Health Committee - The Government's Alcohol StrategyWritten evidence from Quaker Action on Alcohol and Drugs (GAS 13)

Quaker Action on Alcohol and Drugs (QAAD) is a listed group of the Religious Society of Friends (Quakers). QAAD is an independent national charity that has a concern with the use and misuse of alcohol and other drugs, legal, illegal and prescribed, and with gambling. QAAD does not represent the Religious Society of Friends as a whole, but the views we express are grounded in our Quaker principles. We present evidence-based arguments that prevention and treatment save society’s resources, but our values are also that people affected by alcohol problems deserve support in their own right.

QAAD offers prevention and information services for Quakers and contributes to public policy discussions. Trustees give their time to QAAD freely, and bring voluntary and statutory experience from settings that include prevention, a variety of treatment and support interventions, medical services, and criminal justice. Like any other group, we have in our number people who have been personally affected by alcohol problems.

1. Executive Summary

1.1. We warmly welcome many aspects of the new Alcohol Strategy, particularly its willingness to address current consumption. We support the view advocated by Professor Ian Gilmore in oral evidence, that population level consumption is high in historical terms, and that this is related to the high level of alcohol problems experienced by individuals in our society.

1.2. We welcome minimum pricing per unit as a key preventative and harm-reduction measure. We hope the opportunity will be taken to set this at an effective level. We would like to see a rate of 50p, which would give substantial health benefits and set a prevention framework for the future.

1.3. We also welcome the measures that strengthen the ability of local areas to deal with alcohol problems and the measures to reduce alcohol content via the Responsibility deal.

1.4. Public health messages will continue to have limited effects if there is such an imbalance with resources put into advertising by the industry. Consideration should be given to tightening advertising, and moving towards the restrictions seen in France and Norway.

1.5. If a total ban on advertising appears too great a step, other measures for which there is a reasonable evidence-base can be taken more quickly. These include a ban on pre-watershed advertising of alcohol, advertising at PG films, and ceasing other forms of marketing and sponsorship that are directly seen by children.

1.6. Only 6% of those in need receive services, and in some areas, residential treatment for the most severely affected people is already not available. New arrangements for local commissioning under the aegis of Public Health England have yet to be finalised, but on recent figures the average PCT spend on alcohol treatment was £600,000—0.1% of budget. Robust arrangements are needed to ensure that those needing services get access to the full range of support.

1.7. The only alcohol indicator in the proposed Public Health Outcomes Framework relates to hospital admissions, but this is wholly insufficient to ensure that commissioning covers the range of alcohol-related need. Developing further indicators (using advice from the NTA and possibly Alcohol Concern) is one possible approach that could usefully be explored. More simply, providing evidence of appropriate access to the major types/tiers of service (from brief advice through to residential or hospital treatments) could be placed as a requirement on commissioning bodies. Appropriate, needs-related funding formulae, and ring-fenced budgets should be part of this, recognising that alcohol problems are most acute amongst those suffering from other forms of disadvantage.

Specific issues

2. Establishing who is responsible within Government for alcohol policy in general, policy coordination across Whitehall and the extent to which the Department of Health should take a leading role

We believe that alcohol policy in general is best located in the Department of Health. This is not only because the majority of services are based or commissioned from there, but because those suffering from alcohol problems will develop significant health problems over time. We also think a health focus would be helpful to families and close others, who can be deeply affected and suffer their own health problems as a result. However, the prime consideration is that the Strategy should be well integrated, and deliver progress for individuals across the many government department areas involved.

3. Coordination of policy across the UK with the devolved administrations, and the impact of pursuing different approaches to alcohol

31. It would be highly desirable for minimum pricing rates to be as close as possible in order to prevent policies being undermined, particularly in border areas. In other respects we welcome the fact that the Alcohol Strategy is considering adding public health as a licensing objective, as it is in Scotland. The convergence of approach to a preventative rather than a reactive framework is the most important factor.

4. The role of the alcohol industry in addressing alcohol-related health problems, including the Responsibility Deal, Drinkaware and the role of the Portman Group

4.1. The industry has an important role, as the strategy outlines. Some Drinkaware initiatives have been useful (website self-monitoring, for example). The increase in lower alcohol drinks that has been agreed through the Responsibility Deal is welcome, particularly as regards reducing the alcohol content of wine, which is one the factors underlying increased unit consumption by women. However, there is a limit on how far the industry can be expected voluntarily to promote practices that risk adverse effects on profitability. Legislators and government departments have a wider public health remit; this entails a leadership role, which needs to be exercised.

