JSNA - Alcohol
- Key issues and gaps
- Who is at risk and why
- The level of need in the population
- Current services in relation to need
- Service users and carers opinion
- Expert opinion and evidence base
- Projected service use in 3-5 years and 5-10 years
- Unmet needs and service gaps
- Recommendations for consideration by commissioners
- Recommendations for further needs assessments
- Annual Public Health Reports 2013
- Key contact
- Print-friendly version of this section (PDF, 219KB)
In Haringey, as in the rest of England, alcohol-related hospital admission rates are rising rapidly (See footnote 1). Since 2002 Haringey rates have almost tripled (Kuczowska et al, 2013). Men in Haringey have the highest death rate from alcohol-specific causes in London per 100,000 population and the second highest mortality rate for chronic liver disease (NWPHO, 2012).
Alcohol misuse is associated with a number of health-related problems including: hypertension, cardiovascular disease, cancers, liver disease, mental and behavioural disorders, alcohol poisoning, accidental injuries, road traffic accidents, violence and premature death. Alcohol has a significant social impact including alcohol-related crime, anti-social behaviour such as street drinking, domestic violence, teenage pregnancy, loss of workplace productivity and homelessness (Department of Health, 2007). Parental drinking is also a factor in a number of cases focused on the protection of children.
The Department of Health (DH) has estimated that the annual cost to the National Health Service (NHS) for alcohol-related hospital admissions, Accident & Emergency (A & E) attendances and primary care was around £2.7 billion in England in 2006/07 (Alcohol Concern, 2011).
Whilst national trends in alcohol consumption suggest an overall decrease in consumption since 2005 (ONS, 2013a), levels of alcohol use in the UK are still amongst the highest in Western Europe (WHO, 2012a). It is estimated that liver disease could overtake stroke and coronary heart disease as a cause of death within the next 10-20 years (Alcohol Concern, 2011). Moreover, the harms associated with alcohol are more pronounced in deprived areas. Department of Health analysis indicates that the alcohol-related death rate is higher in areas of high deprivation as are rates of alcohol-related admissions and crime (DH, 2007).
Many factors influence alcohol consumption and harm, chief among them being the increase in affordability (Academy of Medical Sciences, 2004) and availability (Bryden et al 2011) along with expert and targeted marketing, especially to the young, who are more susceptible to advertising (Smith & Foxcroft, 2009, Collins, 2007). The most recent national alcohol strategy (HM Government:2010) pledged to tackle some of the pricing and marketing factors that influence consumption and harm by: introducing a minimum price per unit of alcohol (45p), imposing a ban on multi-buy promotions of alcohol in off-licenses and supermarkets, giving stronger powers to local authorities to control the density of licensed premises (including adding health as a licensing objective) and tighter control of alcohol advertising, particularly those which are covertly aimed at under 18s. Whilst plans for minimum unit price have been put on hold, and the proposed ban of multi-buy promotions has also been dropped as has the introduction of a public health based licensing objective, the transfer of public health into local authorities as part of the Health and Social Care Act (2012) does bring with it the opportunity for Public Health to influence local alcohol licensing policy as one of the named Responsible Authorities’ under the Police Reform and Social Responsibility Act (2011)
Tackling alcohol misuse is a priority for Public Health England at a national level and at a regional level through the work of the Safe Social London Partnership. Haringey’s 2013 Annual Public Health Report Is Haringey over the limit report (PDF, 292KB) focused on alcohol and demonstrates local commitment to tackle alcohol-related harm. The work is supported by a yearly partnership alcohol action plan.
This chapter focuses on the health harms associated with alcohol misuse amongst adults. See related topics: Crime, teenage pregnancy, employment, housing, domestic violence, safeguarding adults and safeguarding children.
- Haringey’s alcohol related hospital admissions are higher than the London and England averages (NWPHO, 2013).This places a significant burden on health services in Haringey.
