Agenda item 3 is our first evidence session on the Alcohol (Licensing, Public Health and Criminal Justice) (Scotland) Bill. I welcome to the committee Alison Christie, policy officer, Scottish Families Affected by Alcohol and Drugs; Dr Peter Rice, honorary consultant psychiatrist, NHS Tayside, and chair of Scottish Health Action on Alcohol Problems; Dr Colette Maule GP, BMA Scotland; Tim Ross, chief inspector, Police Scotland, and North Ayrshire health and social care partnership; and Petrina Macnaughton, research and policy co-ordinator, Alcohol Focus Scotland. Welcome to you all.
Before we begin the questions, I make the witnesses aware that Richard Simpson MSP, who is the member in charge of the bill, has joined us today. Richard will have an opportunity to ask questions at the end of our session. Welcome to you, too.
No opening statements will be made, so we will move directly to Malcolm Chisholm, who will ask the first question.
As there are 10 different proposals in the bill, it is quite difficult—in fact, impossible—to deal with them all simultaneously. I have read all the submissions, which were extremely useful—thank you very much. I thought that it might be useful to start with the areas on which there is unanimous agreement. There might be more such areas, but I think that everyone is agreed on the minimum price for packages containing more than one alcoholic product—I am sure that I will be contradicted, but my impression is that everyone agrees on that; community involvement in licensing decisions; and restrictions on alcohol advertising. Those are certainly the areas on which there is broad agreement. There is a measure of disagreement on all the other areas, even if just one organisation disagrees with what is proposed, but I wondered whether the witnesses had any issues in the three areas that I have mentioned, on which it looks as if there is a lot of agreement. I am sure that people will tell me that I am wrong if that is not the case.
Can we take it that there is broad agreement on those areas? Thank you. Right, Malcolm—now for the hard stuff.
11:00
Oh, right—I had expected to hear some comments on that. Well, Richard Simpson will be pleased because he has three proposals in the bag and only seven to go.
There might be some merit in taking the proposals one by one. Perhaps we can start with the issue of alcoholic drinks with caffeine, because people know the background to that. Such drinks are related in many people’s minds to antisocial behaviour, but there might also be health issues with them. There are different opinions, however, so it might be useful to kick off on that issue.
Petrina, were you attempting to come in earlier and I cut you off? I am sorry if I did.
I think that there is broad agreement about restrictions on alcohol advertising, tightening up the quantity discount ban and community involvement in licensing. However, Alcohol Focus Scotland believes that the measures need to go further than what the bill proposes. I do not know whether that constitutes broad agreement, but we definitely think that marketing restrictions, for instance, need to extend beyond what is proposed.
Would it be helpful to ask the basic question? Do you believe that the bill is likely to have a noticeable impact on reducing alcohol consumption?
Voluntary agreements are already in place for each of the measures in the bill to restrict marketing. There is a voluntary agreement not to advertise around schools and a voluntary agreement not to have alcohol sponsorship of sporting events that primarily involve young people and children or where they are the audience. If such restrictions are made enforceable through legislation, that will add something, because we know that the voluntary agreements are breached in some cases—for example, in relation to advertising around schools; a few instances of that have been noted in Wales.
The bill’s proposals will provide an additional element, but that will not make much of a difference because voluntary restrictions are already in place. To make a difference, we should consider extending the restrictions to prevent children from seeing advertising, because we know that they do. Our research has found that children as young as 11 or 12 have a high level of awareness of alcohol brands and advertising. We would advocate a ban on alcohol advertising in more public spaces and an extension of restrictions on advertising in cinemas, on television and in other broadcast media. There is support for such measures among the population. For instance, there is widespread support for a ban on alcohol advertising in cinemas for under-18 films, which is a much clearer and simpler measure than what is currently in force.
Just to add to that, the measures in the bill would undoubtedly be a step in the right direction, but I agree with Petrina Macnaughton that there is still more to be done. As has been quoted in some of the evidence, we have 10 and 11-year-olds who are more familiar with lager brands than they are with ice cream brands, which is not a happy situation and not the way we would like things to be.
There are discussions going on in Europe about this issue but, at the moment, the requirement is to prove that the marketing is targeted at young children, not that they are exposed to it. If a young person goes to see their football team and the team jersey has a beer logo on it, that is substantial exposure to brand advertising but, because it is not targeted at the child, it has proved very difficult to regulate it. That is just one example of the further steps that we need to take. These are good steps to address marketing that targets young people, but most of the marketing that young people see is targeted at the wider population rather than young people, but young people see it in the general run of things. We need to take steps to address that, but the bill is a move in the right direction.
Does anyone else want to comment?
For the Department for Work and Pensions review, we had responses from 70 family members, and the constant comment was that alcohol is everywhere. For example, if you take your children to the deli for breakfast on a Saturday morning, its shelves are lined with wine. It is about the marketing but, as Peter Rice and Petrina Macnaughton said, the bill has to go further on the exposure to alcohol.
I can see that no one else wants to comment at the moment, and I am aware that I interrupted Malcolm Chisholm earlier.
No, that was useful, because it is clear that people want to add to the list of proposals, not take away from it. It is up to you how to proceed, convener, but I suggest that we move to the issue of caffeine, if there are seven other issues that are more controversial.
Can we have a response to Malcolm Chisholm’s original question about caffeine?
From a personal perspective, when I see patients in my surgery who are having problems with alcohol, it tends to be because it is lower priced rather than because it has caffeine in it. I would not like to concentrate on one area of low-priced alcohol; we have to take into account all the other types that are out there. At times, there is not a lot of discrimination between which alcohol people take. It is really the price that is the problem.
Is that a generally agreed position?
All the data that we have is about the quantity of alcohol. We do not have any families who are concerned about particular brands or products. It is about volume and how accessible it is to buy it cheaply.
