Hywel Dda University Health Board Response to the National Assembly of Wales Call for Evidence on the introduction of the Public Health (Minimum Price for Alcohol) (Wales) Bill
Introduction
From reviewing the strengthening evidence base on the impact of an introduction of minimum unit price for alcohol (MUP) as a means of reducing alcohol related harm, Hywel Dda University Health Board strongly supports this policy initiative as evidenced in the proposed introduction of the Public Health (Minimum Price for Alcohol) (Wales) Bill. We believe that if the rate is set at a minimum of 50p per unit of alcohol this will result in a reduction of health related alcohol harms, which impact upon services delivered by the University Health Board to its population.
Legislation of this kind is one of the most important and most powerful tools available to tackle public health issues. In bringing forward this policy, we acknowledge that Welsh Government is seeking to shape the social, economic and environmental conditions that are conducive to good health and averting health harms, and we welcome policy change that results in improved health and wellbeing for our population. Furthermore this policy approach supports an increased emphasis on personal responsibility, an approach at the forefront of prudent health care that is vital to the long term sustainability of the University Health Board and the NHS in Wales. More detailed justification in support of this proposal is outlined below.
Principles and Impact on Health and Well Being
The impact of alcohol on health is a significant issue. Alcohol consumption has increased over the past decade, resulting in the growth of associated health harms. Drinking alcohol increases the risk of developing over 60 different health problems[1] , including a range of cancers, liver disease, high blood pressure, injuries and a variety of mental health conditions. It also increases the risk of causing harms to the health of others. Furthermore alcohol related deaths in Wales have risen, as has the rate of alcohol related hospital admissions. Alcohol is now one of the three biggest lifestyle risk factors for disease and death in Wales after smoking and obesity.
In Wales, a report by the Public Health Wales Observatory, Alcohol in Wales (2014)[2] states: “Every week in Wales, alcohol results in 29 deaths; around 1 in 20 of all deaths. The impact of alcohol on health also creates enormous pressures on our health systems. Every week our hospitals handle as many as 1,000 admissions related to alcohol, increasing strains on already stretched services. Such admissions are only the tip of an iceberg which includes many more presentations at emergency departments, ambulance requests and GP appointments, all resulting from alcohol.”
Data shows increasing levels of health related harm both in terms of binge drinking and short term problems from alcohol use but also chronic alcohol misuse. Hospital admission data for the year 2012/13 shows that 16,128 bed days in Hywel Dda hospitals were taken up by patients with alcohol related conditions costing the Health Board over £5.3 million per year in inpatient treatment alone. The majority of costs were incurred in non elective general medical and adult mental health admissions. In relation to alcohol related attendances at Emergency Departments, it is estimated that nearly £6.5 million per annum is spent by Hywel Dda attendances having a link to alcohol misuse. A broad estimate of direct costs to the University Health Board from addressing the health impacts of alcohol misuse would suggest a figure of £11,852,493 for 2012/13[3]. Alongside this, our rates of person based alcohol specific and alcohol attributable admissions in 2016/17 in Carmarthenshire and Ceredigion has seen the highest rises of all local authority area of Wales compared with the previous year (25% and 13% respectively)[4].
There is compelling strong, consistent, and robust evidence that alcohol price increases, reduce alcohol consumption and related harm[5] . Introducing a minimum unit price (MUP) for alcohol in Wales would lead to significant improvements in health and well-being for the population of Wales. NICE[6] guidance called for alcohol to be made less affordable by introducing a MUP (Recommendation 1), and provides further evidence for this justification within its NICE guidance evidence update[7]. In addition to this the Advisory Panel on Substance Misuse for Wales has also strongly supported the introduction of MUP to address alcohol related harm in those vulnerable groups most affected by hazardous and harmful levels of drinking[8].
Minimum unit pricing is a targeted measure that will impact beneficially on alcohol consumption of harmful and hazardous consumers as well as other groups particularly at risk from alcohol related harms – such as young people. Moderate consumers of alcohol will experience relatively little change in the amount they have to pay for alcohol. The intended effect of this initiative is to reduce the harms associated with excessive consumption such as the number and associated costs of alcohol related crimes; alcohol related health problems, and deaths due to alcohol.
Minimum Unit Pricing is based on fundamental principles that are widely supported by evidence:
· when the price of alcohol increases, consumption by most drinkers decreases, critically including hazardous and harmful drinkers
· When alcohol consumption in a population declines, rates of alcohol related harm also decline.
