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Now you see it, now you don't - the National Alcohol Strategy revisited

The national alcohol strategy, which has been repeatedly promised for four years and which has been subject to countless delays, appears to have been hit into the long grass and may lie there for some time. In more sedate days, a Royal Commission might have been set up and the issue would have disappeared forever; the Chairman would have received a knighthood but nothing much else would have happened. In this more urgent, modernised world, the problem disappears – in this case not forever but for "six months" - into the maw of the Strategy Unit, a division of the ever-expanding Cabinet Office. This is precisely what has happened to the subject of alcohol misuse and the thorny topic of the national strategy. In response to a parliamentary question, Douglas Alexander, Minister of State for the Cabinet Office, has announced that "the Prime Minister, Tony Blair, has asked the Strategy Unit to carry out a project looking at how to tackle the problems associated with alcohol misuse".

At first sight, it appears that other arms of the Government did not know that this was about to happen. At the dispatch box on 18th June, Hazel Blears, the minister for public health who "leads" on alcohol issues, gave a categorical assurance to Glenda Jackson, MP, that the alcohol strategy was, even as she spoke, moving through the process of consultation between relevant government departments. On the 28th June, speaking at a conference in Newcastle-upon-Tyne, the Chief Medical Officer, Sir Liam Donaldson, said that a draft version of the strategy would at last go out to consultation in "the late summer".

It is worth looking at what Sir Liam said on 28th June, since it was implicit that he was outlining the main points of the national strategy. After emphasising that the problem of alcohol misuse not only involved the effect on people's health, but also social damage such as crime and disorder, accident and injury, and social exclusion he went on to say that "action to deal with this will therefore need to go beyond action by the NHS the Government, working together with the NHS, non-governmental organisations, the drinks industry and other stakeholders can: (i) identify early people who are problematic drinkers and intervene to help them modify their drinking patterns; (ii) work to change attitudes to problematic drinking to make it less socially acceptable; (iii) convey a consistent message on how to minimise the risk of using alcohol; (iv) provide treatment for those who suffer alcohol-related illness or who are chronically alcohol-dependent; and (v) act to limit the social damage, such as violence and disorder, created by alcohol misuse."

In the light of the wording of the Strategy Unit's "scoping note", it may well be that the ground was being prepared for the removal of responsibility for the national strategy from the Department of Health to a body more responsive to the requirements of other stakeholders – such as the drinks industry mentioned by Sir Liam.

Echoing the refrain of the drink industry's Portman Group, the scoping note begins with the statement, "The large majority of people in Britain who consume alcohol, enjoy doing so without causing any harm to themselves or others." It then goes on to outline "the range of possible problems" which may result from excess drinking:

  • crime, disorder and anti-social behaviour, particularly violent crime outside pubs and clubs and domestic violence;

  • a range of health impacts from accidents and injuries to serious chronic conditions, such as liver cirrhosis;

  • hazardous drinking by underage drinkers, who are more vulnerable to the detrimental health and other impacts of alcohol misuse;

  • problems for vulnerable groups e.g. children with alcohol-dependent parents or carers, those suffering mental illness and rough sleepers.

Asked by Alert why the issue had been removed from the Department of Health, a spokesman for the Strategy Unit said that it was felt that it was best addressed by an "overarching" body which brought together all the departments of government with an interest in the alcohol problem. In the words of the scoping note, "These are significant issues which cut across a number of policy agendas and need co-ordinated action from Government and service deliverers". There is no explanation given as to why it has taken four years to come to this very obvious conclusion, years during which the Department of Health has dealt with the issue whilst failing to produce the promised strategy. Either other departments demanded equal influence in the formulation of the strategy, or it was decided that Health had failed to deliver, or that its likely conclusions were too public health driven and contrary to the interests of other "stakeholders". The spokesman confirmed that these included the commercial interests of the drink industry. As reported elsewhere in this issue, a House of Lords committee recently accused the Government of being too much influenced by the industry and its mouthpiece, the Portman Group

We reproduce the outline of Government's part in the solution of the problem of alcohol misuse, its present policy, and the raison d'être of the Strategy Unit Project given in the scoping note:

The Government's Role

There are a number of good reasons why Government could play an active role in trying to prevent or mitigate the harmful effects of alcohol misuse. They include:

  • helping individuals make informed choices about potential risks (to themselves and others);

  • protecting the vulnerable, particularly children and people suffering from mental illness;

  • providing treatment and care for those who develop alcohol-related problems;

  • intervening to strike a balance between respecting individual choice and protecting society from the ill effects of alcohol – both the effects themselves (e.g. crime, domestic violence, negligent parenting and anti-social behaviour etc) and the avoidable costs to the tax-payer (which include considerable costs to the NHS as well as costs to the economy through absenteeism etc).

