Alcohol Policy UK

More action needed by local authorities, says Alcohol Concern review of JSNAs

Alcohol Concern have assesed the level of priority given to alcohol across 25 local authorities in England in a new report. The audit found that although most key local needs assessment documents recognised alcohol, most did not go far enough to address the full impact of alcohol misuse on the local population. 

Download 'An audit of alcohol-related harm in Joint Strategic Needs Assessments, Joint Health and Well-being Strategies and CCG Commissioning Plans' [pdf]

The report highlights the "unprecedented and wholesale changes to health service" over recent years, impacting on local structures and commissioning. The shift in responsibility means that Joint Strategic Needs Assessments (JSNAs) should now be taking centre stage for local action and decision making by Clinical Commissioning Groups (CCGs) and local authorities. 

However many key alcohol needs assessments gave alcohol only a brief mention – far from the ‘comprehensive section on alcohol harm’ that Public Health England recommends. Local prioritisation to alcohol also appeared less in areas classified as lower need in the NWPHO dataset, but Alcohol Concern warn such areas must not overlook the still significant impact of alcohol misuse. The report raised other specific concerns, including a gap in some areas failing to recognise key evidence based approaches including addressing hospital admissions or delivering Identification and Brief Advice (IBA) or treatment.

The report makes 11 recommendations. In particular, local Directors of Public Health need to ensure alcohol is sufficiently prioritised with attention to the local picture, with needs assessments making use of wider datasets. As one example, the needs of young people should not over-emphasised in comparison with other groups, including older adults.

It also recommends that Public Health England (PHE) should note the positive impact of the alcohol-related hospital admissions indicator on local prioritisation of such work, and consider indicators around IBA or treatment provision to improve local responses. Public Health England have an Alcohol stocktake self-assessment tool to encourage local areas to take a systematic review of their strategy for addressing alcohol-related harm. The report suggest this may not be going far enough to promote widespread local prioritisation.

Last year Alcohol Concern published a Guide to Alcohol for Councillors, which aims to help councillors meet the new commissioning challenges and tackle alcohol abuse in their communities. NICE has a comprehensive set of alcohol guidance and quality standards, including alcohol pathways and further tools. NICE also recently released Public Health Guidance for local authorities.

The new indicator for alcohol-related hospital admissions - simple?!

As explained in a recent post on Public Health England's blog and our initial report, the all-encompassing alcohol-related hospital admissions indicator we came to know and love now has a new slimline companion, to be published in the Public Health Outcomes Framework. 

This follows a consultation by PHE last year after the PHOF identified a "preferred option" of an indicator "based on just alcohol-related primary diagnoses".

The new headline indicator is simpler than the previous, although it still relies on 'attributable fractions', which are explained here by the Local Alcohol Alcohol Profiles for England (LAPE) boffins. Attributable fractions are just a scientific way of saying that, on average, some hospital admissions are more related to alcohol than others. This allows calculations as to the overall contribution of alcohol to hospital admissions given its wide health impact.

Hospital admissions are coded for the purposes of data collection according to ICD-10, and each admission is assigned a primary code and up to 19 secondary codes for any diagnoses that affect the treatment needed. The secondary codes may include 'external cause' codes such as motor accident or fall - ie describing the circumstance of the patient that lead to admission.

The original indicator searches every hospital admission for a code that is linked to alcohol and applies the attributable fraction to it. Where an admission has more than one alcohol-related code, the code with the highest attributable fraction is used. The sum of all these fractions of admissions is then used to calculate the rate of alcohol-related admissions for a given population.

The new indicator uses a much narrower search: it looks only for primary or external cause codes that relate to alcohol. These are counted in the same way as before, ie by applying attributable fractions.

