3 Policy Response |
OBJECTIVES AND TARGETS
22. The Committee believes it
is important to ensure that the objectives of policy on alcohol
are clearly stated and calibrated. The great majority of citizens
enjoy alcohol without significant evidence of harm to their health.
The Committee accepts that it is not possible to define a level
of alcohol consumption which is, in any absolute sense, safe for
all citizens at all times. We do not believe, however, that this
conclusion should lead to disproportionate or heavy handed controls
which are justified neither by public support nor evidence of
proportionate health gain.
23. The Committee also believes
that healthy societies expect all citizens, both corporate and
individual, to exercise their individual freedoms in ways which
respect the rights and interests of their fellow citizens and
observe shared standards of responsible behaviour. It is part
of the function of Government to stimulate, lead and if necessary
regulate, in order to encourage the development of this culture.
24. Against this background the Committee believes
it is important for policy to be guided by objectives which are
clearly stated and defined. The Strategy outlines a series of
outcomes that the Government wishes to bring about:
Our ambition is clear - we will radically reshape
the approach to alcohol and reduce the number of people drinking
to excess. The outcomes we want to see are:
- A change in behaviour so that
people think it is not acceptable to drink in ways that could
cause harm to themselves or others;
- A reduction in the amount of alcohol-fuelled
- A reduction in the number of adults drinking
above the NHS guidelines5;
- A reduction in the number of people "binge
- A reduction in the number of alcohol-related
- A sustained reduction in both the numbers of
11-15 year olds drinking alcohol and the amounts consumed.
25. There are, however, no specific targets or
measurements to say how the Government will judge the success
of the strategy. The Alcohol Health Alliance noted its concern
"about the absence of specific targets and timeframes for
achieving changes in consumption, violent crime and incidence
of alcohol-related chronic conditions".
This contrasts with the example of Birmingham's local strategy
that we looked at in evidence, which had some quite specific measures:
In order to achieve this overall vision we have set
three key outcomes. These will direct all our work and activity
will only be taken forward if it will impact upon them. The outcomes
we will be seeking to achieve are:
- Increased healthy life expectancy
and reduced differences in life expectancy and healthy life expectancy
- Reduction in alcohol related crime and disorder
and perception of crime and disorder;
- Reduction in the adverse impact of alcohol on
families and the wider community
Key Performance Indicators
To measure our overall progress towards achieving
these outcomes we have set three key performance indicators. These
indicators are linked, as closely as available data allows, to
- Stabilisation of the rate of
alcohol-related hospital admissions by reducing the rate of increase
by 2% year-on-year;
- Reduction in alcohol related crime and disorder
by 10% by end of strategy period;
- Reduction in the loss of months of life lost
due to alcohol by 10% by end of strategy period.
26. On the question of targets, the Minister
We have a public health outcomes framework out at
the moment with two highlevel objectives and looking at
a number of public health issues in four domains. We will be developing
that and are consulting on specific objectives and highlevel
outcomes as we go along. But, essentially, the money given to
local areas on public health in the light of the strategy will
be against the public health outcomes framework.
27. We believe that in order for the alcohol
strategy to be effective it needs to have quantified objectives.
The Minister said that the public health outcomes framework would
provide these objectives, but that framework is very broad and
only one of the more than 60 indicators contained within it is
entirely alcohol related (alcohol-related hospital admissions).
The Committee believes that an Alcohol Strategy should be seen
as part of a wider public health strategy, and should contain
some key quantified, alcohol-specific objectives which will provide
both a framework for policy judgements and an accountability framework.
28. We address later in the
report the issue of all local areas having an alcohol strategy,
flowing from the national strategy but using local approaches
to deal with local problems. It seems logical that Public Health
England should oversee this process, given its overarching responsibility
for public health matters. It also seems logical that Public Health
England should devise the national measures against which the
strategy can be tested.
WHAT IS 'SAFE'?
29. If the objective is to allow consumers to
make "informed choices", the question "what is
safe?" is fundamental. Professor Sir Ian Gilmore, special
adviser to the Royal College of Physicians on alcohol and Chair
of the Alcohol Health Alliance, told us:
There are great difficulties and this is the nub
of the problem of the health messages to the general public. Everyone
is different and probably responds differently to alcohol. If
you take 100 very heavy drinkers the majority will never get cirrhosis
of the liver, but we cannot yet tell you which group you fall
into. There are those individual differences. Then there is the
fact that for different diseases the threshold is very different.
If you stick within socalled safe limits then there are
certain diseases you are virtually guaranteed not to get, whereas
there are other conditions, like some forms of cancer, where drinking
well below safe recommended limits will significantly increase
your risks. I am afraid that, at the moment, you cannot generalise
and say you will be totally safe if you stick to such and such
a level. But I do welcome the recommendation in the strategy that
guideline advice is revisited. It should be possible to personalise
that more than we have at present and to try to get round some
of the understandable confusion in the general public.
30. Eric Appleby, of Alcohol Concern, told us:
It seems to me that one of the problems we have is
that we are not very good at talking about alcohol. At one end
it is a bit of a joke: going down the pub and getting drunk is
comfortable and jokey. At the other end, talking about real problems
is almost a taboo subject. In between we are not very good at
having that conversation about the dichotomy, if you like, that
alcohol is quite enjoyable and we like it but it also carries
harms. Having this conversation about managing risk is something
we just do not do, and people tend not to want to do. It is instigating
that conversation which is to some extent what is needed.
31. The Committee also heard that the message
about sensible levels of drinking had been confused. Eric Appleby
We have what were originally called "Sensible
drinking guidelines", which, when they were framed, were
relatively straightforward, but the world has changed since thenthe
strength of drinks, the size of servings, and all that. It is
now very confusing for people. The strategy talks about reviewing
those. The important thing is reviewing how we communicate them,
because I think you will find that the science has not changed
very much. It is about how you communicate that and how you can
get the message across to people of the true nature of the issue.
It is a very loaded subject. Nobody wants to be told that they
should drink less than they are currently drinking. We have this
spectrum between, at one end, a sort of fatalism about drinking,
"You cannot do anything about it. People drink. It just happens"
and a denial at the other end, "Yes, I have my bottle of
wine with a meal every night. I do not get drunk. I do not cause
anyone any problems. There is nothing wrong with that," except
20 years down the line when you end up in one of Ian's hospital
32. As the Strategy notes, the Government launched
a campaign earlier this year to communicate the health harms of
drinking above the lower risk guidelines and provide a range of
tips and tools to encourage people to drink responsibly.
It also says that "we will ask Dame Sally Davies, the UK
Government's Chief Medical Officer, to oversee a review of the
alcohol guidelines for adults. This will also take account of
available science on how we can best communicate the risks from
alcohol, improving the public's understanding of both personal
risks and societal harms".
