Health Committee - Minutes of EvidenceHC 132

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Oral Evidence

Taken before the Health Committee

on Tuesday 12 June 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Barbara Keeley

Mr Virendra Sharma

Chris Skidmore

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Anne Milton MP, Parliamentary Under-Secretary of State for Public Health, Chris Heffer, Deputy Director, Alcohol and Drugs, and Dr Mark Prunty, Senior Medical Officer, Alcohol and Drugs programme, Department of Health, gave evidence.

Q296 Chair: Good morning. Thank you for coming. Welcome to the Select Committee. Minister, we know your background and role here, but could I ask you to introduce the two officials you have brought with you and tell us, briefly, their roles in the Department?

Anne Milton: Chris Heffer is one of the officials in the alcohol team. He covers a number of other areas, but specifically alcohol for today. Dr Mark Prunty is an addiction expert. I am looking at him to check if he wants to add anything.

Dr Prunty: I am an addiction psychiatrist.

Anne Milton: He is an addiction psychiatrist, yes. Mark is the science and Chris is the policy.

Q297 Chair: In the policy context, that is both policy in terms of the Alcohol Strategy and prevention as well as service delivery.

Anne Milton: It is both ends of it, yes, the preventative work and indeed the treatment.

Q298 Chair: Thank you very much. Could we start with a general question? It would be helpful to the Committee to hear from you, Minister, your view of what the problem is that we are trying to solve.

Anne Milton: Yes, with pleasure. I must apologise. I am a bit hoarse but feel very well, so do not be sorry for me.

Over half the population drink below the recommended guidelines, and 15% of people actually abstain. However, those remaining are suffering harm from alcohol. From my point of view, it is about seeing harm in every respect. There are the harms to health, both primary and secondary. The obvious one is alcoholrelated liver disease, but you also have the contributory effects of alcohol to other diseases, like cancer.

There are harms to local communities from antisocial behaviour caused by people being drunk. That can just amount to noise, which indeed can be very disturbing, but also criminal damage to cars and all the rest of it.

We have harms to the economy. That is time off work due to alcohol misuse. In the extreme, that would be somebody who is dependent on alcohol, but, to a lesser extent, there are hours lost off work due to hangovers, latenight parties and so on.

There is harm to families. People who misuse alcohol often find themselves losing jobs, so there is the impact of poverty on families. The other thing that possibly does not get as much attention as it should is the harm to children, both in terms of some of the safeguarding issues that arise-violence-and domestic violence generally. Alcohol is something that affects our lives in all sorts of different ways.

Q299 Chair: It is quite striking that you started off by defining out, as it were, the ones that are not a problem. However, you regarded only 50% of the population as not a problem and, therefore, by implication and in varying degrees, half the population are part of the problem.

Anne Milton: I would not put it in those terms. I would say that they are not part of the problem but alcohol probably impacts on their life in some way or another.

Q300 Chair: What is the cutoff point in terms of alcohol consumption between those who are completely in the clear, on that view, and the other half?

Anne Milton: By definition, if you can drink and it does not affect your life, your family’s life, your neighbour’s life or, indeed, the community in which you live, and is not causing any primary or secondary disease, you are probably drinking within the recommended guidelines.

Q301 Chair: That is understood, but I am surprised because the implication of what you are saying is that half the population drink above recommended guidelines, which I do not think is-

Anne Milton: No, I am not quite saying that, and I will turn to Dr Prunty to elaborate. I think it is important to recognise that over 50% of the population do not drink above recommended guidelines and 15% of the population abstain. Of those who are left, we may or may not have a problem that they may or may not be affected by. But it is important to recognise that alcohol causes quite a large ripple among families and communities.

Q302 Chair: I understand that. I was trying to get to an understanding of the proportion of the population that gives us a problem.

Anne Milton: I can give you facts and figures. There are 9 million people who say that they drink above the guidelines, and there are 1.2 million hospital admissions. I can give you lots more statistics, which I am sure you have already had access to through your officials. Alcohol misuse costs the NHS £3.5 million a year, but, as I have said already, the human cost is not always quantified in those terms.

Q303 Chair: But it is quite important, is it not, if we are trying to develop a set of policy instruments to achieve an outcome, to be clear to whom those policy instruments need to be directed: how big the population is; who they are; how they are identified, and the characteristics of the population that are the targets of the policies we are seeking to develop?

Anne Milton: Absolutely, and they are wide and varied. As I say, all the harms I talked about will affect different sections of the community to different degrees, and some people pass through and come out the other side. Students would be a good example. They go off to university and probably drink way above recommended guidelines, and when they get jobs and settle down they stop drinking so much. So they are a problem for a brief period of time. I know what you are after, but there is a danger in being very simplistic about this because it is not a simple story. I do not know, Mark, if you want to add anything to this.

Dr Prunty: You can pick out a range of harms that are caused by alcohol consumption. It contributes to a minority of cancers and to 60% of alcoholic liver disease. In different areas and different populations, regionally and locally, you have a different balance between dependence and risky drinking. In order to look at the need that you are addressing, you have to look at the data at a national level but, in terms of planning for responding, you need to look at the balance of the different types of drinking at a local level-and that information is made available through the North West Public Health Observatory-and at the range of harms. Local areas then need to determine their priorities against the whole range of different harms in their local communities. So it is difficult, as the Minister says, to give a simplistic answer on that. There are priorities that might be seen at national level, such as admissions to hospital, with a huge impact directly on the NHS, and then the way in which alcohol affects communities varies in the way communities drink; the kinds of services available; social deprivation and so on. It is not easy to give that answer without quite a complicated analysis, but that local analysis is available and is produced for all areas.

Q304 Mr Sharma: The way that young people use alcohol is often extreme. The strategy notes that about one third of alcoholrelated A and E attendances are by under 18-year-olds, that those under 25 report being drunk more often than any other adult age group and about 50% of students drink more than the lowerrisk guidelines. How will the strategy help to address this issue?

Anne Milton: It will help in a variety of ways. We have started by highlighting that it is a complex problem. If you take students as a population, a proportion-Mark or Chris will have the exact figures-will pass through that phase and come out the other side. In terms of hospitalrelated admissions, there is no doubt that the brief interventions which are mentioned are important, as indeed are alcohol liaison nurses and the powers that local authorities will have to change some of the licensing. The consideration of the harm as an opportunity for opposing licensing applications, I think, sends an important message. That is exactly what the Alcohol Strategy has done. It has gathered together a complex problem and made sure that a lot of the agencies involved have the powers to take some action. There is also action that we can take at the centre, such as the Change4Life campaign which raised the whole issue of the harms done by drinking alcohol at just above the recommended guidelines, which is targeting a different audience. It all has an impact.

As I say, the strategy is bringing together a number of things. But I have to add, as Minister for Public Health, that, in conjunction with that and also as a constituency MP with a university in my patch, the move of public health to local authorities will give, in an area like mine, the local authority opportunities to do specific things that might be targeted-students-on top of that.

Q305 Mr Sharma: The national strategy sets out a series of outcomes the Government wishes to see but sets no specific targets or objectives. Why is this? How will you measure the effectiveness of the strategy?

Anne Milton: We have a public health outcomes framework out at the moment with two highlevel objectives and looking at a number of public health issues in four domains. We will be developing that and are consulting on specific objectives and highlevel outcomes as we go along. But, essentially, the money given to local areas on public health in the light of the strategy will be against the public health outcomes framework.

Q306 Chair: Reverting to the general picture for a second, it is slightly paradoxical, is it not, that we are having this discussion about alcoholrelated harm, of which there is clear evidence, but that alcoholrelated harm seems to be rising at a time when alcohol consumption is falling?

Anne Milton: Yes, correct.

Q307 Chair: I wonder whether the Department has a view about what is behind that paradox.

Anne Milton: I will leave an opportunity for officials to come in here, but that is interesting. It is really why I started where I started, because, as you say, a small number of people are drinking more and more alcohol. It should focus our attention on the fact that a message is getting through to some people, but not everybody. That is why I think the Alcohol Strategy in many ways is so important and that a very crossGovernment approach is important. Obviously, we are failing to hit a number of people.

One has to look at some of the parallels with smoking, although it is different. We have passed a great deal of legislation and run a lot of public health campaigns and no one is in any doubt. If you look at awareness of the harm of smoking, I think 96% of the population agree that smoking harms your health, whereas with alcohol the figure is much lower. Despite that, one in five continues to smoke. With alcohol-and officials will get cross with me-we are not seeing the same pattern. We are meeting a proportion of the population but not hitting everybody. That is where I think the Alcohol Strategy has some good things, such as the alcohol liaison nurses; the opportunity for brief interventions; as I say, a change in the licensing laws; and the acceptance that alcohol harm is a valid reason for opposing a licensing application. They are all important.

Q308 Chair: I am struck, again, that the way you reconcile the paradox is by saying that the problem is becoming progressively more concentrated on a number of people who are abusing alcohol. One of the answers that we have been given by previous witnesses refers to the delayed impact, that alcoholrelated harm can be built up over a period of years and that is part of the reason why the caseload is increasing. Clearly, both of those things can be true, but which one is relatively more important?

Anne Milton: I would always struggle to say any one thing is more important than the other.

Q309 Chair: I will say "statistically more significant": which one is the more significant driver of the current rising load of alcoholrelated disease?

Anne Milton: I hesitate to say one or the other. They have different impacts of concern for different reasons.

Q310 Chair: What evidence is there of the increasing concentration of the problem in a reducing population?

Anne Milton: Chris, do you want to come in on this?

Chris Heffer: There are a couple of things. As you say, consumption has risen over 30 years and quite dramatically peaked-if you want to use that word-in about 2004 and is down about 10%. But one needs, I think, to be cautious of overinterpreting yearonyear falls in that. There are a number of measures of alcohol harm. We can look at deaths, which fell the year before last but then did not fall last year. So has that followed? You may come back to hospital admissions as a measure and, as you know, we are consulting now on both a broader and narrower definition of that, looking at both primary and secondary coding. The primary coding has only grown about 2% or 3% over the period, not quite in line with falling consumption but certainly not growing rapidly while consumption falls. So I think the timelag theory that Ian Gilmore talked about is very real. You might expect deaths to respond faster, which may be why you saw that in one year. We know that the higher social classes drink more but the harm occurs more in the lower social income groups. Professor Brennan, I think, spoke about some reasons why. So the harm is definitely more concentrated in some groups. I am not sure we know whether it is becoming more concentrated.