Some examples that illustrate the difference between the old and new indicators are highlighted below:

• Patient admitted with a broken leg but also has hypertension (and no alcohol-attributable external cause codes) - IN OLD INDICATOR BUT NOT IN NEW INDICATOR
• Patient admitted with hypertension and various other conditions but hypertension is recorded as the primary code (or reason for admission) - IN OLD INDICATOR, AND IN NEW INDICATOR
• Patient admitted for head injury (primary code) and acute intoxication (secondary code) but no external cause codes -  IN OLD INDICATOR BUT NOT IN NEW INDICATOR (comment: an unfortunate anomaly in the new methodology)
• Patient admitted for head injury (primary code) and a car accident (secondary <external cause> code) - IN OLD INDICATOR AND IN NEW INDICATOR
• Patient admitted for acute intoxication (primary code) - IN OLD INDICATOR AND IN NEW INDICATOR

Pros and Cons?

Clearly the new indicator will produce a much smaller headline figure of alcohol-related admissions. As we highlighted last year, this revised annual figure is likely to come in under 300,000 - way down from the previous annual headline figure of well over one million. This could result in far less press attention to the issue of alcohol-related admissions, which may please critics of the previous one.

PHE argue that the new methodology will be more sensitive to local action on alcohol-related harm (by including a higher proportion of acute admissions due to alcohol), and less influenced by changes in coding practice. However, others fear that the impact of excessive drinking on chronic conditions will be sidelined by the new indicator. See the PHE blog Understanding alcohol-related hospital admissions and associated comments for more on this.

News & updates March 2014: liver disease warning; Vaportini; boozey school fetes; E-cigarettes and alcohol; trade news

Some selected media stories since the February round-up:

Alcohol and health

The all-party Parliamentary Hepatology Group says deaths from liver diseasee in England have risen 40% between 2001-2012, and that the lack of Government action to tackle it is 'scandalous', reports the BBC and the Guardian.

Research by the University of Leeds suggests drinking alcohol during the first three months of pregnancy is linked to a higher risk of having a premature or unexpectedly small baby.

Hidden levels of sugar in alcohol revealed, says the Telegraph. It suggests one pint of cider contains almost as much sugar as the WHO recommended average daily intake.

New alcohol 'craze'?

Experts have warned against a new 'Vaportini' drinking craze, suggesting the inhalation of alcohol "has the potential to be a very dangerous phenomenon", says the Express.  See a review of the Vaportini in Cosmopolitan.

Should school events allow alcohol to be served? A warning has been issued by the charity Swanswell over the example being set at around 8,000 school events and fetes granted alcohol licenses each year, reports the Guardian.

E-cigarettes and alcohol

Welcoming a consultation on the rules governing how their products should be advertised, e-cigarette makers will fight proposals to ban linking them with alcohol, reports The Grocer.  Meanwhile, anti-smoking campaigners are urging pub operators to keep their policies on e-cigarettes under review as controversy grows around the device, reports The Morning Advertiser.

Trade news

The rise of 'dry' bars has been explored in a PRI reports article on Sobar in Nottingham and a Guardian piece which asks 'is England sobering up?' - perhaps rather simplistically.

New research from the Campaign for Real Ale (CAMRA) has shown how communities are banding together to take over their local pub under the Community Right to Bid, which allows residents to nominate pubs as Assets of Community Value, reports the Morning Advertiser.

The Daily Mail has proclaimed the death of alcopops, quoting health minister Earl Howe: ‘Sales of alcopops are in marked decline, to such an extent that the market for these products looks like disappearing in the next few years’.

Police chiefs claim they are on the verge of winning major supermarket backing for a national clampdown on super-strength beer and cider, reports The Grocer, as Ipswich's Reducing the Strength scheme gains traction across the country.

Cheltenham's late night levy (LNL) came into force on April 1st, see the BBC. This is only the second such levy in operation (after Newcastle), although Islington council recently voted to implement a LNL after September 1st this year, with more expected to follow (see previous APUK update).

Running a pub is amongst the toughest jobs, as explored in a Guardian piece 'Why are pub landlords in low spirits?. Indeed a bid to better protect bar workers by introducing a specific offence of assaulting aworker selling alcohol was put forward, however it was blocked as MPs thought it wouldn't help.

