Safe. Sensible. Social The next steps in the National Alcohol Strategy A response from Alcohol Concern Prepared by Don Shenker, Director of Policy and Services June 2007 62 Leman Street, London E1 8EU Tel: 020 7264 0510, Fax: 020 7488 9213 contact@alcoholconcern.org.uk 1
Introduction The new strategy has a far sharper focus on the active promotion of sensible drinking, reduction of crime and ill health as a result of excessive drinking. It targets not just under-18s and binge drinkers, but also anyone who drinks harmfully. In its intent, this is a vast improvement on the strategy s predecessor and Government should be applauded for a more comprehensive, focused and strategic paper that begins to identify the most effective route to reducing harms. Safe. Sensible. Social. contains however, particular areas of omission, some worrying assertions and fundamental flaws in measurement which may ultimately lead to the new Strategy being judged as a further missed opportunity in tackling alcohol harm. There are nevertheless significant improvements in the Strategy s main expected outcomes which, if promoted successfully, may yet provide the local levers required to reduce alcohol harms. This paper sets out the key sections of the new alcohol strategy and analyses the strengths and weakness of the government s approach. Overall Goals and Objectives of the Strategy The strategy s long term goal is to minimise the health harms associated with alcohol and reduce levels of violent crime, disorder and anti-social behaviour. Its target groups are under-18s who drink, 18-24 year old binge drinkers and importantly, harmful drinkers, described in the strategy as people who don t realise their drinking patterns damage their physical mental health and may be causing substantial harm to others. Specifically the Government s aims are to reduce the level of violent crime, disorder and anti-social behaviour, reduce the public s perception of drunken and rowdy behaviour and to reduce chronic ill-health, in order to achieve fewer accidents and hospital admissions. The strategy s objectives (described in the paper as outcomes ) are to: Increase the proportion of those drinking sensibly Reduce the number of those drinking above 50 units (men) and 35 units (women) per week, or drinking more than twice the recommended guideline on a regular basis; and Reduce the number of under-18s who drink and the amount of alcohol they consume 2
The new strategy s stated aims, objectives and expected measurable outcomes are a huge step forward in redefining alcohol as part of the new public health agenda. Alcohol Concern along with other activists have been working hard to achieve this recognition and it is gratifying to see this change in emphasis from government. For the first time we have a government strategy that aims to reduce consumption among at risk groups. This should add much needed fuel for those arguing the case for statutory partnerships to meet these outcomes at a local level. The downside of the paper is that there are no specifics for how much these reductions should be and by when. In this sense the objectives are not exactly SMART (specific, measurable, achievable, realistic, timed). There is also a complete lack of any commitment to see more problem drinkers entering treatment, or to narrow the gap between treatment demand and the acknowledged lack of provision in all Government Office regions. Once again, the issue of ongoing unmet demand for structured treatment for problem drinkers has been sidelined. Most worryingly the need for treatment appears to be actively downplayed and downgraded in its importance to tackling alcohol harm. Key areas of focus for the Strategy Reducing harm Local Partnerships There is positive work planned to increase support for GOs (Government Offices) to further support local initiatives to tackle alcohol related crime and disorder and to ensure strategic co-ordination on this. Following the Police and Justice Act 2006, CDRP (Crime and Disorder Reduction Partnership) strategies will be required to address alcohol related issues and from April 2008, GOs will ensure that CDRPs are supported to deliver local strategies and improve targets via Local Area Agreements. However, while the focus here is rightly on GOs ability to support local strategies tackling crime and disorder, there is no mention of increased GO monitoring, guidance or support for action to reduce health harms. This is an omission which could have supported public health groups within GOs to have a more strategic role in ensuring PCTs (primary care trusts) and other health providers and commissioners meet the Strategy s objectives. It is unclear why the Home Office will support Government Offices to tackle crime and disorder, but no mention is made of how the Department of Health will do likewise to tackle health harms. Earlier identification, intervention and treatment The strategy usefully plans action to provide a better commissioning framework for decisions to be made locally. This framework will provide much 3
needed intelligence for commissioners to plan for the range of interventions required locally. This is most welcome. There is also a plan for a national review of NHS expenditure on alcohol and a new healthcare collaboration to allow the learning from the SBI (screening and brief interventions) Trailblazers and other initiatives to be shared. Where the strategy could and should have gone further would have been in pinpointing levels of accountability and consequences if PCTs or local areas consistently deny resources to achieve comprehensive coverage of both early identification systems and adequate levels of structured treatment provision. In this sense there is the very real danger that simply issuing further guidance and support to increase intelligent commissioning decisions will not be enough of a lever to release much needed resources. The Strategy does not provide alcohol targets for PCT commissioners to reach, or any ring-fenced funds, despite the multitude of other national targets that commissioners are required to meet. Commissioners wanting to improve their provision even for SBI work would have been better served by an actual target to work towards. As things stand, the new strategy is probably overrelying on commissioners having more detailed and accurate information with no further money or targets to work with. Even with 15m provided by the Department of Health in 2007/8 for alcohol, it appears many PCTs have used this money for other purposes. Offending The strategy is strangely non-committal about new actions to reduce alcoholrelated offending. Most of the actions mentioned are already underway, although there will be revised ATR (Alcohol Treatment Referral) guidelines and much needed new work to share the learning from new alcohol arrest referral schemes. The greater emphasis on interventions for offenders is to be welcomed, and is something for which Alcohol Concern has been pressing for some time now. There is still much more work to be done to improve treatment for prisoners with alcohol problems, despite the mention of two new treatment programmes being developed by RAPt (Rehabilitation for Addicted Prisoners Trust), and Alcohol Concern s own befriender schemes. The Strategy contains no suggestion CARAT (Counselling, Advice, Referral, Assessment and Throughcare) resources can be used to work with prisoners with alcohol problems, unless they have illicit drug issues. Such prisoners will still be denied standard treatment other than detoxification and possibly AA support. A commitment to invest in the two new initiatives mentioned in the Strategy, if found to be effective, would have suggested a real improvement for problem drinkers in prison. Responsible retailing 4
