1
Select Committee on the Licensing Act 2003
Oral evidence: The Licensing Act 2003
Tuesday 25 October 2016
10.45 am
Members present: Baroness McIntosh of Pickering (The Chairman); Lord Blair of Boughton; Lord Brooke of Alverthorpe; Lord Davies of Stamford; Baroness Eaton; Lord Foster of Bath; Baroness Goudie; Baroness Grender; Baroness Henig; Lord Mancroft; Lord Smith of Hindhead; Baroness Watkins of Tavistock.
Evidence Session No. 10 Heard in Public Questions 102 - 112
Witnesses
Professor Sir Ian Gilmore, Chair, Alcohol Health Alliance; Dr Adrian Boyle, Chair of the Quality Emergency Care Committee, Royal College of Emergency Medicine; Dr Jeanelle de Gruchy, Vice-President, Association of Directors of Public Health; and Professor Colin Drummond, Chair of the Faculty of Addictions Psychiatry, Royal College of Psychiatrists.
Professor Sir Ian Gilmore, Dr Adrian Boyle, Dr Jeanelle de Gruchy and Professor Colin Drummond.
Q102 The Chairman: Good morning. I bid you a very warm welcome. Thank you very much indeed for contributing to our inquiry and coming to give evidence to us today.
There is some housekeeping before we start. So that you are aware, the session is open to the public, it is broadcast live and is subsequently accessible via the parliamentary website, audio only. A verbatim transcript will be made of the evidence and placed on the parliamentary website. A few days after this session you will be sent a copy of the transcript, and we ask you to check it for accuracy. It will be extremely helpful if you could return any corrections you wish to make as quickly as possible. If after the session you wish to amplify, clarify or add to any points you have made, perhaps you could submit supplementary evidence to us. That would be extremely helpful.
We should inform you of our declarations. We will go round the table. Today, it might be relevant to say that I am a doctor’s daughter, doctor’s niece and doctor’s sister, but none of the doctors is practising now. I have a small shareholding in Diageo. I am honorary president of Pickering Conservative Club and a member of the all-party groups on beer, wines and spirits and possibly whisky as well.
Lord Smith of Hindhead: I am chief executive officer of the Association of Conservative Clubs, of which there are about 900 throughout the UK. I am the chairman of CORCA, the Committee of Registered Club Associations. I am on the executive of the APPG on beer, and I am on the executive of the clubs APPG. I am the trustee of more than 200 clubs, and I am an honorary member of the Carlton Club and many other clubs.
Baroness Eaton: I have no relevant interest to declare.
Lord Blair of Boughton: I thought I had no relevant interest to declare until the Chairman moved into her genealogical tree, in which case I have to admit that I have a couple of doctors lurking about somewhere, maybe a grandfather somewhere. Until that I did not think I had any interests.
Lord Davies of Stamford: I have no interests that I believe to be relevant to this inquiry.
Baroness Grender: Recently, I was the holder of a temporary event notice for a school summer fair, which I have to declare as an interest.
Lord Foster of Bath: I have none.
Lord Mancroft: I have no interest beyond the fact that my family historically has been keen consumers of alcohol; consequently, I have always had an interest in alcohol-related health conditions.
Baroness Watkins of Tavistock: I did not think I had any relevant interests, but I am a member of the APPG on global health. I am a mental health nurse and a visiting professor at King’s, and I am married to a surgeon.
Lord Brooke of Alverthorpe: I am vice-chair of the All-Party Parliamentary Group on Alcohol Harm. I am patron of the British Liver Trust and the Kenward Trust, which is a rehab centre in Kent for recovering alcohol and drug addicts. I am also a member of the all-party parliamentary group on obesity, which in my opinion has a link to this.
Baroness Henig: I am a committee member of two all-party parliamentary groups—wine and spirits, and beer. I am non‑executive chair of a company that, among other things, employs door supervisors, and I am the president of a security institute.
The Chairman: I just realised that I have a registrable interest as I advise the board of the Dispensing Doctors’ Association whose headquarters used to be in the constituency I represented.
The purpose of today is to look behind the purposes of the Licensing Act 2003, to see how it is currently functioning and how policy has developed, whereby we do not prohibit alcohol in our society to persons over 18. We recognise that alcohol tends to undermine health.
The question I would like to put to you is how we can reconcile the freedom to drink alcohol with the promotion of health and well-being, and whose responsibility that promotion should be.
Dr Jeanelle de Gruchy: I am here as a jobbing director of public health and as vice-president of the Association of Directors of Public Health. With public health directors and public health teams moving from the NHS into local authorities, it has been helpful for us to get a perspective on how local authorities shape places and the importance of places in how people live their lives—how their residents live their lives.
We are keen to shape healthier environments, which is key. Although people make individual choices, they make them within the environment available to them. The availability of alcohol has gone up hugely over the past while. Just in my borough, we now have more than 900 licensed premises, which is an increase of 41%, more than 250 premises, since 2005-06. Those premises include a lot of off-licences. In my borough, we have less night-time economy but more pervasive off-licences down high streets, where there are also hairdressers, schools and so on. That presence of alcohol in our culture has hugely increased over recent times, and it is reflected in high levels of consumption.
My answer to the question is that we as local authorities are very keen to shape a much healthier environment—I believe it is our responsibility—so that people can much more easily make choices not to overconsume alcohol.
Professor Colin Drummond: I am a professor of addiction psychiatry at King’s College London and an NHS consultant addiction psychiatrist, so I see first-hand the impact of alcohol on people with mental health problems and people with alcohol dependence. We did a study in south London a few years ago that looked at mental health in-patients; 50% of them drank excessively and 25% were alcohol dependent. That is six times the rate in the general population, so we are talking about a very vulnerable population who drink alcohol.
The issues I have are that, given the impact of alcohol on health generally, but particularly mental health, people who are alcohol dependent find it very difficult to make free choices about what they drink. By virtue of being alcohol dependent, their brain has adapted to the chemical effects of alcohol in such a way that they find it very hard to choose freely whether or not to drink. Any responsible society has to take account of that in making decisions about how freely available alcohol should be.
Professor Sir Ian Gilmore: I am a physician by background, not a public health doctor. After spending 30 years saving drowning people, I came late to walking upstream to see why they were falling in in the first place. I had better say that I am said to be conflicted. I was recently on the Chief Medical Officer’s guideline group on safe drinking limits and was accused of being conflicted because I had an interest in improving the health of the population and reducing alcohol health harm.
