Aneurin Bevan University Hospital Board
Response to the Health, Social Care and Sport Committee on the Public Health (Minimum price for Alcohol) (Wales) Bill
1. Introduction
Aneurin Bevan University Health Board (ABUHB) welcomes the opportunity to respond to the Health, Social Care and Sport Committee consultation on the Public Health (Minimum Price for Alcohol) (Wales) Bill.
ABUHB strongly support the implementation of the minimum unit pricing for alcohol in Wales and have articulated the same opinion in previous consultation submissions, which include a comprehensive response to the Public Health (Wales) Bill in 2015. ABUHB’s position supporting the implementation of MUP in 2015 has been strengthened by further evidence which has since been published, and highlighted below.
As outlined in ABUHB’s submission in 2015:
· There is evidence that excessive alcohol consumption significantly increases short and long term harms to health. Evidence indicates that increased consumption is linked to increased harm: there is a dose-harm response[1]. The UK Chief Medical Officers report reinforced this, concluding that the risk of developing health problems increases with the amount of alcohol consumed on a regular basis[2].
· There is clear evidence linking the affordability of alcohol with the quantity of alcohol consumed (and thus resultant alcohol harms). More than 100 international studies clearly demonstrates a link between the affordability of alcohol and alcohol consumption[3]. Alcohol has become steadily more affordable in recent years, with there being a real term reduction in the cost of alcohol[4].
· There is strong evidence to support decreasing the affordability of alcohol to reduce consumption and thus reduce harm from alcohol[5]. When the price of alcohol increases consumption by most drinkers reduces including, critically, consumption by hazardous and harmful drinkers[6]. When alcohol consumption in the population declines, rates of alcohol related harms also decline[7]. The intervention for increasing affordability with the strongest evidence is Minimum Unit Pricing (MUP) of alcohol[8].
In conclusion robust evidence indicates that:
(i) alcohol consumption levels are linked with levels of harm
(ii) affordability is one of the key drivers of alcohol consumption, and
(iii) MUP is the most effective price mechanism to reduce the affordability of alcohol
Since the ABUHB consultation submission in 2015 there has been additional published evidence which provides further insight into the harms caused by alcohol. This includes an extremely comprehensive review of the evidence of the health harms associated with alcohol consumption resulting in new low risk drinking guidelines published in 2016: the UK Chief Medical Officers’ Low Risk Drinking Guidelines, published in 2016. Other reports which ABUHB considered are: Public Health Wales (2015) ‘Adverse Childhood Experiences and their impact on health-harming behaviour in the Welsh adult population’, Alcohol Health Alliance (2016) ‘Cheap Alcohol, the Price We Pay’.
2.1 Terms of Reference
The general principles of the Public Health (Minimum Price for Alcohol) (Wales) Bill and the extent to which it will contributed to improving and protecting the health and well-being of the population of Wales, by providing for a minimum price for the sale and supply of alcohol in Wales and making it an offence for alcohol to be sold or supplied below that price.
ABUHB support the general principles of the Public Health (Minimum Price for Alcohol) (Wales) Bill after considering the following evidence:
Alcohol consumption linked to affordability
Evidence indicates that recent decades have seen increases in alcohol consumption and health harms associated with alcohol consumption in Wales. These increases in consumption and harms are associated with real terms reductions in the cost of alcohol (alcohol being more affordable). Introducing a MUP for alcohol would be a targeted measure of increasing the price (and therefore reducing affordability) of alcohol. This approach would target those at greatest risk of harm from their drinking: heaviest drinkers and those at particular risk from alcohol related harm such as young people.
There is strong evidence that alcohol affordability is one of the main determinants of alcohol consumption and resultant level of alcohol harms. More than 100 international studies clearly demonstrate a link between the affordability of alcohol and alcohol consumption[9]. There is overwhelming evidence to support policies which reduce affordability[10].
MUP is based on two fundamental principles:
1. When the price of alcohol increases, consumption, especially by the heaviest drinkers, goes down, and:
2. When alcohol consumption in the population declines, the rates of alcohol related harms decline[11].
Health harms from alcohol consumption
Drinking alcohol increases the risk of developing over 60 different health problems[12] as well as increasing the risk of causing a range of harms to others[13]. Worldwide, the harmful use of alcohol ranks amongst the top five risk factors for disease, disability and death[14]. Recent decades have seen increases in alcohol consumption and associated health harms across Wales[15]. These harms are preventable. Alcohol misuse is detrimental, not only to the drinker, but also in the harm to their family and local community. Alcohol misuse places an avoidable burden on public services. The estimated to cost the Welsh nation is £1 billion per year[16] (Alcohol Concern Cymru, 2013), with the cost to the NHS in Wales for alcohol related hospital admission in 2012-13 being £109m alone[17].
