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Alcohol Misuse in Scotland

Trends and Costs

ALCOHOL MISUSE IN SCOTLAND: TRENDS AND COSTS

- FINAL REPORT -

OCTOBER 2001

ALCOHOL MISUSE IN SCOTLAND:

TRENDS AND COSTS

- FINAL REPORT -

PREPARED FOR THE SCOTTISH EXECUTIVE

BY

CATALYST HEALTH ECONOMICS CONSULTANTS LTD

October 2001

CONTENTS

Page No

EXECUTIVE SUMMARY 1

1. INTRODUCTION 6

2. TRENDS IN ALCOHOL MISUSE IN SCOTLAND 8

3. COSTS ASSOCIATED WITH ALCOHOL MISUSE IN SCOTLAND 18

4. HEALTHCARE RESOURCE USE AND COSTS 24

5. SOCIAL WORK SERVICES RESOURCE USE AND COSTS 45

6. CRIMINAL JUSTICE SYSTEM & EMERGENCY SERVICES RESOURCEUSE AND COSTS 53

7. WIDER ECONOMIC COSTS 63

8. HUMAN COSTS 70

9. COMPARISONS AND CONCLUSIONS 74

10. REFERENCES 86

APPENDIX 1: Deaths due to alcohol by sex and specific cause for 93Scotland 1999

APPENDIX 2: Read codes for conditions directly attributable to alcohol 94misuse for CMR GP rates

APPENDIX 3: Conditions indirectly attributable to alcohol misuse 96

APPENDIX 4: Unit resource costs at 2001/2002 Prices 97

APPENDIX 5: Working party on alcohol misuse and social work caseload 98

APPENDIX 6: Crimes and offences in Scotland 1999 99

APPENDIX 7: Organisations and people contacted in the course of the study 102

1

EXECUTIVE SUMMARY

Aims

1. The aim of this study is two-fold:

s To present and analyse trends pertaining to alcohol misuse in Scotland;

s To estimate total costs associated with alcohol misuse in Scotland.

Trends in Alcohol Misuse in Scotland

2. The recommended levels of alcohol consumption in Scotland as elsewhere in the UK are less

than 22 units a week for men and less than 15 units a week for women.

3. Recent trend data have shown changes in alcohol consumption for particular societal groups.

Thirty three per cent of men aged 16-64 were drinking more than 21 units a week in 1995

and this was unchanged in 1998. However, the proportion of women exceeding 14 units a

week increased from 13% in 1995 to 15% in 1998. Furthermore, it is those in the younger

age group who are most likely to exceed these recommended limits. Forty-three per cent of

men and 24% of women aged 16-24 exceeded the limits.

4. Alcohol consumption differs by social class and regionally (by health board) within Scotland.

The highest proportion of men exceeding recommended limits in 1998 was in Greater

Glasgow (36%) while for women it was Lothian and Fife (17%) and Borders, Dumfries and

Galloway (17%). Women in non-manual social classes are more likely to exceed the

recommended limits than those in manual social classes, although the latter are more likely to

consume six or more units on their heaviest drinking day in the previous week. In men, manual

workers are more likely to exceed eight units on their heaviest drinking day.

5. Concern exists about the extent of underage drinking in Scotland with the proportion of pupils

aged 12-15 drinking alcohol increasing from 19% in 1998 to 21% in 2000.

2

6. In terms of trends in mortality due to alcohol misuse, there has been a 180% increase in

deaths directly related to alcohol from 1980-1999, although this should be interpreted with

caution due to changes in recording practices over time.

Costs Associated with Alcohol Misuse in Scotland

7. The total economic costs of alcohol misuse are made up of:

s Healthcare costs (NHS Scotland);

s Social work services costs;

s Criminal justice and emergency services costs;

s Wider economic costs (i.e. the reduction in output and hence productivity of the Scottish

economy if people are prevented from working through ill-health and if people of

working age die prematurely from alcohol-related illness);

s Human costs (i.e. pain/suffering and mortality caused by alcohol-related illness).

The cost estimated for each component is summarised in Table S1.

8. It should be noted that these costs do not represent the absolute amount of expenditure on

alcohol misuse in Scotland, but are estimates often based on assumptions rather than

documented statistics. The costs should therefore be interpreted with extreme caution and are

at best an indication of the order of magnitude of the various cost components. The

information gaps in Table S1 indicate the dearth of information pertaining to alcohol misuse in

some areas and thus the limitations of the study. It should also be noted that some cost

estimates are more robust than others (see methodology sections in individual chapters). In

particular, there is a lack of published information pertaining to the extent of alcohol-related

caseloads within social work services and the criminal justice system.

9. The total annual societal cost associated with 795,008 men and 368,984 women in Scotland

whose weekly alcohol consumption was above the recommended limits was estimated to be

£1,071 million. Of this, 9% was due to resource use by NHS Scotland, 8% by social work

services, 25% by the criminal justice system, 38% due to wider economic costs and 20% due

to human costs (i.e. premature mortality in the non-working population).

3

Table S1: Annual societal cost of alcohol misuse in Scotland at 2001//02 prices.

Health service resource use associatedwith:

Annualresource use

Annual cost(£ million)

GP consultations 211,516 3.6GP-prescribed drugs 6% of drugs prescribed by GPs for substance

dependency0.2

Consultations with practice nurses,district nurses and health visitors

No information currently recorded. Unable toquantify

Laboratory tests 147,256 1.8Hospitalisation days 275,775 54.3Accident and emergency attendances 187,951 9.6Outpatient visits 93,999 8.1Day hospital attendances 44,800 3.1Community psychiatric team visits 8% of total community psychiatric team

expenditure4.0

Ambulance journeys 64,382 9.1Health promotion/prevention by HealthEducation Board for Scotland (HEBS)Scottish Executive and health boards

HEBS, Drinkwise, Alcohol DevelopmentOfficers

1.2

Health board expenditure to alcohol-related voluntary organisations

Funding to 25 organisations 0.6

Total for NHS Scotland 95.6

Social work services and associatedorganisations resource use:Children and Families 24% of total expenditure on children's and

families social work71.8

Community Care 20% of social work expenditure on thesubstance misuse client group

2.2

Criminal Justice social work 27% of total expenditure on criminal justicesocial work

11.1

Children’s Hearing System 6% of expenditure 0.8Voluntary and private sector alcoholservices

Expenditure directly on alcohol misuseunavailable

Total for social work services 85.9

Criminal justice system and emergencyservices resource use associated with:Custodial sentences 565,172 days in prison 46.1Court time and legal costs forprosecutions

42,530 offences proceeded against 19.8

Property damage Unable to quantifyPolice time 26% of all expenditure 201.8Fire services time on alcohol-related roadtraffic accidents

Unable to quantify

Fire service time on alcohol-related fires Unable to quantifyDrink-driving campaign £141,000 on the drink driving campaign and

£70.000 to be spent on research0.2

Total for criminal justice system andemergency services

267.9

4

Wider economic costs due to:Annual

Resource useAnnual cost(£ million)

Inability to work (unemployment) 3,536 unemployed individuals 84.0Working days lost (absenteeism) 1,164,344 days absent from work 119.0Working days lost by those caring forthose with alcohol problems

Unable to quantify

Premature mortality in the workingpopulation (discounted)

1,641 deaths resulting in 12,546 working yearsof life lost.

201.5

Reduced productivity in the workplace Unable to quantify

Total wider economic costs 404.5

Human costsPremature mortality in the non-workingpopulation (discounted)

15,457 non-working life years lost 216.7

Morbidity Unable to quantify the cost of reduced qualityof life

Total human costs 216.7

Total annual societal cost 1070.6

10. The local authorities which incurred the greatest expenditure on community care services for

drug and alcohol misuse in 1999/2000 were, in order of decreasing expenditure per capita,

Glasgow City, Inverclyde, Aberdeen City, Shetland Islands and Perth and Kinross. Glasgow

City and Aberdeen City local authorities had the highest reported expenditure on substance

misuse both overall and in terms of per capita. However, it should be noted that expenditure

and use of both health and social work services may only be an indication of service provision

and not be informative about service requirements.

11. It was estimated that 26% of all crimes and offences recorded by the police are associated

with alcohol misuse at the time of an offence. The acute effects of alcohol misuse are

additionally associated with accidents and thus accident and emergency admissions, fires and

fire service resource use, property damage and inefficiency at work. Hence, the cost of the

acute effects of alcohol impact significantly on Scottish society.

12. Alcohol consumption is increasing in the younger age groups, particularly those aged 11-15

years. This is reflected in the increasing number of referrals to the Children's Hearing System

for drug and alcohol misuse (although the proportion of each is unknown) and is causing

increasing concern in social work departments. Additionally, there were 486 non-psychiatric

hospital admissions in 1999/2000 where alcohol was the primary diagnosis by those under 16

years of age.

5

13. Previous work has shown that alcohol appears to be similar to other psychoactive substances

in that problem use is associated with social structural factors such as poverty, disadvantage

and social class. The finding that alcohol-related hospital admissions are higher among those

from deprived areas is consistent with this.

14. Comparisons with other cost of alcohol misuse studies are hampered by differences in the

costs included, methodological issues, differing societal infrastructures and alcohol

consumption levels. However, a recent study by the Royal College of Physicians estimated

inpatient costs due to alcohol misuse to be between £500 million and £2.9 billion in 1998/99

for the UK. As the population of the UK is 12 times that of Scotland, the estimated cost of

£54.3 million for Scotland is in line with UK cost estimates.

