By stewartb

The TuS piece (12 June) on Minimum Unit Pricing (MUP) for alcohol and the negative claims appearing on the front-page of the Sunday Post merits expansion. By fortunate coincidence, a regular browse through the latest output from Westminster’s select committees came across this very recently:

House of Commons Public Accounts Committee (18 May 2023) Alcohol treatment services. (https://committees.parliament.uk/publications/40045/documents/195525/default/ )

Focused on the present state of alcohol consumption and the track record of the Tory government on service provision in England, the report is not only revealing in these regards but also records the expert evidence it received on the effectiveness of MUP in Scotland.

On minimum pricing

Firstly on the subject of MUP, in the main report the Committee notes:

Page 5: ‘While downstream measures (i.e. treatments) are important, to tackle the significant costs to the NHS and wider society, we heard from experts in the field of the need for a whole system approach which includes preventative measures around the price, availability and marketing of alcohol. The Department (i.e. the Department for Health and Social Care) does not share their assessment of the evidence but has not set out what it will do.’

The senior civil servant giving evidence is clearly determined to cast doubt on the case for adopting MUP in England.

Page 10: ‘On discussing the merits of preventative measures, the Department told us that what works and does not work on alcohol was very well researched but that the right approach for some areas was highly contested. By way of example, it referenced alcohol pricing and the introduction of minimum unit pricing in Scotland, commenting that the results were unclear.’

However the Committee went on to note: ‘Ms Wiseman (one of the expert witnesses – see below) told us that in her view the evidence on what was needed was clear and Sir Ian (another expert witness) commented that there was “international evidence that would break the benches here with its weight”. Both told us that tackling alcohol harm needed preventative action on price, availability, and promotion.’

(Expert witnesses: Sir Ian Gilmore, Chair, Alcohol Health Alliance and Alice Wiseman, Director of Public Health for Gateshead Council; and Board Member and Alcohol Policy Lead, Association of Directors of Public Health.)

Looking back at the transcript of oral evidence to the Committee given on 2 March 2023 we find more details (see https://committees.parliament.uk/oralevidence/13049/html/ ).

Sir Ian Gilmore: ‘Prevention, or harm reduction, is the most important part. We certainly do not want to ignore those who have been caught up in the problem already, which is why treatment services are one of our priorities in the AHA. None the less (sic), if you want to make an impact, there is no doubt that you need to go upstream. Price first, then availability and marketing—those are the three big drivers. There is international evidence that would break the benches here with its weight. As Dame Carol (Professor Dame Carol Black, another expert witness) said, we could do an independent review, but in a sense we have got the evidence. Public Health England produced a wonderful paper in The Lancet in 2017 enumerating all the evidence on the benefits of a strategy of prevention. I really think it is time to push Government into a strategy.’

Asked directly by a Committee member if minimum unit pricing works:

Sir Ian Gilmore: ‘… I would say that about a dozen studies have come out, and 11 out of the 12 have shown a real benefit. There has been a lot of publicity given to one study that came out recently, which said that heavily dependent drinkers did not cut down their drinking, but seemed to move money from other things, such as food, into drink. That was a highly selected group of heavily dependent drinkers who were accessing treatment. That was at one end of the spectrum, and in a sense you would not expect a big impact on them, although if you could reduce their drinking from, say, 2 litres of Scotch a day to 1 litre, you would help them.’  

Sir Ian added: ’The evidence from Scotland is that the minimum unit price does target the heaviest drinkers. The heaviest drinking households showed the biggest reduction in consumption, and hospital admissions and deaths are down. There is very strong evidence of the benefit, and we will have evidence coming from Wales.We have evidence from Canada of a very closely related way of tackling price: a floor price. They have seen a health benefit. I think it is something we should do. It has somehow got a bit of a bad name in Westminster in the last year or 18 months. We have not been going on about it, but there is no doubt that prices are the single most important thing. MUP is very good because it targets the heaviest drinkers; the non-dependent heavy drinkers are targeted.’