There is very welcome news that Government will commission an independent review of the evidence on the relationship between alcohol price, promotion and harm. This will also include a review of whether current advertising restrictions are sufficient to protect children and young people. The review will particularly focus on the impact of pricing on heavy drinkers, young people and those on low incomes. In spite of the existing international evidence which Government must be aware of, of the link between price and alcohol harm, the fact that this is even being discussed by Government is a massive step forward. Price promotions The strategy rightly states that there is concern that deep discounting of alcohol can result in harmful drinking. The Competition Commission is looking into discounting in general (including alcohol), with a report expected later on this year, however there is no other action to address this area. This is a missed opportunity for Government to have come down harder on irresponsible retailers, although the results of the Competition Commission paper may possibly yield some follow up action. Review of social responsibility standards There is much better scope in addressing the industry s Social Responsibility Standards. There will be a wide ranging review of the effectiveness of the standards with a hint that independent monitoring may follow. At this stage there are still no moves to ensure the drink industry s CSR agenda is independently monitored and evaluated. There will however be monitoring of the level of industry contribution to the Drinkaware Trust and this will be considered under the consultation on legislation relating to the sale and promotion of alcohol. Labelling Government will consider legislation for labelling all alcoholic drinks with unit contents and sensible drinking messages. This will depend on the extent of the implementation of the voluntary arrangement agreed with the industry in 2007. Raising awareness The Strategy asserts that most people no longer want to tolerate drunkenness and anti-social behaviour as normal and states that Government now seeks to take a lead on challenging these assumptions, while providing more information to the general public as well as parents and young people in particular. This is most welcome. 5
Promoting sensible drinking Government have committed to a sustained awareness campaign to raise awareness of units, and targeted work to raise awareness of the risks of harmful drinking and the dangers of drinking during pregnancy. There is further mention of mainstreaming awareness raising through GPs, NHS health trainers and schools via help-lines or self-help materials. There is also work planned to raise awareness of the calorific content of alcohol. There is no indication of the duration of this work or the level of resources that will be committed to it. Support for harmful drinkers The strategy worryingly states that many harmful and dependent drinkers are able to modify their drinking levels without the need for professional treatment. While this may be the case for some harmful drinkers, there is a dangerous precept here for dependent drinkers, and the tone of this section of the strategy is decidedly unhelpful. The Strategy appears to stray from MoCAM (Models of Care for Alcohol Misurers) which argues for a comprehensive tiered approach to providing for people who need help to tackle their drinking problems. There is also reference to help-lines, internet tools and self help support for harmful and dependent drinkers. While clearly it is crucial for hazardous and harmful drinkers to have access to a range of support, these tools should not be seen as a catch all for dependent drinkers who do require professional support, and therefore as an excuse not to provide adequate formal treatment opportunities. The Strategy admits that resources for those who want to reduce their consumption are poorly developed in comparison with those seeking to stop smoking or losing weight. No mention is made of why this might be. In particular it does not identify the failure of Government public health planning as outlined in Choosing Health s, or the failure to provide resources for alcohol in 2005-7 as being one possible reason for this. The wording of this section is of some concern with respect to treatment for dependent drinkers. While the strategy continues the general policy trend of pushing for more screening and brief interventions alongside self-help models, there is a serious omission in not sticking more categorically to MoCAM s assertion that appropriate tiered interventions should be provided for all drinkers on a stepped care basis. Treatment services appear to have become more and more sidelined with each strategy the Government produces and this is particularly concerning when considering the cost savings that could be made from investment. 6
There is no clear action here other than developing a new range of information and advice for harmful drinkers and their friends and families. Under-18s The Strategy identifies three key actions to reduce levels of under-age drinking: a sustained awareness raising campaign further guidance to parents convening a panel to look at the latest evidence on the effects of alcohol on young people s physical and mental health. This bodes well in relation to reducing alcohol harms among young people, however there is no mention of current work underway with the Blueprint project, nor of any action to increase interactive and evidence based alcohol education. The Substance Misuse budget for young people was reduced this year and there is no mention at all of developing services for young people who are drinking at an earlier age and consuming more than before. The strategy has admitted there is a problem, set out a key objective to reduce the amount that under-18s drink but not outlined actions that will significantly address this in the short term. Conclusions The strategy is at its strongest in providing objectives to reduce rates of problem drinking amongst at risk groups. However no targets are set for the level of reductions required, nor any timescales for doing so. All actions outlined in the Strategy are to be welcomed, but it is clear that further levers will be needed to achieve the stated objectives. The usefulness of the Strategy for those working to reduce alcohol harms will be in promoting the objectives at a local level. These alongside other actions should, in theory, raise awareness and provide new evidence on price and alcohol s impact on young people. However, the rate of improvement to health in relation to alcohol will continue to be slow. 7