15. Alcohol misuse imposes a substantial burden on Scottish society which is greater than many

prevalent illnesses such as stroke, Alzheimer’s disease and diabetes. When only direct costs

are considered (i.e. excluding wider economic costs and human costs), then unlike these other

conditions where criminal behaviour is generally not relevant, 60% of the societal cost of

alcohol misuse is attributable to the criminal justice system.

16. In conclusion, alcohol misuse imposes a substantial burden on Scottish society, costing

£1,071 million per year at 2000/2001 prices. Nine percent of this is due to NHS Scotland

expenditure, 8% to social work services resource use, 25% to resource use by the criminal

justice system, 38% due to wider economic costs and 20% due to human costs. In terms of

the statutory agencies, alcohol misuse imposes the greatest burden on the criminal justice

system followed by NHS Scotland and social work services.

6

CHAPTER ONE INTRODUCTION

Background

1.1 Alcohol misuse in Scotland is increasing, not only in terms of excessive drinking levels among

adults, but also in the frequency and level of drinking among teenagers. While it is widely accepted

that there are significant costs associated with alcohol misuse, the total cost of alcohol misuse in

Scotland is not known.

1.2 The Scottish Executive advised by the Scottish Advisory Committee on Alcohol Misuse

(SACAM) are currently working together to develop a Plan for Action on Alcohol Misuse. This

study is one of a number of studies commissioned by the SACAM to generate the information

required to inform the development of the Plan.

Purpose of Study

1.3 The purpose of this study was to:

s Present and analyse trends pertaining to alcohol misuse in Scotland.

s Estimate the total economic cost associated with alcohol misuse in Scotland.

Structure of Report

1.4 This report is structured as follows:

s Chapter 2 - describes the available trends pertaining to alcohol misuse in Scotland;

s Chapter 3 - identifies and describes the cost components associated with alcohol misuse, all of

which have been measured in this study;

s Chapter 4 - estimates the annual costs that have been incurred by NHS Scotland as a result of

alcohol misuse and describes the methodology employed to estimate these costs;

s Chapter 5 - estimates the annual costs that have been incurred by social work departments and

other associated organisations as result of alcohol misuse and describes the methodology

employed to estimate these costs;

7

s Chapter 6 - estimates the annual costs that have been incurred by the criminal justice system

and emergency services as a result of alcohol misuse and describes the methodology employed

to estimate these costs;

s Chapter 7 - estimates the wider economic costs (lost output, reduced productivity) that result

from alcohol misuse and describes the various methods which can be employed to estimate

these costs;

s Chapter 8 - estimates the human costs of premature mortality in the non-working population

and morbidity associated with alcohol misuse and describes the various methods which can be

employed to estimate these costs;

s Chapter 9 - summarises the costs of alcohol misuse in Scotland, noting the study's limitations

and compares the estimates with those generated by other studies.

8

CHAPTER TWO TRENDS IN ALCOHOL MISUSE IN SCOTLAND

Introduction

2.1 The purpose of this chapter is to:

s Identify sources of data on alcohol consumption in Scotland;

s Present the most recent data and trends in alcohol consumption.

2.2 This chapter presents:

s General trends in alcohol consumption;

s Alcohol consumption by social class;

s Alcohol misuse in Scotland compared with England;

s Data on binge drinking;

s Data on problem drinking;

s Alcohol consumption in children and teenagers;

s Regional trends in alcohol misuse;

s Trends in mortality due to alcohol misuse.

Alcohol Consumption Data Sources

2.3 Although recent data concerning alcohol consumption in Scotland are available, it is difficult to

obtain information on the changing trends over time in respect of alcohol misuse. There are three

surveys that include questions on daily or weekly alcohol consumption. However, many of these

have only been introduced within the last five to ten years and they are not repeated annually,

consequently trend data for Scotland are limited.

2.4 Specific consumption data for adults in Scotland can be obtained from:

s The Scottish Health Survey (introduced in 1995 and repeated every three years);

s The General Household Survey conducted by the Office of National Statistics (ONS) (started

in 1971, but questions on alcohol consumption were only introduced in 1998; this is UK-based

and has a sample size for Scotland of less than 2,000).

9

s A survey on Smoking, Drinking and Drug Use among Young Teenagers by the ONS

(introduced in 1990 and carried out biennially).

General Trends in Alcohol Consumption in Scotland

2.5 Alcohol consumption per capita in Scotland and the UK steadily increased between 1960 and

1980. Over the same time, the relative retail price of alcohol declined (Scottish Council on Alcohol

1994). Since 1980, consumption has remained fairly steady. During the 1980s and 1990s

approximately 7 litres of 100% alcohol were consumed per capita per year in the UK. However,

this is relatively low in comparison with other European countries where a comparative figure was

14 litres for France and 12 litres for Hungary (Scottish Council on Alcohol 1994). Nevertheless,

alcohol consumption in Scotland is probably at its highest level now since the First World War

(Scottish Council on Alcohol 1994). It is notable that the number of liquor licenses in force in

Scotland has increased from 13,892 in 1980 to 17,244 in 2000, equivalent to an increase of 24%

(Scottish Executive 2000a).

Prevalence of Alcohol Misuse in Scotland

2.6 In 1998, 32% of men and 14% of women aged 16-74 years in Scotland drank more than the

weekly recommended levels of alcohol, which are over 21 units a week for men and over 14 units a

week for women (Scottish Health Survey 1998). Men and women in the 16-24 age group were the

most likely to exceed recommended limits; 43% and 24% exceeded the limits respectively. Alcohol

consumption of more than 50 units per week for men and 35 units per week for women is thought to

pose a potentially serious risk to health (Lord President’s Report 1991). Seven per cent of men and

3% of women continue to drink at this level (Scottish Health Survey 1998).

2.7 The percentage of men aged 16-64 drinking more than 21 units a week was 33% in both

Scottish Health Surveys in 1995 and 1998. However, among women there is a suggestion of an

upward trend in consumption. The proportion of women exceeding 14 units a week increased from

13% in 1995 to 15% in 1998. Furthermore, their estimated mean weekly consumption increased

from 6.3 units in 1995 to 7.1 units in 1998 (Scottish Health Surveys 1995 and 1998).

10

2.8 Changes in overall consumption between 1995 and 1998 stratified by age group and gender

can be seen in Figures 2.1 and 2.2. The Scottish Executive set a target to reduce the percentage of

men drinking more than 21 units per week to 31% by 2005 and 29% by 2010 (Scottish Office

1999). For women, the targets are to reduce the percentage drinking more than 14 units per week

to 12% by 2005 and 11% by 2010 (Scottish Office 1999).

Figure 2.1 Mean weekly units of alcohol consumed by men in 1995 and 1998.

22.819.4 19.7

16.523.4

17.7 20 17.420.8 20.5

0

5

10

15

20

25

16-24 25-34 35-44 45-54 55-64Age group (years)

Mean weekly units of alcohol

consumed

1995 1998

Source: Scottish Health Survey 1995 and 1998

Figure 2.2 Mean weekly units of alcohol consumed by women in 1995 and 1998.

6.3 6.6 5.6 4.6

10.07.4 6.2

4.4

8.4 7.4

0

2

4

6

8

10

12

16-24 25-34 35-44 45-54 55-64Age group (years)

Mean weekly units of alcohol

consumed

1995 1998


11

Alcohol Consumption and Social Class

2.9 Women in non-manual social classes are more likely to exceed the recommended weekly

limits than those in manual social classes. However, women in the manual social classes are more

likely to consume at least six units on their heaviest drinking day. Little difference exists in terms of

social class and exceeding the recommended limits in men, although mean weekly consumption is

higher among manual workers and they are more likely to exceed eight units on their heaviest

drinking day (Scottish Health Survey 1998).

Alcohol Misuse in Scotland Compared with England

2.10 Overall consumption levels for men aged 16-74 years are similar in Scotland and England.

Mean weekly units consumed were 18.8 units in England and 19.1 units in Scotland in 1998 and the

likelihood of exceeding 21 units per week was 32% in both countries. Women, however, drink

more in England than in Scotland in every age category and women in Northern England drink more

than the average for women in England as a whole. Mean weekly consumption for women aged

between 16 and 74 years was 6.5 units in Scotland, 7.6 in England and 8.5 in Northern England in

1998 (Scottish Health Survey 1998).

Binge Drinking

2.11 In terms of peak weekly consumption patterns (binge drinking) among men aged 16-74 who

had consumed alcohol in the week before being surveyed, 44% had consumed 8 units or more on

their heaviest drinking day. The comparable figure for women was 27% (drinking more than 6 units

on their heaviest drinking day). Young people were by far the most likely to exceed these amounts;

among those aged 16-24 years, 62% of men and 49% of women did so. Furthermore, 45% of all

men and 25% of all women aged 16-74 years said they had been slightly (or very) drunk in the last

three months (Scottish Health Survey 1998). Notably, one Scottish study reported an excess of

deaths on Mondays and attributed this to weekend binge drinking (Evans et al 2000).

12

Problem Drinking

2.12 In the Scottish Health Survey (1998), agreement with two or more of the six “CAGE”

questionnaire items was seen as an indication of problem drinking. CAGE is an alcohol-related

questionnaire, validated in general population studies, and is appropriate for screening surveys. It

was found that 10% of males and 4% of females aged between 16-74 years could be classified as

“problem drinkers”. By way of comparison, Meltzer (1995) found that 8.7% of men and 2.1% of

women are alcohol-dependent in Scotland.

