Examination of Witnesses (Question Numbers
1006-1019)
GILLIAN MERRON
MP, SIR LIAM
DONALDSON AND
MR WILLIAM
CAVENDISH
16 JULY 2009
Q1006 Chairman: Good morning. I welcome
you to the Committee for our sixth evidence session in relation
to our inquiry into alcohol. For the record, would you please
give us your name and the current position that you hold.
Gillian Merron: Gillian Merron,
Public Health Minister.
Sir Liam Donaldson: Liam Donaldson,
Chief Medical Officer, the Department of Health.
Mr Cavendish: Will Cavendish,
Director of Health and Wellbeing at the Department of Health.
Q1007 Chairman: You will be aware
that this is our sixth evidence session and therefore there has
been quite a lot of evidence put in front of us about the issue
of alcohol at this stage. On the current projections for the state
of the nation's health as a result of alcohol misuse, we have
had evidence that is truly shocking in relation to that. Minister,
has your national alcohol strategy failed comprehensively?
Gillian Merron: Is it acceptable
that I make a few opening remarks which might help frame some
of our comments?
Q1008 Chairman: I understand that
you have time constraints as of course have the Committee, so
please take that into account.
Gillian Merron: I will be very
brief. I do want to thank the Committee for inviting us to give
evidence today. It is an early opportunity for me as a Public
Health Minister to meet with the Committee. I would like to put
a few points on record which I hope will be useful about the Government
recognising that alcohol is indeed a rapidly rising concern and
it is a challenge to health and wellbeing of individuals, but
also to families and communities. In our strategy the Committee
will know that we have added tackling what is a silent epidemic
of the longer term effects of harmful drinking in addition to
binge drinking and underage drinking. I also wanted to make it
clear to the Committee that, whilst I see we have made some progress,
there is an awful lot to do. I particularly wanted to say that
we do find unacceptable the level of alcohol-related admissions
to hospital, crime and the level of death that we see. We know
the truth is that the majority of drinkers are able to deal with
alcohol responsibly and we have a duty to ensure that the public
is well-informed and supported, but we also have a duty to protect
the most vulnerable, including children, and we also have a responsibility
to the health of the public as well as their safety. I will be
making visits during the summer recess to see the work out in
the field. I am only interested in what works, as I know the Committee
is. We do have a real challenge. I think we need greater responsibility
from industry, we need the right action from government and we
need personal responsibility from drinkers. In conclusion, I look
forward to the Committee's report because I do feel that it will
help us very much in meeting the challenge before us, so I am
grateful for that opportunity.
Q1009 Chairman: That is an acceptance
of its findings and I am more than pleased, given that we have
got none together at this stage. I have a couple of related questions
and one is that if you look round at related alcohol harm in other
not dissimilar countries in Europe, it is actually falling in
those countries and it is not here certainly in England and Wales.
Why do you think that is?
Gillian Merron: That is the challenge
that we have before us. It is true that the overall pattern that
we have in the UK is that consumption is and has been rising for
some 40 years but we started at a relatively low level. I think
the levels of harm are rising below consumption, although they
are of great concern. There are a variety of factors for the UK:
social, economic changes and particularly we can look at the example
of women and girls and their involvement, drinking glasses have
got bigger, wine has got stronger, but we have the challenge of
binge drinking upon us. The initial question was about the workability
of our strategy in tackling that. It is too early for me to say
that the strategy has failed. There has been progress and I hope
we will go on to explore that but we have a lot more to do. There
are a number of areas where we are starting to make an impact
about better informed decisions, a healthier environment for people,
we are improving services and also we are seeking to improve the
whole system like bringing in a performance indicator, which I
think is focusing the minds of PCTs perhaps more and we are seeing
some good signs in that, which again I am sure we will go on to
explore.
Q1010 Chairman: The other thing about
the Cabinet Office 2004's Alcohol Harm Reduction Strategy, we
were told it argues that alcohol taxation should no longer be
related to public health. Is this the case and how can this be
justified?
Gillian Merron: Some of that is
a little above my pay grade and of course is a matter for the
Chancellor. I know you have just had an evidence session on taxation
and the Treasury. I do think that there is an imperfect relationship
between tax consumption and price. For me tax and price are not
necessarily the same thing. For example, any potential increase
in tax is not necessary. I do not just say this in relation to
alcohol; we see it in other environments and not necessarily passed
on. What matters is overall what are we seeking to achieve and,
overall, what is the best instrument to get there.
Q1011 Chairman: Sir Liam, what are
your views about this whole area? We will be asking more specifics
about taxation or the price of alcohol but what about the strategy
itself?
Sir Liam Donaldson: Most people
reflecting on the earlier strategy would say that it was probably
too narrowly-based and looked specifically at tackling harm; it
did not go broader than that. Thinking has moved on a lot and
I think the 2007 strategy was much more enlightened and broad-based
in its approach. You asked about the health-related outcomes and
this is a source of great concern—I highlighted them in
my 2001 report—showing an increase in liver cirrhosis particularly
in young people and I think the Minister is right, the broader
factors of price and availability which influence all of this
are relevant there, but then the particularly harmful pattern
of binge drinking has a big medical impact on people's livers
particularly, so it is a little early to say whether the strategy
is working, but it has certainly moved in the right direction
in being much more broadly based.
Q1012 Stephen Hesford: Sir Liam,
do you agree with the RCP that deaths from alcohol are in the
region of 40,000 a year?
Sir Liam Donaldson: There are
different death figures cited. Liverpool John Moores University
gives a lower figure—but the bottom line is that we need
to get through the Office for National Statistics a more reliable
figure. It is similar when you look at obesity-related deaths
that actually attributing a proportion of deaths from a range
of different causes to alcohol is quite difficult and is disputed
amongst different statisticians. I do not know whether that figure
is the right one but what we do need is a much better, regular
measure which people can rely on more than the different estimates
that we have at the moment.
