Health Committee - The Government's Alcohol StrategyWritten evidence from the Royal College of Psychiatrists (GAS 44)

This submission has been led by Dr Peter Rice, Chair of the Royal College of Psychiatrists in Scotland and member of the Addictions faculty, with contributions from the Addictions faculty, the Neuropsychiatry section, the Royal College of Psychiatrists in Northern Ireland and the Royal College of Psychiatrists in Wales.

1. Summary

1.1 The Royal College of Psychiatrists (RCPsych) is the leading medical authority on mental health in the United Kingdom and is the professional and educational organisation for doctors specialising in psychiatry.

1.2 The RCPsych Faculty of Addictions comprises medical doctors who have completed extensive training in psychiatry and addiction, and service users with lived experience of addiction and addiction services. It thus has expertise in all aspects of addiction, including individual brain mechanisms, behaviour, and its overall effect on the family, society and the economy. It has unique expertise in the management of addiction problems in complex cases, particularly co-morbid mental health problems.

1.3 The Faculty supports a holistic approach that considers how biological, psychological and social factors impact on a person’s life and recovery journey.

1.4 The RCPsych welcomes the Government’s Alcohol Strategy. The strategy recognises the broad range of effects of alcohol and that there are many opportunities for Government at all levels to influence rates of alcohol-related harm. The recognition of the relationship between price, particularly of the cheapest alcohol, and alcohol-related harm, is a major development. There is very good evidence which leads us to expect that the introduction of a minimum unit price that is set, monitored and adjusted on the basis of good information on trends in price, consumption and harm, will make a major contribution to improving public health, including public mental health. We believe that the potential health benefits have been understated in the strategy, and that these are at least equivalent to the community safety benefits to which the strategy gives greater emphasis.

1.5 The emphasis on public health in the operation of the Licensing system is welcomed; if fully implemented, this will be a major step forward.

1.6 There is less innovation evident in the strategy’s approach to the development of treatment services, including Screening and Brief Intervention (SBI), and this issue will require continued work to be resolved. There needs to be action to ensure that screening and brief intervention becomes a mainstream part of Primary Health Care and to secure the much-needed expansion of treatment services.

Another important area requiring service development is that of assessment and management of brain damage or cognitive deficits associated with alcohol use. Improved management of alcohol problems in prison populations and rehabilitation of people with established cognitive damage also merits urgent service planning.

1.7 We are concerned that there is little prospect for progress in the proposals controlling the promotion and advertising of alcohol. We do not believe that an approach based on self-regulation will be effective.

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

2.1 Alcohol is an issue where policy coordination is vital to the effectiveness of National Policy. There is a wide range of Government Departments involved in prevention of alcohol harm. Over the 20 years from 1991, alcohol death rates in the UK doubled (ONS 2011), indicating the lack of an effective co-ordinated approach by Government and other bodies and a relative lack of attention to the many individual, family and societal harms caused by alcohol, when compared to the sustained government focus on illicit drug use. In 2008, Patricia Hewitt MP was reported as saying that she had “pleaded with the Treasury for higher alcohol duty at every budget” while Health Secretary (http://www.dailymail.co.uk/health/article-517930/Now-middle-aged-women-targeted-anti-drink-campaign.html).

2.2 The recognition of the need for inter-departmental co-ordination is a strength of the Government’s alcohol strategy. The College has no view on which Department should lead policy, but there is a clear need for leadership on this complex issue.

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

3.1 Rates of alcohol-related harm vary across the UK. The longstanding higher rates of harm in Scotland than the rest of the UK are widely recognised, but the considerable variation in rates of harm within England, less so. In Wales, it is estimated that 15% of hospital admissions are alcohol-related and the overall cost to the NHS is around £70 million. The trends in alcohol harm show similar patterns in the UK, supporting the importance of price in determining rates of change in mortality and morbidity (ONS 2011).