Alcohol Consumption in Children and Teenagers

2.13 Concern also exists about the extent of underage drinking in Scotland with 12% of boys and

9% of girls aged 13-15 years saying they had consumed some alcohol in the last seven days

(Scottish Health Survey 1998). The average weekly amount consumed per pupil fell from 1.8 units

in 1996 to 1.4 units in 1998. However, this is still well above the number of units (0.8) that were

being consumed in 1990 (ONS Survey 1998a). Changes in the percentage of boys and girls aged

13-15 years who had consumed alcohol in the week before being surveyed since 1990 are shown in

Figures 2.3 and 2.4. Clearly boys are more likely to have consumed alcohol in the previous week

than girls and for both the likelihood of consumption increases with age. There have been clear

overall percentage increases since 1990, peaking in 1996. This is concordant with the Scottish

Health Behaviour in School-Aged Children (HBSC) survey, conducted by the World Health

Organisation (WHO 1998), in which the percentage of 11-15 year olds who drank at least weekly

rose significantly from 16.7% to 23.8% between 1990 and 1998.

2.14 A recent Scottish Executive press release (July 2001) provides figures for the 2000 schools

survey undertaken by the National Centre for Social Research (NCSR). This survey of 12-15 year

olds found a decrease in the proportion of regular smokers from 12% in 1998 to 10% in 2000 and

drug misuse remained unchanged from 1998, with one in ten reportedly misusing drugs. However,

the proportion of pupils drinking alcohol in the week before being surveyed had increased from 19%

in 1998 to 21% in 2000.

13

Figure 2.3 Percentage of boys in Scotland who drank in the week prior to being surveyed from 1990 and 1998.

7 6 8 9 610

1418 21 19

24 2226

3125

3035 37

48

39

0

10

20

30

40

50

60

1990 1992 1994 1996 1998

Years

% of Boys12 years 13 years 14 years 15 years

Source: Smoking, Drinking and Drug Use Among Young Teenagers, ONS 1998

Figure 2.4 Percentage of girls in Scotland who drank in the week prior to being surveyed from 1990 and 1998.

3 25 7

410 12 13

1815

19 18

2926 2525

28

35

46

35

0

10

20

30

40

50

1990 1992 1994 1996 1998

Years

% of Girls12 years 13 years 14 years 15 years

Source: Smoking, Drinking and Drug Use Among Young Teenagers, ONS 1998

2.15 In Scotland, referrals of children under 16 years of age are made to Reporters within the

Children's Hearing System if it is thought that a child is in need, regardless of whether they have

committed an offence themselves or have suffered from abuse or neglect at the hands of others.

14

Figure 2.5 shows the annual number of referrals for 1997-2001 (2001 figures are provisional) for

children who have misused alcohol or drugs (Scottish Children’s Reporter Administration 2000).

Figure 2.5: Annual number of referrals to the Children's Hearing System on the grounds of children misusing drugs and alcohol.

553

880

1260

1846

0200400600800

1,0001,2001,4001,6001,8002,000

1997-98 1998-99 1999-00 2000-01

Annual number of referrals

Year

Source: Scottish Children’s Reporter Administration Statistical Bulletin 1997-2000 (2000-2001 figures are provisional)

2.16 Figure 2.5 illustrates the increase in the annual number of referrals due to children misusing

alcohol and drugs, with an average annual increase of 50% between 1997-2001. In 1999-2000 the

majority of the referrals (86%) were by the police.

Regional Trends in Alcohol Misuse

2.17 In terms of variations throughout Scotland by region (i.e. by health board), the proportion of

men drinking more than 21 units a week is highest in Greater Glasgow and Forth Valley, Argyll and

Clyde. The proportion drinking more than 50 units a week is highest in Greater Glasgow and

Lothian and Fife while it is lower than average in Borders, Dumfries and Galloway, Highlands and

Islands and Grampian and Tayside. For women, the regions with the highest percentage drinking

over the recommended limits are Lothian and Fife and Borders, Dumfries and Galloway. See Table

2.1.

15

Table 2.1: Alcohol consumption levels by health board areas in 1998 (age-standardised) 1995 figures are in parentheses.

Consumption

GreaterGlasgow

Highlands& Islands

Grampian& Tayside

Lothian& Fife

Borders,Dumfries &Galloway

LanarkshireAyrshire &

Arran

Forth ValleyArgyll &

Clyde

Total

MenMean weeklyunits

22.9(26.2)

16.5(18.7)

16.4(19.9)

20.7(18.4)

17.2(15.7)

18.6(20.6)

20.5(19.1)

19.2(20.3)

% drinking >21 units

36(37)

25(35)

31(33)

32(32)

31(31)

32(34)

37(33)

32(33)


9(12)

5(8)

5(9)

9(7)

5(3)

8(7)

6(8)

7(8)

WomenMean weeklyunits

6.6(6.5)

5.5(5.6)

6.1(6.2)

7.1(7.9)

6.5(5.4)

5.5(5.9)

6.2(5.5)

6.2(6.4)


12(15)

11(11)

14(13)

17(16)

17(9)

12(12)

14(12)

14(13)

% drinking>35 units

2(1)

1(1)

2(1)

3(3)

3(1)

1(0)

2(0)

2(1)


2.18 Weekly alcohol consumption in 1998 by region had changed little since the 1995 survey. For

men, the biggest change was a decrease in the number of men that drank more than 21 units a week

in the Highlands and Islands, from 35% in 1995 to 25% in 1998. For women, all the regions either

show either an increase or no change in the proportion drinking more than 14 units a week. The

biggest change was found in Borders, Dumfries and Galloway where the percentage of women

drinking over 14 units had doubled.

2.19 Other surveys have been completed in particular regions and sub-groups, often undertaken by

health boards (e.g. Lanarkshire Health and Lifestyle Survey 1996). However, different surveys often

use different methodologies so comparisons cannot always be made between different areas. In one

study, the drinking habits of teenagers in the Western Isles were surveyed and found to be extremely

polarised. Results showed that while a fifth of the 13-16 year olds had never consumed alcohol,

40% of males and 33% of females reported having consumed at least 11 units on their last drinking

occasion (Anderson and Plant 1996).

2.20 Of particular note regionally has been the reported increase in alcohol-related brain damage,

mainly Korsakoff’s psychosis in the East End of Glasgow (Ramayya and Jauhar 1997). Korsakoff’s

psychosis is an irreversible demented state brought about by a particular pattern of brain damage

16

resulting (usually) from a deficiency of thiamine in the diet of heavy drinkers. The incidence of

Korsakoff’s psychosis in this area has increased from 12.5 per million in 1990 to 81.3 per million in

1995, with a particularly high incidence in females. It has been postulated that one factor in the

increasing incidence may be related to changes in thiamine prescribing, however all the cases had

confirmed histories of alcohol abuse.

2.21 Smith and Flanigan (2000) concluded from their analysis of psychiatric hospital residents with

Korsakoff’s psychosis in Scotland that higher rates in the West of Scotland (Greater Glasgow and

Argyll and Clyde) were likely to reflect higher rates of alcohol-dependence. It has also been noted

however, that the particularly high level of people with Korsakoff’s psychosis in the East End of

Glasgow may be associated with the concentration of hostels for single homeless people in that area

(Greater Glasgow Health Board 2000). Individuals with alcohol-related brain damage (ARBD) are

often very socially isolated and vulnerable, frequently lacking financial and personal resources due to

the consequences of years of problem drinking. As a result of not being able to look after

themselves properly they require long-term care.

2.22 An analysis of psychiatric inpatient care discharges in 1998 provided by the Information and

Statistics Division, found that 43 patients coded as F10.6 (ICD 10) or “mental and behavioural

abuse due to alcohol – amnesic syndrome” (the code for Korsakoff’s psychosis) were inpatients for

longer than a year, with an average length of stay of 1,906 days. Accordingly, there is increasing

recognition of ARBD and Korsakoff’s psychosis in Scotland and its impact on health and social

care services.

Trends in Mortality due to Alcohol Misuse

2.23 While some causes of death can be directly attributed to alcohol (e.g. alcoholic cirrhosis of the

liver), there are a number of conditions for which alcohol is a known risk factor and, thus, may have

been the main contributory factor (e.g. cancers or injuries). Consequently, the number of deaths

calculated from death certificates that report alcohol as a cause of death underestimate the total

number of deaths caused by alcohol. As a result, most studies, including this one when calculating

17

alcohol-related death add an “attributable proportion” of other non-directly related deaths (e.g.

McDonnell and Maynard 1985).

2.24 Mortality statistics obtained from the General Register Office, Scotland showed that in 1999

there were 1,032 deaths in Scotland directly as a result of alcohol misuse (calculated by totalling all

deaths with an underlying cause recorded as an ICD 9 code directly related to alcohol - see

Appendix 1). The annual number of deaths directly attributable to alcohol misuse appears to have

risen by 180% over the last nineteen years, as shown in Figure 2.6.

Figure 2.6: Annual number of deaths directly due to alcohol misuse.

370 405 452641

1,032

0

200

400

600

800

1,000

1,200

1980 1985 1990 1995 1999

Annual numberof deaths

Source: General Register Office, Scotland

2.25 These mortality figures should, however, be interpreted with caution. A false impression of the

real trend may arise from changes in recording practices over time, the completion of death

certificates by doctors who may be unaware of a history of alcohol-related disease, or an

unwillingness to stigmatise the patient or their relatives. Figures published by the Scottish Council on

Alcohol (1994) recorded a 653% increase in alcohol-related deaths between 1968 and 1992 in

Scotland. However, once again, the extent to which this is a real increase due to alcohol misuse in

Scottish society, or a reflection of changing recording practices is unknown.

