Health Committee - The Government's Alcohol StrategyWritten evidence from Newcastle City Council and Newcastle Primary Care Trust (GAS 30)

1. 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.

2. We have found that one when a single government department leads on alcohol policy then the focus naturally becomes skewed towards the priorities of that department. The current strategy published by the Home Office, has a strong criminal justice focus and is about enforcement interventions and less about the health, wellbeing and social interventions that are required for individuals in active addiction to recover. Whereas the Department of Health’s policy position of “nudging” behaviour change would not necessarily meet the objectives of the Home Office. As action is required across a number of government departments with often competing priorities and objectives, then this requires the agreement of a shared policy direction for alcohol and leadership at the highest level ie the Cabinet Office to make this happen.

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

4. We welcome the accelerated progress of devolved administrations on alcohol policy, in particular on the affordability of alcohol, which we believe has been instrumental in prompting action in England on minimum unit price (MUP). Population level interventions such as addressing advertising, availability and affordability need to be coordinated across the whole of the UK. Without this, there is the issue of cross boundary access to cheaper products/advice as well as the potential to widen health inequalities.

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

6. The Alcohol Industry should not be involved in the setting of alcohol policy or its implementation as this presents a direct conflict of interest. There are many examples showing why this is inappropriate:

6.1.1The industry appears to have had a key role in setting alcohol policy such a proposing the banning of the sale of alcohol below cost plus VAT where there is research that this will be ineffective in reducing alcohol consumption.1

6.1.2The industry has been frustratingly slow in complying with the alcohol labeling pledges under the Responsibility Deal.

6.1.3The industry has been aggressively and highly critical of minimum unit pricing for alcohol and the impact of alcohol advertising on young people when there is a long standing, international, robust and credible evidence base.

6.1.4Drinkaware’s website has recommended a “daily alcohol allowance” rather than “low risk limits” which could give the public the impression that it is recommended to drink alcohol on a daily basis which is contrary to Department of Health advice.

7. The Mainstreaming Health Promotion Project2 which carried out a rapid review of the current evidence for health promotion actions for hazardous and harmful alcohol use, with specific reference to low- and middle-income countries; identified evidence which showed self-regulation by means of industry voluntary codes was found not to prevent the exposure of younger people to alcohol marketing.

8. Balance the North East Regional Alcohol Office has developed work which provides a helpful thought process for policy makers to go through when deciding if it is appropriate to work locally with industry. This could provide a model of working with the industry at a national level.

9. 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.

10. Newcastle City Council3 along with all the Councils in the North East Region4 fully support the introduction of a national MUP for alcohol and will continue to campaign for its introduction. Balance recently completed a survey of supermarkets in the North East which showed that alcohol was available for as little as 16p per unit. It is not responsible drinkers that are drinking cheap alcohol but our children and young people and individuals drinking at harmful levels.

11. The introduction of a national MUP would also level the playing field for local community pubs which have been closing on a regular basis and have been adversely affected by the sale of low cost alcohol particularly from supermarkets.

12. The School of Health and Related Research at Sheffield University identified that the introduction of a MUP of 50p per unit would:

reduce the number of deaths from alcohol related causes by more than a quarter;

reduce the number of crimes by 46,000;

reduce hospital admissions by almost 100,000; and

save the county an estimated £1 billion a year.

13. Sheffield University has recently re-modeled the impact of a MUP which continues to show that the higher the minimum price is then the greater the harm reduction and this goes up steeply. The modeling found there to be relatively little effect for a 25p minimum price, but 40p, 50p and 60p have increasing effects. It is important to recognise the impact of changes to the price of alcohol as a result of inflation and deflation. Therefore the MUP level will require continuous monitoring to ensure it continues to achieve the desired reduction in consumption.

14. This study also showed that the introduction of a MUP would be most effective in reducing consumption amongst young people and the most harmful drinkers who are most likely to be drinking at harmful levels. Those drinking moderately or at low risk limits would only be marginally affected.

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

16. We are particularly concerned about the impact of alcohol advertising on children and young people. That is why the Council has supported the North East campaign See What Sam Sees. This campaign aims to raise awareness of how much young people are exposed to alcohol advertising on a daily basis. Alcohol Concern5 monitored television advertising and found that during the period of the research there was a rising number of alcohol adverts shown from 3pm to 5pm which coincides with the time when most children arrive home from school.

17. Studies6 consistently suggest that exposure to media and commercial communications on alcohol is associated with the likelihood that adolescents will start to drink alcohol at a younger age and they go on to drink more.

18. A report by Alcohol Concern7 highlights the issue of social networking sites such as Facebook, You Tube and Twitter which are hugely popular with under 18’s. According to Ofcom8 almost half of children aged 8–17 years of age who use the internet have set up their own profile on a social networking site. Despite age verification gateways, these sites are popular with young people and alcohol brand websites often include interactive games, competitions and videos which appeal to young people. It has been reported that in 2009 online alcohol advertising expenditure overtook television expenditure for the first time. The National Alcohol Strategy is currently silent on this issue.

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

20. Rather than quote national statistics of which the Health Select Committee will already be familiar, we have highlighted the perspective from local health practioners:

Dr Chris Record a liver specialist from Newcastle University and Newcastle Hospitals has reported that only a few years ago alcoholic liver disease was very unusual in people in their early 30s, now many patients are presenting with terminal liver disease in Newcastle in their late-20s and early-30s.

Our alcohol specialist nurses who were told when training that they would be unlikely to see a case of Korsakoff’s syndrome9 during their career, report seeing one or two cases a year.

21. Alcohol related health issues can be prevented and therefore a significant proportion can be avoided. There needs to be integrated alcohol care pathway from prevention and early identification through to specialised treatment and recovery, with sufficient resource to staff and manage the populations’ needs.

