The Socialist Health Association was founded in 1930 to campaign for a National Health Service and is affiliated to the Labour Party. We are a membership organisation with members who work in and use the NHS. This includes doctors and other clinicians, managers, board members and patients. We have held a number of seminars and discussions across the UK on public health topics, some specifically in respect of alcohol, and this submission is informed by those discussions and by contributions from some of our public health practitioners.
This submission is made on behalf of the Association.
- 1. The scale of ill-health related to alcohol misuse is immense. No doubt the committee will receive much evidence on this point, but we understand that alcohol misuse is associated with:
- 50% of street crime
- 33% of burglaries
- 30% of sexual offences
- 33% of domestic violence offences
- causing some 60 different diseases/ conditions, including injuries and mental and behavioural disorders,
- between 15,000 and 22,000 deaths each year
- 150,000 hospital admissions
- up to 35% of A&E attendances and ambulance costs (rising to 70% between midnight & 5am at weekends)
- 49% of attendances at A&E after an assault, in Merseyside
- £2.4 billion annually lost to the economy due to premature death
- 17 million days of absences from work each year
- annual losses in productivity of £6.4 billion
- People of all ages, although it is young people who are often highlighted, are more likely to have unprotected and otherwise risky sex when alcohol has been consumed. This results in accelerated transmission of sexually transmitted infections, unplanned pregnancy and emotional distress.
2. All these figures are of course debatable, but in our submission the damage caused by alcohol appears to be similar in kind but much greater in quantity than that caused by the abuse of other addictive substances, but resources directed to alleviating the problems are not in proportion.
3. Evidence released by the Mental Health Foundation shows the impact of the poverty gap to both individual and collective mental health. Their report, “Mental Health, Resilience and Inequalities”, shows how the gap between rich and poor affects the mental health of individuals by causing psychological and physiological changes. Their report argues that mental health is the lynchpin between economic and social conditions. Poor mental health experienced by individuals is a significant cause of wider social and health problems, including:
- low levels of educational achievement and work productivity
- higher levels of physical disease and mortality
- violence, relationship breakdown and poor community cohesion
Mental ill health is closely linked to the abuse of alcohol and other drugs.
In contrast, good mental health leads to better physical health, healthier lifestyles, improved productivity and educational attainment and lower levels of crime and violence. This appears to be entirely consistent with the work of Prof Richard Wilkinson and Sir Michael Marmot which relates the excessive inequality in British (and US) society with high levels of all kinds of social pathology.
4. It appears to us that nobody wants to take charge of alcohol policy. Responsibilities at a national level are spread over a number of different departments and we don’t see much evidence that they talk to each other. Culture Media and Sport deal with licensing hours, the Home Office and Department of Justice with policing, Customs and Excise and the Treasury have a major impact on the price; The NHS picks up the pieces; and the Dept for Business, Enterprise & Regulatory Reform presumably regards the increasing consumption of alcohol as something to be celebrated. The Treasury appear to have very little interest in the problems caused by alcohol, or indeed the cost of dealing with them. They regard taxation of alcohol as merely a revenue raising exercise. Because there is no co-ordination between them over the last decade they have effectively decided to make alcohol cheaper in real terms than before, more widely available through supermarkets etc. and available for longer hours. Then just to add to the fun the industry has decided to make it stronger. Wines are now 12-14% instead of 10 – 12% and beers are often 5 – 8% rather than 3.5 – 5%. The impact has been to at least double the harm done. The strategy of relying on voluntary regulation by the alcohol industry is been shown to be ineffective. Budgets have repeatedly raised the duty on drinks with lower alcoholic content (beers, cider & wine) to a greater degree than the harder drug of spirits. Presumably this is to support the whisky industry but there could be more imaginative ways than increasing the accessibility of higher strength drugs both neat and as incorporated into mixers.
5. Two structural changes took place in the drinks industry during the 1990s that the drinks industry should take full responsibility for. One was the market segmentation of the pub trade and the other the introduction of alcopops. These are interlinked. Prior to this decade, drink had an unpleasant taste to most young palates and indeed was an acquired taste. Pubs tended to contain a mix of ages, it was the nightclubs that were the preserve of younger people. Young people were initiated into the use of alcohol in pubs with more experienced users and had to conform to the peer pressure around conduct and alcohol use of the established users. Use of alcohol tended to commence with high volume relatively low alcoholic content drinks such as beers and ciders, spirits being an older taste that was graduated to. Spirits were also expensive compared to beer and cider.
The pub market was segmented demographically with pubs targeted at young people only or being for food mostly or families. Alcopops were introduced. So we moved to a situation where drinks designed for a young palate are being promoted in establishments targeted at young people. Without the barriers of an unpleasant initial taste, social mores of more experienced users and with the encouragement of low price (the duty on the spirit base of an alcopop being pegged or increasing at a much lower rate than beer), it is unsurprising that as intended by the drinks industry, consumption of alcohol increased.
During the 1990s there were changes in the pattern of student drinking. There was a move from having a pint, having another pint and maybe a gradual escalation that from time to time resulted in extreme drunkenness to going out less frequently but with the advance intention of getting drunk and as fast and cheaply as possible.
6. Sadly central government presents an example of the weakness of a partnership approach, which enables all the partners to deny their responsibilities except for those who have to clear up the mess. Such performance by a local authority would be labelled as failing. The resultant costs falling on the NHS (and the criminal justice system) are rising so rapidly as to threaten its viability as a comprehensive service. The only cost effective approach to health problems is to devote resources to prevention.