The experience of introducing a MUP in two provinces in Canada, showed that when alcohol price was raised by 10% there was a reduction in alcohol consumption, alcohol related mortality and alcohol related hospital admissions[9] [10]
Minimum Unit Pricing will form part of a comprehensive package of measures and non legislative action to deal with problems and harms associated with alcohol as set out in the proposed Bill and also the implementation of ‘Working Together to Reduce Harm’ (The Substance Misuse Strategy for Wales 2008-2018) and its delivery plans. In line with NICE guidance (2010; 2014) 2,3 such policy changes complement ongoing work at national and local levels to reduce the harm caused by alcohol in Wales such as Alcohol Brief Intervention engagement, increased scrutiny of licensing applications and education in the school environment via mechanisms such as the Police Core Schools Liaison Programme and the All Wales Network of Healthy Schools. As such these provide a combination of interventions that are needed to reduce alcohol-related harm in order to benefit society. Both population-level and individual level approaches are important because they can help reduce the aggregate level of alcohol consumed and therefore lower the whole populations’ risk of alcohol-related harm.
In order to further strengthen actions to reduce alcohol related harm we would also reiterate that Welsh Government should continue to lobby strongly for a Public Health objective to be included within any licensing objectives under the Licensing Act 2003. Therefore due to the weight of evidence outlined above, Hywel Dda University Health Board believes that the proposed legislation to introduce a minimum unit price for alcohol in Wales will strengthen the existing actions being undertaken by the Welsh Government to reduce alcohol consumption and alcohol related harm.
Potential Barriers to Implementation
Public Acceptance
Over the last few years, Hywel Dda University Health Board has undertaken a number of consultations in partnership with Public Health Wales, its three Local Authorities and Dyfed Powys Police around the issues of alcohol misuse. Questions on MUP have been included in each of these consultation processes and it is positive to note that a significant percentage of respondents have indicated their support for MUP as concept.
For instance Carmarthenshire 50+ Forum members were asked in 2015 to indicate the extent to which they would agree with a minimum price of 50p per unit of alcohol in Wales[11] . Results show that nearly half of all respondents (48%) support the idea of a minimum price for Wales (28% strongly support; 20% support), with 27% against (15% opposed; 12% strongly oppose). Over a quarter (26%) of respondents refrained from making judgment in favour or against29.
Respondents were asked to explain their answer. A range of responses were cited, covering the following points (noted below in order of frequency):
· Amelioration of binge drinking – a commonly held view was that increases in price would impact upon binge drinking levels
· Unduly penalises responsible drinkers – a perception that responsible drinkers are being penalised for the actions of a few
· Improves drinking culture – There was agreement that minimum pricing would put a swift end to the increasing tendency to ‘pre-drink’ – consuming a significant amount of alcohol before a night out
In 2014 the three local authority areas of Hywel Dda as part of their regular Citizen Panel consultations included questions on MUP. The Carmarthenshire Citizens’ Panel results showed 53% (200 respondents) supported the idea of a minimum price of 50p per unit of alcohol in Wales, while 32% (122 respondents) did not, and 16% (59 respondents) were unsure[12].
For Ceredigion[13], 56% (175 respondents) support the idea of a minimum price of 50p per unit of alcohol in Wales, 30% (93 respondents) do not, while 14% (44 respondents) are unsure.
Finally for Pembrokeshire[14] 50% (225 respondents) supported the idea of a minimum price of 50p per unit of alcohol in Wales, while 34% (152 respondents) did not, and 17% (75 respondents) were unsure.
Unintended Consequences
Impact on Off/On Licensed Retail Outlets
It is important to distinguish between the impacts of MUP upon the on and off license trades. Cheap alcohol in the off trade has contributed to the closure of many local pubs due to an increase in home drinking and pre loading. A number of surveys have highlighted that there is significant support for MUP amongst pub landlords.
Impact on Drinks Manufacturers
The introduction of MUP may have the effect of encouraging drinks manufacturers to give serious consideration to producing alcohol products that have a lower alcohol by volume percentage, in order to maintain profit levels. For example, alcohol by volume in table wines has been increasing over time and introduction of MUP may support a reversal in this trend thereby further decreasing population level health harms related to alcohol. This may also be the case for high-strength lagers.
Serious consideration should be given to measures in order to ensure that any increase in profits to drinks manufactures following the introduction of MUP, should be subject to appropriate levy by government in order to develop population level alcohol awareness campaigns and prevention programmes including those with children and young people.