Local Alcohol Action Areas announced as Home Office demands more industry action

Last week the Home Office announced the twenty Local Alcohol Action Areas (LAAAs) areas across England and Wales it would support to "combat drink-fuelled crime and disorder and the damage caused to people’s health."

Although no additional funding is available to the LAAAs, each will receive support from the Home Office and relevant central health bodies such as Public Health England. The initiative follows the much larger 2008-2011 Alcohol Improvement Programme (AIP) and a 2008 Home Office scheme.

Government input is likely to cover areas identified in the PHE alcohol stocktake tool, an emphasis on industry-led Local Alcohol Partnerships and support around licensing and night time economy issues. Few if any areas seem to have 'cracked' an effective mechanism for public health input into licensing decisions following changes to the law. Just a few areas such as Newcastle and Cheltenham appear to have approved a local Late Night Levy, whilst recently Blackpool's bid to implement the first EMRO was unsuccessful.

Expect more industry-led action?

Announcing the LAAAs, Home Office Minister Norman Baker stated he was "pressing the industry itself to take more responsibility for the problems that inappropriate use of their products cause." A subsequent Independent story reports the alcohol industry has been "ordered by the Home Office to produce plans to tackle the sale and promotion of cheap super-strength beers and cider by the summer or face government action".

The Indy reports that Baker is insisting they must speed up the development of a voluntary code agreed last year to set up voluntary commitments, such as minimising alcohol advertising and confining displays and promotions to single areas. The Portman Group and the Wine and Spirit Trade Association have apparently agreed to take the industry lead on proposals.

Of course health groups wanting tougher action are unlikely to be pleased with emphasis on industry-led partnership schemes or voluntary action. Last year ASDA quit its pledge to stop promoting alcohol in its foyers after other supermarkets had not followed suit - CEO Andy Clarke said the Government needed to do more to 'level the playing field'.

ASDA had originally announced the pledge in 2011 following the controversial Responsibility Deal, which saw further health partners walk out following the minimum pricing u-turn. However industry led work to deliver on the Responsibility Deal alcohol pledges such as labelling, unit reduction and support for Drinkaware is continuing.

Home Office offers support through Local Alcohol Action Area (LAAA) project

The Home Office has written to Local Authority Chief Executives inviting them to apply to take part in a Local Alcohol Action Area (LAAA) project. The LAAA project aims to offer 15-20 areas with high alcohol-related harms help with local initiatives over a 15 month period.

The Home Office and Public Health England say they will provide advice and support to areas in formulating their action plans and reviewing progress, but will not be prescriptive. For instance it will be up to Local Authorities to decide their own priorities for local action or how large an area to focus on. However no additional funding is offered as part of the support.

Projects must be in line with three key aims: tackling alcohol-related crime and disorder; reducing alcohol-related health harms; and promoting growth by establishing diverse and vibrant night-time economies. The letter says the Home Office will make connections with mentor areas and bring together areas to share learning and solve joint problems. They are also "challenging the alcohol industry to support LAAAs, prioritising the roll-out of best practice schemes and galvanizing the support of businesses".

Local Authorities wishing to opt-in to the LAAA project need to complete an EOI template by 15 November 2013. See the letter to Chief Executives here. In selecting the LAAAs the main criteria will be that the areas "must have higher levels of alcohol-related crime and disorder, alcohol-related health harms or have a night-time economy that offers little beyond drinking alcohol."

Recently PHE released an alcohol stocktake tool to help local areas assess their local strategic approach to addressing alcohol harms. An evaluation of the Department of Health's 2008-2011 'Alcohol Improvement Programme' (AIP) was also recently released. The AIP included the alcohol National Support Team (ANST) which included diagnostic and support visits for local areas.

Public Health Licensing event presentations available

DrinkWise recently organised a Public Health Licensing workshop to explore and discuss the challenges and opportunities facing Public Health playing a meaningful role in licensing.

