Health Committee - The Government's Alcohol StrategyWritten evidence from Lundbeck (GAS 60)

Summary

Alcohol is a major health problem; it contributes to 60 types of disease and injury, including 80% of deaths from liver disease and it is the second biggest risk factor for cancer after smoking. Lundbeck therefore proposes that the Department of Health takes central responsibility for Alcohol Strategy and co-ordinates policy across Whitehall.

There are estimated to be 1.6 million dependent drinkers in England and 2.6 million people drinking twice the recommended limit. Over 10 million adults drink more than the recommended limit.

Current levels of alcohol consumption will in the longer term contribute to poorer health and greater health inequalities.

As the number of people being screened for alcohol misuse increases, through measures such as the NHS Health Check, local commissioners will need to ensure that appropriate treatment and support services for alcohol problems are made available. Currently, access to alcohol services is limited, only 1 in 18 (less than 6%) of dependent drinkers receives treatment.

Tackling alcohol harm will require investment in alcohol services. Alcohol Concern has recommended at least 15% of dependent drinkers should be able to access treatment.

The Health and Social Care Act reforms to the NHS and public health systems will create a number of challenges and opportunities for producing an integrated approach to the future planning of alcohol services.

1.0 Introduction

1.1 Lundbeck are specialists in psychiatry and pioneers in neurology. Lundbeck is an ethical research-based pharmaceutical company specialising in central nervous system (CNS) disorders, such as depression and anxiety, schizophrenia, Alzheimer’s and Parkinson’s disease. We also have an interest in alcohol policy.

2.0 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

2.1 The Government’s Alcohol Strategy is a cross-governmental approach to reducing alcohol harm and tackling crime and disorder related to alcohol. The Strategy was launched by the Home Office in April 2012.

2.2 A significant proportion of the policies in the Strategy are Home Office led, such as licensing, irresponsible promotions in pubs and clubs and alcohol minimum pricing. The Strategy also addresses health policy and initiatives for reducing alcohol harm, such as the inclusion of alcohol screening in the NHS Health Check assessments and the new public health responsibilities of local authorities in tackling alcohol misuse. It is clear that alcohol misuse has a significant impact on various public policies, such as policing and advertising—and the Alcohol Strategy reflects this.

2.3 We would propose that the Department of Health, not the Home Office, takes central responsibility for the Alcohol Strategy and co-ordinates policy across Whitehall. The reason for this is that alcohol is a major health problem; it contributes to 60 types of disease and injury, including 80% of deaths from liver disease and it is the second biggest risk factor for cancer after smoking.1 ^, 2 If the Department of Health led on the Alcohol Strategy it would send a clear signal to the public that alcohol is a significant health problem.

2.4 Furthermore, health interventions, such as alcohol screening and brief advice, have been proven to be effective tools in helping people to reduce their alcohol consumption or abstain from alcohol, preventing the progression and development of alcohol-related health problems, eg liver disease and hypertension. Brief advice on alcohol misuse in primary care leads to one in eight people reducing their drinking to sensible levels, compared to smoking cessation where only one in 12 change their behaviour.

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

3.1 Lundbeck welcomes a co-ordinated approach to alcohol harm across the devolved administrations.

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

4.1 There are estimated to be 1.6 million dependent drinkers in England and 2.6 million people drinking twice the recommended limit. Over 10 million adults drink more than the recommended limit.¹

4.2 Evidence indicates that current levels of alcohol consumption will have a detrimental impact on the long term health of the public. It is predicted that liver disease could overtake stroke and coronary heart disease as a cause of death within the next 10–20 years. It has also been predicted that there could be an additional 8,900 deaths from alcohol by 2019 based on current levels of drinking.3

4.3 A substantial range of medical conditions are affected by alcohol use, as the Table 1 in the appendix demonstrates. Evidence also shows the risk of liver disease increases three times if a person drinks three units a day and seven times if a person drinks six units a day.4 The risk of developing hypertension is increased by 26%5 by consuming one drink a day, whilst two drinks a day can increase the risk of developing diabetes by 82%.6

4.4 It is also important to note that alcohol misuse is a major contributor to health inequality. In the most deprived areas of the UK, men are five times more likely and women three times more likely to die an alcohol-related death than those in the least deprived areas.7 Alcohol consumption has an inverse social gradient; people with lower socioeconomic status are more likely to have problematic drinking patterns and dependence.8

4.5 Furthermore, hospital admissions for alcohol-specific conditions are associated with increased levels of deprivation across all regions in England. Thus, current levels of alcohol consumption will in the longer term contribute to poorer health and greater health inequalities.

5.0 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

5.1 The Alcohol Strategy recognises that there are a significant number of adults drinking over and above the recommended guidelines. It sets out measures to support individuals to change their alcohol consumption through the provision of screening and subsequent brief advice within the NHS Health Check for adults aged 40 to 75 and a review the alcohol guidelines for adults. The Department of Health will also consider the recently published Screening and Intervention Programme for Sensible Drinking (SIPS) research to see if it can support further action by GPs on alcohol misuse via the Quality and Outcomes Framework.

5.2 Lundbeck welcomes the inclusion of these measures in the Alcohol Strategy. Screening and early intervention are vital tools in helping individuals change their behavior, along with identifying those with alcohol dependence.

5.3 Lundbeck’s view is that as the number of people being screened for alcohol misuse increases, through measures such as the NHS Health Check, local commissioners will need to ensure that appropriate treatment and support for alcohol problems are made available. Currently, access to alcohol services is limited, only one in 18 (less than 6%) of dependent drinkers receives treatment. Over 70% of GPs said there was a shortage of detoxification and rehabilitation services. Tackling alcohol harm will require investment in alcohol services. Alcohol Concern has recommended at least 15% of dependent drinkers should be able to access treatment. Furthermore, alcohol interventions have been proven to be cost-effective; screening and brief interventions in general practice will save £58,000 for every 1,000 patients screened.