18

CHAPTER THREE COSTS ASSOCIATED WITH ALCOHOL

MISUSE IN SCOTLAND

Introduction

3.1 This chapter identifies the wide range of costs associated with alcohol misuse, including the

resources used in the management of alcohol misuse as well as the human cost (due to premature

mortality and morbidity) and the cost to the economy in terms of lost output. Where possible, a

monetary value has been estimated for each component in subsequent chapters. It must be

recognised, however, that in some cases (e.g. impact that a person with an alcohol problem has on

other family members) it is difficult to monetise. In such cases, the burden is presented in either

quantitative (e.g. number of cases) or in qualitative terms.

3.2 The major cost components associated with alcohol misuse are as follows:

s Costs to NHS Scotland;

s Costs to social work services;

s Costs to the criminal justice system and emergency services;

s Wider economic costs;

s Human costs.

Costs to NHS Scotland

3.3 The clinical management of alcohol misuse involves both primary and secondary healthcare

services and because the nature of the outcome of alcohol misuse can be both physical (e.g. liver

cirrhosis) and psychological (e.g. amnesic syndrome), it can impact on a vast array of services. The

healthcare resources utilised by alcohol misusers include:

Primary care resources:

s GP consultations;

s Practice nurse/health visitor consultations;

s Community psychiatric team contacts;

19

s Drugs;

s Laboratory tests.

Secondary care resources:

s Inpatient stay (i.e. psychiatric and non-psychiatric);

s Accident and emergency attendances;

s Outpatient attendances;

s Day hospital attendances;

s Ambulance transportation.

Other:

s Health promotion and prevention;

s Health board payments to alcohol-related voluntary organisations.

Costs to Social Work Services

3.4 Social work services are divided into three main areas, each of which involves the use of

resources by those with alcohol problems, as described below. It is notable that some of the

services, especially addiction services, may be only partly funded by social work departments and

may receive funding from health boards, voluntary donations or the private sector. The Children’s

Hearing System is included as it works closely with social work services, however it should be

noted that it is an independent body with a separate budget.

Children and Families

3.5 The provisions within the Children (Scotland) Act 1995 have redefined services for children,

young people and families. Local authorities provide child protection services, responding to reports

suggesting children may be at risk and then take action to protect a child from harm and promote

their welfare. Local authorities also provide adoption and fostering services, day care services for

children under five, respite care to provide back-up support for carers, and look after some children

20

in residential care settings. Additionally, they work with the Children's Hearing System and the

Courts.

Reporter’s Administration: The Children's Hearing System

3.6 The Children’s Hearing System deals with children under 16 years of age who are in need or

at risk regardless of whether they themselves have committed an offence or have suffered from

abuse or neglect. The system is not part of social work departments or local authorities, however it

works closely with the children and families division. Reporters are full-time officials through whom

all referrals must be made. One of the grounds for referral is the misuse of alcohol and/or drugs.

Community Care

3.7 The introduction of the NHS and Community Care Act 1990 aimed to shift the balance of

care for a range of client groups away from hospitals and long-stay institutions into the community,

by providing support to enable people to live in their own homes or in a community setting. People

with alcohol and/or drug problems are identified as one of the priority groups under the legislation.

Criminal Justice Services

3.8 In Scotland, local authorities are responsible for working with young and adult offenders to

provide criminal justice services. Social workers within criminal justice services are involved at all

stages of the criminal justice system including supervision of court orders through to support services

for both offenders and victims of crime. Specific core services include:

21

s Social Enquiry Reports - This involves a background report written by a social worker offering

advice to a sheriff, magistrate or judge on the most appropriate sentence;

s Parole and Home Background Report – This involves a report written by social workers for

use by a parole board commenting on the risks a prisoner poses and outlines plans for their

release;

s Probation Orders - These are orders of between six months and three years in length which the

courts impose on offenders who have a particular problem which needs addressing. Offenders

are supervised by a qualified social worker;

s Community Service Order – This has to be completed within 12 months and comprises

between 80 and 300 hours of unpaid work in the community for an offender. Offenders are

supervised by a qualified social worker.

Some of the burden on these services will be as a result of alcohol-related crimes and offences.

Other Services

3.9 Alongside the statutory responsibilities of local authorities there are many other services which

are often carried out with partner agencies to promote the general health and welfare of all people

e.g. counselling and support services. Social work departments often run or fund/partly fund

specialist alcohol and drug services.

Costs to the Criminal Justice System and Emergency Services

3.10 Alcohol is known to be a contributory factor in many committed crimes. For example, about

64% of offenders and 44% of victims are deemed to have been drinking at the time of a violent

offence (Murdoch et al 1990). However, it has been noted that no causal link has been established

between alcohol and crime (The All Party Group on Alcohol Misuse 1995). Nevertheless, there are

some offences that are alcohol specific and these include:

s Drunk and disorderly;

s Driving under the influence of alcohol;

s Drunk in charge of a child.

Costs can be incurred in terms of police time, court appearances and custodial sentences.

22

3.11 In terms of the emergency services, many accidents and fires are associated with the use of

alcohol and this will also impact on police time and additionally on the fire services.

Wider Economic Costs

3.12 The Framework for Economic Development in Scotland (Scottish Executive 2000) highlights

increased productivity (output per worker) as the key to stimulating economic growth in Scotland.

Alcohol misuse, however, has the opposite effect. It has a negative impact on output and

employment and hence reduces productivity. There are a number of mechanisms through which

alcohol-related illness may reduce the productive capacity of the Scottish Economy:

s A higher number of working days lost (both for those who are ill and carers);

s Reduced productivity for those experiencing the effects of alcohol at work;

s Inability to work (unemployment);

s Early retirement;

s Premature deaths among people of working age and under.

Human Costs

3.13 Alcohol misuse results in mortality and morbidity. The impact of alcohol misuse on health can

be seen in Tables 3.1 and 3.2 which report the acute and long-term effects of alcohol misuse.

Table 3.1: Acute effects of alcohol.

Blood alcohol level (mg/100ml) Effects20 Warmth and relaxation40 Mood and behaviour begin to alter, driving ability impaired50 Less control over behaviour and lowered judgement80 Legal upper limit for driving a motor vehicle

100 Unsteadiness, impaired speech and emotional judgement150 Muscle incoordination, double vision, sluggish reactions200 Nausea, depression, irritability300 Gross intoxication, loss of sight/hearing, confusion400 Progressive stupor, “passing out”500-800 Coma, paralysis of respiratory centre, fatal outcome

Source: Hughs, Bellis and Kilfoyle 2001

23

3.14 Long-term misuse of alcohol is a serious health risk to individuals and may contribute to many

cases of illness and premature deaths not specified as alcohol-related.

Table 3.2: Long-term health risks associated with alcohol misuse.

Disorder Associated IllnessLiver disorders Hepatitis; cirrhosis of the liverGastrointestinal problems Pancreatitis; cancer of the oesophagus; digestive problems; gastritisNerve and muscle damage Weakness; burning sensations in hands/feet; paralysisCirculatory problems High blood pressure, strokeCancer Cancer of the voicebox (larynx) the throat and the gullet as well as the

oesophagus and possibly breast cancer.Reproductive problems Impotence and infertility (in men); disruption of the menstrual cycle (in women)Malnutrition Obesity; weight loss through under-eating; disrupted metabolismRespiratory problems Fractured ribs, pneumonia; low blood sugarMental health Suicide; depression (more likely to drink and alcohol is likely to exacerbate

feelings of depression); psychiatric disorders

Source: Hughs, Bellis and Kilfoyle 2001

3.15 The cost of mortality among those of working age is included in the costs of lost output. The

cost of mortality of the non-working age population has also been considered. There are also

human costs associated with alcohol-related morbidity in terms of the pain/suffering and reduced

quality of life associated with these illnesses.

24

CHAPTER FOUR HEALTHCARE RESOURCE USE AND COSTS

Introduction

4.1 This chapter estimates annual levels of healthcare resource use attributable to alcohol misuse

and the corresponding costs incurred by NHS Scotland. In particular, the chapter covers:

s GP consultations;

s Community psychiatric team contacts;

s Drugs;

s Laboratory tests;

s Hospitalisations;

s Accident and emergency attendances;

s Outpatient attendances;

s Day hospital attendances;

s Ambulance transportation;

s Health promotion and prevention;

s Health board expenditure to alcohol-related voluntary organisations.

4.2 In terms of GP consultations and hospitalisations, data were available to look at resource use

in terms of attendances by those in different age groups, from different regions and the cause of the

attendance. The chapter ends by estimating the cost of healthcare resource use in Scotland and

undertaking a sensitivity analysis to test the robustness of the results by changing all the estimates of

resource use to 100% above and 50% below baseline values. Additionally, the limitations of the

costings in this area are noted.

GP Consultations

4.3 The Continuous Morbidity Recording in General Practice (CMRGP) database consists of 71

general practices in Scotland with a combined list size of 387,007. Thus, the database covers 7.2%

of the Scottish population. A CMRGP data set containing the rate of GP consultations for 1999

stratified by age, gender, and ICD 10 codes (see table 4.1) for conditions where the primary

25

diagnosis was directly attributable to alcohol (which were derived from Read codes - see Appendix

2) was obtained from the Primary Care Information Unit of the Information and Statistics Division

(ISD) in Scotland. An estimate of the number of consultations in each group was calculated by

combining rates with Scottish population statistics (General Register Office Scotland 2000a).

