House of Commons - Government's Alcohol Strategy

Government's Alcohol Strategy - Health Committee Contents

3 Policy Response

OBJECTIVES AND TARGETS

22. The Committee believes it is important to ensure that the objectives of policy on alcohol are clearly stated and calibrated. The great majority of citizens enjoy alcohol without significant evidence of harm to their health. The Committee accepts that it is not possible to define a level of alcohol consumption which is, in any absolute sense, safe for all citizens at all times. We do not believe, however, that this conclusion should lead to disproportionate or heavy handed controls which are justified neither by public support nor evidence of proportionate health gain.

23. The Committee also believes that healthy societies expect all citizens, both corporate and individual, to exercise their individual freedoms in ways which respect the rights and interests of their fellow citizens and observe shared standards of responsible behaviour. It is part of the function of Government to stimulate, lead and if necessary regulate, in order to encourage the development of this culture.

24. Against this background the Committee believes it is important for policy to be guided by objectives which are clearly stated and defined. The Strategy outlines a series of outcomes that the Government wishes to bring about:

Our ambition is clear - we will radically reshape the approach to alcohol and reduce the number of people drinking to excess. The outcomes we want to see are:

A change in behaviour so that people think it is not acceptable to drink in ways that could cause harm to themselves or others;
A reduction in the amount of alcohol-fuelled violent crime;
A reduction in the number of adults drinking above the NHS guidelines5;
A reduction in the number of people "binge drinking";
A reduction in the number of alcohol-related deaths; and
A sustained reduction in both the numbers of 11-15 year olds drinking alcohol and the amounts consumed.[21]

25. There are, however, no specific targets or measurements to say how the Government will judge the success of the strategy. The Alcohol Health Alliance noted its concern "about the absence of specific targets and timeframes for achieving changes in consumption, violent crime and incidence of alcohol-related chronic conditions"[22]. This contrasts with the example of Birmingham's local strategy that we looked at in evidence, which had some quite specific measures:

Key Outcomes

In order to achieve this overall vision we have set three key outcomes. These will direct all our work and activity will only be taken forward if it will impact upon them. The outcomes we will be seeking to achieve are:

Increased healthy life expectancy and reduced differences in life expectancy and healthy life expectancy between communities;
Reduction in alcohol related crime and disorder and perception of crime and disorder;
Reduction in the adverse impact of alcohol on families and the wider community

Key Performance Indicators

To measure our overall progress towards achieving these outcomes we have set three key performance indicators. These indicators are linked, as closely as available data allows, to the outcomes:

Stabilisation of the rate of alcohol-related hospital admissions by reducing the rate of increase by 2% year-on-year;
Reduction in alcohol related crime and disorder by 10% by end of strategy period;
Reduction in the loss of months of life lost due to alcohol by 10% by end of strategy period.[23]

26. On the question of targets, the Minister told us:

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.[24]

27. We believe that in order for the alcohol strategy to be effective it needs to have quantified objectives. The Minister said that the public health outcomes framework would provide these objectives, but that framework is very broad and only one of the more than 60 indicators contained within it is entirely alcohol related (alcohol-related hospital admissions).[25] The Committee believes that an Alcohol Strategy should be seen as part of a wider public health strategy, and should contain some key quantified, alcohol-specific objectives which will provide both a framework for policy judgements and an accountability framework.

28. We address later in the report the issue of all local areas having an alcohol strategy, flowing from the national strategy but using local approaches to deal with local problems. It seems logical that Public Health England should oversee this process, given its overarching responsibility for public health matters. It also seems logical that Public Health England should devise the national measures against which the strategy can be tested.

WHAT IS 'SAFE'?

29. If the objective is to allow consumers to make "informed choices", the question "what is safe?" is fundamental. Professor Sir Ian Gilmore, special adviser to the Royal College of Physicians on alcohol and Chair of the Alcohol Health Alliance, told us:

There are great difficulties and this is the nub of the problem of the health messages to the general public. Everyone is different and probably responds differently to alcohol. If you take 100 very heavy drinkers the majority will never get cirrhosis of the liver, but we cannot yet tell you which group you fall into. There are those individual differences. Then there is the fact that for different diseases the threshold is very different. If you stick within socalled safe limits then there are certain diseases you are virtually guaranteed not to get, whereas there are other conditions, like some forms of cancer, where drinking well below safe recommended limits will significantly increase your risks. I am afraid that, at the moment, you cannot generalise and say you will be totally safe if you stick to such and such a level. But I do welcome the recommendation in the strategy that guideline advice is revisited. It should be possible to personalise that more than we have at present and to try to get round some of the understandable confusion in the general public.[26]

30. Eric Appleby, of Alcohol Concern, told us:

It seems to me that one of the problems we have is that we are not very good at talking about alcohol. At one end it is a bit of a joke: going down the pub and getting drunk is comfortable and jokey. At the other end, talking about real problems is almost a taboo subject. In between we are not very good at having that conversation about the dichotomy, if you like, that alcohol is quite enjoyable and we like it but it also carries harms. Having this conversation about managing risk is something we just do not do, and people tend not to want to do. It is instigating that conversation which is to some extent what is needed.[27]

31. The Committee also heard that the message about sensible levels of drinking had been confused. Eric Appleby said:

We have what were originally called "Sensible drinking guidelines", which, when they were framed, were relatively straightforward, but the world has changed since then—the strength of drinks, the size of servings, and all that. It is now very confusing for people. The strategy talks about reviewing those. The important thing is reviewing how we communicate them, because I think you will find that the science has not changed very much. It is about how you communicate that and how you can get the message across to people of the true nature of the issue. It is a very loaded subject. Nobody wants to be told that they should drink less than they are currently drinking. We have this spectrum between, at one end, a sort of fatalism about drinking, "You cannot do anything about it. People drink. It just happens" and a denial at the other end, "Yes, I have my bottle of wine with a meal every night. I do not get drunk. I do not cause anyone any problems. There is nothing wrong with that," except 20 years down the line when you end up in one of Ian's hospital beds.