Q1013 Stephen Hesford: So that we
do not go round pointlessly in a statistical circle, is there
an acceptable minimum figure of deaths annually—40,000,
30,000 25,000—that alarms the Department of Health that
we can work with?
Sir Liam Donaldson: We are not
alarmed but we are concerned by the relatively high level of alcohol-related
deaths generally. I would not want to put a figure on it. I feel
that the main priority is to sort out a proper methodology for
it and be able to give a figure that does not lead to arguments
and disputes every time it is published.
Q1014 Stephen Hesford: This Committee
and yourselves have been round this track with tobacco, for example,
successfully. In 1999 we reported and things have moved on successfully
over time. One of the startling figures for that and one of the
reasons that government eventually were caught up short with it
and had to act is the number of tobacco-related deaths—120,000
at that time—and unless we can nail down a figure and understand
what the patterns are, government will not act because you will
get this blancmange of an argument that it is not a real figure,
it is not going anywhere, so we need to know where we are going
with these figures.
Sir Liam Donaldson: I absolutely
agree with you, we do need to nail down a figure. It is not quite
as straightforward as with tobacco because the research on tobacco-related
deaths started in the 1950s with Doll and Hill, so it was easier
to attribute the fraction of tobacco-related illnesses to tobacco
and therefore work had been done over many years, but it is important
as a priority to sort this out.
Q1015 Stephen Hesford: What are the
projections then for alcohol-related deaths? What is the DoH thinking
on this? Where is it going?
Sir Liam Donaldson: It is a fairly
simple relationship if the level of alcohol consumption continues
to go up then we will see the related mortality go up. If we have
a measure of mortality we will be able to put numbers on that.
Q1016 Stephen Hesford: The Minister
said before that alcohol consumption is going up but alcohol-related
harm is not rising in proportion. Is that right? That appears
to be slightly different to what you have just said that there
is a direct relationship between consumption and harm rising.
Mr Cavendish: We do not have a
perfect measure of alcohol consumption, but in aggregate the amount
of alcohol consumed seems to have plateau-ed for the last three
to four years, perhaps has dropped a little in the last couple
of years, so there has been a halting in the rise of overall alcohol
consumption and given that the relationship between overall consumption
and forecasts of alcohol-related deaths, you would expect the
rate of alcohol-related deaths to be stable too. That has also
happened in the last couple of years. Obviously we can provide
more information to the Committee if you wish.
Q1017 Stephen Hesford: Yes, please.
If we bring it down to the individual, people seem to be uncertain
about what sensible drinking is. The Minister very helpfully indicated
the idea about large glasses and that sort of thing. Could you
tell us more about what danger drinking is if he or she consistently
drinks one or more units above this daily allowance? How does
that work?
Sir Liam Donaldson: As you know,
the recommended levels for lower risk drinking are two to three
units a day for women and three to four units for men. The higher
risk levels are six units for women and eight units a day for
men. The use of units of alcohol does date back to the mid 1990s
and I do think that it is something that we have to look at again
because most of the medical research into the risks of alcohol
relate to grams of alcohol—that is the scientific measure
that is usually used—and this is a subject that, although
the public are now very aware of units of alcohol and that is
extremely helpful, over time it would be nice to try and find
a stronger correlation between the research evidence which uses
grams of alcohol and the use of units.
Q1018 Stephen Hesford: So that we
are not overselling the dangers of the public becoming immune
to the message because it does not happen in real life, if you
have your minimum alcohol unit intake and you are just one or
two over those, is that really harmful? How does the public understand
the relationship?
Sir Liam Donaldson: This may be
a hard message but as far as cancer is concerned there is no safe
limit of drinking. That is well established in the international
literature. As far as heart disease is concerned, there is some
evidence that very moderate drinking can be beneficial. It is
for the individual really to trade those things off. What there
is no doubt about is that heavier levels of drinking, particularly
binge drinking, will shorten many people's lives.
Gillian Merron: That is why we
are very keen on our "Know Your Limits" campaign about
know your limits, know your units and also on labelling so that
people understand and can make the choice about how much they
are drinking.
Q1019 Dr Naysmith: According to the
Department's own figures, three quarters of all the alcohol is
drunk by people who drink too much. The fact that quite a lot
of the alcohol is drunk by a significant proportion has effects
in all sorts of different ways. It has effects on the profits
of the drink manufacturers and those who sell it because they
would lose a large proportion of their income if problem drinking
were to be eliminated. That is one aspect of it. The other one
is: is it possible to reduce consumption and simply to concentrate
on those who consume too much in just that group?
Gillian Merron: Perhaps I could
start with a few points and I am sure Sir Liam will want to come
in afterwards. The first point about the industry, and I know
the Committee has talked to the industry, but what the industry
does not want is to be tarnished as a toxic industry. We are seeking
to try to work with them to assist in that. In terms of reducing,
Dr Naysmith is right, this is a group that we need to focus on
which is why we put them into the new strategy. In general terms
the first change is that we not waiting for people to come to
us—we are going to them—and that is the big shift
and I hope we will see more success. If I could briefly go through
how we are targeting the higher risk group, first of all the identification
and brief service, which I would describe as the tap on the shoulder,
the very direct but brief conversation and direction by professionals
at times when people are most likely to be amenable, first of
all; so perhaps when they are seeing their doctor or they are
at a hospital or in any other cases. We are also investing £8
million a year in the direct enhanced service which is about providing
incentives for GPs as new people come in to register that they
do an assessment in terms of alcohol. We have tried to catch people
as they are coming to us rather than the other way.
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