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October 2020: An update from the BSG Alcohol Lead

At the recent BSG Council meeting, I updated on some important recent alcohol issues that I have been concerned with. The President thought many of the issues would be of interest to the wider BSG membership and asked me to share some of them with you.

In September 2020, the report from a Westminster Parliamentary Commission on alcohol harm was launched.  The Commission’s remit was to gather evidence on the impact of alcohol-harm across the UK, particularly evidence emerging since 2012, when the Westminster government last proposed a (short-lived) alcohol strategy.[1]  In particular, it examined the need for a new comprehensive alcohol strategy for England, taking into account the strategies already in place in Scotland, Wales and Northern Ireland, and to consider UK-wide priorities in areas where policy is not devolved.

The BSG provided evidence on the impacts of alcohol on physical health, liver disease and on the NHS.  In 2018/19, hospital admission related to alcohol reached a record level (1.26million in England alone)[2], with 5,698 alcohol-specific deaths in England, a sustained increase over the last decade.[3] Worryingly, the majority (78%) of these deaths were premature (aged 40-69) occurring in working-aged adults.  While mortality rates from other common diseases are falling in the UK, liver disease deaths have increased dramatically, with a 400% increase in the standardised mortality rate during 1970-2010.[4]  Whilst much of this will be very familiar to those working with alcohol-harm, the commission also gave particular voice to the wider impact on families and society.  Some of the most compelling evidence was from those who spoke of their experience of the often hidden cost of alcohol, including the unacceptable suffering of children who live with parents who drink excessively.  Sadly, during the pandemic, the interplay between alcohol and domestic violence has become starkly more apparent.

The commission report is now available: #ItsEverywhere[5]. The commission’s main recommendations were a ‘call to action’ for the UK (Westminster) government to do more to tackle alcohol harm.  In particular, the UK (Westminster) government should have a defined, well-led alcohol strategy that protects vulnerable people and communities.  It should implement evidence-based policies (e.g. minimum unit pricing) to reduce alcohol harm, with properly funded treatment services.  Indeed, the commission also noted the encouraging progress made by devolved governments – in particular highlighting the introduction of minimum unit pricing in Scotland and, more recently Wales.  Please share the report on social media, or send it to your local MP and encourage them to take more action on alcohol harm.

Much of the lobbying and secretariat support for the parliamentary commission was driven by the Alcohol Health Alliance, a strong coalition of 55 non-governmental organisations, chaired by Sir Ian Gilmore.  I represent the BSG on the AHA steering committee, where we collaborate on our common goal of reducing alcohol harm.  The work of the AHA was exemplified by its contribution towards the commission.  Through the AHA, we propose evidence-based solutions to reduce alcohol-harm and work to influence and lobby decision-makers to address this.  In particular, through the BSG’s ongoing commitment to the AHA, we continue to emphasise the focus on prevention, access to treatment services and the early detection of liver disease.

Beyond this, I represent the BSG on a group convened by Public Health England, commissioned by DHSC, to develop UK-wide clinical guidelines for alcohol treatment.[6] These guidelines focus on how to develop best practice and help all alcohol services implement NICE-approved interventions for alcohol use disorders – from harmful drinking and alcohol dependence to detection and treatment of liver disease.   Again, aligning with the BSG aims of improving health outcomes, we highlight the need to focus on physical health and liver disease, specifically emphasising the role for early detection of liver disease and fibrosis assessments across a wider range of settings.  A CQUIN indicator “Early identification of alcohol-related cirrhosis or advanced liver fibrosis” had been incorporated into the 2020/2021 scheme.  Following the successful NHSE CQUIN targets around screening for risky alcohol consumption, this CQUIN looked specifically at incentivising liver disease detection for patients admitted to acute hospitals with a coding of alcohol dependence.  With the pandemic, all transformation activity has been paused, although we hope this target will re-emerge in future years.