33. There is clearly a need for such educational
measures. The Royal Geographical Society (RGS) quoted evidence
very few people acknowledge the use of 'units' as
a way of either measuring, and hence controlling, their own levels
of drunkenness, or of monitoring the health impacts of alcohol
consumption. In a survey of drinkers in urban Stoke-on-Trent and
rural Eden, Cumbria, not one single person surveyed said that
they used units in their day to day life and that measuring 'units'
simply did not work. However what the study did find was that
people tend to consider the impact of drinking on their health
in terms of how they felt, with their level of drunkenness determined
by a number of factors including their mood, food intake, level
of tiredness, and their own personal (often changing) tolerance
The conclusions is that a whole range of factors,
including cultural norms and peer pressure, are what are important
in determining what, and how much, people drink. This suggests
the use of 'units' in alcohol policy may not resonate as a useful
public health tool: first, 'units' do not always correlate to
the actual negative health effects of alcohol on our bodies; second,
under current government guidance, a majority of drinkers are
being classified officially as 'bingers'. In practice, however,
these same drinkers may experience little or no harmful (immediate)
health issues because of their alcohol consumption.
34. The RGS also noted "that in the UK people
have tended not to worry about their consumption, even when reporting
excess consumption... evidence shows that the amount of alcohol
consumed reported in surveys is considerably (about one third)
less than that sold".
35. The Minister agreed that there were problems
with the guidelines:
I think that public understanding of units is quite
poor. In fact, there has been quite a lot of voluntary work from
some of the producers and supermarkets on units. Most people look
at how much alcohol they drink by the number of glasses they drink
and glasses are very large now. They can hold a lot more units
than they used to when I was younger. The [Chief Medical Officer]
is reviewing the guidelines across the piece and that will be
important. It is a recognised thing. Scientists and Government
can use units but what we have to do is get across messages that
are easy for people to understand. It is about the messaging more
than whether the unit itself is a useless thing.
36. Although we accept that
it is a complicated issue, we regard a clearer, evidence-based
definition of the health effects of alcohol consumption as fundamental
to successful policy development in this area. The work of the
Chief Medical Officer needs to be carried forward as a matter
of urgency. Public Health England, acting independently of Government,
then needs to use the outcome of the review as the basis for its
promotion of public understanding of the issues, setting out the
level at which harms are likely to result alongside sensible drinking
37. The strategy highlights the public order
and related issues concerning binge drinking, but there are clearly
health issues which also need to be addressed. As the Department
due to single, heavy drinking episodes ('binge drinking') has
been shown to have a number of health and social consequences
on the drinker and/or on other people, such as:
- Injuries, for example from
- Violence and aggression, including alcohol-related
crime and disorder and domestic violence increase with drunkenness
and with heavier drinking in general. If the heavy drinker is
a parent, this can contribute to a variety of childhood mental
and behavioural disorders. Systematic reviews have suggested that
alcohol is a contributory factor in 16% of child abuse cases.
- Increased risk of stroke, heart arrhythmias,
and sudden coronary death, even in people with no evidence of
pre-existing heart disease - any protective effect of regular,
moderate consumption may be lost through binge drinking, even
if this is infrequent.
- Harming home life or marriage
- Damaging work performance
- Limiting young people's educational attainment
38. Chris Sorek of Drinkaware noted changes in
attitudes to excessive drinking:
during my first time in the United Kingdom in the
late 1970s and early 1980swhen I was working heregoing
out and getting drunk, at that age, was seen as losing face. People
would think less of you. That has changed and there has been a
39. The London Health Improvement Board told
Heavy binge drinking by adolescents and young adults
is associated with increased long-term risk for heart disease,
high blood pressure, type 2 diabetes, and other metabolic disorders.
A UK study found that binge drinking in adolescence was associated
with increased risk of health, social, educational and economic
adversity continuing into later adult life. The problems included
increased risk of alcohol dependence and harmful drinking in adulthood,
illicit drug use, poorer educational outcomes, criminal convictions
and lower socioeconomic status.
40. Despite some perceptions
that binge drinking is largely a public order issue, the evidence
presented to us suggests that it does contribute to some of the
long-term health harms that have concerned us. We conclude that
these health problems need to be addressed no less urgently than
problems with public order and anti-social behaviour.
MINIMUM UNIT PRICE
41. In the Strategy, the Government notes measures
already taken on price to address what it calls the 'heavily discounted'
price of alcohol:
- Raising alcohol duty by 2%
above retail inflation (RPI) each year to 2014-15;
- Introducing a 'minimum juice' rule for cider,
so that high strength white ciders can no longer qualify for the
lower rates of duty that apply to cider; and
- Introducing a new higher rate of duty for high
strength beer over 7.5% Alcohol By Volume (ABV) and a new lower
rate of duty for beer at 2.8% ABV and below to align duty more
closely to alcohol strength.
42. The Government notes, however, that
as there is such a strong link between price and
consumption, we need to go further still to end the irresponsible
promotion and discounting of alcohol.... We will introduce a minimum
unit price (MUP) for alcohol meaning that, for the first time
ever in England and Wales, alcohol will not be allowed to be sold
below a certain defined price. We will consult on the level in
the coming months with a view to introducing legislation as soon
No figure is suggested for the minimum price in the
body of the Strategy, but the Prime Minister, in his introduction,
says "if [the minimum price] is 40p that could mean 50,000
fewer crimes each year and 900 fewer alcohol-related deaths a
year by the end of the decade."
43. Written evidence to the Committee reveals
a clear divide on this issue between industry and health bodies.
For example, the Wine and Spirit Trade Association is outspoken
on price, saying that:
The WSTA is opposed to a policy of minimum unit pricing
both in principle and in practice. There is no evidence to prove
that it will tackle alcohol misuse yet it will raise prices for
consumers who do not have a problem with alcohol. A 40p minimum
unit price will hit the poorest 30% of households in England and
Wales the hardest... It is inconsistent with the operation of
the free market for the state to intervene on price. Minimum pricing
could therefore represent a barrier to trade and be illegal under
44. The question of the legality under European
law of a minimum unit price was also raised by the Office of Fair
... it is...important to distinguish between the
current proposal for a statutory minimum price unilaterally imposed
by Government, and the alternative of a voluntary agreement between
retailers to agree prices (with or without Government encouragement).
A voluntary agreement on price would almost certainly infringe
[The Competition Act 1998] and European competition law.
There may be constraints on minimum pricing legislation
arising from wider European law. For example, minimum pricing
legislation may raise issues of compatibility with European free
movement rules. The OFT does not have jurisdiction over these
areas of law - enforcement takes place at the European level.
The OFT understands that this is currently a live issue in relation
to proposals for minimum alcohol in Scotland, and it is possible
that there may be legal action which would clarify the position.
45. In its written evidence the Department told
There are a number of issues to consider when implementing
minimum unit pricing. The Government continues to take legal advice
and will consider any potential legal implications as we take
forward this proposal and consult on a proposed level of minimum
46. The British Beer and Pub Association (BBPA)
in its memorandum notes that "The BBPA's membership has a
range of views on the subject of minimum pricing", but overall
expresses a cautious view:
Whilst there is clearly a relationship between alcohol
pricing and alcohol consumption, evidence of a link between pricing
and harmful consumption is less well established. Are the heaviest
drinkers affected by increased prices? The Sheffield study, in
line with most international evidence, found that the heaviest
drinkers are least responsive to changes in price.