We certainly agree that price and affordability are the key drivers that increase consumption and harm. There is research that shows that a high proportion of young offenders drink caffeinated alcoholic drinks. Considering that the caffeinated alcoholic drinks that are sold in the country make up only about 2 per cent of the total alcohol market, they figure quite high in alcohol-related offending, so we take a precautionary approach. There is some evidence to indicate that caffeinated alcohol can exacerbate alcohol-related offending, and on that basis we would advocate for a restriction to be considered and implemented, and then we could evaluate the results. The evidence is indicative, not conclusive, but I am not sure whether the cost of implementing a restriction on caffeine content would be high. I do not know whether it would be costly to implement a measure about putting less caffeine into a drink, but the effect of doing so on alcohol-related offending could be evaluated.
We feel that it is not a priority action, on a number of grounds. One is that, as has already been said, most of the harm that we see in clinics comes from low-cost alcohol, and the tonic wines and caffeinated drinks tend not to be low cost. The evidence about the relationship between caffeinated alcohol and offending is restricted to quite a limited part of Scotland, and even the McKinlay report had no tonic wine consumers from the east coast, which is an interesting phenomenon. That report showed that the same high numbers of people were consuming spirits, cannabis, benzodiazepine and ecstasy, and only 30 per cent of that sample reported that their alcohol-related offence was purely caused by alcohol; it was caused partly by other drugs. We should not pick out caffeine from that cocktail of drugs, as it is not the priority drug.
A further element is the emerging neuroscience, which indicates that the immature male brain—and the male brain stays immature for quite a long time, probably into the mid-20s—has an alerting reaction to alcohol, and our response to alcohol becomes more sedative as we age. Some of you might even know people to whom that has happened. The alerting effect of alcohol in young men, which is often attributed to caffeine, may in fact be an intrinsic effect of the interaction between alcohol and the still-developing male brain. Putting all of that together, our feeling is that, although we understand the public concern, restricting caffeinated alcohol is not a priority action.
My final point is that suggestibility is a very important effect in intoxication. When people become intoxicated, they behave in the ways in which they expect to behave. The belief that a drink will make such and such happen is a strong predictor of what is going to happen. My view is that the discussions around tonic wines may in fact have made things worse. They may have established a reputation for a particular product that will become a self-fulfilling prophecy, and what might have been a short-lived craze has become more long lived. We have never drawn attention to caffeinated products, because we think that some of the public attention to them might be detrimental.
Are you okay with that answer, Malcolm? Did you just want some of that on the record?
Yes. That was interesting.
Bob Doris has a supplementary on the caffeine issue.
I will be brief, because there are other substantial parts of Dr Simpson’s bill that I would like to ask questions on.
In relation to the point that Dr Rice made, if the bill were to go through and a ban on caffeinated drinks imposed, what is the likelihood that the young people who are involved in social disorder or who put themselves at risk with those drinks would stop drinking? Would they not just switch to another form of drink that might be lower cost? Would someone not just market the next big thing that would become the magnet for young people to drink? I want to be sure that the ban would actually have a positive effect.
My view is that if people are setting out to become intoxicated and expecting to become violent and disorderly as part of that, that will still happen.
The question about caffeine is very legitimate. Does caffeine have a neurochemical effect that enables people to keep drinking when otherwise they would have collapsed and passed out? Does the alerting and stimulating effect of caffeine allow people to keep going, keep drinking and get more intoxicated with alcohol, leading to more disorder? That is a very legitimate question that is, to an extent, unanswered. I think that a recent meta-analysis has shown that the effect of caffeine in keeping people drinking is not powerful—it does not happen. As I said earlier, there is evidence that the alerting effect in fact happens even without caffeine.
It is likely that people who set out to drink with the intention of becoming violent, and who see that as part of the experience, will still become violent.
Chief inspector, do you want to respond?
I have a similar point. The fact that such behaviour exists in areas outside the west coast where those types of drinks are not so prevalent suggests that there would be alternatives and that the issue is more to do with cost and availability. Although we are supportive of the ban as a step, we would like to see the research that shows whether the effect of caffeine augments the effect of alcohol and to have that considered more fully before we take decisive action on it.
I have a question about alcohol advertising and then would like to move on to container marketing and off-sales.
Although I am not a football supporter, I know that in the past we have had sports events that were sponsored by Tennent’s, we have had the Carling cup and we used to have the Martell Grand National. Dr Rice, a couple of moments ago you mentioned that quite a number of football teams have the logos of drinks brands on their jerseys and so on. Do you feel that alcohol advertising, particularly sponsorship by alcohol brands, should be banned at sporting and cultural events that principally target those under the age of 18?
I go to a sports centre with my grandson and see kids of five or eight playing football, but there is no advertising of beers or wines there. If I take my son or my grandson, when he is older, to a football match, there will be a Tennent’s cup or a Carling cup and advertisement boards will be flashing up different brands of alcohol. Do you think that what is proposed in the bill is workable?
11:15
I think that it is workable. One of the first things that I did on alcohol policy was to run a campaign to get the drinks logos removed from child-size football strips. That was eventually successful, although it took some years. The Welsh research shows that the issue that you raise is undoubtedly a major part of young people’s exposure to alcohol brands, with the one that was most recognised by young people being the company that sponsors the rugby union competitions in Wales. It is a big channel for exposure.
Many countries in Europe do not allow that sort of sponsorship. In two of Celtic’s three away games in Europe so far, they have not been able to wear their cider logos on their shirts, because they were playing in Azerbaijan and Iceland, which do not allow that. Other countries, such as France, have made such a restriction work perfectly successfully. It is not a proposal that is on the table today, but my view is that that type of sports sponsorship is inappropriate.