- Men and people living in more deprived areas of Haringey have higher standardised rates of alcohol-related hospital admissions (Kuczowska et al, 2013).
- Alcohol specific mortality and mortality from chronic liver disease for men is significantly higher than the national averages (NWPHO, 2012).
- There is a visible street drinking population that consists of ‘traditional’ street drinkers along with individuals from Eastern European countries.
- There has been a considerable rise (62%) in the number of licensed premises since 2005 with a greater concentration in the east of the borough.
- Density of licensed premises and hours and days of sale are known to influence consumption and harm.
- Estimates for alcohol related crime rates in Haringey are higher than London and national averages (NWPHO, 2012).
Men in England are more likely to drink heavily than women. 38% of men and 16% of women consume more alcohol than is recommended (Department of Health (DH), 2005). Whilst those from higher income households are more likely to drink at higher levels than those from lower income households, it is the most deprived fifth of the UK population who suffer two to three times greater loss of life attributable to alcohol; three to five times higher death rates due to alcohol specific causes and two to five times more admissions to hospital because of alcohol than wealthy areas (DH, 2009). This is a pattern that is recognisable in Haringey with the majority of alcohol related hospital admissions coming from the more deprived east of the borough.
The most common cause of partially attributable (See footnote 1) alcohol admissions is high blood pressure; which is most prevalent in white British, African Caribbean and ‘any other white’ men - however, we know that generally hypertension is more prevalent in the African Caribbean community which will inflate these figures. Irish men and ‘any other ethnic group’ have the highest rates of admissions wholly attributable to alcohol; it is thought that ‘any other ethnic group’ category includes people from Poland and Eastern Europe. It is also known that the lowest income groups are more likely to suffer negative effects of ‘risky’ health behaviours than people in higher income groups (DH, 2009). Research also suggests that those most susceptible to developing problematic substance misuse problems are from ‘vulnerable groups’ such as children in care, persistent absentees or excludees from school, young offenders, the homeless and children affected by parental substance misuse. (DfES,2005; The NHS Information Centre, 2011). In particular in Haringey (Kuczowska et al, 2013):
- Males are more at risk than females
- People from deprived areas have higher rates (25%) of alcohol related admissions than the Haringey average
- The percentage of alcohol-specific hospital admissions is highest among middle-aged people 40-49 years (fewer than one in three alcohol-specific admissions are in people aged 60 and over)
- Men from the Irish community seem particularly vulnerable to alcohol-related problems
- Mental and behavioural disorders due to the use of alcohol are the most common cause of alcohol-specific admissions whilst hypertensive diseases (39%), mental and behavioural disorders due to the use of alcohol (20%) and cardiac arrhythmias (13%) make up the majority (72%) of alcohol-related hospital admissions.
At a national level the DH use the terms ‘increasing risk’ and ‘higher risk’ to refer to individuals who are drinking at levels that increase risk. DH use the terms ‘binge drinking’ and ‘dependent drinking’ to refer to two sub-groups of people who potentially fall into the categories of lower, increasing and higher risk drinking. Figures 1 and 2 below describe the UK population consumption patterns and the definitions of alcohol categories.
Figure 1: UK alcohol consumption patterns
Figure 2: Explanation of Department of Health alcohol consumption categories
|Lower Risk (following recommended daily drinking guidelines)||No more than 3-4 units per day on a regular basis||No more than 2-3 units per day on a regular basis|
|Increasing Risk||4 or more units per day on a regular basis||3 or more units per day on a regular basis|
|Higher Risk||8 or more units per day on a regular basis or 50+ units per week||6 or more units per day on a regular basis or 35+ units per week|
Source: Department of Health presentation to Haringey GP’s, Don Lavoie, November, 2011
For more detailed information about the impact of alcohol on health and who is at risk locally, see Haringey profile: Alcohol related hospital admissions, 2013.