Q311 Chair: That relates back to some of the earlier questions. If it is true-which is why I asked what the evidence is-that this is a problem that is becoming progressively more concentrated, it puts greater importance, does it not, on identifying which are the populations where the risks arise and targeting those populations rather than relying on populationbased initiatives?

Chris Heffer: I am not sure we know it is becoming more concentrated. It always has been that harm has been found-if you look at alcoholrelated hospital admissions-more in the lower social classes than the higher ones, despite the fact that they drink less. Professor Brennan spoke about some reasons why he thought that might be true. I do not know that we know it is becoming more concentrated. As the Minister said, there are 9 million people drinking above the guidelines, and you could argue that is targeted equally. That is a quarter of the population and is quite a large number to find. That is based on selfreport, so the actual number could be higher still. It is a large group to try to target and cannot always be defined that narrowly.

Anne Milton: The other thing I would add, which is stating the obvious, is that if you take deaths, for instance-and this is in the light of increasing opportunities for medical care and increasing improvements in medical care-one has to be quite wary of statistics per se. You would expect deaths from a disease to have gone down, so maybe the figures are worse. The other thing is that we tend to collect numbers, not people. The same people who have been treated for the alcoholrelated liver disease may be the same people who are causing a problem in the town with violence. You have to be wary. This is a complex picture of a number of groups, all of whom have to be targeted at different times. That is why our whole approach to public health has been a life course approach to it.

Q312 Mr Sharma: Are you satisfied that the Alcohol Strategy has the right balance between health and social policy and public order issues?

Anne Milton: Yes, I am. I have to add that it is in light of the changes we are making elsewhere to public health.

Chair: That was a straightforward answer.

Anne Milton: I will not be long winded if I do not have to be.

Q313 Barbara Keeley: Witnesses have noted that the most serious problems arise from the chronic longterm impact of drinking. Clearly, binge drinking at a weekend might cause the antisocial behaviour-noise, town centre problems and then the hangovers-that you talked about. Maybe that is one population. But in terms of the other things that you discussed-chronic health problems, loss of job, poverty, harm to children and families-and I know both are problems, clearly they are very serious, with an impact on a wider group. How will the strategy affect those chronic problems? There is a concentration on the town centre problems, the licensing and those sorts of things, but those longerterm harms should concern us as well.

Anne Milton: Yes, and it is very important to raise it. As you say, there is a lot of attention on the antisocial behaviour problems and possibly less attention on the longterm chronic problems. The strategy will address it because it is a crossGovernment strategy. It has been discussed with all the other Departments because some of those chronic longterm problems will not be solved by one Department alone and it needs a crossGovernment approach. So, in its very self, the approach to developing strategy will have an impact.

As I say, the brief interventions-and the inclusion of what the NHS can do in terms of intervening, not just treating but trying to prevent some of the further harms that might ensue-are important, but also the involvement of local authorities particularly, and I can think of quite innovative schemes that the strategy, in a way, acknowledges. I cannot remember whether it is an example, but, for instance, linking noise-nuisance helplines to domestic violence teams. So the acknowledgment within local authorities, the powers given to local authorities on licensing that raises the awareness of what local authorities can do in an area that they have not traditionally been involved in except for the antisocial behaviour, I think is very important.

Q314 Barbara Keeley: Could I follow up on that? You have mentioned brief interventions a couple of times, and we heard from Birmingham council, which seems to have a good strategy and has done a lot of work. But other areas are not doing well and a lot of GPs do not use brief interventions. It is fine to cite good practice somewhere but for this to work across as many as 9 million people these things are going to have to take off a bit better than they seem to be doing.

Anne Milton: That is right. You will probably have to stop me if I go on too long on this because you have touched a button. Why we continue to do what we know is not very effective and fail to do what we know is effective, and why we fail to adopt other people’s best practice is a story that goes on for a long time in healthcare, and it is a shame. We are putting together more opportunities, but we have to understand why people are reluctant to share. If Birmingham is doing good things, why does not Brighton follow it? What is quite interesting, and you have possibly raised street pastors before-Was it you?

Barbara Keeley: Yes.

Anne Milton: Take something like that which, actually, has been adopted. There is a piece of nonGovernment intervention, if you like, interestingly, which has been copied. We have a very successful one in my patch. It is about who makes the decisions. The Alcohol Strategy, combined, as I say, with the changes in public health, is devolving a lot of the responsibilities to local authorities and giving them the opportunities. It seems odd, but giving people a licence to work together will maybe free up the system. Birmingham has examples of all sorts of good things, not only in this area. They feel free and more liberated to do the sort of things that they know work but had failed to do because somehow the framework was not in place.

Q315 Barbara Keeley: In fact, my first question was: how will the strategy enable more of the Birmingham outcomes, if you like, to happen in other places if it is left entirely up to a local authority?

Anne Milton: The strategy is not a piece of legislation.

Barbara Keeley: Indeed.

Anne Milton: It is not a permissive document. It is setting out what the Government think. It will inform local authorities and their new public health responsibilities. That is perhaps the point, actually. The reason why places do not do things is that it is not a piece of legislation. A lot of the things could be done anyway. It will give-

Q316 Barbara Keeley: So it will be up to any local authority to do it or not do it?

Anne Milton: No, it will not be, because the moneys for public health are ringfenced and it is quite clear that they will be set against an outcomes framework.

Q317 Barbara Keeley: Coming on to the units system, and we have obviously had it for some time-we are talking about 9 million people drinking more than the recommended level, and it might even be more than that-do you think we should now conclude that the system of units is not the best way to help people measure how much they are drinking? There is a second part to this question, but that is the first part. A unit is not working as a measure.

Anne Milton: I think that public understanding of units is quite poor. In fact, there has been quite a lot of voluntary work from some of the producers and supermarkets on units. Most people look at how much alcohol they drink by the number of glasses they drink and glasses are very large now. They can hold a lot more units than they used to when I was younger. The CMO is reviewing the guidelines across the piece and that will be important. It is a recognised thing. Scientists and Government can use units but what we have to do is get across messages that are easy for people to understand. It is about the messaging more than whether the unit itself is a useless thing.

Q318 Barbara Keeley: On messages, how can it be put across to people that may be turning from problem into chronic drinkers that, even if they do not see immediate or many problems in their health, they still may be developing a longterm health problem? Is that not a difficulty-

Anne Milton: It is.

Barbara Keeley: -that you can go around binge drinking for a number of weekends or across a year or in your student life, as you mentioned earlier, and not really understand the impact on your health? How can the messages get that across?

Anne Milton: That is right. I talked about smoking and awareness of the harm that smoking causes being so much higher than alcohol. I think that is an area that has long been neglected. People do not understand that and if they see it or hear it talked about they do not quite believe it yet. I do not know if you saw any of the Change4Life adverts on television. They were designed to address exactly that issue, with the website with some tools and tips to suggest to people ways of cutting down their alcohol. But we do have a battle. We cannot make people understand. We have to provide information in a way that people accept that alcohol and chronic use of alcohol can harm their health.

Q319 Barbara Keeley: As an example-and I think I have said this in other evidence sessions-in my local authority area, Salford, there has been some wonderful success with campaigns on smoking and quitting and a whole celebration of people who have managed to quit. I do not see anything like that sort of messaging and support for people either to cut down, and radically cut down, or give up drinking. I think, partly, you are not going to get success until you make it, "You are helping your children and your family if you cut down the amount that you drink". We seem to be able to do that as to smoking and not get anywhere near it for drinking.

Anne Milton: Of course, the message for smoking is a little easier because it is "Do not smoke". We are not saying to people "Do not drink at all". We are saying "Drink moderately within recommended guidelines". That is the first complication in the message. I would fully acknowledge that this is an area that has been neglected. The Change4Life campaign is a start. In fact, we were quite pleased with how successful it has been. It has raised awareness and there were 92,000 hits on the website because of it. So it demonstrates that there is a receptive audience to some messaging. What we have to do is make sure that gets across. A lot of those tools will be made available to local authorities to use and build on in different areas. Stopping people drinking harmfully in an area like Salford is very different from doing it in Cornwall. Local authorities will reinterpret those messages, but there is some national work that we have done and will continue to do on that.

Q320 Chair: Presumably the definition of "safe" in Cornwall is broadly the same as it is in Salford.

Anne Milton: Indeed. But, of course-Yes. I will not get complicated.

Q321 Chair: I thought that was a oneword answer.

Anne Milton: It is. It is a "Yes". It is just that-and this is the other problem-there is a science to this that we have to catch up with, and I do not want to make this more muddled, which is that individuals react to alcohol in very different ways.

Q322 Barbara Keeley: I think people in Salford are quite capable of taking in health messages.

Anne Milton: No, I am not saying that they are not. I am certainly not saying that. I am saying that there is some science, which we need to catch up with, about the impact that alcohol has on our health. It is not the same in every person but it is not necessarily geographically attributable.

Q323 Dr Wollaston: Can I move on to the problem of the heaviest drinkers? The figure of the cost to the NHS of £2.7 billion a year was based on figures in 2006 to 2007 so it is likely to have significantly increased since then because the number of admissions has increased. My understanding is that 70% of the cost to the NHS actually comes from the inpatient admissions for the heaviest drinkers. Turning to one of the issues that the Department itself has acknowledged, it is very likely that there is a significant underprovision overall of treatment for people who are dependent. These are the patients who are causing the most cost to the NHS and the greatest harms to themselves. How will the strategy enable the best practice in some areas to be taken up-this is focusing only on treatment, not what happens in local authorities-for that inpatient provision and treatment for those most severely affected to be improved, and nationwide, not just in some centres?

Anne Milton: That is right. What is quite interesting-and, Mark, I will leave you to add a bit, if I may-is that the work we have done on the Payment by Results codesign project for drug treatment has unearthed a huge willingness in the treatment sector to provide similar opportunities for people with alcohol problems. That work is ongoing and will produce a model that is about best practice. As I say, what is very encouraging is the enthusiasm from the sector because it is widely acknowledged that it was poorly provided. I have mentioned brief interventions, alcohol liaison nurses, which I think are going to be quite important in terms of referral, and also the specialist alcohol treatment. Mark, do you want to add anything?

