Derek Rutherford, now the chief executive of the United Kingdom Temperance Alliance, was between 1972 and 1980 the Director of the principal Government-backed agency on alcohol misuse, then known as the National Council on Alcoholism. Before his days at the NCA, he founded and directed TACADE, and after leaving it he established the Institute of Alcohol Studies. He has thus been involved in alcohol policy for over 30 years.
Here, he reviews a new book charting the development of alcohol and social policy from the beginning of the 1950's to the present day.
It has taken Betsy Thom some ten years to complete this book and it has appeared whilst we await the Department of Health's new strategy on alcohol.
For those who wish to understand how attitudes and responses to alcohol and alcohol problems developed over this period, and the changing reaction of Governments to alcohol policy, this book is a must. Those currently involved in alcohol prevention and treatment services will learn that the struggles they experience are not new and also that much has been achieved since the barren years of the 1950s. Older hands, despite some disappointments, ought to feel a sense of achievement at the vast improvement in the range of services available to problem drinkers. All who read the book will realise that 'alcohol policy today is embodied in the past'.
At the beginning of the 1950s state supported services for people with alcohol problems were virtually non -existent. In 1951, the Ministry of Health refused permission to a psychiatrist to attend a WHO conference on alcoholism on the grounds that `as there was no alcoholism in England and Wales', the subject did not merit the expence. The British Medical Association and other bodies held similar views. People with drinking problems found themselves, as Thom points out, 'in the terrible back wards of mental hospitals'.
Today, these attitudes strike us as extraordinary. We have to remember that alcohol consumption in 1950 was at a historically low level of 4.5 litres per head of population and the level of alcohol problems was also very low compared with both earlier and later.
It was also a question of how alcohol problems were perceived and defined. Throughout the 1950s the Ministry of Health considered alcoholism as a symptom of underlying disease, not a disease in itself. However, due to Alcoholics Anonymous influence on a number of professionals there was to be a re-emergence of the disease concept. Lincoln Williams in 1951 was to describe alcoholism as "an illness every bit as real and compelling as any of the maladies generally recognised as such". Thom poses the question "Why did the disease concept appeal so quickly and so widely?" and gives three reasons:
First, medical involvement was legitimised by defining alcoholism as a medical problem. Second, viewing alcoholism as a disease and not a moral failing or a sin made it easier to gain public support.Third, it provided a bridge between different interest groups and facilitated interaction between lay and professional discourses.
It was the growing acceptance of alcoholism as a disease which provided the impetus for treatment services. However, having served its purpose the disease concept began to be discarded in professional circles. It was replaced by the concepts of 'dependence on alcohol' and 'alcohol related disabilities' which incorporated physiological, psychological and social dimensions. A new 'public health' view of alcohol problems emerged with emphasis on the consumption of alcohol in the population as a whole and the link between consumption and alcohol related harm.
Dr D. L. Davies, Dean of the Institute of Psychiatry was to play an important rôle in giving alcoholism an academic framework. Dr Max Glatt, the psychiatrist who was refused permission to attend the WHO conference, later established in the 1950s an alcoholism unit at Warlingham Park, Surrey, and became the 'clinical leader' in the field. Thom in assessing official correspondence feels that Davies' approach to alcohol treatment was more in line with government policy than Glatt's. He was a member of several influential governmental committees and was in a strong position to influence the Ministry of Health whilst Glatt was an outsider. Yet it was Glatt's model of special inpatient units which the Ministry of Health recommended to Regional Health Authorities in 'The Hospital Treatment of Alcoholism' in 1962. This was the first official statement regarding alcoholism treatment within the NHS. It was a response to a 1961 report by a joint committee of the BMA and the Magistrates Association on the problems of alcoholism treatment, of which Glatt was a member.
During the same period, under the influence of Griffith Edwards clinical and epidemiological studies of alcoholism, gathered momentum and these began to influence policy decisions. Edwards was to play a decisive rôle in the development of services and in prevention strategies.
Outpatient treatment was shown to be as effective as in-patient care. It was at this stage that D. L. Davies began to exert his influence. He always had doubts about the need for specialist units but kept quiet with regard to the 1962 memorandum because he believed it necessary to get the Government in some way to respond to alcoholism.