We all espouse the principles of freedom and that people should have the choice to do what they do, but in a lot of cases that freedom is illusory. By the time children reach the age of 18, they are totally saturated and primed, through advertising and sponsorship, that alcohol is the norm. At 11, most children can identify different brands of vodka by the shape of the bottle with the label obscured, so imprinting goes on from an early age.
Alcohol is a psychoactive drug with dependent properties, so it is not an entirely free choice in all people. Much of the harm is not to the individual but to others, particularly children, the unborn child, victims of crime and so on. Our own choice, although we often find it hard to recognise it, is distorted by factors such as where alcohol is placed in a store. If alcohol is at the front of the store rather than in the back aisle, we know that sales go up by between 20% and 40%. We know that special offers—any three bottles for £10—encourage us to buy more, so we are all susceptible to the alcogenic environment that Dr de Gruchy talked about.
To an extent, the responsibility has to be with individuals, but it also has to be with government, both local and central, to take account of public health and promote an environment that allows free choice as much as possible. That includes indirect things such as narrowing health inequalities, because we know that the poorest are the most vulnerable to harm; protecting children; and restructuring the NHS to make it easier to tackle alcohol-related harm. There are also direct things. We are very proud of the fact that this country is the world leader in reducing the harm from smoking, so we can do it. Most of that was achieved by direct government intervention, and the Government are rightly proud of that, but other public health issues could benefit from a more interventionist approach without restricting the freedom of the vast majority.
Dr Adrian Boyle: I am an emergency physician and a pure NHS clinician. I echo a lot of my colleagues’ comments. Too many people are drinking too much alcohol. We have had a slight improvement over the last 15 years, but the overall trend is that there is still a huge burden, and the opportunity cost of alcohol to our emergency departments is enormous; Professor Drummond has published work showing that about 70% of attendances at night are related to alcohol. The opportunity cost and avoidable cost this creates and the harm it creates to other people attending our overstretched hospitals is significant.
The Chairman: Professor Gilmore, you did not mention individual responsibility but you alluded to it through education. I remember seeing lectures about the inside of a lung if you smoke cigarettes. Is that what we should be looking at to educate people—showing them a liver that has been diseased—through schools, which is where most people pick up the information?
Professor Sir Ian Gilmore: I certainly meant to imply that there is an individual responsibility, and I think there is an obligation on society to make sure the facts are available to people. That includes proper labelling and health warnings on alcohol products. However, the evidence that behaviour change can be brought about solely by education, even of children, is not very strong. We should be doing it; it is people’s right to know, but I do not think we can sit back and say it is all a matter of sending people into schools to tell them of the harms. It is a multipronged approach, and education alone is probably the least effective intervention we have.
Q103 Lord Brooke of Alverthorpe: In Scotland, the promotion of public health is one of the licensing objectives, but in England, so far, Ministers have declined to add it to the four existing objectives that came in in 2003. Health professionals tend to support a fifth objective, of promotion of health and well-being. How would that objective work in practice in a regulatory regime such as licensing, which looks at the merits of individual premises?
Dr Jeanelle de Gruchy: Our members, who are directors of public health, feel that the fifth licensing objective is hugely important. This year, in a survey of our members on all policies, the licensing objective was in the top three. We think it is really important to be able to look at licensing applications with health and well-being as one of the objectives. The fact that we are responsible authorities is important and helpful, but if we are commenting on the objectives and there is not one on health and well-being, it limits our effectiveness.
Work is being done on how it would work in practice. There are various pilots. Public Health England is doing work on how you might do that. A more general issue is that licensing decisions are made on individual licences, but often the impact is as I said; you step back and say, “What is the impact on the community of giving 900 licences in one borough?” How it would work in practice is something that needs to be worked through, but it is important that we start to look at how we can do that, and having health as a fifth licensing objective will help us to move that forward.
Dr Adrian Boyle: My experience is based on attending licensing courts and seeing presentations from other public health specialties. Public health can have a useful effect in pulling together evidence. There are examples of good practice, particularly in Chorley in the north-west. There has been a lot of work where public health nurses collated information about applications from problem premises. That is useful, but it is extremely labour intensive and there are concerns about whether public health has the capacity to take this on at the moment.
Professor Sir Ian Gilmore: We know that there is a strong link between the density of alcohol outlets and the violence and harm in a community, and it makes sense to be able to look at the local community. If you take just one part on its own and another part on its own, you lose the overall picture. There have been attempts in things such as the cumulative impact programmes to address this, but the preliminary evidence from Scotland is supportive. They have made a difference by being able to take public health into account as a licensing objective.
Professor Colin Drummond: We need to look at the evidence base on licensing where it has been carried out in countries across the world. There is good evidence that increasing the hours when alcohol is available and the number and density of outlets all lead to increased health harm. One thing that has been missed in the current Licensing Act is that we have seen a doubling of the number of off-sales in the past 10 years. This is having a cumulative impact on the amount people are drinking, particularly as supermarkets and off-sales generally sell alcohol at much lower prices than on-trade, including in some cases selling alcohol below the cost of duty and VAT as a loss leader. In those circumstances, licensing should have a legitimate interest in reducing overall health harm by reducing the availability of alcohol.
Q104 Lord Mancroft: I have some difficulty in seeing a pub or licensed premises as a health centre. I cannot see that the licensing of any establishment will be a health objective. If we are to get this right, it is not about whether it is promoting public health and well-being, but whether it is negating public harm, which is slightly different. By limiting the number of licences, or their terms, you might reduce the harm, but I cannot see any way in which issuing a licence can ever promote health and well-being, much as a pub is a lovely thing. Is it the right way round?
Dr Jeanelle de Gruchy: You are right. It is about whether this will bring about more health harm. You got at it a little bit; the onus at the moment is on responsible authorities or evidence to show that there will be health harm rather than on the licensee to show that there will not be health harm. Therefore, at the moment the balance of the onus tends to be the other way round.
Baroness Eaton: You said you would like to see it as a fifth objective. How do you see it working in practice?
Dr Jeanelle de Gruchy: It will enable us to gather data to look at how we can argue the point that granting licences may impact negatively on the health of residents. There is quite a bit of ongoing work by Public Health England and various local authorities to look at how you would make those arguments.
Baroness Eaton: It is putting the cart before the horse.
Dr Jeanelle de Gruchy: The work is happening, so that is where we will be able to use the fifth objective to argue licensing cases. I do not quite see it as putting the cart before the horse; I see it as giving us an ability. At the moment, directors of public health as responsible authorities have to use the other objectives, and try to weave arguments on meeting the other objectives, whether it is crime, nuisance or harm to children, when actually what we are very concerned about is harm to health, yet we do not have that objective to argue the case.