4.4 It was estimated that 73,628 GP consultations in 1999 were directly attributable to alcohol

misuse. Of this, 69% of consultations (n=50,714) were made by men and 31% (n=22,912) by

women. There were an estimated 2.48 million women and 2.63 million men in the Scottish

population in 1999. Hence, men made 204 GP consultations per 10,000 male population per annum

directly attributable to alcohol misuse compared to 87 GP consultations per 10,000 female

population per annum.

GP Consultations Stratified By Age

4.5 The annual number of GP consultations was stratified by age, as shown in Figure 4.1. This

illustrates that most GP consultations directly attributable to alcohol misuse were by individuals in the

25-44 and 45-64 year old age-groups.

Figure 4.1: Annual number of GP consultations due to alcohol misuse, stratified by age.

713601

3091832625

6411

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

0-14 15-24 25-44 45-64 >64Age group (years)

Annual number of GP

consultations

Source: Calculated from CMRGP rates from ISD, Scotland

26

4.6 When the annual number of GP consultations were estimated per 10,000 population (Figure

4.2), the GP consultation rate was found to be higher in the 45-64 year old age group than in the

other age groups. Furthermore, the GP consultation rate in the >64 year old age group was

comparable to that in the 25-44 year group.

Figure 4.2: Annual number of GP consultations per 10,000 population due to alcohol misuse, stratified by age.

2

112

398

541

420

0

100

200

300

400

500

600

0-14 15-24 25-44 45-64 >64

Age group (years)

Annual number of GP consultations

per 10,000 population


GP Consultations Stratified By Cause

4.7 When the annual number of GP consultations directly attributable to alcohol was stratified by

the different ICD code causes (Table 4.1), an estimated 91% of the GP consultations were found to

be due to mental and behavioural disorders, of which 98% were due to alcohol dependency and

withdrawal (94% and 4% respectively - not shown). Table 4.1 also illustrates that alcoholic liver

disease accounted for an estimated 7% of all GP consultations directly attributable to alcohol in

1999.

27

Table 4.1: Annual number of GP consultations stratified by causes directly attributable to alcohol.

GP consultations in 1999Condition by ICD 10 code

Annual number %Mental and behavioural disorders due to alcohol abuse (F10.0-F10.9) 66819 91%Degeneration of nervous system due to alcohol (G31.2) 0 0%Alcoholic polyneuropathy (G62.1) 425 1%Alcoholic myopathy (G72.1) 33 0%Alcoholic cardiomyopathy (I42.6) 156 0%Alcoholic gastritis (K29.6) 767 1%Alcoholic liver disease (K70.0-K70.4 & K70.9)) 5059 7%Alcohol-induced chronic pancreatitis (K86.0) 369 1%Maternal care for suspected damage to the foetus from alcohol (O35.4) 0 0%Foetus and newborn affected by maternal use of alcohol (P04.3) 0 0%Foetal alcohol syndrome (Q86.0) 0 0%TOTAL 73628 100%


GP Consultations Indirectly Due to Alcohol Misuse

4.8 The rate of GP consultations was also obtained from the CMRGP database for other

conditions associated with alcohol misuse (e.g. cardiovascular and hepatic diseases, some cancers

and injuries) where these conditions were the primary diagnosis. The proportion of consultations

attributable to alcohol misuse was calculated by combining current estimates of relative risk

associated with certain levels of consumption, with the percentage of individuals estimated to be

consuming alcohol at that level in Scotland (Appendix 3).

4.9 Thus, it was estimated that there were 137,890 GP consultations among individuals with

conditions associated with alcohol misuse in addition to the 73,626 GP consultations directly due to

alcohol misuse in 1999. Hence, it was estimated that there were 211,516 GP consultations in 1999

attributable to alcohol misuse.

Community-Dispensed Drugs

4.10 During 2000, an estimated £3 million was spent on drugs used to treat substance dependence

in Scotland (Information and Statistics Division 2001). According to the English Prescription Cost

Analysis data (Department of Health Statistics Division 1998), 6% of the cost of drugs used to treat

28

substance abuse are attributable to those with alcohol problems. Hence, the annual cost of drugs

attributable to alcohol misuse was estimated by assuming that 6% of the annual cost of drugs used to

treat substance misuse in Scotland was for drugs used specifically to treat alcohol problems (i.e.

acamprosate and disulfiram).

Laboratory Tests

4.11 Anecdotal evidence suggests that GPs would undertake blood tests to measure blood alcohol

levels and mean corpuscular volume, and liver function tests to measure levels of enzymes such as

gamma glutamyl transpeptidase. Therefore, the analysis assumed that patients consulting with their

GP because of an alcohol problem would undergo blood and biochemistry tests at the same time. It

was also assumed that individuals having GP consultations for conditions associated with alcohol

misuse would also undergo tests, but they would not necessarily be as a result of alcohol misuse.

Consequently, it has been assumed that the costs of tests for these individuals were not necessarily

attributable to alcohol misuse and they have therefore not been included in the analysis.

4.12 Since there were 73,626 GP consultations in 1999 directly attributable to alcohol misuse, it

was estimated that there were the same number of haematology and biochemistry tests. This equates

to 147,252 tests in total.

4.13 The costs of those tests and procedures attributable to alcohol misuse which are undertaken in

secondary care have been included as part of the cost of hospitalisation.

Inpatient and Day Case Episodes

4.14 Hospitalisation data were obtained from the inpatient databases (SMR01 for non-psychiatric

and SMR04 for psychiatric) held by the Information and Statistics Division, Scottish Executive,

which consist of data from all Scottish NHS Trusts. Data on non-psychiatric discharges where the

primary diagnosis was directly attributable to alcohol misuse for the year ending March 2000 were

provided according to ICD 10 code (the same codes as in Table 4.1) and stratified by specialty,

age, health board, and deprivation score (Carstairs index). Psychiatric discharge data where the

29

primary diagnosis was directly attributable to alcohol misuse were obtained for the most recent

available year (1998/1999). This was also stratified by age, health board and deprivation category

according to ICD 10 code. Data are presented as the annual number of inpatient episodes, day

cases and bed days.

4.15 The number of psychiatric inpatient discharge episodes in Scotland directly attributable to

alcohol misuse was estimated to be 4,078 in the year ending March 1999, accounting for 118,608

bed days. There were no day cases recorded for psychiatric episodes. Additionally, there were

8,924 non-psychiatric inpatient episodes in Scotland directly attributable to alcohol misuse in the

year ending March 2000, which accounted for 60,566 bed days and 455 day cases (Table 4.2).

Table 4.2: Annual number of non-psychiatric inpatient episodes, day cases and bed days directly attributable to alcohol misuse for the year ending March 2000, stratified by specialty.

Non-psychiatric hospitalisations:Inpatient episodes Day cases Bed days

Specialty Annualnumber

% Annualnumber

% Annualnumber

%

Acute medical 6497 73% 365 80% 50923 84%Acute surgical 780 9% 54 12% 3648 6%Elective medical 57 1% 4 1% 455 1%Elective surgical 57 1% 0 0% 195 0%Rehabilitation 619 7% 0 0% 4754 8Other 914 10% 32 7% 591 1%TOTAL 8924 100% 455 100% 60566 100%

Source: ISD, SMR01 database

4.16 Table 4.2 illustrates that acute admissions accounted for 82% of non-psychiatric

hospitalisations, with elective admissions accounting for 2% of episodes. Table 4.2 also shows that

there were relatively few day cases compared with inpatient episodes.

Hospitalisation Stratified By Age

4.17 The annual number of inpatient episodes directly attributable to alcohol misuse, stratified by

age, is shown in Figure 4.3.

30

Figure 4.3: Annual number of inpatient episodes directly attributable to alcohol misuse, stratified by age.

486595

764

1,786

2,237

1,710

973

1155

709564

28980 826

276

1,0391,233

0

500

1,000

1,500

2,000

2,500

<16 16-24 25-34 35-44 45-54 55-64 65-74 75-84 >85

Age group (years)

Annual number of inpatient episodes

Non-psychiatric episodes Psychiatric episodes

Source: ISD, SMR01 & SMR04 databases

4.18 Figure 4.3 illustrates that the 45-54 year old age-group accounted for 25% of non-psychiatric

inpatient episodes and the 35-44 and 55-64 year old age groups accounted for a further 20% and

19% respectively. The <35 year olds and >64 year olds accounted for a further 21% and 14%

respectively of non-psychiatric inpatient episodes during the year. It is also noteworthy that

individuals <16 years of age accounted for 486 non-psychiatric admissions directly attributable to

alcohol misuse during the year.

4.19 Figure 4.3 also illustrates that the 35-44 year old age-group accounted for 30% of the annual

number of psychiatric inpatient episodes and the 45-54 year old age group accounted for a further

25%. The <35 year old and >54 year old age groups accounted for a further 21% and 9%

respectively of psychiatric inpatient episodes during the year.

4.20 Figure 4.4 illustrates the annual number of inpatient episodes per 10,000 population, stratified

by age.

31

Figure 4.4: Annual number of inpatient episodes per 10,000 population directly attributable to alcohol misuse, stratified by age.