32. As the Strategy notes, the Government launched a campaign earlier this year to communicate the health harms of drinking above the lower risk guidelines and provide a range of tips and tools to encourage people to drink responsibly.[28] It also says that "we will ask Dame Sally Davies, the UK Government's Chief Medical Officer, to oversee a review of the alcohol guidelines for adults. This will also take account of available science on how we can best communicate the risks from alcohol, improving the public's understanding of both personal risks and societal harms".[29]

33. There is clearly a need for such educational measures. The Royal Geographical Society (RGS) quoted evidence that showed

very few people acknowledge the use of 'units' as a way of either measuring, and hence controlling, their own levels of drunkenness, or of monitoring the health impacts of alcohol consumption. In a survey of drinkers in urban Stoke-on-Trent and rural Eden, Cumbria, not one single person surveyed said that they used units in their day to day life and that measuring 'units' simply did not work. However what the study did find was that people tend to consider the impact of drinking on their health in terms of how they felt, with their level of drunkenness determined by a number of factors including their mood, food intake, level of tiredness, and their own personal (often changing) tolerance to alcohol.

The conclusions is that a whole range of factors, including cultural norms and peer pressure, are what are important in determining what, and how much, people drink. This suggests the use of 'units' in alcohol policy may not resonate as a useful public health tool: first, 'units' do not always correlate to the actual negative health effects of alcohol on our bodies; second, under current government guidance, a majority of drinkers are being classified officially as 'bingers'. In practice, however, these same drinkers may experience little or no harmful (immediate) health issues because of their alcohol consumption.[30]

34. The RGS also noted "that in the UK people have tended not to worry about their consumption, even when reporting excess consumption... evidence shows that the amount of alcohol consumed reported in surveys is considerably (about one third) less than that sold".[31]

35. The Minister agreed that there were problems with the guidelines:

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 [Chief Medical Officer] 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.[32]

36. Although we accept that it is a complicated issue, we regard a clearer, evidence-based definition of the health effects of alcohol consumption as fundamental to successful policy development in this area. The work of the Chief Medical Officer needs to be carried forward as a matter of urgency. Public Health England, acting independently of Government, then needs to use the outcome of the review as the basis for its promotion of public understanding of the issues, setting out the level at which harms are likely to result alongside sensible drinking guidelines.

BINGE DRINKING

37. The strategy highlights the public order and related issues concerning binge drinking, but there are clearly health issues which also need to be addressed. As the Department told us:

Drunkenness, due to single, heavy drinking episodes ('binge drinking') has been shown to have a number of health and social consequences on the drinker and/or on other people, such as:

Injuries, for example from falls
Violence and aggression, including alcohol-related crime and disorder and domestic violence increase with drunkenness and with heavier drinking in general. If the heavy drinker is a parent, this can contribute to a variety of childhood mental and behavioural disorders. Systematic reviews have suggested that alcohol is a contributory factor in 16% of child abuse cases.
Increased risk of stroke, heart arrhythmias, and sudden coronary death, even in people with no evidence of pre-existing heart disease - any protective effect of regular, moderate consumption may be lost through binge drinking, even if this is infrequent.
Harming home life or marriage
Damaging work performance
Limiting young people's educational attainment[33]

38. Chris Sorek of Drinkaware noted changes in attitudes to excessive drinking:

during my first time in the United Kingdom in the late 1970s and early 1980s—when I was working here—going out and getting drunk, at that age, was seen as losing face. People would think less of you. That has changed and there has been a cultural shift.[34]

39. The London Health Improvement Board told us that:

Heavy binge drinking by adolescents and young adults is associated with increased long-term risk for heart disease, high blood pressure, type 2 diabetes, and other metabolic disorders. A UK study found that binge drinking in adolescence was associated with increased risk of health, social, educational and economic adversity continuing into later adult life. The problems included increased risk of alcohol dependence and harmful drinking in adulthood, illicit drug use, poorer educational outcomes, criminal convictions and lower socioeconomic status.[35]

40. Despite some perceptions that binge drinking is largely a public order issue, the evidence presented to us suggests that it does contribute to some of the long-term health harms that have concerned us. We conclude that these health problems need to be addressed no less urgently than problems with public order and anti-social behaviour.

MINIMUM UNIT PRICE

41. In the Strategy, the Government notes measures already taken on price to address what it calls the 'heavily discounted' price of alcohol:

Raising alcohol duty by 2% above retail inflation (RPI) each year to 2014-15;
Introducing a 'minimum juice' rule for cider, so that high strength white ciders can no longer qualify for the lower rates of duty that apply to cider; and
Introducing a new higher rate of duty for high strength beer over 7.5% Alcohol By Volume (ABV) and a new lower rate of duty for beer at 2.8% ABV and below to align duty more closely to alcohol strength.[36]

42. The Government notes, however, that

as there is such a strong link between price and consumption, we need to go further still to end the irresponsible promotion and discounting of alcohol.... We will introduce a minimum unit price (MUP) for alcohol meaning that, for the first time ever in England and Wales, alcohol will not be allowed to be sold below a certain defined price. We will consult on the level in the coming months with a view to introducing legislation as soon as possible.[37]

No figure is suggested for the minimum price in the body of the Strategy, but the Prime Minister, in his introduction, says "if [the minimum price] is 40p that could mean 50,000 fewer crimes each year and 900 fewer alcohol-related deaths a year by the end of the decade."

43. Written evidence to the Committee reveals a clear divide on this issue between industry and health bodies. For example, the Wine and Spirit Trade Association is outspoken on price, saying that:

The WSTA is opposed to a policy of minimum unit pricing both in principle and in practice. There is no evidence to prove that it will tackle alcohol misuse yet it will raise prices for consumers who do not have a problem with alcohol. A 40p minimum unit price will hit the poorest 30% of households in England and Wales the hardest... It is inconsistent with the operation of the free market for the state to intervene on price. Minimum pricing could therefore represent a barrier to trade and be illegal under EU law.[38]

44. The question of the legality under European law of a minimum unit price was also raised by the Office of Fair Trading:

... it is...important to distinguish between the current proposal for a statutory minimum price unilaterally imposed by Government, and the alternative of a voluntary agreement between retailers to agree prices (with or without Government encouragement). A voluntary agreement on price would almost certainly infringe [The Competition Act 1998] and European competition law.

There may be constraints on minimum pricing legislation arising from wider European law. For example, minimum pricing legislation may raise issues of compatibility with European free movement rules. The OFT does not have jurisdiction over these areas of law - enforcement takes place at the European level. The OFT understands that this is currently a live issue in relation to proposals for minimum alcohol in Scotland, and it is possible that there may be legal action which would clarify the position.[39]

45. In its written evidence the Department told us:

There are a number of issues to consider when implementing minimum unit pricing. The Government continues to take legal advice and will consider any potential legal implications as we take forward this proposal and consult on a proposed level of minimum unit price.[40]

46. The British Beer and Pub Association (BBPA) in its memorandum notes that "The BBPA's membership has a range of views on the subject of minimum pricing", but overall expresses a cautious view:

Whilst there is clearly a relationship between alcohol pricing and alcohol consumption, evidence of a link between pricing and harmful consumption is less well established. Are the heaviest drinkers affected by increased prices? The Sheffield study, in line with most international evidence, found that the heaviest drinkers are least responsive to changes in price.

