Health Committee - The Government's Alcohol StrategyWritten evidence from Royal College of Nursing (GAS 29)

1.0 Introduction

1.1 With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2 The RCN welcomes the Health Select Committee’s decision to hold an inquiry into the Government’s alcohol strategy and is pleased to have the opportunity to submit written evidence.

2.0 Executive Summary

2.1 The RCN general election manifesto of 2010, Nursing counts,1 called for the introduction of a single mandatory code to better regulate the drinks industry and to minimise the dangers and health care costs associated with excessive drinking. This mandatory code would include a minimum unit price. Therefore, the RCN broadly welcomes the Government’s intention to move in this direction.

2.2 The RCN believes that a minimum unit price is key to tackling the increasing problem of excessive alcohol consumption and the impact this has on the health of the nation.

2.3 Tackling alcohol misuse and its effects upon the general public should be seen as a priority across Government and not the sole responsibility of one department. As well as a drain upon the NHS, the effects of alcohol misuse are seen in schools, prison services and the welfare system.

2.4 Nurses are the health workers who have the most interaction with patients. They are ideally placed to carry out early interventions and to educate patients about the dangers of excessive alcohol consumption.

2.5 Nurses working in Accident and Emergency departments and elsewhere in the NHS, are often exposed to inebriated patients who unfortunately frequently turn violent.

2.6 We welcome the focus upon binge drinking and acknowledge the damage that this causes to individuals. However, the strategy, in order for it to truly tackle the issue of excessive alcohol consumption, should also focus on the chronic health impact of alcohol consumption on long-term moderate to high drinkers.

2.7 Any alcohol industry code must be mandatory as past voluntary codes have proved to be ineffective. The Government must maintain oversight and accountability for adherence to any regulatory alcohol code.

2.8 A disproportionate amount of those individuals who succumb to illnesses related to excessive alcohol consumption, such as liver disease, come from the most deprived areas of England.

3.0 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 The RCN accepts that the scale of alcohol related harm in the UK means that alcohol misuse is an issue which naturally falls within the remit of a number of Government departments, for example those covering (but not limited to) health, crime and disorder and welfare. We therefore both support and encourage Departments outside the Department of Health to prioritise efforts to reduce alcohol related harms. For example, we engaged with and supported the changes made by the Home Office to the licensing regime in 2011 to shift the balance in favour of public health promotion.2

3.2 However, we note that within the recently published alcohol strategy, the foreword by the Prime Minister focuses on tackling alcohol misuse as a problem of crime and violence, and clamping down on “binge drinking”. The strategy was issued by the Home Office, which suggests that their remit of crime and licensing is the dominant area of concern for the Government. In contrast, the previous Government’s strategy document Safe, Sensible, Social in 2007 was issued jointly by the Home Office and the Department of Health.3

3.3 The RCN agrees that binge drinking is harmful to health in both the short and long term, and can result in acute injuries requiring medical care. Nurses working in Accident and Emergency departments, and elsewhere in the NHS, also fall victim to alcohol-fuelled violence.4 We therefore support efforts to reduce binge drinking and anti-social and violent behaviour.

3.4 However, we believe that the UK’s alcohol misuse problem must be primarily framed as a problem resulting in acute and chronic health harms, and we urge the Government to focus on the huge health toll that alcohol misuse takes on individuals, families and communities in the long-term. Whilst premature death from heart disease and stroke has reduced in recent years, deaths from liver disease have increased. By focusing on binge drinking and its impacts, the strategy therefore fails to recognise the chronic health impacts on long-term moderate to high drinkers. It is preferable to focus energy and resources on preventing alcohol misuse, rather than building a strategy around penalising poor or criminal behaviour related to that misuse.

3.5 We also note that Government strategy is not always as joined up as it could be. For example, during the legislation to alter the Licensing Act, the RCN and other experts in public health argued that there should be a fifth licensing objective on the “prevention of health harm”. This would have empowered relevant authorities to make licensing decisions which specifically take into account the protection of the current and future health of their communities. However, the recommendation was not included in the final legislation and represents a missed opportunity to align health, crime and anti social behaviour objectives.

3.6 We support the alcohol strategy’s stated commitment to tackling the root causes of alcohol abuse and support plans to introduce a minimum price per unit of alcohol. However, tackling these root causes of alcohol abuse also means understanding the cultural role that alcohol plays in society, and supporting people to make healthier choices in a number of ways. This might include regulation where necessary (for example on price, labelling and promotions); health promotion and education activities; and also investing in the professional workforce which can support behaviour change.

