked-through stepping up process, so moving somebody from referral, unless they are presenting with very, very acute problems right through for example to detox would not be the right step, you would want to go through several steps before doing that which would include properly constructed questionnaires, interviews, some counselling and so on before getting to the end. Q74 Dr Pugh: Would it be fair to say that at the moment the data is not there on what is the most effective patient pathway. Mr Taylor: I am certainly influenced by the fact that I sat with some of the most eminent people who told me that the evidence is there of what works: it is a stepped process of interventions and I think the issue for us is communicating that more effectively out to the field. One of the things we have committed to is to publish what evidence we have on best practice in the field through what we are describing as a learning centre so that practitioners out there can look at what works. Q75 Dr Pugh: The Chairman put before you the fact that you spend £197 on the alcohol dependent but on drug dependency you spend £1,744 per capita. When asked to explain this you said actually drugs problems and drug addictions are quite tricky, but what seems to be the case in your answers so far is that an alcohol dependency is just as difficult and just as intractable. Severe alcohol effects that means. Mr Taylor: Severe alcohol dependency is intractable. My recollection is that the difference is - and I am going to do this off the top of my head so you will forgive me - that around 50% of people with severe drug problems effectively recognised the need for and get services, which means that there is a higher overall percentage of the problem who have that issue and who have that problem get through to treatment services. The proportion of alcohol dependent people is much lower - the international standard in my mind is about one to ten; we might be benchmarking ourselves against one to ten and we are 5.6. Secondly, the drug treatment itself involves methadone substitution use of drugs, which we do not have. We do not use substitute drug therapy very much in alcohol and it is inherently more expensive. That is all I meant when I was talking about the cost. Dr Pugh: A friend of mine who is an alcoholic - not a Parliamentary friend --- Mr Bacon: So a Liberal Democrat. Q76 Dr Pugh: Not a Liberal Democrat either, stated that one reason why he felt he could not get the clear support that he wanted within his own areas and neither could other alcoholics was because when alcoholics present themselves and deal with their problems, what they do is they go to the off licence and purchase alcohol and by and large drink it at home, and there is no real social dimension to it, whereas the drug user if they cannot get their drugs, first of all have not obtained them legally and, secondly, may well commit crime in order to obtain them, so although the problems are much the same the social cost to society of a person persisting with a drug habit as opposed to a severe alcohol habit may differ. I am not necessarily convinced of that but have you done any sort of calculation that would enable you to know what the social cost is, all the costs of maintaining a population of alcoholics as opposed to maintaining a population of drug addicts Mr Taylor: There are some estimates of the total cost of alcohol abuse, both to society --- Q77 Dr Pugh: But that does not disaggregate things like binge drinking and misbehaviour and so on. Mr Taylor: No, it does not. Just from the highly dependent group I do not think we have such information. Q78 Dr Pugh: Because they go to A&E pretty frequently and they do not work and may even get extra benefits for all I know. You do not know that information but you are not surprised that most GPs talk about a shortage of rehab, 73% according to the NAO Report, and 63% say that there are too few alcohol counselling sessions. Mr Taylor: We recognise that there is a need for more provision both of rehab and, for example, detox. I am not surprised to hear GPs say that they feel that is a need. Q79 Dr Pugh: That seems to reinforce the point that you are simply not spending enough money on this problem, or do you think in fact that even if you do spend money you do not solve the problem? Mr Taylor: It is to do with working out what services are needed. As PCTs prioritise this area, which they are showing evidence of doing, what will follow from that is more investment so I would expect there to be an increase in provision in services as people prioritise. Chairman: We have a division now and I am warned that there may be multiple divisions which will make our life very difficult. We are going to drive the divisions, go down and come back as quickly as possible to get through the last few questions. It is going to be a problem but we will try our best. The Committee suspended from Chairman: We are now quorate. Phil Wilson? Q80 Phil Wilson: The first thing I want to ask you is: do you feel overwhelmed at the problem when you have got 10 million problem drinkers who drink regularly, 31% of men and 20% of women? Do you feel the whole service is being overwhelmed? Mr Taylor: No, I do not think we do feel overwhelmed, certainly in comparison to what I think is an even more challenging problem which is that of obesity. Provided we focus this properly by effective public campaigns and by the sorts of steps which have been under discussion in this Committee about improving the way drink is promoted and sold, and by then ensuring that we get better services at local level to deal with hazardous and harmful drinkers as well as dependent drinkers, then I think we should begin to see progress in this. I think it would be fair to say that already there is a sense - and Barbara and I were talking about this before - partly as a result of the public awareness campaigns that we have been driving and partly because of the drip-drip-drip on PCTs in relation to this as an issue, of growing awareness both publicly and in the NHS of the need to address this issue. Nevertheless, as the Report confirms, we have got a way to go. Q81 Phil Wilson: However perfect the system is and if every PCT has worked out what its priorities are as far as alcohol is concerned, it is ultimately a cultural problem, is it not? Mr Taylor: Not just, but the fact of the matter is levels of alcohol consumption in this country grew dramatically in the period between 1970 to 2000 and that has to be as a