3.2 There have been different approaches in alcohol policy across the UK for many years. For instance, the restriction of alcohol to designated areas within supermarkets which was introduced in Scotland in 2010 and has been called for by Alcohol Concern in England and Alcohol Concern Cymru, has been in place in Northern Ireland since the introduction of alcohol to supermarkets in the province in 1997. The work of Dr James Nicolls of Bath Spa University on the many historical differences between Scotland and England is summarised in the report Rethinking Alcohol Licensing (SHAAP/AFS 2011).

3.3 The Northern Ireland Assembly has announced its intention to reduce the drink-drive limit to 50mg/100ml and the Scotland Bill will give the Scottish Government the opportunity to fulfil its wish to do likewise. The Scottish, Northern Irish and Welsh jurisdictions all expressed their wish to introduce minimum alcohol pricing prior to the UK government’s announcement in 2012.

3.4 The UK has thus been familiar with different approaches to alcohol policy throughout its history. In recent times, the UK Parliament and English alcohol strategies have been characterised as being both weak on public health policy and influenced by alcohol industry interests, to the detriment of public health. (Drummond 2004, House of Commons Health Committee 2010). The 2012 strategy has been more positively received by health organisations, particularly because of the recognition of the links between price and harm, and the commitments to introducing a minimum price per unit and to exploring the introduction of a multi-buy discount ban.

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 involvement of Business Interest Non Governmental Organisations (BINGOs) in health promotion and harm reduction is a controversial issue recently highlighted by the Non Communicable Disease (NCD) Alliance in their response to the UN Draft Resolution on NCDs (Lincoln et al 2011). In brief, the NCD Alliance, which includes UK alcohol charities, shares the view of the Strategy that “industry needs and commercial advantages have too frequently been prioritised over community concerns” in a range of health issues. (Alcohol Strategy para 1.4, p12).

The College encourages the Health Committee to consider this issue from first principles.

We believe that BINGOs should not be part of Government policy fora. In our view, their role should be to influence the practice of their members, and their relationship with Government should be restricted to implementation of Government policy.

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 evidence base for the effectiveness of different pricing mechanisms has been reviewed by the University of Sheffield in a series of reports for the UK and Scottish Governments. This work has been peer reviewed and published in the leading academic journals in the field; the Committee will be familiar with its findings. In brief, minimum alcohol price is the most effective and selective mechanism to reduce heavy drinking and alcohol-related harm. The modeling suggests greater benefits at a higher minimum price. The most recent report estimates that a 40p per unit price will reduce deaths cumulatively by 5.4% per annum. A 50p price produces a 17.2% annual reduction and 60p price a 33.2% reduction. The estimated crime reduction at 60p (3.7%) is more than five times that at 40p (0.6%) (University of Sheffield 2012).

5.2 The minimum price should not be permanently fixed, but will require regular review based on accurate and timely data on consumption, sales, health and crime. We support a minimum price of at least 50p per unit and suggest the price should be reviewed and adjusted as necessary at least annually.

5.3 With regard to legality, the Medical Royal Colleges commissioned a legal opinion in Scotland in 2007 which concluded that setting a minimum price would not be illegal under UK or EU law as long as the alcohol industry was not involved in setting the price. While industry bodies have repeatedly asserted that price measures are illegal, we remain of the view that this is not the case. We are encouraged that the UK government appears to share our view.

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

6.1 The issue of marketing was fully reviewed by the House of Commons Health Committee in 2009–10 (House of Commons Health Committee 2010). The Committee concluded that “The current system of controls on alcohol advertising and promotion is failing the young people it is intended to protect” and recommended that regulation should be completely independent of the alcohol and advertising industries. The College agrees with this position and therefore we fully supported Dr Sarah Wollaston MP’s Private Member’s Bill on alcohol advertising in March 2011. The 2012 strategy does not propose the sort of step change on advertising and promotion we believe to be necessary. This is one of the most disappointing elements of a strategy which in many other areas shows welcome courage and vision.

