David Oliver: Government’s approach to alcohol harm is incoherent

For a decade or more we’ve been hearing big government rhetoric on prevention of ill health, promotion of wellbeing, and “parity of esteem” for mental health. Speaking at last week’s NHS Expo Conference, Public Health England’s chief executive, Duncan Selbie, said that NHS England’s 2014 Five Year Forward View had “told a fantastic story,” yet its ambitions for prevention hadn’t been implemented.12 With the upcoming 10 year plan,3 things had to change, he said.

In public health, prevention and treatment of alcohol misuse and its effects illustrate a huge mismatch between platitudes and practice.

The 2012 Health and Social Care Act shifted public health funding and provision to local authorities, ostensibly because local government has influence over wider societal determinants of health, such as education, housing, leisure, transport, and social care.4 But local government budgets have been cut hard ever since, with public health hit hard.56 In 2012-13 the ringfence on council budgets for drug and alcohol services was lifted.

In 2017 UK Addiction Treatment Centres published a report that was based on replies from 118 English local authorities to a freedom of information request. Their combined spending on services for drug and alcohol misuse from public health grants had fallen from £535m (€595m; $690m) in 2013-14 to £452m in 2016-17, a 16% cut.7

In two of the report’s examples, Manchester had reduced the proportion of its public health grant spent on drug and alcohol services from 30% to 16%, and Lancashire from 34% to 24%. Central government cut overall public health grants by more than £200m in 2016, so this is a smaller proportion of a smaller budget. In 2017 the Advisory Council on the Misuse of Drugs warned on the government’s own website that sustained cuts to funding for drug and alcohol services were “short sighted and a catalyst for disaster.”8 It recommended that such services should be made mandatory within local government and brought more closely into local NHS commissioning.

The Institute of Alcohol Studies has shown, based on the retail price index and real terms income, that alcohol is now 60% more affordable than it was in 1980.9 A 2017 systematic review by Boniface et al, including 33 studies and meeting all nine Bradford Hill criteria for establishing causality, concluded that price based policy interventions, including minimum unit alcohol pricing, were likely to reduce population alcohol consumption and related mortality and morbidity.10 The Alcohol Health Alliance, comprising over 50 medical organisations and health charities, has called for these to become policy.11

Other expert groups, such as the Institute for Fiscal Studies, have argued that tax changes could have a similar effect on price, while generating revenue for the exchequer that could be ploughed back into prevention and tackling health inequalities.12

In Wales and Scotland minimum unit pricing is on the table or enacted.13 The government’s failure in England to act on price seems to disregard the weight of expert and empirical evidence. Such is the reality of having a tax funded, politically accountable NHS while public policy relating to wider determinants of health rests with other government departments, Treasury included. The drinks industry has a powerful and persistent lobby.14 Pro-market think tanks such as the Adam Smith Institute repeatedly oppose pricing policies.15

Why does any of this matter? Public Health England estimates a cost to the NHS of alcohol related harms of around £3.5bn a year and a social return of £3 for every £1 spent on alcohol services.16 NHS Digital reported 337 000 hospital admissions related primarily to alcohol, 5507 alcohol specific deaths, and 80 000 people receiving treatment for alcohol misuse or dependence in 2017-18. This is a small fraction of the estimated 590 000 dependent drinkers in England.17 Alcohol is the biggest risk factor for death, ill health, and disability in adults younger than 49 and the fifth biggest across all ages.18

Dependent and hazardous drinking brings much wider harms to society, to individuals, and to families, hence Public Health England’s estimated cost to society beyond the NHS of around £21.5bn a year.16 Alcohol is heavily implicated in use of emergency services, attacks on their staff, and violent or motoring criminal offences, including those that lead to imprisonment.18

NHS chief executive Simon Stevens said at the same NHS Expo Conference last week that we needed to “get serious about new public health threats.”19 I am sure he hasn’t forgotten some of the older ones, such as alcohol. My concern is that however switched on our health service and public health leaders may be, the funding and the wider social policy to make their ambitions a reality rely on ministers, government communications teams, and Treasury officials. These parties are late to the party.