Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd
Health, Social Care and Sport Committee - Fifth Senedd23/11/2017
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Caroline Jones AM|
|Dai Lloyd AM|
|Dawn Bowden AM|
|Jayne Bryant AM|
|Julie Morgan AM|
|Lynne Neagle AM|
|Rhun ap Iorwerth AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Conrad Eydmann||Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro|
|Cardiff and Vale University Local Health Board|
|David Jones||Safonau Masnach Cymru|
|Trading Standards Wales|
|David Riley||Cadeirdydd Penaethaid Safonau Masnach Cymru, a Phennaeth Gwasanaethau Diogelu’r Cyhoedd yn Ynys Môn|
|Chair of the Wales Heads of Trading Standards, and Head of Public Protection Services in Anglesey|
|Dr David Bailey||BMA Cymru Wales|
|BMA Cymru Wales|
|Dr Julie Bishop||Iechyd Cyhoeddus Cymru|
|Public Health Wales|
|Dr Ranjini Rao||Coleg Brenhinol y Seiciatryddion|
|Royal College of Psychiatrists|
|Dr Ruth Alcolado||Coleg Brenhinol y Meddygon|
|Royal College of Physicians|
|Fiona Kinghorn||Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro|
|Cardiff and Vale University Local Health Board|
|Professor Kelechi Nnoaham||Bwrdd lechyd Lleol Cwm Taf|
|Cwm Taf Local Health Board|
|Simon Wilkinson||Cymdeithas Llywodraeth Leol Cymru|
|Welsh Local Government Association|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Claire Morris||Dirprwy Glerc|
|Gareth Pembridge||Cynghorydd Cyfreithiol|
Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle y mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.
The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.
Dechreuodd y cyfarfod am 09:32.
The meeting began at 09:32.
Croeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma yng Nghynulliad Cenedlaethol Cymru. A gaf i estyn croeso yn gyntaf i fy nghyd-Aelodau, gan hefyd ddatgan ein bod ni wedi derbyn ymddiheuriadau gan Angela Burns ac nad oes dirprwy i Angela y bore yma? A allaf i bellaf egluro bod y cyfarfod yma yn ddwyieithog? Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. A allaf i atgoffa pobl i naill ai diffodd eu ffonau symudol ac unrhyw gyfarpar electronig arall, neu eu rhoi ar y dewis tawel? Yn bellaf, a allaf i hysbysu pobl y dylid dilyn cyfarwyddiadau'r tywyswyr os bydd larwm tân yn canu? Nid oes angen i neb gyffwrdd â'r meicroffonau; mae'r system yn gweithio yn awtomatig pan fyddwch chi'n siarad.
Welcome to the latest meeting of the Health, Social Care and Sport Committee, here at the National Assembly for Wales. Can I please welcome, first of all, my fellow Members, and also let you know that we have received apologies from Angela Burns and that there is no substitute for Angela this morning? Can I also explain that the meeting is bilingual? You can use headphones to hear the interpretation from Welsh to English on channel 1, or for amplification on channel 2. Can I also remind you to either turn off your mobile phones and any other electronic equipment or to put them onto silent mode? In the event of a fire alarm, please follow the directions of the ushers. You don't need to touch the microphones; the system works automatically when you speak.
Felly, rydym ni'n symud ymlaen i eitem 2: Bil Iechyd y Cyhoedd (Isafbris am Alcohol) (Cymru). Sesiwn dystiolaeth 1 ydy hon, yn gyntaf y bore yma, ac o'n blaenau mae cynrychiolwyr o Iechyd Cyhoeddus Cymru a chyfarwyddwyr iechyd y cyhoedd y byrddau iechyd. Yn benodol, felly, rydw i'n falch iawn i groesawu Dr Kelechi Nnoaham, cyfarwyddwr gweithredol iechyd y cyhoedd Bwrdd Iechyd Lleol Cwm Taf; Fiona Kinghorn, dirprwy gyfarwyddwr iechyd y cyhoedd Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro; Conrad Eydmann, pennaeth strategaeth a chomisiynu partneriaeth Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro; a hefyd Dr Julie Bishop, cyfarwyddwr gwella iechyd Ymddiriedolaeth Gwasanaeth Iechyd Gwladol Iechyd Cyhoeddus Cymru. Croeso i chi i gyd. Diolch am bob tystiolaeth ysgrifenedig ymlaen llaw, ac yn ôl ein harfer, mi awn ni yn syth i mewn i gwestiynau. Mae gyda ni ryw dri chwarter awr, ac fe awn ni'n syth iddi. Mae'r ddau gwestiwn cyntaf o dan ofal Caroline Jones.
Therefore, we move on to item 2: Public Health (Minimum Price for Alcohol) (Wales) Bill. It is evidence session 1 today. Before us, we have representatives from Public Health Wales and the health boards' directors of public health. Can I please welcome, therefore, Dr Kelechi Nnoaham, executive director of public health, Cwm Taf Local Health Board; Fiona Kinghorn, deputy director of public health, Cardiff and Vale University Local Health Board; Conrad Eydmann, head of partnership, strategy and commissioning, Cardiff and Vale University Local Health Board; and also Dr Julie Bishop, director of health improvement, Public Health Wales NHS Trust? Welcome to you all this morning, and thank you for the written evidence you have already submitted to us. Can we please now go straight into questions? We have three quarters of an hour, and we'll make a start immediately if that's okay. The first questions are from Caroline Jones.
Diolch, Gadeirydd. Bore da. Good morning. Further information about recent trends in alcohol consumption, for example, Public Health Wales's 2016 substance misuse profile, show that consumption has actually decreased, particularly in the under-45 age group. So, I wonder if I can ask you: what do you think are the reasons for this decrease? And have we seen, as a consequence of this decrease, associated reductions to harm in any way?
Shall I take that? Well, I think alcohol's a complicated problem, and what we're seeing is a mixed picture in terms of what's happening to trends. So, you're right in saying that there's some evidence that the consumption of alcohol is decreasing, but it's not decreasing equally in all population groups, so the impact is felt differently between different groups in the population. What we're also seeing is an increase in the number of people who don't drink at all, and that has an impact on the population levels. So, when we actually look at the harm that arises from alcohol, it's still quite substantial. In our most recent work looking at the burden of disease in Wales, we find that alcohol is the sixth-highest cause of what we call disability-adjusted life years: so, an impact on people living less long and in poorer health. So, it is a substantial impact on the health of the population of Wales. We would say that whilst there are some sub-groups of the population who have changed their alcohol consumption, amongst those who drink at the highest levels, we're not seeing reductions. So, the reductions are happening in those people who don't drink at all; those people who are moderate drinkers are drinking slightly less; but the people who drink to excess at potentially harmful or hazardous levels aren't bringing about the reductions we'd like to see.
Right, okay. Anyone else want to come in?
Perhaps, Chair, if I could just add, actually, there's a time lag in terms of, if we think about some of the statistics you have in front of you relating to alcohol-specific admission trends, they may have decreased very slightly, but that's marginal. But with many public health issues, there's a long-term impact for some of the more serious consequences and serious harms. So there's a difference between the acute intoxication on a Saturday night and some of these longer term harms that are caused by alcohol.
Okay, thank you.
The Bill's particularly aimed at reducing alcohol consumption and harm among hazardous and harmful drinkers—that is, those that drink above the recommended guidelines. So, what proportion of the Welsh population are drinking at hazardous and harmful levels? What population groups do they represent? And which at-risk are witnesses most concerned about?
The statistics suggest that about 62 per cent of the population are drinking at moderate levels and the harmful and high-risk, hazardous drinkers are about 7 per cent. So, as a proportion of the population, I think, as Julie was alluding to earlier, they're not a majority, they're the minority, but the proportional amount of harm that results and therefore puts pressure on the health and social care system, from that 7 per cent of the population, is significant.
Can I just ask about that figure? Is that 7 per cent the same in Wales as in England, or—?
They are roughly the same. There will be slight variations, but the sense is that there isn't any massive, significant difference in terms of those proportions.
Just a quick supplementary to that: there was a report this morning on the radio about alcohol-related brain disease. Is that what you would see particularly amongst that group, within that 7 per cent, or is it wider than that?
It's a lot more. If you think about the sort of conditions that result directly or indirectly from alcohol, the count is at least 60 different conditions. Alcohol-related brain damage is one of those conditions, but there's a whole lot more. It is one thing that pretty much affects the entire body system. So, it's a lot more than alcohol-related brain damage.
So it's not just that 7 per cent, then.
No, not that much.
Perhaps I could just add, you know, I think sometimes the public don't realise the effect that alcohol has on certain cancers, on cardiovascular disease, liver disease. So, there is a whole host and we don't always make the connection.
Sure. Okay, thank you.