Dr Prunty: It relates to the earlier question on how one decides to allocate interventions or resources against the need identified. At the moment, in treatment services, demand is relatively well met: 82% of people seen are starting treatment within three weeks, 54% of those successfully complete treatment and the numbers of new entrants into treatment are increasing. As I say, there is success. The experience within the services in general is that there has been improvement and there is continuing improved access. The difficulty, to some extent, is knowing the need and how you make that decision at a local level. That, again, relates to this whole issue of the complexity. In some areas there are much higher rates of hazardous and risky drinking-people who do not need treatment but would be very likely to benefit from interventions and brief advice-other areas which have higher levels of dependence and other areas which have higher levels of social deprivation and, therefore, more harm. So each area has to look at that information.

There has been a general consensus about the kind of capacity requirements for services-of the order of 10% to 15%-and it has been advised that services across the country ought to aim for 15% of their dependent population having treatment places in any one year. But it is important that the consensus on that, which is in the NICE guidance, the National Audit Office review and in various sources, is getting on a bit, so we also need to look at driving this by the evidence. The DH is now commissioning research to identify how you best make that decision with the range of detailed tools that are available. How do local commissioners make that decision taking all those other factors into account? What is the evidence now for what is the balance? We have said we have a 1.6 million dependent population. In any one year you would not expect more than a minority of those to need treatment places because a large number of them are not ready to change yet. They need support, encouragement, assessment, access to services, IBA and all those things. So local commissioners have to balance all these different pieces of evidence to try to determine how best to focus resources in order to reduce their hospital admissions to meet their other local priorities on alcoholrelated harm. Work will be published in 2014 which looks at a researchdriven, evidencebased capacity model to try and help local commissioners to bridge that gap. The information is there. The question is how we help commissioners to make those decisions and invest in the areas that require that investment locally.

Q324 Dr Wollaston: So you are confident that, with those tools, you will see it appropriately rolled out depending on the pattern of drinking in different areas?

Dr Prunty: Yes. That is because the demand, as I say, is largely being met. The trouble is there is variation across the country. You will always get that and that is an issue. NICE is encouraging that everyone should be doing IBA because the evidence for the impact of treatment of dependence on reducing hospital admissions is high. In fact, the biggest single action you can take to reduce your hospital admissions immediately is to improve your treatment for dependence. So the evidence is out there. The issue is about how we help local areas, local authorities and partnerships in future to bring that together.

Q325 Dr Wollaston: So you will be able to target those areas which you think are significantly underproviding?

Dr Prunty: The information will be available for all areas on how they determine what their need is, their underprovision, and put that into action. That is the aim of the research.

Anne Milton: I will add for the Committee’s interest, if I may, something about Transport for London. Employers are doing some good work and I highlight that done by Transport for London in terms of offering opportunities for treatment for its workforce. There are absolutely excellent schemes. There are a few and that is growing. That is some of the work we are also doing in the Department, which is about responsibilities of employers and encouraging them to invest in their workforce.

Q326 Dr Wollaston: Can I reflect something back from a director of public health whom I met recently about a measure they think would help dependent street drinkers? That is that dependent street drinkers congregate in certain areas, and there is a high density of offlicence providers providing alcohol to dependent street drinkers. They would like to have greater powers to prevent those premises from selling alcohol. Do you think that is something the strategy will help them to be able to do?

Anne Milton: Without a doubt. It is clear, and I think that is an important part. I have mentioned it before, that one should not underestimate the importance of making the public health considerations a factor in considering licensing applications.

Q327 Dr Wollaston: So for those premises that already have a licence to sell alcohol in areas where there is a serious health issue with street drinking, licences could retrospectively be taken away from premises that are supplying alcohol to dependent street drinkers?

Anne Milton: You are taxing my knowledge of licensing laws. Could you take away a licence, Chris?

Chris Heffer: Yes, you can. At the moment you would have to do it on the existing objectives, which would include health and safety and public order. What the current changes do is encourage health authorities-

Q328 Dr Wollaston: This is the trouble. It is the health objective, and I am wondering whether, retrospectively-

Anne Milton: No. What it depends on is how long the licence lasts for.

Chris Heffer: Yes, you can take them away. In particular, if you saw them presenting at hospital or you saw public order issues locally you could go for an existing objective. The strategy says, "We will look at a density power", which includes health. That would explicitly, with the point taken, address that issue about the concentration in the area. That would give local authorities a power to do exactly that, to refuse-

Anne Milton: I think Dr Wollaston is drawing a distinction between an existing licence and a new licence.

Chris Heffer: Yes, depending on how it is framed.

Q329 Dr Wollaston: An existing licence, yes. But I think very often those are not public order issues, so they do not have the power.

Anne Milton: No, it is about public health.

Dr Wollaston: But with health as well now they could actually say-

Anne Milton: It is clear in the strategy.

Q330 Dr Wollaston: With existing licences, where there is excess density contributing to the problem, they could address that?

Anne Milton: Yes.

Q331 Chair: In making that decision, the licensing bench or authority, presumably, has to balance the public health angle for the problem community and the legitimate interest of the majority community in reasonable access to offlicence alcohol sale, do they?

Anne Milton: Absolutely. It is a decision made by the local authorities and it has local councillors sitting on the committees. It is the best place to address exactly those things. It is, as with planning, a balance.

Q332 Mr Sharma: The NICE guidelines on treatment for people with alcoholrelated conditions have been praised in evidence to us. Are you encouraging the use of these guidelines? Secondly, why are they not more widely adopted? Is it because services for alcoholrelated conditions are not given a high priority in some areas?

Anne Milton: The short answer is yes. We would always encourage people to adopt NICE guidelines. That is precisely what they are there for. It comes back to the point I made earlier. Why do some places do things well and some places not do things well? Why do successful schemes like Birmingham-and I could cite other places as well-not get adopted? The changes that we are making-and one of the big drivers of the changes is going to be the Health and Wellbeing Boards whose work will be informed by the Joint Strategic Needs Assessment and the strategy-will help that. I think that will help it along, but we have to continue to do more to encourage areas to adopt what we know does work and the NICE guidelines will be in there.

Dr Prunty: As a practising psychiatrist working in drug and alcohol services, I have already had to do an audit on whether my services are compliant with the NICE guidelines. That would be true, I am sure, for trusts across the country because of the monitoring of the quality of NHS services. I have had to go through a detailed itemisation of "Do we provide this? If not, are we going to provide it?" and that sort of thing. So there is a process that automatically follows for services to consider whether they are "consistent with".

Anne Milton: What you are saying is that you do not feel it is consistent.

Dr Prunty: That’s it, yes.

Anne Milton: But I think this is the point of the strategy being a crossGovernment strategy. Addiction psychiatry is something that has not touched the lives of local authorities and I think it is about to start to do so. The impact will be extraordinarily positive and possibly enlightening to some areas.

Q333 Valerie Vaz: I do not know whether I have misheard, Minister, but did you say earlier that the strategy is only guidance and that no one need take any notice of it?

Anne Milton: No, I did not say that. I said it is not a piece of legislation.

Q334 Valerie Vaz: So you expect people to take notice of it?

Anne Milton: Yes.

Q335 Valerie Vaz: It feels a bit-and I do not know whether it is because I have a cough as you have-like wading in treacle. I thought your job as the Minister for Public Health, with immense power, which apparently we all want, was to pull together this strategy, and you can get the best practice and tell everybody how it is done.

Anne Milton: Correct.

Q336 Valerie Vaz: Are you doing that?

Anne Milton: Yes, I am.

Q337 Valerie Vaz: How are you doing that?

Anne Milton: I am flattered that you believe I have immense power.

Q338 Valerie Vaz: Why are you there then, if you do not have immense power?

Anne Milton: We could wade into a discussion about individual ministerial levers-

Valerie Vaz: No, I do want to-

Anne Milton: Just to say it is absolutely my job to put forward what I know works. It is my job to make sure that what we do is evidence based. I think Professor Brennan-I cannot remember which of your witnesses-said that this is a good example of evidencebased strategy, which is very important if we are going to get messages across. It is my job to make sure that we have the framework and the levers in place to ensure that local areas adopt the strategy and are held accountable.

Q339 Valerie Vaz: That is what I am hoping you are saying. So you can pull levers then?

Anne Milton: Yes, absolutely. I can pull levers-never as much as I would like, but that is because I would love to rule the world, probably.

Q340 Valerie Vaz: I know that we all hate structures and things to a certain extent, but it seems to me that it needs someone at the centre to get a grip of it because a lot of people are doing different things. The Home Office seems to have responsibility for alcohol. The Department of Health seems to have some sort of strategy. There is not someone pulling it all together. Can I refer you to your evidence at paragraph 13? There is a plenary group chaired by the Secretary of State for Health. My imagination about the new structures and the new NHS is that these Health and Wellbeing Boards could report to someone. But what I am hearing from you is that they are just going to sit and talk among themselves within their local authorities and the information is not going anywhere. Perhaps in your answer you could explain how you see the structure from the Health and Wellbeing Board being fed back to the centre, and also refer to this plenary group which is chaired by the Secretary of State for Health.

Anne Milton: That is quite a long question, forgive me-so different areas.

Valerie Vaz: I am sorry.

Anne Milton: I think there is a problem inasmuch as we all want Government to work together. We do not like silos. We talk endlessly about how the fact that working in silos is not effective and we do that in national Government and locally. Then, when we produce something that is truly not working in silos and not confined to one Department, we say, "Who is responsible for this?" In the framework, the Home Office and the Department of Health take the lead responsibility. There is the Public Health Cabinet SubCommittee, which the Secretary of State chairs, which is an opportunity to bring together all the other Departments as well because this has an impact on all the rest of them. If we do not want the students to turn into chronic drinkers, if we want the public better informed and if we want our 15yearolds not to drink, we have to involve education in the process of informing young people about the harms alcohol does. So it takes everybody together.

As to who eventually will crack the whip, I turn back to Health and Wellbeing Boards. Health and Wellbeing Boards and local authorities are accountable to local people through the democratic process. They will be held to account by the centre through the public health outcomes framework and we will give that more definition and clarity. But we are only giving them ringfenced money on the basis that they improve the health of their local population and that they improve the health of the poorest fastest. Those are the two overlying objectives, if you like. Also, it will protect the public’s health. As to the Health and Wellbeing Boards, if they are just a talking shop, the local authority will not achieve the objectives that you are talking about. So when it comes to the local elections, the councils will be held to account for that and they will also be held to account by the centre. But not everything-

Q341 Valerie Vaz: By whom in the centre?