10 10

24

34 3222

110 916 16

115 3 13

73

05

1015

2025

3035

40

<16 16-24 25-34 35-44 45-54 55-64 65-74 75-84 >85

Age group (years)


per 10,000 population



4.21 Figure 4.4 illustrates that the rate of non-psychiatric inpatient episodes was highest among the

45-54 year old age-group followed by the 55-64 year old age group and then the 35-44 and 65-74

year old age groups. The rate among the 16-34 year old and 75-84 year old age groups was less

than half that among the 35-74 year old age group. Additionally, there were 5 admissions per

10,000 population in the <16 year old age group.

4.22 Figure 4.4 also illustrates that the annual rate of psychiatric inpatient episodes was the same in

the 35-44 and 45-54 year old age groups, and these were higher than the rates in the other age

groups.

Hospitalisation Stratified By Deprivation

4.23 The annual rate of inpatient episodes per 10,000 population directly attributable to alcohol

misuse, stratified by deprivation, is shown in Figure 4.5.

32

Figure 4.5: Annual number of inpatient episodes per 10,000 population due to alcohol misuse, stratified by deprivation.

8

17

30

8144

0

10

20

30

1-2 3-5 6-7

Carstairs Deprivation Category

Annual number of episodes per

10,000 population



4.24 Figure 4.5 illustrates that the annual number of inpatient episodes increases in accordance with

worsening Carstairs deprivation category.

Hospitalisation Stratified By Cause

4.25 Table 4.3 illustrates the annual number of inpatient and day case episodes associated with

causes directly attributable to alcohol.

33

Table 4.3: Annual number of inpatient episodes stratified by alcohol-related ICD codes.

Non-psychiatric hospitalisations Psychiatric hospitalisationsInpatientEpisodes

Day caseepisodes

BedDays

Inpatientepisodes

BeddaysCondition by

ICD code Annualnumber

% Annualnumber

% Annualnumber

% Annualnumber

% Annualnumber

%

Mental andbehaviouraldisorders due toalcohol abuse(F10.0-F10.9)

5448 61% 21 5% 28675 47% 4078 100% 118608 100%

Degeneration ofnervous systemdue to alcohol(G31.2)

41 0% 3 1% 592 1% 0 0% 0 0%

Alcoholicpolyneuropathy(G62.1)

23 0% 0 0% 672 1% 0 0% 0 0%

Alcoholicmyopathy(G72.1)

9 0% 0 0% 75 0% 0 0% 0 0%

Alcoholiccardiomyopathy(I42.6)

59 1% 5 1% 362 1% 0 0% 0 0%

Alcoholicgastritis (K29.6)

474 5% 17 4% 1011 2% 0 0% 0 0%

Alcoholic liverdisease (K70.0-K70.4 & K70.9))

2501 28% 403 89% 26939 44% 0 0% 0 0%

Alcohol-induced chronicpancreatitis(K86.0)

369 4% 6 1% 2240 4% 0 0% 0 0%

TOTAL 8924 455 60566 4078 118608


4.26 Table 4.3 illustrates that mental and behavioural disorders accounted for 61% of non-

psychiatric inpatient episodes during the year, 5% of day cases and 47% of all bed days. This was

followed by alcoholic liver disease, which accounted for 28% of inpatient episodes, 89% of day

cases and 44% of all bed days.

4.27 Maternity-related hospitalisations are recorded on separate databases (SMR02 and SMR11)

at the Information and Statistics Division of the NHS Scotland. These two databases were searched

for hospitalisation episodes due to: foetal alcohol syndrome (Q86.0), maternal care for suspected

damage to the foetus from alcohol (O35.4) and foetus and newborn affected by maternal use of

alcohol (P04.3). The search by primary diagnosis for episodes related to these three codes only

34

revealed three episodes, all for “maternal care for suspected damage to the foetus from alcohol” for

the year ending March 2001 (provisional data). These episodes were all classified as antenatal.

Two cases were in Lothian and were both day cases. The other case was in Fife and was admitted

and discharged on the same day. It is likely that there may be some under-reporting in this area.

4.28 As seen in Table 4.3, mental and behavioural disorders are treated on both non-psychiatric

and psychiatric wards. This may be because alcohol misuse resulting in a mental and behavioural

disorder can manifest as a somatic as well as a psychiatric complaint. Figure 4.6 illustrates the

distribution of the annual number of hospitalisations for the different mental and behavioural

disorders (F10 Codes) between psychiatric and non-psychiatric specialties.

Figure 4.6: Distribution of the annual number of inpatient episodes for mental and behavioural disorders, stratified by specialty

5%

35%

82%

13%

16%

85%

71%

70%

71%

39%

95%

65%

18%

87%

84%

15%

29%

30%

29%

61%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Acute intoxication

Harmful use

Dependence syndrome

Withdrawal state

Withdrawal state with delirium

Psychotic disorder

Amnesic syndrome

Late-onset psychotic disorder

Other

Unspecified

Percentage of annual number of hospitalisations

Psychiatric specialties Non-psychiatric specialties


4.29 Figure 4.6 illustrates that most admissions for mental and behavioural disorders arising from an

alcohol withdrawal state and acute intoxication are managed on a non-psychiatric ward. In contrast,

most admissions due to a mental and behavioural disorder arising from a psychotic disorder and

dependence syndrome are managed on a psychiatric ward. The other admissions are managed on

both psychiatric and non-psychiatric wards.

35

Hospitalisation Stratified by Health Board

4.30 Figure 4.7 shows the annual number of inpatient episodes stratified by health board.

Figure 4.7: Annual number of inpatient episodes due to alcohol misuse, stratified by health board.

132 176413 332

802

1924

586

969 1064

39 56

47814452 71 2 2 4

1100706

131435

685

149 223

765

292227432

608

0

500

1,000

1,500

2,000

2,500

Arg

yll &

Clyd

e.

A

yr & A

rran

Bor

ders

Dum

fries

& G

allow

ay

Fife

.

For

th V

alley

Gra

mpian

Grea

ter G

lasgo

w

Hig

hlan

d

Lan

arks

hire

L

othia

n

O

rkney

She

tland

Tay

side

Wes

tern I

sles




4.31 Figure 4.7 illustrates that the greatest number of non-psychiatric inpatient episodes due to

alcohol misuse was found in Greater Glasgow (22% of all episodes), followed by Lothian (12%)

and Argyll and Clyde (12%). In contrast, Highland accounted for 7% of all non-psychiatric inpatient

episodes due to alcohol misuse during the year and Orkney, Shetland and Western Isles collectively

accounted for <2%.

4.32 Figure 4.7 also illustrates that the greatest number of psychiatric inpatient episodes due to

alcohol misuse was in Greater Glasgow (19% of all episodes), Argyll and Clyde (17%) and Lothian

(15%) followed by Ayr and Arran (11%), Tayside (11%), Lanarkshire (7%) Highland (6%) and

Grampian (5%).

4.33 When the annual number of non-psychiatric inpatient episodes is adjusted for population size

(Figure 4.8), it was found that the rates per head of population of inpatient episodes due to alcohol

misuse were highest in Western Isles (52 per 10,000 population), Highland (28 per 10,000

36

population), Argyll and Clyde (26 per 10,000 population) and Shetland (24 per 10,000 population)

compared with Greater Glasgow (21 per 10,000 population) and Orkney (20 per 10,000

population).

Figure 4.8: Annual number of inpatient episodes per 10,000 population due to alcohol misuse, stratified by health board.

2619

12 12 12 12 1521

28

17 1420

24

12

52

1612

5 5 4 5 48 11

5 81 1

11

10

102030405060

Arg

yll &

Clyd

e

A

yr & A

rran

Bor

ders

Dum

fries

& G

allow

ay

Fife

.

For

th V

alley

Gra

mpian

Grea

ter G

lasgo

w

Hig

hlan

d

Lan

arks

hire

L

othia

n

O

rkney

She

tland

Tay

side

Wes

tern I

sles

Annual number of inpatient episodes per

10,000 population



4.34 Figure 4.8 also illustrates that Argyll and Clyde had the highest rate per head of population of

psychiatric inpatient episodes due to alcohol misuse. However, the rates were also high in Ayr and

Arran, Highland and Tayside, followed by Greater Glasgow and Lothian.

4.35 Table 4.4 illustrates the reasons for hospitalisation onto psychiatric wards for each Health

Board.

37

Table 4.4: Percentage of hospitalisations for mental and behavioural disorders admitted onto psychiatric wards for each health board.

HealthBoard

Acuteintoxication

Harmfuluse

Dependence syndrome

Withdrawalstate

Withdrawalstate withdelirium

Psychoticdisorder

Late-onsetpsychoticdisorder

Amnesicsyndrome

Unspecified

Argyll & Clyde 2% 7% 79% 1% 1% 3% 5% 0% 1%Ayr & Arran 0% 11% 80% 0% 0% 2% 3% 3% 0%Borders 0% 2% 79% 13% 2% 0% 4% 0% 0%Dumfries &Galloway

17% 7% 62% 0% 1% 10% 1% 1% 0%

Fife 5% 12% 56% 7% 3% 10% 5% 1% 1%Forth Valley 0% 20% 68% 4% 2% 2% 4% 1% 0%Grampian 4% 22% 44% 13% 9% 3% 4% 2% 0%GreaterGlasgow

1% 21% 61% 5% 2% 3% 6% 1% 0%

Highland 5% 20% 62% 7% 1% 1% 2% 1% 0%Lanarkshire 0% 40% 48% 1% 1% 4% 5% 1% 0%Lothian 7% 12% 63% 4% 2% 4% 5% 3% 0%Orkney 0% 50% 0% 50% 0% 0% 0% 0% 0%Shetland 0% 50% 50% 0% 0% 0% 0% 0% 0%Tayside 2% 9% 80% 2% 1% 3% 1% 3% 0%Western Isles 75% 0% 0% 0% 25% 0% 0% 0% 0%


4.36 Table 4.4 illustrates considerable concordance between the health boards, with the majority

of admissions onto psychiatric wards in most health boards being due to dependence syndrome

followed by harmful use.

