Health CommitteeWritten evidence from Alcohol Health Alliance UK (GAS 27)

About the Alcohol Health Alliance UK

The Alcohol Health Alliance UK (AHA) is a group of 31 organisations whose mission is to reduce the damage caused to health by alcohol misuse. The Alcohol Health Alliance works together to:

Highlight the rising levels of alcohol-related health harm.

Propose evidence-based solutions to reduce this harm.

Influence decision makers to take positive action to address the damage caused by alcohol misuse.

While coalitions have previously been formed on specific topics in the medical field, notably tobacco control, this is the first time a group has existed specifically to co-ordinate campaigning on alcohol, which brings together medical bodies, patient representatives and alcohol health campaigners.

Members of the Alliance

Academy of Medical Royal Colleges, Action on Addiction, Alcohol and Health Research Trust, Alcohol Concern, Alcohol Focus Scotland, Balance North East, British Association for the Study of the Liver, British Liver Trust, British Medical Association, British Society of Gastroenterology, College of Emergency Medicine, Drink Wise North West, Faculty of Dental Surgery, Faculty of Occupational Medicine, Faculty of Public Health, Institute of Alcohol Studies, Medical Council on Alcohol, National Addiction Centre, National Heart Forum, National Organisation for Foetal Alcohol Syndrome, Royal College of Anaesthetists, Royal College of General Practitioners, Royal College of Nursing, Royal College of Physicians Edinburgh, Royal College of Physicians London, Royal College of Physicians and Surgeons, Glasgow, Royal College of Psychiatrists, Royal College of Surgeons of England, Royal Pharmaceutical Society, Royal Society for Public Health, Scottish Health Action on Alcohol Problems, Scottish Intercollegiate Group on Alcohol.

1. Summary

The AHA welcomes The Government’s Alcohol Strategy (2012) and its acknowledgement of the harms associated with current levels of alcohol consumption in England.

A number of issues need to be addressed at the same time to successfully reduce the negative health and social impacts of alcohol. The most effective interventions address price, availability and marketing of alcohol, and should be coupled with efforts in early identification and ongoing treatment of both acute and chronic alcohol-attributable health harms.

The strategy makes clear commitments to address areas such as pricing and licensing. The AHA particularly applauds the proposal of a minimum unit price for alcohol, and the recognition that affordability is a major factor in driving levels of excessive consumption and associated health harms.

However the strategy’s commitments in other areas are weaker, particularly in relation to restricting alcohol marketing and investing in a range of patient-focused treatment services. The ongoing involvement of the alcohol industry in public health campaigns is also an area of concern. A lack of action in these areas will hinder the government’s capacity to ensure widespread changes to consumption and its health and social consequences.

The strategy proposes interventions for specific groups within the English population, including offenders and young people who binge drink. While the AHA welcomes these measures, we are concerned about the lack of actions and investment to address the significant proportion of the population who regularly drink at or above published guidelines over a sustained period of time, which can lead or contribute to a range of chronic illnesses.

A strong national framework, underpinned by effective governance, quality research and evaluation, will be essential in supporting local authorities and clinical commissioning groups to deliver effective services for their communities in the new public health system.

2. Overall response to The Government’s Alcohol Strategy

2.1 The growing costs to individuals and society of excessive alcohol consumption are well documented. Alcohol is a factor in over 40 serious medical conditions, is a contributing factor in accidents, violence, self-harm and sexual assault, and recent analysis indicated 3% of all deaths in the UK in 2005 were attributed to alcohol consumption.(1) In 200910 there were 1.1 million alcohol related admissions to hospital in England, more than twice as many as in 2002–03.(2) 2003 estimates indicated that the annual cost of health, crime and employment problems caused by alcohol consumption at around £20 billion a year, and there strong evidence that these costs are continuing to rise.(3)

2.2 The AHA welcomes The Government’s Alcohol Strategy (“the strategy”) as an important step forward in addressing the negative impacts of alcohol consumption in England. For the first time we are seeing clear government acknowledgement that there is a need to reduce consumption in order to tackle the negative impacts of alcohol on public health and social disorder.

