Memorandum by the Socialist Health Association
(AL 16)
The Socialist Health Association was founded
in 1930 to campaign for a National Health Service and is affiliated
to the Labour Party. We are a membership organisation with members
who work in and use the NHS. This includes doctors and other clinicians,
managers, board members and patients. We have held a number of
seminars and discussions across the UK on public health topics,
some specifically in respect of alcohol, and this submission is
informed by those discussions and by contributions from some of
our public health practitioners.
This submission is made on behalf of the Association.
1. The scale of ill-health related to alcohol
misuse is immense. No doubt the committee will receive much evidence
on this point, but we understand that alcohol misuse is associated
with:
— 30% of sexual offences;
— 33% of domestic violence offences;
— causing some 60 different diseases/conditions,
including injuries and mental and behavioural disorders;
— between 15,000 and 22,000 deaths
each year;
— 150,000 hospital admissions;
— up to 35% of A&E attendances
and ambulance costs (rising to 70% between midnight and 5.00 am
at weekends);
— 49% of attendances at A&E after
an assault, in Merseyside;
— £2.4 billion annually lost to
the economy due to premature death;
— 17 million days of absences from
work each year;
— annual losses in productivity of
£6.4 billion; and
— people of all ages, although it is
young people who are often highlighted, are more likely to have
unprotected and otherwise risky sex when alcohol has been consumed.
This results in accelerated transmission of sexually transmitted
infections, unplanned pregnancy and emotional distress.
2. All these figures are of course debatable,
but in our submission the damage caused by alcohol appears to
be similar in kind but much greater in quantity than that caused
by the abuse of other addictive substances, but resources directed
to alleviating the problems are not in proportion.
3. Evidence released by the Mental Health
Foundation shows the impact of the poverty gap to both individual
and collective mental health. Their report, "Mental Health,
Resilience and Inequalities", shows how the gap between rich
and poor affects the mental health of individuals by causing psychological
and physiological changes. Their report argues that mental health
is the lynchpin between economic and social conditions. Poor mental
health experienced by individuals is a significant cause of wider
social and health problems, including:
— low levels of educational achievement
and work productivity;
— higher levels of physical disease
and mortality; and
— violence, relationship breakdown
and poor community cohesion.
Mental ill health is closely linked to the abuse
of alcohol and other drugs.
In contrast, good mental health leads to better
physical health, healthier lifestyles, improved productivity and
educational attainment and lower levels of crime and violence.
This appears to be entirely consistent with the work of Prof Richard
Wilkinson and Sir Michael Marmot which relates the excessive inequality
in British (and US) society with high levels of all kinds of social
pathology.
4. It appears to us that nobody wants to
take charge of alcohol policy. Responsibilities at a national
level are spread over a number of different departments and we
don't see much evidence that they talk to each other. Culture
Media and Sport deal with licensing hours, the Home Office and
Department of Justice with policing, Customs and Excise and the
Treasury have a major impact on the price; The NHS picks up the
pieces; and the Dept for Business, Enterprise & Regulatory
Reform presumably regards the increasing consumption of alcohol
as something to be celebrated. The Treasury appears to have very
little interest in the problems caused by alcohol, or indeed the
cost of dealing with them. They regard taxation of alcohol as
merely a revenue raising exercise. Because there is no co-ordination
between them over the last decade they have effectively decided
to make alcohol cheaper in real terms than before, more widely
available through supermarkets etc. and available for longer hours.
Then just to add to the fun the industry has decided to make it
stronger. Wines are now 12-14% instead of 10-12% and beers are
often 5-8% rather than 3.5-5%. The impact has been to at least
double the harm done. The strategy of relying on voluntary regulation
by the alcohol industry is been shown to be ineffective. Budgets
have repeatedly raised the duty on drinks with lower alcoholic
content (beers, cider and wine) to a greater degree than the harder
drug of spirits. Presumably this is to support the whisky industry
but there could be more imaginative ways than increasing the accessibility
of higher strength drugs both neat and as incorporated into mixers.
5. Two structural changes took place in
the drinks industry during the 1990s that the drinks industry
should take full responsibility for. One was the market segmentation
of the pub trade and the other the introduction of alcopops. These
are interlinked. Prior to this decade, drink had an unpleasant
taste to most young palates and indeed was an acquired taste.
Pubs tended to contain a mix of ages, it was the nightclubs that
were the preserve of younger people. Young people were initiated
into the use of alcohol in pubs with more experienced users and
had to conform to the peer pressure around conduct and alcohol
use of the established users. Use of alcohol tended to commence
with high volume relatively low alcoholic content drinks such
as beers and ciders, spirits being an older taste that was graduated
to. Spirits were also expensive compared to beer and cider.
The pub market was segmented demographically
with pubs targeted at young people only or being for food mostly
or families. Alcopops were introduced. So we moved to a situation
where drinks designed for a young palate are being promoted in
establishments targeted at young people. Without the barriers
of an unpleasant initial taste, social mores of more experienced
users and with the encouragement of low price (the duty on the
spirit base of an alcopop being pegged or increasing at a much
lower rate than beer), it is unsurprising that as intended by
the drinks industry, consumption of alcohol increased.
During the 1990s there were changes in the pattern
of student drinking. There was a move from having a pint, having
another pint and maybe a gradual escalation that from time to
time resulted in extreme drunkenness to going out less frequently
but with the advance intention of getting drunk and as fast and
cheaply as possible.
6. Sadly central government presents an
example of the weakness of a partnership approach, which enables
all the partners to deny their responsibilities except for those
who have to clear up the mess. Such performance by a local authority
would be labelled as failing. The resultant costs falling on the
NHS (and the criminal justice system) are rising so rapidly as
to threaten its viability as a comprehensive service. The only
cost effective approach to health problems is to devote resources
to prevention.