But on MUP the senior civil servant present pushes back:

Sir Chris Wormald (Permanent Secretary, Department of Health and Social Care) ‘… Just take one of the examples you gave: alcohol pricing, on which Scotland has obviously made a big move. The results of that are currently unclear. From the evidence available so far— obviously, it’s quite early—the impact is quite different on different groups. These are contested areas ….’

One of the expert witnesses responded:

Alice Wiseman: ‘I am going to politely disagree with you, Chris.’ 

‘I think the evidence on what we need to do to tackle alcohol is really robust and clear. …. The evidence coming out from Scotland, which Sir Ian referred to, is good: there is that 3.5% reduction in off-trade sales per adult; a 7% sustained reduction in household consumption; reductions in household expenditure; and the lowest volume of pure alcohol sold in 26 years. In comparison, England is going in the opposite direction, with a consumption rise.‘

‘For me, minimum unit price is not a silver bullet; we need all the things mentioned: we need alcohol duty, which was also referred to, a minimum unit price, and restrictions on marketing—and we certainly need to protect children from exposure to alcohol marketing. It is not good that our 10year-olds are able to name alcohol brands because they are plastered over the fronts of their favourite football team. It is not good enough, and we really could take robust action in that space.’

The Committee on Tory-governed England

The report makes the following damning statements about alcohol misuse and treatment services in England (with my emphasis):

Page 3: ’… despite the alarming increase in alcohol-related deaths over the past twenty years and sharp rises since 2019, the number of people receiving treatment for alcohol dependency has generally been falling. A staggering 82% of the 600,000 dependent drinkers in England are not in treatment.’

‘…. it is surprising and disappointing that the Department is not taking a more proportionate and serious approach to addressing the harms. The Department’s understanding of the prevalence of alcohol dependency and the ten-year-old estimate of the cost of alcohol harm are out of date meaning it is not even in a position to identify an appropriate response. Despite the widespread harm, there has been no alcohol- focused strategy since 2012 and the latest plans to publish one were abandoned in 2020. While government’s 10-year drugs strategy does support treatment services for people with alcohol dependency, the Department, along with local authorities, could do more to prevent them from ever needing that treatment. Though some experts in the field told us that preventative measures around price, availability, and marketing, are very effective, the Department points out that the evidence for the right approach for some areas is highly contested. The Department needs to secure a consensus to break this impasse and act on the best available evidence.’

Page 4: ‘ Since 2012, local authorities have been responsible for commissioning drug and alcohol treatment services. In most cases, treatment provision has moved from separate alcohol and drug services to one integrated service. Local authorities receive an annual ring-fenced grant from the Department of Health and Social Care to help fund public health services’ but notably ‘In 2021–22, local authorities reported spending £637 million on alcohol and drug services, a real term fall in spending of 27% compared with 2014–15.’

Page 5-6: ‘ Since 2015–16, local authorities have seen the grant they receive from central government to help fund public health services fall by £630 million in real terms. This has had inevitable consequences on funding for drug and alcohol treatment services, leaving services “on their knees” according to Dame Carol Black (author of the government’s independent review of drugs).’

This Committee, with nine out of its 16 members Tory MPs, concludes among other things:

Page 5: ‘We are concerned that the Department is not taking alcohol harm sufficiently seriously.’

‘The Department for Health and Social Care, as the lead department, does not have sufficient understanding of total cost of alcohol harm.’

Page 8: ‘In 2021–22, the amount local authorities reported spending on alcohol treatment varied from £4,000 per 100,000 people to over £1 million, with median spending of £313,000. In her independent review, Dame Carol Black did not disaggregate local authority spending on drugs and alcohol because of a lack of robustness in the reported expenditure data, so these numbers, while the only figures available, will mask actual spending on alcohol treatment services.’

End note

One wonders why the Tories turn their faces against MUP despite the expert evidence. You will recall the resistance from the drinks industry to its introduction in Scotland.

If this Public Accounts Committee report had been written by MSPs in Holyrood who were making such damning criticisms of a Scottish Government department, one can easily imagine the news headlines: it would also have dominated FMQs! But when it’s about a government’s record on public health in England … nothing here to interest journalists and opposition politicians?

It’s small comfort but next time the Tories in Holyrood try on their SNPbad tactic regarding public health policies, remember the above!