4.37 Table 4.5 illustrates the reasons for hospitalisations onto non-psychiatric wards for each health

board.

38

Table 4.5: Percentage of hospitalisations admitted onto non-psychiatric wards for each health board.

HealthBoard

Mental &behavioural

disorders

Alcoholicdegeneration

of the nervoussystem

Alcoholicpolyneuropath

y

Alcoholicmyopathy

Alcoholiccardiomyopathy

Alcoholicgastritis

Alcoholicliver

disease

Alcoholicchronic

pancreatitis

Argyll & Clyde 68% 1% 0% 0% 0% 6% 22% 3%Ayr & Arran 71% 0% 1% 0% 0% 5% 20% 3%Borders 75% 0% 0% 0% 0% 2% 21% 2%Dumfries &Galloway

64% 0% 0% 0% 1% 7% 18% 9%

Fife 53% 1% 0% 0% 1% 7% 32% 7%Forth Valley 59% 1% 0% 0% 2% 2% 30% 5%Grampian 65% 1% 0% 0% 1% 3% 27% 3%GreaterGlasgow

55% 0% 0% 0% 1% 7% 32% 5%

Highland 74% 0% 1% 0% 1% 6% 16% 2%Lanarkshire 57% 0% 1% 0% 1% 5% 33% 4%Lothian 47% 0% 0% 0% 1% 7% 39% 6%Orkney 92% 0% 0% 0% 0% 5% 3% 0%Shetland 75% 2% 0% 0% 0% 0% 21% 2%Tayside 61% 1% 0% 0% 0% 3% 28% 7%Western Isles 88% 1% 0% 0% 1% 4% 4% 1%


4.38 Table 4.5 illustrates considerable concordance between the health boards, with the majority

of admissions onto non-psychiatric wards in most health boards being due to mental and behavioural

disorders, followed by alcoholic liver disease.

Hospitalisation Indirectly Due to Alcohol Misuse

4.39 Hospital discharge data were also obtained by primary diagnosis for those conditions where

the incidence of alcohol misuse is raised (e.g. cardiovascular and hepatic diseases, cancer and

injuries; see Appendix 3). The proportion of inpatient episodes indirectly due to alcohol misuse

among individuals with conditions associated with, or exacerbated by, alcohol was estimated by

combining current estimates of relative risk associated with certain levels of consumption with the

percentage of individuals estimated to be consuming alcohol at that level in Scotland.

4.40 The number of non-psychiatric inpatient episodes indirectly attributable to alcohol misuse was

estimated to be 13,191 (94,907 bed days) in the year ending March 2000. The number of

39

psychiatric inpatient episodes indirectly attributable to alcohol misuse was estimated to be 5 (1,236

bed-days) in the year ending March 1999.

Accident and Emergency Attendances

4.41 The number of attendances at accident and emergency departments in Scotland attributable to

alcohol misuse was not available. Nevertheless, in 1998/1999 there were a total of 1,566,258

attendances at Scottish accident and emergency departments (Information and Statistics Division

2000b). In Liverpool, an estimated 12% of accident and emergency attendances over two months

were considered to be alcohol-related (Pirmohamed et al 2000). Assuming a similar trend in

Scotland, it was estimated that there are 187,951 attendances per annum at accident and emergency

departments in Scotland attributable to alcohol misuse.

Outpatient Attendances

4.42 The number of outpatient attendances in Scotland attributable to alcohol misuse was not

available. It was estimated that 3% of all GP psychiatric consultations arise from alcohol misuse,

based on an estimate that 10-20% of GP consultations are due to psychiatric conditions (Office of

Health Economics 1999) and the proportion of all GP consultations that are attributable to alcohol

misuse (Information and Statistics Division 2001). Similarly, it was estimated that 13% of all

psychiatric inpatient episodes in Scotland are due to alcohol misuse (Information and Statistics

Division 2001). Hence, it was assumed that 8% (i.e. the mid-point of 3% and 13%) of all

psychiatric outpatient visits are attributable to alcohol misuse.

4.43 It was estimated that there were 358,000 outpatient attendances for psychiatry in 1998/1999

in Scotland (Information and Statistics Division 2000b). By assuming that 8% of these attendances

were due to alcohol misuse, it was estimated that there are 28,640 outpatient attendances due to

alcohol misuse annually.

4.44 A similar methodology was employed to estimate the annual number of non-psychiatric

outpatient attendances due to alcohol misuse. It was estimated that 1.4% of all non-psychiatric GP

40

consultations arise from alcohol misuse, based on the number of GP consultations for alcohol misuse

for each alcohol-related ICD code (Table 4.1) and the annual number of all non-psychiatric GP

consultations (Information and Statistics Division Scotland 2001). It was also estimated that 2% of

all non-psychiatric inpatient episodes in Scotland are due to alcohol misuse (Information and

Statistics Division 2001). Hence, it was assumed that 1.7% (i.e. the mid-point of 1.4% and 2%) of

all non-psychiatric outpatient visits are attributable to alcohol misuse.

4.45 There were approximately 3,844,669 non-psychiatric outpatient attendances (excluding

obstetrics, dental and learning disabilities). By assuming that 1.7% of these are due to alcohol

misuse, it was estimated that there are 65,359 attendances annually due to alcohol misuse.

Community Psychiatric Team Contact

4.46 The amount of community psychiatric team contact in Scotland attributable to alcohol misuse

was not available. Nevertheless, the annual cost of community psychiatric teams in 1999/2000 was

an estimated £46.9 million (Information and Statistics Division 2000a). Using the methodology

outlined in 4.42, it was assumed that 8% of this cost is attributable to the community psychiatry

teams managing individuals who are misusing alcohol.

Day Hospital Attendances

4.47 The number of day hospital attendances in Scotland attributable to alcohol misuse was not

available. Nevertheless, there were an estimated 201,000 day patient episodes for general

psychiatry and 359,000 for psychiatry of old age in Scotland during 1998/1999 (Information and

Statistics Division 2001). Using the methodology outlined in 4.42, it was assumed that 8% of

attendances were due to alcohol misuse. Hence, it was estimated that 16,080 day patient episodes

annually for general psychiatry and 28,720 for psychiatry of old age are due to alcohol misuse in

Scotland.

4.48 Non-psychiatric day hospital attendances due to alcohol misuse have not been quantified. The

majority of these episodes are due to stroke patients. However, the proportion of stroke patients

41

attending day hospitals is unknown and the proportion of strokes caused by alcohol is relatively

small (Wannamethee and Shaper 1996).

Ambulance Transportation

4.49 The proportion of ambulance transportation in Scotland attributable to alcohol misuse was

not available. Nevertheless, there were an estimated 495,248 ambulance responses in Scotland in

1999/2000 (Information and Statistics Division 2000). Of these, an estimated 12% may be alcohol-

related (Pirmohamed et al 2000). Hence, 64,382 ambulance responses per annum in Scotland were

estimated to be due to alcohol misuse.

Health Promotion/Prevention

4.50 In the year 1999/2000, the Health Education Board for Scotland (HEBS) spent £281,981 on

preventing alcohol misuse (Health Education Board for Scotland 2000). This was 7% of their total

expenditure on individual therapeutic areas. In contrast, 17% of their budget was spent on

cardiovascular disease. Of the expenditure on alcohol misuse, £216,098 (77%) was spent on the

general public programme and £65,883 (33%) was spent on voluntary sector programmes. Other

non-programme specific expenditure including staff, administration and communications amounted to

£3.9 million. It was assumed that 7% of this expenditure was attributable to alcohol misuse.

4.51 Responsibility for ensuring that there is appropriate health promotion at local level rests with the

individual health boards. However, it was difficult to assess the proportion of a health promotion

budget that is spent on alcohol misuse. Greater Glasgow's health promotion department commented

that their specialist Addictions Team undertakes a range of alcohol-related projects. Additionally,

aspects of alcohol-related work involve many other teams and sections within the department such

as the Youth Team, Research and Evaluation Team, and the Geographic Teams. For this reason, it

is highly probable that the costs reported are an underestimate.

4.52 “Drinkwise” is the national campaign for preventing alcohol misuse in Scotland. It emphasises

the role of choice in determining drinking outcomes, challenging the happy but misplaced philosophy

that implies that “the drink was to blame”. Core funding for Drinkwise in 2001/2002 is £287,322,

half of which is from HEBs and has thus already been accounted for.

42

4.53 Funding is additionally provided via health boards to fund local Alcohol Development Officers

(ADOs) and the current annual budget for this is £450,000.

Health Board Funding for Voluntary Organisations

4.54 Recent research (Coid et al 2000) found that 25 (9%) of all the voluntary organisations (278)

funded by health boards are for alcohol-related services at a cost of £535,334 in 1997/1998.

Approximately half of this funding came from Grampian, which has the fourth largest population of

the fifteen health boards.

