The politics of drinking
            March 11 , 2015

While public health fiddles, alcohol harm inequality widens

Ever had that thing where you’re really looking forward to something and then when it gets here you wonder what you were getting so excited about?

The long-promised research paper Understanding the Alcohol Harm Paradox, penned by what reads like a list of the most influential names in alcohol academia, has finally been published – and it raises far more questions than it answers. Not least, why they bothered.

I have to admit that I was delighted when I heard Alcohol Research UK had initiated this work, obsessed as I am by the observation that while the most disadvantaged sections of the population drink no more than better-off folk, they are far more likely to suffer alcohol-related illness and far more likely to die of it.

It’s the elephant in the room as far as alcohol policy is concerned, so it’s good that it’s finally getting some attention, although I’ve been worrying about calling it the ‘alcohol harm paradox’.

The close correlation between poverty and poor health is long established and, far from being a paradox, is obvious to anyone. Alcohol-related harm is one aspect of a complex tangle of problems at the root of which is the difficult objective circumstances many people struggle against.

The authors of Understanding the Alcohol Harm Paradox complain that “the precise pathways and mechanisms through which SES (socioeconomic status) and alcohol-related harm are associated remain unclear” because of a lack of research, something I stupidly thought the authors were going to put right.

Instead, they merely confirm once again, though in quite a lot of detail, what we already know, and suggest, as far as I can make out, a total of two policy recommendations: minimum unit pricing and the inclusion of public health objectives in licensing decisions.

Ho-hum. Nothing to see here, then.

Much more revealing, if rather disturbing, is another new Alcohol Research UK-sponsored report, this time by Alcohol Concern. A Measure of Change is a survey among local authorities and NHS clinical commissioning groups (CCGs) about the impact on alcohol services of measures contained in the Health & Social Care Act, especially the devolution of public health responsibilities to local councils and CCGs.

It shows that in the last two years not only has the number of local authorities reducing spend on alcohol services trebled from 7% to 21% of the total, but that among councils designated as having ‘high’ levels of alcohol harm 50% have made cuts, and over the next three years 62% expect to cut services still further.

(Strangely, most CCGs don’t see alcohol services as their responsibility at all, despite drink being increasingly explicitly blamed for the crisis in the NHS.)

Areas with high levels of alcohol problems are, of course, pretty much the same areas that suffer the greatest deprivation. And, shockingly, Alcohol Concerns points out these authorities actually get less government money per capita than wealthier areas to spend on public health.  

For instance, my old manor Waltham Forest is ranked the 15^th most deprived area in the country and receives £42 per head for public health. Yet across London in Kensington and Chelsea, ranked 103, they get £130 per head, more than three times as much.

So there’s part of the paradox solved. Places that need most help are getting less money, and they’re cutting alcohol services as a result, even while recognising the importance of addressing drink problems.

There is a suspicion, too, one that Alcohol Concern almost dare not contemplate, that frontline services are losing out to a growth in the fluffier but cheaper ‘whole population’ solutions that the organisation itself has promoted so vigorously.

As the report notes, “whilst a greater population focus is welcome, it should not be at the expense of acute and entrenched problems”.

But as councils, especially poorer councils, come under increasing pressure to find cuts from somewhere we should not be surprised that they turn to the services that support stigmatised sections of the community, such as those with drink problems.

And if this results in a deepening of the so-called alcohol harm paradox, we shouldn’t need too much more academic research to find out why.