Ocê, symud ymlaen: Rhun, efo'r ddau gwestiwn nesaf.
Okay. We'll move on to Rhun with the next questions.
Ac mi wnaf i, os y gallaf i, arwain ymlaen o'r cwestiwn diwethaf. Rydych chi'n dweud mai 7 y cant o'r boblogaeth sydd yn yfed ar lefelau a fyddai'n cael eu hystyried yn wirioneddol niweidiol neu'n broblemus. Un feirniadaeth am gyflwyno isafbrif alcohol ydy ei fod o'n targedu pobl sy'n yfed yn gymedrol. A ydych chi felly yn credu bod y Bil a'r hyn sy'n cael ei gynnig yn gymesur, yn proportionate? Os ydych chi, beth sy'n gwneud ichi gredu bod hwn yn gymesur?
And I will attempt to lead on from that previous question. You say that 7 per cent of the population is drinking at levels that would be considered as truly harmful or problematic. One criticism of introducing a minimum unit price is that it targets those people who drink moderately. Do you therefore believe that this Bill and what is proposed are proportionate? If you do believe that, then what convinces you of that fact?
Can I pick it up? So, I think it's just worth, perhaps, coming back on that. This minimum unit pricing does not target moderate drinkers. All of the evidence that we are aware of suggests that the drinking habits of more moderate drinkers are not likely to be affected necessarily. The people who are—so to use that word 'targeting', I'm not very comfortable with using that word 'targeting'—
If I could just interrupt, it may not target them—I'll still use it—in terms of trying to get them to drink less, but it will affect them, in that the drink that they do consume will be more expensive. Is that a fair outcome?
I'm still challenging that premise. That is not our understanding. All of the modelling and all of the experience from other places where some form of minimum unit pricing has been put in place is suggesting that the implications, or the changes in habits for those who are drinking at moderate levels—it's unlikely they change. The change that we are anticipating is likely to happen within that 7 per cent of people who drink at harmful or high-risk levels. So, that's why I'm coming back to challenge that premise, because it's not accurate.
Can you point me to the evidence that would back that assertion of yours, either now or let us know again?
I can give you specific evidence, but in all of our submissions, the submissions from Public Health Wales, the submissions from the Welsh NHS Confederation, we pointed to that evidence, both from modelling studies and references to some other places where this has been—. That's why I'm just interested in coming back to that premise, because the premise that it's targeting moderate drinkers is, perhaps, not accurate, and that's why I just wanted to come back. Again, to use the word 'targeting', we know from the modelling that the people who are most likely to change their habits as a result of this are those people in the high-risk, harmful drinking levels. That's our hope and that's what the evidence is suggesting is likely to happen.
Thank you, and I'm sorry to have interrupted.
I'm just really going to completely agree with what Kelechi has said. I think the research evidence shows that those people who are moderate drinkers, the vast majority of alcohol that they purchase is already above the threshold for the minimum unit price, so their drinking habits are less likely to be affected, because, actually, they're paying more than the minimum unit price already for their alcohol. It is the people who are drinking to excess, who are buying the cheaper alcohol and, therefore, are very specifically being focused upon in this measure.
Sorry, before we go on. Caroline, you had—. On this point?
Yes, it was just following on from something that Rhun had said, if I may, and that is: could we be pushing people into poverty and homelessness? What I'm saying is they get their rent and they're just about purchasing the alcohol that they perceive that they need and, therefore, when the alcohol price goes up, could we then see people forgoing their rent, spending an element of their rent, so they think they can catch up next time, they can't, and therefore we have more homelessness as a consequence?
Perhaps I could highlight that I think there is an issue of people living in poverty, per se, and how they manage their money. There has been lots of discussion about that in the welfare reform arena, and I've certainly been part of local authority-led committees about how we support people, how they receive their benefits, how they spend those. I think that's difficult and it's a challenge. I'm currently chairing the Cardiff and Vale area planning board for substance misuse, and we will very much look at how we gear up to provide support to people in the challenges that they face. But, equally, there is a whole arena of work around welfare reform and providing support to people in poverty on how they manage their money. We could equally argue the case within healthy food and other issues.
But the rent goes straight to the tenant, doesn't it? That's what I'm saying, would they be enticed into getting what they want and forgoing the rent? That's the condition—
For most people, alcohol purchases are discretionary. It is something you make a choice to do. There is a very, very small number of people who are dependent on alcohol, but estimates would say far less than one—probably about 1 per cent of the population. So, I think we need to bear that in mind.
But, nevertheless, we have to consider those people.
Reit, symudwn ni ymlaen. Rhun.
Right, we will move on. Rhun.
Picking up on that, it's discretionary for the heavy drinkers too?
Yes, for most of them—the vast majority of them—yes.
And, again, we might be asking the same question in 30 different ways today, but I think it's important that we do, because there's a narrative around it and some people are fearful about perhaps unintended consequences, and, as well as getting a good Bill, people need to be reassured. How significant a factor is the affordability of alcohol in relation to consumption levels? What is the evidence that people make a decision to buy something or to consume something or not based on what that price tag is?
So, we have something called the alcohol affordability index, and that is a combination of price and disposable income, and that directly impacts demands on alcohol usage. If you look at statistics between 1980 through to 2010, that graph has just gradually risen. So, as people's disposable income has risen, that has directly impacted on their ability to buy alcohol. So, it's an absolute key factor and minimum unit price plays a part in that.
If I can just add something to that, there's this statistic that I always like to use to contextualise the challenges around alcohol, and it's the statistic that suggested that, between 1960 and 2002, the price of alcohol as a proportion of the household income in Britain more than halved. In the same period, the per capita consumption of alcohol in people aged 15 plus in Britain increased from about 6 litres per year to about 11 litres per year. So, to put it very simply, during that period, the affordability of alcohol increased—it became a lot more affordable—and in the same period the per capita consumption more than doubled. So, the relationship between affordability and consumption is out there significantly in the evidence, and that, for me, is a fundamental reason why this minimum unit pricing Bill is absolutely needed. If we can tackle consumption, then we know we can tackle the alcohol-related harm that the rest of society is honestly grappling with.
A difficult question perhaps, but can you point us to a point in time where the balance between affordability and consumption was at a level that you would be comfortable with as public health professionals? What are we trying to turn the clock back to?
I don't know. In the evidence that I've looked at people randomly use pre-1970 periods. I don't know if that is accurate or not, but I have seen people make reference to, 'If we can get drinking levels to what they were before 1970'. Whether that is true or not, I don't know, but I'm just saying that, in the evidence that I've looked at, people have used pre-1970 levels. Whether we will quite get there or whether this will take us there across the general population, I don't know.
It's something we can look at and just let you know.
Chair, can I just add to that? It's a combination of multiple things in our society, isn't it, and the availability of alcohol? So, price and availability are two absolute key influences on alcohol consumption, as well as advertising. If you look at how licensing has changed over the years, it's a completely different picture today than what we used to have. Now, we're not going to turn the clock back to the 1970s—
Well, some people want to, to the 1950s, but, anyway, that's a separate argument. [Laughter.]
And they may be known as the public health police. I'm Scottish, and I've lived in Wales for 20 years. Alcohol is a key part of our culture, and I think our key messages in our communications are that we're not trying to change that; we're trying to have impact. We've got really good evidence of a modelled impact on a targeted, small component of our population where harmful drinking impacts on health outcomes and healthcare and social care. So, I think that's the key message here.
Ocê. Iawn, Rhun?
Great. Okay, Rhun?
Ie, ie. [Chwerthin.]
Yes, yes. [Laughter.]
Thank you, Chair. I think you've touched on a couple of points but I'd just like you to expand on a few of them. What health and other outcomes you believe will result from the introduction of a minimum pricing policy? Do you agree with the outcomes that are in the explanatory memorandum? Do you agree with that?
Yes. I think that, for me, one of the most important reasons why this Bill is the right thing to do is—. I'll give you a very simple example. If you buy a drink for £5, and then you drink it, and then you get drunk and then go out, and then get in a fight, and then break bottles and get an injury and litter the street—let's just paint that very ugly scenario—what happens is that, for your £5, you've created a lot of work for doctors in accident and emergency; you've created a lot of work for the local authority street-cleansing services; you've created a lot of work for the surgeon or whoever is going to stitch up the wound. Now, the consequences of the £5 spend on your drink is far greater for society. Health economists call that negative externalities. The whole idea of taxing alcohol or putting minimum unit pricing on alcohol is about correcting those negative externalities because they are not fair on society.