Q105 Lord Davies of Stamford: Anybody listening to the evidence so far this morning would never guess that in our country alcohol consumption has been falling for a number of years, as has alcohol-related crime. You might think that the trends are relatively positive, albeit that the underlying problems remain, and are real. I am concerned about two aspects of the issue of adding public health to the criteria. First, it may be very difficult to argue in a particular case that just one would-be publican coming before the committee would have a material effect on public health. Secondly, it seems to be a very ineffective and inefficient way of addressing the issue Dr de Gruchy has been describing. You may have 900 licensed premises in Haringey, and you may think there are too many, but it would take you centuries to reduce that number simply by not allowing any more, hoping that natural wastage would reduce the number. It just would not be an efficient way of achieving what you yourself state to be your objective, so I am concerned about both the equity of what is being proposed and its effectiveness.
Professor Colin Drummond: Perhaps I could tackle the issue of falling alcohol consumption, because that is really important. It is the case that alcohol per capita consumption has been falling in the UK, both England and Scotland, for some years. However, that overall fall in per capita consumption on average conceals shifts in sub-populations. The falls have been mostly among young people under the age of 30, whereas middle‑aged people have been increasing the amount they drink. It is because people in their middle ages who are heavy drinkers are at greater risk of hospital admission that we have seen a 110% increase in alcohol-related hospital admissions in the past 10 years. Looking at the overall consumption level distracts one from the serious health problems that have built up through middle-aged people drinking more.
Baroness Grender: What do we learn from the young? Why have they changed, in your view?
Professor Colin Drummond: There are a few possible reasons. There is a possibility that young people are turning away from alcohol and drugs because they see how those affect their parents. The problem is that among the adult population, the baby boomer generation, we see no such change in that direction, and that is driving the health consequences.
Professor Sir Ian Gilmore: To comment on the point about consumption, it has been falling since 2008-09, but it is a very small fall against the background of a huge increase since the 1950s and 1960s. Within that fall, there are the important changes Professor Drummond alludes to. It is very difficult to have a level playing field because things are changing all the time, but the two key things that changed in 2008-09 were, first, the financial downturn and, secondly, the Government at the time imposing a 2% duty escalator above inflation on alcohol, so alcohol got more expensive in real terms in 2008, and that exactly mirrored the fall. It is directly alcohol-related deaths, not consumption, that began to fall in 2008 and mirrored price and affordability. Without wishing to widen the conversation into other levers, price is probably the most important single lever, with availability and marketing. Today, we have talked mainly about availability, but there are very good reasons, probably regulatory ones, why we have seen that fall since 2008.
The Chairman: We will come to pricing in a moment.
Dr Adrian Boyle: If we look at rates of violent injury, which are a good measure of alcohol-related harm, but with limitations, we have seen declines throughout the UK, but the declines in Scotland have been greater, albeit from a higher peak. If we are looking at the effectiveness of the Licensing Act, there is a suggestion that what has gone on elsewhere in the UK has been more effective than what has happened in England and Wales.
Lord Smith of Hindhead: I thought the statistics were that alcohol consumption has dropped since 2004, when there was not a financial crisis, and it is down by 17% since its height. It has come down quite a lot from that peak. To go back to the specific question about getting the health thing into licensing, it will apply only to those who are applying for a licence now, and the majority of licences being applied for now are for off-trade, not on-consumption, so they are for supermarkets and stores and would apply specifically only to those. Although you say that you have seen a big increase, overall there has been only a 1% increase in the number of premises licences. There has been a huge reduction in the number of pubs, so the on-trade is going back; it is the off-trade that is growing.
Dr Jeanelle de Gruchy: I totally agree with you. Certainly, in my borough the number of off-trade licences has increased hugely. The consumption pattern is that people are buying alcohol and consuming it at home to a large extent, and it is available at every corner store.
Lord Smith of Hindhead: You are really saying that, although the consumption of alcohol has gone down nationally, a small number of people are drinking more, and that is the problem. We are talking about a very specific group who are vulnerable and perhaps drink too much, rather than the overall situation, where consumption is down.
Dr Jeanelle de Gruchy: We still have 10,000 high-risk drinkers in our borough, so it depends on how you define small. For me as a director of public health, 10,000 high-risk drinkers is a real concern.
Lord Smith of Hindhead: It is a concern for all of us.
Dr Jeanelle de Gruchy: There is a tail where there is very high consumption of alcohol, but if 6% of hospital admissions are alcohol related, we have a major problem at a population level. It is more than just a small group of people who might be having alcohol-specific problems.
Professor Colin Drummond: There is good evidence that alcohol harm is a huge health inequality issue, with people drinking the same amount at different ends of the economic spectrum. Those in the highest socioeconomic groups suffer less harm than people in the lowest socioeconomic groups, even controlling for the amount they consume. We see concentrations of very high levels of alcohol-related harm in the poorest communities in our country.
Lord Davies of Stamford: Why is that? The physiology is the same irrespective of income.
The Chairman: We are coming to a lot of this, so perhaps we can hold fire.
Lord Brooke of Alverthorpe: Is the work being done by Public Health England publicly available, or likely to be in future?
Dr Jeanelle de Gruchy: It is likely to be in the future. I am not sure it is available at the moment, but we can certainly look at that and respond in written form.
Lord Brooke of Alverthorpe: We would welcome that.
Lord Blair of Boughton: A lot of the discussion has already covered most of these questions, so I will concentrate on the assumption that the promotion of health inevitably means limiting the quantity of alcohol consumed, with all the caveats of problem communities and so on. Somewhere there has to be a limit. We will talk later about the overall number of licensed premises and so on. Is there clarity now about whose responsibility it is to impose and enforce limits on alcohol availability? Are we clear that that should be the state? Should it be through statutory roles or through local government? Who is responsible for this?
Professor Sir Ian Gilmore: It is not just limiting consumption. Patterns of drinking are linked to different sorts of harm. The night-time culture of binge drinking and so on is associated with violence, unwanted pregnancy and all the sorts of things associated with intoxication, but that does not necessarily correlate with total consumption. The biggest burden on the NHS by far is from the chronic diseases related to alcohol consumption, such as cirrhosis of the liver, alcohol dependence and mental health issues. There is no doubt at all that shifting the consumption curve down for everyone will produce considerable health gains. There are health gains from reducing someone’s consumption from 30 to 15 units a week, even though that person is not necessarily running into overt health problems from alcohol.