The BBPA believes that it is important that alcohol should be retailed in a manner that is socially responsible and supports a ban on below-cost selling...Whilst minimum pricing might cut the differential between the price of beer in a supermarket or pub, it must not be seen as the answer to pub closures which are clearly down to high taxation. Minimum pricing is, by definition, a blunt tool and clearly the higher the minimum price the greater the impact on the vast majority who enjoy alcohol responsibly; particularly those on the lowest incomes.[41]

Not all of the industry is opposed to minimum unit pricing, however. In evidence to us both Greene King[42] and Waitrose[43] strongly supported its introduction.

47. Professor Brennan's explanation of his research did not support the BBPA interpretation of his group's findings on the effects of price:

The key advantage of minimum pricing, from a targeting perspective, is that it is, in the data, the harmful drinkers who tend to drink more of the cheaper alcohol. Compared to putting general prices or general taxes up, putting a minimum price means that it is the harmful drinkers who are disproportionately affected by the policy. Those are the kinds of analyses that we have done.[44]

48. Alcohol Health Alliance UK says that:

The AHA strongly supports the Government's commitment to introduce a minimum price on alcohol in England and Wales. This step acknowledges the clear relationship between price and the consumption of alcohol and associated harms, which is supported by substantial and robust evidence and modelling...Minimum unit pricing is particularly important in helping to address alcohol consumption's contribution to chronic disease and will primarily target harmful and hazardous drinkers, with comparatively little impact on the spending of moderate drinkers^.8Evidence shows that it is the cheapest alcohol that is causing high levels of harm - in the UK on average, harmful drinkers buy 15 times more alcohol than moderate drinkers, yet pay 40% less per unit.[45]

49. Canada already has a minimum price for alcohol, so we asked about the evidence of its effects there. Professor Brennan told us:

Canada has had a minimum pricing policy for quite some time and its differential in different states has changed at different time points. It is quite clear that when they have changed their minimum price there has been a direct impact on consumption. Once they have had this policy for a while and they ratchet it up a little bit, or put it down, consumption follows quite quickly in terms of decreases and increases.[46]

50. Given the policy commitment to introduce a minimum price, it is the level at which it should be set that was the subject of greatest discussion in evidence. Most of those giving evidence to the Committee who commented on price argued in favour of a minimum unit price of more than the 40 pence[47] mentioned in the Prime Minister's forward to the strategy (although there is no statement of the anticipated level of the unit price in the document itself).

51. The Scottish Government announced on 14 May that it is proposing to introduce a minimum unit price of 50 pence. The Scottish Health Minister, Nicola Sturgeon MSP, said that

We have a big package of measures that are addressing the problems Scotland has with alcohol misuse so minimum pricing is by no means the only part of the solution, it's not a magic bullet... But there is plenty of evidence that says unless you have a pricing mechanism at the heart of the package of measures, then that package of measures is not going to be as effective as it would otherwise be.[48]

52. The Scottish Parliament Bill which establishes a minimum price per unit provides that the power to set a minimum price will expire after six years unless the Scottish Ministers bring forward an order to continue it, which they may only do in the sixth year (the so-called "sunset clause").[49]

53. The Minister told us:

I cannot tell you where we are heading [on unit price] because it would be premature to do so until we are at the end of [the consultation]... 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.[50]

54. The Committee welcomes the Government's decision to introduce a minimum unit price for alcohol. It is, however, struck by how little evidence has been presented about the specific effects anticipated from different levels of minimum unit price. The proposition that demand for alcohol is relatively price-elastic seems uncontroversial. Rather than relying on generalised statements about the effect of price on consumption, the Committee urges the Government to build its case for a minimum unit price by establishing direct links: between specific alcohol products and specific alcohol-related harms; between different levels of minimum unit price and the resulting selling prices for the products which are linked to alcohol-related harms; and the likely effect of different levels of selling prices for those products on demand for those products in the target range of households.

55. Given the Government's decision to introduce a minimum unit price, the debate has been about the level at which it should be set- whether it should be 40, 45 or 50 pence - but the setting of a minimum unit price will not be a one-off event. Once a minimum price is introduced, if it is judged to be successful, the level will need to be monitored and adjusted over time. A mechanism will need to be put in place in order to do this, but as yet there has been no indication from the Government of what it intends to do other than to consult on the price. One way of setting the level would be to establish an advisory body (there are a number of these already, dealing with a range of issues)[51] to analyse evidence and make recommendations to Government. Whatever mechanism is chosen should be used when setting the initial level of the minimum unit price to ensure that from the beginning the price is clearly evidence-based.

56. It has already been announced that the minimum unit price to be introduced in Scotland will be 50 pence per unit. There are practical arguments in favour of the same minimum price being set in England to avoid the problems with cross-jurisdiction trading that we refer to later when we discuss the case for banning multi-buy promotions. Our main concern, however, is that the level of minimum price that is set should be evidence-based and designed to be effective. If the minimum unit price in England were to be fixed at a different level to that in Scotland, we would expect the evidence supporting that decision to be set out clearly. This is another argument in favour of establishing a transparent mechanism for setting the price.

57. We recommend that there should be a "sunset clause" on any provisions for setting a minimum unit price for alcohol, and that a decision by Government to make a minimum price permanent should be taken following advice from the advisory body or other mechanism used to monitor and adjust the price during the initial period.

58. Throughout this section of the report we have emphasised the need for the decision on minimum price to be evidence-based. The debate so far is based almost entirely on the work of the Sheffield Alcohol Research Group, though research from Canada has become available more recently. It is not a criticism of the integrity of that research to say that, if there is to be a minimum unit price, a more substantial evidence base needs to be developed in the future to help in the assessment of whether the minimum unit price is achieving the anticipated benefits.

