Where next for public health and alcohol?

Alcohol is often seen as a public health issue. The problem with that is that there isn’t a single public health approach or solution. While there is interest in and appetite to reduce alcohol harm through public health measures in the UK, there isn’t consensus on how best to do so.

On 19 June 2019 people working in public health and alcohol treatment, policy makers, researchers and people with personal experience of alcohol harm will come together at the Alcohol Change UK national conference. The day will offer the chance to hear all sides of the many debates on alcohol harm reduction, to forge connections, and for some clarity amongst the complexity. I will be hosting a session in which we’ll attempt to answer the question, “Where next for public health and alcohol?” In this blog I want to share a taster of what I hope we discuss in this session. Hopefully this will whet your appetite, and I’ll see you there.

First up: alcohol treatment. When public health responsibilities (and budgets for substance misuse treatment) moved over from Primary Care Trusts (PCTs) to local authorities in 2013, there was concern in the drug treatment sector that this would lead to a diluting of support. Resources would be directed towards alcohol, and used in a more population-wide approach rather than being targeted at the most vulnerable in our society.

Some specialists in alcohol treatment and prevention welcomed this as an opportunity to stop alcohol being seen as the ‘poor relation’ of drugs, which had been allocated money in the 2000s as part of New Labour’s commitment to be “tough on the causes of crime.”

In practice, neither scenario came to be. The cuts to the overall public health budget have overshadowed any specific disagreements in the substance misuse field, though arguably alcohol treatment provision has been affected disproportionately. And there’s the additional problem of some in need of alcohol treatment being less likely to seek it when drug and alcohol treatment services are combined.

In this climate of severe cuts, we have to ask ourselves tough questions. Should we be rebalancing spend towards prevention? In terms of treatment, who needs our support the most? I worry that in an environment of financial pressures and political uncertainty these vital questions get lost in the task of simply fire-fighting. The Alcohol Change UK conference will offer a chance to step back and think.

Looking beyond treatment, many public health advocates argue that price and availability are the biggest drivers of consumption, and therefore harm. These can be affected by national policies: licensing legislation, tax and duty rates, and policies like minimum unit pricing (MUP). What policy changes would make the greatest impact on alcohol harm? Which are feasible?

But the most recent changes in consumption can’t just be explained by price and availability. At a population level we’re drinking less than we were a decade ago. At the same time as alcohol consumption at a population level fell, starting in 2004, we introduced the 2003 Licensing Act, which increased opening hours of pubs and clubs (though by less than many people anticipated), and alcohol became more affordable (as people increasingly drank at home).

We can’t call this fall in consumption good news and leave it at that. There are some quite different patterns visible amongst different groups, particularly when we look at age and see a worrying trend for older people drinking more, which is already presenting challenges for health and social care services.

Taken from Drink Wise Age Well, 'A generation of hidden drinkers: What’s happening to the drinking of the over 50s?'

Crucially, we don’t quite know why the fall has happened, and why it hasn’t been seen equally amongst all groups in society. Finding out should be a public health priority if we’re trying to reduce serious alcohol harm.

Even if we did know what has driven this, and wanted to make changes to national policy to improve public health outcomes in relation to alcohol, it can feel like Brexit is the only game in town and calls to make policy change are futile.

But let’s not despair just yet. At some point, there will be a more stable policy-making environment, and in a post-Brexit world there may be new opportunities to affect price and availability of alcohol. Currently taxes on alcohol are shaped by EU regulations, and the introduction of MUP was delayed by a challenge through the European Court of Justice; who knows what will be possible post-Brexit?

Public health professionals should be ready to take these opportunities, making their case with evidence and powerful arguments. I’m not sure we’re ready at the moment, which means there’s work to do. And where better to start than at the Alcohol Change UK conference?