7. At a local level various departments within local authorities have an interest, including planning, leisure, youth, trading standards, social services, environmental health, education and those concerned with community safety, crime and disorder and licensing. Outside the local authority there are more players:
businesses including pubs and clubs and supermarkets; police; primary care trusts; alcohol industry; strategic health authorities and sometimes two tiers of local government
As with any partnership approach local effectiveness varies very considerably, but the impression we have is that in many places is that the police and the casualty department are left to pick up the pieces with the other partners hoping that the sale of alcohol will keep the local economy moving.
8 We need a strategy which covers
- early interventions and
- proper services.
We must consider honestly why we use alcohol and be clear about what behaviour we actually want to change. There are many mixed messages. Alcohol is a drug that seems to meet a need in many of us, all users need to understand more about why and how they are using it and policy needs to consider whether there are alternatives with better outcomes for society. Like other behaviours that have risks – self-injury for example, alcohol use may well be a much needed coping strategy. There are many who consider moderate to high use a perfectly acceptable pleasure.
The current messages seem to be that we want to prevent violent and irritating behaviour that impacts on others and risky behaviour that exacerbates the situation of vulnerable people. In addition we want to make people aware that even at what many would consider low levels of use can cause health problems. These are very different messages not necessarily of relevance to the same person.
Thought should be given to the terms used and social norms. It is most unhelpful to label “binge drinking” a level of consumption that whilst causing health problems, is below what many consider low or average. This just alienates the user who then ignores the rest of the information.
9. Prevention has to cover price, and availability and possibly advertising. We do not think that social marketing approaches will be effective without an increase in the retail price of alcohol. Alcohol consumption is quite sensitive to levels of disposable income. The most price sensitive groups are the young and the very heaviest drinkers. Unlike most pathology abuse of alcohol is not confined to the poor and so our present economic situation is likely to lead to a reduction in consumption, just as increasing consumption over the past 10 years has been driven by increasing prosperity. Alcohol policy has tended to focus on the minority of the drinking population who are the heaviest drinkers. However, it is actually the much greater number of drinkers in a population who, on occasions, drink to excess, who account for most of the alcohol-related problems. A greater proportion of the overall burden of harm is associated with the acute effects of alcohol use and drinking to intoxication, rather than the chronic effects of sustained heavy drinking over a long period of time. There seems good reason to suppose that in an increasingly mobile world putting up prices could encourage smuggling unless this issue is tackled across the whole of the EU.
10. Alcohol is a public health problem that needs to be addressed within a social model of health promotion, rather than focusing on treatment. It is not possible to order the range of interventions into a hierarchy, with one being considered more effective than another. The evidence points to multi-component approaches, where attempts are made to make progress with each intervention, within available resources.
11. The problems of price relate primarily to supermarket sales. Wider availability of alcohol in supermarkets has coincided with the phenomenon of young people getting drunk before they go out for the night. It has also been accompanied by very severe economic pressure on public houses. In our view consumption of alcohol in the relatively supervised environment of the public house is safer for all concerned than the alternatives. We think serious consideration should be given to limiting the amount of alcohol people can buy from supermarkets or off licences at one time. This strategy seems to have been quite successful when applied to the sale of paracetamol. We would also like to see taxation much more closely related to alcohol strength and the removal of various measures designed to protect indigenous manufacturers of alcoholic drink. We need to be wary however of the Scandavian experience where the price barrier results in sporadic heavy drinking – true binge drinking with the attitude of “if I’m going to spend £10, I might as well spend £1,000”
12.There are also problems associated with some clubs and vertical drinking establishments. Our impression is that police intervention in these establishments is very limited. Prosecutions under sections 141 and 142 of the licensing act (sale and supply of alcohol to people who are drunk) seem to be extremely rare, although the streets and hospitals are full of evidence of offences under these sections every week. We do not understand why the provisions enabling licensed premises to be charged for the cost of policing associated disorder have not been widely used.
We would like to see consultation on the possible raising of the age at which young people are allowed to buy alcohol, and particularly spirits (we understand in some European countries young people are only allowed to drink beer), although we should be mindful that a major source of alcohol for young people is parents and carers and that removing alcohol simply pushes young people towards other drugs that may be more harmful both from a health perspective (particularly as they are supplied in varying and unpredictable strengths) and incur increased risks of being drawn into criminality. We are in favour of lowering the driving blood/alcohol limit from 80 to 50, and Random Breath Tests for motorists.
13. Early intervention is about getting GPs (and other professionals) to recognize the problem at a time when fairly minimal intervention can be quite effective. That’s about training etc, but practitioners should only be regarded as qualified to give advice if they understand their own motivation around alcohol use, non use or abuse. Every polyclinic and casualty department should have an alcohol-adviser available.
14. Services for those with serious alcohol related problems MUST be properly funded and provided. At present, we have been told repeatedly that they are the poor relation of drug services. The tendering process is a disaster, bringing uncertainly to services especially as often the contracts are for shorter periods that a client will use a service. (Many clients are with a service for 5 years, from de-tox through dry houses, therapy and aftercare; this is impossible where the service provider is constantly having to retender, and may lose the service.) Also, funding is often only for new initiatives, but the on-going, high quality and much needed services are devilishly difficult to fund.