Presentations on the day included:

• 'Expect delays and cancellations' Ian Leete, Local Government Association

• 'Evidence -The Reality' James Button, James Button Solicitors

• 'Outlet density and cumulative impact' James Nicholls, Alcohol Research UK

• 'Licensing Policy' Sharon Davies, Blackpool Council

• Public Health in Licensing approaches in London – Safe Sociable London Partnership

DrinkWise are also encouraging discussion and best practice sharing on the Drink Wise discussion forum. In London the Safer Sociable London Partnership have also been running Licensing masterclasses to help support London boroughs - large pdf slide set here.

In England new licensing powers have been in effect since last year as part of the the Police Reform and Social Responsibility Act (PRSA) 2011. The changes included councils becoming 'responsible authorities'. However only a few local authorities have so far implemented measures such as the Late Night Levy, though in Scotland an evaluation of Scotland's Licensing 2005 Act has reported positive impacts.

A number of toolkits and guidance documents have since been released to try and support local action in England, including developing effective public health responses. However with public health absent from England's licensing act core objectives, progress may rely on good data sharing to improve responses to existing objectives.

Evaluation of the Alcohol Improvement Programme: too soon to tell?

An evaluation of a national led programme to reduce alcohol-related hospital admissions and improve local level action has been published.

It finds although the Alcohol Improvement Programme (AIP) was not found to have impacted on national level hospital admissions, it did help improve the prioritisation and delivery of local action.

The 3 year £22 million AIP was funded by the Department of Health and ran from 2008-2011. It provided support to the NHS and third sector in delivering alcohol harm reduction, particularly around identified 'High Impact Changes' such as IBA and hospital liaison. Investment was delivered primarily through Early Implementer areas, Regional Alcohol Offices, NWPHO alcohol figures, the Alcohol Learning Centre (ALC) and the alcohol National Support Team (ANST).

The primary aim of the AIP was to contribute to a reduction in the rate of increase of alcohol-related hospital admissions (ARHAs), which it was not shown to have achieved. However the evaluation identified a number of issues with measuring this aim, including the wider and longer term context of rising admissions, despite falls in consumption since 2004. Other possible problems with this measure were the potential for increased coding or referral of alcohol-related problems, although it noted this should be regarded as a positive outcome.

Asides, the AIP and its aims were regarded positively, particularly as a 'change agent' for instigating local level action. Areas that received 'Early Implementer' support were regarded to have significantly strengthened strategic development of local actions. Indeed the ongoing prioritisation by many local areas in the new policy context may be regarded as part of the AIP's legacy. The Alcohol Learning Centre remains a useful 'one stop shop', and efforts around IBA and alcohol hospital liaison have continued or even increased.

The evaluation recommends that many such aspects of the AIP should be retained and built into the new policy context. In particular, actions to support and foster 'virtuous' partnership approaches and strategic leadership are crucial. This may be undermined by a decrease in specific strategic level alcohol roles and the absence of alcohol-specific funds. Retaining targets such as those to reduce hospital admissions is also advised as, if nothing else, they provide an incentives and focus for action. However under the current localism agenda, this recommendation may fare less well.

The report also calls for the need to maintain a strong policy focus on alcohol and attention to service development. These areas are now being led by action from Public Health England (PHE), who having incorporated the former NTA, are keen to ensure continued prioritisation and support around alcohol. Recently PHE released an alcohol stocktake tool which clearly reflects key approaches set out in the AIP.

The report highlights the AIP was always a time limited programme, so it's ambition to maintain a legacy of an improving evidence base, infrastructure and capacity for alcohol harm reduction should be recognised. Continuing falls in consumption are certainly likely to reflect economic difficulties, but the alcohol harm reduction agenda can surely also take some credit. Nonetheless, such evaluations cannot truly answer to what extent alcohol harm reduction efforts have - or will - impact on drinking, its impacts and trends.

'Guide to Alcohol for Councillors' published by Alcohol Concern

Alcohol Concern have released a Guide to Alcohol for Councillors, which aims to help councillors meet the new commissioning challenges and tackle alcohol abuse in their communities. 