Anne Milton: As I say, in terms of public health it will be myself. In terms of licensing, it will be the Home Office. In terms of education and whether the local authority is delivering on appropriate preventative measures and educative programmes, it will be education. I understand your difficulty. You would love to put one person on the spot for this, but that will not work.

Q342 Valerie Vaz: I think you have got me wrong. It is not "on the spot". It is simply that there is a problem for society and someone needs to take responsibility for it. It seems to me, given all these structures-and I am not saying that someone has to be blamed, that is completely different-

Anne Milton: I know you are not.

Q343 Valerie Vaz: It needs someone to pull all the strings together, and whether it is you-I think you are able and perfectly capable of doing that, a wonderful Minister-

Anne Milton: Thank you.

Valerie Vaz: It just seems to me that someone needs to get a grip of the whole thing.

Anne Milton: That is right. That is absolutely right. Every time I listen to Mark I am reminded of the complexity, and you have listened and will be reminded of the complexity of this. It is a crossGovernment strategy because no one Department will solve this problem that we have. As Public Health Minister, it is down to me to crack the whip on health. For the Home Office it will be on licensing and for Education it will be education. That joint working is important for spreading best practice. We all have a responsibility. You talk about responsibility but we all, as individual Members of Parliament, have some responsibilities.

Q344 Valerie Vaz: I mean responsibility. But, as I said, it is not someone to blame.

Anne Milton: No. I am saying it is an opportunity.

Q345 Valerie Vaz: Normally, you can have incidences of crossGovernment and you can have strategies, but clearly this is a huge issue for society, both in terms of cost to the NHS and to wider society. So it seems that someone should be at the heart of Government taking a lead on this, and you can do that. Different Departments do.

Anne Milton: As I say, we are, yes.

Q346 Valerie Vaz: So is it the Department of Health that is taking a lead on it, as opposed to the Home Office?

Anne Milton: We have dual responsibility for alcohol, but Health has responsibility for the public health side of it. It is absolutely clear. The Secretary of State chairs-the more I say, the more we go backwards, sorry, but just to say-the Public Health Cabinet SubCommittee which brings together all of Government. So obviously that is the central role. Public health is in the Department.

Q347 Valerie Vaz: Is that the plenary group that you talk about? It is in paragraph 13 of your statement.

Anne Milton: I think so. We will get an answer, but carry on.

Q348 Chris Skidmore: In terms of there being joint responsibility between the Home Office and the Department of Health, do the Health Ministers sometimes feel compromised in terms of the health messages you might wish to promote because they might get clouded by the messages on reduction of violent crime, for instance? In terms of the evidence that you presented, a lot of it, as to the Alcohol Strategy, will help reduce violent crime, with a focus on binge drinking. But the evidence we have received from people like Professor Gilmore is that, obviously, looking at the Department of Health, an issue is middle class drinkers who are drinking lots of bottles of wine which is detrimental to their health and they will get chronic liver disease in 40 years’ time. For him, the Alcohol Strategy is not dealing with that and, in a way, the focus on violent crime, binge drinking and antisocial behaviour is pushing that issue away from the centre of the agenda.

Anne Milton: First, I do not feel compromised. I never do because I will say what I think and that is it. There is no more about it really.

Secondly, the danger is that whenever you produce a strategy-and I always read the draft strategies with this in mind-somebody is going to count up the number of lines that are dedicated to issues A, B, C or D and say there has not been enough focus on X, Y or Z. In fact, the words used to describe some of the problems and complexities in violent crime get more lines, which is why I started where I did about the different harms. There are a huge amount of harms. I do not think that sexual violence gets mentioned a huge amount in the strategy, but it is no less important because of that. The antisocial behaviour and crime associations of alcohol affect almost everybody’s life in some way or another. The health harms affect probably fewer people’s lives but they are still very relevant. There are huge financial costs, and we have concentrated on the financial costs, but I say that we should also concentrate on the human cost. I do not feel compromised. I do not think there is any diminution of the other harms that alcohol causes at all.

Q349 Barbara Keeley: I wanted to come back on what you said about the impact of addiction psychiatry because we have obviously heard it discussed that different local authorities are tackling this in different ways. How will addiction psychiatry affect and get through to and help with the complexity of these issues in every local authority? How will that happen?

Anne Milton: The Health and Wellbeing Boards are probably the vehicles. I do not know if you want to add to this, Mark, but I think the Health and Wellbeing Boards are the vehicles. The Joint Strategy Needs Assessment will highlight some of the problems.

Q350 Barbara Keeley: How will they get the input? You specifically said you think that local authorities will start to feel the impact of addiction psychiatry. How?

Anne Milton: As I say, with their new responsibilities to improve the public’s health, which is about treatment and prevention, they will go to places where they will find the answers to solving some of those problems. Addiction psychiatry is one of them. I do not know if you want to come in at all on that.

Q351 Barbara Keeley: I do not understand. You seem to feel-and you volunteered this-that the impact of addiction psychiatry is going to be felt. I want to know how. It seems that some areas are doing this well and pursuing the answers. They are looking at the complexity and trying to understand it. They are doing something about it. Other areas are not. Talk to me about the areas that are not.

Anne Milton: Quite. I will let Mark come in, but we are in the early stages of the Health and Wellbeing Boards. I was talking to a group only yesterday morning who are striding ahead at enormous rates. They have a joint chairmanship with a local GP. It is going great guns and they have opened their doors to everybody to come in.

Barbara Keeley: But what if-

Anne Milton: Give me a minute. So we are in the early days. What we have to do is identify areas and put support in, if necessary, to areas that are doing less well. I could glibly sit here and say, "We need to share best practice". I could say that. What I know is that we do not find it very easy to do. I think that Public Health England is going to have an important role to play in ensuring that weaker areas are helped to gather the strengths. Some of it will be about enlightening the local members. Some of it will be giving officer organisations some support. Some of it will be things like the work that emerges from the Payment by Results projects, which will help inform them.

I think we have not always traded as well as we should do on the goodwill of local councils. I am a walking advert for local councils because I think there is a lot of goodwill and people do want to make things better. They have not always known how to do that and they have not always had the powers. The strategy talks about some of the powers, some of the changes in the Health and Wellbeing Boards or the opportunity, if you like, to bring all that together, with Public Health England having some input as well.

Q352 Barbara Keeley: But the Boards are a DCLG responsibility rather than a Department of Health responsibility.

Anne Milton: No. You see, you are wanting to put things in silos.

Barbara Keeley: No. They are.

Valerie Vaz: We do not. You did it.

Q353 Barbara Keeley: You have us entirely wrong, actually, but the difficulty is that they are a DCLG responsibility.

Anne Milton: The Health and Wellbeing Boards, as I see it, are the local authority’s responsibility. There are some things that are laid down in legislation, but they can go to whatever lengths they want to improve the public’s health.

Q354 Barbara Keeley: But I am concerned about the ones that do not.

Anne Milton: Aren’t we all? Absolutely. This is where Public Health England will come in. Its biggest role-the most important impact it will have-is in facilitating, giving areas the tools to bring themselves up to some of the best. That is what we should be doing, as you know. We should be excelling. Do you want to come in on that?

Dr Prunty: The Health and Wellbeing Boards’ responsibility to develop the Joint Strategic Needs Assessment and the health and wellbeing strategy plants that responsibility for need and priority with them. They are also going to be involving the directors of public health who will look to the question of medical expertise. But addiction psychiatry-in a sense, the responsibility of the Joint Strategic Needs Assessment to look at the issue-suffuses through NICE, and that is largely driven by addiction psychiatrists, by all the tools that are out there, as well as by questions about understanding local need. But I think, again, local areas are inevitably going to determine locally what their need is for more input and more information and what sources they are going to draw on. But the responsibility is there, and that now sits with local authorities. The output will need to be a Joint Strategic Needs Assessment and health and wellbeing strategy.

Q355 Dr Wollaston: Could I follow up a question with Dr Prunty, please? Concerns have been expressed that some private providers of addiction services are excluding patients who have mental health problems and yet, of course, the mental health problems and dependent drinking are very often closely knit. Would you recognise that concern? Do you think that is a concern?

Dr Prunty: Different providers will have different levels of expertise and competence within a system in mental health experience and clinical skills. That exists currently and different organisations locally allocate resources in different ways to address problems with dual diagnosis, increasing the use of the IAPT services, the psychological therapies locally. That is because, in a sense, you cannot exclude completely, whatever service provider you are, because of the level of mental health problems, that you will have anxiety and depression within the treatment population.

There is an issue about what are the most effective care pathways to identify need and to respond to it. Sometimes that will involve dedicated dual diagnosis services, sometimes it is about having joint working and sometimes it is about having good access to specialist services. Clearly, it is a risk when providers change and providers may have different levels of competence and experience. I cannot answer on the specifics, but the risk, in a sense, needs to be managed. Services are not perfect at the moment for addressing complex needs. It is difficult. An individual may only want to go to one service and they may not want to deal with a severe mental health problem, which is predominantly the responsibility of specialist mental health services. They may not be ready to attend IAPT services. It is a risk, but I think there are potentially a number of solutions.

Q356 Dr Wollaston: What I am getting at is: do you think there is any evidence at all that services for patients with a complex dual diagnosis have been worsened?

Dr Prunty: I am not aware of that evidence.

Dr Wollaston: Thank you.

Anne Milton: Interestingly, it has not come to me. Did you-

Chris Heffer: Can I come back on the earlier question about the Cabinet SubCommittee? I will refer you, slightly earlier, to our written evidence at paragraphs 3 and 5. Paragraph 3 talks about the Cabinet SubCommittee on Public Health, which is a subcommittee of the Cabinet Home Affairs Committee, and that is the one chaired by the Secretary of State for Health. Paragraph 5 talks about the joint responsibility for alcohol policy between the Department of Health and the Home Office. Paragraph 13, about the plenary group, is in the context of the Responsibility Deal, which has four different networks-the health network, the food network, the alcohol network and the physical activity network-between industry, NGOs, the Government and that plenary group, which is the one chaired by the Secretary of State Health. So he chairs two.

Q357 Valerie Vaz: I understand that. Thank you. I just wanted to know whether that was the group that could slap people across the wrists if they needed to.