There are shades within the issue, and you would not want to interfere with a situation in which, say, a local hotel was sponsoring an amateur team. However, I am opposed to big corporate sponsorship of major sporting events by alcohol firms.
It is a big business. FIFA forced the Brazilian Government to change the law in order for it to stage the world cup, and the Russian Government just agreed to do the same in order to have the alcohol sponsors selling their product in the football grounds. National Governments come under pressure from sports associations and have gone along with what has been asked of them. They are powerful forces, but I think that such sponsorship is inappropriate and I would like it to be removed.
It comes back to what Peter Rice said about the rule that advertising and sponsorship must not appeal particularly to children. However, that distinction is quite meaningless, because children are targeted by all the advertising that adults are targeted by. All the advertising and sponsorship that appeals to adults appeals to children, too—humour, depictions of social and sporting successes and so on all influence children’s attitudes. It has been shown clearly that that influences their intentions to drink, when they start to drink and how much they drink. That needs to be addressed in all our rules regarding the marketing of alcohol. We must recognise that, to protect children, we have to consider all advertising. There is no such thing as advertising that does not appeal to children. It all does, so that has to be addressed.
I want to move on to deal with the issue of container markings. My question is for Chief Inspector Ross.
I am sorry to interrupt, Richard, but I thought that you had another question about advertising.
I said that I was going to move on to container markings.
I must have misheard you. Other members want to come in on the back of your first question. I am sure that that is in the interests of everyone.
I have a couple of questions about the influence of alcohol companies on sporting competitions. Has there been an assessment of the amount of money that is involved? I am sure that the sporting authorities might complain if a massive amount of sponsorship money suddenly left because we happened to change the law on sponsorship.
As I was coming into the meeting today, it was put to me that a lot of sports clubs, golf clubs and so on receive preferential loans and things such as that through alcohol companies—Belhaven beers are quite prevalent in golf clubs, for example. Has there been an assessment of how much money might be taken from sporting organisations and events if we changed the law?
I do not think that there is a recent assessment. Ireland was considering phasing out alcohol sponsorship of sport. For its public health bill, it might have done an impact assessment, but I have not seen it so I do not know for sure.
Beer companies have preferred beers at events, with sponsors’ beer and so on. However, there are alternative models for funding sport. Heart of Midlothian Football Club has led the way on that; it requires a different ethos.
We recognise that alternative sources of funding would be required. If we were to go down this road, we would advocate a phased removal to allow other funders to come on board.
At the moment, a lot of funding of football is related to addiction—to betting, alcohol and payday lenders. It attracts those kinds of funders. If we were to move away from that and get more congruence in funding and more family-oriented funders of football, we would have to phase out that funding. Such a change would need to be planned, and a change of ethos would be needed.
Before we try to find a way to get out of such funding, would it be appropriate at least to work out the financial hit on sporting events and clubs? As we all know, funding can be difficult to find.
This is about a principle. We are not talking about introducing a law to ban such funding overnight. It would be a phased removal, which would allow people to source alternative funders and to allow other models of funding for games. We live in quite a rich society and there are a lot of businesses that are not alcohol related that can fund sport and sporting events. That is not impossible.
If there is no financial assessment, how can we tell what the hit will be?
Other members of the panel want to come in.
I will try to keep it brief. I am a football supporter and one of my arguments has always been that this might mean that Scottish football was dragged down to the level of French football. As France functions perfectly well without such advertising, I could live with that.
We did some work at the UK level on sponsorship of sport. In the English Premier League, which is very financially successful, only one football team is sponsored by a beer company, and that is a far eastern beer company. It seems that English football has become too big for the beer market. In fact, the biggest club that is sponsored by an alcohol company in the UK is in Scotland.
The argument that we will hear is that sport is hooked into that money and cannot live without it. I do not think that the evidence supports that. Colin Keir is absolutely right, though. If a ban on such advertising was a firm proposal, there would need to be appropriate analysis of it.
The restrictions on alcohol advertising that are described in the bill might be much more limited. You have argued that such restrictions should be extended. What is your understanding of the limits of what is being proposed?
What has been proposed is a group of good ideas, but one of the limits is that they work on the presumption that advertising is targeted specifically at young people around schools and so on, when in fact most of the exposure is not there.
Another issue is that billboard advertising is becoming a smaller and smaller part of the advertising industry. The real prize is social media, which is very difficult to legislate for. Finland is trying to do that.
The measures in the bill are useful, but there are bigger fish to fry, if it is possible to construct legislation on that. The social media issue in particular is not easy, but it needs to be taken on.
Does anyone else have questions before I go back to Richard Lyle?
Just a quick one.
On advertising, surely.
I will be brief, convener. We probably want to ensure that advertising is more ethical and perhaps moral. If alcohol advertising were to be removed and the advertising instead related to—as Petrina Macnaughton said—payday lending or betting, we would create another problem and perhaps an even bigger problem in terms of people’s wellbeing and addictions. How do you suggest that we control advertising to ensure that we do not create a bigger problem? Alternatively, Dr Rice suggested that perhaps we should not allow such advertising at all.
I will have another crack at that one. The first thing that we need to do is stop advertising being self-regulated. That would be a big change. My profession used to be self-regulated and now it is not: the majority of the membership of the GMC is now non-doctors. Somehow, the advertising industry has retained the right to self-regulate. The number 1 priority on my list would be to change advertising regulation.
My question is for Chief Inspector Tim Ross. Most of the complaints that we receive locally are about the fact that, when police catch an under-age drinker, they do not know or cannot find out where the person bought the container. The bill proposes that there should be an identification mark—it would be interesting to find out later how that would be done—on each container to show where it was bought. Is that workable?
