HC 1048-III Health CommitteeWritten evidence from Lundbeck (PH 144)

Summary

Lundbeck broadly supports the Government’s public health proposals and welcomes the recognition that alcohol misuse is a key public health priority. The challenge posed by alcohol misuse is significant and growing. It affects 4% of the population and over 10 million people drink over the recommended limits.

The Government has stated that Public Health England will give local authorities the responsibilities to commission “treatment, harm and prevention services for alcohol misuse in their local population.” However, there is a lack of additional detail about how the full range of NICE recommended services and treatments, from primary prevention through to NHS delivered secondary prevention, will be commissioned. Greater clarity is needed in a number of areas.

In particular, it would be helpful to understand exactly who will have responsibility for commissioning alcohol services. In other areas, such as mental health, a clearer distinction has been made between primary prevention which will be funded by the local authority and secondary prevention which will be funded by the NHS. It would also be useful to know what priority (if any) secondary prevention will be given in the ring-fenced public health budget.

Tackling alcohol misuse must be a priority within local government. This will need coordinated action across public health, the NHS and social care led by Directors of Public Health. In addition, where the outcomes for these areas overlap, as for alcohol, Joint Strategic Needs Assessments will be key in ensuring that appropriate services are commissioned.

Given that alcohol is a major contributor to health inequalities and has a causal relationship in almost 60 diseases and injuries, we would welcome an indication of how root public health problems such as alcohol misuse, will be addressed in patients presenting with illnesses such as diabetes, cancer and heart disease.

Response

1. We are an ethical, research-based pharmaceutical company and specialists in psychiatry and central nervous system (CNS) disorders, with an interest in alcohol policy.

2. We broadly support the reforms to the NHS as set out in the Health and Social Care Bill, including the creation of a public health service both nationally and locally with a ring-fenced £4 billion budget.

3. We welcome the recognition within the Government proposals that alcohol misuse is a significant and growing public health challenge. Alcohol misuse affects 4% of the population and over 10 million people drink over the recommended limits, compared to the 0.5% of people who use drugs. The harm to health and society caused by alcohol is also well documented; the prevalence of liver disease, of which alcohol is the major contributor, is growing and it is set to overtake stroke and coronary heart disease as a cause of death within the next 10 to 15 years. There were 1.1 million hospital admissions due to alcohol misuse in 2009-10, an increase of 100% since 2002-03 and it is estimated that the cost of alcohol related harm to the NHS in England is £2.7 billion in 2006/07 prices. ,

4. The Department of Health paper “Health Lives: Healthy People: Consultation on the funding and commissioning of public health routes” states that Public Health England will give local authorities the responsibilities to commission treatment, harm and prevention services for alcohol misuse in their local population.

5. Lundbeck supports local authority commissioning of alcohol services, as they will often be best placed to understand, plan and deliver services to meet the unique local needs of their communities. However, greater clarity is needed on how local authorities will commission the full range of interventions across the three domains of public health: health protection, health promotion and healthcare.

6. Services for alcohol misuse can vary, as set out in the NICE guidelines for alcohol use disorder, including the provision of advice and information to the wider population, screening & identification and treatment such as brief interventions and assisted withdrawal in a community or residential setting. These services straddle both public health for primary prevention and the NHS for treatment including secondary prevention in primary care.

7. In other areas, such as sexual health and mental health, the consultation document on commissioning and funding routes for public health outlines how different prevention and treatment services would be funded and commissioned. For example, in sexual health local authorities are to commission sexual health services, except for contraceptive services which will be the responsibility of the National Commissioning Board via GPs. In public mental health, there is also a clearer split between how primary prevention measures are funded and commissioned by local authorities and treatment is commissioned and funded by the NHS.

8. The consultation on public health commissioning routes also states that the NHS will fund some alcohol services. The example given is that Alcohol Health Workers would be commissioned in all healthcare settings, but no additional activities are mentioned. NHS funding of Alcohol Health Workers is to be welcomed, but we would not suggest that NHS funding for alcohol misuse services be confined solely to Alcohol Health Workers. Whilst we accept this is just an example more detail would be useful.