Whose responsibility is it? At the end of the day, it has to be done through central and local government by some form of regulation. There are examples of extremely successful voluntary schemes and non‑statutory tools, but the problem is making them sustainable. There are examples all over the world of initiatives. They are wonderful while one or two individuals are there to push them, but to make them sustainable they have to be within some form of regulatory framework to support them.
Professor Colin Drummond: There is very strong international evidence that reducing the whole-population level of consumption reduces the level of harm in that nation. That happens across countries and across time when there have been changes in the affordability of alcohol. In the last 25 years, there has been a 50% increase in the affordability of alcohol in the UK, so people have more disposable income to spend on alcohol relative to its price. That is one of the main drivers behind the increase in health harm. The converse is that making alcohol more expensive would be a very strong way of reducing alcohol harm, either by taxation through duty and VAT, which has been the way for many years in this country, or the approach Scotland has been looking at recently, which is minimum unit pricing. I do not know whether you want to go into that right now, because I think there is another question later on. Minimum unit pricing would be a more targeted strategy than just general taxation.
Equally, restricting the availability of alcohol, through licensing hours and the number and density of outlets, would be a strong evidence-based approach. These are whole-population measures that do not preclude more local measures, such as enforcing laws about serving people who are already intoxicated. That would have a huge impact at local level if it was actually done. Looking at the international evidence, in some countries making people who serve alcohol legally liable for the adverse effects if they serve someone who is intoxicated has had quite a major impact.
Dr Jeanelle de Gruchy: The analogy of smoking raised by Professor Gilmore, the link with obesity and the debates and discussions about who is responsible for the massive increase in obesity are all pertinent. The state has responsibility in shaping the culture, the availability and the consumption patterns. I agree with Professor Drummond that at population level national policy tends to be the most effective, but giving powers to local authorities to shape a healthier environment for residents is very important, too.
Q106 Baroness Watkins of Tavistock: Public health data, which you have already alluded to, is often gathered on a national or regional basis. What data do you think would be required and what would it need to show in order to apply an objective case by case? When somebody applies for a licence, is there a way you could collect the right public health data to inform the argument? If so, what changes would we need in data collection to see whether the scale of pre-loading is a problem? I think you have already alluded to the fact that it is definitely a problem, but could you put those two things together?
Dr Adrian Boyle: On data collection, in England and Wales there is something called the ISTV programme—information sharing to tackle violence—which has been relatively successful. It is based on sharing information collected in emergency departments to triangulate police data. It is supported by what will be the next data collection set based on emergency departments, called the emergency care data system, which we hope will be rolled out by October 2017. It provides detailed information to community safety partnerships about the location, time and date of assault cases and the weapons used. The overlap between police data and emergency department data in cases of violent crime is about 25%, so the police do not know about 75% of the cases that come to hospitals.
In addition, there are pockets of good practice. There are 12 ambulance trusts in the UK; only three of them share with community safety partnerships routine data about where they are picking up alcohol-related injuries. Where that has been done, it has proved reasonably effective. The data is already collected; it is just a process and information-governance issue, to make sure that the data can be shared with community safety partnerships.
Baroness Watkins of Tavistock: I want to understand the pathway. If the information was shared with community safety partnerships, the public health team in the local authority would have it, and it could inform the licensing committee if health were added as an objective. Is that right?
Dr Adrian Boyle: Yes, but this provides only a single perspective; it is related only to violence. The vast majority of alcohol-related problems I see in emergency medicine at the moment are injuries, mental health crises and flare-ups of chronic diseases.
Dr Jeanelle de Gruchy: It also will not address the more chronic difficulties of alcohol admissions or longer-term alcohol-related matters.
Baroness Watkins of Tavistock: How would you get the data to inform those?
Dr Jeanelle de Gruchy: It is very difficult to use that data to inform a licensing decision on one premise, so that is a greater challenge.
Dr Adrian Boyle: There is no research data around to tell us what the attributable fractions are for emergency department presentations. It is based largely on research evidence. We know that about 55% of assaults are alcohol related. We do not have nearly the same level of understanding for injuries or other presentations with which people come to hospital.
Professor Colin Drummond: We already have a lot of evidence that pre-drinking is a big problem, particularly in the UK compared with other countries. I was part of a group on the AMPHORA project funded by the European Commission. The Liverpool John Moores team led on a particular piece of research looking at pre-drinking across four European countries among 18 to 35 year-olds. They found that the UK had the highest measures on all aspects; 61% of people in the UK going into pubs had pre‑loaded with alcohol before they went in, which is the highest in Europe. They had the highest blood alcohol concentrations, which on average were above the legal limit for driving, at the point they went into the pub. In addition, 82% of women and 96% of men said they expected to binge throughout the course of the evening. These are people going out with the express purpose of getting intoxicated, having pre-loaded beforehand. We have the dubious privilege of being best at that in Europe, according to that study.
Lord Foster of Bath: I want to pursue a little further the issue of data collection. Dr Boyle, I note that in the paper you very kindly sent us you say that alcohol misuse accounts for 15% of emergency department attendances, rising to 70% overnight and at weekends. I note that that is data based on 2000 and 2015 from just one inner city A&E department. You go on to comment that 10% of ambulance callouts are for alcohol-related health problems, which comes from a 2012 study in one English region. I am sure you would agree that we need more data. You have already talked about some sharing of data. Between you, could you tell us what more we could be calling for as regards the collection of data from both A&E and ambulance services? Building on what you have already said, what form, co‑ordination and sharing do we need?
Dr Adrian Boyle: It is very easy for the ambulance services to share with local community safety partnerships data about date, time and location of assaults they are called to, because ambulance staff have the GPS data already; it is completely automated. That would provide a unique perspective that is not captured at the moment by the ISTV programme and is not collected by the police. That is an easy, simple recommendation. As to estimating the burden, I appreciate that the figures were from single studies, but I suspect they have not changed very much over time. I want to follow up the further questions you raise.
Lord Foster of Bath: What I am trying to get at is whether we should propose that all A&E departments collect certain data in a comparable way across the whole country, so that we have comparable data we can use in research.
Dr Adrian Boyle: It is already being done. There is a programme—ISTV—but only for violent crime, because that is easy to measure. We do not have that for injuries. It would be useful to look at it for injuries, but probably the best way to do that would be by some primary research to establish the attributable fractions of various presentations.
Lord Brooke of Alverthorpe: Why is it only for violent crime?
