As drink gets cheaper and licensing hours get longer, stemming the effect on the nation's health and the NHS budget is causing headaches. Stuart Shepherd reports

Here’s a toast to your good health! Yes, Christmas is coming and that means it is party time. Rest assured, there will be plenty of wine available, mulled or otherwise, along with beer, cider and spirits, all relatively cheaper, stronger, more widely available and consumed in greater quantities than at festive parties a decade ago.

Religious or health reasons aside, is there anything wrong with a little overindulgence once in a while? Probably not. However, there is a problem with hazardous episodes of considerable overindulgence – binge drinking – and the chronic misuse of alcohol at above the recommended daily and weekly maximum levels.

The statistics, emphatically relayed most recently by public health minister Dawn Primarolo at last month’s third national alcohol conference, make for disturbing reading.

About 10 million adults in England, or 26 per cent, drink in excess of government guidelines and more than 2.5 million consume alcohol at levels associated with “high risk”. This means more than 50 units a week for men or 35 units a week for women. Around 3 per cent of all deaths in England – 15,000 people a year – are related to alcohol use. And mortality rates in the poorest areas are double those of more affluent areas, while hospital admission rates can be as much as five times as high.

The new smoking

The impact on the health service is considerable. Six per cent of hospital admissions, along with 35 per cent of all accident and emergency attendances and ambulance service costs, are thought to be related to alcohol. The overall cost of alcohol misuse to the health service is estimated at£2.7bn.

And that could be set to rise. Reducing Alcohol Harm, published by the National Audit Office in October, found hospital admissions for the three main alcohol-specific conditions (alcohol related liver disease, mental health disorders linked to alcohol and acute intoxication) more than doubled from 1996-2007.

“There is an argument, a very strong argument, that problem drinking is, in a sense, becoming the ‘new smoking’ in terms of the challenge it presents to public health,” Ms Primarolo told the conference. “If we don’t step in, the consequences are enormous for our communities.”

Ms Primarolo’s address came just a few weeks after the close of the Department of Health’s Safe, Sensible, Social consultation, which invited opinion on a number of policy options, including regulatory change, in the light of an independent review of the alcohol industry’s voluntary social responsibility standards.

The review, itself promised in the 2007 paper Safe, Sensible, Social: the next steps in the national alcohol strategy, found the voluntary standards were not being followed and a significant number of retailers were breaking the law by selling alcohol to people who are either already intoxicated or not old enough to buy it.

“When the original alcohol harm reduction strategy for England was published in 2004, it was welcomed by all health professionals,” says Ian Gilmore, president of the Royal College of Physicians and consultant gastroenterologist at Royal Liverpool and Broadgreen University Hospitals trust.

“But the feeling at the time was that there was an undue emphasis on voluntary partnerships with the drinks industry. I don’t think that confidence has been realised, which is why there is more attention now on the possibility of a regulatory approach.”

The national alcohol strategy, as Professor Gilmore points out, was introduced almost simultaneously with changes to licensing laws, with overall responsibility for licensing passing from the Home Office to the Department for Culture, Media and Sport and the control of local licensing passing from magistrates to local authorities.

Ministers at the time argued that extended drinking times would help cut down on disturbances following pub closures at 11pm, while creating a continental style café culture.

“In relation to health, this seemed a curious juxtaposition of policies, especially as the changes have made it harder to turn down a licence on the grounds that an area is already well served with bars.

“While it may strengthen powers to suspend or withdraw licences, it also makes it easier to get them and, when granting a licence, makes no requirement for any consideration of public health,” Professor Gilmore adds.

Community health

A continental style drinking culture in England seems a long time coming. In recent weeks, Police Federation vice chair Simon Reed has been reported as saying that in the early hours of Saturday and Sunday some market towns now resemble the “Wild West”, with groups of drunk and loud people dispersing from pubs not just once but several times, as they move from venue to venue to take advantage of staggered closing times. With half of all violent incidents occurring from 11pm-3am, it seems England is still a long way from being a nation of wine sippers.

“The problems of closing time don’t seem to have gone away,” says UK Faculty of Public Health president Professor Alan Maryon-Davis. “We hear reports of the situation worsening because people have the time to get through more alcohol and are being turned out into town and city centres later and later.

“Perhaps there is some reluctance on the part of local authorities and the police to use the powers they have been given and join up the legal side of the licensing agenda with community health and safety issues.”

Where Professor Maryon-Davis does see cause for optimism, however, is in the new cross-departmental public sector agreement 25, which includes a vision to reduce the harm associated with alcohol and drugs, alcohol related performance indicators and a clear target for reducing alcohol related hospital admissions. But as the National Audit Office report shows, the agreement is not gaining universal take-up.

“We need to persuade more local strategic partnerships to adopt it as part of their area agreements, moving away from ‘picking up the pieces’ and towards a more multi-sector preventive approach, raising public awareness and using licensing laws more creatively to cut back on happy hours and low pricing,” he adds.

The Portman Group – a social responsibility body for the UK’s drinks producers – also believes education is central to reducing alcohol harm. “It is only really in the last few years since the start of the social marketing we now see, such as the government’s Know Your Limits campaign and those from the Drinkaware Trust, plus unit labelling to provide information to consumers, that we have seen improvements. The numbers of harmful drinkers is on the way down and has been for the last five years,” says Portman Group head of communications Michael Thompson.