Current policy within Government

Currently, lead policy responsibility for alcohol rests with the Department of Health, but other departments – including the Home Office and DCMS – also have policy interests. This structure requires good co-ordination to be effective.

The Government declared its intention to introduce a cross-cutting strategy for tackling alcohol misuse in the 1998 Green Paper and the 1999 White Paper Our Healthier Nation. The Department of Health has been leading on the strategy.

The Department of Health sponsors the National Treatment Agency, which currently deals only with drugs treatment, although it is possible that this remit could be expanded to include alcohol in future. The Department of Health is also funding the pilot of a training course in brief interventions for GPs and practice nurses.

DCMS took over responsibility for licensing from the Home Office following the General Election in 2001. Following the White Paper 'Time for reform: Proposals for the Modernisation of our licensing laws' published by the Home Office in 2000, DCMS plan to introduce the Alcohol and Entertainment Licensing Bill. This will provide freedom for longer opening hours, rationalise the existing legislation covering premises that sell alcohol, and pass control of licenses from magistrates to local government. These changes will be a key step in the development of night-time economies in town and city centres, may help tackle town-centre crime and disorder associated with 'last orders' binge-drinking behaviour.

The Home Office leads on tackling crime and anti-social behaviour resulting from alcohol misuse. The recent Criminal Justice and Police Act 2001 gave the Police the powers to order the immediate closure, for up to 24 hours, of unruly or excessively noisy licensed premises; and to seize alcohol from those who are drinking in designated public places. It also introduced the requirement that all staff serving alcohol have a legal duty to satisfy themselves that a customer is not underage; and provided a legal basis for underage test purchasing.

Problems of alcohol are being addressed through a number of the Crime and disorder reduction partnerships. An action plan for 'Tackling alcohol related crime, disorder and nuisance' was produced in August 2000 and is being developed as one strand of crime reduction polices in SR2002. The Home Office is exploring further initiatives on the use of safety glasses and plastic bottles in licensed premises. The use of fixed penalties for being drunk and disorderly is being piloted in five areas.

There are also important links with drugs initiatives, though policies on this are being developed. Local delivery of the drugs strategy is co-ordinated by Drugs Action Teams (DATs) most of which also cover alcohol. In April 2002 each DAT produced Young People's Substance Misuse Plans detailing how education, prevention and treatment activities for drugs and alcohol will be expanded and integrated within wider provision for children and young people.

The Department of Transport leads on drink driving policies including the limits on alcohol levels in blood. DfES have an important role in providing education on alcohol through the national curriculum, alongside other work on drug misuse. DEFRA have the sponsorship role for the food and drinks industry.

Treasury and Customs and Excise have the leading role on taxation of alcohol, in developing policies and collecting revenue. Excise duty accounts for around 20% of household expenditure on alcohol and VAT accounts for another 15%. Customs estimate that around £750m of tax revenue is fraudulently evaded on alcohol, and there are also enforcement costs for Customs. This fraud is often perpetrated by organised crime. Customs have had recent successes in reducing the level of cross channel smuggling of alcohol.

In the Office of the Deputy Prime Minister, other policies and programmes where alcohol plays an important role include the SEU [Social Exclusion Unit] work on teenage pregnancies and prisoners and probation; the NRU [Neighbourhood Renewal Unit] initiatives on regeneration in deprived areas, where the problems of substance misuse are often disproportionately worse; and the Homelessness Directorate's interest in tackling the high incidence of alcohol dependency amongst the homeless.

Current and potential policies

There are a range of policy levers that are, or might be, used to reduce the worst harms associated with misuse of alcohol and the risks of young people developing harmful drinking patterns. These include licensing and policing measures, prevention through education and awareness raising, brief interventions to provide advice through PCTs [Primary Care Trusts] or at hospitals, treatment programmes, working with industry on serving policies, control of inappropriate drinks promotion and advertising and marketing. The effectiveness of these will depend upon the groups and problems that are being targeted. Research suggests that some measures e.g. brief interventions, stricter enforcement of licensing and extending opening hours can be successful in reducing the problems of alcohol misuse. However there is currently only limited evidence on the cost-effectiveness of different measures.