North West Public Health Observatory (NWPHO) synthetic estimates suggest that 20.1% of the local population are drinking at increasing risk and 6.4% are drinking at high risk levels in Haringey (NWPHO, 2012). However, only a small percentage of this population will go onto become dependent drinkers and require specialist alcohol treatment.
Alcohol related hospital admission rates remain above London and England averages. The latest published rate for Haringey is 2349 admissions per 100 000 population in 2012/13 (NWPHO, 2013).
Nearly 600 dependent drinkers were accessing specialist alcohol treatment services in 2012/13 (see footnote 2). National and local trends of alcohol-related hospital admissions suggest the upward trend in alcohol-related admissions are likely to continue, this means the need is likely to increase, at least in the short to medium term.
The current service provision is comprehensive and consists of:
- Identification and Brief Advice (IBA) for alcohol in primary care and at the North Middlesex Hospital emergency department, gastroenterology and outpatient wards, along with sexual health and criminal justice settings
- A community alcohol treatment service Haringey Advisory Group on Alcohol (HAGA)
- Specialist alcohol workers available in GP settings offering Extended Brief Advice (EBA)
- Street outreach programmes to traditional ‘street drinkers’, and to individuals from Poland and Eastern European communities
- Social reintegration services including access to supported housing and education, training and employment support
- A specialist domestic violence worker
- Abstinence based day programme
- Services for children and families affected by substance misuse
- Support for families and carers
- Inclusion of alcohol in the NHS Health Checks Programme
Identification and Brief Advice (IBA) form a key plank of our prevention and early identification strategy and is in place in primary care, A & E, sexual health and criminal justice settings, along with other front-line services. Alcohol screening also forms part of the NHS Health Checks Programme and increasingly the use of on-line alcohol screening through the don’t bottle it up website (external link) is being encouraged. Work is also in train to seek agreement for our local hospital to share non confidential data on alcohol-related violence with the Community Safety Partnership and public health in order to better understand extent of alcohol related-violence, target resources, and inform the alcohol licensing process.
However, early identification and treatment are only part of the solution to tackling alcohol misuse. Making alcohol less affordable is recognised as one of most effective ways of reducing alcohol-related harm (NICE, 2010). Extensive evidence exists that raising alcohol prices reduces consumption on a societal level (Rabinovich, 2009, HM Government, 2012) however the Coalition Government does not currently have plans to set a minimum price on alcohol.
Alcohol is one of the priority areas of the governments Public Health Responsibility Deal (DH, 2011). This deal aims to encourage businesses to support public health initiatives. International evidence stresses the importance of making alcohol less available by controlling the number of outlets selling alcohol and having shorter opening hours (NICE, 2010), however as noted earlier the government have not included a public health licensing objective which in practice makes it challenging for public health to influence the licensing process.
The local alcohol service HAGA has a well established user forum and a user run physical exercise group, ‘Wheels for Recovery’. Family and Friends of alcohol users have their own service ‘Chrysalis’ and a newsletter.
In addition to an annual service user survey, proposed changes to drug and alcohol treatment service provision from January 2014 was put out to consultation, results of which are found in the consultation report.
The Recovery Champions Group is also another means by which service users can influence the substance misuse treatment system.
The first Alcohol Harm Reduction Strategy for England was published in 2004. An update on the progress made through the national strategy was published in 2007 (Department of Health, 2007) and the latest strategy was published in March 2012 (HM Government, 2012).
The evidence base around interventions to prevent and respond to alcohol misuse has grown substantially since 2007 and expanded rapidly during 2010 with the publication of three sets of guidance on alcohol by the National Institute of Clinical Excellence (NICE, 2010). This guidance not only emphasised the importance of interventions at a national level but also promoted the use of identification and brief advice (IBA) around alcohol by a wide range of practitioners (NICE, 2010). The evidence base on effectiveness of IBA is well documented and includes a Cochrane Review on the subject (Kaner et al, 2007). All of Haringey’s alcohol provision is informed by this guidance and evidence base.