As producers, the Portman Group cannot tell retailers at what price they should be selling their drinks. Competition laws prevent retailers being able to set minimum prices, so if cost is to be the main determinant for reducing alcohol harm it would have to be legislated for.

Working with supermarkets

Legislation, in the form of a minimum price per unit of alcohol, has been suggested by campaign group Alcohol Health Alliance as one means of reducing bouts of binge drinking and the effects of regular or daily drinking at harmful levels.

“Deep discounting alcohol [selling it too cheaply to make a profit] has been one of the contributory factors to the expansion of home consumption, increases in alcohol related assaults and injuries and higher levels of all the longer term health conditions related to alcohol use, which include some cancers,” says Don Shenker, chief executive of the charity Alcohol Concern.

“Supermarkets have been able to deep discount ciders, beers and wines. For example, very recently at one large retailer you could buy a three-litre bottle of strong dry cider for£2.66. As the bottle contains 16 units – more than four times the maximum daily guideline for a man – that works out at just over 16p per unit. Set the minimum unit price, as has been discussed, at 35p and the price of that three-litre bottle of cider would go up to£5.60, which potentially could cut levels of binge drinking quite drastically.”

Enabling powers to set the direction for any future legislation on minimum pricing and discounting, or on regulations for standard health messages on labels and health warnings in advertising, will have to be included in both the NHS Reform and Policing and Crime Reduction Bills announced in last week’s Queen’s Speech.

Meanwhile, newly formed alcohol national support teams funded by the DH aim to continue to offer guidance on improvements in early intervention and specialist treatment to those primary care trusts with the highest rates of alcohol related hospital admissions.

Trusts are helped to identify and reduce the numbers of hazardous drinkers at risk of moving on to alcohol dependency and associated liver, cardiac and other health problems through screening and brief advice or interventions.

The DH has funded a two-year research programme of “trailblazers” to evaluate their impact on alcohol consumption and health and assess the potential cost savings to health and social care.

“Alcohol is an increasing problem both overtly and covertly and, because we see the long term damage to individuals and their families, we see the consequences of misuse probably more than any other group of healthcare professionals,” says Royal College of GPs chair Professor Steve Field.

“Brief interventions in primary care have been shown to reduce both total alcohol consumption and episodes of binge drinking and the effects can last up to a year.”

Wirral PCT, one of England’s top 50 areas for alcohol related hospital admissions, is offering anonymous alcohol screening services via a call centre and website. This builds on earlier work to provide screening and brief advice or interventions at GP surgeries and a more recently established network of community pharmacies providing screening.

“We have been putting the focus on setting up an assessment and treatment system to meet the needs of our estimated 60,000 hazardous and harmful drinkers that is responsive and that works,” says PCT head of involvement Andy Mills. “One of the problems people who misuse alcohol face when seeking early interventions is having to ‘confess’ in public. That puts a lot of people off, so we hope the online and telephone options provide people with something they can feel more comfortable about.”

The accident and emergency department is equally suited as a venue for identifying the need for and offering brief advice on alcohol harm reduction, says Robin Touquet, an A&E consultant at Imperial Healthcare trust’s St Mary’s Hospital and College of Emergency Medicine spokesman on alcohol.

“At the end of a consultation, there is an opportunity for any member of the team, clinical or administrative member of staff, to enquire if the patient uses alcohol, can see a connection between that and their visit and would value some time in a day or two with a specialist nurse,” he says.

“We have been able to show that using this approach, for every two patients referred to see the alcohol nurse specialist, even if they don’t go to the appointment, there is one less accident and emergency attendance over the next 12 months.”

Hard nights in Blackpool

In September the newly formed national alcohol support team made the first of its scheduled visits to towns and cities identified as having the highest rates of alcohol related hospital admissions. On this occasion, the team’s hosts were NHS Blackpool and partner organisations.

Blackpool has 1,900 licensed premises. Staggeringly, almost a quarter of its population of 142,000 work in a place where alcohol is sold.

“We were reassured [from the team] that our own local intelligence has been taking us in the right direction,” says NHS Blackpool alcohol harm reduction policy officer Stephen Morton. “They are now assisting us in developing new approaches to analysis for service development for our estimated 9,000 problem drinkers.”

Staff at the Victoria Hospital, part of Blackpool, Fylde and Wyre Hospitals foundation trust, bear the brunt of the town’s drinking culture. Alcohol related admissions to accident and emergency have tripled in recent years and patients can be as young as 10.

“The chronic effects of alcohol misuse are now affecting people earlier, more severely and in greater numbers. We are seeing patients with cirrhosis of the liver in their twenties,” says emergency medicine consultant Nigel Kidner. “They turn up because they feel very ill or it is making them mentally confused.”

People coming in after excess drinking may need to be kept in overnight so that they do not get into difficulty with their breathing or blood sugar levels, says Dr Kidner.

“Many patients are in their late teens or early twenties and have come to Blackpool to have a good time. That means having a lot to drink. Between 11pm and 4-5am they turn up with alcohol poisoning – some so unconscious they need scanning to check they haven’t a significant head injury. These are the ones that will spend the night in intensive care. Then there are those who get intoxicated, take risks and are injured because their judgement is impaired. They are all a huge drain on resources.”

The trust recently appointed two alcohol liaison nurse specialists.