Emphasis began to be placed on early intervention strategies for people with drinking problems. The 1978 Advisory Committee Report on Pattern and Range of Services for Problem Drinkers confirmed the need for community based services and supported the drive for Community Alcohol Teams and a primary care response to identify and support problem drinkers.
The problem here was that the development of a primary care response was a 'top down' initiative. It came from policy makers and specialists and as a result there has been difficulty in selling it to primary care workers. However, Thom takes too bleak a view: she does not mention the way in which the Probation Service has developed programmes for offenders with alcohol problems.
Thom considers that the major service development emerging in the 1960s was in the voluntary sector. It matured in the 1970s when government funding was made available. Partnerships between the voluntary and statutory services were established through the creation of Councils on Alcoholism. The formation of the Camberwell Council on Alcoholism and the National Council on Alcoholism in 1962 provided a national focus point for the advocacy of alcohol policy and a community based response to alcoholism.
By 1972 the National Council had been able to encourage the development of six local councils on alcoholism. More could have been achieved had there been adequate funding. Thom makes the point that "it is a common observation about British political life that it works through who knows whom". This was the case for Davies, Glatt and Edwards. They were well equated with people who had political clout or who sat on the appropriate committee.
However, Thom fails to mention that behind the Secretary of State, Sir Keith Joseph's interest in alcoholism lay his uncle, Harry Vincent, who was the Chairman of Bovis and the NCA. It was through Vincent that Keith Joseph took the important step of funding the voluntary sector and the famous DHSS Circular 21/73 was issued. Sir Keith also sought out Sir Bernard Braine, who under Harold Macmillan had been a junior minister and had a real interest in health matters, to succeed his uncle as Chairman of the NCA. Keith Joseph promised Sir Bernard that if he developed professionalism in the NCA and succeeded in the tasks he set for it more money would be found. The difficulties for the NCA had been largely caused by lack of funds. Since its inception in 1962 it had relied mainly on a grant from the Rowntree Social Service Trust. From 1973, aided by Government grants, the NCA was able to support existing councils and by 'pump priming' grants able to establish a sustainable network of local councils with the support of health and local authorities. The success of the policy is evidenced from a 1990 Alcohol Concern report which stated that councils on alcoholism had become the largest network of services for problem drinkers within the voluntary sector with over ninety regional and local councils in the UK.
The value of this aspect of the work of the NCA after its forced closure by the Conservative government was the determined effort by the DHSS Alcohol Policy Group to make sure Councils on Alcoholism were seen as an essential part of the network of service: "We pushed very hard and got approval from ministers that one of the major roles of Alcohol Concern should be the promotion of new Councils on Alcohol". (Dr Warman from DHSS interview). Thom provides evidence of the fact that the alcohol policy group was somehow not trusted by Sir George Young junior minister of health at the time.
The reorganisation of the national voluntary sector was done without consultation with the group responsible for the implementation of ministerial policy: "...things happened over official heads....suddenly we were presented with a fait accompli....it was done without the consultation of the Alcohol Policy Group" (Wawman's interview).
Thom does not cast any light on why the minister was so distrustful of his civil servants in charge of alcohol policy. Sir George when he was a backbencher was closely associated with the Federation of Alcohol Rehabilitation Establishments. Was it because the group was pro-active in its advocacy of the consumption model, disliked by the drinks industry which we know for the 1980s was exerting tremendous pressure on the government.
Thom shows that conflicts over interdepartmental responsibilities for the problems relating to alcohol consumption existed as soon as government took an interest in services.
In 1960 the Ministry of Health, the Home Office and Prison Committee officials held meetings to address the many sided aspects of alcohol problems and departmental interests and responsibilities. Issues relating to 'drunkenness' and 'alcoholism'; prevention and treatment impeded co-operation between departments. When the Ministry of Health confined itself to the narrow medical aspects then the Home Office withdrew from any further involvement. This division of responsibility between these two important departments became a major issue in responding to habitual drunken offenders.
Further conflict between the DHSS and Home Office surfaced over the Department's Advisory Committees Report on Prevention. DHSS were champions of the consumption model and it became clear that there were those in the Home Office opposed this view. A Home Office report was prepared by Mary Tuck which was not only not in line with DHSS thinking but which was published without the courtesy of interdepartmental consultation.
