­National Assembly for Wales, Health Social Care and Sport Committee


Consultation into Public Health (Minimum Price for Alcohol) (Wales) Bill


Written evidence submitted on the behalf of the RCEM Wales (December 2017)


The Royal College of Emergency Medicine Wales (RCEM Wales) is the single authoritative body for Emergency Medicine in the Wales. RCEM Wales works to ensure high quality care by setting and monitoring standards of care, and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.



Views on: The general principles of the Public Health (Minimum Price for Alcohol) (Wales) Bill and the extent to which it will contribute to improving and protecting the health and well-being of the population of Wales, by providing for a minimum price for the sale and supply of alcohol in Wales and making it an offence for alcohol to be sold or supplied below that price.


1.    The Royal College of Emergency Medicine is extremely concerned by the harm attributable to alcohol in our society, particularly those relating to short and long-term health, crime and disorder. The brunt of the short-term health consequences of excess and irresponsible alcohol consumption falls on the ambulance service and the UK’s already hard-pressed Emergency Departments (EDs).[1] It is with this in mind that the RCEM Wales supports any initiative to improve the health and well-being of Wales’ population – including the Minimum Price for Alcohol Bill.


2.    The short and long-term negative effects of alcohol on a person’s health is undeniable. Alcohol abuse can affect your body, lifestyle, personal relationships and mental health. Short-term harms consist of deaths and illness from accidents and injuries, drownings, alcohol poisoning and self-harm related to alcohol. It is also associated with an increased risk of high blood pressure, liver diseases (such as cirrhosis), stroke, oropharyngeal cancer, esophageal cancer, pancreatitis, depression, dementia and infertility.[2]


3.    The Welsh Government’s Annual Statement of Progress for Liver Disease shows that in 2015, 807 people died from liver disease, an increase of 131 deaths (19.4%) over the past five years. Of these, alcohol-related liver disease accounts for over a third of liver disease deaths.[3]


4.    Although the report also shows a fall in alcohol-related liver disease deaths, from 504 in 2012 to 463 in 2015[4], people in Wales are statistically more likely to binge drink than anywhere else in Britain. An Office for National Statistics (ONS) survey found that almost one in seven adults (14%) in Wales had drunk 14 units or more in a single day - higher than England (8%) and Scotland (13%).[5] To put this in perspective, the NHS recommends that “to keep health risks from alcohol to a low level, men and women are advised not to drink more than 14 units a week on a regular basis”.[6] Drinking the weekly recommended amount in the space of a day increases the likelihood of harm.  


5.    The impact of alcohol on health also creates a significant pressure on our health systems. In Wales, it is estimated that every week our hospitals handle as many as 1,000 admissions related to alcohol, contributing to stresses on services already working at maximum capacity.[7] A Public Health Wales report revealed that in 2015-16, there were around 54,000 alcohol-attributable hospital admissions in Wales[8] - just short of 150 per day. A significant proportion of these patients will have entered into the service via the front door, the Emergency Department.


6.    Estimates vary, but a significant proportion of Emergency Department attendances are alcohol related, presenting 24 hours a day. In England, it has been estimated that 70% of incidents at the weekend are alcohol-related.[9] The RCEM Wales believe that we can reasonably make similar connections to Welsh Emergency Departments located in densely populated areas. These cases hamper the ability of our emergency care systems to look after other patients.


7.    ED staff are confronted daily with the health impacts of alcohol use, including: serious accidents (some resulting in death and permanent disability, particularly road traffic collisions), assaults, domestic abuse, collapse and self-harm. Furthermore, all Emergency Departments admit, on a daily basis, patients suffering from the longer-term health effects of sustained alcohol misuse, for example acute withdrawal fits secondary to alcohol dependence, liver failure and Wernicke’s Encephalopathy - a neuropsychiatric disorder.[10]


8.    Many of our Members have reported that it is common practice to attend to acutely intoxicated patients throughout every night of the week, and what was previously a weekend problem, confined mostly between the hours of 2200 and 0200, is now a 24-hour issue.[11] Yet, many alcohol-related attendances at EDs are potentially avoidable.