Guidance has been published for commissioners of alcohol services to improve services provided (Department of Health, 2009). Public Health England has recently taken over responsibility for alcohol and we await information from them on the operating systems that will be instigated.
National and local trends of alcohol-related hospital admissions suggest the upward trend in alcohol-related admissions will continue. Increased emphasis on alcohol misuse identification and improved patient pathways in short term may increase demand for treatment. However, in the longer term the earlier identification of alcohol problems through IBA should ultimately mean a reduction in alcohol harm, hospital admissions and specialist treatment. This coupled with population level policies such as minimum unit price and reduction in availability should reduce population level consumption and harm.
The main gaps/unmet needs are:
- There is a need to further extend the coverage of IBA to community settings in line with guidance(NICE, 2010) and promote online screening through the don’t bottle it up website (external link)
- There is a need to increase our more targeted work with communities who appear to be particularly vulnerable to developing alcohol problems e.g. the Irish, Polish and homeless residents
- Due to the evidence of increasing numbers of older people consuming alcohol at higher risk levels, there is a need to develop a tailored response to address this
- The Alcohol Liaison Service (ALS) at the North Middlesex Hospital will be enhanced by the introduction of a nurse prescriber who will be better able to support detoxification
- There is work planned for increased joint work with the Gastroenterology department
- There is a gap in service provision for the alcohol hospital link worker post at the Whittington hospital
- The Accident & Emergency department data sharing protocol on alcohol and violent incidents needs to be established to ensure that timely data is delivered to partners
- New drugs i.e. Selincro (or Nalmefene hydrochloride) have come onto the market to reduce alcohol cravings for those drinking at higher risk levels but who are not dependent. These drugs are yet to be piloted locally
- Women looking to become pregnant/or who are pregnant are not receiving clear information regarding safe limits of alcohol use
- Develop a voluntary ‘reducing the strength’ campaign as part of the ‘Responsible Retailers’ scheme currently in development
- Increase early identification of alcohol problems by commissioning a training programme for staff who may be in contact with people with alcohol issues e.g. safeguarding staff, domestic violence staff
- Support implementation of the CQUIN (Commissioning for Quality and Innovation) across North Central London, Accident & Emergency departments and urgent care centres
- Extend the Alcohol Link Worker role to include Whittington Hospital
- Ensure individuals involved within the criminal justice system are screened for alcohol and develop more coherent treatment pathways with the police and probation services
- To maximise the impact of work around health inequalities; combine alcohol interventions with other public health work streams e.g smoking cessation and ‘make every contact count’
- Ensure that alcohol continues to be an integral part of the NHS Health Checks Programme
- Continue to encourage service user and carer involvement by working with service users to increase social capital to enable recovery
- Embed provision of Extended Brief Advice in alcohol hubs in GP surgeries.
- Work with service providers to ensure that local alcohol treatment provision meets local population needs – for example targeted work with the Irish and Polish communities
- Pilot with GPs and the alcohol service use of Selincro (or Nalmefene hydrochloride)
- Commission an EHO post to work with public health on the responsible sale of alcohol
- Commission an elders social isolation project which encompasses alcohol
- Design with midwives a leaflet regarding alcohol and pregnancy and roll out training to midwives
- Work with the Irish community to establish their needs and the types of interventions that will help reduce harmful levels of alcohol consumption
- Establish the needs of individuals from Eastern European countries. We know that this group is over represented in the numbers of local street drinkers
- The impact of IBA training and the levels of resulting referrals in the community needs to be monitored
- Review effectiveness of Selincro (or Nalmefene hydrochloride)
- Sarah Hart Senior Public Health Commissioner
Public Health Directorate
- Email: sarah email@example.com
- Tel: 020 8489 1480
- Academy of Medical Sciences (2004) Calling time: the nations drinking as a major health issue (external link, PDF 185KB). Academy of Medical Sciences (Last accessed 22 February 2012)
- Alcohol Concern (2011) New Media, New Problem. London: Alcohol Concern (Last accessed 22 February 2012)
- Alcohol Concern (2011) Making Alcohol a Health Priority. London: Alcohol Concern (Last accessed 22 February 2012)
- Bryden, A., Bayard, R., McKee, M., & Petticrew. M. (2011) A systematic review of the influence on alcohol use of community level availability and marketing of alcohol Health and Place 18 pp.349-357
- Collins, R.L., Ellickson, P.L., McCaffrey, D. (2007) Early Adolescent exposure to alcohol advertising and its relationship to underage drinking. Journal of Adolescent Health, 40 (6) pp. 527- 534.
