Alcohol misuse is becoming an increasing problem. Three particular consumption patterns are associated with harm:

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1 18. ALCOHOL INTRODUCTION Alcohol is a complex field. It plays an important role in our society and economy, and is widely associated with socialising, relaxing and pleasure. The value of the UK drinks market in 2003 was estimated at 30 billion and is associated with around one million UK jobs. It is estimated that over 90% of the adult population drink alcohol, with the majority drinking within safe limits. There is some evidence that moderate amounts of alcohol may be protective against some health conditions. At the same time, alcohol harm adversely affects a wide range of physical and mental health conditions and social and economic outcomes, and the full extent of alcohol-related harm is often hidden. Alcohol misuse is becoming an increasing problem. Three particular consumption patterns are associated with harm: Binge drinking refers to large amounts of alcohol drunk in a relatively short time, often with the specific objective of getting drunk. Hazardous and harmful drinking refers to the regular consumption of alcohol beyond the recommended maximum amounts (1). Dependent drinking refers to chronic heavy drinking, significantly in excess of recommended maximum limits, associated with increasing levels of harm to physical and mental health. Alcohol-related health disorders and disease include acute events (alcohol poisoning, accidents and sudden death) and chronic conditions (hypertension, liver disease, pancreatitis, foetal damage, certain cancers, premature death). In addition to health-related problems, alcohol misuse is associated with crime and disorder (including anti-social behaviour and domestic violence), social problems (worklessness, teenage pregnancy, school exclusions) and the economy (lost productivity, incapacity benefits.) 1

2 WHICH GROUPS ARE PARTICULARLY VULNERABLE TO HARM FROM ALCOHOL? There are a number of vulnerable groups which are at higher risk from alcohol use. These include: Children and young People Although most young people do not drink, average alcohol consumption has increased significantly among those that do. Young people are more likely to binge drink than other groups, making them more likely to engage in risk-taking behaviours including other substance misuse, unsafe sexual activity and crime. Women Women metabolise alcohol in a different way from men, which places them at earlier risk of alcohol harm. Average alcohol consumption has increased among women over the past 20 years, with more drinking above maximum recommended limits (2). Drinking patterns vary with age and social class, with a particularly marked increase in alcohol consumption among women in professional groups (3). Older people Alcohol use amongst older people is relatively common. Often problems go undetected for long periods due to issues around social isolation and professionals attitudes. Physiological and lifestyle changes associated with ageing reduce tolerance and increase risk of falls, memory loss, and management of medications. Ethnicity Indian, Pakistani, Bangladeshi, Black Caribbean and Black African groups are less likely to drink, or are more likely to drink moderately, than the general population (3). However, the prevalence of alcohol dependence is similar to the White population. Men and women from Irish communities are most likely to drink above sensible levels. Social Class Hazardous and harmful drinking is linked to social class. Men in manual and unskilled classes are more likely than men in professional classes to die of alcohol-related causes. In older women, professionals have the highest risk of dying from alcohol-related causes, but in younger women, manual and unskilled groups are most at risk. 2

3 Other vulnerable groups include ex-prisoners, homeless people, those who suffered abuse as a child, and people with a family history of alcohol misuse. THE ISLINGTON PICTURE (4) Patterns of drinking behaviour 21% of Islington adults were estimated to engage in hazardous drinking, similar to London (19%) and England (20%). Prevalence of binge drinking was 15%, similar to London and England averages (13% and 18% respectively). 6% were estimated to be drinking harmfully, similar to London (5%) and England (5%). Alcohol-related illness and mortality The directly standardised rate of hospital admissions for alcohol-related harm in Islington in 2007/8 was 1,843 per 100,000 population, significantly higher than London and England (1,386 and 1,472 per 100,000 respectively). The impact on average life expectancy due to alcohol-attributable mortality in Islington in for men was a reduction of 12.3 months (London: 8.7 months, England: 9.2 months) and from women 3.9 months (London: 3.6 months, England: 4.3 months). Deaths due to alcohol-related transport accidents in 2008/09 were 0.7 per 100,000 population (directly standardised rate), compared with 1.1 per 100,000 in London and 1.8 per 100,000 in England. Although the rate in Islington was low by national standards, it should be remembered that all of these deaths were preventable. Islington has the highest rate (85.5 per 100,000) in London for alcohol-related admissions to hospital among people under 18. Alcohol related crime and disorder 3,009 alcohol-attributable crimes were recorded in 2008/09 i.e. 16 per 1,000 residents. This was the sixth highest rate among the London boroughs, and twelfth 3