3.7 Nurses are the biggest group of health care professionals in the NHS, and as such have significant numbers of opportunities for teachable moments with patients each day. The nursing workforce can play a substantial role to identify and support people with alcohol misuse problems (eg alcohol liaison nurses in acute settings). They can also offer health promotion advice and signpost people to further support as well as to help ensure integrated care across the system, where people may have complex needs.

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

4.1 As an organisation which represents nurses and nursing across the four countries of the UK, the RCN supports the principle that each country should have the power to initiate its own policies to improve public health, independently of others, where necessary.

4.2 We also believe there is value in learning lessons where other countries have implemented innovative public health policies. Scotland was the first country in the UK to introduce smoke free public places, and will be the first to implement the minimum price per unit for alcohol. The rest of the UK can use the evidence generated by the Scottish Government for example, the updated research commissioned from the University of Sheffield, as well as benefit from any learning points which result from evaluation of the policy’s implementation and effectiveness.

4.3 We further understand that in Northern Ireland there have been discussions with the Republic of Ireland about synchronising legislation on minimum pricing for alcohol, an example of public health “knowing no borders”.

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

5.1 The RCN acknowledges that there is a role for everybody, including the alcohol industry, in tackling alcohol misuse in the UK. The industry for example, should commit to behaving more responsibly in the way alcohol is promoted. However, we believe ultimate accountability for the strategy to reduce harm caused by alcohol misuse should not rest with the alcohol industry, but with the Government.

5.2 There are examples that demonstrate the failure of the alcohol industry to date to take the appropriate voluntary action. For example, in 2010 the RCN responded to a consultation on whether mandatory alcoholic drinks labelling should be introduced.5 Independent evidence published alongside this consultation showed that the industry had failed to establish a widely used, comprehensive and consistent alcohol information system, despite pledging to do so. The RCN and others therefore argued that the industry had failed to meet its commitments and that there should be a mandatory alcohol code, which would include a mandatory labelling system. This was not implemented.

5.3 In 2011, during discussions about the alcohol pledges being made by the industry as part of the Public Health Responsibility Deal, key stakeholders in improving public health were concerned at the level of commitment, ambition and monitoring attached to the pledges. As such many stakeholders refused to endorse them, including the RCN and other Royal Colleges. The RCN believes the Government must listen to the concerns of public health experts and for any future agreements achieve buy-in and support from all sectors and professionals.

5.4 The RCN believes that we need to support the population to make healthier choices and we know that empowering people with the right information helps them to change their lifestyle. However, people do not make decisions in a vacuum. The wider environment plays an important role, and the work of health professionals in helping people to improve their own health is undermined by the proliferation of cheap, readily available alcohol and inconsistent messages about the impact of alcohol on health.

5.5 We believe that whilst the alcohol industry should be encouraged to behave more responsibly, it should be acknowledged that there are limitations to the role industry can play in reducing alcohol harm. It is inevitable that the interests of the industry, who wish to profit from the sale of alcohol, and public health will not always align. Therefore the Government must maintain oversight of and accountability for the alcohol strategy, by taking regulatory action where necessary (for example on price) and strictly monitoring voluntary pledges taken by the industry. Where the industry is found to have failed in these pledges, the Government should step in to regulate without delay.

6.0 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.

6.1 The RCN supports the conclusions of the modelling developed by the University of Sheffield6, first in 2008 and updated in 2012.

6.2 Nurses witness the impact of dangerous and excessive consumption of alcohol every day. For RCN members the problem is too urgent not to take every available step to tackle the issue, including addressing price. In a survey of RCN members carried out in 2009.7 81% of respondents believed that if alcohol was more expensive there would be a decrease in consumption. We have therefore been calling for the Government to introduce a minimum price per unit across the UK for some time and were keen to support the efforts of the Scottish Government to introduce a minimum price per unit.

6.3 The recently updated University of Sheffield research found that a minimum price of 45p a unit would reduce consumption by 4.3%. There would be a fall in hospital admissions of 6,630 within ten years and a reduction of 1,000 acute and 260 chronic illnesses in the first year.8

6.4 RCN notes that some parties have expressed concern that a minimum price would penalise people who drink responsibly. However, findings from Sheffield University suggest that whilst a harmful drinker would pay an extra £132 a year, a moderate drinker would only be £9 a year worse off if a minimum price was introduced.9 We therefore support the presumption that people who are only drinking moderate amounts, within recommended guidelines, will not be disproportionately impacted by a minimum price.