MULTIBUYS

59. The Strategy says that:

We will...consult on a ban on multi-buy promotions in the off-trade (shops) meaning that multiple bottles or cans could not be sold cheaper than the multiple of one bottle or can. This would put an end to any alcohol promotion or sale that offers customers a discount for buying multiple products in stores and therefore those that encourage and incentivise customers to buy larger quantities than they want.[52]

60. The Alcohol Health Alliance welcomed this move:

The AHA strongly supports this ban. The University of Sheffield modelling shows that increasing restrictions in off-trade discounting (ie through multibuys) does have increasing effects in a similar way to minimum pricing. Restrictions to 40%, 30%, 20% and 10% discounting give estimated consumption changes of -0.1%, -0.3%,
-1.6%, -2.8% respectively. A 2.8% reduction in consumption is similar to the change estimated for a 40p minimum price.[53]

61. The Advertising Association, representing the advertising industry, was not convinced. It said:

We do not believe multi-buy alcohol promotions are inherently irresponsible; consumers are used to such multi-buy promotions in respect of many different goods and services. The focus should not be on banning a form of marketing, but rather on ensuring that all forms of marketing are undertaken in a responsible manner. We will respond to this consultation when launched by the Government but in the meantime we urge the Government to ensure that any proposals are proportionate and evidence-based.[54]

62. A ban on multi-buy promotions came into effect in Scotland in October 20911. Alcohol Focus Scotland told us that

Experience in Scotland shows that to ensure maximum effectiveness, the ban on multi-buy discounts should be implemented alongside minimum pricing and across the UK. A ban on multi-buy discounts came into force in Scotland on 1^st October 2011 with the implementation of the Alcohol etc. (Scotland) Act 2010. During the first weekend of the new legislation being implemented, a number of the major supermarkets sought to undermine the spirit of the Act by encouraging online purchasing of alcohol from distribution centres in England.

Moreover, many of the major supermarkets slashed their prices when the ban came into effect in Scotland. The Grocer magazine published figures which showed that whilst supermarket multi-buys had disappeared, the number of products on price reduction promotions in the first four weeks following the ban period rocketed from 753 to 1,178. Whilst legal, these practices call into question the large supermarkets' claims to be responsible retailers and reinforce the case for a ban on multi-buy discounts to be introduced in conjunction with minimum unit pricing.[55]

63. The Minister told us that the consultation on multi-buy promotions would be on the principle of whether they should be banned.[56] When asked if it would cover selling wine by the case. as an example, she told us: "That is the one representation that I have already had, whether the newspaper offers, for instance, would be affected...".[57]

64. This evidence does not convince us that a ban on multibuys is either desirable or workable. The proposed minimum unit price will provide a floor price for the sale of alcohol, including discounted sales. The Committee supports the principle of setting the minimum unit price at a level which is effective at reducing identified alcohol-related harm; it believes that an attempt to outlaw well-established and convenient retailing techniques for alcohol products, regardless of price level, would simply create opportunities for retailers to find innovative and newsworthy work-arounds which would invite ridicule and bring the wider policy objective into disrepute.

CHALLENGING THE INDUSTRY TO ACT RESPONSIBLY

65. It is an old truth that with freedom comes responsibility. That is true of freedom of speech as it is of all other forms of freedom, and it is true of advertisers, as it is of all other forms of speech.

66. Messages contained in alcohol advertisements play an important part in forming social attitudes about alcohol consumption. The Committee believes that those involved in advertising alcoholic products should accept that their advertisements contain positive messages about their products and that these messages are supported by considerable economic power. If this were not the case it is not clear why shareholders should be content for their companies' resources to be spent in this way. Since it is true, however, it is important that the alcohol industry ensures that its advertisements comply in all respects with the principles of corporate social responsibility. Closer definition of these principles as they apply to alcohol advertising is a key objective of the Government's Responsibility Deal.

67. The Strategy argues that:

We are clear that it is not just the responsibility of Government or local agencies to tackle the issue of alcohol-related harm. It is the ethical responsibility of the entire industry - alcohol retailers, alcohol producers and both the on-trade and off-trade - to promote, market, advertise and sell their products in a responsible way. This is recognised by the major alcohol producers, who have established the Portman Group as a self-regulator. We are working with the industry in collaboration with Non-Governmental Organisations (NGOs) through the Responsibility Deal, which does not cover pricing issues or other measures that only Government can take.[58]

68. The Department of Health memorandum says that:

Both the Alcohol Strategy and Healthy Lives, Healthy People make clear that everyone has a part to play in improving public health, including Government, business, the third sector and individuals themselves. We have made clear from the start that the Responsibility Deal is just one strand of the Government's wide public health policy. It is part of our wider strategy to achieve responsible growth where economic development and businesses' role in improving health and wellbeing go hand in hand.

Priorities for action to improve public health are defined by Government; and informed by research, advice from scientists, health professionals and others. But this does not mean that Government is necessarily best placed to deliver them. The Public Health Responsibility Deal is a new mechanism to deliver on these priorities.

The Responsibility Deal taps into the potential for businesses to improve public health through their influence over food, physical activity, alcohol, and health in the workplace. These are areas where 'doing nothing' simply isn't an option, but the 'something' to be done is not necessarily best done by Government. However, that is not to say that Government does not have a role. The role of Government in this case is to facilitate action and to build the partnerships that will enable genuine advances to be made in a way that is consistent with the public health needs of the country.[59]

69. The Portman Group says that:

The Responsibility Deal is the right approach. It enables industry to deliver practical measures quickly to effect positive behaviour change. It encourages local partnerships to reduce anti-social activity and uses innovative consumer marketing and education programmes (eg the industry-funded Drinkaware) to communicate the Government's sensible drinking guidelines and promote responsible behaviour.

70. The BBPA also supports this approach:

BBPA believes the industry has a key role in addressing alcohol-related harms. Our members have an inherent interest in the responsible consumption of their products and believe that beer is there to be enjoyed and pubs are the home of sociable and responsible drinking. Industry expertise can be harnessed, as is being demonstrated through the [Public Health Responsibility Deal] and campaigns such as "Why Let The Good Times Go Bad?", to ensure the right consumer reach to raise awareness, encourage a responsible attitude to alcohol and provide the information to make informed decisions.

