“A tale of two cities”: Is local variability in alcohol policy a virtue or a vice?

In this guest post, John Mooney, a Senior Lecturer in Public Health at the University of Sunderland, explores the findings and potential lessons from a recently published case study research project exploring two differing approaches to local alcohol strategies.

There is no doubt that the transfer of public health (PH) teams back to local authorities (LAs) in England held considerable promise for addressing the “so-called” wider determinants of health that underpin so much of modern complex public health priorities [1]. Indeed many PH teams have enthusiastically embraced the opportunities to work with colleagues to explore how existing ‘policy levers’ such as in housing standards or using the planning system to restrict fast-food takeaways [2] can be genuinely informed by public health aspirations and insights.

In respect of alcohol, a major change has been the inclusion of directors of public health as statutory consultees or as one of the ‘responsible authorities’ involved in the appraisal of new applications for licences to sell alcohol [3, 4]. Since public health teams in local government also now to a large extent are involved in commissioning alcohol services [5], their role could be said to extend across every aspect of treatment and prevention.

With regard to alcohol misuse and harmful consumption, recent evidence in a series of papers led by de Vocht and colleagues [6-8] have pointed to the potential gains that might be realised from more pro-active approaches to alcohol licensing in particular. There is also a considerable international consensus that structural interventions such as measures around price and availability are among the best evidenced polices nationally and internationally [9-12]. However, translating how best to incorporate the most promising policies in a local authority context has to deal with a high degree of uncertainty about the prospects of success for any particular policy or programme. The not inconsiderable diversity for example in respective circumstances, local economic factors as well as prevailing population characteristics and cultural differences, are all likely to impact significantly on the feasibility, practicability and likely effectiveness of different local alcohol ‘policy mixes’.  Efforts to establish ‘transferable evidence’ in relation to single policies or interventions is likely to be of limited value therefore without any appreciation of the contextual factors that have given rise to a particular approach.

The use of case studies is one widely accepted means of delving into the detail and complexity of different circumstances, whether the unit of analysis is individuals, groups or organisations [13]. We recently employed a comparative case-study design to examine in detail the underlying drivers of local variability on alcohol policies in two purposefully selected local authorities [14], both located in the northern half of England but in different regions (see box 1). Sites were deliberately selected that were known to exhibit contrasting approaches to reducing alcohol harms, although both had rated it as one of their top three priorities.

Box 1: Local Authority (LA) Case Study Sites Selected

[Extracted from published paper [14]].

A total of 13 key stakeholders were interviewed beginning with public health, licensing / trading standards and commissioning, then snowballing to recruit other relevant stakeholders including the police and those involved in the delivery of clinical interventions. Each LA’s respective alcohol harm reduction strategy and statements of licensing policy were also reviewed. As an integral part of the case study method, we sought corroboration across different sources and between stakeholders about the relative importance of the many and varied influences on policy preferences and direction.

The major contrast in the approach of the two study sites, partly established at the pre-selection phase, then subsequently confirmed on detailed review, was the degree to which one LA (LA2 in the study), seemed to focus very strongly on licensing and availability, while the other (LA1) had a more upstream approach to tackling alcohol harms, much more orientated around clinical approaches such as screening and brief interventions.

As the study progressed it became clear that these seemingly divergent approaches had developed for very understandable reasons attributable to each LA’s particular situation and set of circumstances. For LA1 for instance, there was an apparent tension between the drive to ensure proper public health scrutiny of licence applications and not wishing to discourage investments in the city centre. LA2 in contrast saw tackling some of the excesses of their night time economy and its impact on public disorder as a high priority, an area where there was strong support from the police and emergency services. This ‘downstream’ focus on the very visible aspects of alcohol harms also capitalised on the award of a modest grant from a charitable foundation specifically targeted at resolving inner city problems. The third key facilitator of an approach which focused on regulating the commercial alcohol environment, was the capacity and expertise of a legal team to anticipate and successfully deal with challenges from industry and retailer legal challenges.