The BBPA believes that it is important that alcohol
should be retailed in a manner that is socially responsible and
supports a ban on below-cost selling...Whilst minimum pricing
might cut the differential between the price of beer in a supermarket
or pub, it must not be seen as the answer to pub closures which
are clearly down to high taxation. Minimum pricing is, by definition,
a blunt tool and clearly the higher the minimum price the greater
the impact on the vast majority who enjoy alcohol responsibly;
particularly those on the lowest incomes.
Not all of the industry is opposed to minimum unit
pricing, however. In evidence to us both Greene King
and Waitrose strongly
supported its introduction.
47. Professor Brennan's explanation of his research
did not support the BBPA interpretation of his group's findings
on the effects of price:
The key advantage of minimum pricing, from a targeting
perspective, is that it is, in the data, the harmful drinkers
who tend to drink more of the cheaper alcohol. Compared to putting
general prices or general taxes up, putting a minimum price means
that it is the harmful drinkers who are disproportionately affected
by the policy. Those are the kinds of analyses that we have done.
48. Alcohol Health Alliance UK says that:
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...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.
49. Canada already has a minimum price for alcohol,
so we asked about the evidence of its effects there. Professor
Brennan told us:
Canada has had a minimum pricing policy for quite
some time and its differential in different states has changed
at different time points. It is quite clear that when they have
changed their minimum price there has been a direct impact on
consumption. Once they have had this policy for a while and they
ratchet it up a little bit, or put it down, consumption follows
quite quickly in terms of decreases and increases.
50. Given the policy commitment to introduce
a minimum price, it is the level at which it should be set that
was the subject of greatest discussion in evidence. Most of those
giving evidence to the Committee who commented on price argued
in favour of a minimum unit price of more than the 40 pence
mentioned in the Prime Minister's forward to the strategy (although
there is no statement of the anticipated level of the unit price
in the document itself).
51. The Scottish Government announced on 14 May
that it is proposing to introduce a minimum unit price of 50 pence.
The Scottish Health Minister, Nicola Sturgeon MSP, said that
We have a big package of measures that are addressing
the problems Scotland has with alcohol misuse so minimum pricing
is by no means the only part of the solution, it's not a magic
bullet... But there is plenty of evidence that says unless you
have a pricing mechanism at the heart of the package of measures,
then that package of measures is not going to be as effective
as it would otherwise be.
52. The Scottish Parliament Bill which establishes
a minimum price per unit provides that the power to set a minimum
price will expire after six years unless the Scottish Ministers
bring forward an order to continue it, which they may only do
in the sixth year (the so-called "sunset clause").
53. The Minister told us:
I cannot tell you where we are heading [on unit price]
because it would be premature to do so until we are at the end
of [the consultation]... It is important to set it at a level
at which it is effective. That is the thing. We know that alcohol
is, to a greater or lesser extent, price sensitive, so it is important
to have something that is effective. I go back to what I said
earlier, that it has to be evidence based.
54. The Committee welcomes the
Government's decision to introduce a minimum unit price for alcohol.
It is, however, struck
by how little evidence has been presented about the specific effects
anticipated from different levels of minimum unit price. The proposition
that demand for alcohol is relatively price-elastic seems uncontroversial.
Rather than relying on generalised statements about the effect
of price on consumption, the Committee urges the Government to
build its case for a minimum unit price by establishing direct
links: between specific alcohol products and specific alcohol-related
harms; between different levels of minimum unit price and the
resulting selling prices for the products which are linked to
alcohol-related harms; and the likely effect of different levels
of selling prices for those products on demand for those products
in the target range of households.
55. Given the Government's decision
to introduce a minimum unit price, the debate has been about the
level at which it should be set- whether it should be 40, 45 or
50 pence - but the setting of a minimum unit price will not be
a one-off event. Once a minimum price is introduced, if it is
judged to be successful, the level will need to be monitored and
adjusted over time. A mechanism will need to be put in place in
order to do this, but as yet there has been no indication from
the Government of what it intends to do other than to consult
on the price. One way of setting the level would be to establish
an advisory body (there are a number of these already, dealing
with a range of issues)
to analyse evidence and make recommendations to Government. Whatever
mechanism is chosen should be used when setting the initial level
of the minimum unit price to ensure that from the beginning the
price is clearly evidence-based.
56. It has already been announced that the minimum
unit price to be introduced in Scotland will be 50 pence per unit.
There are practical arguments in favour of the same minimum price
being set in England to avoid the problems with cross-jurisdiction
trading that we refer to later when we discuss the case for banning
multi-buy promotions. Our main concern, however, is that the level
of minimum price that is set should be evidence-based and designed
to be effective. If the minimum
unit price in England were to be fixed at a different level to
that in Scotland, we would expect the evidence supporting that
decision to be set out clearly. This is another argument in favour
of establishing a transparent mechanism for setting the price.
57. We recommend that there
should be a "sunset clause" on any provisions for setting
a minimum unit price for alcohol, and that a decision by Government
to make a minimum price permanent should be taken following advice
from the advisory body or other mechanism used to monitor and
adjust the price during the initial period.
58. Throughout this section
of the report we have emphasised the need for the decision on
minimum price to be evidence-based. The debate so far is based
almost entirely on the work of the Sheffield Alcohol Research
Group, though research from Canada has become available more recently.
It is not a criticism of the integrity of that research to say
that, if there is to be a minimum unit price, a more substantial
evidence base needs to be developed in the future to help in the
assessment of whether the minimum unit price is achieving the
59. The Strategy says that:
We will...consult on a ban on multi-buy promotions
in the off-trade (shops) meaning that multiple bottles or cans
could not be sold cheaper than the multiple of one bottle or can.
This would put an end to any alcohol promotion or sale that offers
customers a discount for buying multiple products in stores and
therefore those that encourage and incentivise customers to buy
larger quantities than they want.
60. The Alcohol Health Alliance welcomed this
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
-1.6%, -2.8% respectively. A 2.8% reduction in consumption is
similar to the change estimated for a 40p minimum price.
61. The Advertising Association, representing
the advertising industry, was not convinced. It said:
We do not believe multi-buy alcohol promotions are
inherently irresponsible; consumers are used to such multi-buy
promotions in respect of many different goods and services. The
focus should not be on banning a form of marketing, but rather
on ensuring that all forms of marketing are undertaken in a responsible
manner. We will respond to this consultation when launched by
the Government but in the meantime we urge the Government to ensure
that any proposals are proportionate and evidence-based.
62. A ban on multi-buy promotions came into effect
in Scotland in October 20911. Alcohol Focus Scotland told us that
Experience in Scotland shows that to ensure maximum
effectiveness, the ban on multi-buy discounts should be implemented
alongside minimum pricing and across the UK. A ban on multi-buy
discounts came into force in Scotland on 1st October
2011 with the implementation of the Alcohol etc. (Scotland) Act
2010. During the first weekend of the new legislation being implemented,
a number of the major supermarkets sought to undermine the spirit
of the Act by encouraging online purchasing of alcohol from distribution
centres in England.