So, when you look at the outcomes that this Bill could achieve, it would be things like correcting those externalities. Now, from a very simple standpoint, it would be things like: I talked about the 60 conditions that are related to alcohol. In Wales, there were 504 alcohol-related deaths last year; over 30,000 bed days, hospital admissions; 15,000 admissions related to alcohol in 2016-17. Now, all of those outcomes can be reversed. So, we can reduce the number of deaths related to alcohol, we can reduce bed occupancy in hospital, reduce pressure on our NHS, improve the sustainability of local authority services, all by a simple measure like this. So, I completely agree with all of the outcomes that are set out in the explanatory memorandum, and there is evidence that these are outcomes that are completely achievable.
So, I would agree with that too. I would also just add about health inequalities. We talk a lot about how we will reduce health inequalities, and each 10-year period, we sit down and we go, 'Well, how much impact have we had on health inequalities?' In Cardiff and Vale, for example, we have got 21 to 23 years' health expectancy life differential for women and men, respectively. Just as poverty itself, employment and education are all key impacts on that, so are levels of smoking, levels of drinking. So, we have to relate legislation like this to health inequalities.
I was going to come on to health inequalities. Sorry, did you want to comment?
Yes, only really to also reiterate the fact that there are a whole range of outcomes that we're seeking to achieve for alcohol, and this measure will only be a contribution to them. So, a lot of the work that we're doing as well is, for example, dealing with the impacts of poverty, housing and homelessness on particularly vulnerable groups. We're trying to ensure that the health promotion and protection messages get out there. Hence you do see some positive impacts with certain groups of the population—25 to 45. But, none of these tools independently is ever going to achieve what we need to achieve in terms of alcohol. So, minimum unit pricing is an absolutely critical piece of a jigsaw, without which many of the other interventions we provide and the work that we do don't achieve their full benefit. They only work as an entire package, and, for us, we have always seen this particular measure as a critical component of that package.
What would you say to the people who have a concern that it will have a disproportionate effect on those on low incomes?
I think what we've got to remember is that those are the groups who have got the most capacity to benefit, and I think I would rather look at it that way around. That's actually where the harm is being felt, both to individuals and the wider society. So, actually, it's those groups of the population where we can actually bring about the greatest benefit here, and I think we need to start thinking about it from that perspective rather than seeing it as a negative. So, we have got substantially greater alcohol-specific-related mortalities. So, death rates relating specifically to alcohol are over three times higher in the most deprived groups than in the least deprived groups. So, that's really where we want to make the difference, picking up the point that Fiona has made.
Can I just add that people care about their health, and they care about the health of their families? We talked earlier on about connections—connections to ill health. If you are in work, when you retire, you want to live well in retirement, and all of these things contribute to whether people are going to live well in retirement.
Thank you, Chair. We've already said that this isn't really about dealing with alcohol dependency; that's a different group and a relatively small group. Nevertheless, picking up Caroline's point from earlier on, if you are alcohol dependent, then you will spend your money on alcohol and there's no two ways about that. So, are you concerned that we need to have in place more robust support services for those who are alcohol dependent, because the increased cost for those people is not going to make any difference?
I think, absolutely, making sure that the availability of adequate and evidence-based support programmes is going to be critical, particularly if people, further down the line, discover a dependence that they weren't previously aware of, making sure that accessibility to those programmes is as easy as possible. So, developing policies around establishing walk-in services as opposed to appointment-based services is one example. I think, as well, there is a huge level of need for alcohol support programmes for those that are approaching dependence, but haven't achieved it. It's a very effective way of bypassing very costly clinical services to be able to provide, for example within the third sector, structured responses to help people reduce alcohol consumption in a risk-managed way and then move into long-term support and aftercare beyond that, without having to go through clinical processes of detoxification. So, I think, in terms of the commissioning of local service systems to make sure that all those population groups are catered for, that is going to be a critical responsibility of the commissioners locally and the area planning boards that we work in.
And you'd like to see that running alongside the implementation of this.
Did anybody else want to say anything on that before I move on? No, okay.
The other one is still on dependency, and certainly the high-risk drinkers, I guess—hazardous drinkers. Do you have any concerns that that group might switch to other substances instead of going to alcohol? I mean, all of us will have seen in our own constituencies the switch to things like spice, for instance, as a very cheap alternative to other street drugs that are available, and that will probably be cheaper than alcohol. So, do any of you have any concerns about that?
I think the word is 'substitution'. So, substitution, as we understand it from the evidence, is a theoretical risk. In other places or other contexts where we might refer for evidence, there hasn't been any substantive evidence of that nature of substitution, simply because they are fundamentally different substances, for want of a better word. But, having said that, I think it would be a very sensible thing to do, to say that, once this Bill progresses, if you like, and it's implemented, we should be watching it, we should be monitoring to see if there is any real evidence of substitution. But if we refer back to what is currently out there, published in the evidence, it is, at best, a theoretical risk, but I think it is one that we should absolutely be watching out for.
There's probably a greater risk among those people who are already co-users, or have a co-dependency, so that they're already using some other substance where they might shift—
Quite often, they're not alone, are they, those dependencies? Yes, that's fair enough.
Okay, thank you.
Moving on to Lynne.
Thanks, Chair. Can I ask what you think the impact of the Bill will be on children and young people in terms of their own behaviour and any knock-on effect you think there might be in terms of the impact of changes to family budgets?
One of the things we know about price is that one of the groups that is most positively influenced by changes in prices are young people, typically. So, we would expect a benefit in young people not starting to consume large quantities of alcohol at a young age as being one of the positive things that would arise as a result of this measure. I think there is a positive impact on young people that we would expect to see.
I think the positive second impact that we would expect to see is—. Obviously, you'll be aware that much of the work that Public Health Wales has been doing, and colleagues in health boards as well, has been around looking at the impact of adverse childhood experiences on long-term outcomes, both in childhood and throughout life. Substance misuse, particularly the violence that can be associated with heavy drinking, is one of those outcomes, and so we would expect that to be, again, one of the areas where children may benefit. So, I think whilst there is a very small potential, theoretical impact on family budgets—we've already talked about the fact that actually we don't feel that that's likely to be a significant factor—we actually think young people are likely to benefit as a result of this measure.
So, have we got a particular problem at the moment with young people going out and buying cheap alcohol? You think so. Yes, okay. Right, okay.
Just moving on, then, to the minimum price per unit, that's going to be specified in regulations, but 50p has been used as the example in the EM. Can I get your views on that minimum price and also how often you would anticipate that would need to be reviewed going forward?
I think it's clear, if you look at the evidence from elsewhere and the modelling work, that the level of price set has a differential impact on outcomes. So, the higher the price, the bigger the impact on outcomes. I guess we could say, if we're going to do this, we've got to set it at a level that will have the impact that we'd like to see. Sorry, was part of your question about review?
Well, it was also whether you think 50p per unit is the right kind of level and also how often you think that should be reviewed going forward.
I think 50p, as opposed to 40p or 45p, had something like a doubling of effect on outcomes, so I think we would say that 50p is a really good level to set it at. But, since that modelling was done—and I know it's being redone, so we'd have to look at the results of the remodelling—time has changed, so it's worth relooking at whether that would have a similar impact. I think something like an annual review of price, given what we said about the alcohol affordability index, inherently linked to people's disposable income—. So, it is something that should probably be reviewed, perhaps on an annual basis, linked to the retail price index.
Ac mae'r cwestiynau olaf o dan ofal Julie Morgan.
And the final questions are from Julie Morgan.
Diolch. I think Conrad has already said that this shouldn't be done in isolation, and that it should be done with other measures, and I think you've referred to some of the other measures. Could you just tell us what programme should be run alongside this sort of measure and explain what it could provide for people?
Okay. It would be very dependent on the presentation. So, for someone who does have a physical dependency on alcohol, there are evidence-based routes through clinical services that would involve detoxification coupled with psychotherapeutic support to look at behavioural change, so that the gain from the clinical work can be sustained for the long term. In many ways, the programmes that we would want to see for non-dependent drinkers are almost a replica of that minus the detoxification component. So, there is a very strong evidence base around the impact of psychological therapy such as cognitive behavioural therapy. There is new, emerging evidence around the family support services model and family-based therapies where alcohol use impacts on the whole family unit, and, increasingly, through the adverse childhood experiences work, we're seeing the benefit of trauma-informed therapy, so, making sure that the counselling, the treatment and the interventions that are provided to people who want to look at reducing or eliminating their alcohol use are based on those new trauma-informed approaches. The evidence is very strong for what works and what's effective in terms of alcohol support.
Right. And are those services widely available now?
They are, and they continue to be increased according to levels of need and demand. So, yes, we regularly assess need and respond to service capacity.
So, anybody who needs and wants those services can get them at the moment?
Thank you very much for that. Then, in response to Lynne, we talked about reviewing the price, I think you said, Julie, every year, was it, for the price? The Welsh Government would plan to report on the effectiveness of the Bill after five years. So, apart from the actual price, do you think an evaluation after five years will give us a clear picture of how well it's working?