The anticipated benefits of MUP: the modelling
The OECD report[18] stated that “approximately four in five drinkers would decrease their risk of death by cutting their alcohol intake by just one unit per week”. A model-based appraisal of MUP in Wales conducted by the Sheffield Alcohol Research Group for a MUP of 50p estimated that there would be a reduction in alcohol consumption for the overall population per person of 4% (30 units per drinker per year).
The Sheffield Alcohol Research Group, Sheffield University, applied the Sheffield Alcohol Policy Model (SAPM) in Wales and estimated that a 50p MUP would result in:
· 53 fewer deaths a year
· 1,400 fewer hospital admissions a year
· 3,684 fewer criminal offences a year
· 10,000 fewer absent days from work a year from heavy drinking
The SAPM indicates savings of £131 million over 20 years relating to direct costs to healthcare services over 20 years. The authors concluded that the societal value of these impacts totals £882 million over the 20 year period. This figure includes savings from healthcare costs, reduced crime and policing, reduced workplace absences and financial valuation of the health benefits measured in quality-adjusted life years[19].
MUP and the impact on crime and associated costs to health and well-being
The Crime Survey for England and Wales reported that within the year 2011/12 there were 917,000 violent incidents where the victim believed the offender(s) to be under the influence of alcohol, accounting for 47% of violent offences that year. Alcohol routinely accounts for over 40 per cent of all violent crimes committed and, as well as youth violence, is strongly associated with domestic violence, child abuse and self-directed violence such as suicide[20].
The SAPM estimated that the cost of alcohol related crime would fall by £248 million over 20 years, with an estimated 3,684 offences a year resulting from a MUP of 50p. As well as reducing the harm to the individual who is drinking, it can also impact on the wellbeing of family members, friends and the wider society through reducing alcohol related crime, including anti-social behaviour and domestic violence.
MUP would target those experiencing most harm from alcohol consumption
MUP operates at a population level to reduce alcohol consumption and primarily targets drinkers who tend to drink alcohol which is cheap relative to its strength. The modelling undertaken by the Sheffield Alcohol Research Group[21] demonstrated that the implementation of MUP in Wales would have a small impact on moderate drinkers, and the greatest impact on hazardous and harmful drinkers as they tend to favour the under priced/discounted alcoholic drinks which will be mostly affected by the implementation of a 50p MUP. These are the drinkers who are causing most harm to themselves and society.
MUP would target those living in poverty who consume alcohol
The SAPM estimated that the greatest positive health improvement impact would be experienced by adult drinkers living in poverty. Sheffield Alcohol Research Group estimated that people living in poverty who are hazardous drinkers would reduce their consumption by 6.2% or 84.3 units per year as compared to those hazardous drinkers not in poverty who would reduce their consumption by 1.2% or 17.7 units per year. When comparing harmful drinkers it was estimated there would be a reduction of 13% (or 487.3 units) a year for harmful drinkers living in poverty compared to a reduction in consumption by 5.8% (or 243 units) for harmful drinkers not in poverty. This would have a greater health impact on those drinkers living in poverty with a 50p MUP estimated to result in 5 fewer deaths and 120 hospital admissions per 100,000 drinkers in poverty compared to 2 and 50 for those drinkers not in poverty[22].
For those people living in poverty the financial costs of MUP will be higher but the potential health benefits are more significant.
MUP would target young people – a group particularly vulnerable from alcohol consumption
Comprehensive reviews have clearly highlighted that the consumption of alcohol by children and young people is linked with significant harm[23]. A wide range of potential harms have been outlined by the Chief Medical Officer for Wales and include: a range of developmental problems, increased risk taking behaviour, inappropriate sexual activity and violence[24]. There is evidence that regular consumption of alcohol at this critical development time will lead to significant changes to brain chemistry and structure which will set a pattern for continued heavy use, and may affect brain functioning into adulthood. The introduction of MUP would potentially have a beneficial impact in preventing this.