Thom shows the importance during the 1970s of DHSS civil servants such as Dr Alan Sippert and Chris Ralph in promoting and developing alcohol policy. Dr Wawman, testifies to the latter's ability in getting Ministers to give the right message. "Patrick Jenkin ... he was made to say things like 'Alcohol abuse is of epidemic proportions. His having said that, we were able to say ..... "The Minister said that, but when Ministers will not do this, it takes away your ability to influence official policy".
But things did change. `Drinking Sensibly' was issued by the Government and although the consumption model had made some inroads, it was so watered down that the document was dismissed as 'facile and inadequate' by the public health lobby. Wawman admits that large chunks were written by other departments such as the Ministry of Agriculture and Fisheries and the Treasury. He confirms that the decision to publish the document was taken by the Cabinet. To Dr Wawman it was therefore Government Policy.
The Government set up in 1987 an Interdepartmental Group on Alcohol Abuse. Thom from an interview says that the intention of the Group was to co-operate with the Drinks Industry and to this end the Portman Group was established in 1989.
Thom also outlines changes and diversity in treatment approaches developed during the period. Controlled drinking was developed as a therapeutic goal. This did create tensions within the field. Anthony Thorley, who at that time was the consultant psychiatrist at Parkwood House in Newcastle (he later became a senior medical officer at the Department), is quoted as saying "that staff wanted to counsel people with controlled drinking as a goal. They were virtually sacked, or marginalised or kicked out".
This is not my recollection. I know of no director of a Council of Alcoholism who was sacked for holding and practising such views. What did happen was that the NCA set up a working party under the chairmanship of Dr Raj Rathod and with as a member Jim Orford, a clinical psychologist and a well known advocate of controlled drinking. The working party set out guidelines for counselling problem drinkers in relation to both abstinence and controlled drinking.
It is a pity that Thom omits some significant developments which had a lasting impact. In 1977 the NCA issued its working party report on Alcohol and Work. The report itself was written by Dr Sippert and myself. It did much to encourage the development of alcohol policies in the workplace and this was acknowledged later by the Health and Safety Executive.
Whilst a brief reference is made to voluntary counsellors, there is no mention of the fact that this was an innovative initiative of the NCA in 1975. In 1975 the NCA was able to get a grant from the Baring Foundation on condition it was matched by the DHSS to initiate a voluntary counsellor training scheme. Chris Ralph was sceptical and I am told he went into the interview determined to turn it down. I came away with approval of the scheme. Chris Ralph had been won over to at least an experimental trial. This was successful and showed that ordinary men and women could be trained to counsel problem drinkers. Use of voluntary counsellors is a feature of the service provision of many advice centres today.
There was also the Blennerhassett Committee which reviewed the working of the 1967 Road Safety Act. Alan Sippert tried to persuade the Committee to recommend the introduction of a high risk offender procedure. The DHSS urgently requested the NCA to prepare written evidence in support of Sippert's proposal. When the report was published a high risk offender category was in their recommendations. In road traffic debates in the House of Commons in the early 1980s a high risk offender procedure was raised by Sir Bernard Braine and eventually the Department of Transport introduced it.
Even in this excellently researched and written book there some errors. One such is the view that in their early days Councils on Alcoholism were linked to temperance networks. This is not correct. The mistake probably arises from a misunderstanding of the nature of the Church of England Temperance Society which supported the creation of the NCA. The CETS had long ceased to be part of the mainstream Temperance movement. Indeed, relations between the temperance movement and the new alcoholism organisations were characterised by mutual mistrust and dislike. Temperance organisations did not support the disease concept while the alcoholism organisations did not wish to be seen as against alcohol as such.
Thom is also wrong in claiming that the NCA gave evidence to the Erroll Committee on liquor licensing in 1972. Basing his view on the old fashioned disease concept, the then Director of the NCA agreed that, "alcoholism comes in persons not in bottles" and he saw no relevance of liquor licensing to the problem. He therefore declined to give evidence.
My congratulations to Betsy Thom for a very thorough review of the development of social policy during the last 40 years. It has much to teach us all today and perhaps government officials facing a rising tide of problem drinking among the young could learn some valuable lessons from the past. However, the leadership must come from their political masters for it is the lack of political will that has hindered the application of effective policy to control rising alcohol problems.