9. The public health budget is to be significant, up to £4 billion. An indication of priorities for spending the public health budget would be also useful, for instance which public health priorities will be invested in. Additionally, will the focus of the budget be on primary prevention or will secondary prevention services, such as brief interventions, be included. In the consultation document, it is stated that for drugs services, brief interventions will be funded by the NHS, but this is not indicated for alcohol services. For alcohol misuse, brief interventions are recommended by NICE guidance and should be included as an example of NHS funded activities, to ensure consistency and appropriate funding is made available.

10. Given the scale of the challenge of alcohol misuse outlined above, it is clear that the issue will need to be a high priority for local government, with coordinated partnership working between all organisational levels involved in delivering public health care.

11. The proposed creation of Directors of Public Health and Health and Wellbeing Boards at a local authority level will be important in helping to ensure that people who misuse alcohol, do not fall through the gaps between the public health service, NHS and social care, and that the full range of NICE recommended treatments are available to them.

12. The Joint Strategic Needs Assessment will be an important tool in enabling local partnerships to work together on health and well-being priorities. The Health and Social Care Bill must ensure that effective structures and incentives are in place to ensure consortia and local authorities coordinate activity across the boundaries of public health and health. The consultation on commissioning and funding routes indicates that where a health, public health and social care outcome overlap, as set out in Department of Health outcome framework documents, this should be a “focus of Joint Strategic Needs Assessment” for joint working. Alcohol misuse is included as an outcome in the frameworks for health, public health and social care and should therefore be a priority for the Joint Strategic Needs Assessment.

13. If this collaborative working is not taken into account, the danger is that this issue will fall even further behind other health problems in the change to the commissioning structure. In England, 26% of the adult population, including 38% of men and 16% of women, consumes alcohol in a way that is potentially or actually harmful to their health, and 4% of adults in England are alcohol dependent. Under the current system only a small minority of dependent drinkers currently receive treatment, estimated at one in 18 which is less that 6%. If this were to fall any further it would have a devastating impact on individuals’ health, society and the NHS, as treating alcohol-related conditions already cost the NHS approximately £2.7 billion a year.

14. We welcome the development of the Public Health Outcomes Framework to sit alongside the NHS Outcomes Framework and Adult Social Care Framework. As alcohol misuse is recognised across the three Outcomes Frameworks, it is vital that there is clear accountability for achieving improved health outcomes between the three services.

15. As argued above, the Government has stated that if an outcome measure is identified across the three domains then it should be a priority for the Joint Strategic Needs Assessment. However, it is unclear how health priorities that overlap in two frameworks should be dealt with. We would propose that these issues are also recognised in the JSNA.

16. Alcohol misuse is a major contributor to health inequality, ill-health and societal harm. The World Health Organisation states that alcohol consumption is the third largest risk factor for disease burden in developed countries, and has a causal relationship with more than 60 types of disease and injury, including diabetes, heart disease, and cancer.

17. We would welcome an indication of what the public health approach will be to co-morbidities related to public health problems, such the relationship between alcohol and diabetes. How will the reforms ensure that underlying public health problems such as alcohol misuse are detected and tackled in patients presenting with illnesses such as diabetes, cancer and heart disease.

18. We support the proposed Health Premiums, aimed at incentivising action to reduce health inequalities. In order to utilise the health premium most effectively, it should concentrate on health issues that overlap across the outcomes frameworks and the domains within Public Health Outcomes Framework. The Government proposals state that the Health Premium will depend on progress made in improving the health of the local population and reducing health inequalities. Rates of admission for alcohol misuse are one of the proposed indicators for health improvement. Given the scale of alcohol misuse, we believe that local authorities will need to have a clear focus on indicators relating to alcohol when they are formulating health.

19. A focus on secondary prevention in primary care will be necessary to effectively address health inequalities. The Department of Health paper Tackling health inequalities: 2006-08 policy and data update for the 2010 national target makes clear that one of the quickest ways to tackle inequalities in health is through proactive secondary prevention in primary care.

20. We would welcome more information about how the important work of Public Health Observatories will be maintained and strengthened in the reformed public health services. PHOs have a vital role in providing high-quality intelligence on alcohol related harm, which can be used to support effective evidence-based public health interventions. Particularly important has been the work of North West Public Health Observatory in association with Liverpool John Moores University to create local profiles of alcohol related harms for every Local Authority in England.

June 2011

Prepared 28th November 2011