The world health organisation
The World Health Organisation has indicated that alcohol and its use is a growing problem on a global scale with alcohol causing 3.2% of all deaths worldwide (1.8million per annum) accounting for 4.2% of disease burden. Almost half (46%) of these deaths can be attributed to injuries with 54% attributable to chronic alcohol related disease (WHO, 2007). In January 2010 the Faculty of Public Health and the Royal Society of Public Health released a manifesto of ‘12 Steps to better public health' to challenge policy makers in taking clear steps in protecting our populations health. One target urged A MINIMUM PRICE OF 50P PER UNIT OF ALCOHOL SOLD the rationale for which is the doubling of average consumption over the last 40 years (see figure below), the strong links between consumption levels and harm which is also subsequently linked to affordability with alcohol being 69% more affordable now than in 1980 as a proportion of income.
The manifesto supports the English Chief Medical Officers suggested 50p per unit minimum price target especially as minimum pricing may have the greatest impact the most at risk populations (HOC:HC151-I, 2010). The evidence available for supporting the need for policy change is compelling 31% men and 21% women are consuming over the recommended amount of alcohol (GHS, 2007), 13 years olds in Wales have highest rates of being drunk twice across 40 countries (HBSC 2005/06); and inequities in Wales show that the most deprived experience a three times higher mortality related to alcohol than the least deprived (WCfH, 2009).UK deaths from liver cirrhosis increased more than five fold between 1970 and 2006 (as affordability and consumption soared); in contrast in France, Italy and Spain the number of deaths shrank between two and four fold; UK deaths from cirrhosis are now above all of them (see below).
In 2003 the PM's Strategy Unit estimated the total cost of alcohol to society to be £20 billion. One appropriate method of having a positive change population wide relates to affordability with minimum pricing being one tool (Babor et al, 2003). This could also have positive economic gains for the on trade drinks industry (i.e. pubs and restaurants), as it eradicates the loss leading on alcohol at many supermarkets and large retailers and levels off the on and off trade alcohol sales price differentials (HOC:HC151-I, 2010).
Despite the evidence available the current Alcohol Harm reduction Strategy (PM Strategy Unit, 2004), remains focused on strategies that receive support from the drinks industry, but that when mapped against alcohol reduction strategies (Babor et al, 2003) have at best medium to low effectiveness (HOC:HC151-I, 2010). Alongside this when considering that of the 10 million drinkers consuming above recommended levels; who consume 75% of all alcohol in the UK (annual income from alcohol in UK 33.7 billion) then if those over consuming, reduced to within recommended levels there would be a 40% reduction in total consumption (13 billion per annum) it is hardly surprising the industry funded self regulatory watchdog Portman group are in favour of the current strategic objectives and resist legislative population based measures such as minimum pricing (at 40p a unit), which when modelled could have the effect of saving 3,000 lives per annum (Sheffield University, 2009), would possibly benefit traditional pubs, would have the bonus of targeting the cheapest alcohol thus, having greatest impact in heavy drinkers in low income groups and younger drinkers and encourage a switch to weaker beers and wines (HOC:HC151-I, 2010). It would also have little impact on moderate drinkers as a man purchasing up to his unit allowance would incur a cost of around £10.50. and women around £7.00
Based upon theory there are four pillars for affecting policy change:
These four elements operate as a complex set of inter-relationships with Actors at the centre of the whole process. Whilst Actors are influenced by the context in which they live the context is affected by the ideological culture and process of policy making. The process of policy making (i.e. how an issue makes its way onto the table and gains enough credence to be focussed upon) is affected by the Actors (or stakeholders) and their relative position in the power structure along with their values and expectations, and the content of a policy will reflect some of all of these elements.
Whilst support is evident from key actors such as the Commons Health Committee (Jan 2010), leading health professionals such as the Chief Medical Officers for England, Wales and Scotland along with organisations such as FPH, RSPH and the BMA and some licensees' forums (Nick Newman; Cardiff Licensee Forum in Wales Online, 2009), there are still a large numbers of protagonists for the legislative change most notable are supermarket retailers and drinks industry leaders; additionally both Gordon Brown and David Cameron have indicated less than favourable views on wide spread minimum pricing legislation when raised in early 2009 (Guardian,2009; Mail 2010) .