Moreover, many of the major supermarkets slashed
their prices when the ban came into effect in Scotland. The Grocer
magazine published figures which showed that whilst supermarket
multi-buys had disappeared, the number of products on price reduction
promotions in the first four weeks following the ban period rocketed
from 753 to 1,178. Whilst legal, these practices call into question
the large supermarkets' claims to be responsible retailers and
reinforce the case for a ban on multi-buy discounts to be introduced
in conjunction with minimum unit pricing.
63. The Minister told us that the consultation
on multi-buy promotions would be on the principle of whether they
should be banned.
When asked if it would cover selling wine by the case. as an example,
she told us: "That is the one representation that I have
already had, whether the newspaper offers, for instance, would
64. This evidence does not convince
us that a ban on multibuys is either desirable or workable. The
proposed minimum unit price will provide a floor price for the
sale of alcohol, including discounted sales. The Committee supports
the principle of setting the minimum unit price at a level which
is effective at reducing identified alcohol-related harm; it believes
that an attempt to outlaw well-established and convenient retailing
techniques for alcohol products, regardless of price level, would
simply create opportunities for retailers to find innovative and
newsworthy work-arounds which would invite ridicule and bring
the wider policy objective into disrepute.
CHALLENGING THE INDUSTRY TO ACT RESPONSIBLY
65. It is an old truth that with freedom comes
responsibility. That is true of freedom of speech as it is of
all other forms of freedom, and it is true of advertisers, as
it is of all other forms of speech.
66. Messages contained in alcohol
advertisements play an important part in forming social attitudes
about alcohol consumption. The Committee believes that those involved
in advertising alcoholic products should accept that their advertisements
contain positive messages about their products and that these
messages are supported by considerable economic power. If this
were not the case it is not clear why shareholders should be content
for their companies' resources to be spent in this way. Since
it is true, however, it is important that the alcohol industry
ensures that its advertisements comply in all respects with the
principles of corporate social responsibility. Closer definition
of these principles as they apply to alcohol advertising is a
key objective of the Government's Responsibility Deal.
67. The Strategy argues that:
We are clear that it is not just the responsibility
of Government or local agencies to tackle the issue of alcohol-related
harm. It is the ethical responsibility of the entire industry
- alcohol retailers, alcohol producers and both the on-trade and
off-trade - to promote, market, advertise and sell their products
in a responsible way. This is recognised by the major alcohol
producers, who have established the Portman Group as a self-regulator.
We are working with the industry in collaboration with Non-Governmental
Organisations (NGOs) through the Responsibility Deal, which does
not cover pricing issues or other measures that only Government
68. The Department of Health memorandum says
Both the Alcohol Strategy and Healthy Lives, Healthy
People make clear that everyone has a part to play in improving
public health, including Government, business, the third sector
and individuals themselves. We have made clear from the start
that the Responsibility Deal is just one strand of the Government's
wide public health policy. It is part of our wider strategy to
achieve responsible growth where economic development and businesses'
role in improving health and wellbeing go hand in hand.
Priorities for action to improve public health are
defined by Government; and informed by research, advice from scientists,
health professionals and others. But this does not mean that Government
is necessarily best placed to deliver them. The Public Health
Responsibility Deal is a new mechanism to deliver on these
The Responsibility Deal taps into the potential for
businesses to improve public health through their influence over
food, physical activity, alcohol, and health in the workplace.
These are areas where 'doing nothing' simply isn't an option,
but the 'something' to be done is not necessarily best done by
Government. However, that is not to say that Government does not
have a role. The role of Government in this case is to facilitate
action and to build the partnerships that will enable genuine
advances to be made in a way that is consistent with the public
health needs of the country.
69. The Portman Group says that:
The Responsibility Deal is the right approach. It
enables industry to deliver practical measures quickly to effect
positive behaviour change. It encourages local partnerships to
reduce anti-social activity and uses innovative consumer marketing
and education programmes (eg the industry-funded Drinkaware) to
communicate the Government's sensible drinking guidelines and
promote responsible behaviour.
70. The BBPA also supports this approach:
BBPA believes the industry has a key role in addressing
alcohol-related harms. Our members have an inherent interest in
the responsible consumption of their products and believe that
beer is there to be enjoyed and pubs are the home of sociable
and responsible drinking. Industry expertise can be harnessed,
as is being demonstrated through the [Public Health Responsibility
Deal] and campaigns such as "Why Let The Good Times Go Bad?",
to ensure the right consumer reach to raise awareness, encourage
a responsible attitude to alcohol and provide the information
to make informed decisions.
71. Brigid Simmonds from the BBPA and Henry Ashworth
from The Portman Group both noted that there is evaluation group
as part of the Responsibility Deal to assess the effectiveness
of the work it is doing.
72. The Government notes in the strategy a recent
pledge by the industry through the Responsibility Deal to take
one billion units out of the market by 2015.
Brigid Simmonds told the Committee:
That is being done in a number of ways. I have one
major member of the BBPA who is reducing the strength of its three
main premium lagers from 5% to 4.8%. That will take a million
units from the market. We are obviously introducing newer, lowerstrength
beersyou will be aware that the Government reduced taxation
for 2.8% beersand we have over 30 brands out there which
will be creating that change over a period of time.
73. Henry Ashworth added that:
We are also going to be looking at some behavioural
trials to see what happens when you change, for example, the alcohol
strength of a bottle of wine from 14% to 12%, or if a beer product,
for example, came down from 5% to 4.5%. The behavioural assumptions
are that people will continue to drink the products that they
enjoy because they enjoy the drink and are loyal to the brand.
Brand marketing is going to be crucial in the delivery of this
unit reduction pledge. It will take a significant number of units
out of the market and enable the growth of a loweralcohol
market. We may well be looking back in five years time and saying
that this was a paradigm shift.
74. Professor Gilmore expressed reservations
about the drinks industry having a role in policy development:
It is very difficult to get away from the conflict
of interest of industry. There are areas where they can make a
contribution, making sure that existing regulations as to serving
underage drinkers and people that are drunk and so on are adhered
to, but I have always had concerns about industry getting round
the table to discuss how you produce a public health strategy
for alcohol because you cannot get away from the conflict of interest.
The same applies to supermarkets.
75. The Minister told us:
...it is not the role of the industry to develop
or dictate policy. It never has been and it will not be. Priorities
and policy should be informed by research, advice and evidence.
However, we would be crazy to ignore the reach that business has.
I think 17 million families use the supermarkets every week, so
the opportunities to influence are very great. The Responsibility
Deal, which is where industry, NGOs and we come together, is an
opportunity to persuade industry to be responsible, if you like,
to recast responsibility for the industry as doing something that
is seen to be in the public good. It is an opportunity to add
something. It is not a substitute for and it is not a forum for
developing policy. Anything that we can do without legislation
is quick and easy. What will be quite interesting is that with
any of the pledges made by the Responsibility Deal...there could
be evaluation of the Responsibility Deal. We could test how effective
it has been, and it will be independent.
