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Measuring and reducing alcohol-related harm

National UK policy is based on the calculation that the adverse consequences of drinking each year cost the economy £21 billion. This figure given in the UK alcohol strategy was unpacked in the government’s response to the consultation on the strategy: alcohol-related crime, £11 billion in England and Wales at 2010/11 prices; and at 2009/10 prices, across the United Kingdom £7.3 billion for lost productivity and in England, £3.5 billion in costs imposed on the National Health Service for the treatment of alcohol-related illness – estimates repeated by the National Institute for Health and Care Excellence (NICE) in its quality standards on preventing harmful alcohol use.

Though these estimates were unreferenced, their pedigree can presumably be traced to a long line of comparable estimates, handily compiled by the Institute of Alcohol Studies. Among these, in 2003 the UK’s Cabinet Office estimated that in 2001/01, alcohol-related death, illness and crime cost England about £20 billion. An update of the costs to the NHS included in that estimate raised it to £2.7 billion at 2006/7 prices. In 2010 NICE limited its calculations to costs associated with healthcare, crime, antisocial behaviour and employee absenteeism, calculating an annual total for England of £12.6 billion. In that report inflation was estimated by 2008/09 have raised the costs to the NHS to £2.9 billion. At 2006/7 rates, alcohol was estimated to have cost Scotland £2.25 billion, of which the greatest part was due to lost and diminished productivity including unemployment and years of work lost due to premature death. For the UK as whole, in 2005/06 costs borne by the NHS were estimated at about £3 billion. The same study funded by the British Heart Foundation calculated alcohol-related deaths at 31,000 in 2005 and that in 2002, one in ten disability-adjusted life years had been lost to alcohol. Liver disease is a major component, in England and Wales predicted to lead to a cumulative total of 143,000 deaths over the 20 years from 2010, during which year the number was 6,317.

What to count, what not to count

Such figures seem to demand action, and are cited with this purpose in mind by government, authorities seeking to generate a better response to harmful drinking, and by campaigners on the harm caused by drinking. Some figures such as liver disease deaths seem relatively solid, but others are subject to assumptions and decisions about what to include and what to record which if varied would hugely change the estimates.

The uncertainty is nowhere greater than when analysts attempt to attach £ signs to the impacts of drinking. In 2009 a review found 20 such studies which varied substantially in their methodologies and in their estimates, resulting for example in an implausibly large tenfold gap between estimates of the per capita costs imposed on the populations of Portugal and the USA. A prominent alcohol expert has argued that estimates of the net cost imposed on society by drinking have often been grossly inflated because (among other things) they assume that hazardous drinking must be irrational consumption, that crime benefits no one, that drinking has no social, psychological or indirect business benefits, and that productivity losses are not counter-balanced by benefits elsewhere and by other workers taking over the jobs of the alcohol-impaired, eventually balancing the original job loss with one more unemployed person gaining work. Critiques from some of the world’s leading alcohol researchers broadly supported the thrust of the argument.

As this critique exposed, calculating costs alone is only part of the equation – drinking happens because the drinkers at least feel they get some benefits – but when an attempt is made to calculate net costs (ie, benefits minus costs) what is missing from the calculations becomes even more critical than when costs alone are calculated. Notably, how much drinkers value the pleasure they get from drinking and its social roles are omitted.

How cataract surgery could be counted as an alcohol admission

Calculations of the burden imposed on the NHS exemplify the shifting-sands nature of some estimates. The main indicator is alcohol-related hospital admissions, in England until 2014 understood to total over a million a year and rising. This figure is not in fact a number of admissions but an addition of the proportion that research suggests each type of illness is on average attributable to drinking. Someone admitted with an illness which in 50% of cases is attributable to drinking plus someone else with another illness also 50% due to drinking would, for example, count as one alcohol-related admission.