9.    Furthermore, a survey undertaken by the Alcohol Health Alliance UK (AHA) revealed that most Emergency Department and ambulance staff feel as though they are at risk of harm at work – whether it be risk of assault, threatened or verbally abused by drunken members of the public.[12] Figures from Wales, obtained via a Freedom of Information request, show that there were 18,000 physical assaults against NHS hospital staff in a five-year period from 2011 to 2016 (or 360 reported cases per year on average).[13] No-one should be made to feel unsafe at work. The well-being of our emergency services staff is vital, and the College believes that the implementation of minimum pricing might help to curb these issues.


10.  There is a growing body of evidence and research that shows a link between raising prices of alcohol and reduced consumption, leading to improved well-being. Researchers from the University of Sheffield, for example, have estimated that hundreds of deaths could be avoided every year with a minimum price for alcohol units. The recent study evaluated the potential impact of two alcohol control policies that were under consideration in England - banning below cost selling of alcohol and minimum unit pricing. It concluded: “a minimum unit price, if set at levels between 40p and 50p per unit, is estimated to have an approximately 40-50 times greater effect” and would save lives and cut hospital admissions.[14]


11.  Another study on the effects of unit pricing for alcohol, found that a minimum unit price of 45p led to an immediate reduction in consumption of 1.6%. It showed that moderate drinkers were least affected in terms of consumption and spending but concluded: “the greatest behavioural changes occurred in harmful drinkers with a reduction in consumption of -3.7% or 138.2 units per drinker per year and a decrease in spending, especially in the lowest income quintile”.[15] Therefore, the minimum unit price seemed to safeguard the most vulnerable in society against dangerous alcohol consumption.


12.  The Scottish Government also predicts that a minimum unit price of 50 pence would cut alcohol-related deaths by 392 (from 1,265 to c.873) over the first five years of the policy.[16] In Scotland, a date of May 2018 has been set for the minimum unit pricing for alcohol to come into force.


13.  Numerous other research projects across the globe have evidenced the benefits of raising prices of alcohol in order to reduce consumption and harm, including a paper prepared for the European Commission and a study by the Society for the Study of Addiction. The latter concluded that raising the minimum price of the cheapest beverages is effective in influencing heavy drinkers and reducing rates of harm. It also highlighted that this method of reducing harm from drinking has been under-used.[17]


14.  The Welsh Government should not remain behind the curb on such an important initiative that might help to save lives and cut hospital admissions. The RCEM Wales fully supports the Minimum Price for Alcohol (Wales) Bill. The evidence suggests that it has the potential to alleviate the current burden on our services that accompanies substance abuse and to help to improve the health and well-being of Wales’ population.


View on whether there are any unintended consequences arising from the Bill.


15.  The argument against minimum price for alcohol in terms of health is twofold:


a.    Other alcohol-related problems, for example the ‘drinking culture’, may remain despite the Bill. A significant number of adults continue to binge drink despite price increases. Therefore, setting a minimum price may not meaningfully reduce the quantity of consumption or improve the health of those drinking an excessive amount.

b.    A higher minimum price could encourage people to use to illicit ‘home brews’ as a replacement. This can be dangerous as it leaves people exposed to alcohol of an unknown concentration.


16.  The College also considers that tackling alcohol marketing might be instrumental in the Bill’s success and in helping Wales’ population to live happier and healthier lives. The Alcohol Health Alliance UK has shown that awareness of the harms attributable to alcohol is very low. The Alliance’s research found that 82% of people are not aware of national alcohol guidelines and only 1 in 10 people are aware of the link between alcohol and cancer.[18]


17.  Researchers that have studied the labelling of cigarette boxes have speculated that similar labelling of alcohol products has the potential to increase awareness of the harm associated with drinking - as was the case with cigarette labelling.[19] Although unproven, labelling might better educate some and prevent the downward spiral into alcohol abuse and dependency. 