Additional Enforcement Costs
There may well be resource implications to Local Authorities in relation to introducing MUP and the requirement to enforce any new legislation. Although both trading standards and licensing teams currently undertake inspection and control of some alcohol vendors, consideration should be given to whether or not to introduction of MUP would place an increased demand on already stretched services.
Impact on Low Income Households
Consumers who currently purchase alcohol priced at less than the set MUP will be directly affected with the introduction of this policy, and this includes those on low income. Those in poverty may experience a greater impact than those not in poverty, as they tend to buy cheaper products. There may also be a risk that harmful and hazardous drinkers from low income households may continue to consume alcohol at existing levels and thereby utilise money that is needed for other household expenses. There is evidence however to support that there will be a substantive impact on harmful drinkers with the lowest income gradient[15], who may experience larger relative gains in health from this policy.
Financial Implications
Review of MUP Level
Further consideration of MUP setting should be linked to an inflationary measure to ensure it remains an effective measure to reduce alcohol health harms, as outlined by NICE (2010; 2014)[16] [17] guidance Recommendation 1: Regularly review the minimum price per unit to ensure alcohol does not become more affordable over time.
Costs of Enforcement
As noted above, the introduction of a MUP in Wales could lead to additional regulatory inspection requirements for colleagues in local authority public protection teams. Within the Explanatory Memorandum this is explicitly referred to in sections 295-298 (pages 106-107) and an acknowledgment given that additional costs may therefore be incurred in enforcement activity. This acknowledgement is to be welcomed and we would ask that Welsh Government make realistic provision for such costs in light of financial challenges faced by local authorities within the existing funding climate.
Legislative Powers
Hywel Dda University Health Board has no comment to make on the appropriateness of the powers in the Bill for Welsh Ministers to make subordinate legislation on this issue.
Conclusion
Hywel Dda University Health Board has consistently supported the introduction of a Minimum Unit Price for alcohol over many years of previous submissions to UK and Welsh consultations on this policy initiative. We see no evidence to alter our view on this matter and, as has been referenced in our response and in the papers circulated with this latest request for evidence, the research base has significantly strengthened the argument in favour of its introduction.
Therefore, due to the positive impact on health and well being that the introduction of the Public Health (Minimum Price for Alcohol) (Wales) Bill will bring, we fully support this proposal and look forward to it being brought forward to the chamber of the Senedd for debate.
[1] World Health Organisation (2009) Harmful Use of Alcohol http://www.who.int/nmh/publications/fact_sheet_alcohol_en.pdf
[2] Public Health Wales (2014) Alcohol and health in Wales. Wales profile.
[3] Hywel Dda University Health Board (2014) Alcohol issues in Hywel Dda Board Paper
[4] Public Health Wales (2017) Data Mining Wales The annual profile for substance misuse 2016-17.
[5] Welsh Government Social Research (2014) Model-based appraisal of minimum unit pricing for alcohol in Wales Summary Report
[6] NICE (2010) Nice recommends action to reduce alcohol related harm (NICE press release, 2 June 2010
[7] NICE (2014) Alcohol-use disorders: preventing harmful drinking Evidence Update Public Health Guidance PH24
[8] Advisory Panel on Substance Misuse. 2014. Minimum unit pricing: a review of its potential in a Welsh Context. Available at: http://gov.wales/docs/dhss/publications/140725uniten.pdf
[9] Stockwell, T and Thomas, G, (2013), Is alcohol too cheap in the UK? The case for setting a Minimum Unit Price for alcohol, Institute of Alcohol Studies report
[10] Stockwell, , Auld MC, Zhao JH and Marin G. (2012) Does minimum pricing reduce alcohol consumption? The experience of a Canadian province. Addiction, 107 (5): 912-20
[11] Carmarthenshire County Council (2015) 50+ Forum Survey
[12] Carmarthenshire Citizen’s Panel (2014) survey 40 Hywel Dda University Health Board Alcohol Awareness Report
[13] Ceredigion Citizen’s Panel (2014) survey 17 Hywel Dda University Health Board Alcohol Awareness Report
[14] Pembrokeshire Citizen’s Panel (2014) survey 27 Hywel Dda University Health Board Alcohol Awareness Report
[15] Welsh Government (2014) Model-based appraisal of minimum unit pricing for alcohol in Wales
[16] NICE (2010) Alcohol-use disorders: preventing harmful drinking. Public Health Guidance PH24
[17] NICE (2014) Alcohol-use disorders: preventing harmful drinking Evidence Update Public Health Guidance PH24