Although the proposal in the bill refers to off-sales premises, my view is that every place where alcohol is sold, including supermarkets or wherever—as someone said previously, some local shops and eating places sell alcohol—should have a specific code or identification mark. Is that workable? Would that help the police to establish where alcohol had been bought by, say, an under-age drinker?
Container-marking schemes are workable, as they have been undertaken before voluntarily, although they have not been widespread. I understand that the proposal in the bill is that such a scheme would be established by order of a licensing board in a particular area, so we are not looking at population-wide schemes. The schemes are workable on a local basis and they enable us to track containers back to premises. The proposal relates to off-sales because we are trying to address the sale of alcohol to young people in off-sales premises.
Nevertheless, such schemes have limits. The licensing environment has changed since bottle-marking schemes were first used, which was before the introduction of the current licensing legislation. The likes of the challenge 25 scheme and test purchasing perhaps give us stronger options when we are dealing with premises that sell drink to under-age people. The strength of bottle-marking schemes is in developing intelligence to allow more targeted enforcement to take place.
The schemes have worked in the past and I would not say that they could not work again, although they have had varied success in different areas. I fully appreciate that there are difficulties, as the fact that somebody has a drink that came from certain premises does not mean that the premises committed an offence in selling it—that depends on who the third party was who bought the drink.
Bottle-marking schemes have worked and if there is community support for such a scheme and—perhaps more important—support for it among the premises in the area that might wish to take part in it, it could well be a success. As I said, such schemes might be more about informing future work on the management and operation of premises.
Are you saying that such a measure could or should be available to a licensing board in a given area?
That is an interesting question. I am certainly not against the measure. I should point out that I am at the meeting as a representative of North Ayrshire alcohol and drug partnership rather than as a representative of the police, but never mind that, because I am of course a police officer.
I am certainly not against such schemes. The environment has changed slightly in recent years. On what such schemes deliver, it is good if the premises licence holders take part in the scheme voluntarily, because we need that buy-in.
On the evidence that that provides, the outcome and the impact on drinking in the area, we would have to take that case by case. As I said, perhaps its greatest potential would be in providing the evidence or intelligence base to allow further action.
11:30
I turn to the section of the bill that deals with notifying GPs about offenders. It seems counterintuitive that GPs and the BMA have concerns about that provision. I want to get those concerns on the record, because it appears to me that that requirement would give GPs a full picture of their patients. We talk about treating the whole person and their circumstances and the like. If a piece of information from the jigsaw is missing, I do not understand why someone would not want to have it.
I start by saying that the piece of the jigsaw probably is not missing—GPs are probably aware of the alcohol problems that their patients are suffering with. We have to accept that the medical record is fundamentally there for treating patients. Bringing in information across the board is probably not the way that we want to go.
We have to look at the doctor-patient relationship. We spend a long time over our careers building up a relationship with our patients. It is a relationship of trust that what we discuss and have in the records is something that we have both consented to, which we have spent a long time dealing with.
If a patient presents daily in the surgery with anything that suggests an alcohol issue, I will address the matter with them. If they do not raise the issue but I suspect that they have an alcohol problem, I will raise that with them. I will investigate it and bring them back in to discuss the outcome of the investigation with them. I would not like to jeopardise that relationship by the patient having—or possibly not having—consented to me being given information about a criminal offence that alcohol might have played a part in.
There would be an issue with data coming into the record. I am the data controller of the record. I would have to know that the patient had been appropriately counselled and informed. The patient would have to have been told exactly what would happen with the information coming into their record, and what would happen to the information should the patient leave my practice and move on to someone else, which often happens when people have chaotic lifestyles in which alcohol plays a part.
I am particularly concerned about receiving information on spent convictions, because that would require GPs and their practices to spend considerable time following up the information that had been placed on the record. How would I be informed about that? What would happen between the patient being convicted and the conviction becoming spent? How would that information be passed to a GP who the patient had moved to?
Consent is a big issue. I want patients to be fully aware of the information that is part of their medical record. I do not perceive that the system is foolproof enough to ensure that that would happen for their medical record for their entire life.
A large administrative burden would also be placed on GPs and patients. I was slightly disappointed to note that no impact would be expected on a GP consultation from placing the additional information in the record. If I had to deal with something because it was there—the GMC clearly states that, if something is put into a patient record, I have a responsibility to act on it—that would impact on my personal relationship with the patient and the time that I could spend dealing with other aspects of their health in the consultation.
In the practice, a lot of my staff’s time would be taken up with bringing in the information and sending it to a doctor to be actioned. That would also be the case in doing the opposite, when information needs to be taken out at the other end.
The doctor-patient relationship is critical. It must be accepted that general practitioners have a very good idea of their patient’s health problems. Even if a patient is not forthcoming, we are trained to tease out the information from them. I am perfectly content that I would be able to deal with the possibility of an alcohol problem with any patient who presents in the practice.
One of our concerns about the proposal came from family members. The ones who spoke to us were unclear and therefore hugely anxious about what would happen next, because they immediately started to think that that simple statement would lead to social work, the police and so on getting involved. The families already face a huge amount of shame and stigma, and the family members who spoke to us felt that this was just another layer that would be added to what they already have to carry.
How does that square with what we just heard from Dr Maule? Families do not want doctors to know the information and want it withheld, but Dr Maule said that she knows all the people in her practice who have a drink problem.
There are families who will go to their GP, but we have found that on average a family member will cope with someone’s problem alcohol use for seven years before they seek help—partly because of the fear of the unknown, particularly if children are involved. I agree that a GP is likely to know their patient’s history, but the situation is different for family members, who will hide things and try to cope for a long time.
Families will live with the problem for seven years without seeking any help.
Yes. We already knew that anecdotally from our family members, but research that we have recently completed with the University of Edinburgh is likely to provide evidence of that.
In that case, could intervention happen earlier to prevent the eventual crisis?