76. The Committee does not believe
that participation by the alcohol industry in the Responsibility
Deal should be regarded by anyone as optional - we regard it as
intrinsic to responsible corporate citizenship. We welcome the
willingness of the industry to address the harms that alcohol
can cause - for example by tackling issues with licensed premises
through the formation of a business improvement district - but
we believe that it should be clear that the Responsibility Deal
is not a substitute for Government policy.
77. It is for the Government,
on behalf of society as a whole, to determine public policy and
ensure that a proper independent evaluation of the performance
of the industry against the requirements of the Responsibility
Deal is undertaken. We recommend that such an evaluation is commissioned
by Public Health England. We will be particularly interested to
see the assessment of the effect of reducing the alcohol level
in certain drinks. We do not believe that reducing the alcohol
in some lagers from 5% to 4.8%, for example, will have any significant
impact. If the industry does not bring forward more substantial
proposals than this it risks being seen as paying only lip service
to the need to reduce the health harms caused by alcohol.
EXPECTATIONS WITHIN THE RESPONSIBILITY
78. It is important to be clear about expectations
of the industry within the Responsibility Deal. The Strategy says
There is known to be a link between advertising and
people's alcohol consumption, particularly those under the age
of 18. Some countries have introduced a complete ban on alcohol
advertising (Norway) or a ban on TV advertising with other controls
(France) to tackle this. So far we have not seen evidence demonstrating
that a ban is a proportionate response but we are determined to
minimise the harmful effects of alcohol advertising.
The Government proposes a number of initiatives,
- Work with the Portman Group
to ensure that where unacceptable marketing does occur, it results
in the removal of offending brands from retailers.
- Work with the ASA and Ofcom to examine ways to
ensure that adverts promoting alcohol are not shown during programmes
of high appeal to young people.
- Work with the ASA to ensure the full and vigorous
application of ASA powers to online and social media and work
with industry to develop a scheme to verify people's actual ages
which will apply to alcohol company websites and associated social
- Work with the ASA and other relevant bodies to
look at the rules and incentives that might inhibit the promotion
of lower strength alcohol products.
79. Alcohol Concern in its briefing comments
that "[Alcohol Concern] knows from our own work with our
Youth Advertising Advisory Council on alcohol that marketing has
a strong impact on young people. We will be seeking to work with
the Government on these issues to ensure we have robust policing
in place that protect young people from the pressures of £800m
of yearly advertising spend on alcohol."
80. The Institute for Social Marketing at the
University of Stirling told us:
The promotion of alcohol is extremely widespread
and young people in particular are inundated by pro-drinking messages.
This advertising has been shown to have a direct effect on both
the age at which drinking starts and the amount consumed - reducing
the former and increasing the latter. Despite this evidence, there
are no proposals in the strategy to reduce the amount of alcohol
advertising, or even to introduce a degree on independence into
the regulatory process. Instead it is business as usual, with
an industry driven focus on content regulation - and approach
which lacks any evidence base and has been shown to fail. Nowhere
is this complacency more apparent than with online advertising,
which the strategy treats as a mere extension of current promotion.
In reality it completely changes the landscape, with young people
not just being marketed to, but being recruited as a peer to peer
brand advocates, unwittingly feeding marketing campaigns with
their personal details and generating their own promotional content.
How, for example, can the current regime of content controls deal
with this last phenomenon? And the talk in the strategy of better
age restrictions on digital marketing is simply fanciful. Digital
marketing has to be treated much more seriously.
81. The Portman Group says that:
Critics believe alcohol marketing encourages people,
particularly under 18s, to start drinking earlier or to drink
more. However, official statistics show fewer young people (16-24)
and children (11-15) are drinking...
The influence of marketing on alcohol consumption
is subject to various studies. Whilst there is longitudinal research
showing a modest relationship between marketing exposure and drinking
among young people, the strength of association varies between
Furthermore, the marketing impact on young peoples'
drinking behaviours is likely to be outweighed by other factors
(such as family environment, peer behaviour, socioeconomic status,
and personal attitudes.
82. It also says that it is reviewing these issues:
The Strategy has asked us to look at other ways to
tighten self-regulation around retail, sponsorship and marketing.
These are being addressed in our Code review.
The Strategy has also given a clear mandate to ASA
and Portman Group to review any advertising rules which currently
inhibit the promotion of lower strength alcohol products; this
is being addressed by our Code review.
83. The BBPA argues along similar lines:
The UK has some of the tightest restrictions on the
marketing of alcohol in the world, particularly designed to avoid
exposing children and young people to alcohol advertising. The
large decline in youth consumption over the period that self-regulation
has been in place serves as proof that alcohol advertising is
not encouraging children to consume alcohol.
Research into the link between advertising and alcohol
consumption remains inconclusive, and many studies have found
no correlation. For example, a study by Gerard Hastings at the
University of Stirling found no association between awareness
of alcohol marketing at age 13 and either the onset of drinking,
or the volume of alcohol consumed two years later.
84. This issue of interpretation of the findings
of the Institute for Social Marketing's research came up in the
Committee's inquiry into public health in the previous session
of Parliament. It was stated in evidence that the research
found no association between awareness of alcohol
marketing, the onset of drinking or how much the youngsters drank
between the ages of 13 and 15. The study was designed to prove
that alcohol marketing increases or has an effect on youngsters
drinking; in fact, it proved the opposite.
85. We asked Professor Hastings to comment on
that statement. He told us:
The peer-reviewed journal article published by my
research team clearly demonstrates an association between response
to alcohol advertising and marketing at age 13 and initiation
of drinking and increased frequency of drinking by age 15. The
interpretation given...appears to rest on a misunderstanding of
the research methodology.
86. The Committee is concerned
that those speaking on behalf of the alcohol industry often appear
to argue that advertising messages have no effect on public attitudes
to alcohol or on consumption. We believe this argument is implausible.
If the industry wishes to be regarded as a serious and committed
partner in the Responsibility Deal it must acknowledge the power
of its advertising messages and accept responsibility for their
87. The industry will take a
significant step down this road when it makes it clear that alcoholic
products should not be marketed in ways which address audiences
a significant proportion of whom are aged under 18, and cannot
therefore legally purchase the product.
88. There are already regimes in place in some
sectors which the Committee thinks could be implemented more widely.
Ofcom described the way in which television advertisements for
alcohol are regulated:
Scheduling rules already limit where alcohol advertisements
may appear in the schedules. Alcohol may not be advertised in
or adjacent to children's programmes or programmes commissioned
for, principally directed at or likely to appeal particularly
to audiences below the age of 18.
Since 1999 a system of "indexing" has helped
to prevent adverts being directed at children. A programme of
"particular appeal" to children is deemed to be one
that attracts an audience index of 120 for this age group. If
a programme attracts an under-16 audience in a proportion similar
to that group's presence in the viewing audience as a whole, it
is said to index at 100. So an index of 120 is an over-representation
of that group by 20 percent. For example, the proportion of 10-15
year olds in the viewing population is 8.24 percent, so any programme
where more than 9.84 percent (8.24 x 1.2) of the audience is made
up of 10-15 year olds would not be allowed to carry alcohol advertising
in or around it.
