Scotland's national plan on alcohol problems

Scotland has a special relationship with alcohol. It is known throughout the world for its principal beverage Scotch whisky, which plays a major part in the export trade of Scotland, although beer, in common with the rest of the UK, is the most popular drink. Scotland's drinking habits are not dissimilar to those in other parts of the UK although in Scotland there is a tendency to concentrate the drinking into a shorter space of time during each week, with binge patterns of consumption predominating. Alcohol related problems have been a major concern in Scotland over many years. Recently the opportunity arose to address these problems at a more specifically national level. Scotland, which has always had a measure of independence from within the UK, recently re-affirmed this by the creation of a Scottish Parliament with extensive powers. Even before the new Parliament was created, in 1999 a consultation document entitled 'Working Together for a Healthier Scotland' had promised a strategic review of alcohol issues (Scottish Office, 1998). In 1997 there was a national symposium which set the basis of the Strategic Plan which was to follow (Scottish Office, 1997).

In January 2002 the Scottish Executive launched a 'Plan for Action on Alcohol Problems'. Broadly its aim is to reduce alcohol related harm. The Executive identified a number of milestones towards this target which they hope to achieve over the next three years. The Plan prepared by the Scottish Advisory Committee on Alcohol Misuse (SACAM) has evolved as a result of extensive consultation within the country and this has been augmented by a series of review papers summarizing the evidence base from the UK and elsewhere for preventive and treatment strategies. These background evidence reviews are commendable and a very useful source of information [l].

Consultation has been widely cast, views were gathered from the alcohol industry and related business organizations, service providers, individuals who had problems related to alcohol, the general public, children and young people, community groups and organizations with 'an interest in the broader issues of alcohol for society'. It is therefore based on a very broad approach that attempts, with varying degrees of success, to reconcile competing interests. After acknowledging the benefits of alcohol, the Plan for Action overviews the disturbing impact that alcohol has on the quality of life in many Scottish communities.

Inevitably there is an emphasis on young people. The two key priorities of the plan are to reduce binge drinking and harmful drinking by children and young people. A third of Scots men and 15% of Scots women aged 16-64 years reported drinking more than the weekly recommended limits. The younger age groups were particularly likely to exceed these limits. Men living in the most deprived areas of Scotland were shown to be seven times more likely to die an alcohol related death than those in the least deprived areas. This telling statistic shows the link between social deprivation and alcohol related harm. Social inclusion is a major part of government policy in Scotland, as it is in England, and should highlight the need to include alcohol misuse in policies for preventing urban decay.

The annual health costs of alcohol to Scotland have been estimated at around £96 million, the costs to social work services and associated organizations around £80 million and the costs to the criminal justice system £268 million. The wider economic costs through lost productivity resulting from alcohol problems were estimated at around £405 million. Alcohol problems are costing the Scottish economy approximately £l billion pounds a year. No doubt therefore about the extent of the problem; what then of the Plan for Action?

This is not the first time that Scotland has assigned priority to taking action on alcohol, although it is the first time that a national strategy has been proposed by government. Fine words alone are not enough and, the sceptic notes, the contrast between the investment in combating drug misuse and the still relatively paltry sums committed to tackling alcohol.

The goals in the Plan for Action include achievement of the following.

Culture change by an immediate investment in a 'national communication strategy' that will challenge current stereotypes of binge drinking.
Prevention and education with a particular emphasis on drink-driving, occupational health and school based education.
A framework for services leading to the improvement of and support for treatment services.
Protection and controls for individuals and the wider community; early action will focus on strengthening community safety.
A coherent 'delivery strategy' which particularly strengthens local Alcohol
Misuse Co-ordinating Committees and in most cases will align these with Drug Action teams.

It is surprising that, despite scant evidence for public information and education having much impact on alcohol misuse (with the possible exception of road traffic safety), the Plan for further investment in this area is given immediate priority. Control policies and the evidence of effective treatment strategies seem to be given a rather less prominent position. Why is there so much emphasis on 'what works' when, having gone to considerable and commendable lengths to evaluate the evidence, much of it is then ignored?

The Plan aims to combine a population approach with a focus on specific harmful drinking patterns such as binge drinking and the habits of children and young people. The policy promises to bring alcohol issues firmly up the agenda alongside drugs but does not suggest how this is to be achieved. None of the recent funding directives suggests any real shift in this balance of funding. Drug Action Teams will be more closely aligned with the Alcohol Misuse Co-ordinating Committees but a mechanism, for instance of positive discrimination towards alcohol, is not identified.