71. Brigid Simmonds from the BBPA and Henry Ashworth from The Portman Group both noted that there is evaluation group as part of the Responsibility Deal to assess the effectiveness of the work it is doing.[60]

72. The Government notes in the strategy a recent pledge by the industry through the Responsibility Deal to take one billion units out of the market by 2015.[61] Brigid Simmonds told the Committee:

That is being done in a number of ways. I have one major member of the BBPA who is reducing the strength of its three main premium lagers from 5% to 4.8%. That will take a million units from the market. We are obviously introducing newer, lowerstrength beers—you will be aware that the Government reduced taxation for 2.8% beers—and we have over 30 brands out there which will be creating that change over a period of time.[62]

73. Henry Ashworth added that:

We are also going to be looking at some behavioural trials to see what happens when you change, for example, the alcohol strength of a bottle of wine from 14% to 12%, or if a beer product, for example, came down from 5% to 4.5%. The behavioural assumptions are that people will continue to drink the products that they enjoy because they enjoy the drink and are loyal to the brand. Brand marketing is going to be crucial in the delivery of this unit reduction pledge. It will take a significant number of units out of the market and enable the growth of a loweralcohol market. We may well be looking back in five years time and saying that this was a paradigm shift.[63]

74. Professor Gilmore expressed reservations about the drinks industry having a role in policy development:

It is very difficult to get away from the conflict of interest of industry. There are areas where they can make a contribution, making sure that existing regulations as to serving underage drinkers and people that are drunk and so on are adhered to, but I have always had concerns about industry getting round the table to discuss how you produce a public health strategy for alcohol because you cannot get away from the conflict of interest. The same applies to supermarkets.[64]

75. The Minister told us:

...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...there could be evaluation of the Responsibility Deal. We could test how effective it has been, and it will be independent.[65]

76. The Committee does not believe that participation by the alcohol industry in the Responsibility Deal should be regarded by anyone as optional - we regard it as intrinsic to responsible corporate citizenship. We welcome the willingness of the industry to address the harms that alcohol can cause - for example by tackling issues with licensed premises through the formation of a business improvement district - but we believe that it should be clear that the Responsibility Deal is not a substitute for Government policy.

77. It is for the Government, on behalf of society as a whole, to determine public policy and ensure that a proper independent evaluation of the performance of the industry against the requirements of the Responsibility Deal is undertaken. We recommend that such an evaluation is commissioned by Public Health England. We will be particularly interested to see the assessment of the effect of reducing the alcohol level in certain drinks. We do not believe that reducing the alcohol in some lagers from 5% to 4.8%, for example, will have any significant impact. If the industry does not bring forward more substantial proposals than this it risks being seen as paying only lip service to the need to reduce the health harms caused by alcohol.

EXPECTATIONS WITHIN THE RESPONSIBILITY DEAL

78. It is important to be clear about expectations of the industry within the Responsibility Deal. The Strategy says that:

There is known to be a link between advertising and people's alcohol consumption, particularly those under the age of 18. Some countries have introduced a complete ban on alcohol advertising (Norway) or a ban on TV advertising with other controls (France) to tackle this. So far we have not seen evidence demonstrating that a ban is a proportionate response but we are determined to minimise the harmful effects of alcohol advertising.[66]

The Government proposes a number of initiatives, including:

Work with the Portman Group to ensure that where unacceptable marketing does occur, it results in the removal of offending brands from retailers.
Work with the ASA and Ofcom to examine ways to ensure that adverts promoting alcohol are not shown during programmes of high appeal to young people.
Work with the ASA to ensure the full and vigorous application of ASA powers to online and social media and work with industry to develop a scheme to verify people's actual ages which will apply to alcohol company websites and associated social media.
Work with the ASA and other relevant bodies to look at the rules and incentives that might inhibit the promotion of lower strength alcohol products.[67]

79. Alcohol Concern in its briefing comments that "[Alcohol Concern] knows from our own work with our Youth Advertising Advisory Council on alcohol that marketing has a strong impact on young people. We will be seeking to work with the Government on these issues to ensure we have robust policing in place that protect young people from the pressures of £800m of yearly advertising spend on alcohol."

80. The Institute for Social Marketing at the University of Stirling told us:

The promotion of alcohol is extremely widespread and young people in particular are inundated by pro-drinking messages. This advertising has been shown to have a direct effect on both the age at which drinking starts and the amount consumed - reducing the former and increasing the latter. Despite this evidence, there are no proposals in the strategy to reduce the amount of alcohol advertising, or even to introduce a degree on independence into the regulatory process. Instead it is business as usual, with an industry driven focus on content regulation - and approach which lacks any evidence base and has been shown to fail. Nowhere is this complacency more apparent than with online advertising, which the strategy treats as a mere extension of current promotion. In reality it completely changes the landscape, with young people not just being marketed to, but being recruited as a peer to peer brand advocates, unwittingly feeding marketing campaigns with their personal details and generating their own promotional content. How, for example, can the current regime of content controls deal with this last phenomenon? And the talk in the strategy of better age restrictions on digital marketing is simply fanciful. Digital marketing has to be treated much more seriously.[68]

81. The Portman Group says that:

Critics believe alcohol marketing encourages people, particularly under 18s, to start drinking earlier or to drink more. However, official statistics show fewer young people (16-24) and children (11-15) are drinking...

The influence of marketing on alcohol consumption is subject to various studies. Whilst there is longitudinal research showing a modest relationship between marketing exposure and drinking among young people, the strength of association varies between studies...

Furthermore, the marketing impact on young peoples' drinking behaviours is likely to be outweighed by other factors (such as family environment, peer behaviour, socioeconomic status, and personal attitudes.[69]

82. It also says that it is reviewing these issues:

The Strategy has asked us to look at other ways to tighten self-regulation around retail, sponsorship and marketing. These are being addressed in our Code review.

The Strategy has also given a clear mandate to ASA and Portman Group to review any advertising rules which currently inhibit the promotion of lower strength alcohol products; this is being addressed by our Code review.

83. The BBPA argues along similar lines:

The UK has some of the tightest restrictions on the marketing of alcohol in the world, particularly designed to avoid exposing children and young people to alcohol advertising. The large decline in youth consumption over the period that self-regulation has been in place serves as proof that alcohol advertising is not encouraging children to consume alcohol.

Research into the link between advertising and alcohol consumption remains inconclusive, and many studies have found no correlation. For example, a study by Gerard Hastings at the University of Stirling found no association between awareness of alcohol marketing at age 13 and either the onset of drinking, or the volume of alcohol consumed two years later.[70]

84. This issue of interpretation of the findings of the Institute for Social Marketing's research came up in the Committee's inquiry into public health in the previous session of Parliament. It was stated in evidence that the research

found no association between awareness of alcohol marketing, the onset of drinking or how much the youngsters drank between the ages of 13 and 15. The study was designed to prove that alcohol marketing increases or has an effect on youngsters drinking; in fact, it proved the opposite.[71]

85. We asked Professor Hastings to comment on that statement. He told us:

The peer-reviewed journal article published by my research team clearly demonstrates an association between response to alcohol advertising and marketing at age 13 and initiation of drinking and increased frequency of drinking by age 15. The interpretation given...appears to rest on a misunderstanding of the research methodology.[72]

86. The Committee is concerned that those speaking on behalf of the alcohol industry often appear to argue that advertising messages have no effect on public attitudes to alcohol or on consumption. We believe this argument is implausible. If the industry wishes to be regarded as a serious and committed partner in the Responsibility Deal it must acknowledge the power of its advertising messages and accept responsibility for their consequences.