In other words, if the audience for a programme is
expected to contain a disproportionately large number of young
people, the broadcaster cannot place alcohol adverts in or around
it. This is a more targeted approach than a pre-watershed ban
as it hones in on specific programmes appealing to young people
regardless of what time they appear in the schedule. For example
Glee is broadcast after 9pm on Sky One, but alcohol advertisements
cannot be placed in or around it because of the disproportionately
high number of young people watching the show.
89. It is useful to contrast this with the so-called
CAP code, the industry's
own regulations on advertising in non-broadcast media. Specifically
on the issue of alcohol and young people under 18, it says:
Marketing communications must not be directed at
people under 18 through the selection of media or the context
in which they appear. No medium should be used to advertise alcoholic
drinks if more than 25% of its audience is under 18 years of age.
90. The Advertising Association told us:
Further to these exposure rules based on percentages,
the [Cinema Advertising Association] also takes other steps to
reduce the incidence of youth exposure to alcohol advertising.
For example, unless the film is '18' certificate, the CAA takes
the view that all releases featuring comic book characters in
a central role are not permitted to carry alcohol advertising,
given the potential appeal of those characters to younger audiences.
This has meant that a number of highly successful films - including
Marvel Avengers Assemble, which is currently making box
office records, cannot carry alcohol [advertising]. Similar data
analysis has meant that "gross out" comedies receiving
'15' certificates rarely carry alcohol advertising.
It is also essential to also note that many films
that are popular with adults are lower certificate films, for
example The Best Exotic Marigold Hotel. This film received
a 12a certificate but, as the majority of its viewership was middle-aged
or older, it would be wholly disproportionate to have banned alcohol
advertising around this film.
The CAP code therefore does provide protection against
the marketing of alcohol to those under the age of 18, but to
a lesser extent than the Ofcom broadcast code and on an entirely
91. Advertising of alcoholic
products on television is subject to rules which are relatively
targeted and sophisticated. The Committee believes there is scope
to apply these principles more widely - for example in cinemas
- and recommends that this principle be reviewed in the context
of the Responsibility Deal. Serious consideration should be given
to reducing to 10% the proportion of a film's audience that can
be under 18 and still allow alcohol to be advertised, or to prohibiting
alcohol advertising in cinemas altogether except when a film has
an 18 certificate.
92. Education and public awareness campaigns
clearly have a part to play in attempts to change people's behaviour
and drinking habits. Drinkaware, established in 2007, exists to
provide "consumers with information to make informed decisions
about the effects of alcohol on their lives and lifestyles. Our
public education programmes, grants, expert information, and resources
help create awareness and effect positive change."
It also told us that:
Drinkaware is entirely funded by voluntary donations
from across the drinks industry, but operates completely independently
from it. Our board is made up of five members of the health community,
five members of the drinks industry and three independents. This
structure enables the organisation to act independently whilst
being fully funded through voluntary donations from industry.
Our behaviour change campaigns are designed using
an evidence-based approach. Drinkaware provides consumers with
best evidenced information and facts about alcohol. Our independent
medical advisory panel checks all information, web, and printed
materials to ensure their accuracy and that it reflects the most
93. Chris Sorek, Chief Executive of Drinkaware,
said that the organisation was
looking at the demand side...changing people's demand
for alcoholchanging their behaviour as to why they want
to drink and what they are drinkingis something that we
are focusing our attention on. What we are trying to do is reduce
the amount of alcohol that parents give to their children. If
they followed [Chief Medical Officer's] guidance you would not
see the average age of first drink at 13.8 years. You would see
it at 15, which is what CMO guidance says. That says that there
are quite a few parents who are giving alcohol to children at
a much earlier age. If you take a look at what we are doing with
adults, we are trying to talk to them about units and unit guidelines.
What they will then do is reduce the amount of alcohol they are
drinking on a daily basis.
94. Chris Sorek stressed that Drinkaware is an
but its role is seen by some as compromised because of its links
with the alcohol industry. The British Medical Association told
The involvement of the Drinkaware Trust in providing
public health communications is a significant area of concern.
This form of industry social marketing is counterproductive because
industry responsibility campaigns are less effective than ones
from other sources, keep messages in a commercial comfort zone,
and distract attention away from more effective measures to regulate
alcohol use. Industry-related messages about alcohol have been
found to subtly enhance sales and company reputations. This is
despite the fact that the public is cynical about the motives
of corporate sponsors, and that non-governmental organisations
make a more effective and credible source.
95. In the Alcohol Strategy, the Government says
that through the Responsibility Deal it expects to see progress
A long-term commitment (through to 2020) to an increased
scope and funding for Drinkaware, including how it can best direct
interventions to the target groups. There is a strategic review
this year of Drinkaware and the Government will participate to
seek to maximise its effectiveness and accountability.
96. The Committee believes that
it is right that the industry should support education and awareness
campaigns about the harms that alcohol can cause, and doing so
through a separate organisation such as Drinkaware seems appropriate
in principle, but the independence of the organisation is vital.
The value of this contribution is likely to be very limited if
the campaigns it promotes are considered to be constrained by
97. We acknowledge that the
Board as presently constituted has a majority of non-industry
Members, and we welcome that fact. Nevertheless, if Drinkaware
is to make a significant contribution to education and awareness
over the coming years its perceived lack of independence needs
to be tackled, and as part of the review that is to be held this
year the Committee recommends that further steps are taken to
entrench that independence.
98. A number of submissions drew our attention
to the French Loi Evin as an example of an effective way
of regulating alcohol marketing. For example, the National Heart
The NHF recommend a UK adapted version of Loi
Evin - a French regulatory framework that allows alcohol marketing
and promotion only in media where adults are at least 90% of the
audience. The Loi Evin model...provides a simple framework that
can offer clarity on what marketing practices are and are not
allowed. Under this model, the promotion of alcohol would be explicitly
restricted to: media that adults use; at point of sale in licensed
premises; and at local producer events.
99. The Loi Evin was introduced in 1991.
Its provisions are that:
- all drinks over 1.2 per cent
alcohol by volume are considered as alcoholic beverages. Places
and media where advertising is authorised are defined:
- no advertising should be targeted at young people;
- no advertising is allowed on television or in
- no sponsorship of cultural or sport events is
- advertising is permitted only in the press for
adults, on billboards, on radio channels (under precise conditions),
at special events or places such as wine fairs, wine museums.
When advertising is permitted, its content is controlled:
- messages and images should refer only to the
qualities of the products such as degree, origin, composition,
means of production, patterns of consumption;
- a health message must be included on each advertisement
to the effect that "l'abus d'alcool est dangereux pour la
santé": alcohol abuse is dangerous for health.
100. In its evidence the Institute for Social
Marketing at the University of Stirling told us that the Government's
misrepresents the Loi Evin as a ban on advertising.
It is nothing of the kind. Rather it is exactly the type of imaginative
response to a major public health problem that the UK lacks, and
it simply ensures that alcohol advertisers behave responsibly
by a) restricting their messages to verifiable statements of fact
b) making sure these messages only reach adults. If the Government
could not bring themselves to learn from this excellent cross-channel
experience, there were a number of intermediate steps they could
and should have taken, including: prohibiting alcohol advertising
on television before the watershed; limiting or prohibiting sponsorship
of sport; and requiring health promotion messages to be screened
before programmes or films promoting drinking.