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

7.1 Sheron, Gilmore and colleagues have estimated that, over a 10-year period, well over 200,000 alcohol-related deaths could be prevented by effective alcohol policies (Sheron et al 2012). This would include prevention of many thousands of suicides because of the impact of alcohol on mental health. The Sheffield series of studies similarly estimates considerable health benefits of the reduced consumption which would result from effective pricing policies. All deaths and other harm linked to alcohol should be regarded as preventable.

7.2 The impact of alcohol on mental health is substantial due to its effects on mood, cognition and behaviour, as well as its neurotoxic effects. The recognition of this impact will be crucial to success in the implementation of the “No Health Without Mental Health” mental health strategy in England.

7.3 Parental misuse of alcohol can have harmful effects on children, and while the Strategy acknowledges this, the issue is not given the emphasis it merits. Parental alcohol misuse is associated with child abuse and domestic violence, which can lead to children developing emotional, behavioural and mental health problems. Parental substance misuse, most often involving both alcohol and illicit drugs, is a significant factor in many child protection cases, including in cases of serious injury and death. It has been described as “a formidable social problem” and is a factor in up to two thirds of care cases (Harwin, Ryan and Tunnard, 2011).

8. 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

8.1 Our comments focus on service use issues in substance misuse treatment services and wider mental health services, though we recognise that the increasing demand on hepatology services has been very considerable.

8.2 Interventions for alcohol problems, including dependence, are effective and cost-effective (NICE 2011); these range from brief interventions in some settings to more intensive treatment programmes for those with dependence. Good quality UK research has shown that investment in treatment produces five-fold savings in Health and Social Care costs alone (UKATT 2005).

8.3 The Health Committee described the state of alcohol treatment services in England as “dire” in 2010 and concluded that this was a disincentive for early detection of alcohol problems in Primary Care and other settings. This is consistent with the findings of the Alcohol Needs Assessment Research Project which found capacity in treatment services for 5.6% of the need. It was estimated that 1 in 18 people with alcohol dependence were in contact with treatment services. In some parts of England the figure was close to one in 100 (Drummond et al 2004).

This unmet need for treatment requires urgent attention.

8.4 Responses to parents with substance misuse problems whose children are at risk should include further development of the Family Drug and Alcohol Court model, which involves multi-disciplinary input from family justice, social care and health services. This should build on the positive findings of the piloting of this service and be attentive to the recommendations made in the evaluation report (Harwin, Ryan and Tunnard, 2011).

8.5 Another important area requiring service development is that of assessment and management of brain damage or cognitive deficits associated with alcohol use. There is a need for coordinated effort involving public health education measures, and improved alcohol misuse and cognitive deficits screening in Accident & Emergency, Acute Medicine, Trauma, Gastroenterology, and Mental Health Units. Improved management of alcohol problems in prison populations and rehabilitation of people with established cognitive damage also merits urgent service planning.

9. 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

9.1 The proposed reforms do offer the potential to improve the development of services. The development of Health and Wellbeing Boards and Public Health England offers the opportunity to better integrate the work of the NHS and Local Authorities. This could bring together strands such as Licensing, Criminal Justice, Community Action, Trading Standards, Primary Health Care, Family Justice, Mental Health and specialist Addiction services to produce effective change. This depends on strong leadership focused on alcohol issues. Otherwise there is a risk, perhaps because of the size of the issue that alcohol becomes everyone’s concern, but no-one’s responsibility. Alcohol should be identified as a high priority by Health and Wellbeing Boards. It is estimated that alcohol costs the NHS £2.7 billion. The National Audit office showed that spending on alcohol treatment is £217 million. The new planning arrangements for alcohol should allow for whole-system redesign using a wide range of funding sources.

9.2 The transfer of the National Treatment Agency (NTA) to Public Health England should be managed to ensure that the plans to expand the NTA function to cover some elements of alcohol misuse rest in Alcohol services achieving parity with Drug services.

9.3 There is now a well developed consensus on what a good alcohol treatment system looks like. The conclusions and recommendations at the end of Chapter 5 of 2010 Select Committee report are a good plan for action for the development of early intervention and treatment services. These have been supported by the subsequent NICE guidance on alcohol use disorders (NICE 2011).