Dr Adrian Boyle: Because it is easy to measure. There is what is called a minimum dataset for emergency departments that gives a list of about 40 presentations, of which assault is one. Work done by Jonathan Shepherd’s group in Cardiff demonstrated that if you used this information and identified those patients, and shared anonymous information about the time, data and assault with community safety partnerships and the police, you could bring about big reductions in community violence.
Professor Colin Drummond: We conducted two national emergency department surveys, both for the Department of Health, looking at alcohol-related attendances at A&E departments. The first one was in 2003. We found that over a 24-hour cycle 40% of A&E attendances were hazardous drinkers, increasing to 70% after midnight. We repeated it in 2010, seven years later, and found that it was again 40%; it was almost exactly the same rate. We have not seen a shift in that percentage over that period of time.
Lord Foster of Bath: What about the absolute numbers?
Professor Colin Drummond: Obviously, we did not survey every A&E department in the country but, extrapolating from the 32 A&Es we looked at selected randomly across England, we thought that at weekends there were about 1.2 million alcohol-related A&E attendances across England.
Professor Sir Ian Gilmore: We have very good data on the burden of alcohol on hospital admissions for chronic conditions such as cirrhosis of the liver, and the alcohol-attributable fractions of a large number of conditions, including several cancers. Although consumption is falling, the burden of harm is not falling; indeed, it continues to rise.
Lord Smith of Hindhead: I wonder whether you could put together this very interesting data and send it to the Home Office. When we were questioning witnesses from the Home Office, they did not think that pre-loading existed, because they had no evidence to suggest that it did. Therefore, it made my line of questioning on that day rather difficult. Bearing in mind that it is the department responsible for licensing, it might be useful for all of us if the data you are collecting is sent to the correct department.
The Chairman: Ministers are coming to see us, so that will be an opportunity. We can certainly send it in advance.
Lord Blair of Boughton: Professor Gilmore, to go back to what you just said, presumably there will be outliers, but there must be an average age when cirrhosis and other chronic conditions from long-term drinking first arise. Is there a link to the change in generations, in the sense that 10 years ago people in their 60s would have been growing up at a time when alcohol was not freely available, whereas people now in their 60s have had 30 or 40 years of alcohol? Is that what is happening?
Professor Sir Ian Gilmore: As you imply, the peak for alcohol-related deaths in this country is between about 45 and 65. That is why alcohol as a risk factor for premature death exceeds tobacco and obesity, because, although those have a bigger burden, they tend to kill people later in life. The tragedy of alcohol is that things such as cirrhosis, pancreatitis et cetera tend to affect people at a relatively young age, in the prime of life. Young people are tending to drink a little less, but whether we will see that come through in 10 or 20 years as a reduction in those deaths, only time will tell. It will depend on many factors other than the availability of alcohol. What is striking to those of us who work in the hospital service and see these patients is how relatively young they are; they are dying off in their prime.
Baroness Watkins of Tavistock: I want to ask about the reduction in alcohol intake by younger people. I may be wrong, but from what I have seen, having worked in a university, it was largely because of the change in cultures of different students. I am not convinced that a core group are not drinking just as much as they always did in that young population.
Professor Sir Ian Gilmore: You are absolutely right. There is a change in the ethnic mix of young people, and that is a factor. It is not the only factor. A very good report on why young people are drinking less has been published in the past three months by the Institute of Alcohol Studies. We will send you a copy. It is almost certainly multifactorial.
Q107 Baroness Goudie: It is our understanding that directors of public health in England and local health boards in Wales are currently the responsible authorities relating to public health. Is this correct? If so, how do they discharge that role, and are they effective? To add to that, perhaps they ought to link up with the Home Office on some of their findings.
Dr Jeanelle de Gruchy: The director of public health is now the responsible authority. That has helped considerably, along with public health moving into local government. In many areas, not all, the shifts and moves are reasonably recent; relationships take time to build up, and we all have a lot on. It has helped, certainly in my borough, to bring together public health with the other responsible authorities, the police and enforcement, for conversations about applications. Conversations are had, and sometimes informal discussions with the applicants happen and licence applications might change as a result. Public health is now much more party to and part of those conversations, whereas it was not beforehand. That has been really positive. Having said that, the fact that the prevention of health harm is not an objective limits the ability for a director of public health to make that argument, as we discussed previously, so it is a matter of using the other objectives and supporting conversations in that context.
Q108 Baroness Eaton: The Licensing Act 2003 has tended to regulate businesses licensed primarily for on or off-sales in a similar way, yet evidence suggests that the public health risks they pose may be different. Should the regulation of those businesses in the interests of public health be approached in different ways and, if so, how? We touched on off-sales earlier in the conversation. Certainly, more beer is sold now in off-sales than on-sales. Perhaps you could tell us your thinking about the differences, and how they should be treated.
Professor Sir Ian Gilmore: You are absolutely right. This is a very important question. There has been a real shift in culture over the last 10 to 20 years, almost certainly driven by the increasing differential between the price of off-licence drink in supermarkets and off-licences and the price in bars. You said that now more beer is drunk at home. If you look at all other forms of alcohol, about 80% is consumed at home compared with 20% in bars and clubs. Often, in discussions, people say that it is nothing to do with price or availability and that we need to change the culture. That differential between on‑trade and off-trade has driven a change in culture in this country; it has turned us into a home-drinking nation.
I have been on the front page of the Publican magazine twice, once being castigated and once being praised for saying it is a bad thing that pubs are closing, often in areas where they are central to local communities. If people are drinking, it is often better in a social environment than at home. We need a different approach to considering off-licences, particularly supermarkets whose financial power is such that they can absolutely distort the market. They can demand reductions from their producers; they can bring out loss leaders. Perhaps later we may get on to the topic of white cider. I have never seen white cider being ordered in a bar or pub, but it is the mainstay of consumption for my patients and, I suspect, Colin Drummond’s, too.
Dr Jeanelle de Gruchy: There are differences, but there is a huge amount of commonality—discounting in pubs, supermarkets and so on.
Baroness Eaton: It is about licences. Can we differentiate?
Dr Jeanelle de Gruchy: I do not have a strong view on that. Part of the difficulty is adding extra bureaucracy. It is hard enough as it is for local authorities to be clear on how to look at licences. When I discussed this with colleagues in enforcement, they were concerned about introducing more complexity in how licences are provided. My caution would be about how that would work. It sounds like quite a good idea, because there are differences, but are they sufficiently substantial to ensure that we look at licences in different ways? Would that not just mean it was more complex and, therefore, the arguments would be more complex? It would be good to look at it, but I am not sure whether we have a view either way at the moment.