101. Although the precise terms
of the Loi Evin reflect the circumstances of a different
society at a different time, the Committee believes that the approach
adopted in the French legislation merits serious examination in
the English context. In particular the Committee recommends that
Public Health England should commission a study of the public
health effect which would be delivered in the UK by adopting the
principles of Loi Evin; such a piece of work would provide
a valuable reference point for the evaluation of the effectiveness
of the Responsibility Deal which the Committee has recommended
should also be undertaken by Public Health England.
102. The Strategy encourages local agencies to
take responsibility for tackling alcohol-related problems in their
areas. As it says in chapter 3:
Local communities, services and businesses are best
placed to tackle alcohol-related issues in their area and enforce
the behaviour and develop the cultures that they want.
103. We took evidence from people involved in
developing and implementing the strategy in Birmingham to see
how one locality is dealing with the problems alcohol causes Jacqui
Kennedy, Director of Regulation and enforcement at Birmingham
City Council told us:
Our strategy is very much an holistic approach to
alcohol harm in Birmingham. We have based it on the framework
that was the national strategy because we felt that that gave
us the golden thread from neighbourhoods through to the national
strategy. We have tried to consider the implications around health,
crime and disorder, young people and antisocial behaviour. The
strategy has tried systematically to structure a response to alcohol
harm, and there are benefits associated with that.
The new strategy has very strict and strong governance
around it. It is responsible and accountable through the Health
and Wellbeing Board; it is accountable through the community safety
partnership board; and it is also responsible through a corporate
management team of the local authority. The city council is the
sort of guardian for it, but all those partnerships are absolutely
key to govern how we deliver because the strategy has been developed,
again, with another strong delivery plan underpinning it and each
of the partners is called to account as part of a scrutiny approach
to make sure that we deliver against the plan. It is very much
business as usual.
104. The Birmingham team reported some significant
successes in the development of their services. We were told,
for example, that there are no waiting lists in Birmingham for
NHS patients referred to specialist alcohol services and that
the establishment of business improvement districts in the two
main night time economy areas had helped address issues of crime
and antisocial behaviour. The costs are also contained within
'normal' activity. As Jacqui Kennedy said:
...this is our day job. It is linked into licensing,
trading standards and environmental health. It is the day job.
It is not a speciallyfunded activity.
105. We were told that, having set specific targets
for the strategy, there is also a structured monitoring plan in
place in Birmingham to assess how well the aims of the strategy
are being implemented. Barry Everleigh, of the Birmingham Drug
and alcohol Action Team said "We are looking at six monthly
reviews from creation of the strategy, and then a lower level
with the providers, on a monthly and quarterly basis."
106. Birmingham is one example
of local action that has been drawn to our attention during the
inquiry, and it does demonstrate how local agencies can put together
an effective action programme without the need for a substantial
additional bureaucratic support structure. This model of local
action, linking in with national priorities, makes sense as a
pragmatic, practical way of addressing serious problems. As we
recommended earlier in this report, Public Health England should
use this model as the template for all local areas to address
the various problems that alcohol causes in their communities,
and to link local objectives to those at the national level. Central
Government cannot direct a local area to address alcohol problems
in a particular way, but the new public health structures, in
which local authorities have a key role, should provide the opportunity
to establish a national framework of local initiatives.
107. The NHS Confederation told the Committee:
The increase in alcohol abuse in the UK has resulted
in an increased demand for NHS services. It was already costing
the NHS £2.7 billion a year in 2006/07 (the most recent year
for which figures are available) and demand has increased significantly
since then. For example, alcohol related admissions to hospital
more than doubled between 2002-03 and 2009-10, from 510,200
to 1,057,000. Difficulties in recording alcohol-related harm mean
that the impact is likely to be even higher. The burden on the
NHS will be unsustainable if demand continues to grow.
With the pressure to react to a growing number of
urgent needs, preventative and specialist services have struggled
to keep pace with alcohol driven demand and hospitals have been
bearing the brunt of the burden. In 2008 over 70% of the cost
of alcohol to the NHS was spent on hospital treatment. Inpatient
costs were almost 45% of the total NHS expenditure in alcohol
related services that year compared to around 12% in 2001.
108. There are difficulties with treatment of
people with alcohol-related problems. The Department of Health
told us in its memorandum:
While there has been some improvement in provision
for treatment of people dependent on alcohol, it is very likely
that there is still significant under-provision overall. We estimate
that numbers of people in England mildly or severely dependent
on alcohol rose by 24% between 2000 and 2007. Without the decisive
steps we are taking through our strategy to end the availability
of cheap alcohol and to strengthen local powers to prevent the
growth of alcohol misuse, it is likely that needs for treatment
would grow in the future.
Levels of need vary greatly from place to place.
It is right that plans for investment in alcohol treatment and
prevention are for decision at local level. Our reforms to the
NHS and Public Health will ensure a greater focus on commissioning
of alcohol services to meet local needs.
109. St Mungo's told the Committee that
The Government appears to have recognised that services
are not available for tens of thousands of people who are alcohol
dependent and need support to recover. Although investment is
needed urgently, we are yet to see any solid proposals around
how this problem will be addressed. We are concerned that central
Government's ability to deliver this investment will be curtailed
as the assessment of need and decisions on commissioning are all
It is right that there is a focus on integrated services.
People who are dependent on alcohol often have a range of complex
needs that require holistic support, not a disparate collection
of needs that can be treated sequentially. This is especially
true for our clients, our latest client needs survey shows that
42 per cent of our clients with an alcohol problem also have a
mental health problem and 50 per cent have a significant medical
NICE guidance makes clear that there should be services
tailored to maximise engagement with the homeless population due
to the extra complications that working with this group can bring.
However, our clients often have to wait for weeks or months to
access rehab services and our staff report that it is becoming
more difficult for them to secure access to services.
110. One of the main ways the Strategy suggests
that health problems associated with alcohol could be reduced
is through a process known as Identification and Brief Advice:
Identification and Brief Advice (IBA) is a simple
intervention aimed at individuals who are at risk through drinking
above the guidelines, but not typically seeking help for an alcohol
problem. IBA has been proven to reduce drinking, leading to improved
health and reduced calls on hospital services. At least one in
eight at risk drinkers reduce their drinking as a result of IBA.
The National Institute for Health and Clinical Excellence (NICE)
recommends that NHS health professionals routinely carry out alcohol
screening as an integral part of their practice, focusing on groups
at increased risk.
111. In oral evidence, Eric Appleby and Professor
Gilmore both supported the use of Brief Advice. Mr Appleby also
supported the NICE guidelines as a model for treatment. Professor
Gilmore emphasised that there is a role for treatment right through
to the most serious cases:
Right at the far end, with the heavilydependent
patients that unfortunately are often considered "no hopers",
treatment is still effective and cost-effective. We only remember
the ones that come back and not the ones that do well. It is very
good that the strategy acknowledges that treatment works but it
perhaps has not identified fully the levers that people can use
locally to implement good care.