6.5 We are not suitably placed to comment on the legalities of minimum unit pricing.

7.0 The impact that current levels of alcohol consumption will have on the public’s health in the longer term.

7.1 Excessive alcohol consumption is a major source of morbidity and premature death in the UK. The World Health Organisation lists alcohol as the third leading risk factor for premature death in developed countries, with only tobacco and blood pressure causing more premature death and disability.10

7.2 Alcohol misuse can cause and contribute to a range of illnesses and diseases including, but not limited to, liver damage, brain damage, stroke, heart disease and cancer. It can also lead to dependency and other mental health problems. Alcohol inebriation is also associated with individuals taking greater risks during sexual encounters, including failure to take safer sex precautions.

7.3 Premature death from liver disease is rising, in contrast to many other chronic diseases. Whilst available statistics suggest that, as a nation, we drink less than we once did, there is still a significant minority who are drinking at dangerous levels which will have inevitable consequences.

7.4 Figures released in 2012 show that the number of people who died from liver disease in England rose by 25% in the last decade.11 The report by the NHS National End of Life Care Programme also showed that liver disease disproportionately affects younger age groups with 90% of people who die from the disease being aged under 70. Statistics show that three times as many deaths from alcoholic liver disease occur in the most deprived areas of England, compared with the least deprived.

8.0 Whether the proposed reforms for the NHS and public health systems will support an integrated approach to future planning of services for people who experience alcohol-related harm?

8.1 The RCN notes that in England the Government provides no specific money to the NHS for alcohol treatment in comparison with other cessation and prevention services such as those provided for drug abuse. We are concerned about a lack of clarity around the provision of alcohol programmes. We know that a number of service commissioners will be involved and responsibilities shared across the various NHS commissioning bodies as well as local Government and crime and youth offending bodies. This may create barriers to integrated and collaborative working. For example, whilst Local Authorities will pick up some responsibility for commissioning to reduce alcohol harm, the new Police and Crime Commissioners will also have some responsibilities in this area, as will Probation Trusts. In addition, the NHS Commissioning Board will have some responsibilities for prison health services which will include alcohol programmes; and Clinical Commissioning Groups will likewise have some responsibilities for NHS services. Services designed for young people will also be divided between commissioners from the NHS as well as youth offending teams.

8.2 We believe the situation for the planning and integration of services for alcohol programmes will become more, rather than less, complicated. Furthermore, the above examples focus on treatment rather than prevention services. The role of Public Health England in health promotion and prevention of alcohol misuse is still unclear.

8.3 In the current environment of financial constraint, with the NHS required to save £20 billion and local authorities also making huge savings, the RCN is concerned that alcohol services could potentially fall through the gaps between different commissioners. Whilst welcoming the Government’s focus upon alcohol misuse within the strategy, it is vital that the desired outcomes are robustly monitored and sufficient Government focus remains during the delivery of the strategies aims.

May 2012

1 RCN General Election Manifesto campaign Nursing Counts – http://generalelection.rcn.org.uk/

2 http://www.rcn.org.uk/__data/assets/pdf_file/0006/339270/RCN_response_to_Rebalancing_the_licensing_Act_Sept2010.pdf

3 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_075218

4 http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/SecurityManagement/2009-10_Physical_Assaults_Against_NHS_Staff_FINAL_241110.pdf

5 http://www.rcn.org.uk/__data/assets/pdf_file/0003/323157/Options_for_improving_information_on_the_labels_of_alcoholic_drinks.pdf

6 University of Sheffield, Alcohol Research Group http://www.sheffield.ac.uk/scharr/sections/ph/research/alpol/publications

7 Royal College of Physicians and Royal College of Nursing Survey on Alcohol Treatment Services, 2009

8 University of Sheffield, Alcohol Research Group http://www.sheffield.ac.uk/scharr/sections/ph/research/alpol/publications

9 University of Sheffield, Alcohol Research Group http://www.sheffield.ac.uk/scharr/sections/ph/research/alpol/publications

10 World Health Organisation (2002), World Health Report: Reducing Risks, Promoting Healthy Life.

11 http://www.nhs.uk/news/2012/03march/Pages/liver-disease-death-alcohol-increase.aspx

Prepared 21st July 2012