18.  However, the unintended consequences of the Bill are only hypothetical. The RCEM Wales strongly urge the Welsh Government to support the Minimum Price for Alcohol (Wales) Bill and the consequential possibility of improving the health and well-being of the population of Wales.


Views on: the financial implications of the Bill.


19.  A study undertaken by Astrid Ledgaard Holm on the cost-effectiveness of changes in alcohol taxation in Denmark, concluded: “increasing the current level of alcohol taxation can be a cost-saving way to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse.”[20]


20.  The Society for the Study of Addiction highlighted that the cost of restricting physical availability of alcohol is cheap relative to the costs of health consequences related to drinking.[21]


21.  Perhaps then the financial burden that alcohol misuse places upon the NHS can be partially mitigated by the introduction of the Bill, when considering long-term possibilities.


22.  Hospital admissions due to alcohol abuse costs the Welsh NHS at least £109 million every year, as reported by Public Health Wales.[22] As discussed above, researchers predict that minimum pricing has the potential to cut hospital admissions considerably. Therefore, it is reasonable to assume that the £109 million might be reduced if we are able to improve the health and well-being of Wales’ population over a sustained length of time.


23.  Spending on gastrointestinal problems (which include alcohol-related liver disease) has increased from £339.3 million in 2014-15 to £362.6 million in 2015-16. Spending per head of population has increased from just under £110 to £117 over the same timeframe.[23] If incidents of alcohol-related liver disease can be lessened by reducing cases of excessive alcohol consumption, then the Bill has the potential to cost-save for the NHS, in time. Similarly, perhaps in the long-term the Bill might help to save time, work and money with regards to Emergency Departments and Ambulance services, which are confronted daily with the health impacts of alcohol use.


24.  Therefore, if the Bill can help to improve the health and well-being of the population in Wales, we can hope that some of the financial consequences associated with alcohol related issues may be reduced. The College consequently recommends that to achieve the Welsh Government’s stated objective, option three – introduce a minimum price for which alcohol can be sold or supplied in Wales – as outlined in the Explanatory Memorandum, is taken into further consideration.

[1] RCEM, Alcohol-related harm position statement (2015)

[2] NHS Choices, The risks of drinking too much

[3] Welsh Government, Annual Statement of Progress for Liver Disease (2017)

[4] Ibid.

[5] ONS, Adult drinking habits in Great Britain: 2005 to 2016 (2016)

[6] NHS Choices, Alcohol Units

[7] NHS Wales, Alcohol and health in Wales(2014)

[8] Public Health Wales, Piecing the puzzle: The annual profile for substance misuse (2016)

[9] K. Parkinson et al., Prevalence of alcohol related attendance at an inner city emergency department (2015)

[10] RCEM, Alcohol-related harm position statement (2015)

[11] Ibid.

[12] AHA, Alcohol’s impact on emergency services (2015)

[13] BBC Wales, 18,000 physical attacks on hospital staff in Wales(2016)

[14] A. Brennan, Potential benefits of minimum unit pricing for alcohol(2014)

[15] J. Holmes et al., Effects of minimum unit pricing for alcohol on different income and socioeconomic groups (2014)

[16] Scottish Government, Minimum unit pricing(2017)

[17] Society for the Study of Addiction, Alcohol: No Ordinary Commodity(2010) and Lila Rabinovich et al., The affordability of alcoholic beverages in the European Union (2009)

[18] AHA, Right to know: are alcohol labels giving consumers the information they need? (2017)

[19] G. Agostinelli et al., Alcohol counter-advertising and the media. A review of recent research (2002) and C. Wilkinson et al., Warnings on alcohol containers and advertisements: international experience and evidence on effects(2009)

[20] Astrid Ledgaard Holm et al., Cost-effectiveness of changes in alcohol taxation in Denmark: a modelling study (2014)

[21] Society for the Study of Addiction, Alcohol: No Ordinary Commodity(2010)

[22] NHS Wales, Alcohol and health in Wales(2014)

[23] Welsh Government, Annual Statement of Progress for Liver Disease (2017)