The communication strategy is being developed with the support of a Sub-Committee of the National Co-ordinating Committee on Alcohol and will include representatives of the alcohol industry. Some will look askance at this alliance while others see it as simply realpolitik: the products of this collaboration will need to be evaluated carefully.

Education, particularly of young people, is not surprisingly one of the further planks of the strategy. The efficacy of education still needs to be demonstrated. No one would suggest it is unimportant but we most urgently need to test new approaches rather than relying on tired but attractive models which make significant impact.

There is widespread concern at the dearth of services provided for individuals with alcohol problems. It is to be hoped that the development of the framework of alcohol services will progress rapidly. This framework will recommend a tiered approach to services and link prevention with treatment and rehabilitation with help being easily accessible and tailored to the needs of the individual. All of this is welcome. Once the framework is visible the Scottish Executive will indicate 'in due course' how any additional resources will be phased in, what types of services will be prioritized and how funds will be distributed. It seems that Alcohol Misuse Co-ordinating Committees will have a key role in ensuring the implementation of the framework. In a Plan which sets some firm dates for its objectives, I could not find one date for implementing and funding the framework.

The Plan gives commendable support to the need to work with families and children of problem drinkers. Alcohol problems will be included amongst the priorities for the 'changing children's services' fund. This is good news but any resultant initiatives need to be integrated with other services.

The Plan contains a chapter on 'protection and controls'. Fiscal policy is outwith the powers of the Scottish Parliament and it is not considered further although some replies to the consultation pointed out the powerful relationship between price, disposable income and consumption. The Executive has created a separate review of the Licensing Act and this is currently taking evidence. Hopefully it will work closely with the SACAM and will pull in the same direction.

Community safety is a topical concern as is alcohol related crime. A range of strategies are identified: proof of age schemes; restricting alcohol at sporting events; server and door steward training; and proper enforcement of existing laws.

The contentious issue of advertising controls is identified but largely side-stepped because it requires to be addressed at a UK level. The report states 'The UK Government considers that non-statutory controls are effective in subjective areas of advertising and promotion content, such as alcohol, when formal regulation is apt to be contentious'.

The need for much more training of professionals at undergraduate and postgraduate level is recognized and a training agency was recently established to support this message. It has a long way to go in obtaining its training objectives.

The delivery of the Plan is clearly critical and rightly acknowledges 'the need for joint working communication, co-operation and collaboration at national and local level'. The SACAM will remain and continue to play a part in monitoring and promoting the implementation of the Plan. The responsibility at a local level will centre particularly on Alcohol Misuse Co-ordinating Committees. Whilst these are already in existence in many parts of the country, they have lacked sufficient power and influence, particularly in comparison with the Drug Action Teams. In some areas the two may well combine but the continuing monitoring of the progress of this Plan should help to give force to the decisions of the Alcohol Misuse Co-ordinating Committees. The funding has been provided to support these developments.

What then has the Report and Published Policy achieved? It has provided a very welcome focus on alcohol related problems in Scotland. It has drawn together valuable background information both from national and international sources and very useful reviews of the research evidence supporting various approaches. It has acknowledged the importance and the complexity of the problem and the need for intersectoral collaboration. It has not always acted on the evidence base provided and continues to promote some activities whose effectiveness has not been demonstrated. It has an ill-justified faith in the benefits of public education and a communication strategy that relies heavily on education to effect cultural change.

The development of a framework for treatment services is a necessary first step but the real test will come with the need to invest in proper services. When this comes before the Executive, will they be willing to invest in the same way as they have been doing for drug misuse? It is good that Scotland has arrived at a strategy and of course the continued absence of a strategy in England has not escaped our notice but the rhetoric now needs to be translated into action. Hopefully the

Scottish Executive's commitment to monitoring the unfolding of its Plan is genuine and certainly it will be up to all of us concerned with alcohol related problems to ensure that they are required to keep their word.

Bruce Ritson
Department of Psychiatry, Edinburgh University

Note
[1] All the reports mentioned in this paragraph can be found at the Scottish Executive website: www.scotland.gov.uk/health/alcoholproblems

References
SCOTTISH OFFICE (1997). Alcohol Conference Action Plan Working Group Report. Edinburgh: Department of Health

SCOTTISH OFFICE (1998). Working Together for a Healthier Scotland. Edinburgh: The Stationery Office.

This article is reprinted by kind permission of the Editor of Drugs: education, prevention and policy