Anne Milton: No.

Chris Heffer: No.

Q358 Valerie Vaz: So there is not actually a group that can slap people across the wrists if they need to, "Please put forward this strategy. This is very important. This has not been taking place." You pull your levers and get something done.

Anne Milton: As I say, the responsibility will lie in the local authorities.

Q359 Valerie Vaz: So they were all talking shops really?

Anne Milton: No.

Q360 Valerie Vaz: Is something happening? Is something coming out of them then?

Anne Milton: What are you referring to? The Responsibility Deal plenary group, which is completely different and out of scope on this, in a way-

Q361 Valerie Vaz: But the Alcohol Strategy must feed into that Public Health Responsibility Deal. You are talking about public engagement.

Anne Milton: No.

Q362 Valerie Vaz: That is what I am trying to get at. It is in your evidence so that is why I was asking the question.

Anne Milton: I am happy to talk about the Responsibility Deal, but it is slightly separate from what we were talking about. It is nothing to do with policy, slapping people over the wrists or ensuring the enforcement of Government policy.

Q363 Valerie Vaz: No, but we are moving along now, are we not, to doing something? We are not simply sitting and chatting about an alcohol strategy. We want something to be done.

Anne Milton: We do. That is right.

Q364 Valerie Vaz: That is our job, to find out from you what is going on and how we can make it better.

Anne Milton: The Alcohol Strategy, yes, that is right.

Q365 Valerie Vaz: I am trying to get the information from you.

Anne Milton: Do you want me to-

Valerie Vaz: No, that is fine. Maybe you can write to me then.

Chair: Go on. If there is an answer to Valerie’s question, we might as well hear it now.

Anne Milton: The Responsibility Deal is an opportunity, as Chris has said, for Government to work with industry and NGOs to take voluntary action. I think, in our evidence we have talked about some of that. It is not a substitute for Government policy. It did not feed into the Alcohol Strategy. That has meant major cross-Government. So the Responsibility Deal is not a substitute for, it is in addition to-

Valerie Vaz: The strategy.

Anne Milton: To the strategy, yes.

Q366 Rosie Cooper: Who implements it? How does it happen? This feels like a meeting of West Lancashire Council where everybody develops strategies for England but nobody has any money and nobody is in charge of measuring the real outcomes. Who is going to make this happen?

Anne Milton: Local authorities.

Q367 Rosie Cooper: With what-money?

Anne Milton: Yes, the ringfenced money for the first time.

Q368 Rosie Cooper: How much?

Anne Milton: We have put out initial figures which were based on previous spend by PCTs. It has been quite difficult for PCTs to disaggregate what they actually spend on public health. So that was the first stab, if you like, and any allocations will only be upwards from that point, and we will make further announcements on that.

Q369 Rosie Cooper: What about alcohol? Are they going to be able to spend X on alcohol or is any money being ringfenced? This agenda is huge. How are we going to deal with this problem?

Anne Milton: It is not simple. I am sorry, but there were too many questions all in the same breath. The money is ringfenced for public health against an outcomes framework. Chris, do you want to say a little bit more about the payment for alcohol specifically?

Chris Heffer: The total ringfenced grant I think was £2.2 billion, which was the initial figure. That covers the wide range of services that are going to local government, to public health, and that includes-

Rosie Cooper: Alcohol.

Chris Heffer: Alcohol and drugs. All the money spent on alcohol at the moment transfers from the PCTs, so that money is for prevention, for Identification and Brief Advice, for treatment-hence the link-and that goes across from PCTs to local authorities alongside the drugs budget, sexual health, obesity, weight management and a bunch of things. That is ringfenced, as the Minister says, overall in public health. So that transfers across to local authorities to invest as they see fit against the outcomes framework. Clare Gerada-of the RCGP-sat in this very House and said that she was optimistic about alcohol in that new world, and you heard from Birmingham about how they would look at the strategy and how they would spend that money across a range of priorities.

Q370 Rosie Cooper: They do not have any waiting lists or any difficulties and the world is fine. Do you know what, I would be more successful nailing blancmange to that wall than getting any sensible answers?

Anne Milton: From whom?

Q371 Rosie Cooper: The people involved here seem to think that the problem will be solved simply by taking it from the PCTs and dumping it on local authorities where the pressures are great. Social care is going to be a bigger and bigger problem and it is wrong to think that alcohol is going to be a really high priority unless somebody is in charge of actually making it happen. If we just say, "The local authorities can do it" we are going to be still talking about this in 10 years’ time with very little difference from where we are.

Anne Milton: Can I come in? I feel your frustration but I have to say that it is somewhat offensive to say that we have simply "dumped" public health on local authorities.

Q372 Rosie Cooper: You have dumped public health on local authorities. They would need a massive injection of resources to make that really work. They are desperate in terms of social care and, because of the cuts that have been made to local government, they are in a really difficult position. This is only a strategy-which is great, whatever-and you are passing it over. Since I have been here, I have heard a lot about Health and Wellbeing Boards, but I do not know what power Health and Wellbeing Boards will have to deliver. They will influence and do all those great things. They will talk and they will formulate strategies and get involved in public health. But who is going to be the person who makes it deliver?

Anne Milton: Nobody could be more with you on the fact that the world is littered-and has been over the last 30 or 40 years-with strategies, frameworks and accountability regimes with nothing actually delivered on the ground and nobody ever held accountable. This is not dumping public health. This is putting public health where we think we can make a difference, not just improving the public’s health-

Q373 Rosie Cooper: Without the money-money, money, money-and power.

Anne Milton: -but reducing inequalities in health which continue to rise. Public health has a good home. It is not about dumping it. We are not the Public Accounts Committee or a committee that is enabled to discuss the public finances. I know local authorities are having a difficult time at the moment, as indeed is everybody, but we are where we are. I think the strategy will make a difference. It is not always about-and I have to say it emphatically-the amount of money you spend. It is how you spend it.

Q374 Rosie Cooper: But it needs power as well.

Anne Milton: What is quite interesting in my job, going round the country, is seeing examples of very good practice. Birmingham has been mentioned and I can mention a number of other places that, with no additional resources, are having quite a significant impact. It has an outcomes framework against which the money will be spent. If these are only talking shops, they will not deliver the outcomes that they are expected to deliver on the basis of the money they will receive. I agree that we need to make sure we pull up areas that do not do it so well and actually celebrate the excellence of areas that do it well. It is particularly tough if you look at public health and at inequalities in areas that really struggle to get through the day-individuals who struggle too-but until we move public health into local authorities we will not achieve that because, my goodness, the solution is not found in one area only.

Rosie Cooper: I would 100% agree with you, with money and power.

Q375 Chair: Can I bring us back to the specifics of alcohol policy?

Anne Milton: Indeed.

Chair: Virendra was going to ask you a question, I hope, about liver disease.

Q376 Mr Sharma: It is not forgotten. The strategy, Minister, states-in my view, incorrectly-that a liver disease strategy has been published. The Department’s memorandum says that it will be published "in due course". Are you able to say when that will be and can you give the Committee some idea of the approaches that the strategy is likely to promote?

Anne Milton: "In due course" is what Government always say, is it not? It is a bit like "the spring" and I always wonder whether it is before the daffodils come out or after.

Chair: It is not as immediate as spring.

Mr Sharma: But we are expecting it.

Anne Milton: One of the frustrations that you and other people must feel is when we say "in due course". Why do we say "in due course"? It is because events buffet politicians and Departments around, so you never want to make promises that you cannot fulfil. It is imminent. In other words-and I shall probably get shot down in flames for saying this-it is likely to be out before the summer recess. It is important and it is an important part of this.

Q377 Mr Sharma: So we are talking about the next four or five weeks?

Anne Milton: No. You see, you are wanting to pin me down.

Q378 Mr Sharma: You never said the summer recess of this year or the next year.

Anne Milton: I congratulate you on that point. For somebody who is as pedantic as me, it is frustrating. I find it frustrating and sometimes things suddenly speed up. It is important-critical.

Chris Heffer: You are quite right that it has not been published. That error was spotted and there is a correction on the Home Office website alongside the strategy pointing out that it has not been published.

Anne Milton: No.

Q379 Chair: But it is planned to be published before the summer recess?

Chris Heffer: As the Minister has-

Mr Sharma: 2012.

Anne Milton: I have discovered-talking about ministerial powers-that the one way of making sure something does happen is to say it in a session like this which is recorded and then it will happen.

Chair: We are glad to have been able to influence events to that extent.

Q380 Dr Wollaston: Can I turn to the minimum price? There is some evidence that the Government is considering the price of 40p per unit but it would be helpful for the Committee to understand: is the final decision going to rest entirely on the outcome of the consultation? Where are you heading, and what is the impact of the Scottish Government’s decision to set a minimum price of 50p? Do you think there would be significant problems if we set a different minimum price from Scotland? Would it not be more logical for us to go for the same minimum price across the United Kingdom?

Anne Milton: You have probably highlighted all the things that will be taken into consideration in deciding where the minimum unit price is set. You rightly highlight what the Scottish Government are doing and that has to be a consideration and I think we have to consider the responses to the consultation. All these things are about balance. I cannot tell you where we are heading because it would be premature to do so until we are at the end of this. Probably this Committee’s deliberations will add to our view on that. It is important to set it at a level at which it is effective. That is the thing. We know that alcohol is, to a greater or lesser extent, price sensitive, so it is important to have something that is effective. I go back to what I said earlier, that it has to be evidence based.

Q381 Dr Wollaston: The point is often made that the higher you set the level, the more of an impact you will have on drinking. But at some point you might start to see other harms such as people using alcohol substitutes which would be harmful in themselves. Have you taken any evidence about where that crossover might occur?

Anne Milton: We are collecting evidence and it is interesting that you talked about alcohol substitutes. I did ask officials yesterday if people still drink meths because, in my youth, when alcohol was very expensive, we used to talk about meths drinkers. People used to drink it. So your point is valid. It is about getting that balance right.

Q382 Dr Wollaston: But have you heard any evidence yourself about where that crossover might occur?

Anne Milton: Yes, I have seen some evidence. This is how policy is formed. I have seen lots of evidence saying all sorts of things. Also all evidence-and it is maybe important to say-should always be seen in the light of whence it comes.

Dr Wollaston: Yes, of course.