I imagine that, if a patient of mine was attending court or whatever, the ideal time for intervention would be when they were being dealt with by those who were raising the alcohol problem with them. I think that Ms Christie is saying that relatives are more loth to come forward with the information, which is certainly an issue.
When a patient comes to my surgery, I have a one-on-one relationship with them at that time. It would be rare to have a consultation at which a GP would not address the possibility of alcohol as a factor. If a patient were to present at the surgery in a way that gave me concern, I would intervene at that point.
The proposal might be that I would not have to do anything if I received information that one of my patients had a drink problem, but the GMC says that I have to. That would just lead to confusion. I would not ignore the information, but the question is whether I would be tasked with bringing in a patient to address it. More often than not, I am absolutely aware that a patient has issues with alcohol.
I do not know whether you have already alluded to this, but do you feel that the justice system provides support to and helps to identify and track those who are being dealt with for drink-related offences?
As I worked for 20-plus years as a specialist psychiatrist in alcohol problems, I know that there was a common route of referral, sometimes from criminal justice services and from courts for, say, people on probation orders, and sometimes from people going voluntarily to their GPs, precipitated by an offence. It was a common pathway for people to get into specialist treatment through criminal justice routes.
You said that it was common.
Yes.
Is that still the case?
Yes.
I have been out of clinical practice for a couple of years, but I do not think that things have changed much. You can take it that that is still a common route for people to get into specialist services. The GP is often, but not always, involved in the process; sometimes, the referral comes from criminal justice probation teams and so on.
That is interesting, because I am not awfully sure where the difference lies, apart from ensuring that this sort of thing happens routinely when there is a problem with alcohol, instead of someone having to take the additional step of referral to a GP, counselling services and the like. If that was happening, health professionals could intervene earlier, get support for the person and perhaps deal with the problems long before they got worse and people found themselves in prison because of their offending behaviour.
The first intervention should be at the earliest possible time. If we were informed down the line when a conviction had happened, rather than the patient being in the system and alcohol having been perceived as a problem, there would be a delay.
Patients are still referred to us by probation officers, counsellors and addiction workers. The bill does not need to be put in place to ensure that that system exists. I would certainly rather see the patient two to three months before their conviction than wait until it had happened, as I could then intervene at the right time. I think that the current informal system works.
But people will be missed.
People will be missed, but that must be balanced against all the other issues that I have raised that are to do with the loss of the doctor-patient relationship, the potential impacts on families, the administrative burden, the data controller procedure and the GMC opinion. I do not think that the proposal would help my relationship with my patients.
I wrote down a couple of phrases—“trust” and “patient buy-in”—that relate to the discussion. If I am being honest, I am not sure that the provisions in the bill facilitate either of those things.
On patient buy-in, I think of my constituents. Let us imagine that one of us around the table gets involved in an offence in which alcohol has been consumed, irrespective of how major or otherwise that offence is, and is convicted. I do not know how any of us would feel about that being flagged up to a GP in terms of trust, or how we would feel about part of a criminal record being kept in our medical records. I think that we would all be thick-skinned and worldly wise enough to get on and deal with the matter, but for a number of my constituents—particularly those in hard-to-reach groups—it is a significant achievement to go to the doctor in the first place. I am concerned that those who are least likely to seek medical help for a variety of conditions and who are most likely to need support from GPs might be those who take greatest umbrage at the breach in the trust relationship. I would welcome comments from the witnesses on whether they agree with that.
I also wrote down the word “targeting”. I am delighted that it looks as if the quality and outcomes framework is on the way out from 2017 onwards. If politicians were to say to medical professionals, “Pick the 100 people in your practice who you think are most at risk of alcohol abuse, and we’ll give you more time to spend with them in a targeted way,” would you pick the 100 people who had committed an offence during which they were intoxicated, or would there be another way of doing things? Is targeting the GP’s time the most effective way to get the outcome that Dr Simpson quite understandably wants to achieve?
Can you say a bit more about the hard-to-reach groups whom you struggle to get to make and keep appointments? In particular, would Dr Simpson’s proposal dissuade them from going to the GP? Is it the best approach? Obviously, it would take up GPs’ time. Is targeting at-risk groups of people who abuse alcohol and damage their health the best use of clinical time?
I agree with your first point. I definitely agree that those patients are difficult to reach and that any barrier that is put in the way will have only negative consequences. As you say, those consequences will relate to not just alcohol-related problems but all the other medical conditions that can go with them.
On the second point, the first thing that would have to be decided is whether the GP was best placed to deal with the initial presentation. The GP possibly is best placed to recognise initially that there are problems, but who is best placed to deal with the long-term effects of those problems and has the time and expertise to go along with that? As members know, we essentially have 10-minute consultations, during which it is very difficult to achieve anything. The impetus is lost if you bring someone back a week later. GPs see most patients most of the time, but we would probably be best placed acting as a route to someone who has the time and expertise to deal with the on-going problems.
11:45
I am trying to get at the issue of targeting. Dr Simpson obviously wants to target at-risk groups where alcohol is a contributing factor to offending—although I suspect that it is a public health initiative rather than a criminal justice initiative. If you want to target those who are most at risk of a public health hazard due to alcohol abuse, is Dr Simpson’s proposal the way that you would like to use your time as a GP, or can you think of other ways of using that time?
That is a difficult one. I do not think that I can answer it just now without having more information. I would have to know the balance of who had been convicted and whether what happened with an individual was a one-off or whether they had a long-term alcohol problem.
As GPs, we have embraced that sort of work in the past. We have done brief interventions and we have targeted patients, but generally time is of the essence in the consultation and we really rely on having a support network that we can send people on to. We target anyway, because we tend to ask most people who come in with a medical problem whether they smoke or drink and we assess whether they are overweight. We do public health promotion in every consultation anyway. Taking that next step is where we get the best support.