- Department of Health (2005) Alcohol Needs Assessment Research Project (ANARP): The 2004 national alcohol needs assessment for England. London: DH
- Department of Health (2007) Safe. Sensible. Social. The next steps in the National Alcohol Strategy .London: DH
- Department of Health (2011) The Public Health responsibility deal (external link). London: DH (Last accessed 22 February 2012)
- Department of Health (2009) Signs for Improvement: Commissioning Services to reduce alcohol related harm (external link, PDF 763KB). London: DH (Last accessed 22 February 2012)
- Haringey Council (2012) Haringey Health and Well Being Strategy 2012-2015. Haringey Council
- Health and Social Care Act (2012) (external link)
- HM Government (2012) The Government's Alcohol Strategy (external link). London: STO
- Kaner E et al (2007) Brief Interventions for excessive drinking in primary health care settings. Cochrane Database of systematic reviews, Issue 2.
- Kuczkowska, K. Rousseau, C., Lyons, G. & Cronberg, A. (2013) Haringey profile: Alcohol related hospital admissions, 2013. Islington Public Health Intelligence Team [Online] Available from: (Accessed 1st August 2013)
- London Health Improvement Board (2011) Taking Action on Alcohol in London: the case for action.
- Murali V & Oyebode F (2004) Poverty, Social Inequality and mental health (external link). Advances in psychiatric treatment, Vol 10, pg 216-224. (Last accessed 22 February 2012)
- NICE (2010) Alcohol Use Disorders: Reducing Harmful Drinking (external link). NICE public health guidance 24. London: NICE (Last accessed 22 February 2012)
- NICE (2010) Alcohol use disorder: diagnosis, assessment and management of harmful drinking and alcohol dependence (external link). NICE clinical guideline 115. London: NICE (Last accessed 22 February 2012)
- NICE (2010) Alcohol use disorders – physical complications (external link). NICE clinical guideline 100. London: NICE (Last accessed 22 February 2012)
- NWPHO (2012) Local alcohol profiles for England (external link). Liverpool: NWPHO (Last accessed 29 October 2012)
- ONS (2013a) Alcohol-related deaths in the United Kingdom 2011 (external link) Newport: ONS.
- Police Reform and Social Responsibility Act (2011) London: The Stationary Office
- Rabinovich L et al (2009) The affordability of alcohol beverages in the European Union: Understanding the link between alcohol affordability, consumption and harms (external link). Cambridge: Rand Corporation.
- World Health Organisation (2012a) Alcohol in the European Union: Consumption, harm and policy approaches. WHO: Regional Office for Europe.
- Smith, L. & Foxcroft, D. (2009b) Drinking in the UK: An exploration of trend (external link). Joseph Rowntree Foundation, Oxford Brookes University.
1. Alcohol related admissions refer to both, conditions wholly and partially related to alcohol. Wholly alcohol attributable, or ‘alcohol specific’, conditions include diagnoses such as mental and behavioural disorders due to use of alcohol, alcoholic cardiomyopathy, alcoholic gastritis, alcoholic liver disease, alcohol induced chronic pancreatitis and ethanol or methanol poisoning. Partially alcohol related conditions are attributed to alcohol consumption but not fully: they include, for example, hypertensive diseases, cardiac arrhythmias, acute and chronic pancreatitis, heart failure, fall injuries and drowning.
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