2.3 While we welcome the intent of the strategy, the AHA is concerned about the absence of specific targets and timeframes for achieving changes in consumption, violent crime and incidence of alcohol-related chronic conditions.

2.4 The strategy focuses on the effects of young people binge drinking, and the social disorder caused by excessive alcohol consumption. The AHA would like to see this focus to be equitably balanced to better acknowledge the long term health harms, including chronic disease and alcohol dependence. There is a large section of the population that is consuming well over the recommended limits, often in their own homes, and storing up problems (and demand for services) for the future.(4), (5)

2.5 Quality research and evaluation will be essential to implementing the strategy’s actions. The AHA welcomes the recent launch of the NIHR School for Public Health Research, and would like to see further commitments to ensure alcohol-related interventions and initiatives have the longitudinal, large-scale and rigorous monitoring and evaluation processes, as well as commissioning independent research, required for national and local bodies to make informed decisions about the most effective ways to allocate resources.

3. Establishing a Minimum Unit Price

3.1 The AHA strongly supports the Government’s commitment to introduce a minimum price on alcohol in England and Wales. This step acknowledges the clear relationship between price and the consumption of alcohol and associated harms, which is supported by substantial and robust evidence and modelling.(4), (6), (7), (8), (9)

3.2 Minimum unit pricing is particularly important in helping to address alcohol consumption’s contribution to chronic disease and will primarily target harmful and hazardous drinkers, with comparatively little impact on the spending of moderate drinkers.8 Evidence shows that it is the cheapest alcohol that is causing high levels of harm—in the UK on average, harmful drinkers buy 15 times more alcohol than moderate drinkers, yet pay 40% less per unit. (10)

3.3 Modelling conducted by the University of Sheffield found that increasing levels of minimum pricing show substantial increases in effectiveness (see Figure 1 below). The AHA supports the introduction of a minimum unit price of at least 50p per unit, which the modelling suggests would reduce total alcohol consumption by 6.7%, saving around 20,000 hospital admissions in the first year and 97,000 a year once the policy has been in place for 10 years. This would result in direct costs saved in relation to health, crime and workplace impacts in England of £7.6 billion over 10 years.(8)

Figure 1

Data taken from University of Sheffield 2009 (8)

3.4 Once it has been implemented it will be essential to establish an effective mechanism for reviewing and adjusting the minimum unit price over time to account for inflation and rising disposable incomes. The AHA recommends this occurs on an annual basis as a minimum. Robust independent evaluation of the impact of the minimum unit price will be essential.

3.5 Further consultation should also be taken on how best to use the additional profits generated by retailers through a minimum unit price, which are estimated at several hundred million pounds. Given the limited investment in alcohol treatment services as previously identified by the Health Select Committee(9) and National Audit Office,11 the AHA would like the government to explore introducing a levy that would see the funds reinvested in specialist alcohol treatment services.

Banning multi-buy discounts

3.6 The strategy also commits to consulting on a ban of multi-buy promotions in the off-trade. The AHA strongly supports this ban. The University of Sheffield modelling shows that increasing restrictions in off-trade discounting (ie through multibuys) does have increasing effects in a similar way to minimum pricing. Restrictions to 40%, 30%, 20% and 10% discounting give estimated consumption changes of −0.1%, −0.3%, −1.6%, −2.8% respectively. A 2.8% reduction in consumption is similar to the change estimated for a 40p minimum price (see Figure 1 above).(8)

3.7 The AHA argues that this ban should be expanded to include multi-buy discounts in the on-trade as well as the off-trade.

4. Addressing Marketing and Advertising

4.1 Evidence shows that exposure to alcohol marketing encourages children to drink at an earlier age and in greater quantities than they otherwise would. The Science Committee of the European Alcohol and Health Forum concluded in 2009 that “alcohol marketing increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol.”(12)

4.2 The Health Select Committee reported in 2010 that the current regulatory framework for alcohol marketing was inadequate. ‘9’ Current controls are intended to limit the exposure of children to alcohol advertising, however clear failures with the controls can be identified. For example, an OFCOM audit of exposure showed that for approximately every five 24 year olds, four 10 year olds saw the same TV alcohol advert—this does not protect children.(13) A study funded by the Medical Research Council showed that in the UK 96% of 13 year olds were aware of alcohol advertising and had, on average, come across it in more than five different media.(9)