87. The industry will take a significant step down this road when it makes it clear that alcoholic products should not be marketed in ways which address audiences a significant proportion of whom are aged under 18, and cannot therefore legally purchase the product.

EXISTING PRECEDENTS

88. There are already regimes in place in some sectors which the Committee thinks could be implemented more widely. Ofcom described the way in which television advertisements for alcohol are regulated:

Scheduling rules already limit where alcohol advertisements may appear in the schedules. Alcohol may not be advertised in or adjacent to children's programmes or programmes commissioned for, principally directed at or likely to appeal particularly to audiences below the age of 18.

Since 1999 a system of "indexing" has helped to prevent adverts being directed at children. A programme of "particular appeal" to children is deemed to be one that attracts an audience index of 120 for this age group. If a programme attracts an under-16 audience in a proportion similar to that group's presence in the viewing audience as a whole, it is said to index at 100. So an index of 120 is an over-representation of that group by 20 percent. For example, the proportion of 10-15 year olds in the viewing population is 8.24 percent, so any programme where more than 9.84 percent (8.24 x 1.2) of the audience is made up of 10-15 year olds would not be allowed to carry alcohol advertising in or around it.

In other words, if the audience for a programme is expected to contain a disproportionately large number of young people, the broadcaster cannot place alcohol adverts in or around it. This is a more targeted approach than a pre-watershed ban as it hones in on specific programmes appealing to young people regardless of what time they appear in the schedule. For example Glee is broadcast after 9pm on Sky One, but alcohol advertisements cannot be placed in or around it because of the disproportionately high number of young people watching the show.[73]

89. It is useful to contrast this with the so-called CAP code,[74] the industry's own regulations on advertising in non-broadcast media. Specifically on the issue of alcohol and young people under 18, it says:

Marketing communications must not be directed at people under 18 through the selection of media or the context in which they appear. No medium should be used to advertise alcoholic drinks if more than 25% of its audience is under 18 years of age.[75]

90. The Advertising Association told us:

Further to these exposure rules based on percentages, the [Cinema Advertising Association] also takes other steps to reduce the incidence of youth exposure to alcohol advertising. For example, unless the film is '18' certificate, the CAA takes the view that all releases featuring comic book characters in a central role are not permitted to carry alcohol advertising, given the potential appeal of those characters to younger audiences. This has meant that a number of highly successful films - including Marvel Avengers Assemble, which is currently making box office records, cannot carry alcohol [advertising]. Similar data analysis has meant that "gross out" comedies receiving '15' certificates rarely carry alcohol advertising.

It is also essential to also note that many films that are popular with adults are lower certificate films, for example The Best Exotic Marigold Hotel. This film received a 12a certificate but, as the majority of its viewership was middle-aged or older, it would be wholly disproportionate to have banned alcohol advertising around this film.[76]

The CAP code therefore does provide protection against the marketing of alcohol to those under the age of 18, but to a lesser extent than the Ofcom broadcast code and on an entirely voluntary basis.

91. Advertising of alcoholic products on television is subject to rules which are relatively targeted and sophisticated. The Committee believes there is scope to apply these principles more widely - for example in cinemas - and recommends that this principle be reviewed in the context of the Responsibility Deal. Serious consideration should be given to reducing to 10% the proportion of a film's audience that can be under 18 and still allow alcohol to be advertised, or to prohibiting alcohol advertising in cinemas altogether except when a film has an 18 certificate.

DRINKAWARE

92. Education and public awareness campaigns clearly have a part to play in attempts to change people's behaviour and drinking habits. Drinkaware, established in 2007, exists to provide "consumers with information to make informed decisions about the effects of alcohol on their lives and lifestyles. Our public education programmes, grants, expert information, and resources help create awareness and effect positive change."[77] It also told us that:

Drinkaware is entirely funded by voluntary donations from across the drinks industry, but operates completely independently from it. Our board is made up of five members of the health community, five members of the drinks industry and three independents. This structure enables the organisation to act independently whilst being fully funded through voluntary donations from industry.

Our behaviour change campaigns are designed using an evidence-based approach. Drinkaware provides consumers with best evidenced information and facts about alcohol. Our independent medical advisory panel checks all information, web, and printed materials to ensure their accuracy and that it reflects the most current evidence.[78]

93. Chris Sorek, Chief Executive of Drinkaware, said that the organisation was

looking at the demand side...changing people's demand for alcohol—changing their behaviour as to why they want to drink and what they are drinking—is something that we are focusing our attention on. What we are trying to do is reduce the amount of alcohol that parents give to their children. If they followed [Chief Medical Officer's] guidance you would not see the average age of first drink at 13.8 years. You would see it at 15, which is what CMO guidance says. That says that there are quite a few parents who are giving alcohol to children at a much earlier age. If you take a look at what we are doing with adults, we are trying to talk to them about units and unit guidelines. What they will then do is reduce the amount of alcohol they are drinking on a daily basis.[79]

94. Chris Sorek stressed that Drinkaware is an independent charity[80], but its role is seen by some as compromised because of its links with the alcohol industry. The British Medical Association told us that

The involvement of the Drinkaware Trust in providing public health communications is a significant area of concern. This form of industry social marketing is counterproductive because industry responsibility campaigns are less effective than ones from other sources, keep messages in a commercial comfort zone, and distract attention away from more effective measures to regulate alcohol use. Industry-related messages about alcohol have been found to subtly enhance sales and company reputations. This is despite the fact that the public is cynical about the motives of corporate sponsors, and that non-governmental organisations make a more effective and credible source.[81]

95. In the Alcohol Strategy, the Government says that through the Responsibility Deal it expects to see progress on

A long-term commitment (through to 2020) to an increased scope and funding for Drinkaware, including how it can best direct interventions to the target groups. There is a strategic review this year of Drinkaware and the Government will participate to seek to maximise its effectiveness and accountability.[82]

96. The Committee believes that it is right that the industry should support education and awareness campaigns about the harms that alcohol can cause, and doing so through a separate organisation such as Drinkaware seems appropriate in principle, but the independence of the organisation is vital. The value of this contribution is likely to be very limited if the campaigns it promotes are considered to be constrained by industry links.

