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The United Kingdom is ninth of 14 leading European Union countries in the per capita consumption league table but second only to Germany as a producer of beers. Some 1.47 million people are employed in licensed retailing and related industries [1]. The number of fully licensed premises, public houses and hotels has remained fairly steady in recent years at around 88 000 [1]. The public enjoy eating out and drinking as a prime leisure activity and in 2003 spent £74 766 on alcohol every minute of the year, generating £13 477 million in revenue, 4.5% of the total, for the Treasury [1]. The per capita consumption of alcohol in the United Kingdom has increased from 6.6 l per head in 1973 to 9.1 l in 2003 [1], which is reflected in the 2002 General Household Survey [2] as 27% of men and 17% of women drinking over safer weekly limits (21 and 14 units) and 7% and 3% drinking over dangerous limits (50 and 35 units). Best estimates for England and Wales are of at least 7 million hazardous or harmful and at least 1 million dependent drinkers. The cost of alcohol-related harm has been estimated at up to £1.7 billion to the health service, accounting for between 11 300 and 17 900 deaths due to chronic disease, up to £7.3 billion attributable to crime and public disorder and up to £6.4 billion in costs to the economy [3]. There are other costs that are difficult to quantify, notably the impact on children, the dysfunction of families and the despair experienced by individuals. The total costs may reach £20 billion or, viewed another way, £6 billion more than income.

Alcohol policy has developed somewhat differently across the United Kingdom. In 2000 Wales opted for an integrated alcohol and drugs policy called Tackling Substance Misuse in Wales: a Partnership Approach[4]. Wales has the same licensing laws as England. In the same year Northern Ireland adopted a Strategy for Reducing Alcohol Related Harm[5], which has an alcohol health promotion focus but is to be implemented by drug and alcohol co-ordination teams. The Scottish Executive produced its national plan in 2002 [6] and supported the plan with a service framework which set out a four-tier structure for treatment services. Scotland has different licensing laws to England, but new legislation has the same aims as the 2003 Licensing Act for England and Wales [7]. In the Department of Health policy document Choosing Health[8] there are welcome references to alcohol: astonishingly, the Portman Group is given a high profile as the key partnership agency to tackle ‘binge drinking’. Publication of the first Alcohol Harm Reduction Strategy for England[3] in 2004 was of particular importance because it revealed thinking at central government level. There is a belief that the strategy was influenced unduly by the Portman Group, which is widely thought to represent the interests of the drinks industry by promulgating ineffective control measures [9]. The strategy states explicitly that no action will be taken to cap per capita consumption, an essential plank of prevention strategy, and focuses actions on binge drinking as the problem. This idea was first mooted with the publication of Sensible Drinking[10], a very competent document but carrying a complicated message, which was interpreted by the media and public as a relaxation of safer limits rather than a restriction on binge drinking. The strategy for England has been followed-up with a consultation document called Drinking Responsibly[11], which is largely about ways of containing the adverse consequences of extended drinking hours allowed under the new Licensing Act.

The Health Technology Board for Scotland has produced a review of the effectiveness of alcohol treatment [12], concluding that behavioural self-control training, motivational enhancement therapy, marital or family therapy and coping or social skills training be recommended as treatments with the strongest evidence base. Acamprosate and supervised oral disulfiram were also recommended as adjuncts to psychosocial interventions. The National Treatment Agency for England will publish a Models of Care for Alcohol in 2005, which will define four tiers of services similar to the Scottish approach: the Agency has also commissioned a review of treatment effectiveness. There is now a substantial evidence base which underpins clinical practice and there is broad agreement on the future direction of treatment services. Brief interventions, motivational, and social therapies have grown in both popularity and the scientific confirmation of their effectiveness [13]. Mindful of this, the UK Alcohol Treatment Trial [14] compared a standard motivational therapy against a novel social networking therapy and found that both performed equally well. This common finding, that theoretically different treatments produce similar results, has led to a better questioning of treatment processes, in particular the importance of therapist variables [15] and life events outwith specific treatment [16]. The National Treatment Agency has taken a lead on disseminating key research findings such as these and setting out the implications for practice. The Department of Health supports eight programmes of research in England and Wales, with the aim of bringing a more strategic approach to research activity; however, underfunding and short-term planning constrain the potential for good quality research [17].

There is a mismatch in the United Kingdom between the available evidence and the evidence selected to inform policy. The health-care agenda has been largely replaced by a public order agenda as has happened for illicit drugs. The current preoccupation with binge drinking and its companion responsible drinking release the government and the industry from imposing limits on the availability of alcohol: treatment will be directed at binge drinking individuals. There are some 800 substance misuse treatment agencies in the United Kingdom, most of which are combined alcohol and illicit drug services. Performance management of these services against centrally set targets is omnipresent, as are the enforcement agencies: the Department of Health, the National Treatment Agency, Drug Action Teams, Strategic Health Authorities and the Government Office. Provider agencies experience scant opportunity for independent thought. There have been benefits from the approach, generally manifest in some form of improved and more uniform standard, but at a huge cost in bureaucracy and migration of skilled clinicians into the attractively remunerated management network. The checks and balances in the shape of professional bodies, research institutions and campaigning groups such as Alcohol Concern are weak. The Society for the Study of Addiction [18] is an exception, in that it is a truly independent think-tank responsible for projects such as Tackling Alcohol Together[19] and supporting similar projects at an international level.

The debate here is really about whether central government is best placed to take an overview on alcohol policy or whether independent institutions, those free of government control, should be the policy drivers at least for treatment and prevention strategy. The bureaucracy to coordinate and deliver substance misuse policy has not been evaluated, but is both poor value for money and too politically controlled. The National Strategies are inevitably cross-cutting but once agreed then one department, presumably the Treasury, needs to ensure that the cost of alcohol does not reduce, or better still to ensure per capita consumption does not increase. Rather than a relentless flow of new initiatives, effective implementation of what is already known would deliver low-cost, high-impact results. The United Kingdom has a habit of only partially translating the experience of other countries into its own culture. Importing knowledge and systems more fully would provide a welcome boost to UK alcohol services: how to work with service users, how to assure quality of treatment delivery and how to work with purchasers of clinical services are three examples where the United Kingdom could look to other countries with longer experience in developing these areas.

Acknowledgements

  1. Top of page
  2. Acknowledgements
  3. References

Thanks to Clare Pace, Social Policy Tutor, Leeds Addiction Unit for an update on prevention initiatives.

References

  1. Top of page
  2. Acknowledgements
  3. References
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