5. The evidence base for, and economic impact of, introducing a fixed price per unit of alcohol of 40p, including the impacts on moderate and harmful drinkers; evidence/arguments for setting a different unit price; the legal complexities of introducing fixed pricing

5.1. The Committee is well aware of the peer-reviewed ScHARR report and its findings. Whilst up-dates are always desirable (like those recently undertaken by ScHARR for the Scottish government), this remains the most authoritative work on which to base policy.

5.2. We believe 50p should be the minimum unit price, and have extracted the following figures from the ScHARR report to illustrate the case for this.1

	40 per unit 1 year benefits	40 per unit 10 year benefits	50p per unit 1 year benefits	50p per unit 10 year benefits
Hospital admissions	6,300 fewer	40,800	16,400 fewer	97,900 fewer
Deaths	157 fewer	1,381 fewer	406 fewer	3,393
Violent crimes	3,200 fewer		10,300 fewer
Total consumption	-2.6%		-6.9%
Reduction in 11–18 year old drinkers (all)	4%		7.3%
Reduction among 18–24 year old “hazardous” drinkers	0.7%		3%
Direct public costs (?millions)	-353.9	-3,284	-739.7	-7,426

If figures were updated there may be some variation, but it is apparent that substantially higher benefits accrue when the minimum unit price is higher.

5.3. A weighty argument is the stronger impact that 50p per unit would have on young hazardous drinkers, who are one of the groups that consume cheaper alcohol. A recent qualitative and quantitative study of 15–16 year olds bears out the importance of this:

“Results suggest a strong relationship between consumption of cheaper alcohol products and increased proportions of respondents reporting violence when drunk, alcohol-related regretted sex and drinking in public places”.2

Aside from immediate damage in terms of these problems and acute manifestations like hospital admissions, early drinking patterns tend to follow through into later life—so this consideration is really critical.

5.4. As regards lighter or moderate drinkers, the economic costs of 50p per unit would be relatively light (less than £20 per annum). Much has been made of the effects of minimum pricing on poorer people, but those in the most deprived groups are actually more likely not to drink at all: in a recent study only 33% of households on the lowest income band purchased alcohol in the last week, as opposed to 70% in the highest.3However, if they do drink, men in the most deprived areas are five times as likely to die of an alcohol-related illness as those in the most affluent areas, and women are three times as likely. Effective minimum pricing would thus help the poorest groups.

5.5. Focusing only on the price a person pays to buy alcohol also disregards the costs they pay in taxation for the NHS, and for criminal justice services. The overall costs of alcohol harms are estimated to be three times the amounts raised in revenue duty4—and the environmental ill-effects of alcohol problems are felt particularly strongly in less affluent areas.

6. The effects of marketing on alcohol consumption, in particular in relation to children and young people

6.1. International studies indicate that marketing and advertising do affect children and minors. Two recent reviews concluded:

“Longitudinal studies consistently suggest that exposure to media and commercial communications on alcohol is associated with the likelihood that adolescents will start to drink alcohol, and with increased drinking amongst baseline drinkers. Based on the strength of this association, the consistency of findings across numerous observational studies, temporality of exposure and drinking behaviours observed, dose-response relationships, as well as the theoretical plausibility regarding the impact of media exposure and commercial communications, we conclude that alcohol advertising and promotion increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol”.5

“exposure to alcohol advertising in young people influences their subsequent drinking behaviour”.6

“The ScHARR study reported that “There is some evidence to suggest that bans have an additive effect when accompanied by other measures within a general environment of restrictive measures”.

6.2. More generally for adults, public health messages are likely continue to have limited effects if there is such an imbalance with resources put into advertising by the industry. We believe consideration should be given to tightening advertising and moving towards the restrictions seen in France and Norway.

A recent WHO report states that:

“There is some evidence and experience that the self regulation of commercial marketing of alcohol does not prevent the kind of marketing that has an impact on younger people, particularly when it is not backed up by a legal framework and effective sanctions”.7

6.3. If a total ban on advertising appears too great a step, other measures for which there is a reasonable evidence-base could be taken more quickly. These include a ban on pre-watershed advertising of alcohol, advertising at PG films, and ceasing other forms of marketing and sponsorship that are directly seen by children.