As of April 2013, local authorities are responsible for the commissioning of alcohol prevention and treatment services as part of their new public health responsibilities. The guide sets out the context of alcohol harm, local government's role, an action list and other insights such as good practice case studies.

It highlights tackling alcohol misuse will positively affect every key local authority department. Local authorities will also be additionally incentivised and measured against the health indicators set out in the Public Health Outcomes Framework for England 2013 – 2016, and estimates that alcohol plays a role in almost a third of them.

Eric Appleby, Chief Executive of Alcohol Concern said:

“With local authorities taking responsibility for public health there is a huge opportunity to begin tackling alcohol harms at a local level and to save lives and cut crime.

“We know that the cost of alcohol misuse is enormous and that it takes its toll on so many aspects of our communities, whether it’s policing, providing hospital treatment or supporting children living with parents with an alcohol problem.

“We produced this guide to illustrate to councillors the extent of the damage done by alcohol misuse and to support them to develop a robust and effective alcohol strategy which benefits their entire community.”

NICE has a comprehensive set of alcohol guidance and quality standards, including alcohol pathways and further tools. NICE also recently released Public Health Guidance for local authorities. Also recently available is commissioning guidance for alcohol and mental health.

DrugScope have released a briefing on 'Public Health Reforms: What they mean for drug and alcohol services'. A recent RCGP briefing explores Primary Care Drug and Alcohol Commissioning. See the Alcohol Learning Centre commissioning pages for more.

National alcohol survey data to be axed? ONS consultation

As forecast, the Office for National Statistics (ONS) has opened a consultation on axing some of its statistical products, including:

• General Lifestyle Reports (Smoking and Drinking; General Health; Households, Families and People; and Marriage and Cohabitation) and associated data
• annual statistical bulletin on Alcohol related deaths in the United Kingdom
• Decennial Analysis of social inequality in alcohol related causes of death by NS-SEC and sex

The ONS needs to save £9 million over the next two years. The consultation questionnaire lists each option for saving and asks about the impact these possible reductions could have on you and your work. A pdf version of the questionnaire is provided for information and discussion purposes. Responses should be submitted via the online questionnaire by 31st October 2013. 

The General Household Survey/Lifestyle Report is an important source for monitoring trends in alcohol consumption, annually released since 1971. Drinking data from the Survey are widely used by universities and health organisations. The Public Health Observatories (PHOs) use the data on drinking to produce model-based estimates of alcohol consumption at local authority level to inform local decision making.

ONS could save between £100,000 and £500,000 by stopping the Survey. Chopping the bulletins on alcohol-related deaths could save £10,000 to £50,000 each. These savings are small beer compared to the £21 billion a year alcohol-related harm is estimated to cost the UK. ONS aims to publish a summary of the findings of this consultation in early 2014.

Alcohol Research UK have called for those in the alcohol field to respond to the consultation.

PHE release 'alcohol stocktake self assessment tool'

Public Health England have released an Alcohol stocktake self-assessment tool [doc]. It allows local areas to take a systematic review of their strategy for addressing alcohol-related harm in the adult population. See here for a slides overview [ppt] of the tool.

The resource allows local areas to check activity against 7 key domains:

1. Needs assessment and Data
2. Finance
3. Pathways
4. Population Level Actions
5. Targeted Interventions
6. Hospital-based Alcohol Services
7. Specialist treatment

The tool aims to address the integration of activity by all local partners across all levels of prevention and covers interventions that are thought to be most effective. It is in line with NICE guidance, which previously produced detailed benchmarking tools. NICE also recently released Public Health Guidance for local authorities.

A host of other alcohol-related guidance has also been released in recent years, and the Alcohol Learning Centre also includes pages highlighting data tools and commissioning.

Domain 1: Needs assessment and Data

Domain 2: Finance

Domain 3: Pathways

Primary Prevention Section

Domain 4: Population Level Actions

Secondary Prevention Section

Domain 5: Targeted Interventions

Hospital-based Alcohol Services Section

Domain 6: Hospital-based Alcohol Services

Tertiary Prevention Section

Domain 7: Specialist treatment