7. At a local level various departments
within local authorities have an interest, including planning,
leisure, youth, trading standards, social services, environmental
health, education and those concerned with community safety, crime
and disorder and licensing. Outside the local authority there
are more players:
— businesses including pubs and clubs
and supermarkets;
— strategic health authorities; and
— sometimes two tiers of local government.
As with any partnership approach local effectiveness
varies very considerably, but the impression we have is that in
many places is that the police and the casualty department are
left to pick up the pieces with the other partners hoping that
the sale of alcohol will keep the local economy moving.
8. We need a strategy which covers:
(b) early interventions; and
We must consider honestly why we use alcohol
and be clear about what behaviour we actually want to change.
There are many mixed messages. Alcohol is a drug that seems to
meet a need in many of us, all users need to understand more about
why and how they are using it and policy needs to consider whether
there are alternatives with better outcomes for society. Like
other behaviours that have risks—self-injury for example,
alcohol use may well be a much needed coping strategy. There are
many who consider moderate to high use a perfectly acceptable
pleasure.
The current messages seem to be that we want
to prevent violent and irritating behaviour that impacts on others
and risky behaviour that exacerbates the situation of vulnerable
people. In addition we want to make people aware that even at
what many would consider low levels of use can cause health problems.
These are very different messages not necessarily of relevance
to the same person.
Thought should be given to the terms used and
social norms. It is most unhelpful to label "binge drinking"
a level of consumption that whilst causing health problems, is
below what many consider low or average. This just alienates the
user who then ignores the rest of the information.
9. Prevention has to cover price, and availability
and possibly advertising. We do not think that social marketing
approaches will be effective without an increase in the retail
price of alcohol. Alcohol consumption is quite sensitive to levels
of disposable income. The most price sensitive groups are the
young and the very heaviest drinkers. Unlike most pathology abuse
of alcohol is not confined to the poor and so our present economic
situation is likely to lead to a reduction in consumption, just
as increasing consumption over the past 10 years has been driven
by increasing prosperity. Alcohol policy has tended to focus on
the minority of the drinking population who are the heaviest drinkers.
However, it is actually the much greater number of drinkers in
a population who, on occasions, drink to excess, who account for
most of the alcohol-related problems. A greater proportion of
the overall burden of harm is associated with the acute effects
of alcohol use and drinking to intoxication, rather than the chronic
effects of sustained heavy drinking over a long period of time.
There seems good reason to suppose that in an increasingly mobile
world putting up prices could encourage smuggling unless this
issue is tackled across the whole of the EU.
10. Alcohol is a public health problem that
needs to be addressed within a social model of health promotion,
rather than focusing on treatment. It is not possible to order
the range of interventions into a hierarchy, with one being considered
more effective than another. The evidence points to multi-component
approaches, where attempts are made to make progress with each
intervention, within available resources.
11. The problems of price relate primarily
to supermarket sales. Wider availability of alcohol in supermarkets
has coincided with the phenomenon of young people getting drunk
before they go out for the night. It has also been accompanied
by very severe economic pressure on public houses. In our view
consumption of alcohol in the relatively supervised environment
of the public house is safer for all concerned than the alternatives.
We think serious consideration should be given to limiting the
amount of alcohol people can buy from supermarkets or off licences
at one time. This strategy seems to have been quite successful
when applied to the sale of paracetamol. We would also like to
see taxation much more closely related to alcohol strength and
the removal of various measures designed to protect indigenous
manufacturers of alcoholic drink.
We need to be wary however of the Scandinavian
experience where the price barrier results in sporadic heavy drinking—true
binge drinking with the attitude of "if I'm going to spend
£10, I might as well spend £1,000".
12. There are also problems associated with
some clubs and vertical drinking establishments. Our impression
is that police intervention in these establishments is very limited.
Prosecutions under sections 141 and 142 of the licensing act (sale
and supply of alcohol to people who are drunk) seem to be extremely
rare, although the streets and hospitals are full of evidence
of offences under these sections every week. We do not understand
why the provisions enabling licensed premises to be charged for
the cost of policing associated disorder have not been widely
used.
We would like to see consultation on the possible
raising of the age at which young people are allowed to buy alcohol,
and particularly spirits (we understand in some European countries
young people are only allowed to drink beer), although we should
be mindful that a major source of alcohol for young people is
parents and carers and that removing alcohol simply pushes young
people towards other drugs that may be more harmful both from
a health perspective (particularly as they are supplied in varying
and unpredictable strengths) and incur increased risks of being
drawn into criminality. We are in favour of lowering the driving
blood/alcohol limit from 80 to 50, and Random Breath Tests for
motorists.
13. Early intervention is about getting
GPs (and other professionals) to recognise the problem at a time
when fairly minimal intervention can be quite effective. That's
about training etc, but practitioners should only be regarded
as qualified to give advice if they understand their own motivation
around alcohol use, non use or abuse. Every polyclinic and casualty
department should have an alcohol-adviser available.
14. Services for those with serious alcohol
related problems MUST be properly funded and provided. At present,
we have been told repeatedly that they are the poor relation of
drug services. The tendering process is a disaster, bringing uncertainly
to services especially as often the contracts are for shorter
periods that a client will use a service. (Many clients are with
a service for 5 years, from de-tox through dry houses, therapy
and aftercare; this is impossible where the service provider is
constantly having to retender, and may lose the service.) Also,
funding is often only for new initiatives, but the on-going, high
quality and much needed services are devilishly difficult to fund.
March 2008
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