TACKLING ALCOHOL TOGETHER  3

Regulations relating to alcohol

Number and type of outlets

Research from the US has shown a relationship between the number of outlets and specific alcohol-related problems such as road accidents and assaults. In the UK a relationship was demonstrated between number of outlets and consumption, especially for wine but not for spirits. Also in the UK the rise in the number of outlets selling alcohol has

been accompanied by a growth in alcohol consumption. The number of outlets rose from 129,367 to 201,148 between 1960 and 1995, an increase of 55 percent. Over the same period the number of off-licence outlets alone almost doubled. Meanwhile, average alcohol consumption rose from 5.7 litres of pure alcohol per year for every person aged 15 and over in 1960 to a peak of 9.8 litres by 1979. Since this time average consumption has only once (1982) dropped below 9 litres per head.

It is unwise to ignore the links between number of outlets with a license, levels of consumption and adverse consequences.

Restrictions on purchasing times

Evidence from other countries concerning the effects of altering the hours during which alcohol can be sold demonstrates a significant positive relationship, with longer hours leading to increased problems and shorter hours being followed by a reduction in such problems. In the UK, recent licensing reforms have extended permitted hours. Unfortunately other changes, such as a recession and unemployment, were occurring at the same time making the available evidence difficult to interpret. Nevertheless, the evidence from other countries indicates that it would be wise to assume that extending licensing hours will result in more problems rather than fewer.

Children and young persons

Age restrictions on consumption play an important role in the prevention of alcohol-related problems. An Australian study found that overall levels of male juvenile crime rose by between a fifth and a quarter after the lowering of the drinkin g age to 18 in some states during the 1970s. Similarly, in the USA, the reduction of the legal drinking age was associated with an increase in alcohol consumption and alcohol-related road accidents involving young people. Subsequently, when drinking ages in the USA were raised, the rate of traffic accidents among young people fell.

Conclusions

· One way of discouraging both under-age drinking on licensed premises and illegal purchase of alcohol from all types of licensed premises is to enforce the existing law more vigorously.

· Increasing the age limit for drinking in public places has been associated with reductions in alcohol-related problems.

· Legislation is an effective way to control the availability of alcohol. The distribution of outlets and their opening times will have an impact on public order and on consumption.

Generalist treatment and minimal intervention

Generalist treatment involves a range of primary level workers who routinely encounter problem drinkers in their day-to-day work. Within the heath services, these include general medical practitioners, general psychiatrists, hospital physicians, and accident and emergency specialists. Professions allied to medicine, mainly nurses, are also involved.

Social workers, police, probation officers and prison officers can help to identify and change harmful drinking behaviour. Interventions for alcohol problems can also occur in the workplace.

The work of generalists in the alcohol area increasingly consists of formal or informal screening for alcohol problems and minimal intervention to modify drinking behaviour. This kind of activity is usefully called opportunistic: advantage is taken of opportunities that arise when people present to a facility or service for reasons unconnected with a possible alcohol problem. people drinking in hazardous or harmful ways are offered minimal interventions, usually aimed at reducing drinking to low-risk levels.

General medical practice and primary health care

By far the greatest amount of attention has been paid to general medical practitioners. This is for very good reasons. Over 98% of the population of the UK is registered with a general practitioner;

* there are over a million general practitioner consultations every day;

* two-thirds of a practice population visit their general practitioner within a one year period;

* 90% do so within a five year period;

* heavy drinkers visit their general practitioner roughly twice as often as light drinkers.

Several UK and international studies have clearly established that, among male excessive drinkers at least, a minimal intervention delivered at the primary care level and consisting of even just five minutes simple advice, is effective in reducing alcohol consumption and associated harm.

Cost benefits from minimal interventions

In addition to the benefits to the individual drinker one of the chief arguments in favour of the implementation of minimal interventions is that they can save money for the health care system in the longer run. Evidence to support this proposition is beginning to accumulate. For example, a Swedish study found that excessive drinkers who had received a minimal intervention showed an 80% reduction in sick absenteeism from work in the four years following the intervention. There was also a 60% reduction in days in hospital over five years and a 50% reduction in mortality from all causes over six years following intervention.

General hospital services

Just over a quarter of male in-patients on general medical wards, have a current or a previous alcohol problem. The rates for women are lower and more variable. There is also evidence that minimal interventions are effective in this setting. In one UK study patients receiving a minimal intervention showed improved outcome at the 12 month follow-up.

Screening and counselling hazardous and harmful drinkers on hospital wards is an important strategy for early intervention in alcohol problems and should be practised more widely in Britain.

Accident and emergency departments

Excessive drinkers are over-represented among attenders of Accident and Emergency departments. One study found that 40% of casualty patients had consumed alcohol before attending and 32% had a blood alcohol concentration over the legal limit for driving (80mg%).

A Finnish study has demonstrated substantial benefits from three counselling sessions given by a trained nurse in an A&E setting.