I think Fiona mentioned earlier the fact that public health interventions do tend to take a little while to show their impact over time. So, it does seem reasonable to think about five years, and I think we've got some great opportunities actually for evaluation here. We've got something we would call a 'natural experiment' in the sense that this is legislation being considered in Wales. It's also being considered in Scotland, but not across the border. So, I'm very confident that there will be academic colleagues in Wales and Scotland who will be looking at really rigorous research that will help us to evaluate this, as well as the other measures that are proposed in terms of tracking the impact on sales over time, and tracking the impact on hospital admissions and activities. So, evaluation is absolutely critical. We have to make sure that this has the impact that we expect it to.
Yes. And those measures you've mentioned—are there any other measures you think should be used to evaluate?
I think there are a great many. Colleagues may want to suggest others.
All of the measures that are highlighted that we propose there will be impact on—we've obviously got to check whether there is impact on all of those. There are multiple outcome measures and service impact measures in your evidence, and I think we should track all of those.
What's critical is that we can see—. Any number of things can happen that will have an impact on this, because there are a number of different factors that are going to affect the alcohol market, and the alcohol price, potentially. So, what's really important is that we're able to identify what we think might be as a result of this particular measure, as opposed to background trends in what might be going on elsewhere. That's where those comparisons with other places where these changes haven't been made is really important.
We have a full, comprehensive suite of indicators already in place for a whole range of aspects of the alcohol agenda—so, things like emergency admissions, hospital admissions, looking at some of the violent crime, et cetera. So, one of the interesting things at a very local level would be to be able to complete before-and-after comparisons and look at some of the changing trajectories for some of those key performance indicators. For example, anyone who's receiving structured support for alcohol will be reporting on the number of units that they'd be consuming on a weekly basis as part of their ongoing review. So, we'll be able to do direct comparisons with any changes in those drinking behaviours for people in contact with support, both before and after the Bill's introduced. So, there is a breadth of opportunity for us to look at very strategic outcomes at a population level, and also very local outcomes on individuals within treatment and support services.
One other question on this, which I had some involvement with—it's the work of Professor Jon Shepherd and the work to do with changing from glass to plastic. Do you think that sort of initiative is the sort of thing that should be done as well, in conjunction with this?
Jonathan Shepherd's work is renowned internationally, and the impact that that has had on statistics around violence is actually quite stunning. So, that's absolutely something we would want to continue. I think it's back to what we mentioned earlier: price, availability, advertising—a key arena—brief interventions, and that's something we can push and develop, to try to get everybody doing brief interventions. Education has a role, but linked to skills development and confidence in children and young people. So, there are multiple things that we can do, and they all complement each other, but legislation plays an important key role at population level.
Yes. And my last question: as we all know, it was budget day yesterday, and Philip Hammond has announced that duty will rise on cheap, high-strength, low-quality alcohol products such as white ciders, and the UK Government will legislate to increase the duty on these products from 2019. So, could you tell us what your initial views are on this announcement?
The way that price impacts on alcohol consumption can be influenced in a number of different ways, and I think what that recognises is the differential potential of different strengths of alcohol being treated in different ways, and what that potentially addresses is these high-strength ciders and the level of duty that's placed onto those. So, we would support that as a public health measure. Taxation or excise duty is one part of the price equation that we would see as being important. What's really important in addition to that is that, what will typically happen in the market is, without a minimum threshold, the market will bring in newer products that make it possible for people to continue to buy alcohol at affordable prices. So, it potentially undermines that potential benefit. So, we see this kind of measure of minimum unit price alongside the duties that are placed on alcohol, and that those should be proportionate to strength, as being part of a whole suite of measures that will work together effectively to bring about a difference.
The interesting thing about it is that, for me—if I may use this phrase—every little helps, because they all act in concert. If you look at the Canadian minimum unit pricing, it's different from what we're proposing. It's a kind of minimum unit pricing, but, in Canada, what they have—unless they've changed it more recently—is variable floor thresholds for different kinds of drinks. What people initially thought when they were introducing it was that people would simply switch drinks to maintain consumption. Whether that has happened or not, we don't know, but if you look at some of the outcomes that they're getting from their own, if you like, MUP-lite, as I might put it, it's incredible. And that's just because every little helps. So, I welcome that, just echoing what Julie said. I think it's all going to act in concert to move us in the right direction.
Rhun, a oedd gennyt ti gwestiwn olaf?
Rhun, did you have a final question?
Yes, it's on that topic, actually. I just wanted to invite your comments on two ways of getting around the minimum pricing. One of them I would argue is in the spirit of what the Bill is trying to do, which is to invite manufacturers to make weaker products—to sell weaker wine in order to bring it under £4 a bottle. That's a positive, surely, is it?
Lower strength alcoholic products are certainly a positive, yes.
And we have breweries in Wales that make 4.2 per cent very strongly branded lagers. If they sell them at 3.6 per cent to bring the price down in Wales only, that's good?
I think change in the market—. You know, we've said this isn't about stopping people, as part of our cultural heritage, drinking in a reasonable and moderate way. So, anything that the market does to change that—. We have to be really clear about what this is trying to affect. It's the cheap strength alcohol, it's the really hazardous, harmful drinkers. So, changes like that in the market are not necessarily a bad thing.
And it's happened with sugar pricing, for example, hasn't it? In Singapore, I think every main brand has brought down the sugar content of their drinks because of the legislation there.
The other way around it is to seek a loophole, which would be, for example, to give away free food, which would very much be against the spirit of the Bill.
My recollection is that the explanatory memorandum does address that as being part of it. So, there are some where you buy and you get a free pint of something that goes along with it, and it's about how you work out what the minimum unit price component of that is. That's clearly something that would need to be factored into it. There will always be attempts to undermine the benefits, potentially. The market's very clever. I think we need to do everything we possibly can to make sure that the legislation that goes through is futureproofed against those kind of things, and the kind of reviews that we've advocated mean that we can keep an eye on whether or not those kind of things are actually happening.
But do you accept that there will be loopholes, that people will look to get around them, and that we have to live with that, or do you look for ways of strengthening the Bill?
I guess the free food arena, you know—. We're not going to see supermarkets giving away free food and people opening alcohol—
It wouldn't [Inaudible.]
No. So, what you're talking about, I guess, is the licensing arena. Licensing isn't a devolved issue; it's another issue. Health is not a licensing objective, and we would support that too. And it's back to the whole issue of availability. So, that is an arena where we need to seek all possibilities, I would say, to impact in the future. As much as possible that we can avoid loopholes, it would be helpful. I would doubt that that would decrease the benefits that would be achieved by a minimum unit price.
Diolch yn fawr iawn. Ar amser, mae'r cwestiynau wedi dod i ben. Felly, a allaf i ddiolch yn fawr iawn i chi i gyd am eich atebion y bore yma ac am y dystiolaeth ysgrifenedig a gyflwynwyd ymlaen llaw? Gallaf i hefyd gyhoeddi y byddwch chi'n derbyn trawsgrifiad o'r trafodaethau y bore yma er mwyn i chi allu cadarnhau eu bod nhw'n ffeithiol gywir. Felly, gyda hynny o ragymadrodd, diolch yn fawr iawn i chi i gyd.
A allaf i ddweud wrth fy nghyd-Aelodau hefyd y byddwn ni'n torri am egwyl o bum munud rŵan cyn yr ail eitem? Pum munud. Diolch yn fawr.
Thank you very much. The questions have come to an end in a timely manner. Thank you very much for your answers this morning and for the written evidence you submitted in advance. Can I also let you know that you will receive a transcript of this morning's discussions for you to check for accuracy? Thank you very much.
Can I tell my fellow Members that we're going to have a five-minute break now before the second item? Five minutes. Thank you.
Gohiriwyd y cyfarfod rhwng 10:14 a 10:21.
The meeting adjourned between 10:14 and 10:21.
Croeso nôl i aelodau o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon i'r drydedd eitem y bore yma, wedi'r egwyl fer yna. Rydym wedi cael tystiolaeth yn yr eitem flaenorol, ac rydym yn troi, rŵan, at eitem 3 a pharhad o'n tystiolaeth ar Fil Iechyd y Cyhoedd (Isafbris am Alcohol) (Cymru), sesiwn dystiolaeth 2.