112. The Medical Research Council and the Economic
and Social Research Council, in a joint submission, told us;
With three sets of NICE guidance on alcohol published
in the last five years as well as a series of systematic reviews,
there is now a body of evidence on the effectiveness of existing
behavioural and cognitive approaches (such as intensive case management,
motivational enhancement therapy and social network based therapies)
as well as certain pharmacological interventions (e.g. acamprosate
and disulfiram). Nevertheless, many of our advisors highlighted
the lack of joined-up effective delivery and available appropriate
expert services for drinkers, especially in 'real-world' settings.
This is a key element of support that they felt was not fully
addressed in the Government's alcohol strategy.
113. The need to implement what are known to
be effective alcohol care services was referred to in a number
of submissions. The Royal College of Physicians called 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.
The RCP recommends that there should be a multidisciplinary
'alcohol care team', a seven 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.
114. The Alcohol Health Alliance said that
Healthcare modelling methodology suggests that if
each district general hospital established a 7 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
115. The British Society of Gastroenterology
The dramatic impact of Alcohol Specialist Nurses
(ASNs) during a 5-day working week highlights the need for them
to work routinely on a 7-day basis in hospitals, especially since
such a large proportion of alcohol-related problems present out-of-hours,
particularly at weekends. Alcohol specialist nurses pay for themselves
many times over, in terms of improved detection of alcohol misuse,
accessibility, waiting times, [did not attend] rates, reduced
inpatient detoxifications and length of stay, thus achieving 4-hour
trolley waits, relieving bed pressures and reducing A&E attendances,
admissions and readmissions...
Implementation of an ASN service in Nottingham improved
the health outcomes and quality of care of patients admitted to
hospital for detoxification, and also of those admitted for the
complications of alcohol-related cirrhosis (S.D.Ryder et al, 2010).
Hospital admissions were reduced by two thirds, resulting in a
saving of 36.4 bed days per month in patients admitted for detoxification.
Clinical incidents were reduced by 75%. Liver enzyme abnormalities
were halved and there was also a reduction in bed days used in
the cirrhotic group from 6.3 to 3.2 days per month.
116. When we asked about the under-provision
of treatment services, Dr Mark Prunty, Senior Medical Officer,
Alcohol and Drugs Programme, told us:
At the moment, in treatment services, demand is relatively
well met: 82% of people seen are starting treatment within three
weeks, 54% of those successfully complete treatment and the numbers
of new entrants into treatment are increasing. As I say, there
is success. The experience within the services in general is that
there has been improvement and there is continuing improved access.
The difficulty, to some extent, is knowing the need and how you
make that decision at a local level... In some areas there are
much higher rates of hazardous and risky drinkingpeople
who do not need treatment but would be very likely to benefit
from interventions and brief adviceother areas which have
higher levels of dependence and other areas which have higher
levels of social deprivation and, therefore, more harm. So each
area has to look at that information.
How do local commissioners make that decision [about
the level of service on offer] taking all those other factors
into account? What is the evidence now for what is the balance?
We have said we have a 1.6 million dependent population. In any
one year you would not expect more than a minority of those to
need treatment places because a large number of them are not ready
to change yet. They need support, encouragement, assessment, access
to services, IBA and all those things. So local commissioners
have to balance all these different pieces of evidence to try
to determine how best to focus resources in order to reduce their
hospital admissions to meet their other local priorities on alcoholrelated
harm. Work will be published in 2014 which looks at a researchdriven,
evidencebased capacity model to try and help local commissioners
to bridge that gap. The information is there. The question is
how we help commissioners to make those decisions and invest in
the areas that require that investment locally.
117. We welcome the work which
the Department is undertaking to provide an evidence base to allow
commissioners to make informed decisions about which models of
treatment provision are most effective in addressing the health
issues caused by alcohol abuse. In particular commissioners need
evidence about the most effective form of early intervention in
order to reduce the number of avoidable hospital admissions which
currently represent avoidable illness for patients and avoidable
costs for taxpayers. The evidence we received suggested that the
establishment of Alcohol Specialist Nurse services throughout
the country is one of those measures. The fact that over 70% of
the costs to the NHS of alcohol-related services was spent on
hospital treatment demonstrates the scale of the opportunity to
restructure services to achieve better outcomes.
21 Alcohol strategy, paragraph 1.6 Back
Ev 98 Back
Birmingham Alcohol Strategy 2012-16, page 2 Back
Q 305 Back
Improving outcomes and supporting transparency Part 1: a public
health outcomes framework for England, 2013-2016, Department
of Health, January 2012, p27. Back
Q 44 Back
Q 45 Back
Alcohol Strategy, para 5.13. Back
ibid, para 5.14 Back
Ev w133 Back
Ev 134 Back
Q 317 Back
Ev 76 Back
Ev w174 Back
Alcohol Strategy, paragraph 2.5 Back
Alcohol Strategy, paragraphs 2.7 and 2.8. Back
Ev w101 and 102 Back
Ev w16 and 17 Back
Ev 67 Back
Ev 91 Back
Ev w160 Back
Ev w92 Back
Q 21 Back
Ev 98-9 Back
Q 33 Back
For example, the Institute for Social Marketing, Stirling University
Ev w7 Back
Minimum drink pricing 'more effective', BBC News, 14 May
2012. http://www.bbc.co.uk/news/uk-18062406 Back
SP Bill 4B, Alcohol (Minimum Pricing) (Scotland) Bill [as passed]
Session 4 (2012), section 1A. Back
Q 380 Back
Government's alcohol strategy, paras 2.9 . Back
Ev 99 Back
Ev w147 Back
Ev w19 Back
Q 401 Back
Q 402 Back
Alcohol Strategy, paragraph 4.3 Back
Ev 63-4 Back
Q 214 Back
Alcohol Strategy, para 4.8. Back
Q 214 Back
Q 39 Back
Q 423 Back
Alcohol Strategy, paragraph 2.12 Back
Alcohol Strategy, page 9. Back
Ev w8 Back
Ev 105 Back
Ev 91 Back
Q 256, Health Committee, 21 June 2011, Public Health, HC 1048-II Back
Footnote to Q 257, ibid Back
Ev w154 Back
The UK Code of Non-Broadcast Advertising, Sales Promotion and
Direct Marketing, produced by the Committee of Advertising Practice
CAP code, paragraph 18.15 Back
Ev w148 Back
Ev 93 Back
Q 101 Back
Q 70 Back
Ev w81 Back
Alcohol Strategy, para 4.10 Back
Ev w63 Back
The Loi Evin: a French exception: Dr Alain Regaud, Dr Michel
Craplet http://www.ias.org.uk/resources/publications/theglobe/globe200401-02/gl200401-02_p33.html Back
Ev w8 Back
Qq 229 and 230 Back
Q 273 Back
Q 276 Back
Ev 68 Back
Ev w66-7 Back
Alcohol strategy, paragraph 5.16 Back
Q 58 Back
Ev w113 Back
Ev w38 Back
Ev 101 Back
Ev w94-95 Back
Q 323 Back