But the critical fact about this indicator is that an alcohol-related admission (or a fraction of one) can be counted even if the main reason why the patient came to hospital had nothing to do with drinking. This is because clinicians can record up to another 19 secondary diagnoses. If any of those conditions are on average alcohol-related, the admission too is counted as alcohol-related. The example given by Public Health England is a patient admitted to have a cataract removed from their eye who is also recorded as suffering from alcoholic liver disease. That disease may have little to do with the eye complaint or why the patient was admitted to hospital, but still that admission would be counted as wholly attributable to alcohol. Not only is this catch-all number far higher than admissions where the primary diagnosis was alcohol-related, it has also been rising much more steeply as hospitals record more and more secondary diagnoses. Inflation in secondary diagnoses is thought at least partly motivated by the fact that inflating the dire state of their patients makes hospitals’ death rates look better. Whatever the motivation, the more secondary diagnoses are recorded, the greater the chance that some will be among those considered on average alcohol-related; there is no need for a clinician to judge whether in this particular case drinking was indeed a factor in the admission. The result can be more apparently ‘alcohol-related admissions’ even if alcohol-related illness rates have remained stable and in reality alcohol’s contribution to the hospital workload has remained unchanged.

Hospital admissions attributable to alcohol, England: Hospital admissions attributable to alcohol, England

The impacts of including or excluding secondary diagnoses are huge. Between 2002/03 and 2011/12, the broader indicator more than doubled, rising by nearly 140% from 510,700 to 1,220,300, justifying concerns over alcohol-related harm rapidly escalating to epidemic levels. But over the same period, primary admissions attributable to alcohol rose by only 41% from 142,000 to 200,900 – not good, but a rise less than a third as steep chart.

In the end Public Health England decided to continue to publish the broader numbers but to introduce the narrower measure too, though one which additionally included some secondary diagnoses when the cause of the illness rather than the illness itself is on average related to drinking, such as an assault causing a facial injury. Still this made a huge difference to numbers, in 2012/13 resulting in a total of 325,870 alcohol-related admissions compared to 1,008,850 under the old, broader classification. It was this narrower measure which the Department of Health decided to use for the purposes of monitoring public health and assessing the success of health and alcohol policies, slashing the total to a third of the dramatic ‘over a million’ figure and decelerating the previously much steeper long-term escalation in admissions and in the alcohol-related harm they represented.

As rehearsed by Public Health England, there are good reasons for the new, more restricted indicator of admissions, but there are other benefits too for a government concerned to present its policies as working – particularly, according to an article published in one of Britain’s leading medical journals, the voluntary ‘responsibility deal’ the Department of Health brokered with the alcohol industry in lieu of more intrusive intervention.

Reducing the burden

Revisions and critiques which slash alcohol-related harm costs to a fraction of their claimed level are far from splitting hairs, but even with the uncertainties, costs related to drinking are substantial. The public health burden both reflects and calls in to question the embededness of drinking in British society, an embededness which generates controversy over how to reduce the burden. In the mix are universal prevention programmes usually targeting all young people in a population or sub-population, price rises, widespread screening and brief advice in surgeries and hospitals, and treating the worst cases. Each has their enthusiasts and sceptics. Brief interventions in particular have tremendous public health potential, but consistently realising that potential is a challenge yet to be overcome in the UK.

After surveying the field, experts convened by Britain’s National Institute for Health and Clinical Excellence (NICE) prioritised national policy initiatives to restrict alcohol availability by making it less affordable, available in fewer outlets for less time, and promoted less visibly. Perhaps the most promising approach is setting a minimum per unit price in such a way that strong drinks cost more. Primarily to combat alcohol-related disorder and crime, just such a measure was the centrepiece of 2012 alcohol strategy for England. In this the prime minister’s message was “simple”: “We can’t go on like this. We have to tackle the scourge of violence caused by binge drinking ... a real effort to get to grips with the root cause of the problem ... means coming down hard on cheap alcohol”. For England setting a minimum price per unit of alcohol was to be the solution, one already being pursued in Scotland.

In the end that never happened in England, though in the face of legal challenges Scotland is still attempting to implement the law passed in June 2012 which enables the Scottish government to issue regulations setting a minimum price, intended to be £0.50. Another hot topic will take you through the arguments and the politics of setting a minimum per unit price for alcohol. For the moment we can take it as an example of the fact that health benefits and perceived political benefits of a given policy do not always coincide.

The studies thrown up by this search address one of the most pressing of Britain’s public health issues, but one for which the UK has yet to find an effective way of reconciling the need to reduce harm with the centrality of drinking in public and private life.

Last revised 01 May 2015. First uploaded 01 October 2010

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