I have scribbled down a few points to make. From a health and social care partnership point of view, we want to be really clear about the exact purpose of the bill. On the face of it, you might think, “I can see why that’s happening”, but we would have to be really clear about the purpose. For example, is there anything to facilitate patient buy-in or patient engagement in the process? If somebody does not want to engage with their GP, albeit that their GP may well know that they have an issue, how do they buy into the process?
It would also be interesting to see the scale of the issue. There is a degree of subjectivity in a police officer assessing the role that alcohol plays in the commission of an offence. It would be interesting to see the scale of referrals to GPs and the obvious knock-on effect on resourcing.
We talked about earlier schemes. Various police offices throughout Scotland have undertaken pilot alcohol referral schemes, which have been more about giving offenders who are in custody brief interventions. That might be something to look at as well.
The point about targeting is valid, because it comes down to resource issues. How do you choose between the person who committed an offence because they were drunk—but they do not normally drink—and the long-term alcoholic in the community who perhaps does not come to the attention of the police?
I am not saying that what Dr Simpson proposes is a bad thing to do, but maybe we have to consider whether it would be the best way to use our limited resources.
I might come back in later, convener. I found Dr Maule’s final comment on alcohol brief interventions helpful. Let us take the fictitious 100 alcohol brief interventions that Dr Maule is going to do. I know that it would be wonderful if she was given lots of additional time to do them. This might be a difficult question to answer, but do you think that interventions would be more likely to have an impact if you identified the patients in your caseload who would be most likely to benefit, based on your current relationship with them? Alternatively, would it be more effective to do interventions for 100 people who have been up in court as they come forward? What would be more likely to produce an effective brief alcohol intervention and produce the positive health outcome that you are looking for? That is what I am trying to get at.
Do you have an answer to that, Dr Rice?
I will take that one, having been involved in the development of the alcohol brief intervention programme. It is important to put this into context. The Scottish programme, which has been up and running since 2008, is the first national programme of its type in the world. It has been a big success numerically, mostly due to its take-up in general practice. A good structure was established, with good software and all that, to make it easy to do. The programme has outperformed its target every year. People are coming to look at how that has been achieved. It has also coincided with considerable improvements in alcohol-related health in Scotland. The programme has been a big success and primary care has really bought into it. That is part of the context of the discussion. There is lots of very good practice in Scottish general practice, and the ABI programme supports that.
Your question on targeting relates to my previous day job in Tayside. Although things have improved in Scotland, there is still a shortage of treatment—there is unmet need for treatment for alcohol abuse.
The people who were most likely to benefit, and whom I most wanted to see, were those who most wanted to be there. There were various ways of rationing treatment—we need to use the word “rationing”, because that is the reality. I always felt that putting rationing in the hands of the patient seemed to be the fairest way to do it. The people who wanted to be there got there, often via their general practitioner.
That is what I took from your question about targeting. If we have limited resources—we would love to have unlimited resources, but we do not have them—who is it best for us to target? My answer is that we should target resources at the people who really mean business.
The difficult part is getting people who want help to seek it and to go forward from there. We do that in the surgery, day in, day out. We discuss alcohol—in fact, I discuss alcohol in probably about 60 per cent of my consultations—no matter why the person is there. We try to get the network that is around us to support the patient and their family.
That is helpful—thank you.
That takes us on to another part of the bill, which is on alcohol awareness training as an alternative to fixed penalties.
I do not know exactly what is meant by the specific word “training”, but the idea of directing and supporting people rather than imposing a criminal sanction relates to what we have been speaking about. The training could include some sort of counselling support or referral, or it could even just be about asking people whether they have thought about those things or discussed them with their GP.
I wonder what people’s views are on that provision, under which training would be offered—as I said, I do not know about the word “training”, but that is what is in the bill—as an alternative to a fine when someone commits an offence under the influence of alcohol.
We would welcome that approach. We recognise that education and awareness raising are generally more effective in many cases than enforcement—and certainly if enforcement is in the form of a fixed-penalty notice. If we had training as an option in circumstances in which we felt that it would be appropriate for the offender to be offered it as a means of negating the requirement to pay a fine, that would be very welcome. A fine is quite often punitive for the people whom we deal with and does not assist them in their situation.
The early and effective intervention programme for younger people has been really good. We looked at whether it would be possible to do that in Ayrshire. At the time it was not, because the procedures did not allow us to do it, but we would certainly welcome training as an option.
We have just completed a pretty large trial in England, funded by the Department of Health, which looked at brief interventions in a number of settings such as primary care, criminal justice and accident and emergency. Primary care came out as by far the best setting in which to deliver brief interventions.
Brief interventions that were delivered by probation staff in a criminal justice setting also came out well in evaluation. The problem was in getting departments to do those things. The general practitioners were quite well behaved and did the work, but we had a job getting criminal justice services organised so that they actually did it—although those that delivered it did pretty well—and keeping them engaged.
There is merit in the idea of training, but we would need to look at the structure of criminal justice services and at how they can get themselves organised to deliver such training reliably.
Looking at the available models, I think that there are definitely resource implications. The work that we have done in North Ayrshire around trying to improve peer involvement and raising awareness of alcohol issues has been very successful. We could adopt some innovative and exciting approaches that might not be too resource intensive but which would allow us to deliver some really effective interventions.
We definitely support the provision of awareness training and support. The only question in our minds concerns cost effectiveness and what happens if people do not have the motivation to change. If they simply think that they will get out of paying a fine and are not ready to change their behaviour, such an approach may not motivate them to change, and that raises the issue of whether the training would be cost effective. That would have to be evaluated, I guess.