General psychiatry

Up to a fifth of admissions to psychiatric hospitals may be heavy drinkersandyetpsychiatristsoftenfailtotakeaproperdrinkinghistory. This is particularly important since a large proportion of patients with the most severe mental health problems will also have an alcohol problem (32% in one UK study). The UKAlcohol Forum has recently produced guidelines for the management of alcohol problems in primary care and general psychiatry.

Social services and probation

Alcohol is a significant component in between 20% and 40% of all social work caseloads and is likely to exceed these estimates in child abuse cases. Studies have also shown that parental alcohol misuse is the most important factor that leads to the reception of children into local authority care.

The crucial relevance of problem drinking to probation work is shown by the fact that in 1994 probation off icers reported 30% of their caseloads as having severe problems with alcohol. For over seven in ten offenders in this category, an alcohol problem was directly related to the most recent offence.

Conclusions

• Specialist services are able to reach only a fraction of people whose lives are adversely affected by alcohol or whose excessive use of alcohol adversely affects others. The involvement of generalists across all sectors - health, social services, criminal justice and the workplace - in prevention and treatment is essential.

• Strong specialist services are required to treat the more severe cases of alcohol dependence, as well as to provide ongoing support, training and consultation to generalists in the field. A balance between specialist and generalist activity must be struck if treatment is to be widely effective.

• Across all sectors of generalist activity, there is a lack of training and scant use of basic skills in the recognition of an alcohol problem and the provision of minimal interventions.

Specialist treatment

Specialist treatment for major alcohol problems is better than no treatment. A rough estimate is that the rate of naturally occurring improvement is one-third, whereas two-thirds of individuals receiving treatment show some improvement.

American findings show that treatment for alcohol problems as a whole produces net gains for the health care system and is, therefore, a worthwhile and efficient use of financial resources. It has been estimated that for every US$10,000 invested, treatment saves about US$30,000 in medical spending for the managed care provider.

Benefits to the health care system in terms of cost-off sets are only one aspect of possible economic advantages that treatment might bring. It will also result in reduced criminal activity and criminal justice costs, reduced social care and housing demands, reduced accidents as well as productivity and training gains for employers. Added to these third party benefits are possible benefits to individual problem drinkers and their families in improved employment prospects and earnings, improvements in social functioning, reduced risk of arrests for drunkenness, drink driving etc., and reduced expenditure on alcohol, all of which can be considered economic gains.

Alcohol problems and psychiatric co-morbidity

Co-morbidity, or dual diagnosis, is important to a consideration of alcohol treatment services for two reasons. First, people who have an alcohol problem and one or more additional mental health problems have a less favourable prognosis than those people with an 'uncomplicated' drinking problem. Secondly, people with a co-morbid problem use many more health and social care resources.

Dual diagnosis patients are some of the most vulnerable and needy individuals in society, with homelessness, poor physical health and arrests for violence or other criminal behaviour adding to their adjustment problems. Yet the indications are that co-morbid individuals are more likely than others to be excluded from mainstream services, chiefly because of the lack of adequate service provision for this group.

Mutual aid for alcohol problems

A major source of specialist treatment for alcohol problems within the non-statutory sector is often omitted from discussions of treatment because it lies outside the formal planning and funding framework. This is the mutual help that problem drinkers offer to each other in the attempt to recover from their problems. By far the most prominent of these organisations is Alcoholics Anonymous which offers in the region of 2,900 meetings per week in England and Wales, an average of 15 meetings per week for each Health District. Data from Alcoholics Anonymous Headquarters in York indicates a membership in the UK of some 60,000 active members.

All the mutual-aid groups harness powerful psychological processes including the understanding and acceptance of a drinking problem by fellow sufferers, the group cohesion and social support for a new lifestyle, and the availability of help in a crisis.

The current state of alcohol treatment services

The absence of agreement on minimum purchasing and commissioning guidelines for specialist alcohol services have contributed to a highly variable patchwork of treatment provision across the UK. Treatment services are often poorly coordinated and afforded a low level of priority in planning.

Local funding of specialist alcohol services, particularly within the nonstatutory sector, has been resourced through ad hoc monies, gained from central initiatives and time-limited project funds such as joint finance schemes as well as voluntary donations and subventions from Social Work and Health budgets. This has led to local service developments being driven by the availability of specific project funds, rather than on the basis of objective needs assessment.

In the statutory sector, Regional Units have become smaller with a more local focus, have lost key functions such as training and research and development due to lack of a critical mass and, in some cases, have closed.

• Treatment gives value for money.

• Research indicates that treatment reduces the harmful impact of alcohol misuse at the population level, particularly with respect to more chronic alcohol problems.

• The expertise and role of specialist National Health Service alcohol units needs to be strengthened. Specialist services are required to support policy implementation at a local level, to support primary health care teams and alcohol counselling teams, and as a focus for training and research.

• Specialist services involving health, social work and voluntary agencies need to be developed to address the needs of those with psychiatric disorders, brain damage as well as for young people and the homeless