O'n blaenau, mae tystion o BMA Cymru, Coleg Brenhinol y Meddygon a Choleg Brenhinol y Seiciatryddion. Felly, yn benodol, a allaf groesawu Dr David Bailey, cadeirydd cyngor BMA Cymru? Croeso. Hefyd, Dr Ruth Alcolado, Coleg Brenhinol y Meddygon—bore da. A hefyd, Dr Ranjini Rao, seiciatrydd dibyniaethau ymgynghorol, bwrdd iechyd prifysgol Aneurin Bevan, Coleg Brenhinol y Seiciatryddion. Bore da i chi gyd. Rydym wedi derbyn y dystiolaeth ysgrifenedig ymlaen llaw ac y mae hi wedi'i darllen mewn cryn fanylder gan Aelodau. Felly, gyda'ch caniatâd, awn ni'n syth i mewn i gwestiynau penodol, ac mae Caroline Jones yn mynd i ddechrau—Caroline.
Welcome back to members of the Health, Social Care and Sports Committee to the third item this morning, following that short break. We have taken evidence in the previous item, and now we're moving to item 3 and a continuation of evidence on the Public Health (Minimum Price for Alcohol) (Wales) Bill. This is evidence session 2.
Before us, we have witnesses from BMA Cymru Wales, the Royal College of Physicians and the Royal College of Psychiatrists. Can I specifically, therefore, welcome Dr David Bailey, chair of the BMA Welsh council? Also, Dr Ruth Alcolado, from the Royal College of Physicians—good morning. And Dr Ranjini Rao, consultant addiction psychiatrist, Aneurin Bevan university health board, the Royal College of Psychiatrists. Good morning to you all. We have received your written evidence in advance and we have looked at it very carefully. So, if it's okay with you, we're going to go straight into specific questions, and Caroline Jones is going to begin—Caroline.
Diolch, Cadeirydd. Good morning—bore da. Further information about recent trends in alcohol consumption, for example Public Health Wales's 2016 substance misuse profile, shows that consumption has decreased, particularly in the under-45 age group. What do you think are the reasons for this decrease, and have we seen, as a consequence, a reduction in associated harm with substance misuse?
I think the reasons are that there are social changes, particularly in the younger generation. But what we're trying to address with minimum pricing is not so much the general reduction in the population, because the evidence suggests that, in mild to moderate drinkers, it doesn't make a lot of difference. It's the actual problem drinkers that we want to impact on and I don't think there is any good evidence that problem drinkers are reducing their consumption, even though the general population certainly is.
I think what we need to be cognisant of is that, despite the fact that there has been an overall reduction across various cohorts, the significant reduction that we have seen is in the younger people. But, on the contrary, we have seen an increase in the number of alcohol-related deaths since 2015, and the proportion of that increase is 5 per cent since 2015, in males in particular.
The other significant aspect that we have seen in terms of the recent trends is that, despite the fact that the number of problem drinkers has reduced, we have seen increased referrals to specialist services among the elderly population. The advisory committee for substance misuse made a note of that in their document on the ageing population in March this year.
Okay. Thank you. My next question: the Bill is particularly aimed at reducing alcohol consumption and harm amongst hazardous and harmful drinkers—those who drink over the advised limit. What proportion of the Welsh population are drinking at hazardous and harmful levels, what population groups do they represent, and which at-risk groups are witnesses most concerned about?
I think if we take a very conservative view of hazardous drinking, it can mean anything up to about 40 per cent, if you take the chief medical officer's advice about 14 units a week. However, there's no real suggestion that that's a level that is going to cause massive harm to most people. What we're trying to affect is those drinkers who are drinking very significantly more than that. In all the modelling—even though it will obviously affect people with lower incomes slightly more, although they have greater health benefits to gain from it—where it mainly impacts is those people who are drinking very much more than the recommended amounts. It seems to have a quite significant impact on those, whereas the impact on other groups seems to be relatively minor. So, it is a targeted approach, and it's targeting exactly the people that we want to target. Even if nothing else happens, if they reduce their drinking, the potential harms are significantly reduced to them.
When you said that the lower income levels will be affected—do you then see a transference from healthcare needs to dependency on other units in the third sector, the voluntary sector and so on and so forth?
I'd certainly hope not. I don't think that minimum alcohol pricing is a panacea by any manner of means. It's just one of a whole suite of things we need to be doing to help our citizens who have got alcohol problems better. I'm sure colleagues will be able to be more precise than me about this, but it's very important that we actually improve the services for people with alcohol difficulties. It's not just about the physical harms. It's about the huge mental health impact that alcohol has, and also, obviously, the social impact on families and the impact on crime. So, all of those things are the benefits we're looking for, not just trying to reduce, say, the incidence of cirrhosis of the liver, although that will be clearly something we'd like to see as well. It's not just about purely health. It's about a much wider effect on the population than that.
All right. Thank you.
Un feirniadaeth amlwg iawn o gyflwyno isafbris ydy ei fod yn effeithio ar bawb, yn cynnwys yfwyr cymedrol, nid dim ond yr yfwyr problematig. O ystyried bod hynny'n wir, a ydy'r hyn sydd yn cael ei gynnig—a ydych chi'n meddwl—yn gymesur—yn proportionate?
One clear criticism of introducing a minimum unit price is that it impacts everyone across the board, including moderate drinkers, not just those who are drinking at problematic levels. Given that that is the case, is what's being proposed—in your opinion—proportionate?
I would answer that by saying that, actually, minimum unit alcohol pricing is quite targeted. It doesn't really affect the moderate drinker, because for the vast majority of alcohol that is consumed, the minimum unit price will make very little difference to the overall cost. Where it really makes a difference is for those people who are drinking the very strong alcohol—the very cheap strong alcohol. So, that's your white ciders and your very cheap vodkas. The majority of moderate drinkers are not consuming that type of alcohol. There's really good evidence from Scotland that suggests that, if you look at the group of harmful drinkers and the amount they're reported to drink, actually, between them, they consume all of the white cider in Scotland. So, we are not actually looking at something that is disproportionate. We are looking at something that will affect those very heavy drinkers.
I get all that, but it will affect people. Whether it's a lot of money is relative to how much money you have. If somebody with a lower disposable income sticks to a bottle of wine at £3.50 for that special meal once a week, and that bottle of wine goes up by 25 per cent to over £4.50, that might not be a lot to you, but added up, it does mean that everybody is affected, even though that family or that couple only has that bottle once a week. So, there is an effect. You're just not concerned about the effect of that.
I would just suggest it's not a disproportionate effect, because, yes, it will affect those people, but not to the same extent. So, this is why I would say it's a targeted intervention.
The original question—I know you had trouble understanding—was whether you're convinced that it is proportionate, considering that it does, albeit at different levels, affect everybody, whereas a tax on tobacco pretty much affects people who smoke. They take the hit and that's it.
I absolutely accept that. I think that's a perfectly fair point. However, I think it's important to remember—it's like televisions and white goods—that alcohol, compared to 10 or 20 years ago, is much, much cheaper compared to average incomes, and actually this is just restoring some of that balance, really, and getting it back closer to where it may have been even 10 years ago. Certainly, 30 years ago, it was about two and a half times as expensive, relatively.
Just to bring in some statistics, we need to understand that, if we are looking at minimum unit pricing of 50p, as the modelling studies go, the impact on high-risk drinkers is equated as being £32 per annum, which is about 1.1 per cent. On the moderate drinkers, that's as little as £2 per annum. So, this has to be reflected, in a national context, in the savings that we would make in terms of health savings.
I would contest those figures based on what I've seen. If you're talking about a bottle of wine going up by £1, most moderate drinkers would drink more than two bottles a year.
Those statistics are available in the pack. So, I'm more than happy to provide you with that. Moreover, the affordability at the moment for cheap alcohol is quite significant, and the evidence prior to this has alluded to that as well, and I don't want to repeat the statistics, but the minimum unit pricing is targeting the cheap alcohol and excessive drinkers.
How significant a factor is the affordability of alcohol in relation to consumption levels—i.e. what evidence is there that people who do drink at harmful levels—but aren't dependent on it, because they'll spend it anyway—but that those who drink at harmful levels are sensitive to the price, and would adjust their habits because their tipple is more expensive?
The best evidence, probably, is from British Columbia, where there appears to have been something like an 8 per cent or 10 per cent reduction in consumption since they introduced what is essentially a minimum unit price. It's not quite the same as what we're proposing, but it's certainly very similar. That's over four or five years. It's modern, it's a society that's not dissimilar to ours, and I think that that's really quite compelling evidence.
I would tend to agree. There are two key pieces of evidence about affordability, one being the Canadian study, which looked at the larger impact of introducing not minimum unit pricing as we have in front of us today, but on a similar basis. The second one is a Scottish survey that was done in 2011, which was a survey of the drinking preferences of people who were accessing health services. That showed that 70 per cent of the units that people were drinking were pegged at 40p, with 83 per cent of units pegged at 50p. So, clearly price is an indicator of the drink choice that people are making. So, affordability is a key factor that we should be considering when we introduce minimum unit pricing.