I am trying to go through each of the bill’s provisions. Alcohol education policy statements are an aspect that seemed fairly reasonable initially but, on looking at the bill, I began to wonder a little bit. If we go down that road, my thinking is that people would lobby me about having substance abuse education policy statements, healthy diet education policy statements or physical exercise policy statements.
We absolutely agree that there is need for better education and information to allow people to make informed choices, but the issue is whether we should single out alcohol from the areas that I just mentioned. I am open-minded about the matter. I do not know how it would work in relation to Government and to reporting back. I am not so hung up on the process, which is something that we could look at, but should there be stand-alone alcohol education policy statements?
I am not quite sure what the purpose would be of alcohol education policy statements, what they would include and what they would be aimed at, hence my reservations in supporting their introduction. If more information was provided to help us understand what they set out to achieve, we would be open-minded about their introduction.
I can see a clear need, or a context, for policy statements in licensing. When implemented at the local level, they provide communities with the broad framework in which licensing decisions are made. Licensing is often about the individual application, so I can see that they would have a place in meeting the overall objective of the licensing system. However, I am not sure how they would work in an education context, given local authorities’ control over education policy. In addition, would they be national and local? I do not know. There is not enough information for me to come to a decision on that.
That is helpful. Does anyone else want to comment?
I am aware that the preferred approach in education is to see alcohol as a general life skills or personal, social issue. The old-style approach of getting in the doctor or the nurse for half an hour to speak to the kids is not what happens now—I think that the general approach is that teachers incorporate such education in the curriculum.
Many of the submissions have called for caution in being overoptimistic about the effect of education, partly for reasons to do with marketing. As has been said, young people get many messages about alcohol, and education is only a drop in quite a big ocean. It is important to understand that context when you look at the issue. Education can do useful things, but we should not overestimate its effect. In answer to your question, the preferred educationist approach is to focus on general life skills.
Again, it is about evaluating the effectiveness of the approach. Would we be moving resources from a more effective area? Obviously, we need much more information about the policy’s effectiveness, its cost and the balance that we might lose from other areas.
That is helpful. Are there no more comments on that?
They shook their heads; they said no. [Laughter.]
I know, but—
I have a question.
I was going to ask again the other part of my question, which was whether anyone has any concerns. If the concern is only in my head, it does not matter. Is there no concern about compartmentalising health education into alcohol, substance abuse, healthy lifestyles or whatever? That was the main part of my question, but thank you, panel, for not answering it, which is why I came back in. [Laughter.]
The question that I will raise is for the sake of completeness. We are dealing with lots of issues in the bill. What about the age discrimination in off-sales? Licensed premises may voluntarily apply an age limit higher than 18, and we have received mixed responses to that. Section 3 would remove that flexibility and voluntary code. Are people relaxed about that and content with it?
12:00
Convener—
You will have an opportunity to come in, Richard, but you must be patient. You are not a member of this committee any longer, so you will need to wait until we are finished.
I am trying to be patient.
Yes, and we are trying your patience.
I will have a crack at this one, convener. I realise that there is more to the bill than public health, but I really do not see the public health gain in removing the flexibility. I understand that the flexibility has not been used; I am not aware of any licensing board using it. However, there was pretty full discussion of the issue when it was aired in an earlier consultation process, probably about five or six years ago. The idea did not find favour and there was some pretty active lobbying against it. I still think that a split age limit is an interesting idea, with people being able to buy alcohol in a pub or restaurant at the age of 18 but not being able to do so in off-sales until they are 21. It has not found favour in public policy, but I do not see that there is any public health benefit in removing the option for licensing boards to have such flexibility if circumstances demand it.
Are there any other responses?
The apparent absence of any licensing board that exercises the power in question suggests that there is no evidence base for it being required. Therefore, our take on the issue is that we are not sure that there is an evidence base that would suggest that persons aged 18 to 21 are particularly involved in disorder in any area, and it would be quite difficult to measure.
Okay. Malcolm?
I think that there is only one of the 10 proposals in the bill that we have not covered, but it is the one that covers the most sections in the bill and concerns drinking banning orders. There are differing views on that proposal, so I am interested in hearing what the witnesses think of it.
We are looking to you, Mr Ross.
As an alcohol and drug partnership and a health and social care partnership, we welcome the drinking banning orders as an option. There would be two routes to obtaining the orders, and we can see circumstances in which they would be very useful. However, more work needs to be done on exactly how they would work and how effective they would be, because undoubtedly there would be problems attached to them.
They would provide a phased approach. There are elements of the Licensing (Scotland) Act 2005 that allow us to deal with violent offenders linked to licensed premises. The drinking banning orders would maybe allow a bit more of a stepped approach for those who do not reach that threshold and who we can try to influence.
In terms of linking the orders to an approved training course, we have talked already about the benefits of education and awareness for those who are ready and willing to undertake that. It would be good if such training was an option, because it could indeed start to impact on the public’s use of alcohol.
I suppose that you are the person who might be able to answer this question. Would the orders add anything to the options that are already available in criminal law?
Yes, I think that they would. It would be interesting to see exactly what the impact would be in terms of policing, because such an order would, in effect, be a civil order, a breach of which would be a criminal offence. Would that be easy enough to police reactively? Yes. Would there be an expectation of some proactive policing around that? I am not entirely sure how we could do that. However, I certainly think that the orders could fill a gap that exists just now and could be a useful option.
My clinical patch was in Tayside and I had some experience of the same goal being achieved, mostly by sheriffs in smaller towns. A sheriff in such-and-such a town would say to someone “I don’t want you to be drinking any more”, and the police would know that. My observation is that that seemed to work quite well in smaller communities.