The issue of minimum pricing is obviously an emotive one, and has enough credence to make it a significant agenda item with both formal research evidence presenting a clear case for its implementation and widespread support from influential figures promoting discussion around the area this is only part of the Policy process.
In essence the process of policy making is a ‘struggle between groups with competing interests' (p.20 Buse et al, 2005) the stakeholders or actors will have differing beliefs, needs, interest or ideas and whilst some are likely to be in favour of change others will be at polar opposites and resist change. It is within this context that policy reform has to take place. Whilst on occasion there will be focussing events that may drive a large change in opinion creating a more favourable approach to decision and policy making (i.e. in times of emergency), these huge events do not occur often and the backdrop for policy change is often fraught and requires strategic negotiation and potentially coalition development to succeed in driving through change (Weible et al, 2009).
Within the policy cycle alcohol has at present found many supporters and protagonists (Actors) in relation to the minimum pricing agenda with the main arguments for change being the positive effects reductions in affordability will have on consumption particularly in those sections of society at most need i.e. those with less money such as young people and lower socio-economic groups where alcohol has a proportionally greater harm impact. Additionally, minimum pricing is likely to impact upon the retail sector rather than the on trade element of industry such that the difference between prices in supermarkets and shops with those in public houses reducing thus having potential economic gains for a declining part of our economic and social heritage (if the continued opposition of the drinks industry is maintained this is where more effort to highlight benefits for them should focus in addition to encouraging development of new lower ABV drinks). To convince the retail giants more information should perhaps concentrate on how minimum pricing should not ultimately impact hugely on income as they may sell less units but no longer be making a loss per unit; which they currently do as part of their price wars where selling below cost alcohol is widespread (HOC:HC-151-I, 2010) as legislative change will mean that all competitors are equally affected.
To achieve change policy must be viewed prospectively as Analysis for Policy to attempt to influence formulation and acceptability of new or adapted policies in a maelstrom of opposing opinions, interests, values and beliefs (Buse et al, 2005). Affecting policy change requires a balance between having an overarching knowledge of the costs and benefits in relation to the actors, particularly where it is often the case that the most powerful are the one's who often bear the costs of the change for example in the case of alcohol reform this may be the giants of the retail sector and drink industry as opposed to those who should ultimately reap the benefits (i.e. the general population particularly the more disadvantaged lower socio-economic groups and young people). At present the health committee advocate for no financial gain from price increases for supermarkets, however, this may reduce change likelihood with increased income seen as a potential trade off with retailers to create a coalition for pushing the policy through.
In order to successfully influence policy prospectively there is a need to be involved in problem identification and framing, have an understanding of how agenda's are set as well as having a capacity to encourage both acceptance of the problem definition and proposed solution to a wide and influential audience through political manipulation and continual and systematic political analysis throughout the flow of political events in the policy cycle. Within the field of alcohol problem recognition is high, yet problem solutions are diverse and cause different levels of opposition via different powerful groups. To bring about change requires an understanding of the position, interests and power of stakeholders (Actors) based on costs and benefits of the proposed policy, and will likely require negotiated adaptation of proposed solutions to make them more politically feasible and palatable to the widest breadth of interested parties as suggested above. This Analysis for Policy with a clear eye on motivations and power should provide a structure for the development of appropriate tactics to accomplish policy change within a political arena that at present appears stalled in England and Wales.