Evidence demonstrates that young people are more vulnerable than adults to the adverse effects of alcohol due a range of physical and psycho-social factors[25]. There is evidence to indicate that children who begin drinking at a young age will drink more frequently and in greater quantities than those who delay drinking and therefore experience greater harm. This overwhelming evidence has led to the recommendation by the previous Chief Medical Officer for England, which is supported by the Chief Medical Officer for Wales and ABUHB, that an alcohol-free childhood is the healthiest and best option for all[26].
However, despite legislation restricting the sale of alcohol to minors, many young people drink alcohol, and some drink to a level that causes harm. Although drinking prevalence amongst children and young people is decreasing, Wales has the highest alcohol consumption among 15 year olds in the UK[27].
ABUHB anticipate that a 50p MUP would (i) reduce alcohol consumption of children and young people and (ii) protect them from the harms caused as a result of other adults, children and young people drinking.
ABUHB believe that the introduction of MUP would not only be beneficial to children and young people who drink, from their reduced consumption, but to children and young exposed to harms from adults who drink. These harms could be direct or indirect as a result of adults, particularly parents/carers, drinking at a harmful level (e.g. increased risk of domestic violence).
2.2 Whether there are any unintended consequences arising from the Bill
ABUHB acknowledge that the modelling assumes that drinkers will behave rationally, and that not all drinkers will respond the same way to price increases. ABUHB acknowledge that although the largest positive health impact is envisaged for harmful drinkers living in poverty, MUP could negatively impact on them and their families if they were unable to restrict their consumption, and therefore their spending on alcohol. ABUHB acknowledge that heavy and/or dependent drinkers may continue to drink at the same level and for those living in poverty will have less disposable income to spend on other items.
ABUHB acknowledges the potential unintended consequences on a small number of people within the local population. We would welcome guidance on how these consequences might be mitigated and support Welsh Government’s proposal to evaluate the impact of introducing MUP. This should include an assessment of unintended consequences and immediate priority should be given to ensuring access to alcohol services and support families in need and those that are most vulnerable.
Although there may initially be greater demand on local primary care services and specialist treatment services, we envisage there being a long-term savings to the local Emergency Departments and other ABUHB secondary care services. As MUP reduces the level of problematic drinking in future generations ABUHB acknowledges that unintended consequence should become less of an issue over time.
2.3 The financial implication of the Bill (as set out in Part 2 of the Explanatory Memorandum)
There are no additional costs that we are aware of that have not been considered within the financial implications of the Bill set out in Part 2 of the Explanatory Memorandum.
ABUHB welcome the inclusion of £350,000 for the evaluation of the Bill to ensure it leads to the expected outcomes it aims to achieve.
2.4 The appropriateness of the powers in the Bill for Welsh Ministers to make subordinate legislation (as set out in Chapter 5 of part 1 of the Explanatory Memorandum)
ABUHB support the powers for Welsh Ministers to make subordinate legislation to specify the MUP. Based on the evidence in 2014 ABUHB regarded 50 pence per unit MUP as an appropriate level. However, ABUHB consider that MUP should be linked to an inflationary measure to ensure it remains an effective measure to reduce alcohol health harms.
ABUHB recommend that a range of other evidence based measures should be considered to reduce the harms caused by alcohol to Welsh citizens. ABUHB believe there is sufficient evidence to support complementary approaches:
· Licensing authorities being empowered to tackle local availability of alcohol in their localities, by supporting licensing and enforcement partners working in partnership
· Sufficient resourcing of the prevention of underage, intoxicated and proxy sales and ensuring sanctions are applied to businesses breaking the law
· The legal limit for blood alcohol concentration for drivers should be reduced to 50mg/100ml
· All health and social care professionals should be trained to provide early identification and brief alcohol advice
· People who need support for alcohol problems should be routinely referred to specialist alcohol services for assessment and treatment. These services need to be adequately funded and resourced
· Alcohol advertising should be strictly limited to newspapers and other adult press while its content should be limited to factual information
Conclusion
There is a dose-response relationship between the volume of alcohol consumed and the likelihood of harm[28] and therefore any policy which is successful in reducing consumption of alcohol would be welcomed by the ABUHB. The evidence to support the introduction of MUP is strong, consistent and robust and compelling that the introduction of MUP in Wales would lead to significant improvements in the health and well-being of the population.