National alcohol policy in Scotland

“Whisky and freedom gang the gither” wrote Burns in 1786 in support of the Scottish distillers who were complaining about the vexatious and oppressive manner in which excise laws were being imposed by the English establishment.

Although the manufacture of whisky is no longer a particularly labour intensive industry, it is a major source of tax revenue for the UK Exchequer. Whisky is not the most commonly drunk alcoholic beverage in Scotland, but it has a symbolic and emotive power. From a cultural perspective it is evident that alcohol figures frequently in the image of Scotland, as portrayed both by ourselves and by others. What we mean by ‘drinking like a Scotsman or Scotswoman’ is not unimportant because it embodies the cultural significance of alcohol in Scotland. Any strategic plan needs to take this into account. While the drinking patterns in Scotland are no longer particularly distinctive, the harms are very evident and devolution provides opportunities for innovative local action.

Consumption patterns

The first point is to note that there is nothing unique or unvarying about any nation's drinking habits: in common with other countries per capital, alcohol consumption and beverage choice have varied significantly over the centuries (Spring & Buss, 1977). For the first half of the 20th century Scotland had relatively restrictive laws governing the availability of alcohol. These were significantly relaxed following the Clayson Committee Report (1972), which aimed to foster a less pressurised style of drinking. Since then permitted hours and availability have become more and more extended.

In most respects consumption patterns in Scotland do not differ significantly from those in the rest of the UK. Recent surveys commonly show that the heaviest drinkers are to be found in the North of England. Men in Scotland drink more than in England, both in terms of mean units consumed per week and the likelihood of consuming more than 20 units per week. However, men in England are more likely than those in Scotland to consume alcohol on 3 or more days a week. It has often been shown that there is a tendency to more concentrated drinking in Scotland than in England (Office of Population Censuses and Surveys, 1996).

Compared with women in England, those in Scotland drank less frequently and, on average consumed less. Women in the Scottish Health Survey (1995) consumed 6.3 units per week on average, while those in England consume 7 units a week. Moreover, a quarter of the latter drank alcohol on 3 days a week or more, compared with only 14% of women in Scotland (Scottish Executive Department of Health, 1997). These differences were even greater when comparing women in Scotland to those in Northern England. The percentage of Scottish women drinking more than recommended limits has risen more steeply in recent years than that for men.

Around Scotland itself there are relatively few differences in drinking patterns. The highest levels of consumption among men are to be found in Greater Glasgow and the lowest in the Borders, Dumfries and Galloway. In contrast, the highest levels of drinking among women are in the Lothians and Fife. Logistic regression shows that age and social class explain much more of the variance in the level of alcohol consumption than does region (Scottish Executive Department of Health, 1997).

Alcohol and health

Although there have not been dramatic changes in drinking habits in recent years (certainly compared with the escalation in the 1970s), there has been a very disturbing rise in alcohol-related mortality and morbidity in Scotland (Chick, 1997). It is interesting that during this time there has been a decline in discharges from psychiatric hospitals with alcohol-related diagnoses. The latter may reflect a change in pattern of service for individuals with alcohol problems, that is, an increased tendency to treat as out-patients domiciliary detoxification and the growth of counselling agencies. It is also noteworthy that there have been reports of increased levels of Korsakoff states in some parts of Scotland (Ramayya & Jauhar, 1997).

Other social costs

These trends add up to a very proper concern about alcohol and health in Scotland. The health costs are only of course a fraction of the total burden on the community if we consider crime, accidents, family breakdowns, work-related problems and unemployment. The bill that alcohol presents to our Scottish Parliament is very significant, as it is to the UK generally. The real basis for focusing on Scottish drinking habits lies less in their distinctive character, but more in the opportunity for change offered by devolution, which should allow a closer examination of local needs and services than has been possible in the past.

An opportunity for Scotland?

Scotland has always had a significant degree of autonomy in its laws and the organisation of the NHS but devolution has presented an even better opportunity to be innovative and, if necessary, different. A commitment to focus resources on social inclusion, social injustice and changes in priority setting within the NHS in Scotland present the Scottish Executive with opportunities for action tailored to the needs of the community. I hope it will not mean that we have to reinvent the wheel with a tartan design, but that devolution will provide a unique opportunity to develop an integrated and culturally appropriate alcohol strategy.

