Health Committee - The Government's Alcohol StrategyWritten evidence from St Mungo’s (GAS 28)

St Mungo’s has been opening doors for homeless people since 1969. We currently run over 100 projects, providing accommodation for more than 1,700 people every night and helping thousands more who are rough sleeping or at risk of homelessness. St Mungo’s delivers a range of residential services from emergency shelters to semi-independent flats, as well as non-residential health, education and employment services. We also prevent homelessness through our housing advice programmes.

St Mungo’s services are based on a recovery approach and we aim to work in partnership with clients in a personalised, effective way. Our clients often have complex problems that cause, or are caused by, homelessness; we deliver holistic support to help people rebuild their lives.

1. Overview

1.1 We welcome the opportunity to contribute to the Health Select Committee Inquiry on the Government’s Alcohol Strategy and would be delighted to provide further details if required. We have consulted with our clients to inform this response.

1.2 Our client group, single homeless people, are far more likely to be dependent drinkers than the general population. According to our latest client needs survey, 44% of our hostel residents regularly use alcohol problematically, and over two thirds of these have done so for over five years. For many of these clients alcohol dependency is part of a comorbidity, accompanied by illicit drug use, physical illness or mental health problems.

1.3 In the six months from September 2011 to February 2012 alcohol was a factor in over half of the ambulance call-outs to our projects. Research undertaken in partnership with the Marie Curie research team supports our own findings that alcohol-related liver disease is a primary cause of death for over half of the clients who die within our projects.1 Many clients in our services for older people who are dependent on alcohol suffer from alcohol-related brain damage, which causes irreversible damage and in some cases death.

1.4 We believe that the Alcohol Strategy should be a driving force in reducing the harm that alcohol causes to our clients, who are damaged and killed by alcohol.

2. Key Points:

2.1 St Mungo’s supports plans to introduce a minimum price per unit, but believes that this should be at 50 pence per unit as recommended by Alcohol Concern,2 rather than 40 pence.

2.2 The introduction of a minimum price per unit needs to be accompanied by a significantly improved provision of services for dependent drinkers to mitigate these risks. Our clients who are alcohol dependent require long term interventions that reduce the harm caused by alcohol.

2.3 It is vitally important that investment in alcohol treatment services is protected in NHS and public health reforms.

2.4 Government should expect and support the alcohol industry to do more to meet the costs that alcohol inflicts on society. St Mungo’s strongly believes that any extra revenue that the industry earns from the introduction of a minimum price per unit should be directed towards services that support dependent drinkers.

3. 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.

3.1 It appears to be clear from previous Government publications and announcements that the Department of Health will have responsibility for both the clinical and public health aspects of alcohol policy:

According to the Government’s Drug Strategy, the functions of the National Treatment Agency for Substance Misuse (NTA) currently include “helping to improve the provision of services for severe alcohol dependence.”3 The functions of the NTA will be transferred in to Public Health England, which will sit within the Department of Health, from April 2013.

In addition, s.2 of Health and Social Care Act 2012 makes it clear that the Secretary of State has a duty to secure continuous improvement in the quality of services for or in connection with the prevention, diagnosis or treatment of illness, or the protection or improvement of public health.

3.2 St Mungo’s therefore understands that from April 2013 onwards the Department of Health, and ultimately the Secretary of State, will be responsible for improving the provision of services for severe alcohol dependence as well as alcohol-related public health policy.

3.3 The Health and Social Care Act 2012, s.4 states that the Secretary of State for Health is also responsible for reducing “inequalities between the people of England with respect to the benefits that they can obtain from the health service.” It is widely acknowledged that people with substance use issues and psychiatric disorders experience worse outcomes than people with a single disorder,4 the Secretary of State for Health must therefore accept responsibility for addressing this problem.

3.4 We believe that Public Health England must ensure that Local Authorities work with the NHS to commission better services for people who are dependent on alcohol. Public Health England can work towards this through its role in jointly appointing Directors of Public Health, as well as through the information it shares with local authorities and the evidence base that it builds.

3.5 Current investment in drug and alcohol treatment will represent up to half of the public health budget that will be allocated to local authorities and directors of public health. Given that drug and alcohol treatment is identified as one of seventeen public health responsibilities for Health and Wellbeing Boards, and the Public Health Outcomes Framework includes only three drug and alcohol specific indicators out of sixty six, we are extremely concerned that there will be disinvestment in drug and alcohol services.

