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Beeston C., McAdams R., Craig N. et al.
NHS Health Scotland, 2016
The final report evaluating Scotland’s alcohol strategy concludes that while some evidence-based interventions have been implemented, failure to implement minimum unit pricing is likely to have limited the strategy’s contribution to declines in both alcohol consumption and related harm.
Summary The fifth and final report from the Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) programme examines the implementation and medium-term outcomes of Scotland’s 2008/2009 alcohol strategy – focusing on the Licensing Act 2005, brief interventions, specialist treatment and care services, a ban on multi-buy discounts, public knowledge about alcohol and related risks, and minimum unit pricing.
Alcohol-related harm in Scotland has been falling. Though evidence- based interventions flowing from the strategy probably helped, it was difficult to quantify their impact, particularly given external factors.
For instance, the recent drop in alcohol-related deaths has been linked to falling ‘disposable’ income in deprived areas (reducing alcohol affordability) and the passing of a ‘vulnerable’ generation adversely affected by the socioeconomic policies of the 1980s.
Alcohol consumption and related harm remain higher in Scotland than in England and Wales, emphasising the need to continue reducing alcohol-related harm in Scotland.
The strategy consists of four evidence-based components:
(1) The Licensing Act 2005, which includes restrictions on irresponsible promotions and measures to reduce underage selling; (2) the Framework, aiming to reduce alcohol consumption through measures targeted at the whole population and high-risk groups, for example through the scale-up of delivery of brief interventions and increased investment in specialist treatment and care services; (3) the Alcohol Act 2010, which includes a ban on multi-buy discount products; and (4) the Minimum Pricing Act, setting a minimum unit price below which alcohol cannot be sold. Of these four components, all have been implemented except the Minimum Pricing Act.
The Scottish Government tasked NHS Health Scotland with conducting the evaluation. The strategy was designed to impact on two overarching outcomes: levels of alcohol consumption, and levels of alcohol-related harm. A “theory of change” model was developed to map out how the policies and interventions contained in the strategy could be expected to lead to these desired outcomes. This assumed that “a reduction in alcohol harm would be achieved if individuals exhibited safer drinking patterns and if there was a reduction in population alcohol consumption”.
The key evaluation questions
• How and to what extent has implementing the measures (taken together and/or individually) in the Scottish alcohol strategy contributed to reducing alcohol-related harms?
• Are some people or businesses affected more than others?
• How might the strategy be implemented differently to improve effectiveness?
The final paper from MESAS gives an overview of trends in alcohol consumption and alcohol-related harms (discussed in detail in this Effectiveness bank analysis), followed by an assessment of the strategy’s contribution to these outcomes, and finishes with a consideration of factors outside of the strategy that may have influenced these outcomes.
The Licensing Act 2005: The public health objective in the Act established the contribution of licensing to public health. Some components were successfully implemented, including licensing standards officers and test purchasing. However, limitations of data made it difficult to show whether the Act influenced licensing decisions or alcohol availability.
Alcohol brief intervention (ABI) programme: Alcohol brief interventions have been embedded into routine practice in the NHS, particularly in primary care. There was insufficient data to determine the characteristics of those reached, uptake of brief interventions or the impact on alcohol consumption.
Increased investment in alcohol treatment and care services: Investment in specialist alcohol treatment and care services has tripled since 2008/09, and a target to reduce waiting time for specialist alcohol and drug treatments was introduced in 2011. Overall, waiting times reduced, and both staff and patients perceived that there had been improvements in availability and quality of services.
The Alcohol Act 2010: A ban was introduced on multi-buy discounts in late 2011. This was associated with a 2.6% reduction in off-trade alcohol sales. This had no discernible impact on alcohol-related deaths or hospital admissions in the short-term, and it is unknown what the impact will be in the longer-term.
Public alcohol-related knowledge and attitudes: The harm being caused by alcohol in Scotland is increasingly recognised among the general public. However, it was not possible to assess the extent to which the strategy de-normalised heavy drinking.
Alcohol price and affordability: Failure to implement minimum unit pricing is likely to have limited the strategy’s contribution to declining alcohol consumption and related harm.
Falling ‘disposable’ income: Income among the poorest groups in Scotland started to fall before the rest of the population (and before the recession), leaving people with less ‘disposable’ income – reducing alcohol affordability and consumption.
Compared to England and Wales, in Scotland a greater proportion of alcohol-related deaths occur in deprived communities. Analysis shows that the decline in Scotland’s alcohol-related mortality was driven by a decline in the most deprived areas.
A vulnerable cohort effect: An increase in alcohol-related mortality was found among middle-aged adults (particularly men) in the most deprived areas in Scotland from the early 1990s to the mid-2000s, followed by a decline. This cohort was exposed to de-industrialisation and adverse socioeconomic policies in the 1980s.
Evidence suggests that “ageing and subsequent deaths in this cohort contributed to the rapid rise and subsequent fall in alcohol- related mortality in Scotland from the 1990s”.
Whilst the strategy may have had some influence on the key outcomes, two particular external factors (falling ‘disposable’ income and the vulnerable cohort effect) are likely to have contributed to the decline in alcohol-related harm.
The strategy’s impact on alcohol affordability has been constrained by the inability to implement minimum unit pricing. Along with the UK government’s ending of the policy which automatically raised alcohol duty above the rate of inflation, this meant there was little scope for “policy-driven reduction in alcohol affordability”.
Going forward, further “consideration should be given as to how alcohol consumption and related harm can be addressed within the context of the wider socioeconomic determinants of health”.
commentary As often occurs in policy evaluations, the needs of the evaluation came second to the need to implement the policy. The researchers were unable to use a more traditional evaluation method, such as a “concurrent comparison with an area where the strategy had not been implemented”, and unable to influence data collection, which limited their ability to draw firm conclusions about the impact of particular aspects of the strategy – for instance, the impact of the Licensing Act 2005 on licensing decisions and alcohol availability, and the impact of alcohol brief interventions on alcohol consumption.
Approaches to alcohol policy differ widely across the UK, with Scottish policy being the most closely aligned with evidence-based recommendations. There is strong evidence supporting the use of minimum unit pricing to mitigate the impact of cheap alcohol on alcohol consumption and alcohol-related harm. Despite political will to implement minimum unit pricing in Scotland, it is has been delayed by an ongoing legal challenge. For a broader look at the evidence and values informing the debate on minimum unit pricing, see this Effectiveness Bank hot topic.
Other MESAS reports analysed for the Effectiveness Bank deal in greater detail with alcohol treatment and care services, the implementation of alcohol brief interventions in health service settings, and the impact of the Licensing Act.
Thanks for their comments on this entry in draft to Alcohol Focus Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 30 April 2016. First uploaded 13 April 2016
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