7. Any consequential impact on future patterns of service use in the NHS and social care, including plans for greater investment in substance misuse or hepatology services;
Whether the proposed reforms of the NHS and public health systems will support an integrated approach to future planning of services for people who experience alcohol-related harm.

7.1. There have been insufficient resources devoted to alcohol services. Alcohol Concern published findings in 2010 that the average PCT spend on alcohol treatment was £600,000—only 0.1% of budget8 markedly less than drugs. This is regrettable from a human point of view and does not make sense in terms of resources—it is estimated that every £1 spent on services saves £5 in medical, welfare and criminal justice costs.9 At times of stringency, services risk being cut further. This is a particular issue for those for the most severely affected people, because services for them tend to be more expensive. However, this is the group that can show some of the most substantial gains in terms of contributing to society as well as regaining a stable, satisfactory personal quality of life.

7.2. The Strategy is at its weakest in addressing the long-standing problem of resourcing. We have linked concerns that austerity and the new commissioning structures could deepen rather than ameliorate some of these problems, in particular, regarding high needs or marginalised groups. The National Treatment Agency will be transferring its functions to Public Health England and states in its Action Plan 2012–13 that it will “help support residential providers respond to the demands of the payment by outcomes operating environment, and challenge the minority of local areas who deny their population access to effective residential provision.” Consortia or health areas that may not perceive themselves as having a strong need for the full range of services should nevertheless make them available to their local populations.

7.3. Adolescents with high needs are another significant group, as are those suffering from dual diagnosis. Often these groups need access to other related services, such as supported housing, as indeed do those with less severe problems. All of these require linked resourcing across departments both locally and nationally.

7.4. The only indicator in the proposed Public Health Outcomes Framework seems to relate to hospital admissions, but this is wholly insufficient to ensure that commissioning covers the range of alcohol-related need. Developing further indicators (using advice from the NTA and possibly Alcohol Concern) is one possible approach that could usefully be explored. More simply, providing evidence of appropriate access to the major types/tiers of service (from brief advice through to residential or hospital treatments) could be placed as a requirement on commissioning bodies.

7.5. However, it is also apparent that some areas of the country (often the poorest) have the highest need in terms of alcohol problems. National funding formulas need to take account of this. Ring-fenced resources (which appear likely to go) may be the best way to ensure that alcohol services are developed, or at least not eroded.

8. International evidence of the most effective interventions for reducing consumption of alcohol and evidence of any successful programmes to reduce harmful drinking

8.1. As has already been illustrated, social inequality influences how alcohol problems are distributed and experienced. Addressing this across government is the most fundamental contribution that can be made.

8.2. At a specific level there are some promising initiatives such as the “Preventure” project, which develops resilience in young people in a way that responds to their own personality characteristics:10

Public health interventions such as education and information;

Reducing the strength of alcoholic beverages;

Raising the legal drinking age; and

Plain packaging and marketing bans.

8.3. The WHO for Europe publication notes the evidence that public health campaigns alone have a limited impact, and states:

“Providing information and education is important to raise awareness and impart knowledge, but, particularly in an environment in which many competing messages are received in the form of marketing and social norms supporting drinking, and in which alcohol is readily accessible, do not lead to sustained changes in alcohol-related behaviour”.11

Further:

“Consideration could be given to regulating and limiting the content and volume of commercial communications on alcohol, ranging from a Europe-wide roll-out of the principles of the French Evin Law to a ban on all forms of commercial communications that appeal to children and adolescents. Statutory regulation of commercial communications seems to be more effective than self-regulation in limiting inappropriate exposure of commercial communications to young people”.

The wide promotion of alcohol is a fundamental problem, and the evidence suggests that educational approaches need to be given a basis in statute and integrated with wider policies if they are to be effective. We welcomed the private members Bill to tackle advertising in 2011 and regret that this did not come to fruition. We wonder if a Committee devoted to this specific subject would be a useful way forward.

8.4. Enforcement of the existing age restrictions may be the most useful approach. The WHO European report states:

“There is consistent evidence that maintaining and raising minimum purchasing ages for alcohol can reduce alcohol-related harm, provided that they are enforced”.

8.5. We would support any tax measures that promote lower alcohol drinks, and believe that fine bandings would be helpful in reducing alcohol content.

We welcome many features of the Alcohol Strategy and hope the Committee’s work will enhance those areas that could usefully be developed.

May 2012