4 Alcohol-related violent crime, including sexual violence, was significantly higher in Islington in 2008/09 (11.4 per 1,000 persons) compared with London (8.6 per 1,000) and England (6.1 per 1,000). Alcohol and the economy 330 people in Islington (239 per 100,000 people of working age) were on incapacity benefits due to alcohol dependence in November This was a significantly higher rate than London and England. Islington was the fourth most densely saturated borough in London for alcohol licences in 2007/08 (5). 2,100 people were employed in Islington bars in This accounted for 1.1% of all employees, significantly lower than London and England averages. FUTURE NEED In recent years average levels of alcohol consumption have increased across the general population, although the proportion of the population that drinks has not increased. Islington has had an upward trend in alcohol-related hospital admissions and alcohol-attributable mortality in both men and women. Therefore, the trend is towards more binge, hazardous and harmful drinking in the population, with increasing levels of harm (e.g. increased admissions and ill health, alcohol-related crime and anti-social behaviour, and alcohol-related deaths). There is good evidence to show that alcohol consumption at a population level is sensitive to price and income as well as ease of availability, social networks and cultural norms (6). The impact of the current economic downturn and changes in alcohol taxation may therefore exercise downward pressure on levels of alcohol consumption in the general population. Alternatively, however, financial distress and unemployment may result in increases in alcohol consumption if alcohol is used as a way of coping with the resulting pressures. 4

5 SERVICES CURRENTLY PROVIDED IN ISLINGTON Early intervention and treatment services Local alcohol harm minimisation and treatment services are informed by the Models of Care for Alcohol Misusers (MoCAM). MoCAM recommends a tiered service depending on level of intervention required. There are a range of specialist alcohol treatment services available in Islington for adults and young people in a variety of settings, including GP practices, community-based services and inpatients, and the Islington Young People Drug and Alcohol Service. Benchmarking carried out locally as part of Programme Budgeting work showed that in 2008/09, 527 adults were seen by alcohol services in Islington, equivalent to just over one in 20 of the estimated number of harmful drinkers in the borough, which was a similar proportion to other deprived London boroughs. Total direct expenditure on alcohol treatment services in 2009/10 is 1.9 million, which includes 0.3 million of transitional funding. Alcohol-related crime and disorder initiatives and services The Safer Islington Partnership (SIP) brings together stakeholders to tackle crime and disorder. A local mapping of offences showed that there were strong links between alcoholrelated offences and the night-time economy in Islington (7). Islington s Alcohol Task Force conducts intelligence led patrols to prevent alcohol-related crime and anti-social behaviour, as well as providing a rapid response to alcohol-related incidents. The SIP is currently involved in a London-wide A&E data-sharing project to identify alcohol-related A&E admissions (victims), as many alcohol-related crimes are unreported. An alcohol arrest referral scheme in 2008 identified relatively large numbers of dependent drinkers in the Islington custody suites. Working with the licensed trade - initiatives and services Islington council acts as the licensing authority for alcohol licences in the borough. The Public Protection team regulate and manage local licensed premises. The Council facilitates the Pubwatch and Best Bar None schemes, licensing seminars and works with the police and fire service through proactive visits to licensed premises. Trading Standards work in collaboration with the police to identify under-age sales and counterfeit alcohol. Promoting sensible drinking National sensible drinking campaigns by the Home Office and Department of Health inform local activities that are implemented during key times when alcohol consumption is likely to be greater such as Christmas and the summer holidays. In 2008 and 2009, Islington Council and NHS Islington used social marketing approaches to explore attitudes and behaviours of 5

6 bar staff and customers in Islington. The insights from this work will help to inform future plans to promote sensible drinking and reduce harm in Islington. In the school setting, alcohol awareness is part of the current PHSE curriculum and Healthy Schools programme. NATIONAL DRIVERS FOR SERVICE PROVISION Commissioning of alcohol treatment services is based on MoCAM, which sets out good practice guidance for alcohol treatment service pathways (8). This model recommends a tiered service where the tiers refer to the level or intensity of the interventions provided: Tier 1 interventions - alcohol-related information and advice; screening; simple brief interventions; and referral. Tier 2 interventions - open access, non-care-planned, alcohol-specific interventions Tier 3 interventions - community-based, structured, care-planned alcohol treatment Tier4 interventions - alcohol specialist inpatient treatment and residential rehabilitation. NICE recommendations set out a comprehensive set of actions in schools (including within the curriculum, whole school policy, and arrangements for early identification and referral for alcohol problems) to prevent or delay and reduce alcohol use among children and young people (9). New guidance for adults and young people will be released in 2010, covering prevention and early intervention, management of acute alcohol disease and management of alcohol dependence and psychological interventions (10). Safe Sensible Social: Next steps in the national alcohol strategy, the Government s alcohol strategy (11) seeks to balance a tougher approach through criminal justice for drunken behaviour and tighter enforcement of underage sales, together with more help for people who want to drink less. It aims to improve information for parents and young people and support public information campaigns to promote a new sensible drinking culture. The strategy has lead to three national reviews of pricing and promotion, labelling, and industry standards on social responsibility. It also highlighted the need for local strategies. The Home Office provides recommendations and guidance for the police and councils on managing alcohol-related anti social behaviour, and best practice guidance for alcohol retailers (11). More recently the Home Office has launched their consultation on a new code of practice for alcohol retailers. The Home Office has also provided funding for local sensible drinking marketing activities and advertisement. 6