97. We acknowledge that the Board as presently constituted has a majority of non-industry Members, and we welcome that fact. Nevertheless, if Drinkaware is to make a significant contribution to education and awareness over the coming years its perceived lack of independence needs to be tackled, and as part of the review that is to be held this year the Committee recommends that further steps are taken to entrench that independence.

LOI EVIN

98. A number of submissions drew our attention to the French Loi Evin as an example of an effective way of regulating alcohol marketing. For example, the National Heart Forum said:

The NHF recommend a UK adapted version of Loi Evin - a French regulatory framework that allows alcohol marketing and promotion only in media where adults are at least 90% of the audience. The Loi Evin model...provides a simple framework that can offer clarity on what marketing practices are and are not allowed. Under this model, the promotion of alcohol would be explicitly restricted to: media that adults use; at point of sale in licensed premises; and at local producer events.[83]

99. The Loi Evin was introduced in 1991. Its provisions are that:

all drinks over 1.2 per cent alcohol by volume are considered as alcoholic beverages. Places and media where advertising is authorised are defined:
no advertising should be targeted at young people;
no advertising is allowed on television or in cinemas;
no sponsorship of cultural or sport events is permitted;
advertising is permitted only in the press for adults, on billboards, on radio channels (under precise conditions), at special events or places such as wine fairs, wine museums. When advertising is permitted, its content is controlled:
messages and images should refer only to the qualities of the products such as degree, origin, composition, means of production, patterns of consumption;
a health message must be included on each advertisement to the effect that "l'abus d'alcool est dangereux pour la santé": alcohol abuse is dangerous for health.[84]

100. In its evidence the Institute for Social Marketing at the University of Stirling told us that the Government's Strategy:

misrepresents the Loi Evin as a ban on advertising. It is nothing of the kind. Rather it is exactly the type of imaginative response to a major public health problem that the UK lacks, and it simply ensures that alcohol advertisers behave responsibly by a) restricting their messages to verifiable statements of fact b) making sure these messages only reach adults. If the Government could not bring themselves to learn from this excellent cross-channel experience, there were a number of intermediate steps they could and should have taken, including: prohibiting alcohol advertising on television before the watershed; limiting or prohibiting sponsorship of sport; and requiring health promotion messages to be screened before programmes or films promoting drinking.[85]

101. Although the precise terms of the Loi Evin reflect the circumstances of a different society at a different time, the Committee believes that the approach adopted in the French legislation merits serious examination in the English context. In particular the Committee recommends that Public Health England should commission a study of the public health effect which would be delivered in the UK by adopting the principles of Loi Evin; such a piece of work would provide a valuable reference point for the evaluation of the effectiveness of the Responsibility Deal which the Committee has recommended should also be undertaken by Public Health England.

LOCAL RESPONSES

102. The Strategy encourages local agencies to take responsibility for tackling alcohol-related problems in their areas. As it says in chapter 3:

Local communities, services and businesses are best placed to tackle alcohol-related issues in their area and enforce the behaviour and develop the cultures that they want.

103. We took evidence from people involved in developing and implementing the strategy in Birmingham to see how one locality is dealing with the problems alcohol causes Jacqui Kennedy, Director of Regulation and enforcement at Birmingham City Council told us:

Our strategy is very much an holistic approach to alcohol harm in Birmingham. We have based it on the framework that was the national strategy because we felt that that gave us the golden thread from neighbourhoods through to the national strategy. We have tried to consider the implications around health, crime and disorder, young people and antisocial behaviour. The strategy has tried systematically to structure a response to alcohol harm, and there are benefits associated with that.

The new strategy has very strict and strong governance around it. It is responsible and accountable through the Health and Wellbeing Board; it is accountable through the community safety partnership board; and it is also responsible through a corporate management team of the local authority. The city council is the sort of guardian for it, but all those partnerships are absolutely key to govern how we deliver because the strategy has been developed, again, with another strong delivery plan underpinning it and each of the partners is called to account as part of a scrutiny approach to make sure that we deliver against the plan. It is very much business as usual.[86]

104. The Birmingham team reported some significant successes in the development of their services. We were told, for example, that there are no waiting lists in Birmingham for NHS patients referred to specialist alcohol services and that the establishment of business improvement districts in the two main night time economy areas had helped address issues of crime and antisocial behaviour. The costs are also contained within 'normal' activity. As Jacqui Kennedy said:

...this is our day job. It is linked into licensing, trading standards and environmental health. It is the day job. It is not a speciallyfunded activity.[87]

105. We were told that, having set specific targets for the strategy, there is also a structured monitoring plan in place in Birmingham to assess how well the aims of the strategy are being implemented. Barry Everleigh, of the Birmingham Drug and alcohol Action Team said "We are looking at six monthly reviews from creation of the strategy, and then a lower level with the providers, on a monthly and quarterly basis."[88]

106. Birmingham is one example of local action that has been drawn to our attention during the inquiry, and it does demonstrate how local agencies can put together an effective action programme without the need for a substantial additional bureaucratic support structure. This model of local action, linking in with national priorities, makes sense as a pragmatic, practical way of addressing serious problems. As we recommended earlier in this report, Public Health England should use this model as the template for all local areas to address the various problems that alcohol causes in their communities, and to link local objectives to those at the national level. Central Government cannot direct a local area to address alcohol problems in a particular way, but the new public health structures, in which local authorities have a key role, should provide the opportunity to establish a national framework of local initiatives.

TREATMENT SERVICES

107. The NHS Confederation told the Committee:

The increase in alcohol abuse in the UK has resulted in an increased demand for NHS services. It was already costing the NHS £2.7 billion a year in 2006/07 (the most recent year for which figures are available) and demand has increased significantly since then. For example, alcohol related admissions to hospital more than doubled between 2002-03 and 2009-10, from 510,200 to 1,057,000. Difficulties in recording alcohol-related harm mean that the impact is likely to be even higher. The burden on the NHS will be unsustainable if demand continues to grow.

With the pressure to react to a growing number of urgent needs, preventative and specialist services have struggled to keep pace with alcohol driven demand and hospitals have been bearing the brunt of the burden. In 2008 over 70% of the cost of alcohol to the NHS was spent on hospital treatment. Inpatient costs were almost 45% of the total NHS expenditure in alcohol related services that year compared to around 12% in 2001.

108. There are difficulties with treatment of people with alcohol-related problems. The Department of Health told us in its memorandum:

While there has been some improvement in provision for treatment of people dependent on alcohol, it is very likely that there is still significant under-provision overall. We estimate that numbers of people in England mildly or severely dependent on alcohol rose by 24% between 2000 and 2007. Without the decisive steps we are taking through our strategy to end the availability of cheap alcohol and to strengthen local powers to prevent the growth of alcohol misuse, it is likely that needs for treatment would grow in the future.