3.6 We would like to introduction of transitional protection within the ring-fenced public health budget for a minimum of two years from April 2013 to allow drug and alcohol treatment time to “bed into” public health and secure sufficient investment to deliver the 2010 Drug Strategy.5

3.7 We would also welcome further clarification of the relationship between public health and criminal justice agencies. For example, how Police and Crime Commissioners and Community Safety Partnerships will be represented in the planning and commissioning of drug and alcohol services. We would also like to know how integrated offender management can be pursued when responsibility for prison treatment lies with under the NHS Commissioning Board, rather than public health bodies.

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 In 2007 it was estimated that revenue from alcohol sales was £33.7 billion.6 A portion of this revenue comes from people who are suffering considerable harm from alcohol, including our clients, some of whom are being killed by cheap strong cider and lager.

4.2 The economic costs of health care, anti-social behaviour and criminal justice associated with hazardous and harmful alcohol use are huge. The Prime Minister has suggested that the total cost to society from alcohol is between £17 and £22 billion per annum.7 We believe that alcohol producers share a large part of the responsibility for these costs, particularly as it is estimated that they spend £800 million a year promoting their products.8 The Government should ensure that the Portman Group are be more proactive in taking action against producers who market their products in a way that encourages harmful and hazardous drinking.

4.3 We would like the Government to work with alcohol producers and retailers to ensure that the industry contributes more to meeting the costs that alcohol inflicts on society. We believe alcohol producers and retailers should contribute to a fund that is used to support alcohol treatment and accommodation services.

4.4 There is evidence that introducing a minimum price per unit would substantially increase the revenue of alcohol producers and retailers.9 St Mungo’s believes that the Government should ensure this additional revenue is directed towards services that support those who are dependent on alcohol rather than, for example, on increased advertising and marketing.

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 Cheap alcohol, in particular white cider, kills our clients. Research carried out by Alcohol Concern with St Mungo’s illustrates the damaging effects that white cider has on our clients.10 It is currently possible to buy “White Ace” cider at around 17 pence per unit. If it is assumed that a maximum weekly intake of alcohol is 28 units, it is possible to drink the weekly recommended limit of alcohol for £4.76, while a single three litre bottle contains over five and a half times the recommended daily limit.11

5.2 In interviews with staff and clients the following effects of drinking white cider were mentioned: “reduces appetite, dulls conscience, eventually unconsciousness; wake up shaking, no appetite; sleep deprivation, takes over the day; pain in back, really bad heartburn; makes me drunk and nauseous; tummy aches, not pleasant; makes me feel invincible, so more likely to get into fights.”12

5.3 St Mungo’s supports the introduction of a minimum price per unit, however, we believe that the minimum fixed price should be 50 pence, rather than 40 pence. A bottle of cider containing 22.5 units would cost £11.25 if a minimum price per unit of 50 pence were introduced. This would make a three litre bottle of White Ace almost three times more expensive, which is likely to significantly reduce the amount that our clients drink.

5.4 We do not believe that a minimum price per unit would stop dependent users of alcohol from drinking, but do believe that it would encourage them to reduce the amount of strong alcohol that they drink or switch to weaker drinks, reducing the harm caused.

5.5 Research carried out by the University of Sheffield in 2008 found that a minimum price per unit could reduce the number of admissions to hospital due to alcohol by 97,000 each year. The study also found minimum price per unit of 50 pence would also have the most dramatic effect, compared to a range of other measures, on reducing admissions of people with a harmful pattern of alcohol consumption.13

5.6 Although introducing a minimum price per unit of 50 pence would affect people who didn’t necessarily use alcohol problematically, St Mungo’s believes that these costs are outweighed by the benefits that would be achieved through reducing harmful drinking.

5.7 Our clients told us that introducing a minimum price per unit could also bring significant risks, for example homemade or “black market” alcohol could become more common and dependent drinkers may spend a higher proportion of their income on alcohol instead of food. They may also turn to street drugs. The introduction of a minimum price per unit needs to be accompanied by a significantly improved provision of services for dependent drinkers to mitigate these risks.

5.8 Our clients also told us that there are not enough residential detox, rehab or services that can support dependent drinkers’ recovery, and that those that were available were often not appropriate for our client group. As stated above, the Government should expect the increased revenue from the introduction of a minimum price per unit for the alcohol industry to contribute towards the funding of these services.