Professor Colin Drummond: There are differences in the target populations that use pubs versus off-licences, although there is overlap between the two. People who are very heavy drinkers and are alcohol dependent tend not to drink in pubs; they would not be able to afford to do that for the amount they consume, so they get their alcohol from off-sales. They tend to trade down in the cost of the products they choose. The white cider Sir Ian is talking about is preferred by the kind of people I see in addiction clinics in south London, because that is what they can afford to drink. Unless we do something about the very low price of those super-strength products, we will not make an impact on the amount that dependent drinkers consume. Changing licensing of pubs is not going to have an impact on dependent drinkers.
Q109 Baroness Henig: What is your view on the value of super-strength schemes or similar schemes? What components do you think work? What could be done to make them more effective?
Professor Colin Drummond: I think I have answered that already. There are examples where local areas have had a voluntary ban on selling super‑strength drinks; for example, in Portsmouth and Ipswich. They report reductions in issues with street drinkers and in problems in the community. That is probably all very well while the spotlight is on a particular scheme. I doubt their sustainability over a longer period of time, once the cameras have gone. Probably, a more sustainable approach would be a national minimum price at which alcohol can be sold, which does not distinguish white cider or vodka; it simply applies a floor price at which alcohol can be sold. That would be a much more effective approach.
Baroness Henig: You are rather pessimistic about the voluntary type of scheme.
Professor Colin Drummond: Voluntary schemes could have an impact, but they are exactly that—voluntary, even in places like Portsmouth. I saw a presentation recently by Portsmouth City Council about its voluntary scheme. The council got four out of five supermarkets to sign up to a voluntary no-sale of high-strength cider, but everybody went to the fifth one that had decided not to be part of the scheme. That is the problem with voluntary schemes.
Professor Sir Ian Gilmore: It goes back to what I said before. Although there are some pockets of excellence and excellent examples, it is very difficult to make them sustainable. I am not an expert on the detail of how to use licensing—I have a wider perspective on alcohol and health—but it strikes me that there is a fundamental difference between being able to buy a pint of beer in a pub or club at 1 am, and being able to buy a bottle of cheap vodka at a petrol station at 1 o’clock in the morning. We need tools to attack that.
The Chairman: Lord Davies wants to come in, as long as we do not stray into areas that we are about to cover.
Lord Davies of Stamford: Professor Drummond, you say you believe that the solution is a minimum price for alcohol.
The Chairman: We are coming to that. I do not want to take the words out of Lord Mancroft’s mouth.
Q110 Lord Mancroft: They come just as well out of Lord Davies’s. Do you think minimum pricing works? Could it work? Does the level of taxation have a part to play in that in your view? How would it work in practice? So far, the Government have declined to introduce it because they do not think there is enough conclusive evidence that it will be effective. Do you think there is now enough conclusive evidence, or is there more work to be done on that?
Professor Sir Ian Gilmore: I will lead off and then hand over to the experts. One thing that has changed while this Committee has been sitting is a decision in the Scottish courts. They looked in great detail at the evidence and concluded that it was now overwhelming—I do not mean just the criminal burden of proof rather than the civil one—and that minimum unit price was the most effective tool. Taxation and MUP are not mutually exclusive, but MUP targets the cheapest alcohol that underage drinkers and the heaviest drinkers go for. We have real-life examples of the equivalent of minimum unit price in Canada, where there have been quite remarkable benefits in health. A 10% increase in floor price led to a 30% fall in directly alcohol-attributable deaths over the following 12 months. It seems to work.
I very much hope that the decision of the Scottish courts is not appealed yet again, and I hope Scotland implements it. There is a sunset clause such that, if it does not work over a period of time, it will be repealed, so it will be an experiment. This week, a Bill before the Senate in the Republic of Ireland includes a minimum unit price. I do not want to see England and Wales dragged along behind Ireland and Scotland, as happened with smoking in public places, for example. The evidence is there in spades.
The Chairman: If I may interject, are you possibly contradicting what you said to us earlier? You said that from 2009 alcohol consumption had dropped dramatically, which you put down to the financial crisis at the time, and the fact that a duty escalator of 2% above inflation was imposed. You are arguing for price, but it could be achieved by taxation. Earlier, you argued that consumption went down, on taxation.
Professor Sir Ian Gilmore: You could use tax alone and you would get some benefit, but that is not targeted. One of the great arguments against a minimum unit price has been that it would disadvantage the moderate drinker, but all the evidence suggests that it would have very little impact even on the less well-off moderate drinker, whereas tax would; it would affect a pint of beer in a pub or a glass of wine or a decent bottle of wine in a supermarket. I am not saying that price does not have an impact in general, but the most sensitive tool, which really helps the people you want to help, is minimum unit price.
The Chairman: I am intrigued. If you take taxation, you are putting the money into the Exchequer and allowing the Government to have the funding to do all the other things that you suggested to the Committee today should be done.
Professor Sir Ian Gilmore: Yes.
The Chairman: That would not be available through MUP.
Professor Sir Ian Gilmore: It is not, although Scotland certainly discussed a windfall tax of some sort, and that could be pursued. Other potential mechanisms could be looked at, but my understanding is that, when minimum unit price was viewed in a more favourable light in the early days of the coalition Government, the Treasury estimated that it would be better off as a result of minimum unit price than without it, but I am not an expert on the finances.
Professor Colin Drummond: The good thing about the minimum unit price approach, as opposed to duty and VAT, is that it would specifically target underage drinkers and the heaviest drinkers, according to the University of Sheffield modelling exercise. Because the amount spent on alcohol relative to total income is greater for the heaviest drinkers, and they favour the cheaper drinks, it would have a greater impact on them, and very little, if any, impact on moderate drinkers, as Sir Ian said. Although it would not necessarily raise revenue for the Treasury, unless there was some kind of windfall tax, it has been estimated that it would save up to £600 million a year in prevented hospital admissions; it would reduce them by 35,000, which I think was modelled largely on the Canadian experience.
The Chairman: But that was minimum pricing, not MUP. The difficulty for the Committee is that there is a lot of confusion about minimum pricing and MUP. Possibly, it would make sense to wait for the Scottish model to be rolled out to see whether it achieves over a two-year period all that you are telling us it would.
Professor Colin Drummond: It might, but in the meantime there will be a lot more avoidable hospital admissions and more cost to the NHS that could be prevented. I would be interested to know whether the same amount of scrutiny was applied to the introduction of the Licensing Act 2003 in terms of the evidence base. At the time, the evidence base pointed mostly in the other direction.