A health White Paper, Towards a Healthier Scotland, noted Scotland's poor record on health and, among other measures, pointed the way to the creation of a national strategy for tackling alcohol misuse in Scotland (Scottish Office Department of Health, 1999). It signalled steps to cut alcohol misuse and improve services. A devolved parliament for Scotland was established in 1999. In the same year a Scottish Advisory Committee on Alcohol Misuse (SACAM) was established and it will be developing a National Strategy for Alcohol Misuse during the next 2 years. This followed on from an alcohol conference funded by the Scottish Office in 1997, which produced an action plan entitled Alcohol Problems Working Together (http://www.scotland.gov.uk/library3/social/acap-01.asp ). Fiscal policy significantly was not included in the plan, but licensing and bylaws concerned with zoning etc. were to be considered. The newly formed advisory committee is chaired by a member of the Scottish Parliament. It has emphasised the need for:

1. (a) information strategy

2. (b) review of services

3. (c) prevention and health promotion, including the public perception of sensible drinking.

Falling between stools

Partly because of its ubiquity, there is always a danger that proper investment in reducing alcohol-related problems will fall between many stools, gaining a fleeting mention in many agendas, but marginalised on all. Far more prominence and funding is given to tackling illicit drug misuse than is given to alcohol, although the social and health costs of the latter are far greater.

There is the major concern about individuals who suffer from serious mental illness and also misuse alcohol and other drugs. They make more use of services, are less compliant and more prone to suicide and violence. The framework for mental health services in Scotland points out that alcohol dependence was the diagnosis of psychiatric admissions in 66 out of 100 000 population in Scotland compared to 40 out of 100 000 in England and Wales. It has been estimated that alcohol contributes to 65% of attempted suicide, between 60 and 70% of men who assault their partner do so under the influence of alcohol, 50% of attempted murder and 23% of child neglect cases identified via helpline calls involve alcohol misuse. The Mental Health Framework can be used as a basis for expanding services for these individuals with alcohol problems, but too often it appears to be used to exclude alcohol misuse from consideration except where a severe mental illness is associated with alcohol or indeed drug misuse. This is short-sighted and a complementary framework for alcohol services is required.

Excessive drinking often disrupts attempts at achieving equity and social change as part of policies to foster social inclusion. The Temperance Debates at the end of the 19th century were commonly about drinking as a barrier to social improvement (Harrison, 1971). Some have a paternalistic flavour but it would be foolhardy to overlook the significance of drinking as a source of discontent, as well as solace, in areas of deprivation. Problem drinking is twice as common in poorest areas (of which Scotland has a disproportionate number) as in those with more resources. The social inclusion agenda should therefore give prominence to tackling alcohol misuse.

The quality of community life and community safety

Fifty per cent of ‘rough’ sleepers are alcohol reliant, over half of male prisoners and a third of female prisoners have been drinking in a damaging way. In almost a half of assaults and muggings the offenders were intoxicated. Initiatives for rough sleepers need to give thought to relieving clients' drinking problems, which will not disappear simply by translation to a better environment. Dependency on alcohol frequently frustrates attempts to retain new tenancies and achieve secure resettlement. Similarly, prisoners' drinking problems need to be considered just as urgently as drug problems, but they have a very low or no priority at present. The revolving door of the habitual drinker offender, which had such prominence 30 years ago, continues to revolve.

An alcohol strategy needs to be integrated within the community. In Scotland there are now many local initiatives concerned with health, social exclusion and community safety. We should ensure that the reduction of alcohol-related harm is on all of their agendas. The Scottish Parliament has the opportunity to be more responsive to local needs and see that alcohol is a cross-cutting theme running through all these major elements of policy.

The College has been influential in advancing concerns about alcohol and health. It has advocated a public health perspective on alcohol while, at the same time, encouraging the proper provision of services. It has recently acknowledged the need for specialist training in addiction psychiatry. If we do not provide for specialist training in this area we will be neglecting people with drinking problems who still require advocates who are willing to speak up for the need for services. If this does not happen the needs of alcohol dependent individuals will become marginalised and neglected: a state of affairs obtained in this country 50 years ago.