There are potentially a number of specific interventions that would help to tackle the problems associating with alcohol misuse, without interfering with people's legitimate right to drink. The Strategy Unit (SU) project will seek views on existing and other possible interventions and investigate whether they are likely to prove effective.

The range of delivery agencies

Co-ordination of different initiatives and setting the direction are likely to be as important as some of the individual measures. Co-ordination between different delivery agents on the ground, as well as at the centre – and between the public, voluntary and commercial sectors – could also help maximise effectiveness of existing as much as planned initiatives.

Why a Strategy Unit Project?

There are two main reasons why the SU would add value in this area:

  • Alcohol is a genuinely strategic and cross-cutting issue, with a range of departmental and other interests and perspectives. Although overall alcohol consumption is stable, the misuse of alcohol appears to be growing and some of the problems associated with drinking may be getting worse. Policies and programmes both across and within Departments need to be well co-ordinated, not least because many of the costs and policy levers lie outside the lead departments. The Department of Health has lead policy responsibility for alcohol misuse although many of the costs fall on the criminal justice system. The likely extension of opening hours, following licensing reform, will highlight the case for a clear and joined-up approach on the range of potential alcohol-related problems.

  • There is also a clear need for rigorous analysis of the evidence base and fresh and innovative thinking about new ways of tackling problems such as hazardous drinking by the young, all of which are suited to SU's method of working.
    The SU project will provide the main vehicle for progressing the analysis and conclusions for the cross-cutting Government strategy on alcohol misuse. The team will work closely with DH and other key departments such as the Home Office and DCMS.

The aims of the project will be:

  • To analyse the problems and the possible instruments and policies for tackling the harm caused by alcohol misuse – with a particular focus upon alcohol related crime and anti-social behaviour, and vulnerable or 'at risk' groups;

  • To analyse existing activities across Government and the links with external organisations to explore how resources and programmes might be better joined-up;

  • To suggest the changes in data collection and analysis needed to improve understanding of the problem, evaluate success of policies and achievement of any targets;

  • To provide the analysis and key conclusions to underpin the Government's alcohol misuse strategy.

There follows a curious section called:

Key questions and issues

Key questions the project will consider include:

  • What are the key drivers and trends in alcohol consumption and in patterns of drinking?

  • What factors cause people to misuse alcohol?

  • What is the evidence on underage and young people's drinking, and the negative impacts, including crime and anti-social behaviour?

  • What is the evidence on the links between alcohol misuse and health, crime, disorder, domestic violence, family breakdown, rough sleeping etc?

  • What is the boundary between non-harmful and harmful drinking?

  • How do high risk behaviours, such as hazardous drinking, smoking, illicit drug use etc correlate?

  • How should instruments be targeted at different groups e.g. by age, socio-economic class, geographically?

  • What policies will reduce crime and disorder associated with excessive drinking by some? Which measures are most cost-effective?

  • What policies work in education, prevention and treatment, both for influencing problem drinking and tackling alcohol dependency? Are existing treatment programmes cost-effective and do these have the right level of resourcing?

  • Is it possible, and if so how, to bring about changes in drinking culture (particularly amongst young people) to reduce the harm from alcohol misuse?

  • Could more be done to align the interest of pubs, retailers and the brewing industry with the objective of encouraging people to enjoy drink sensibly?

  • Is it possible to raise concern about healthy lifestyles, including alcohol, amongst the more at-risk groups?

The fact that these basic questions are asked implies that the vast amount of research already carried out and the innumerable reports produced are either to be augmented by further, duplicating efforts, or that they are simply to be considered as part of the information brought to the Strategy Unit Project by whoever speaks on behalf of the Department of Health, having no greater status than research and reports carried out on behalf of the drinks industry. It is interesting to note the penultimate bullet point. The implication could not be clearer – public health concerns must be accommodated to the commercial needs of the industry.

Finally the scoping note details:

Timescale and team

The project will start work in July 2002 and aim to complete early in 2003. The project team intends to work closely with a wide range of stakeholders including industry representative bodies, voluntary organisations and other NGOs, external experts and academics, medical bodies, police and criminal justice organisations and service deliverers, as well as with central and local Government.