The Chairman: I presume the Select Committee on Health next door would have done its work.
Dr Jeanelle de Gruchy: I very much agree with colleagues. I mentioned earlier the 2016 survey of directors of public health. Among the vast array of public health issues and policy responses we deal with, directors of public health felt MUP came out as No. 1 in having sufficient evidence of impact and import. As with other issues, a national policy is very important to get population impact. With the best will in the world, we can do things locally, voluntary schemes and so on, but you do not get the same impact as you would if you introduced something like MUP nationally.
Professor Sir Ian Gilmore: People think that modelling is someone sitting with a mug of coffee and writing on the back of an envelope. It is very sophisticated and uses real-life data on sales and consumption, by age group, socioeconomic class, gender and so on. It has been enormously refined and is subject to international peer review. It is very easy to see it as some sort of nebulous thing that has not been put to the test, but it is hard to see how those conclusions are not correct. Targeting those we really want to help is the key benefit of MUP. The Scottish courts have crawled over that with enormous alacrity and come to the conclusion, with new evidence coming to light since it was first put before them, that the case is now overwhelming. It will be a real benefit to public health. I do not say that tax alone is not useful, but if you are going to tackle price, as a single measure MUP is the most important one.
Lord Brooke of Alverthorpe: How do you manage to administer it in an open border situation?
Professor Sir Ian Gilmore: We may well find out shortly.
The Chairman: One question springs to mind from some of the evidence we have heard from the industry. The smoking ban, which obviously you welcomed, was in the public domain, yet we were told quite categorically that it led to a number of bar closures and additional noise, with people having to smoke outside. It points to what you said to us today; it has led directly to more people possibly drinking and smoking at home. You seem to be telling us today that that was a logical consequence of a very good medical and public health reason for banning smoking, but it has led directly to consequences that you have put before us today.
Dr Adrian Boyle: We need to think about that, but the MUP is generally supported by people who work in the on-trade, because it will encourage people out of their homes and back into city centres, which is good for our night-time economy.
The Chairman: But you have not addressed the question of the smoking ban having unintended consequences. My concern is what you are not telling us today about the unintended consequences of MUP. Obviously, you do not know that, but how many hospital admissions have been prevented by the smoking ban? Have we seen a radical reduction? It is something I care passionately about. I lost my mother to lung cancer. When she was young, smoking was de rigueur; it was cool to smoke. Have you seen a direct reduction in hospital admissions through the smoking ban in public places?
Professor Sir Ian Gilmore: I am probably not the person to answer that, but I would be very surprised if there has not been.
The Chairman: That is not evidence.
Professor Sir Ian Gilmore: I would be surprised if there was not evidence strongly to support it.
Dr Jeanelle de Gruchy: There is definitely evidence, although I do not have it to hand or in my head. A Scottish study conducted recently showed reduction in heart attacks after the smoking ban. There is quite a lot of other work. It is one of the single most important public health interventions this country has made, and it has shown a huge impact in health benefits. These are complex issues, and it is difficult to show cause and effect. There is a lot going on in society, not just the smoking ban, as regards pubs closing. To claim that increasing pub closures are due just to the smoking ban is a bit simplistic. It would be interesting to see exactly what evidence there is for that claim. I am not saying it is not correct.
The Chairman: The drink driving ban has not helped in rural areas.
Dr Jeanelle de Gruchy: There are a lot of other reasons. I know that in London it is property prices more than anything else. I would take it with a pinch of salt. Of course, you are right to consider unintended negative consequences of policies, but the evidence on MUP is that it is quite a targeted policy decision, and that is an important focus.
Lord Smith of Hindhead: Now that we do not smoke we are all fat and drink too much.
Baroness Eaton: I do not want to sound facetious, but if you have minimum pricing to help the heaviest drinkers on the lowest incomes, would they not be driven to find an alternative?
The Chairman: Can we turn to Baroness Grender?
Q111 Baroness Grender: Shall I give my question a whirl? That might cover it. Throughout the evidence you have been giving, you have referenced what is called the alcohol harm paradox. Professor Drummond, you talked about the highest level of harm to the poorest. One of the questions we need to get to the root of is whether this can be dealt with in isolation, or whether we are talking about a much wider socioeconomic issue. For instance, mental health issues are tied in. In that context, we are looking at a much smaller issue, which is the licensing regime. Do you believe the licensing regime has a role to play, or is there a much wider issue we need to tackle, in particular relating to the people who are harmed the most in poorest communities?
Professor Colin Drummond: A question was asked earlier about why people in lower socioeconomic groups might suffer more alcohol-related harm. We do not entirely know the answer, but potentially people living in poor neighbourhoods and on low incomes have a worse diet; they may be unemployed; they may be living in poor housing conditions; they may be more stressed; they may have physical and mental health co‑morbidities and obesity, plus their alcohol-related harm. This is quite a vulnerable group. Probably no single thing will solve their problems. However, one thing they really do not need in their lives is excessive alcohol use on top of everything else. If we could do something to make it harder for them to drink as heavily as they do, we would be doing them a great service.
Equally, we need to put in more support; we need our hospitals to be geared up to identify the problems at an early stage, through screening and brief interventions in primary care and acute hospitals where these folk present with health issues; and we need better treatment and support services for people with severe alcohol problems. At the moment, we have about 1.6 million people with alcohol problems in England, of whom about 100,000 a year access specialist alcohol treatments. That is only 6% of the potential population. By comparison, a recent study we did on primary care found that, per annum, 50% of smokers receive advice or support in primary care. It seems we are much better on all levels at tackling smoking, from the policy level right through to the clinical practice level. The smoking experience shows that no single measure has had an impact on reducing prevalence. All those things combined in a concerted and co‑ordinated way have had an impact. You are right to say that licensing is not the only solution; it is one of a whole series of solutions that all have to move in the same direction.
Professor Sir Ian Gilmore: As Colin says, it has to be a multifaceted approach. We sometimes get accused of being a one-trick pony and just talking about MUP. That is not the case, but with something like MUP it is easier to quantify what we think the effect will be, whereas with licensing it is much harder to say that if you did this thing you would save this much money or save that number of lives. It is part of the exercise to try to re-norm alcohol in society. We are not trying to stop alcohol; we just do not want people to be bombarded with cues at the end of every aisle in the supermarket or be able to buy a bottle of whisky at two in the morning in a petrol station. Not only could you put things in place that you know would have a positive impact, but it could be part of a wider strategy.