result of a combination of factors including cultural factors. There have been some indications of stablisation since then but, partly as a result of this increasing alcohol consumption, what we are seeing is increased evidence of the impact on people's health, so I do not think we should see it as an overwhelming problem but one which demands increasing focus both from the Department (because this is an area, as the Chairman has pointed out, where I think we can add value through working across other government departments) and through national campaigning and through effective local prioritisation in the NHS. Q82 Phil Wilson: I am trying to find the international comparisons at the minute. Mr Taylor: There is an interesting annex on that at the back. Q83 Phil Wilson: I am going to come to that. There were some figures where basically as far as the rest of Western Europe is concerned there are a lot of countries whose populations drink similar amounts to us but the problem we have is binge drinking. Do you tend to focus your attention on tackling binge drinking? Dr Hakin: I think the
international picture is mixed in the sense that other countries in Q84 Phil Wilson: You mentioned the international context, Appendix Two on page 39, it is the second paragraph at the bottom there: "In the countries studied for this report, a number of education and awareness campaigns aimed at preventing alcohol misuse and harms have been developed." It goes on to say: "However, for none of these campaigns has their effectiveness in altering drinking behaviour been demonstrated." Ultimately, we can talk about what kind of services PCTs should be developing, and obviously it should be something that is consistent around the country and targeting the appropriate populations, but in the international context the evidence seems to be that the only way that we are going to resolve this is if we increase the price of alcohol - and I am not saying I agree with that, I am just saying this is what the Report is saying - and also the age limits. In the US, for example, those states where the minimum drinking age is 21 years old find that they do not have as many problems with that, so it is big, major cultural changes and also the tax regime as far as drink concerned that need to be the fundamental foundations to make sure that we have a cultural change in drinking. This is what I was getting at about do you feel overwhelmed, not that you cannot deal with it, not that you feel you are being defeated, just that you are overwhelmed that you are taking two steps forward and one step back? Mr Taylor: I think the first thing I would say is that what the Report is saying that there is not always a good evidence base around educational campaigns, internationally or nationally, is a fair cop, and one of the things we have tried to do is to build an evidence base around that. With smoking, for example, we have worked very hard to construct campaigns which are then based on evidence, so for example one of our targets at the moment is to reduce smoking in the routine manual work group, which has stubbornly refused to come down as fast as it has in other groups. We have a campaign plan there which is targeted very specifically. We feel confident enough there because we have some measures to say we are actually going to set an outcome measure for that overall campaign of reducing the number of smokers in that group by a target limit. In a sense that is a public education campaign. We feel that we have enough confidence in the various measures that we have built up over the years to do something like that. I do not think we are quite as confident yet as that on alcohol but that is the sort of evidence base we want to build up. Q85 Phil Wilson: The other question I was going to ask around this is how can you solve the problem with drink when someone can go into a supermarket and buy 20 cans of lager for £10? At least in licensed premises, premises like pubs and clubs for example, I know they have happy hours et cetera, at least it can be regulated and somebody if they are being responsible can monitor what is happening but somebody can just go into a supermarket and buy that much alcohol. What can you do to ensure that these people do drink responsibly, especially when they are taking it home? It is not the same as sending the police round to the pub, is it? Mr Taylor: Clearly in one sense there are limits to what you can do because this is a matter in the end of individual choice. Part of our campaign is to try and get people to make better choices and, as I have said in somewhat Mandarin-ese language I recognise, to create an environment in which it is easier for them to make those choices and certainly not one where they are being encouraged, frankly, to drink more than they need to. For example, one of the things we try to do is to discourage - and the industry have accepted this - promoting alcohol in a way that suggests it is going to improve people's sex lives or attractiveness. But still images of that kind persist, so I think there are things that we can do to make things better in that respect. Obviously in the end if a young person, or indeed anybody else, is determined to get hold of lots of drink and drink it, that is not something that we are in a position to control. Q86 Phil Wilson: In the North East of England, which is obviously an area of the country very close to mine - this is paragraph 4.5 on page 31 - a study estimated that only 1% pf alcohol-dependent people were accessing treatment in the lowest rated region, which is the North East. Has that improved? Mr Taylor: I think one of the real reasons for taking a more positive view of that is the extent to which in the regional strategies which were published in July, which coincided with Lord Darzi's Next Stage Review (which was based on the regional strategies and Barbara will have produced her own), the one for the North East had recognised the particular problems of alcohol dependency and harm and there are clearly dedicated action plans to get moving on that. There is certainly a recognition of the need to make a step change in both commissioning and delivery in the North East and I know the PCTs there are working with the strategic health authority to prioritise that much more effectively. Chairman: Okay, thank you very much, we will come back as quick as possible and try and get our last questioner Mr Mitchell in. The Committee suspended from Chairman: Mr Mitchell? Q87 Mr Mitchell: Cheers! Why is it that access to specialist treatment is so low? Only 5.6% of alcohol dependent people in this country get treatment; it is 10% in the United States and for drug users it is 55%? Why is it so bad? Mr Taylor: I think internationally 10% is regarded as a sort of benchmark and