The project will undertake an extensive process of consultation with all stakeholders and relevant groups. This paper is intended to start this process and we would welcome views on any of the areas it covers. In addition, we will make use of a variety of other consultation routes, including meetings and workshops, together with surveys and further research through the summer and autumn. We expect to issue a further consultation paper jointly with the Department of Health later in the year covering the key issues identified by the SU project and the alcohol harm reduction strategy.

The project team will be drawn from both key Whitehall departments and outside Government. Hazel Blears, Parliamentary Under-Secretary of State at the Department of Health, who leads both on alcohol and public health more generally, will be sponsor Minister for the project.

A number of interesting points arise from this section. Although we are told that "the project will start work" in July 2002 – the announcement was made on 19th July – as early as 11th June officials from the unit were contacting organisations in the United States on how they dealt with the alcohol misuse issue. This was one week before Hazel Blears gave her answer in the Commons about the progress of the national strategy.

It will not ease the suspicions of many that the industry exerts too much influence with this Government when they head the list of "stakeholders".

For four years the appearance of the strategy has been announced and then repeatedly put back – there is still a Home Office website which tells us that it can confidently be expected in 2000. Reasons given for the delay have included staff shortages and the reorganisation of the Health Service. Now, when all indications were that at last it was about to see the light of day, responsibility for its production is taken away from the Department of Health and given to the Cabinet Office.

According to well-informed sources, Alan Milburn had no interest in the subject and did not want it within the remit of his department. This may have accounted for some of the delay and led to frustration within other branches of government. The idea of "issues across government" as part of the Cabinet Office's responsibility is, as has been observed before, a handy catch-all for concentrating power in what has, in effect, become the Prime Minister's Department. Very few issues affect only one department of government and it must have been clear from the beginning that alcohol misuse impinged on several. Presumably the Cabinet Office was aware of the Ministerial Interdepartmental Group on Alcohol Misuse, which issued its first report in 1988, and of the research undertaken jointly by the universities of York and Hull fourteen years ago covering precisely the areas the Strategy Unit Project now proposes to revisit. One of the products of this project was a report entitled Alcohol Policies – Responsibilities and Relationships in British Government. In addition, the Strategy Unit, if it wishes, has only to look at the 1995 Inter-Departmental Report on Sensible Drinking and the mountain of documents, handily summarised in 114 pages, produced for the Scottish National Alcohol Strategy, 2001.

The points set out by Sir Liam Donaldson in Newcastle on 28th June made very clear his awareness of cross-departmental responsibility. He may, of course, already have known that the Strategy Unit was about to take over – indeed, had already begun work with its enquiries in the United States. But why, then, promise a draft strategy "later this summer"? At a stretch, his words, and those of Ms Blears in answer to the parliamentary question of 18th June, could be taken to cover the consultation now to be carried out as part of the Strategy Unit Project but no-one at the Newcastle Conference or in the House of Commons could possibly have understood them to refer to a new exercise.

Answering questions from Alert, the same spokesman implied that the draft strategy promised by Sir Liam and the Minister was one and the same thing as the consultation promised by the Strategy Unit Project, but the "scoping note" makes it quite clear that this is a new and extensive operation and that the work which has been done in the Department of Health over the last four years will only be looked at as one contribution among many. The "scoping note" says:

We would like to hear from you with your views on:

  • Our proposal for this project – is it tackling the most relevant issues, where are the gaps in our analysis, are we analysing the problem in the right way?

  • The evidence base – do you have, or know of, good-quality data and information on the nature of the problems or the effectiveness of interventions that we could use in our analysis?

  • Possible interventions – do you have ideas or evidence for new interventions that might prove effective?

  • Best practice and case studies - Are there any good examples either in the UK or overseas we should look at?

  • Any other comments on the approach or the analysis.

In response to the suggestion that his Unit was beginning with a clean sheet of paper, the spokesman said that he "was not sure we have gone back to the beginning". The questions asked in the "scoping note" and the request for more data, research, evidence of good practice and the like indicates quite the opposite and are a receipt for delay well beyond the "spring of 2003" deadline.

There is no doubt that these developments will strengthen suspicions that the drink industry has succeeded in ensuring that the projected national strategy is formulated where it can exert an influence.

To contact the SU Alcohol Project team, either email:
SU-alcohol@cabinet-office.x.gsi.gov.uk,
or telephone on: 0207 276 1434,
or write to:
SU Alcohol Project Team
Strategy Unit
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London
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