Anne Milton: It is "of course", but people do not always take notice of that.

Q383 Dr Wollaston: But you are not able to share with the Committee what evidence you have heard?

Anne Milton: No, I cannot. I am sorry.

Q384 Dr Wollaston: One of the issues that arose in Scotland when they set the ban on multibuys, for example, was that some of that policy was undermined by big supermarkets mailing customers and offering to send multibuys from south of the border. How concerned are you that we would see the same thing happen if we had different prices set between Scotland and England and that that could then undermine policy with our neighbours?

Anne Milton: Probably the unintended consequence of Government action is what took me into politics in the first place, and it is always a desperately important consideration. You raised two important things. One is the unintended consequences. We have to be very forensic and robust in our look at evidence to ensure we avoid that as much as possible. The other thing that you alluded to is the opportunities for buying things elsewhere. We have seen it certainly in drugs, with drugs sold on the internet-legal highs sold on the internet. People’s opportunities to buy things are hugely expanded. So we have to bear that in mind as well. There is no point in solving one problem if you create another.

Q385 Chris Skidmore: Can I come back to the evidence and, in particular, your own Department’s evidence? Is there not a risk that minimum pricing is effectively using a sledgehammer to crack a nut when you look at, say, point 57 of your evidence, that the Sheffield university study shows that "a 40p minimum unit price will reduce alcohol consumption by 2.4%"? In paragraph 49 of the evidence you say: "Government analysts have estimated that a 40p minimum unit price would lead to an estimated 30,000 fewer alcoholrelated hospital admissions per year after 10 years", but if we set that in the context of alcoholrelated hospital admissions having gone up from 510,200 in 20022003 to 1,057,000 in 20092010, then, with the Alcohol Strategy looking to 2023, you would only have brought alcoholrelated admissions down to 1,027,000. So even the Government’s own analysis, and Sheffield university’s own analysis, suggests that minimum pricing is not really going to have the desired effect, apart from to take us maybe back to 20092010 levels of hospitalrelated admissions, and barely reduces overall alcohol consumption at all. Taking a billion units out of alcohol looks more effective in terms of reducing alcohol consumption compared with minimum pricing.

Anne Milton: You have highlighted the fact that there is no one tool that is going to hit this on the head, which is why the Alcohol Strategy is a crossGovernment strategy and why it involves a number of different Departments. There is, I would say, good evidence to suggest that alcohol consumption is price sensitive. The point about the sledgehammer to crack a nut is always the argument used by people who do not want you to do something. I am not suggesting you do not want us to do it, but it is an important thing.

Chris Skidmore: No. I think we should do it, as you have provided a menu of options.

Anne Milton: One of the problems and frustrations about science is that it is never absolute. There is a lot of evidence-and Mark might want to come in here-on price and its impact. The trouble with these things, although good science takes account of it, is that you can never isolate things. You see the same in advertising as well, that you can never isolate it. The mere fact that we have produced an Alcohol Strategy and talked about minimum unit price will, in itself, have an impact on people’s drinking habits because it has raised awareness-any discussion in the newspaper. I do not think it is a sledgehammer to crack a nut. The mistake is to put all your money on that solving the problem, which is why we have to approach this in a number of different ways. We have not talked a lot about education and information-we will raise it a little bit with chronic drinkers-but that is also in there. Do you want to add anything?

Dr Prunty: Not particularly.

Chris Heffer: Can I add one thing? You talked about consumption and admissions. The other alcohol harm measure is deaths. I think that, because the MUP tends to target the cheaper alcohol which is drunk by the more harmful drinkers, the impact on deaths could be rather larger, and I have some estimates here that there could be up to a 10% reduction in deaths. There could be over a thousand fewer deaths by the end of 10 years. So it seems that the figure for deaths might be rather larger than for admissions.

Anne Milton: Do not forget-just to come back- that the billion units out of alcohol is in addition to, not instead of.

Q386 Chris Skidmore: Yes. I have a couple of other issues with minimum pricing. We saw over the past two months-and it reflects evidence we have had from the Wine and Spirit Trade Association-a suggestion that minimum pricing could, therefore, represent a barrier to trade and be illegal under EU law. That is obviously something which the Minister of State for Universities and Science, David Willetts himself, has picked up, and written in a private letter to the Cabinet, as being an issue. I was wondering whether that is being looked at by Government lawyers as part of the consultation. It is something that may handicap the actual implementation of minimum pricing in the longer term.

Anne Milton: Legal advice, a bit like evidence, is never completely absolute. Of course, we will seek legal advice. I am not disclosing any secret if I say that, like tobacco legislation, I have no doubt the challenges will come down the tracks at us.

Q387 Valerie Vaz: Did you say you had not sought legal advice yet?

Anne Milton: No. We have sought legal advice on a number of occasions.

Q388 Valerie Vaz: Yes, because you did say you would continue to take it?

Anne Milton: We have sought it on a number of occasions and will continue to do so.

Q389 Valerie Vaz: Presumably it must be kind of good, otherwise someone from the Cabinet Office would not have come up with 40p.

Anne Milton: Yes, it must be kind of good. I do not think I am allowed to discuss the legal advice that we received, but, yes, it must be kind of good.

Q390 Valerie Vaz: You can say yea or nay, can you not?

Anne Milton: That is such a good way of putting it.

Q391 Valerie Vaz: We are paying for it, after all. The other quick question is: have you or your officials had any discussions with the Scotland Office on how they have taken things forward, because I know sometimes that takes place when legislation is put through?

Anne Milton: Yes, there has been. I have also had discussions at the European level on this.

Q392 Valerie Vaz: There is no barrier to the minimum price that you know of, as such, that you are able to tell us?

Anne Milton: The advice, as such, is that we can do this. It is critical on a few factors.

Q393 Dr Wollaston: Can I follow up this from the points that Chris made about the figures that are available for the projected benefits from 40p per unit? Could you clarify what those figures would be for a 50p per unit minimum price?

Anne Milton: I cannot, but somebody on my right probably has the figures to hand. We could send it to you in writing for sure. It is probably easier if we do.

Q394 Dr Wollaston: Yes, because I gather the choice is between 40p, 45p or 50p. It would helpful for us to have clarified what the exact benefits would be. That would be helpful.

Anne Milton: Yes. We can do that. We have them.

Q395 Dr Wollaston: In Scotland they have also decided to have a sunset clause so that if there is not an impact after six years they would withdraw a minimum price. Are we planning to do something similar?

Anne Milton: No, but interesting things like that are coming out through the consultation, which I think is quite important.

Q396 Dr Wollaston: Yes. There is no point introducing a measure just to irritate people, but if there are real benefits, then-

Anne Milton: That is why the evidence and the science are so important, and frustrating when they are not clearer.

Q397 Dr Wollaston: But is there a danger that if we set the minimum price too low, we would possibly risk abandoning something that could have been effective?

Anne Milton: There is a danger at times. Actually, on this, I can feel like I am standing in the middle of the road and two juggernauts are heading towards me driven by those who feel that this is nannying and penalising responsible drinkers and those that think it is a solution to all ills. I think it is important to not stay in that middle. What we do has to be based on the evidence, the consultation and the legal advice. We have to be absolutely convinced that it will have some effect.

Q398 Chris Skidmore: In terms of looking at how this would affect the industry and where costs would be applied and, in addition, where costs might be pushed into different areas, is anybody looking at how minimum pricing-even though it affects bottles of White Lightning, or whatever cheap alcohol, but then suppliers would pass those costs on in a different way-would affect the ontrade in pubs, for instance? Do we know that everyone will end up paying for minimum pricing even if minimum pricing is designed to target those people who are harmful drinkers who, we know, buy 15 times more alcohol than moderate drinkers yet pay 40% less per unit? Then everyone ends up paying rather than just the targeted drinkers who would necessarily pay more but the costs get shunted over into the rest of the drinks industry.

Anne Milton: The industry is obviously scurrying away having a look at the impact that it will have. Generally there is a feeling that it is unlikely to affect the pubs and places like that because they are charging quite a lot for alcohol as it is.

Q399 Chris Skidmore: Could there not be a risk that you will have brewers and suppliers who produce similar drinks across the offtrade and the ontrade passing over the additional costs to minimum pricing, in some way, to pubs?

Anne Milton: I do not think we have received any evidence that that will happen. I am looking at Chris.

Chris Heffer: No. Obviously, the impact is primarily on the offtrade. Links to the ontrade are relatively limited. We know less about how the excess profit in the retail sector will be shared-if that is the right word-between the retailers and the suppliers and whether, if that materialises, they compete with retailers across other goods, pass it on beneficially to the suppliers or how they share that out. I do not think we know yet whether it is a cost or in fact a profit which, if it were to be shared, might even reduce ontrade. But who knows?

Anne Milton: Yes. That will be interesting.

Q400 Chair: Can I ask where you have got to on your thinking on regulation of multibuys?

Anne Milton: It is my understanding that we are going to consult on multibuys because it is an issue and people end up buying alcohol that they do not need.

Q401 Chair: Is it a consultation about how to implement regulation on multibuys or is it a consultation where the Government is saying, "We are against retailers selling cheaper by the dozen"?

Anne Milton: It is a consultation on how we do it and the legislation. The officials know more of the detail of where we have got to on this, but it is quite an important part of the mix in terms of pricing.

Chris Heffer: We are planning consultation on two things. One is the level of the minimum unit price, as just discussed, and a consultation on the policy of banning multibuys.

Anne Milton: So it is whether we do it or not.

Chris Heffer: It is whether we do it or not.

Anne Milton: But also out of that, we hope would come how you do it as well-unintended consequences.

Q402 Chair: I have a simple question about the policy on multibuys. The wine trade regularly sells wine by the case. Is that to be illegal in future?

Anne Milton: That is why we are consulting, exactly. That is the one representation that I have already had, whether the newspaper offers, for instance, would be affected by anything like that.

Valerie Vaz: You could say a case is not a multibuy.

Chair: It would be quite difficult to distinguish a case of claret from a CAMRA case of Cameron’s cans of lager.

Chris Heffer: Under Scots law you could still set minimum purchase limits. In other words, you could only buy it by the case but you could not by the single bottle. The Scottish legislation is framed such that, at whatever price you sell the multiple, it has to apply to the single as well. If you took a wine club, it might say a minimum buy is that every time you buy something you have to buy a minimum of 12. It looks like that would be absolutely fine but you could not price 12 at less than proportionally 12 times the single bottle.