22. 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.

23. As a result of increased alcohol assumption incidence of liver related mortality in the UK has approximately trebled since 1970 and continues to escalate, this is in contrast with apparent declines in most other European countries. Liver transplantation is one treatment option to manage the symptoms of liver cirrhosis with approximately 500–600 adult liver transplants undertaken each year. Liver transplants cost in the region of £60,000—£80,000 for the transplant procedure itself , the initial hospital stay after transplantation and the costs incurred in lifelong medical follow-up, investigations and immunosuppressive medications. This is a significant financial cost to the NHS.10

24. As described earlier, we are seeing increasing numbers of younger people in their late 20’s and 30’s with complex health problems as a result of their drinking. This can result in costs to adult social care for residential, personal home care or supported housing which can continue throughout their lifetime. There are also are the increasing costs of looked after children where the main reasons for child referrals being related to domestic violence (where 50% of cases involved alcohol) and parental substance misuse.

25. Without a reduction in alcohol consumption, these costs will continue to escalate.

26. 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.

27. The transfer of commissioning responsibilities for alcohol treatment services to local authorities provides an opportunity to pool resources currently spent on alcohol harm eg social care and supported housing. If the ring fencing of funding for the drug treatment systems is removed it will also present the opportunity for the commissioning of a more integrated treatment system for people who misuse both drugs and alcohol and to rebalance resources locally in recognition of the needs of the population. Whilst there are clearly some similarities in the drugs and alcohol agenda in terms of treatment, recovery, the links with crime and social problems, it is important that the distinctions are also recognised: such as the legality and social acceptability of these substances, and the different demographic profile of people who misuse alcohol in isolation compared with those who also misuse drugs. If this distinction is lost then treatment pathways may not meet the needs of people needing treatment services.

28. It is also essential to have close working relationships with Clinical Commissioning Groups to develop a shared responsibility for the care of this population across multiple service providers. This relationship is critical to be an effective integrated approach.

29. International evidence of the most effective interventions for reducing consumption of alcohol and evidence of any successful programmes to reduce harmful drinking, such as:

30. Public health interventions such as education and information;

31. Education and information should not be seen as a stand alone intervention because by itself it is relatively ineffective. Instead it should be an element of a coordinated alcohol strategy incorporating: social marketing promotional campaigns such as Change4Life, enforcement, screening and brief advice as well as signposting into effective and integrated care pathways. At a local level we should also be supporting national direction regarding minimum pricing and banning advertising to children

32. Children and young people

33. There is a need to have more robust evidence on the most effective interventions to work with young people, especially within the school setting. Newcastle University are part of a large trial researching the impact of alcohol brief intervention and advice within a school setting (Junior SIPS). The results from this research are eagerly awaited.

34. There is stronger evidence to demonstrate the importance of thinking about alcohol in the context of risk taking behavior. Therefore the links with sexual health services is essential and should be prioritized locally.

35. The work on social norms for young people has been proven to be effective in a number of settings. Working with higher education institutions such as universities regarding the social norms of alcohol is vital alongside working with local landlords regarding targeting promotional offers to students, especially during Freshers weeks for new university entrants.

36. Universal and targeted messages

37. There are certain elements of the population who will be more receptive to a health message at a certain point in their life. These “teachable moments” are an opportunity to discuss changing health behaviors and have been well researched. Pregnancy or planning for a baby is one of those teachable moment opportunities and should be optimized at a local level through consistent messages about how alcohol can cause harm to the developing baby.

38. The SIPS alcohol screen and brief intervention research11 looked at a range of different methods of screening and brief intervention across settings A&E, Primary Health Care and Probation. This identified the value of brief intervention and advice and the benefits of having a structured conversation about alcohol with a trained professional. Universal application of alcohol screening and brief advice within a primary care setting has demonstrated effectiveness and should be part of standard care within primary care. The research also found that in some settings a patient information leaflet was also found to be the most effective intervention.

39. Reducing the strength of alcoholic beverages;

40. We are not aware of any studies relating to reducing alcohol strength, but would suggest that the introduction of a national MUP should logically lead to a halt in the upward drift in product strength that has occurred over many years and maybe even lead to reductions in product strength in due course—but this has not really been investigated empirically.

41. Raising the legal drinking age;

42. The Mainstream Health Promotion Project referred to earlier12 found that measures that restricted the affordability, availability and advertising of alcohol had evidence of effectiveness. With regard to young people it found that laws which raised the minimum purchase age reduced alcohol sales provided they were at least minimally enforced. There was also strong evidence that this approach would have substantial impacts on reducing road traffic accidents and other casualties if the purchase age were changed.

May 2012

1 Price Discounts on Alcohol in a City in Northern England – Adams and Beenstock December 2011

2 Mainstreaming health promotion project - rapid review of current evidence for health promotion actions for hazardous and harmful alcohol use, with specific reference to low- and middle-income countries, Bador et al June 2011

3 Notice of Motion at Newcastle City Council 7 September 2011 Minute Number 59

4 Association of North East Councils Regional Leaders and Elected Mayors March 2012

5 Alcohol Concern – Not in front of the children Child Protection and Advertising

6 Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies Anderson, de Bruijn, Gordon and Hastings and studies by Snyder et al., 2006; Anderson et al., 2009,

7 New media, new problem? Alcohol, young people and the internet Alcohol Concern 2011

8 Ofcom: Engaging with social networking sites

9 A neurological disorder caused by a lack of thiamine in the brain linked to chronic alcohol abuse

10 Alcohol Use & Liver Transplantation – Alcohol Learning Centre

11 SIPS Research Factsheets

12 Para 7

Prepared 21st July 2012