Levels of need vary greatly from place to place. It is right that plans for investment in alcohol treatment and prevention are for decision at local level. Our reforms to the NHS and Public Health will ensure a greater focus on commissioning of alcohol services to meet local needs.[89]

109. St Mungo's told the Committee that

The Government appears to have recognised that services are not available for tens of thousands of people who are alcohol dependent and need support to recover. Although investment is needed urgently, we are yet to see any solid proposals around how this problem will be addressed. We are concerned that central Government's ability to deliver this investment will be curtailed as the assessment of need and decisions on commissioning are all taken locally.

It is right that there is a focus on integrated services. People who are dependent on alcohol often have a range of complex needs that require holistic support, not a disparate collection of needs that can be treated sequentially. This is especially true for our clients, our latest client needs survey shows that 42 per cent of our clients with an alcohol problem also have a mental health problem and 50 per cent have a significant medical condition.

NICE guidance makes clear that there should be services tailored to maximise engagement with the homeless population due to the extra complications that working with this group can bring. However, our clients often have to wait for weeks or months to access rehab services and our staff report that it is becoming more difficult for them to secure access to services.[90]

110. One of the main ways the Strategy suggests that health problems associated with alcohol could be reduced is through a process known as Identification and Brief Advice:

Identification and Brief Advice (IBA) is a simple intervention aimed at individuals who are at risk through drinking above the guidelines, but not typically seeking help for an alcohol problem. IBA has been proven to reduce drinking, leading to improved health and reduced calls on hospital services. At least one in eight at risk drinkers reduce their drinking as a result of IBA. The National Institute for Health and Clinical Excellence (NICE) recommends that NHS health professionals routinely carry out alcohol screening as an integral part of their practice, focusing on groups at increased risk.[91]

111. In oral evidence, Eric Appleby and Professor Gilmore both supported the use of Brief Advice. Mr Appleby also supported the NICE guidelines as a model for treatment. Professor Gilmore emphasised that there is a role for treatment right through to the most serious cases:

Right at the far end, with the heavilydependent patients that unfortunately are often considered "no hopers", treatment is still effective and cost-effective. We only remember the ones that come back and not the ones that do well. It is very good that the strategy acknowledges that treatment works but it perhaps has not identified fully the levers that people can use locally to implement good care.[92]

112. The Medical Research Council and the Economic and Social Research Council, in a joint submission, told us;

With three sets of NICE guidance on alcohol published in the last five years as well as a series of systematic reviews, there is now a body of evidence on the effectiveness of existing behavioural and cognitive approaches (such as intensive case management, motivational enhancement therapy and social network based therapies) as well as certain pharmacological interventions (e.g. acamprosate and disulfiram). Nevertheless, many of our advisors highlighted the lack of joined-up effective delivery and available appropriate expert services for drinkers, especially in 'real-world' settings. This is a key element of support that they felt was not fully addressed in the Government's alcohol strategy.[93]

113. The need to implement what are known to be effective alcohol care services was referred to in a number of submissions. The Royal College of Physicians called for

the full implementation of the NICE guidelines relating to alcohol dependence, which provide an excellent, evidenced-based guide to effective intervention, treatment and referral systems that involve a wide range of health professionals.

The RCP recommends that there should be a multidisciplinary 'alcohol care team', a seven day alcohol specialist nurse service and an 'assertive outreach alcohol service' in every district hospital. Transitions between teams and services should be quick and seamless in order to increase the efficiency and cost effectiveness of the service.[94]

114. The Alcohol Health Alliance said that

Healthcare modelling methodology suggests that if each district general hospital established a 7 day Alcohol Specialist Nurse Service to care for patients admitted for less than one day and an Assertive Outreach Alcohol Service to care for frequent hospital attendees and long-stay patients, it could result in a 5% reduction in alcohol-related hospital admissions, with potential cost savings to its locality of £1.6 million per annum. This would equate to savings of £393 million per annum if rolled out nationally.[95]

115. The British Society of Gastroenterology told us

The dramatic impact of Alcohol Specialist Nurses (ASNs) during a 5-day working week highlights the need for them to work routinely on a 7-day basis in hospitals, especially since such a large proportion of alcohol-related problems present out-of-hours, particularly at weekends. Alcohol specialist nurses pay for themselves many times over, in terms of improved detection of alcohol misuse, accessibility, waiting times, [did not attend] rates, reduced inpatient detoxifications and length of stay, thus achieving 4-hour trolley waits, relieving bed pressures and reducing A&E attendances, admissions and readmissions...

Implementation of an ASN service in Nottingham improved the health outcomes and quality of care of patients admitted to hospital for detoxification, and also of those admitted for the complications of alcohol-related cirrhosis (S.D.Ryder et al, 2010). Hospital admissions were reduced by two thirds, resulting in a saving of 36.4 bed days per month in patients admitted for detoxification. Clinical incidents were reduced by 75%. Liver enzyme abnormalities were halved and there was also a reduction in bed days used in the cirrhotic group from 6.3 to 3.2 days per month.[96]

116. When we asked about the under-provision of treatment services, Dr Mark Prunty, Senior Medical Officer, Alcohol and Drugs Programme, told us:

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... 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.

How do local commissioners make that decision [about the level of service on offer] 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.[97]

117. We welcome the work which the Department is undertaking to provide an evidence base to allow commissioners to make informed decisions about which models of treatment provision are most effective in addressing the health issues caused by alcohol abuse. In particular commissioners need evidence about the most effective form of early intervention in order to reduce the number of avoidable hospital admissions which currently represent avoidable illness for patients and avoidable costs for taxpayers. The evidence we received suggested that the establishment of Alcohol Specialist Nurse services throughout the country is one of those measures. The fact that over 70% of the costs to the NHS of alcohol-related services was spent on hospital treatment demonstrates the scale of the opportunity to restructure services to achieve better outcomes.

21 Alcohol strategy, paragraph 1.6 Back

22 Ev 98 Back

23 Birmingham Alcohol Strategy 2012-16, page 2 Back

24 Q 305 Back

25 Improving outcomes and supporting transparency Part 1: a public health outcomes framework for England, 2013-2016, Department of Health, January 2012, p27. Back

26 Q 44 Back

27 Q 45 Back

28 Alcohol Strategy, para 5.13. Back

29 ibid, para 5.14 Back

30 Ev w133 Back

31 Ev 134 Back

32 Q 317 Back