Q403 Chair: I hasten to add that I have no interest other than being a customer, but it would be a substantial change in the way they do business.

Anne Milton: It is unlikely to affect, possibly, many of those buys because they are already quite expensive.

Q404 Chair: No, but as to the principle of a multibuy, that is exactly the point, is it not? The principle of a multibuy has nothing to do with the minimum price. It is whether a retailer can sell multiple units-multiple packages, bottles or cans-at a cheaper price than single cans or bottles.

Anne Milton: Yes. I have no doubt that this will emerge at the consultation.

Chair: I look forward to it.

Valerie Vaz: I think we are heading towards the final post.

Anne Milton: I am not in a rush. Health questions are not till 2.30pm so we have two and a half hours.

Q405 Valerie Vaz: We are very appreciative that you are here anyway. Advertising. I do not know if you could let us know what the current Government thinking or the Department’s thinking is about advertising, whether it has an effect on young people given that the Portman Group says it does not. If you could, tell us what you think. Does it affect people’s behaviour and is there any likelihood of following France and having a ban on advertising before the watershed?

Anne Milton: Yes. The Sheffield review, I think, found that there was substantial uncertainty in the evidence on the impact of advertising restrictions, including the effect of complete bans on advertising. It goes back a little to what I was saying earlier. It is quite difficult to demonstrate causality. Current thinking is not to do anything further than we already do and there are reasonably strict regulations on advertising. But the evidence is thin indeed.

Q406 Valerie Vaz: But your strategy says that there is known to be a link. Does the Department feel there is or is not one?

Chris Heffer: As our written evidence says, there is a link between exposure to advertising and when young people start drinking. The uncertainty is on the scale of that impact, potential policy interventions that mitigate those and, in particular, the proportionality of any of those. It said there is significant uncertainty on all of those. So in the light of the existing controls that the Minister talked about, the question is: are those appropriate for purpose, given that uncertainty as to what interventions might be appropriate?

Q407 Valerie Vaz: Are you looking at that?

Anne Milton: I would say with regard to that, as I would say with regard to everything, that I keep an open mind on all these things. At the moment, it would appear that it would be disproportionate so I would not consider any further action. But I will keep an open mind because there is always evidence emerging. As I said, evidence is often inconclusive. It is, at the moment, on that and the disproportionate nature of it. So I am open-minded always.

Q408 Valerie Vaz: But I am sure Sir Richard Doll would disagree with you if he were around. He was plugging away at tobacco and then, finally, people realised there was a link. So alarm bells should be ringing, should they not, at this stage, that there is some sort of influence? In your very own memorandum, do you say that-

Anne Milton: It is about the proportionality of it. What I am saying is that we are not planning to take any action at the moment. It is about the proportionality of it and there being insufficient evidence that the rules need to be strengthened further.

Q409 Valerie Vaz: Are you aware of the Joseph Rowntree Foundation evidence? Have you had a chance to look at that at all? Would it be helpful for you to look at it?

Anne Milton: I know Joseph Rowntree have done quite a lot of work in this area. I do know that.

Q410 Valerie Vaz: They talk about what was used, a strategy called the Florida truth campaign. There are no such campaigns that you are considering at all.

Anne Milton: No. Tell me more about that campaign.

Q411 Valerie Vaz: They focus not on the actual person who is doing the smoking but on the tobacco companies. That might be slightly difficult because you have them on board in a number of ways, have you not, with the alcohol? Diageo and various other groups are very much part of your strategy, are they not?

Anne Milton: Not part, no. They are part of the Responsibility Deal, which is a voluntary deal.

Valerie Vaz: There is Drinkaware.

Anne Milton: But that is it. Tell me more about this study. I am sorry, I do not know the details of it.

Q412 Valerie Vaz: I am reading from their evidence and wondered if you knew about it, or if it was something that you could look at.

Anne Milton: I do not know the detail of it. Do you, Chris?

Chris Heffer: I am not aware of that one. It sounds like a nonGovernment organisation targeting inappropriate companies. I am aware recently of an NGO in the UK that has written to a cider manufacturer about inappropriate stuff on their website. They have now taken that down and are having a conversation with them. In other words, there is clearly a role for non-Government organisations.

Anne Milton: They are quite useful.

Q413 Valerie Vaz: I do not mean targeting companies. I mean the actual strategy, the campaign. It might be worth your having a look at the evidence because they also point to someone called Velleman who notes that: "Young people who see, hear and read more alcohol advertisements and endorsements are more likely to drink, and to drink more heavily, than their peers". That was done in 2009. So I am saying that there is something out there.

Anne Milton: There is something, yes.

Chris Heffer: Yes, and I think our evidence evinced that there is a link between-

Anne Milton: Yes, there is a link.

Chris Heffer: -exposure and initiation.

Q414 Valerie Vaz: You definitely think there is a link between advertising and-

Chris Heffer: Yes. I think we have said that in writing and I have just said it on the record here.

Anne Milton: So there are no plans to ban or to change anything at the moment.

Valerie Vaz: No. But you accept there is?

Anne Milton: But I accept there is, yes.

Q415 Chair: On advertising, are you familiar with the Loi Evin, as I understand it, that they operate in France which requires an advertiser to restrict messages to verifiable statements of fact and make sure these messages only reach adults? France is not a country of teetotallers, nor is it a country that has gone wholesale on the wagon. Do you think there are some lessons there that could be applied here?

Anne Milton: I am going to ask Mark because you know quite a bit about this.

Dr Prunty: No, I do not.

Anne Milton: No, it is Chris who knows quite a bit about this. I have talked about it at length because I know Dr Wollaston raised this. As you say, it is important to gather information. Comprehensive analysis is difficult to draw on the impact of this. In fact, if you look at the figures and when there was a change in drinking habits, they do not necessarily correlate with the changes in the advertising regulations. Do you want to say anything else?

Chris Heffer: The Loi Evin has quite a long history in France. It had a sort of voluntary agreement in the 1970s and then, when regulation came later on, there was, I think, an evaluation done in French-and one of my team is going to plough through it-which found-

Chair: It is not unreasonable for them to conduct their own examination in French.

Anne Milton: We are a Department of many talents, Chairman.

Chris Heffer: I think they have found a positive impact in reducing alcohol consumption harm but it was not possible to quantify it. The impact on the young, from the substance of it, was unclear. Therefore, in a sense, you are left with a picture, in fact, that something has changed but whether it was due to that or whether it was not-whether in fact we are focusing on pricing and licensing, and that is where the evidence is strongest in the UK context-it is difficult to pick out a direct example. We do have some content regulation and we do have some volume regulation. We are working with the regulators to say, "Is that working and appropriate?" We do not measure, for example, particularly regularly the actual exposure of young people. We know there is a link between their exposure and their intake but there are no systematic measures of the exposure that happens. There are only occasional ones. We are working with the ASA to say, "Can you put in place measures to measure the exposure?", and then you could begin to see if you have a problem that we admit exists but we cannot quantify.

Anne Milton: I would add-not exactly on that point but it is important-that if you look at behaviour changes, which is the opposite, messages about the social norms do have quite a significant impact. Going back to the point about university students, where they put up signs saying, "The average university student only drinks one pint of beer a week", it does have an impact on reducing the amount of alcohol consumed. Messaging, both in terms of advertising and positive messages to change behaviour, are quite complex.

Q416 Chair: The reason it caught my eye is that it comes back to this principle of accurately defining the problem and accurately targeting a solution at the problem. It does not seem to me, almost independent of the evidence, to be that hard to defend the proposition that if you are dealing with a substance such as alcohol an advertiser should confine themselves to the truth and be mindful of who their audience is.

Anne Milton: Yes.

Q417 Chair: If those are the principles in the law operated in France, it seems to me that there is quite a big evidence base there that might be worth looking at.

Anne Milton: We continue to do so. The important point-and maybe I ought to take this opportunity to say it-is that we have accurately defined the problem and we will accurately target a problem which is very complex. The trouble is that, in defining it, we have discovered a very complex picture.

Q418 Valerie Vaz: And we want to help you.

Anne Milton: I know you do, and I take my appearance here and your investigation into this as a positive thing, not a negative thing. Do not worry.

Chair: We are glad you see it in that light.

Anne Milton: I always do, though I am probably alone in that.

Q419 Dr Wollaston: While France is not a nation of teetotallers, they are drinking significantly less than they used to. Do you feel that part of the problem, if we want to say that advertising is not being directly targeted at children, is with the definition of a child and an adult audience in that the threshold is set at 25%? If you were to throw a random set square down anywhere in the country, you would find that, if you look at the number of children that were caught by that definition of people under 18, because of the demographics, it is no longer appropriate. Should we not set the bar a bit lower and say that the threshold is set at an audience where at least 90% are adults as opposed to 75%? Is that part of the problem? Regularly, for example, you can go to a 12-rated cinema showing and find yourself bombarded with alcohol advertising. Surely that cannot be right. We have our definitions wrong.

Anne Milton: What is a child, indeed? It comes up on a number of public health issues. If we are talking about advertising-and you talked about going to the cinema with a 12 rating and alcohol adverts-you have all the social media out there. This is a very complex world, which is why it is important to keep it under review. In terms of influence on children, there is good evidence to suggest that family and what happens in the home probably has far more impact than anything else.

Q420 Dr Wollaston: Indeed, it has a huge impact but looking at the saturation marketing to children, at the branded products that the children aspire to and the way that you have "advergames" on the internet, there are so many vehicles through which children are being bombarded with marketing-be that sponsorship right through a huge range. Yes, family is important, but could we not take a very significant step by changing the thresholds at which we define an adult and a child audience?

Anne Milton: I do not know who would actually take that. The ASA, I think.

Chris Heffer: They are in the codes, are they not, the CAP and the BCAP codes, which the ASA supervise under the aegis of Ofcom and the DCMS? They are regulators and they have to take account of evidence and be proportionate in that. So, in a sense, you go back to the evidence question. If there was strong evidence showing the links, they would have to take that into account as regulators.

Q421 Dr Wollaston: But there is evidence to say that you start drinking younger and you drink more when you do, and that is the evidence that comes from Stirling university. Is that not right? As you say, the scale of that impact is uncertain.

Chris Heffer: It is unclear and the age of initiation is rising and the number that is drinking below is falling. So you go back and ask: is that proportionate, given that context?