7 PROGRESS SINCE LAST YEAR S JSNA Since the JSNA 2008 alcohol recommendations, the development of a comprehensive multiagency alcohol harm reduction strategy is underway. This strategy will provide a comprehensive overview of the current profile in Islington and make recommendations across all partners on how to reduce and minimise harm in the borough. Specific areas that have progressed are: Brief interventions and screening have been introduced in primary care. There has been an expansion of Tier 2 primary care alcohol workers supported through NHS Islington s Business Case for Prevention. An alcohol arrest referral pilot in the custody suite has been implemented and evaluated. A market research project has provided insight into the attitudes and behaviours of customers and bar staff in different types of drinking venues in Islington. OPPORTUNITIES FOR DEVELOPMENT Addressing sensible drinking and alcohol harm was identified as the top developmental policy in Islington s Health Inequalities Strategy (2009). Development of the local multiagency alcohol harm reduction strategy therefore provides an important opportunity to enhance coordination across all partners. It should provide a shared local vision and set of locally agreed actions covering sensible drinking and the prevention of harm, together with the interface with treatment services. Future services and initiatives will need to adopt a multi-agency approach to address the culture of alcohol consumption (particularly binge drinking in younger people and hazardous and harmful drinking in adults), ensure socially responsible alcohol retailing and developing earlier intervention and responsiveness to the needs of people with problem drinking patterns. An alcohol treatment services needs assessment is currently underway to explore service robustness and ensure that services are based fully on the national treatment pathway model. Together with the recent expansion of Tier 2 alcohol services in the community linked to primary care, the greater availability of screening and brief interventions provides a longer term opportunity to address needs earlier before significant harm occurs. This includes A&E and criminal justice sectors, although intervention in the former has not yielded the expected number of referrals and the pilot in the latter setting (in the custody suite) primarily identified dependent drinkers who required more intensive interventions. There has been a significant 7

8 expansion in primary care during 2008/09 and into 2009/10 aimed at new patients and this offer could be developed further. Islington s licensing services have a strong track record of working with local businesses to promote socially responsible drinking, reduce harm and tackle under-age and counterfeit sales. There is good evidence that use of appropriate tools and powers can reduce alcohol related harm across society (12), however, the increasing saturation of outlets across a significant part of the borough and increasing levels of alcohol consumption present a sustained and growing challenge for all emergency and enforcement bodies locally. The Sustainable Communities Act may offer opportunities to implement local alcohol saturation policies, using local evidence of alcohol related harm and disorder. There may also be opportunities to consider further promotion of local voluntary codes of practice and quality standards, building on work to date. There is a growing body of local intelligence brought together to enable effective targeting of action and information. Improved data links between A&E and police intelligence will assist in better ascertaining the true levels of alcohol-related harm in the borough, including victims of alcohol-related violence. Promoting sensible drinking via dedicated resources allocated to developing a communication plan across partners should employ a social marketing methodology to effectively address the differing needs and perspectives of the various target audiences. RECOMMENDATIONS 1. Priority should be given to an integrated alcohol harm reduction strategy setting out Islington s vision for reducing harm from alcohol and promoting sensible drinking, supported by coordinated action across all agencies. 2. Given the high saturation of alcohol outlets in the borough, and links to increased alcohol consumption and alcohol-related crime, priority should be given to developing the business case for a local saturation and enforcement policy under Sustainable Communities Act freedoms. 3. Implement the pan London data sharing project aimed to link alcohol-related injury and crime with A&E data, to identify unreported alcohol-related crime and link the crime location. 8

9 4. Implement a social marketing initiative to address binge drinking and hazardous drinking, based on the findings of the pilot work done to date. 5. Consider steps to improve coverage of screening and brief interventions for hazardous and harmful drinking in key settings and groups. 6. Work towards implementation of the MoCAM treatment model and explore mechanisms to improve treatment coverage. REFERENCE LIST (1) Department of Health, Home Office, Department for Education and Skills and Department for Culture, Media and Sport. Safe Sensible Social: Next steps in the national alcohol strategy (2) Alcohol Concern. Women and Alcohol: The Facts (3) Office for National Statistics. Living in Britain: results from the 2002 General Household Survey (4) North West Public Health. Local Alcohol Profiles for England (5) The Chartered Institute of Public Finance and Accountancy. Environmental Health Statistics, 2007/08. (6) Institute of Alcohol Studies. Available at (7) Safer Islington Partnership. Borough Alcohol Problem Profile (8) Department of Health and National Treatment Agency for Substance Misuse. Models of care for alcohol misusers (MoCAM). 2006:p (9) Interventions in schools to prevent and reduce alcohol use among children and young people. Public Health guidance PH (10) National Institute for Health and Clinical Excellence. Guidance relating to alcohol misuse in adults and young people (11) Department of Health, Home Office, Department for Education and Skills, Department for Culture, Media and Sport. Safe. Sensible. Social. The next steps in the National Alcohol Strategy (12) London South Bank University: Crime Reduction and Community Safety Research Group. What works to tackle alcohol-related disorder?: An examination of the use of ASB tools and powers in London. A practitioner guide prepared for Government Office for London

10 FURTHER INFORMATION Islington Sensible Drinking Strategy (in progress) Islington Health Inequalities Strategy Alcohol chapter 10