David Oliver: Government’s approach to alcohol harm is incoherentBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3836 (Published 11 September 2018) Cite this as: BMJ 2018;362:k3836
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Incoherent Approach to Alcohol Harm – the title of Dr David Oliver’s Comment last week, sums it up very well. How can Government allow such continued health harm and such an expenditure on treating it in the NHS when the cause is largely preventable and with social services at the same time cutting the costs of alcohol treatment services?
Introduction in England of the 50p minimum unit price (MUP) policy now going ahead in Scotland, would give a £2.692billion cumulative saving over ten years. Restoration of the alcohol duty escalator – of proven efficacy over the period of time it was in place (2008-2013) – would save £1.03billion over a five year period including £132million direct costs to the NHS (fuller details of this will be published in the fifth annual report of the Lancet Commission on Liver Disease in the UK). Furthermore the dramatic increase of overweight and obesity now present in some 60% of the adult population, means that this will co-exist with a high alcohol consumption in a substantial proportion of the population. The effects of such a combination are not sufficiently appreciated. Alcohol and obesity have a synergistic impact and the end of a recent paper on lifestyle issues concludes “each exposure sensitises the liver the effects of the other” (Boyle M, et al. J Hepatol. 2018; 68(2): 251-267). It has also been very well documented in several studies that the occurrence of obesity increases the rate of progression of alcohol liver related disorders, and the chances of developing a primary liver cancer. The costs to society from obesity related illness have been estimated at £27billion annually and cutting the calorie intake of existing overweight and obese 4-64 year olds by 20% would save £9.02billion in health and social care costs over a 25 year period.
Not having to spend such large sums on the consequences of largely preventable illness would allow investment in social services for treatment measures that some of the most addicted patients and those that live in deprived areas need. Furthermore, reducing alcohol consumption and lessening overweight, along with further reductions in smoking, would increase the number of years of healthy living. Surely the figure of 20% of life expectancy spent in years of ill health is a damning statistic which should resonate the need for action by Government and policy makers generally.
Competing interests: No competing interests
Thank you for shedding some sense on what is most definitely an incoherent position on alcohol policy. The points raised are certainly valid.
There are other areas of incoherence worth trying to rectify. Most visibly is the recent announcement of a strategic partnership with Drinkaware. The article skirted away (avoided) tackling this murky issue, assumedly on account of timing of publication.
There has been strong opposition to this move, most visibly the resignation of Sir Ian Gilmore from a key advisory committee. PHE is being increasingly compromised by association with DrinkAware. Many have warned of the dangers of this partnership (1). A WHO publication (2) recently highlighted that 1.9% of corporate social responsibility activities were supported by evidence of effectiveness, and only 0.1% were consistent with “best buys” for prevention and control of NCDs. But such activities may have a public-relations advantage for the alcohol industry, as they will be seen by government and the public to be doing something, and thus the 'heat' taken out of pressure for upstream policies.
It is widely accepted that we under invest in alcohol treatment interventions (across all levels) relative to the scale of risk and the need in our communities. It has been well documented that the ongoing cuts to the public health grant are a false economy. Local Government has zero manoeuvring room given the wider evisceration of local government funding over the last 6 or so years. Cuts have consequences. It is widely acknowledged this will simply set up future demand for NHS services and also will have a bearing on economic productivity of the workforce given the nature of epidemiology of alcohol harms.
There are many skills developing issues we can address about scaling up brief interventions, asking wrong and closed questions, reluctance to challenge people.
The message and the culture
Getting the overall message right on alcohol is a huge issue that requires significant work. There are cultural issues here, and issues associated with risk communication.
On risk communication, the communication of the evidence base for alcohol and harm is frequently sited as confusing (red wine is good, red wine is bad, moderation is good, no drinking level is safe). The recent messy coverage of the Lancet story on "no safe level" erodes public trust in the evidence. There is a pressing need to move away from that space and be absolutely clear that we know that some (a lot) of people are harmed by alcohol. Prof Spiegelhalter sums this up most eloquently (3).
Arguably one of the reasons we under invest in treatment because we can because everything in health and wider society is geared towards making a joke of alcohol. There is highly irresponsible continuing practice from alcohol companies which is seemingly allowed on account of blind eye, tax receipts, and tolerance of marketing making jokes of alcoholism and excessive drinking. A beer called ‘delirium tremens brew’ is currently on the market.
Upstream approach to policy and intervention
As a society we have a strong push for a focus on downstream approaches, aided and abetted by industry and their lobbyists. Again the ferocious opposition of the Whisky Distillers against minimum unit price is testament to that.
In almost all circumstances, upstream interventions are always more potent impact wise, and more equitable. Witness the voracity of arguments against specific forms of upstream policy from commercial bodies who stand to lose from more powerful policies.
In order of preference, a public health approach to alcohol intervention would be focused on taxation or other price interventions, labelling, point of sales initiatives, marketing and in last place public awareness campaigns (innocuous at best, maybe net harmful maybe if they divert attention or bandwidth away from more powerful initiatives).
Of course there are many tricky evidence issues to deal with here. Marmot (4) warned us that a strict biomedical approach to evidence will lead to a strong focus on drug treatment at the expense of policy on poverty. This requires careful handling.
DHSC or Treasury
The key incoherence is that alcohol policy is seen as a DHSC responsibility. Of course the NHS demand as a consequence of alcohol use are the domain of DHSC. given the epidemiology of harm, working age populations are also implicated, thus making it a societal and economic issue.
The Treasury is absent seemingly from any coherent conversation about advancing new alcohol policy, certainly publicly.
Those in the alcohol industry including advertisers, and they're paid Associates and lobby groups always claim that the industry pays taxes and the tax receipt from alcohol sales always outweighs the harm that alcohol isn't it good to the economy. I've never seen any coherent analysis that looks at benefit and harm from a whole societal perspective, usually the harm is an NHS perspective only I would also suggest that the evaluations of harm are undervalued and use model parameters most favourable to industry.
The PHE 2016 evidence review (5) provides a great deal of evidence based suggestions. Here are a few thoughts
Minimum Unit Pricing is mostly at the top of the list of policies. It has seemingly been shelved by government at the moment.
I have yet to hear much or any NHS advocacy on Minimum Unit Price in England.
Similarly there is merit in a push for the inclusion of public health as a fifth objective in licensing decisions. This would give local government licensing committees significant additional power to flex local policies where there are specific issues.
Many local places are developing strong recovery models, something to be strongly supported and encouraged.
Some further investment and focus given to "new" areas would be welcome. Two specific examples - firstly scale up of systematic intervention around alcohol across the NHS. This has been done in some places in smoking using the London Clinical Senate Helping Smokers Quit (6) model, the issues are similar in alcohol. The CQIN is helpful, but will likely be short lived, will focus on mechanisms and counting and not get into the culture / hearts and minds.
Secondly a focus on foetal alcohol syndrome as a significant and preventable cause of learning disability.
(1) Be aware of Drinkaware
(2) Alcohol industry CSR actions ineffective - Institute of Alcohol Studies
(3) The risks of alcohol (again) – WintonCentre – Medium
(4) Inclusion health: addressing the causes of the causes - The Lancet
(5) The public health burden of alcohol: evidence review
(6) London Clinical Senate Helping Smokers Quit
Competing interests: No competing interests