4.3 The OFCOM data shows that overall levels of TV advertising are declining, normal advertising comprises only around £250 million of the total £800 million spend—the remainder goes on other forms of marketing such as football sponsorship, promotions, musical festivals and viral and internet promotions where the potential exposure of children is even more problematic.(9)

4.4 While the government’s strategy recognises the link between marketing and consumption, the actions outlined focus on working within the current structures and do not go far enough to curb children’s exposure to alcohol advertising. The evidence above highlights that relying on the Advertising Standards Agency alone is insufficient.

4.5 AHA supports a UK adapted version of Loi Evin. The Loi Evin is a French framework that allows alcohol marketing and promotion in media that is used by adults, but not where a large proportion of children and young people make up the audience. The Loi Evin model provides a simple framework that can offer clarity on what marketing practices can and cannot be implemented whilst ensuring that children and young people are protected from an exposure that poses a risk to their health and wellbeing. It has been upheld in by the European Court of Justice, which found in 2004 that the measure is proportionate, effective, and consistent with the Treaty of Rome.(14)

4.6 Children and young people’s exposure to alcohol marketing should be monitored by an independent body, with no representation within this body from the alcohol industry. This monitoring should be performed systematically and routinely to monitor trends over time. Particular attention should be paid to ensuring that marketing through digital, online and social media is adequately monitored and regulated.

5. The Role of the Alcohol Industry

5.1 The AHA welcomes the acknowledgement in the strategy that “industry needs and commercial advantages have too frequently been prioritised over community concerns”.(15) However the AHA remains concerned that the strategy reinforces existing roles and structures for industry involvement. Evidence indicates that industry self-regulation is not an effective strategy due to industry’s conflicts of interest.(16) The AHA would like to see an immediate commitment to an independent evaluation of the current responsibility deal initiatives.

5.2 The strategy restates the government’s commitment to Drinkaware. While the AHA acknowledges that Drinkaware contributes to raising public awareness about the risks of excessive alcohol consumption, it is important to acknowledge that Drinkaware’s reliance on alcohol industry funding means it has a very specific remit and limited role in a wide-ranging public health strategy.

5.3 In line with WHO recommendations, while we believe business must play a part and have the opportunity to engage with health issues, health experts must lead on setting policy priorities.(17) Although businesses have a role to play in protecting and promoting the health and wellbeing of their employees and the wider community, and implementing and supporting public health initiatives it is not the place or responsibility of business to define public health policy or to be responsible for public health information, as in many cases this is in direct conflict with their interests and responsibilities to their shareholders and employees.

5.4 To address this conflict of interest the AHA recommends that industry contributes to funding for public health initiatives via a truly independent charity or blind trust, constituted as a grant-giving foundation to support bodies operating for the public good with a track record of reducing alcohol harm, without involvement from industry representatives. All programmes and policies should be subject to proactive monitoring and independent evaluation, including those with private investment.

6. Greater Investment in Effective Interventions

6.1 There is a clear need to provide care for a large and growing group of patients with alcohol-related health problems. Presently a lack of coordinated action means that care is imperfect and spending is poorly targeted and ineffective, very few hospitals have dedicated alcohol services and only 5.7% of dependent or harmful drinkers access treatment, compared to 67% of dependent or harmful drug users.(19)

6.2 The strategy proposes interventions for specific groups within the English population, including offenders and young people who binge drink. While the AHA welcome these measures, we are concerned by the lack of actions and investment to address the significant proportion of the population who regularly drink at or above published guidelines over a long period of time, which can lead to or contribute to a range of chronic health conditions.

6.3 The strategy raises a number of health risks such as foetal alcohol spectrum disorders and mental illness, along with highlighting the value of early identification and treatment of alcohol disorders. A comprehensive system of care is required to successfully address the wide spectrum of health harms, however the strategy fails to provide any specific actions or funding in these areas.