Ocê. Hapus? Rŷm ni'n symud ymlaen at Jayne Bryant.
Okay. Happy? We move on to Jayne Bryant.
Thank you, Chair. Dr Bailey, you mentioned the much wider impact on the population, and I'm just wondering if you want to add anything to the other health outcomes that might be beneficial to people.
Yes, absolutely. We know the physical things: the cirrhosis of liver, the much smaller, but probably more important on a population basis, impact on cancers—breast cancer, colon cancer—and even more so on cardiovascular disease. But actually, that's a relatively small part of the whole. The impact on mental health is absolutely vast. The number of people with serious mental health issues that have alcohol as a factor in that is very high, and my colleagues would be much better able to tell you exactly where that is, but it's very significant. What I've seen in my surgery every day is that mental health is closely associated with alcohol.
There are the issues about family continuity, about the way it affects children. There are serious issues about crime and violence. Over 50 per cent of all serious assaults are said to be associated with alcohol consumption, and if we can reduce that even a little bit, that has a wider impact on public health than just the headline cirrhosis of the liver that everybody thinks of with alcohol. That's really quite a small part of the overall impact on the health of the nation.
Any other comments?
I would just refer you to the work on adverse childhood events. If we look at the incidence of domestic violence where alcohol fuels the vast majority of that, we know that for those witnessing those sorts of events during early childhood, it has really negative impacts on both mental and physical health and well-being in the future, and this is something that we would expect not to be able to measure straight away, but we would expect minimum unit pricing to have a significant impact on that.
Okay, thank you. And just thinking about health inequalities, what role do you think this Bill will play in addressing health inequalities? And what would you also say to people who feel that this Bill might have a disproportionate effect on low incomes?
I guess, as a physician, my thing is, yes, it will have a disproportionate effect; it will have a disproportionately beneficial effect on people with low incomes.
The impact of minimum unit pricing on the lower income group has been quite critical in the debate for minimum unit pricing. We have to be cognisant that the lower income group and the higher deprivation areas have the larger proportion of the longer term ill-health effects associated with the use of alcohol excess. We know that ill health and health harms are four times higher—3.8 to be precise—among areas that are highly deprived versus those with a lower deprivation index. So, we do have to be quite cognisant that, whilst this is the population that might see the significant impact from the minimum unit pricing, the minimum unit pricing will go a long way in improving the health inequalities that exist currently.
And the key point is that alcohol abuse actually drives poverty. It's not just about the impact when you are poor; it's that alcohol abuse actually makes you poor. It breaks up families, it increases homelessness and its social impact is almost entirely negative.
Okay. All right. Moving on—Dawn.
Thank you, Chair. I just wanted to ask you about those alcohol-dependent individuals. This Bill isn't aimed at targeting those because if you're alcohol dependent, you'll spend the money on alcohol regardless of the cost. But does that in itself bring some concerns to you, in that knowing that we've got people who are alcohol dependent, with the higher cost of alcohol, they will continue to spend that and then they won't have money for other things, so that we might need, alongside this Bill, to be sure that we've got other support mechanisms in place for those alcohol dependents.
The larger proportion of the impact is predicted on harmful and hazardous drinkers, but we cannot ignore that there is a small minority of dependent drinkers who are likely to be impacted by what we are proposing currently. These dependent drinkers are likely to be impacted, and this may result in increases in attendance at emergency and substance misuse services. So, due merit has to be given to considering supporting the services to accept the increased referrals. I think there's some amount of work that area planning boards need to put in place during the planning process of implementation to support the substance misuse services.
So, that should be going alongside what we're doing here.
I think it's a parallel measure that we need to have. The likelihood is that there is going to be an increase in referrals to substance misuse services. That is a positive impact from the minimum unit pricing, because that would mean that individuals are accessing services and getting help. But we should also be bolstering support systems for those who are out there in the community, who are unlikely to access.
So, there could be some short-term pressures, really, that—
In the longer term, we would be hoping this would be supported by the longer term health changes that would happen.
Okay. Could I—? Sorry, did anyone else want to come in?
Can I ask, then, whether any of you have got any concerns about people, say, moving away from alcohol to other forms of substance misuse? So, in our own constituencies, we've all seen people moving to the very cheap and easily available things like spice. You know, they're street drugs, they—. Do you see that as a potential alternative to alcohol abuse, or not really?
Street drugs aren't as cheap as you think. The evidence is that a bunch of spice, if you like, is something like £20 in Manchester, and something like £35 in London. So, it doesn't compare to 50p—
More expensive than white cider, then.
It doesn't compare to 50p at all. I think that's just something that's been put forward by the industry as a smokescreen, to be honest.
Sure, okay. Fair point.
The consultation process back in 2015 raised similar concerns, and similar concerns were raised in Scotland. However, the evidence that is out there is very scant and does not support the transition or substitution of alcohol with other substance misuse. However, the most recent Public Health Wales report suggests that the novel psychoactive substances—or legal highs, as they were previously termed—are becoming less in number, but they're becoming more highly potent and toxic. So, there is a potential for harm that could be assimilated from that.
However, there is research that was done in Scotland, in 2015, which suggested that most impact is likely where people are dependent drinkers, but also have a concomitant substance misuse problem, and that escalation of behaviour is probably more likely in such a population, rather than people switching between substances.
Yes, and, quite often, they have the dual dependency.
They have a dual diagnosis, yes.
Okay. That's fine. Thank you very much.
Symud ymlaen at Lynne Neagle.
Moving on to Lynne Neagle.
Thanks, Chair. Can I ask about the impact on young people, both in terms of their own drinking behaviour, but also any other impacts? You referred already to adverse childhood experiences, but anything else like, you know, the impact on family income, and any comments, really, on what you think, with this Bill, the benefits or risks could be for young people.
I think, basically, the whole point of this is to make high-strength alcohol less accessible to people with small incomes. And it's not just about affecting people who have problems already; it's also trying to affect young people. We will all be aware that even though it's illegal under 18, most people try it much earlier than that. There's a lot of evidence that 20, 30, 40 per cent of schoolchildren have tried alcohol. Actually, they're likely to be the most price sensitive of all. So, I don't think we should apologise for the fact that it's going to make it more difficult for them to get an alcohol problem when they're very young.
I would agree with that. Certainly, work that we've done locally, at local schools, suggests that, in some of our areas in Cwm Taf, we've got alcohol consumption by the age of 14 in 70 to 80 per cent of our young people, and they will be very price sensitive. So, it should make a very positive impact on those. As I say, I'm pretty convinced from the evidence that the adverse childhood experiences will also be very positively impacted by this this sort of measure.
Okay. So, in the Bill, there is an illustrative figure of 50p per unit. How happy are you with that as a suggestion? Also, what are your views about the regularity of any reviews of that figure, going forward?
I think we are reasonably comfortable with that as an initial figure. Generally, we would prefer that the figure was within regulations so that Welsh Government could actually regularly review it in accordance with economic circumstances, rather than putting it as a hardwired figure. But I think, generally speaking, it's a proportionate figure, yes.
I think I'd agree with that: 50p is a good starting point. If we look at how affordable alcohol is currently as opposed to compared to 20 or 30 years ago, it goes some of the way to mitigate that reduction in costs compared to household incomes. So, it's a reasonable place to start, but again I would agree that that should be written in the instructions so that it can be reviewed on a regular basis.
And how often would you want to see it being reviewed? A previous witness has suggested annually.
Most of the studies, which are done in Canada and Australia, support similar frequencies—the reviews are annual. Most of the evidence suggests that alcohol prices change quite frequently and the annual review should not add significant administrative burdens.
Mae'r cwestiynau olaf o dan law Julie Morgan.
The final questions are from Julie Morgan.
Diolch. You mentioned earlier in your evidence that this should be one measure to tackle the issue. Previous witnesses have told us about very successful ways of having programmes to help people with an alcohol dependency. Could you expand on what programmes you think should be emphasised as this is being developed, and whether there is easy access to those programmes? Do we need more investment in that field?
I think there are two levels of intervention and programmes that we need to be thinking about. There are those programmes that are for the addicted drinkers, the alcohol-dependent drinkers, who we would hope that we've got services in place for already, but as we've already alluded to, we may need to make sure that area planning boards are looking to deal with any increase in referrals to substance misuse services, whether they be third sector based or community drug and alcohol team based services.
But then there's also interventions and support for those who are the hazardous drinkers, and they are the majority of people who will be affected by this. There are a number of interventions that have been piloted across Wales. We started in Aneurin Bevan and Cwm Taf, looking at interventions as part of our delivery plans for cardiovascular disease, looking at overall risk factors for cardiovascular disease, and we've tagged onto that now alcohol, and actually alcohol as part of the liver delivery plans in Wales.