The three most prominent facilitators of the more heavily treatment focused approach in LA1 were first and foremost the undertaking of a large scale health needs assessment around alcohol misuse and its related health impact: the finding that there were substantial proportions of the population at risk of alcohol harm but who were not willing or able to seek help (due to a combination of restricted access and cultural stigma), prompted urgent reviews of the availability and format of screening and brief interventions. This coincided with two complimentary enabling factors, namely the recognition of the cost effectiveness of effective early intervention by a forward looking CCG and the presence of an enthusiastic clinical champion, which is a well-established facilitating factor for primary care related developments in particular [15]. The CCG were sufficiently convinced of the economic case to invest in providing screening and brief intervention within the hospital setting as a means of trying to reduce expensive and clinically risky emergency detox procedures. Provision of screening in an acute setting together with enhanced complementary primary care provision made for a highly integrated service and the area has been highlighted as an exemplar for the provision of screening and treatment services.

Perhaps the most striking aspect of the project as we consolidated information across sources and shared preliminary findings, was that in spite of the evident differences in approach across two very different sites in relatively distant regions, there was also evidence of “convergence” as each LA site independently identified those areas that needed more attention in order to balance harm reduction efforts across the area. This finer scrutiny also revealed that there was likely to be much activity ‘under the radar’ in the areas where each LA was perceived to be less proactive. While LA2 for instance, had a far less co-ordinated approach to the provision of clinical interventions, a multiplicity of providers made it difficult, even for those working within the services, to appreciate how much was being done as a whole. Conversely, a more subtle but highly engaged approach of dedicated police licensing officers in LA1, had proven to be a very effective means of addressing the excesses of the night-time economy, without significant recourse to licensing and review panels (which, being resource intensive, were seen as a last resort). These more subtle ‘monitoring arrangements’ extended even to keeping tabs on premises social media accounts to monitor irresponsible promotions, which would “not be in keeping” with the promotion of the four licensing objectives with which licensees are obliged to comply [3, 4].

The comparative case study has therefore been a useful and insightful method of dissecting the particular circumstances underpinning a contrasting approach by two English LA’s both of whom had prioritised and invested in tackling alcohol harms. The restriction of the above comparison to just two sites and perhaps more importantly to just one point in time flags up an important caution applicable to all such ‘cross-sectional snapshots’ in that local alcohol policy mixes are often in a state of flux, responding to changing patterns of alcohol harm and / or consumption, financial and economic pressures and local political drivers and personnel. Even over a short six month timespan, there were signs of policy evolution in response to such factors, which is hardly surprising and indeed is positively encouraged by the inherent scope for flexibility within the legislation and accompanying guidance. Of course local alcohol policies are also subject to national changes in strategy and direction which can enable or frustrate them, or necessitate changes in emphasis [16]. For all of these reasons, the study described can only really hint at the many complexities involved in the development of local policy responses to alcohol and could be seen as a perfect illustration of the need for the complex systems approach that was recently advocated for all modern but seemingly intractable public health problems [17]. Such an approach would ideally be able to allow for the incorporation of interactions and feedbacks between the key drivers and facilitators, in recognition that none of them act in isolation.

A key ongoing challenge for public health teams in relation to local alcohol policies is therefore the extent to which the traditional ideals of adopting evidence informed practice may be compromised in an environment where other approaches to rationalising policy can predominate [18, 19]. The traditional over-riding focus on crime and disorder when it comes to alcohol harms alongside the continued exclusion of health from the required licensing objectives in England and Wales can also present difficulties for those looking to integrate a population health perspective into local alcohol planning and regulation [20]. Increasing awareness that these challenges face all public health teams in whatever local circumstances they find themselves might help foster more comprehensive solutions as different LA’s pioneer novel policy approaches according to their own priorities and local population profiles of alcohol harm.    

References

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Acknowledgement

This article is based on the following open access publication  [14]:

Mooney JD, Holmes J, Gavens L, de Vocht F, Hickman M, Lock K, Brennan A: Investigating local policy drivers for alcohol harm prevention: a comparative case study of two local authorities in England. BMC public health 2017, 17(1):825.

The work that is the subject of this article was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR). NIHR SPHR is a partnership between the Universities of Sheffield, Bristol, Cambridge, Exeter, UCL; The London School for Hygiene and Tropical Medicine; the LiLaC collaboration between the Universities of Liverpool and Lancaster and Fuse: the Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities.

Any opinions expressed are those of the author.