6.4 The AHA is calling for the full implementation of the NICE guidelines relating to alcohol dependence, which provide an excellent, evidenced-based guide to effective intervention, treatment and referral systems that involve a wide range of health professionals.(4), (5) In particular the AHA would like to see additional support and funding for:

Early diagnosis and treatment of alcohol use disorders

6.5 A wealth of evidence shows that early interventions are both effective and cost effective. ‘4,5,18,20’ An extra £217 million invested in alcohol services—double the current level—would bring about an annual saving of £1.7 billion for the NHS in England.(21)

6.6 The NICE Guidance on alcohol use disorders states that primary prevention of alcohol-related harm at primary care level is both effective and cost effective.(4) This should be incentivised through including a measure in the Quality and Outcomes Framework for GPs to record the alcohol intake of their patients and to give brief advice where indicated. For patients who do not respond to simple advice there should be a stepped programme of further intervention.

6.7 Cost effective treatment interventions for alcohol dependence have been described in NICE guidelines(5) but are currently available only to a small proportion of those who could benefit from it. This will require sustained investment in specialist alcohol services to achieve parity for services for drug misusers.

Secondary care services

6.8 Healthcare modelling methodology suggests that if each district general hospital established a seven day Alcohol Specialist Nurse Service to care for patients admitted for less than one day and an Assertive Outreach Alcohol Service to care for frequent hospital attendees and long-stay patients, it could result in a 5% reduction in alcohol-related hospital admissions, with potential cost savings to its locality of £1.6 million per annum. This would equate to savings of £393 million per annum if rolled out nationally.(18)

6.9 The AHA recommends that there should be a multidisciplinary “Alcohol Care Team”, a 7 day Alcohol Specialist Nurse Service and an “Assertive Outreach Alcohol Service” in every District Hospital. Transitions between teams and services should be quick and seamless in order to increase the efficiency and cost effectiveness of the service.(18)

7. The Changing Public Health System

7.1 The AHA believes there is potential to work more closely with local authorities to drive change and innovation, and deliver services targeted to the needs of local communities. However, with the changes to the public health system come risks that must be mitigated. These include: unjustifiable variation, piecemeal and fragmented service provision, an absence of quality evaluation metrics, and a lack of information sharing and best practice. The AHA are keen to work with central and local government to identify mechanisms that deliver on the localism agenda, whilst protecting the need for coordinated, integrated and evidence-based policy-making and service delivery.

7.2 A national service framework on alcohol, which could be adapted to local needs, would be an effective way of keeping costs down, sharing best practice and getting the best value for money. A framework could be led by a dedicated alcohol team within Public Health England, with established experts leading the research work at the highest level, setting out principles for action, rather than prescriptive plans. This allows for local areas to develop plans to meet local needs with the backing of expertise and knowledge provided by PHE.

7.3 Leaving it to each individual council to decide on priorities may result in some choosing to ignore alcohol harm, even where significant problems exist. There must be robust measures for holding local authorities accountable for these decisions. The AHA recommends that an expert, influential and independent Director of Public Health—supported by robust data analysis and outcome monitoring systems—will be essential.

7.4 Likewise, the NHS Commissioning Board should provide local commissioning groups with guidance on the best practice for commissioning comprehensive alcohol treatment services, based on the NICE guidance and the forthcoming quality standard on alcohol dependence. They must hold clinical commissioning groups to account on their performance against a set of indicators relating to alcohol treatment services, linking to the shared mortality improvement area to reduce the under 75 mortality rate for liver disease in the NHS Outcomes Framework.

8. Measures to Reduce Drink Driving

8.1 The AHA is concerned that there is no mention of measures to reduce drink driving in the strategy. Despite a substantial decline in levels of drinking and driving in Great Britain since the 1980s, drivers drinking alcohol still kill and injure scores of people each year. In 2009 there were 11,990 reported casualties involving drivers over the legal limit (5% of all road casualties) and an estimated 380 people killed in drink drive accidents (17% of all road fatalities).(22)

8.2 The AHA fully supports the recommendations of the 2010 North Review into the Drink and Drug Driving law. In particular, the AHA calls for the present drink drive blood alcohol content limit to be lowered from 80mg% to 50mg%, and giving police unrestricted power to require anyone driving a vehicle on the public highway to give a preliminary breath test.(23)

9. Coordination of Alcohol Policy

9.1 Policies relating to alcohol fall under a broad range of governmental departments, including the Home Office, the Department of Health, the Treasury, the Departments of Culture, Media and Sport, Transport, Communities and Local Government and the Ministry of Justice. There is therefore a particularly strong case for a cross-departmental unit on alcohol, and the AHA suggests that such a unit could be led by the Chief Medical Officer—reporting to the Home Affairs (Public Health) Cabinet Sub-committee. A cross governmental alcohol unit could maximise the impact of the different strands of the government’s strategy and ensure there is rigorous evaluation applied to all aspects of the strategy.