One other thing to consider in devising strategies to affect policy change in the political arena is timing. Many things can have an impact upon whether the topic is successful in being identified and formulated into policy, whilst both epidemiological and economic evidence may by some be seen as proof positive of a need for policy change unless (i.e. House of commons: Health Committee) unless the information required to galvanise action is meaningfully interpreted and available at the right time its utility could be lost and an opportunity missed. Additionally despite what may appear overwhelming evidence if there is not support from powerful groups for example the media to help raise and frame the question again the change process may need to be abandoned. Ultimately there needs to be a convergence of ‘problem', ‘policy (solution)' and ‘politics (political will)' at one point in time for the agenda to be set on a topic for policy change (Kingdon, 1995 cited in Buse et al, 1995). At present there does appear to be some timing issues with regard to the delivery of this policy reform; an impending general election is likely to over-ride what may be considered a non-emergency public health issue. A reform of this kind will impact directly on the pockets of the voting public particularly in a tight economic climate, thus politically it is unlikely to be a useful tool in securing votes. If the evidence had been more clear at the time of developing the initial strategy in 2004 in what was a growing economy then less governmental opposition may have been evident which could have over-ridden other powerful brokers opinions, however, this is only supposition as is the alternative whereby should the recommendations be reinstated following the elections (depending on the incumbent) a more favourable government standpoint may emerge, with this in mind action needs to be taken to add leverage and gain further evidence for how the impact of a policy change such as this might impact on both retail and the drinks industry by using modelling in the same way it has been used already but from a more economic analysis standpoint to look at possible economic and social boosts to the licensee sector. What has yet to be considered however, is the influence of Actors who may be able to have influence amongst powerful politicians who may also front as alcohol health groups, for example the European Forum for Responsible drinking who state that alcohol issues are only related to problem drinking not per capita consumption (funded by Europe's biggest alcohol producers), additionally groups such as ARISE (Associates for Research into the Science of Enjoyment) run by PR group Fishburn Hedges who employ Lobbyists such as Rory Scanlan (former press team member for Tony Blair), Jo Murray Labours head of coummunications until 2008), who may have significant political powers as highlighted by the recent sting (Guardian, 2010).
Another method that could be used to aid in further discussion and decision making in the development of a health impact assessment which would give braoder consideration of all determinants and impacts that the proposed policy change would make, at present this does not seem to have been undertaken but is something encouraged as ‘it places decision makers in a better position to develop appropriate policies with emphasis on maximising positive and mitigating negative proposals' (Ali et al, 2008 p.403)
If all of the above factors align and policy change does occur with new policy legislation on pricing being developed then a means to evaluate its implementation and the outcomes of the change are required. In order to evaluate the policy effectively a three layer evaluation process would need to be developed:
Part 1 Process/Formative evaluation, and Part 2 Output/Monitoring. This would measure achievement of change The breadth of the initial compliance assessment (part 1) could be undertaken similarly to the work done by CCFRAG, (2008 and 2009) assessing the voluntary implementation of drinks labelling on alcohol packaging, using randomized multi-retail outlet purchasing and analysis.
Additionally the ongoing monitoring (part 2) of the policy evaluation is likely to remain a combination of this ongoing work alongside the work of trading standards who may have local knowledge about potential non-compliance within the smaller retail sector based on past work in counterfeit or under-age alcohol sales it would need collaborations with other organisations under local multi-sectoral partnerships, however one issue is increased workload with not increases in capacity possibly mitigating compliance or impact.
Part 3 Outcome evaluation would measure the success of the policy and would again rely upon multi-sectoral data collection and collation including elements of data monitoring focussed upon the key evidence that may have led to initial reasons for identifying, adopting and formulating the policy. This element however, may be more readily monitored and trends assessed over time as it could rely upon routinely collected data such as percentage of children, young people and adults people reporting drinking at various levels, average weekly consumption of alcohol: UK sales, comparison of alcohol related, and alcohol attributed morbidity and mortality statistics, trends in alcohol related hospital admissions, percentage of major causes of crime, positive breath tests and violent crime attributable to alcohol (WCfH 2009). Additional outcomes may also be identified via health impact assessments proposed in the policy formulation stage to enable a holistic approach outside of simple routinely available data collection, however, this may again have implications with new measures of success and data collection methods being required. Again having possible workforce implications for appropriate evaluation of policy outcomes and capacity issues for delivery have a possible impact on compliance. In order to allow a clear time frame for implementing evaluation and assessing changes overtime then a clear implementation/action phase would be required that could provide time for process evaluations, on-going monitoring and outcomes assessments to be undertaken to identify impact of the policy change, need for additional policy reform and continued support for the overall strategic direction of the initial public policy change.
In conclusion bringing about public policy change is a complex web of developing appropriate evidence based recognition of a problem that can be affected by policy reform, development of clear aims and objectives to guide policy change with appropriate definitions of the problem and acceptable solutions for the policy power brokers (i.e. government and industry) that will change the health of the target population. It requires clear methods for executing the policy and clear partners who are responsible for implementing the policy on the ground as well as those responsible for monitoring that the policy reform has taken place and continues to be adhered to. All of this must be underpinned with appropriate methods and statistics to measure the impact of the policy reform and the health outcomes identified as a result of successful change.