6.0 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 Health and Social Care Act reforms to the NHS and public health systems will create a number of challenges and opportunities for producing an integrated approach to the future planning of alcohol services.

6.2 Firstly, the coordinated approach in the NHS and Public Health Outcomes Framework and the Commissioning Outcomes Framework on alcohol misuse provides an incentive to integrate the commissioning of alcohol services. The frameworks include indicators on alcohol-related hospital admissions and the under 75 mortality rate from liver disease, and will therefore require local authorities, clinical commissioning groups (CCGs) and the NHS Commissioning Board to focus on reducing alcohol harm. However, a coordinated approach also raises the question of who is ultimately responsible for reducing alcohol harm—is it local authorities, the NHS Commissioning Board or CCGs?

6.3 Secondly, the Health and Social Care Act will entail the fragmentation of commissioning and funding arrangements for alcohol services. Directors of Public Health in local authorities will become responsible for commissioning of alcohol services from their public health budgets. CCGs will provide treatment for the physical complications of alcohol misuse, such as liver or kidney disease. As well as potentially being commissioned by Directors of Public Health to under additional activities on alcohol misuse. At the same time, Public Health England will take responsibility for national awareness campaigns and building up an evidence base on public health interventions. There is a real risk that the involvement of these different bodies in alcohol services could result in an uncoordinated approach, with some services or patients with alcohol misuse or dependence falling through the gaps.

6.4 Furthermore, multiple commissioners and bodies in the area of alcohol misuse may lead to uncertainty as to who is responsible for commissioning a service. For example, with Directors of Public Health responsible for public health budgets, clinical commissioning groups may take the view that Directors of Public Health are responsible for alcohol services, and that they do not require to take action on alcohol misuse. However, it is vital that GPs also invest resources and time in identifying and treating alcohol problems.

6.5 Thirdly, it will be the role of Health and Wellbeing Boards to ensure to integration across public health services and the local NHS services, based on local health needs established in the Joint Strategic Needs Assessment. However, a number of challenges have been identified with Health and Wellbeing Boards. The Kings Fund has found that board members will need time and resources to develop their skills to effectively fulfill their function.9 Additionally, there will be considerable variations in the remit of the Boards, as local authorities will have discretion over setting up the Boards.

6.6 Finally, an estimated 85% of people with alcohol dependence also have a mental health problem, known as a dual diagnosis.10 Heavy drinkers may also misuse illegal drugs.11 Therefore it is vital that the Government’s alcohol and drug strategies are coordinated to ensure a coherent approach to all people with alcohol misuse and dependence problems. Local commissioners also need to work with alcohol, drug and mental health services to ensure services provide an appropriate and coherent care pathway to meet the needs of local people.

May 2012

APPENDIX

Table 1

ALCOHOL USE AND PHYSICAL COMPLICATIONS

Gastrointestinal	Liver disease, including alcohol-related fatty liver, alcoholic hepatitis, alcohol-related cirrhosis and multiple complications of cirrhosis and portal hypertension Liver cell cancer—hepatocellular carcinoma Parotid enlargement Gastro-oesophageal reflux Peptic ulcer, gastritis, duodenitis Oesophageal rupture from violent vomiting bouts Small bowel damage leading to malabsorption Altered bowel habit with diarrhoea predominating
Cardiovascular	Hypertension High output cardiac failure Acute rhythm disturbances in alcohol intoxication Coronary artery disease
Neurological	Cortical atrophy Cerebellar damage (midline structures maximally affected) Peripheral neuropathy Autonomic neuropathy Wernicke’s encephalopathy Wernicke-Korsakoff syndrome Central pontine myelinolysis Marchiafava-Bignami syndrome Myopathy Cerebrovascular accidents Withdrawal delirium and neuronal damage
Musculoskeletal	Rhabdomylosis Compartment syndromes Gout Osteopaenia Osteonecrosis
Hematological	Thrombocytopaenia from bone marrow suppression Pancytopaenia from hypersplenism Haemolytic anaemia with advanced liver disease—spur cell anaemia Macrocytic anaemia Folate and B12 deficiency anaemias Coagulopathies from liver disease
Immunological	Impaired B and T cell function mediated by alcohol toxicity Autoimmune phenomena triggered by acetaldehyde adducts acting as immunogenic targets IgA nephropathy
Respiratory	Increased predisposition to respiratory infection TB as a common infection Aspiration pneumonia Sleep apnoea
Endocrine	Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Altered thyroid function Altered oestrogen metabolism associated with liver damage Masculinisation in women Pseudo Cushing’s disease Altered calcium and bone metabolism Hypoglycaemia Aggravation of diabetes mellitus Ketoacidosis Hypertriglyceridaemia Testicular atrophy Hypoparathyroidism
Renal	IgA nephropathy
Infectious diseases	Hepatitis C virus Pneumonia Tuberculosis Sexually transmitted diseases
Nutritional disorders	Vitamin and mineral deficiencies; B1, B6, riboflavin, niacin, calcium, phosphate, zinc, magnesium Protein calorie malnutrition
Alcohol and malignancy	The risk of developing certain malignancies increases from base risk levels with any alcohol consumption. These include breast, oropharyngeal and oesophageal cancers. Other malignancies such as colon, pancreatic, hepatic and ovarian are more prevalent in those drinking more than 40 gm per day.

Source: Australian Government Department of Health and Ageing (2009): Guidelines for the Treatment of Alcohol Problems, p146–147