Anne Milton: And the definition of "child" in all that forms a natural chain. But it is important to keep it under review, as I say, because of the social media.

Q422 Mr Sharma: What do you see as the role of the drinks industry in tackling the health problems alcohol causes? Is it appropriate for the industry itself to play a role in the developing policies to address alcoholrelated health problems?

Anne Milton: It is not my job to define the role of any industry. They create it themselves.

Q423 Mr Sharma: But you can encourage them.

Anne Milton: There are three things I would like to be absolutely clear about. First, it is not the role of the industry to develop or dictate policy. It never has been and it will not be. Priorities and policy should be informed by research, advice and evidence. However, we would be crazy to ignore the reach that business has. I think 17 million families use the supermarkets every week, so the opportunities to influence are very great. The Responsibility Deal, which is where industry, NGOs and we come together, is an opportunity to persuade industry to be responsible, if you like, to recast responsibility for the industry as doing something that is seen to be in the public good. It is an opportunity to add something. It is not a substitute for and it is not a forum for developing policy. Anything that we can do without legislation is quick and easy. What will be quite interesting is that with any of the pledges made by the Responsibility Deal-for instance, if you have 82 companies signed up to have health and alcohol unit information, which was raised earlier, clearly labelled on cans and bottles, and 80% of cans and bottles with that information on-there could be evaluation of the Responsibility Deal. We could test how effective it has been, and it will be independent.

This is anecdotal-and I speak not so much as a Minister but as a constituency MP who has a significant nighttime economy-but I think that the industry’s attitude to drinking has changed inasmuch as there were some very negative images, with a lot of it centred around antisocial behaviour and criminal damage. But I think that there has been a change, and I felt it from the industry. They do not necessarily want to have that association any more. So there are other drivers going on outside Government that have encouraged them to take a slightly different attitude. But, as I say, it is no substitute.

Mr Sharma: I am sorry, Chairman, but-

Anne Milton: Was that a long answer? It probably was.

Q424 Mr Sharma: No, it is a good answer, but you agreed that the drinks industry has a role to play. I withdraw the term "policies" if you say they have developed strategies to work with other agencies to tackle this problem.

Anne Milton: They could play a role if they choose to do so.

Q425 Mr Sharma: Do you not think they should be encouraged to do so?

Anne Milton: The reduction of 1 billion units could have quite a significant impact. That would be a drop of 2% in the alcohol sold in this country. A few companies are stepping up to the crease on this and trying to lead the way on reducing the volume of alcohol in bottles and things, and that is to be applauded. So they do have a role to play, absolutely, and we would be, as I say, daft to ignore it when 17 million people go into a supermarket every week.

Q426 Barbara Keeley: I want to follow that up. You talked there about lowering volume, but is there not a question of lowering strength?

Anne Milton: I meant lowering strength, I am sorry, yes.

Q427 Barbara Keeley: Is that not a major thing?

Anne Milton: It is.

Q428 Barbara Keeley: That comes quite strongly from the evidence we had from Birmingham who were, for instance, going to go away from here and start to talk to restaurants and places like that about having, as their house wine, the lowest alcohol because if anything has changed-and I think the units thing is complicated because people think of it as a glass.

Anne Milton: Yes.

Q429 Barbara Keeley: They think of a bottle as 11% or 12% and it is not. A lot of red and even rosé wines are 14%, are they not, so could that not be a major focus for the industry?

Anne Milton: It is a major focus. In fact, one example is of a company who have developed a whole range of wines, potentially removing 25 million units, and they are trying to promote that and working with the supermarkets to promote it. Your example of restaurants which have low-strength house wines is positive. It is going to take a bit of time. I would not be naive enough to think that this is going to happen, but that could have a significant impact on the amount of alcohol we drink. I think it is poorly understood by the public. How many of us look at the strength of the bottle of wine or anything else before we buy it?

Barbara Keeley: It is not printed in very large letters.

Anne Milton: It is fairly small and, as you get older, it is more difficult to see.

Q430 Chris Skidmore: A particular issue with wine is in terms of strength, and probably the most relevant thing the Government could do would be to look at variable rates of duty. I know the Treasury produced a document last November looking at lower duty for beer or ale under 2.7%, with higher rates of duty over 7.5%. That seems to be, if you take those two parameters, quite a wide parameter by which the duty should be charged when you compare it to other countries. Personally, I would think that it would be more favourable to have a lower duty for beers under 4% and then a higher duty coming in at maybe 6%. But you cannot do that because of European regulation and you cannot even touch wine on variable duty. So if you have 14% wines at the moment, European regulations mean that the Government is hamstrung. I wondered what your thoughts were about that. Obviously it extends beyond your brief at the Department of Health, but the Health Secretary raised this as an issue, that there are wider arguments to be won over duty which then would have a knockon effect on the strength of beers and wines.

Anne Milton: That is right. Of course, I am not allowed to discuss anything like this because it is a matter for the Treasury and I would get into really big trouble.

Q431 Valerie Vaz: We should get you to commit to something now.

Anne Milton: Good heavens. A careerlimiting move possibly. That is because, as you have highlighted, of some of the problems with it. Anything that we can do voluntarily in the meantime, which can be done quite quickly, would be good. In fact I have heard at length from a wine producer that it is quite complex because the people who produce the wine have to have the ability to work with the people who are growing the grapes because the volume is dependent on the grapes and when they are picked. So it is not that easy to reduce the alcohol strength. Those are incentives and we should look at those. But those are slow and have long leadin times. Anything we can do voluntarily will be quick. Also there is highlighting to the public that they should have a look at the strength of things, and restaurants offering us low volume house wine. I wonder what the House of Commons does.

Q432 Chris Skidmore: You could almost have a wine strategy. Looking at the evidence, there is the fascinating graph on page 11 of the "Annual Alcohol Consumption per UK Resident 19002010". When you look at the growth, with spirits they have gone up slightly but they have only gone back up to between 1900 to 1915 levels, before prohibition came in. It is the wine which is the real problem here.

Anne Milton: Yes, it is.

Q433 Chris Skidmore: I do not think, in terms of the strategy, apart from the 1 billion units, that there is much to tackle this whole growth area of wine and middleclass drinking. The people drinking the bottles of wine are not the ones going out causing violent disorder. The minimum pricing is focusing on the White Lightning tax but at the same time the health issue of chronic liver disease is going to be generated from wine.

Anne Milton: I feel very acutely as Minister for Public Health that it is desperately important to have the evidence always behind everything we do. We tend to talk about the group in an area like alcohol, where the harms are very varied and where the target population are very varied. We always focus on those that actually do not concern us. I am sure, with one of the sessions on antisocial behaviour-and at one point that was all you could read about in terms of the harm alcohol caused-we focused on that because we are not those people. So you are right that wine is an issue but then you have-if you take the average 15yearold-the super-strength lagers and the ciders and all the rest of it. It is across the board. Anything we can do voluntarily with the industry to reduce the amount of alcohol that is consumed per bottle will benefit us all in numerous ways.

Q434 Valerie Vaz: And you have the power to commission that evidence.

Anne Milton: We do have the power to commission that evidence.

Valerie Vaz: There you go.

Anne Milton: The other very unpublicised part of my job that nobody is ever terribly interested in, but it does give me two minutes to mention it, is, of course, that I have responsibility for European and world health and so I have opportunities to talk to other European health ministers about this. In fact, it is encouraging to note that there is growing enthusiasm for doing something about noncommunicable diseases, certainly in Europe. Awareness of the vested interests, particularly for some countries, is an important part of my role as well. As I say, it is unpublicised and not terribly exciting, I know, but it is important and it is how we move things in terms of the restrictions of EU legislation.

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Q435 Rosie Cooper: I would like to ask, off beat, about the Department of Health statistics on alcohol. The penultimate paragraph talks about the increase in the number of prescriptions for drugs for the treatment of alcohol dependency prescribed in primary care or NHS and dispensed in the community. Did you collect those figures? Obviously it talks really about a 5% increase on the 2010 figure by 2011 and a 63% increase since 2003. Do you have those figures available? How do you collect them-by PCT area?

Anne Milton: Yes, quite.

Q436 Rosie Cooper: Or is it by city? If we were to ask for some of those disaggregated, could we find out? For example, Birmingham keeps being held up as a brilliant place, yet, when we spoke to them-and they were very good at brief interventions and had no waiting lists for anything-deaths from alcoholrelated diseases was rising. I would be very interested to see these numbers because, again, we have this general myth that may not be underpinned by the actual facts about who is doing well and who is not. I find it all very worrying indeed.

Anne Milton: <?oasys [tb ?>We are going to have to write to you on the specifics, if we may, but your point about digging slightly deeper into statistics is really important. I get enormously frustrated and have had discussions with officials about the way we use the term "alcoholrelated admissions". It is widely misunderstood by the press who perceive that to be people coming into A and E. There is a published health question today which is going to ask about A and E admissions. There is no such thing as an A and E admission, of course, so they are widely misunderstood. You are right to talk about the source. It is why we are looking at how we define alcoholrelated admissions. What we have to do, I think, is be much better at being very clear about what we are talking about.<?oasys [nb ?>

Q437 Rosie Cooper: This is prescriptions.

Anne Milton: Yes, prescriptions and how they are collected.

Rosie Cooper: You cannot really mistake a-

Anne Milton: How they are collected, whether they are dispensed or prescribed-

Rosie Cooper: -prescription for the treatment of-

Anne Milton: As you will be well aware, there are lots of drugs prescribed and not nearly as many taken. It is about whether the prescriptions are written or whether they are actually dispensed and there will be a disparity.

Rosie Cooper: But if they are dispensed, whether they are taken or not, there is a perceived need by a clinician that they are required.

Anne Milton: Yes, there is.

Q438 Rosie Cooper: Therefore, the fact that the prescription is issued in the first place suggests a need. So I do not see the point you are making really.

Anne Milton: No, I do not want to get into detail here, but let us tell you how they were collected.

Q439 Chair: Unless any other Member of the Committee wants to come back to any point, or unless you have any concluding comment, Minister-

Anne Milton: No, other than to thank the Committee. I do mean that, actually.

Chair: Thanks from us to you for coming this morning.

Anne Milton: It is a pleasure.

Chair: We will ruminate on what you have told us. Thank you.

Prepared 19th July 2012