Alcohol actually comes up as the most common issue—alcohol consumption over the recommended limits—and so there are already things in place to try and address those, but I think that might need to be looked at on a broader spectrum, and things like brief interventions would need to be improved—access to brief interventions for harmful and hazardous drinkers.
But the services are there—
The services are there.
And if they want and need to access them, they can, at the moment.
I would think that one of the things that a measure like this should do is increase the publicity. The issue that we've had with our interventions for hazardous and harmful drinkers in primary care is that people are cognisant of the fact, they agree, they go through their alcohol history and they agree that they're drinking too much, but actually when you try and then refer them on to places, they say, 'Oh no, we'll deal with that.' We do know that the majority can deal with it on their own, but I think having a significant amount of publicity around this as an intervention to help support people who are drinking at hazardous and harmful levels, rather than looking at it as a punitive measure, could be really used to engage people in the process of seeking help.
It's also helpful to have services that are directly accessible as well, that don't require a sort of chitty from another professional, that people can directly get to. Certainly, in Gwent, that's available. You can always increase availability, obviously. It's almost never that you can provide a service that provides absolutely instant access for everyone. Personal experience in general practice suggests that the people with real problems—the people who are actually dependent—it would be helpful if we could try and get them help quicker, because there's often a very short window. Colleagues will know better than me that the failure rate is still very high, but if we could actually shorten that time to actually access services, that would be helpful.
Thank you. To go on to evaluation, we talked about evaluating the price, maybe every year, but I think the Welsh Government is proposing an evaluation of how successful this measure will be after five years. What do you think of that as a proposal, and how do you think it should actually be evaluated? What are the measures that should be used?
I think the evaluation is very much akin with what the Scottish evaluation is proposing—the five-year annual proposal—and I agree. The pricing review should be on an annual basis, but some of the health benefits do take time to be translated and evaluated, so I think a five-year evaluation would be, probably, a reasonable evaluation period. In terms of the outcome measures for evaluation, we've already spoken at length, but we would recommend that the evaluation review at five years would include studies to assess changes to patterns of alcohol use, availability of alcohol below the minimum unit pricing, as well as studies to assess substitution or use—collateral increase of use—of other substances, included as a part of this evaluation.
In terms of evaluating long-term healthcare outcomes, clearly a year is too short—I would absolutely agree with that. However, we could certainly evaluate the effect on overall consumption probably quicker than that, and I think we should be doing that, because we've seen the evidence from British Columbia. I don't think we need to wait five years to see whether it's actually impacting on overall consumption. I think it's okay to do that much quicker. We should certainly be looking at whether there's an effect on violent crime: always difficult, because that's not a straight-line increase anyway, but it would certainly be interesting to see if that affected trends. In terms of long-term liver damage and things like that, clearly you do need a slightly longer evaluation period to see if that's actually making a difference.
I would go along with some of that and say that you might want to think about a process evaluation at about two years. So, evaluation of the process of introducing the minimum unit price, looking at those issues around whether it actually has had an impact, how easy it is to get availability of alcohol below the set minimum price—that could be done very much earlier, but I agree that some of the other things will take five years.
Thank you. And then, finally, Philip Hammond announced in the budget yesterday that the duty will rise on cheap, high-strength, low-quality alcohol products, such as white ciders, from 2019. What is your initial reaction to that?
I can't see that's going to affect what we want to do here. If duty rises, then the unit cost will rise anyway. What we're aiming to do here is make that proportionate to the actual alcohol content rather than the particular type of drink. So, whilst I would welcome the increase, I don't think it actually stops or impacts on what we're trying to do here.
The higher taxation does not necessarily give us the same kinds of health benefits that a minimum unit pricing would give, because there are ways of offsetting the minimum unit pricing with other products. Furthermore, high taxation would have an equal impact on moderate drinkers as well as high-risk drinkers, so there would be more of a population effect with that.
The thing with some of the taxation interventions—. Personally, I think 'too little, too late' would be my immediate response, as a hepatologist, but equally I think the market is very good at getting around these things. Your buy-one-get-one-free offers, the more you buy, the more money you get off—they can be got around if you just increase taxation without a minimum unit price.
Rhun, following on from that.
Following from that, can I have your thoughts on a couple of ways of getting around minimum pricing, one of which goes against the spirit of the Bill, and one of them, I would argue, runs with the spirit of the Bill? Firstly, it appears to me from the Bill that you could offer free other things, non-alcoholic, in order to, in the minds of your purchaser, bring the price of the alcohol down. There is a loophole; it can be exploited. What would your thoughts be on that?
I think that it will be down to the people who are drafting the regulations to try and be mindful of that as much as possible. I don't think it's going to be an issue in pubs and licensed premises because it's quite clear that minimum unit pricing won't particularly affect those venues anyway. I think that if large supermarkets try and get around it like that, I think they are very vulnerable and very cognisant of the public view, and if the public view is that they're actually trying to benefit problem drinkers, I think that would be very bad news for them. So, I think as long as it's drafted carefully, I think you can probably avoid a lot of that.
Yes, I would agree. I think the main issue is going to be in supermarkets and small outlets where they try and put something else alongside it to reduce the overall cost. I think, for your really harmful drinkers and your alcohol-dependent drinkers who are trying to get 30, 40, 50 units a day, I'm not sure that they're going to want 30, 40, 50 bars of chocolate or whatever it is that's going to be given away.
It could be anything.
Yes, 'it could be' is the answer, but—.
It could be all of their food.
Yes, and if it was fruit, then I might have a bit of sympathy, actually. [Laughter.] Because there's quite good evidence that if you have good nutrition, that alcohol affects you physically less. But, you know, there we go.
So, we'll look forward to the 'giving away fruit with alcohol Bill'. [Laughter.]
That'll do me all right, yes.
The other way of getting around this—which I would argue is a positive one—is to bring down the alcohol content of drinks.
That's not getting around it; that's doing exactly what we want.
Exactly what we want.
And, you know, you could start bringing down the alcoholic content of beers for sale in Wales only— that's good—and you'd like manufacturers to start thinking about that now.
Yes, yes. Because, I mean, the things we're targeting here are the 7.58 per cent ciders that my patients drink, for the really harmful drinkers. But even for those who are just drinking a little bit too much, you know, reducing alcohol content from 4 per cent to 3.6 per cent—fabulous.
I used very similar numbers as an example earlier.
Grêt, a dyna ni, dyna ddiwedd y cwestiynau. Diolch yn fawr iawn i chi am eich presenoldeb. Diolch yn fawr hefyd am y dystiolaeth ysgrifenedig ymlaen llaw. Mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma i gadarnhau ei fod e'n ffeithiol gywir. Felly, gyda chymaint â hynny o ragymadrodd, diolch yn fawr i chi'ch tri am eich presenoldeb. Diolch yn fawr.
A gallaf i gyhoeddi i fy nghyd-Aelodau y cawn ni doriad nawr am 10 munud cyn dod yn ôl at y bedwaredd eitem. Diolch yn fawr.
Great, and that brings us to the end of our questions. Thank you very much for all coming in today, and thank you for the written evidence that you submitted in advance. We will be sending you a transcript of today's discussions to check for factual accuracy. With those few words, I thank you again for your attendance. Thank you very much.
I also announce to my fellow Members that we will take a 10-minute break now before coming back for the fourth item. Thank you.
Gohiriwyd y cyfarfod rhwng 10:58 ac 11:14.
The meeting adjourned between 10:58 and 11:14.
Croeso nôl, bawb, i sesiwn diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nhynulliad Cenedlaethol Cymru. Rydym ni wedi cyrraedd eitem 4 rŵan, sef parhad efo'n trafodaethau wrth edrych i mewn i Fil Iechyd y Cyhoedd (Isafbrif am Alcohol) (Cymru). Dyma, o'n blaenau ni rŵan, ydy sesiwn dystiolaeth rhif 3. O'n blaenau mae cyfarwyddwyr diogelu'r cyhoedd Cymru a Chymdeithas Llywodraeth Leol Cymru. Croeso i chi'ch tri yn benodol, felly, ac a gaf i groesawu David Riley, cadeirydd Penaethiaid Safonau Masnach Cymru, a phennaeth gwasanaethau diogelu'r cyhoedd yng Nghyngor Sir Ynys Môn, David Jones, cydlynydd cenedlaethol Safonau Masnach Cymru, a Simon Wilkinson, swyddog polisi Cymdeithas Llywodraeth Leol Cymru?
Diolch yn fawr iawn i'r tri ohonoch chi am eich presenoldeb. Rydym ni wedi derbyn peth wmbredd o dystiolaeth ysgrifenedig ymlaen llaw ar y pwnc yma. Felly, gyda'ch caniatâd, awn ni yn syth i mewn i gwestiynau. Felly, mae gan Caroline Jones y ddau gwestiwn cyntaf. Caroline.