The challenges of the last few months have changed the practice and priorities of most of our services and alcohol services have been no exception.   At the height of first wave, there was a real concern about the impact the pandemic might have on those with alcohol dependence.  NHS England drew together ‘emergency response’ guidelines which highlighted the need for robust local solutions, including pathways for integrated management and close liaison with community, mental health and addiction services.[7]  The key recommendation, that each trust should designate an ‘alcohol lead’, will seem familiar to those trusts which already have well-established alcohol care teams, but NHS England was also concerned that some trusts had little or no specialist alcohol provision.  Notably, the 2019 NHS Long Term plan had committed to funding alcohol care teams in 25% of all acute trusts, principally those with the highest levels of alcohol dependency[8], but the recent crisis has raised a question as to whether all acute hospitals should be included in any scheme to implement ACT provision.

We are now at a stage where we are trying to quantify the impact that the pandemic and lockdown has had on alcohol services and disease presentations. There is undoubtedly a perception that the lockdown has seen alcohol consumption soar.[9] The evidence currently available is actually more nuanced.  Total alcohol sales are slightly down on previous years, according to HMRC duty receipts.[10]  Specifically, beer and cider receipts have fallen, whilst wine and spirits sales have increased, reflecting changing drinking patterns during lockdown.

A real concern is that within the overall picture, there may be groups that are doing particularly badly. A series of surveys report that, whilst 20-30% of people are drinking less during the lockdown, similar proportions are drinking significantly more[11].  There is some evidence that it is people who are already at risk who are drinking more.  Analysis of PHE data estimates that more than 8 million people may now be drinking at increased-risk levels, compared to 4 million before lockdown with the RCPsych concerned that this could overwhelm treatment services.[12]  The impact on liver disease admission remains unclear.  Anecdotally, many of us witnessed an initial reduction in liver disease admissions but followed by more advanced presentations in recent weeks.  In an attempt to quantify this, the BSG-BASL Special Interest Group in ARLD, led by Ashwin Dhanda, are embarking on some work over the next few months to fully determine the impact on secondary care liver services.

Sadly, the impact of health and services is unlikely to be short term. The impact of a sustained economic downturn in addition to further pandemic waves is likely to impact on the pattern of alcohol-related harm presenting to our services, for a long time to come.

Steven Masson
BSG Alcohol Lead

Consultant Hepatologist, Freeman Hospital, Newcastle
[email protected]


References

[1] The Government’s alcohol strategy, Government HM, 2012 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcohol-strategy.pdf) [accessed 25th Sep 2020]

[2] NHS Digital. Statistics on Alcohol England. Updated 4 Feb 2020 (https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2020/part-1) [accessed 25th Sep 2020]

[3] NHS Digital. Statistics on Alcohol England. Updated 4 Feb 2020 (https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2020/part-2) [accessed 25th  Sep 2020]

[4] Williams R, Aspinall R, Bellis M, et al.  Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384: 1953­­–97

[5] ‘It’s everywhere’ – alcohol’s public face and private harm: The report of the Commission on Alcohol Harm (2020) [https://ahauk.org/commission-on-alcohol-harm-report] [accessed 25th Sep 2020]

[6] https://www.gov.uk/government/news/uk-alcohol-clinical-guidelines-development-begins [accessed 25th Sep 2020]

[7] Clinical guide for the management of people with alcohol dependence during the coronavirus pandemic (https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0157-Specialty-guide_-Alcohol-Dependence-and-coronavirus_8-April.pdf) [accessed 25th Sep 2020]

[8] NHS England. Online version of the NHS long term plan. https://www.longtermplan.nhs.uk/online-version/ (accessed 25th Sep 2020)

[9] [https://www.telegraph.co.uk/family/life/boozy-britain-nation-drank-lockdown/]

[10] UK Alcohol Duty Statistics Commentary, HM Revenue and Customs (https://www.gov.uk/government/statistics/alcohol-bulletin) [accessed 25th Sep 2020]

[11] Alcohol consumption during the COVID-19 lockdown.  Institute of Alcohol Studies, UK. (http://www.ias.org.uk/uploads/pdf/IAS%20reports/sb28062020.pdf) [accessed 25th Sep 2020]

[12] Royal College of Psychiatrists (https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/09/14/addiction-services-not-equipped-to-treat-the-8-million-people-drinking-at-high-risk-during-pandemic-warns-royal-college)