there are some places in this country where we are getting to a 10% figure - in
parts of Q88 Mr Mitchell: You have to do a lot more. Do you not have to be tougher with them in the sense that for every 2.7 referrals, only one person actually made use of specialist services? They drift away, in a happy haze perhaps, but they to not get through. You have got to push these people, you have to hound them and you have do discipline them and yet it says in this letter from Alcohol Concern that they can face waiting times of up to 12 months to access specialist services. That is pathetic. Mr Taylor: The latest data we have is that 89% of people who are receiving alcohol treatment services were getting them within six weeks, so I am not quite sure what Alcohol Concern's figures are based on, although I would say there may well be some cases where people have to wait longer. I think the key thing about this though is that for the sorts of interventions we are talking about to be effective you do have to have a compliance from the individual, they have to want to benefit from the services, and where that is not the case it is going to be very difficult for the services to be effective. Q89 Mr Mitchell: Yes, but it would be much better if you had a national strategy of forcing the PCTs to do it and then gave them the responsibility to lead. Again, it is a letter from Alcohol Concern, which you have probably seen, that says primary care trusts have to lead on the reduction of alcohol-related harm. It goes on that PCTs must show "clearer leadership and be directly accountable for reducing alcohol-related harm and hospital admissions, even if delivery of services is devolved to local agencies". That is true, is it not, unless you get the PCTs pushing it, it is not going to happen? Mr Taylor: We agree that the central responsibility for taking this forward has got to be the PCTs. All we are saying is that we want them to do the commissioning of services effectively. We have got a number of things which we think will help them to do that better than they have in the past. There is the joint strategic needs assessment with local authorities and other partners and the World Class Commissioning process, which is both strengthening their core commissioning capability and is getting them to focus on alcohol as one of their five strategic priorities, so we think there are some positive signs there. Q90 Mr Mitchell: Is it not possible for me to say that you are pussy-footing around, you are not being as tough as you should be, you are not setting national standards in the way you should be, and the reason you are doing that is because you know that drink is the curse of the journalistic classes and there will be an outcry saying "It's the nanny state"? Mr Taylor: No, the reason that we have taken the approach we have done in relation to this for performance management purposes is that we want PCTs to look out to their populations rather than spending their time looking up to please us, and they should be making their own prioritisation decisions on alcohol --- Q91 Mr Mitchell: You should be pushing them. Mr Taylor: I do not think we are pussy-footing. Q92 Mr Mitchell: Let me turn to Dr Cavendish, It seems to me just as an observer (I was going to say as an alcoholic and a fat person!) you are being much tougher on obesity and much firmer about what people should do than you are alcohol. Dr Cavendish I think we are taking the same approach. Our approach is to educate and inform people to make healthy choices, to deal with a changed society so that it is easy for them to do so, and make sure we provide appropriate services that identify, advise and treat. Whether it comes to moving on food labelling, whether it comes to restricting alcohol advertising or food advertising, whether it comes to social marketing campaigns to give people the information and advice they need to make better decisions, it is a common approach because, you are right, we face common problems in both. They are both rising but they both cut to the heart of what individuals and families choose to do, so our approach has to be one about informing, advising and educating but creating a society in which people are better able to lead healthy lives. Those are our approaches in both obesity and alcohol. Q93 Mr Mitchell: I think we have got a good drug treatment programme in North West Lincolnshire and it seems to be working okay, but alcohol abuse is the poor relation of drug treatment. Mr Taylor: I think that is one of the reasons why your care trust is one of those which is in the group of 20 which we have just announced --- Q94 Mr Mitchell: Could you give me some figures on that; I would like to have something to be proud of. Mr Taylor: Okay, what I am saying is we have given you some extra money and provided you with extra support from the centre, giving you the push that you need in order to increase access to specialist treatment for example. Q95 Mr Mitchell: You have done research presumably. You did not want to commit yourself on the Treasury's view on the taxation of alcohol, but the research must show that price is a big deterrent to boozing. I know we are the Labour Party and the Scots are very powerful and they are always wanting to protect the Scottish whisky industry, but we should really approach this by putting up taxation on alcohol because the costs have come down relative to the standard of living and wages, et cetera. The only real solution that is going to deter people is more expensive booze. Mr Taylor: Well, leaving the question of taxation aside, which I get into at my peril --- Q96 Mr Mitchell: What does the research show? Mr Taylor: The research shows there is a link between price and consumption and one of the things we are doing at the moment is we have asked group of specialists in a university to look at that as an issue and ministers are looking at the report as we speak. Mr Mitchell: Thank you. Chairman: I think we can now end our inquiry because of the multiple divisions. Thank you very much for your evidence. I do assure you that this picture by Jan Havicksz on the cover of the NAO Report of a drinking orgy is not a picture of the Committee of Public Accounts! Thank you very much. |