6. 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.

6.1 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.14 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.

6.2 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% of our clients with an alcohol problem also have a mental health problem and 50% have a significant medical condition.

6.3 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.15 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.

Adam—St Mungo’s Client

6.4 Adam came into a St Mungo’s emergency shelter after sleeping rough. On entering the shelter, a substance use worker identified an urgent need for him to attend in-patient alcohol detox followed by residential rehab. Referrals to both of these services were made in January 2011. Adam was also had mental health issues and was an occasional user of heroin and crack.

6.5 Adam could not be admitted into the alcohol detox service until it was established that he could go to straight to residential rehab upon discharge. The way in which Adam used alcohol meant that it would have been unacceptably dangerous for him to be discharged straight back into the community after losing his tolerance to alcohol.

6.6 There is a great demand in London for the relatively few residential rehab services that are willing to admit people with Adam’s range of problems. The earliest date that Adam was able to secure for an assessment that could have confirmed he could enter rehab following detox was on Monday, 28 March. Adam died from a suspected heroin overdose on Saturday 26 March.

6.7 We believe that the Alcohol Strategy is severely lacking in the key area of recovery—the Government needs to clarify how alcohol services in the reformed system can be improved for those who are most in need. Our severely dependent clients require a pathway of support that includes in-patient detox, residential rehab and post-rehab residential support. These services are routinely being cut back as a result of funding cuts, and specialist workers are laid off.

6.8 There is a need for innovative services that can help our clients to make a sustained recovery from alcohol dependence; we have a significant number of clients who have “successfully” completed detox and rehab over five times. There is a particular need for Tier Three A services that can act as “pre-treatment rehab”, which could work with other issues such as mental health or social integration simultaneously; and Tier Five services offering supported discharge from formal programmes, thereby aiding a smooth transition to alcohol dependency-free living in the community.

6.9 There is evidence that personal budgets can lead to improved outcomes through giving homeless people choice and control not offered by standard offers of support,16 we believe that personalised health and social care budgets for homeless dependent drinkers should be piloted.

6.10 We support calls made by the Chief Executive of the National Treatment Agency for local authorities and the NHS to pool their resources to expand specialist alcohol treatment to meet this gap in service provision.17 Public Health England must also ensure that Directors of Public Health and local Clinical Commissioning Groups are aware of these gaps and have the expertise to commission appropriate services.

6.11 St Mungo’s experience shows that service-user involvement can quickly and efficiently improve services. We strongly believe that people with experience of drug and alcohol dependency should be included in the commissioning process.

May 2012

1 St Mungo’s and Marie Curie (2011) Supporting homeless people with advanced liver disease approaching the end of life

2 Alcohol Concern (2012) Briefing paper - The Government’s Alcohol Strategy

3 Home Office (2010) Drug Strategy, p19

4 National Institute of Clinical Excellence (NICE) (2011) Psychosis with coexisting substance misuse: NICE clinical guideline p.120

5 This recommendation is taken from a letter from Drugscope to Theresa May and Andrew Lansley co-signed by St Mungo’s Chief Executive, Charles Fraser.

6 British Medical Association (2009) Under the Influence

7 (retrieved 27 April, 2012)

8 Gordon, R and Harris, F (2009) “Critical social marketing: Assessing the impact of alcohol marketing on youth drinking” International Journal of Non Profit Voluntary Sector Marketing 15(3), pp. 265-275

9 Institute for Fiscal Studies (2010) Briefing note 109:The Impact of Introducing a Minimum Price on Alcohol in Britain

10 Alcohol Concern (2011) White cider and street drinkers

11 A three litre bottle of White Ace cider retails at £3.89 (price is printed on the bottle’s labelling) and contains 22.5 units (as of April 26, 2012)

12 Alcohol Concern (2011) White cider and street drinkers

13 Meier, P et al. (2008) Independent Review of the effects of alcohol pricing and promotion: Part B

14 Inter Ministerial Working Group on Drugs (2012) Putting Full Recovery First

15 National Collaborating Centre for Mental Health (2011) Alcohol use disorders: NICE clinical practice guideline 115, p.38

16 Joseph Rowntree Foundation (2011) Providing personalised support to rough sleepers. See also (retrieved 27 April, 2012)

17 (retrieved 27 April, 2012)

Prepared 21st July 2012