We should also acknowledge the fact that we are no longer a pub-going nation. In 1994, 51 per cent of alcohol was sold in pubs; 20 years on, that figure is heading for less than a quarter. The big shift from pub drinking to drinking at home has been a big part of the challenges that we have faced, and if the thinking behind a drinking banning order is based on a model of risky people going into pubs, I have to say that that battle has already been lost among the very heaviest drinkers. Indeed, the survey from Glasgow and Edinburgh makes it clear that only 3 per cent of the alcohol that the heaviest drinkers who come to our clinics consume is drunk in pubs. They are almost exclusively home drinkers, and the drinking banning order needs to be thought about in the context of that reality and where we are at the moment.
That was helpful. I should say that we have until approximately 12.15 for this session. As members of the committee do not seem to have any more questions, I will now turn to Richard Simpson.
I will go through my points in order, convener.
First of all, I thank the witnesses for their input on the issue of advertising. We are limited in what we can do; after all, we cannot introduce the loi Evin here. Sarah Wollaston tried to do so in England, but she was blocked by the UK Government. There is certainly a problem in that respect, but I wonder whether the witnesses think that we should extend the provisions to include sporting events for adults. Under the bill as drafted, such adverts would not go on screens or on the thing that goes round the football pitch at under-18 matches. We are limited in our legal opportunities, but should we go further at this point in time?
I am all for that.
Me, too.
I know that we were talking about children earlier, but not only children but adults are very much exposed to alcohol. We work with the over-18s and we get many calls from people saying, “It’s everywhere.” How can we stop that kind of exposure? When you get off the subway in Glasgow, the first thing you see is a bollard advertising an alcoholic drink. We need to protect adults as much as children.
That is fairly clear, and the Government might need to consider the matter, particularly in the context of minimum unit pricing. After all, if the courts decide in favour of that policy—which they might well do, given that it is a public health issue in Scotland—the additional profits, particularly for the supermarkets, will amount to more than £100 million a year, some of which might well go into more advertising. I do not know whether the witnesses agree that, even if the bill goes through with its limited scope, the committee should consider recommending such a move in its report.
I think that that was a statement, Dr Simpson. Do you have any questions?
On container marking for off-sales, there seemed to be a suggestion in response to Richard Lyle’s questions that the scheme would be universal when in fact the provision in the bill is limited with regard to the licensees who would be affected and the period for which it would operate. Do the witnesses think it appropriate to keep that as a temporary measure?
In my experience, these schemes have been most effective and have worked best where there has been buy-in from communities and local premises. From that localised point of view, it is absolutely important that the measure is not universal. I suppose the question is about having a statutory power and whether things would still happen on a voluntary basis. I am not entirely clear whether a statutory power is required.
On notification of GPs, I have to say that I put in this provision even though in the consultation the BMA and GPs were against it; indeed, the courts were against it, because of the costs. In my 30 years as a GP, the only people who were referred to me were those with really serious offences while those for whom alcohol was only a small part of their offence were not referred.
Given that GPs now deal with 400 brief interventions per full-time equivalent post a year, the objective of the proposal was to provide focus. Notification would be voluntary; the offender would not need to give the GP’s name. The process would be to say, “Look, you got into trouble through alcohol, and we would like to inform your GP. Is it okay for your GP to be informed?” Is that not a reasonable approach? We are talking about relatively low-level offenders, when the police have said that alcohol is involved in the offence.
I cannot agree with that approach. Notification would impact on the doctor-patient relationship. A part of the proposal suggested that they would not need to consent, and part of the problem would be the ability to consent at that time. I feel that brief interventions are to be performed at the time rather than later when the GP might be informed.
We also have to accept that there would be an administrative burden and workload implications, when GPs currently are failing daily because of the workload that we undertake. We have to prioritise what is important to each patient and we have to go on the doctor-patient relationship that exists. I do not feel that the proposal would bring anything to my practice.
Okay. The courts estimate that 150,000 cases come before them at the moment. How many have you been informed of? How many of your patients have come to you and said that they have been to court and have had a conviction? I am talking about low-level offences, because high-level offenders are referred to a specialist. As a specialist addictions doctor, I had referrals from the courts, as did Peter Rice. Among that low level, how many patients have come to you and said that they have just been done for doing something and got into trouble because of alcohol?
I cannot give you a figure off the top of my head, but in my practice it is not an uncommon occurrence for patients to come either when they accept that they have some form of alcohol issue or when something like that has happened that has a real impact on their lifestyle.
Okay.
The last proposal that I want to raise is the one on caffeine. I accept that it is a very small area of sales, but it is a particular problem in the west of Scotland. What do you feel about the fact that in America the Food and Drug Administration has effectively persuaded producers to suspend production of premixed alcoholic drinks and that at least two, if not three, European countries have limited it? Do you think that they have acted in a way that is not evidence based or that is unreasonable? Have they done it for some other reason? Why would they do it if it was not for a good reason?
My response both today and in my written submission is about priorities. If there is lots of time and scope for legislation, the proposal in the bill might be something that we should look at.
The American situation is interesting. In the American evidence, the perceived trouble with caffeine was to do with sportsmen in universities—they are the people who were thought to be causing trouble because of caffeine—which is quite a different group from the one that was described in Scotland. It fitted with my notion that caffeinated alcohol was a kind of craze, if you like, among a sub-population.
It was interesting that the FDA was able to approach the issue by shutting the market down. It might have been able to do so because the products were only part of those companies’ portfolios, so they could live with it. It was an interesting development.
I have not followed the Danish story too closely, but I am aware of it.
In my view, the issues are whether it is a priority and, as I said earlier, that excessive focus on one type of drink might be detrimental to addressing wider problems. Some of our large producers and large retailers are quite happy to see those products in the spotlight, because it suits them quite well. That worries me.
Okay. Thank you very much.
I thank all the witnesses, who have been with us for quite a while now. All the evidence that you have given has been very helpful, and I hope that you will see it reflected in the committee’s final report.
12:14 Meeting continued in private until 13:15.