9.2 A cross governmental alcohol unit would also be well placed to coordinate policy with the devolved administrations. Greater consistency around policies relating to the price, availability and promotion of alcohol will be important in ensuring success across the UK. In particular, efforts to introduce a minimum unit price on alcohol are already well underway in Scotland and under discussion in Northern Ireland—therefore it is important that the timeframes for introducing a minimum unit price in England and Wales aligns as closely as possible with the devolved administrations.

References

(1) Jones L, Bellis M A, Dedman D, Sumnall H & Tocque K. Alcohol-attributable fractions for England: alcohol-attributable mortality and hospital admissions. NorthWest Public Health Observatory, 2009.

(2) The NHS Information Centre. Statistics on Alcohol: England, 2011. London, NHS Information Centre, 2011.

(3) Meier P. Independent review of the effects of alcohol pricing and promotion: Part A: systematic reviews. University of Sheffield, 2008.

(4) National Institute for Health and Clinical Excellence. Alcohol-use Disorders: Preventing the Development of Hazardous and Harmful Drinking: PH24. London: NICE, 2010.

(5) National Institute for Health and Clinical Excellence. Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. Clinical Guideline 115. London: NICE, 2011.

(6) WHO Expert Committee on Problems Related to Alcohol Consumption. Second report/WHO Expert Committee on Problems Related to Alcohol Consumption. WHO technical report series; no. 944. Geneva: World Health Organization, 2007.

(7) Wagenaar A C, Salois M J, Komro K A. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 2009; 104: 179–90.

(8) Purhouse, R et al, 2009. Modelling to assess the effectiveness and cost-effectiveness of public health related strategies and interventions to reduce alcohol attributable harm in England using the Sheffield Alcohol Policy Model version 2.0. Report to the NICE Public Health Programme Development Group.

(9) Health Committee, First Report of Session 2009–10, Alcohol, House of Commons 151-I, 2010.

(10) Meier P S, Purhouse R and Brennan A. Policy options for alcohol price regulation: response to the commentaries, Addiction, 2010, 105: 400–401.

(11) National Audit Office. Reducing Alcohol Harm: Health services in England for alcohol misuse. NAO, London, 2008.

(12) Anderson P, C. D. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet, 2009: 373:2234–46.

(13) Ofcom, ASA, Neilson Media. Young People and Alcohol Advertising: An investigation of alcohol advertising following changes to the Advertising Code, 2006.

(14) Commission of the European Communities v French Republic, Case C-262/02, Court of Justice of the European Communities, March 11, 2004.

(15) Home Office, The Government’s Alcohol Strategy. 2012:3.

(16) KPMG. Review of the Social Responsibility Standards for the production and sale of Alcoholic Drinks. Home Office, 2008.

(17) World Health Organization. The World Health Report 2002: reducing risks, promoting healthy life. Geneva: WHO, 2002.

(18) The British Society of Gastroenterology and the Royal Bolton Hospital NHS Foundation Trust. Alcohol Care Teams: to reduce acute hospital admissions and improve quality of care. London:NHS Evidence, 2011.

(19) Department of Health. Alcohol needs assessment research project (ANARP). London:Department of Health, 2004.

(20) British Liver Trust. Reducing Alcohol Harm—recovery and informed choice for those with alcohol related health problems. BLT, 2012.

(21) Alcohol Concern. Making Alcohol a health priority. London: Alcohol Concern, 2011.

(22) Department for Transport. Reported Road Casualties Great Britain. DoT, 2009.

(23) North, S P. Report of the Review of Drink and Drug Driving Law. DoT, 2010.

May 2012

Prepared 19th July 2012