Welcome back, everybody, to this, the latest session of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We have reached item 4, which is a continuation of our discussions on the Public Health (Minimum Price for Alcohol) (Wales) Bill. In front of us now we have witnesses for evidence session 3, who are the directors of public protection Wales and the Welsh Local Government Association. Welcome to the three of you. May I welcome, please, David Riley, chair of the Wales Heads of Trading Standards, and head of public protection services at the Isle of Anglesey County Council, David Jones, national co-ordinator, Trading Standards Wales, and Simon Wilkinson, policy officer, WLGA?
Thank you very much for coming here today. We have received a lot of written evidence in advance on the subject. So, if you're happy, we'll go straight into questions. Caroline Jones to start then, please.
Diolch, Cadeirydd. Bore da—good morning.
My first question is—can I ask how closely has local government worked with the Welsh Government on the development of enforcement arrangements as set out in the Bill? And are the duties of local authorities and their powers under the Bill appropriate and proportionate? And how well does the proposed enforcement regime align with local authorities' existing inspection and enforcement?
Shall I take that one?
Yes. Hello, yes, thank you. 'Very closely' is the short answer. I've been working with Welsh Government since the consultation was first put in 2015, and I drafted a response on behalf of the directors of public protection Wales. There was a bit of a delay then. We were invited then when the matter came back on the agenda to engage again with Welsh Government, and I've been involved with all of those meetings, and I've produced a proposal for enforcement for Welsh Government's consideration. So, yes, we've had huge input and we're very grateful for that opportunity. Thank you.
Okay, thank you very much. Anyone else on that question or shall I move on?
Just on the powers, from what we've seen, certainly the powers are consistent with the powers we have in other areas of work. We're very much supportive of the tools that we are being offered in terms of enforcement, which would be the fixed-penalty notices, et cetera, et cetera. So, the detail as we've seen it is certainly consistent.
Okay, thank you. Secondly, what do you consider to be the resource implications for local authorities under the Bill? For example, the Cabinet Secretary has said that there'll be £150,000 for the first year, which decreases to £100,000 the second, £50,000 the third. So, can you elaborate on that, please?
Yes. Initially, when we looked at the number of premises that we would need to get round in Wales, that did seem like a reasonable option. Having reviewed that, I think it may be difficult to get round all of those premises with that budget, but, if it would be possible to use the budget, which I understand was proposed to be over three years—if that could be more sort of front-weighted so we could get round more in the first year and less in the second and third, then that would help us make sure that we had complete coverage of the premises that we believe to be of highest risk of non-compliance in the early period.
We think that, if there is a good education programme, an awareness-raising programme, to complement the enforcement, and a big early concentration from local authorities, that that will lead to a high level of compliance. You generally find the businesses that know what the law is want to comply—most of them. So, we're expecting there not to be so much enforcement required in the second and third years, but certainly in the first year I think it's really important that we make an impact and pick up on the publicity that'll come from the media as a result of the announcement to strike while the iron's hot, if you like.
So, you're saying that the budget, then, was rather an optimistic one?
Not in total, but it would be helpful if it could be front-weighted.
You're saying you want it more in the first year—
And then decrease in the second and the third.
Perhaps £200,000 in the first year would be more realistic, I think, to enable us to do everything that we need to do. If that were not possible, then we'd obviously focus on the highest risk and do what we can with what we've got available, which is what we always do.
So, will there be, in the second, third and fourth, a slackening off then of enforcement, do you think, because of the budget decreasing?
It's intended that, in the second and third years, we'll focus on premises where we believe there to be non-compliance, either because we've seen that as a result of the first inspections, or if intelligence suggests that there has been non-compliance. So, those will be the ones that we'll be focusing on. It's difficult to say at the moment how many that would be, but we'll only know that when the time comes. But we expect that it'll be significantly less than what's required in the first year.
Okay. Thank you.
Rhun, efo'r cwestiynau nesaf.
Rhun has the next questions.
Os caf i barhau a holi ychydig bach mwy ynglŷn â hynny: mae'r memorandwm esboniadol hefyd yn dweud eu bod nhw'n disgwyl lefel uchel o gydymffurfiaeth. Rydych chi hefyd yn dweud eich bod yn disgwyl lefel uchel. Ar ba sail a ydych chi'n dod i'r casgliad yna?
If I may, I'd like to go into a little more depth on that. The explanatory memorandum also states that they expect a high level of compliance, and you've said the same. On what basis do you come to that conclusion?
Our experience, generally, with business is that most businesses want to comply. You have a small number of rogues who deliberately try not to comply for financial gain. Usually, compliance or non-compliance is because of a lack of knowledge, or a lack of resource within business.
So, we think that if they are made aware of the requirements early—picking up on the media publicity that we expect to come with the announcement—that the majority of businesses will want to comply. And, certainly, the bigger chains, things like the supermarkets, they've got huge legal backing and trading standards, licensing and environmental health advisers. So, I think that those will certainly want to comply.
Our focus will be on the small—[Interruption.]—bargain booze, cheap end of the market. Those are the places where we have the problem now, and I expect that that will be the sort of area where those problems would be found as we progress.
I apologise for that. I have some flooding in the constituency, so I was trying to keep in contact with the wider world as much as I can.
It's flooding your phone as well, is it?
A oeddech chi eisiau dweud rhywbeth?
Did you want to say anything?
Rydw i yn ymddiheurio.
I do apologise.
If I could just say, you talk about the evidence; we've experienced the introduction of things like the carrier bag regulations—single use—smoke-free premises, Rent Smart Wales. So, I think, within public protection, we're well used to the approach of front-loading a lot of the education and compliance visits, and I think, in Wales, because we've got so many small and medium enterprise businesses, our research shows that they value that face-to-face contact. As Dai has mentioned, the bigger companies have specialist advisers, but small businesses don't, and they don't often have the time to sit down and read things in detail. So, they really value that face-to-face contact with compliance officers and enforcement officers. And the first six months to 12 months of any new legislation is imperative in terms of making it effective, I think.
Ac o bosib, hefyd, mae yna sgiliau gwahanol sydd eu hangen ar swyddogion, wrth gwrs, achos mae pob deddfwriaeth newydd yn golygu'r angen i ehangu gallu'r swyddogion i ddelio â deddfwriaeth newydd. A ydych chi'n hyderus ynglŷn â'r gallu i hyfforddi swyddogion i ddelio â hwn? A ydy'r memorandwm esboniadol yn delio â hynny'n ddigon da? A oes yna issues o gwmpas hyfforddi a pharodrwydd swyddogion yr ydym ni angen meddwl amdanyn nhw? David neu—?
And there may be a need for additional skills from officers because every new legislation leads to a need to enhance the skills of officers to deal with that legislation. Are you confident on the capacity to train officers to deal with this? Does the explanatory memorandum deal with that sufficiently? Are there issues around training and preparedness for officials that we need to consider? David or—?
In discussions with Welsh Government officials, this has been an issue that has been raised, and we would expect some training for officers in advance of any work in this area. We've got the skills, we've got the enforcement skills, but, obviously, detail—in terms of what's required, it's well worth making sure that the officers are fully competent and prepared when they go out there.
Any other comments?
Exactly. You referred to the memorandum of explanation of the Bill itself, and there are some very good examples there of practical issues that enforcement officers may well come across, but it's not an extensive list, by any means. There will always be some quirks to the business fields where they will find some different ways of trying to promote or to sell alcohol. And it'll be very, very useful for us to be able to sit down across Wales, as enforcement staff, to have a wider discussion about some of those things, and be able to feed in some of those individual experiences, which we're already finding, either as maybe trading standards officers or licensing officers within public protection as well.
Yes, part of the proposal was for a sort of an education pack, if you like. Well, not so much a pack but information to the trade—something concise and simple for the trade—and a more detailed sort of training pack for officers so that we'd be absolutely clear about what we're asking, and that everyone across Wales would be providing exactly the same message. We've suggested that that pack should be produced by Welsh Government in consultation with us, and then, if we do that, we should all be on the same page, so we get a completely consistent response across Wales, and we won't lose the message about questions of competency of officers doing the inspection.
There's no doubt, in terms of the style of the legislation and the content of the Bill as it looks at the moment, that this is well within the sort of style and the range of the competencies of local government staff who are already dealing day to day with businesses—small businesses and medium, as you say—and dealing with, to be perfectly honest, much more technical legislation on a day-to-day basis. So, this, on the face of it, at least, is something that will be able to be incorporated quite well within the normal operating procedures of local government staff.
Thank you. Diolch.
I symud ymlaen, Lynne Neagle.
Moving on now to Lynne Neagle, please.