9.4 A key test for the development of an effective response to alcohol will be the development of systematic Screening and Brief Intervention (SBI). The effectiveness of this has been recognised for decades and has recently been advocated by NICE, and the evidence base further developed by recent findings from the Department of Health-funded Screening and Intervention Programme for Sensible Drinking (SIPS) project (http://www.sips.iop.kcl.ac.uk/)

9.5 Difficulties in establishing Alcohol SBIs, most notably in Primary Health Care, suggests that this requires a national screening programme approach. The Scottish SBI programme, which has delivered 200,000 Brief Interventions over past four years was built on a health improvement target for which local commissioners (Health Boards) were held nationally accountable.

We recommend inclusion of alcohol SBI in the Quality Outcomes Framework.

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

10.1 NICE published its review of preventing harmful drinking in June 2010 (NICE 2010). The recommendations were:

To consider introducing a minimum price per unit.

To regularly review the minimum price per unit.

To regularly review alcohol duties.

To consider revising licensing legislation to ensure:

links between the availability of alcohol and alcohol-related harm are taken into account when licence applications are considered;

immediate sanctions can be imposed on premises in breach of their licence; and

health bodies are “responsible authorities”.

To consider a review of the advertising codes, to ensure that:

limits set by Advertising Standards Authority for the proportion of the audience under age 18 are appropriate;

children and young people are adequately protected where alcohol advertising is permitted; and

a stringent regulatory system covers all alcohol marketing, particularly via new media.

To prioritise alcohol-use disorder prevention as an “invest to save” measure.

To conduct a local joint alcohol needs assessment.

To include screening and brief interventions in commissioning plans.

To provide resources for tier 2, 3 and 4 alcohol services to accommodate a likely increase in referrals.

NICE did not find that education and information approaches were effective as stand-alone measures to reduce alcohol-related harm. However, these activities may be effective for building public support for effective measures, similar to the linkage between awareness campaigns and the introduction of seatbelt legislation. A similar mix of awareness-raising and regulation was also effective in tackling drink driving.

10.2 Measures to increase the attractiveness of lower strength alcohol should be implemented. There are many international examples of success in this area, most notably in Australia. In evidence to the Scottish Parliament Health Committee in January 2012, Tesco reported that sales of low alcohol beer have doubled since the introduction of lower duty for beers with a strength of less than 2.8% ABV. We welcome the statement in the strategy that the UK government would support EU action to revise duty on wine so that it increases with alcoholic strength. We were surprised and disappointed that a similar statement was not made in relation to cider, which is the drink of choice of many alcohol-dependent patients due to its low alcohol duty at higher strength.

We recommend that revision of the cider duty arrangements should be a high priority.

10.3 The international evidence of the harm reduction benefits of a higher legal purchase age are mainly from the USA and the benefits are mainly seen in reductions in Road Traffic Accidents. The possible benefits of a split legal purchase age was raised in the New Zealand Law Commission’s report Alcohol in Our Lives. The suggested advantages of a legal purchase age of 18 in on-licence premises and 20 or 21 in the off-licence environment are:

Moving alcohol use by young people into the supervised on-licence sales environment.

Reducing “pre-loading” at home, thus reducing overall consumption.

Reducing third-party agent purchase by 18/19 year olds, which is a major source of alcohol supply for children.

We recommend that the Committee consider this proposal for England and Wales.

10.4 The Independent Review of Prices and Promotions commissioned by the Department of Health in 2008 found a small but consistent effect of advertising on alcohol consumption, including by young people. The Health Select Committee in 2010 made a series of recommendations on the regulation of advertising, including restriction of cinema advertising to 18 certificate films, a 9 o’clock watershed for TV advertising, and a ban on advertising or sponsorship if more than 10% of the audience is under 18.

We endorse these recommendations.

References

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May 2012

Prepared 21st July 2012