To me, the title of the recent review of alcohol policy, Alcohol: No Ordinary Commodity, gives the game away. Do we really want a mind-altering drug with dependent properties that we all enjoy—including me, and I see the potential for harm every day—to be dealt with in the same way as soap powder in an off-licence or corner shop? I think the answer is no. It is a matter of how far we go in treating it differently, but we cannot treat it the same. By looking at changes in the licensing laws, there is an opportunity to send a message about how we feel about living in an alcogenic environment.
Dr Jeanelle de Gruchy: After smoke-free workplaces, it was interesting to see how many smokers really welcomed them. People who objected before the ban went through said afterwards, “Well, absolutely” about smoke-free restaurants. When you go to a country where there is smoking, it feels really strange. That shift in the norm has happened here and has been welcomed by smokers who are trying to give up. It is about what kind of environment and society we want. It is really important to look at it at population level. In what way can we make our environments healthier? There is a danger of saying that it is down to individuals’ moral ability to withstand the scourge of heavy drinking or whatever. People do not necessarily want to be confronted by alcohol, in the same way as they did not want to be confronted by smoking when they went into a restaurant, but alcohol is much more commonly available and evident in the society in which we live. As directors of public health, we are very keen to look at the way we can support a much healthier environment, where residents are not constantly having to make a decision, in the same way as for fast food, not to buy a six-pack of this or that. In current society, the choice is almost not to do something.
Dr Adrian Boyle: It is difficult to distinguish all the problems that a very dependent drinker has and how much alcohol is contributing to them. I have yet to see a problem drinker who does not have a whole bunch of social problems, and they are made worse by his alcohol, so it is contributing to all of those. We may not be able to distinguish cause and effect, but we know that alcohol is exacerbating almost all of those problems.
Q112 Baroness Eaton: You were talking about helping the most dependent. Would they not be driven to drink meths or illegally brewed alcohol and all of those things? Are we not in danger of driving it underground?
Dr Adrian Boyle: The dependent drinkers I look after usually start drinking at about 9 o’clock in the morning, and by the time they have run out of money, which is a bit later in the day, they are not capable of finding alternative forms of alcohol.
Baroness Eaton: But what if it was not there in the first place?
Dr Adrian Boyle: If it was a bit more expensive, they might run out of money a bit later. I do not know. I see very little illegal alcohol use, because it is so easily available.
Baroness Eaton: I was thinking about home-brewed vodka; it goes on to a considerable extent.
Professor Colin Drummond: One of the drivers for the increasing health harm, the deaths from liver disease and the increase in alcohol-related hospital admissions we have seen over the past 20 years is that alcohol has been more affordable for the heaviest drinkers—the people most at risk of those health consequences. That suggests there was a time when they were not drinking as much as they are now. In countries where they have increased the price of alcohol, the heaviest drinkers cut down as much as lighter drinkers.
Professor Sir Ian Gilmore: There is a notion that the people who are “alcoholics” will be unaffected, and will steal and kill for alcohol. The international evidence is that they will reduce. That alone will not stop them drinking, and it needs to be combined with proper support services for people with alcohol-dependency problems. If somebody is drinking, for example, three litres of white cider a day and they cut down to two or one, it brings about health benefits. If you reduce a nation’s consumption, the death rate from cirrhosis drops within 12 months. It probably takes 10 years to get cirrhosis through heavy drinking, but there are a lot of people just on the edge of the cliff. If you can get them to reduce their consumption a bit, they come back from the edge, so the impact can be immediate and dramatic.
Lord Brooke of Alverthorpe: Did we not have similar problems with cheap alcohol at the beginning of the last century? All parts of society, particularly the working class, were drinking alcohol, and licensing was used to call a halt. People did not turn to meths and other alternatives. We had a change of culture. It is possible to use licensing; it is just that perhaps our Licensing Act is a little limited at the moment.
Baroness Watkins of Tavistock: As you are so in tune with it, could I ask how much three litres of cider cost and how many units of alcohol it is? I have not got that concept.
Professor Sir Ian Gilmore: The usual strength is 7.5%, so that is about half the strength of a very strong wine, or three-quarters of the strength of ordinary wine. There are 7.5 units per litre, so three litres would have between 22.5 and 23 units. You can get almost twice what the Chief Medical Officer recommends as an upper limit in one bottle that would cost between £2.50 and £2.99.
Baroness Watkins of Tavistock: Therefore, just doubling that would halve the amount some people could afford and bring them within much safer limits.
Professor Sir Ian Gilmore: The bottle I described is about 12p per unit. Increasing it to 50p as a minimum unit price would multiply that fourfold, whereas it would not affect the price of a £5 bottle of wine or a pint of beer in a pub.
The Chairman: Do you think there is evidence that supermarkets are using cider as a loss leader?
Professor Sir Ian Gilmore: I do not know whether or not that is the case.
Lord Smith of Hindhead: Small off-licences sell that type of stuff. Our Chief Medical Officer has set the recommended daily amount, which is almost half that of Spain and much lower than every other country in the EU—we are still just about in the EU. Do you think our Chief Medical Officer is right, or are all the others wrong?
Professor Sir Ian Gilmore: I was on the advisory group.
Lord Smith of Hindhead: Perhaps you are not the person to ask.
Professor Sir Ian Gilmore: It is not out of kilter with those who have looked at this in an evidence-based way recently. In particular, Canada and Australia have come out with very similar levels, so it is evidence based and it was reviewed because of new evidence that the protective effect of alcohol, if there is one, was less than previously thought for cardiovascular disease, which fits in with the fact that there was falling incidence of heart disease anyway, and increasing evidence of the link between alcohol and certain cancers. That was new. Those were the two things that caused the chief medical officers of the four UK countries to review it and they came out with the best evidence available, which is guidance.
Lord Smith of Hindhead: The chief medical officer of every other EU state is wrong on that.
Professor Sir Ian Gilmore: I think they—
The Chairman: I do not think you are responsible for the other chief medical officers, but it is an interesting concept. How much did you reduce the limits?
Professor Sir Ian Gilmore: Women stayed the same at about 14 units a week and men came down from 21 to 14.
The Chairman: Probably not best all drunk in one go.
Professor Sir Ian Gilmore: Exactly.
The Chairman: Thank you very much indeed for being with us and for helping us with our inquiry. We are very grateful to you for being so generous with your time and for sharing your knowledge and expertise.
Professor Sir Ian Gilmore: Thank you for giving us such a polite and intelligent hearing.
The Chairman: You are very welcome. Thank you very much.