Total Healthcare Costs

4.55 The total annual cost (at 2001/2002 prices) of alcohol misuse to the NHS Scotland was

estimated by assigning unit resource costs (Appendix 4) to the resource use estimates, as shown in

Table 4.6. When the unit cost at 2001/2002 prices was unavailable, older unit costs were uprated

to 2001/2002 prices using the Health Service Inflation Index.

Table 4.6: Annual cost of alcohol misuse to NHS Scotland at 2001/2002 prices.

ResourceAnnual

resource useAnnual cost(£ million)

Percentage ofannual cost

GP consultations 211516 3.6 4%GP-prescribed drugs 6% of drugs prescribed by

GPs for substancedependency

0.2 <1%

Laboratory tests 147252 1.8 2%Hospitalisation days 275775 54.3 57%Accident and emergency attendances 187951 9.6 10%Outpatient visits 93999 8.1 9%Day hospital attendances 44800 3.1 3%Community psychiatric team visits 8% of total community

psychiatric team expenditure4.0 4%

Ambulance journeys 64382 9.1 10%Health promotion/prevention by HEBS,Scottish Executive and Health Boards

HEBSDrinkwise

ADOs

1.2 1%

Health board expenditure to alcohol-related voluntary organisations

Funding to25 organisations

0.6 1%

TOTAL 95.6 100%

4.56 Table 4.6 illustrates that alcohol misuse costs the Scottish health service £96 million per

annum. Of this, hospitalisation accounts for an estimated 57% of the annual cost. Accident and

43

emergency attendances and ambulance transportation were estimated to each account for a further

10% and outpatient visits for a further 9%. In contrast, GP consultations and community psychiatric

teams were estimated to each account for 4% of the annual cost.

Sensitivity Analyses

4.57 Sensitivity analyses (Figure 4.9) estimated the impact on baseline costs to the NHS Scotland

of changing the activity levels of the resource categories to 100% above and 50% below baseline

values.

Figure 4.9: Sensitivity analyses on NHS Scotland costs.

£101

£150

£104 £99 £100 £105 £105£97 £96

£93

£68

£92 £94 £94 £91 £91 £95 £95

£0

£20

£40

£60

£80

£100

£120

£140

£160

Primary care

Hospitalisation

Outpatient visits

Day hospital attendances

Community psychiatric teams

Accident & emergency attendances

Ambulance transportation

Health promotion/prevention

Other health board expenditure

Annual cost to NHS Scotland attributable to alcohol misuse

4.58 Figure 4.9 shows that the annual cost to NHS Scotland attributable to alcohol misuse is most

sensitive to changes in the annual number of inpatient episodes and day cases. Doubling the annual

number of inpatient episodes and day cases would increase the annual NHS Scotland cost

attributable to alcohol misuse by 57%. Conversely, halving the annual number of inpatient episodes

and day cases would reduce the annual NHS Scotland cost attributable to alcohol misuse by 28%.

£m

44

4.59 Figure 4.9 also shows that the annual cost to NHS Scotland attributable to alcohol misuse is

sensitive to changes in the annual number of outpatient visits, accident and emergency attendances

and ambulance journeys. Doubling the annual number of outpatient visits, accident and emergency

attendances and ambulance journeys would increase the annual NHS Scotland cost attributable to

alcohol misuse by 8%, 10% and 10% respectively. Conversely, halving the annual number of

outpatient visits, accident and emergency attendances and ambulance journeys would reduce the

annual NHS Scotland cost attributable to alcohol misuse by 4%, 5% and 5% respectively.

4.60 The annual cost to NHS Scotland attributable to alcohol misuse is relatively insensitive to

changes in the use of primary care resources, day hospital attendances, annual expenditure on health

promotion/prevention and annual health board expenditure to alcohol-related voluntary

organisations. Changing these parameters by 100% above baseline or 50% below baseline would

only change the annual cost to NHS Scotland attributable to alcohol misuse by 6% or less.

Limitations

4.61 Consultations with practice nurses, district nurses and health visitors have not been quantified

in this analysis. In one Scottish study, the Chief Scientist Office made funding available to train health

visitors in the delivery of brief treatment interventions to women whose drinking was above the

recommended low-risk levels (Scott 2000). However, these programmes are rather the exception

than the norm and there is currently no evidence that nurses (excluding those in community

psychiatric teams) spend any considerable time on alcohol misuse issues. Further information may

become available next year as the Information and Statistics Division, Scotland has just commenced

collecting morbidity data from practice nurses and is in the process of developing data collection

procedures from health visitors and district nurses (Graham et al 2000). Additionally, there will be

more emphasis on this area in the future with the recent launch of a Nursing Council on Alcohol for

the UK with its head office based at Glasgow Caledonian University. Moreover, the Plan for Action

following this study will highlight the contribution which nurses can make.

45

CHAPTER FIVE SOCIAL WORK SERVICES RESOURCE USE

AND COSTS

Introduction

5.1 This chapter estimates annual levels of resource use associated with alcohol misuse and the

corresponding costs incurred by social work departments. In particular, the chapter covers the three

main components of social work: children and families, community care and criminal justice social

work and estimates how much case load in each area is due to alcohol misuse. Additionally, the

chapter includes expenditure incurred by the Children’s Hearing System, which works closely with

social work departments.

5.2 The chapter concludes by estimating the total cost of social work resource use in Scotland

associated with alcohol misuse and examining its sensitivity to changes in each of the major cost

areas. Additionally, the limitations of the costings in this area are discussed.

Children and Families

5.3 Data on all social work expenditure are provided by local authority finance departments to the

Scottish Executive Development Department, Local Government Finance Statistics branch via

“LFR3” returns. This includes expenditure on children’s services.

5.4 In 1999/2000, the total gross expenditure on children’s social work was reported to be £286

million (Local Government Finance Statistics – LRF3 Return 2000). This includes expenditure and

training costs for members of the children’s panels and the children’s panels advisory committees

and the expenses of parents for attending panel hearings, but not the Panel's operating costs (see

section 5.12).

5.5 There is a lack of published data on the proportion of social work due to alcohol misuse. The

most recent study in this area in Scotland appears to be a survey undertaken by Aberdeen City

Council on alcohol as a reason for social work involvement (1997). This survey reported that 24%

46

of children's social work had alcohol cited as a factor in the referral. In 80% of these cases there

was a history of alcohol problems and this was by the parent rather than the child in 93% of the

cases. The working group on social work and alcohol misuse (Appendix 5) was in agreement with

the proportion of 24% and it was therefore assumed that 24% of the total gross expenditure

(uprated to 2001/2002 prices) on children’s social work was associated with alcohol misuse.

Community Care

5.6 Substance misusers (which includes both drug and alcohol misuse) are specified as a client

group within community care. In 1999/2000, the total gross expenditure on community care

specifically for substance misuse was £10.4 million (Scottish Executive 2001a Scottish Community

Care Statistics). Of this, 25% was spent on day centres, 39% on residential and nursing homes and

36% on other services for substance misuse (Local Government Finance Statistics – LRF3 Return

2000). There were 354 residents in private nursing homes specified as having alcohol-related

problems as of 31st March 2000. More than half of these (59%) were less than 65 years of age

(ISD Scotland, ISD(S)34 Return).

5.7 Information on community care expenditure for the substance misuse client group is also

available for the 32 local authorities in Scotland (net expenditure rather than gross is reported) and

can be seen in Table 5.1

5.8 Table 5.1 also shows that in 1999/2000 the local authorities with the highest expenditure per

capita on community care services for substance misuse problems were Glasgow City, Inverclyde

and Aberdeen City. Included in the expenditure for Glasgow City Council are the 50 places

purchased for clients with alcohol-related brain damage in one of three registered nursing homes at

an annual cost of £900,000 (Greater Glasgow Heath Board 2000).

47

Table 5.1: Net expenditure by Local Authorities on community care services associated with alcohol and drug misuse for 1999/2000

Local Authority Expenditure (£000s) Expenditure (£) per capitaAberdeen City 556 2.64Aberdeenshire 318 1.40Angus 102 0.93Argyll & Bute 24 0.27Clackmannanshire - 0Dumfries & Galloway 11 0.07Dundee city 254 1.76East Ayrshire 170 1.40East Dunbartonshire 28 0East Lothian 40 0.44East Renfewshire 11 0.12Edinburgh, City of 454 1.01Eileanan Siar 23 0.83Falkirk 58 0.40Fife 231 0.66Glasgow City 2986 4.84Highland 454 2.18Inverclyde 342 4.05Midlothian 38 0.47Moray 62 0.72North Ayrshire 287 2.05North Lanarkshire 538 1.65Orkney Islands - 0Perth & Kinross 307 2.30Renfrewshire 383 2.16Scottish Borders 37 0.35Shetland Islands 55 2.38South Ayrshire 35 0.31South Lanarkshire - 0Stirling 34 0West Dunbarton 154 1.63West Lothian 108 0.70Scotland (total) 8159

Source: Scottish Community Care Statistics 2000

5.9 It is unknown how much of this total expenditure is specifically associated with alcohol misuse

rather than drugs. The working party on alcohol misuse and social work (Appendix 5) suggested

that the proportion of this expenditure associated with alcohol and drug misuse is likely to differ

between local authorities. The working group considered that, on average, the proportion of

expenditure on alcohol services within community care throughout Scotland would be approximately

20%. Thus, it was assumed that 20% of expenditure on community care services (uprated to

2001/2002 prices) is attributable to alcohol misuse. However, it should be noted that individuals in

other client groups may also have alcohol problems contributing to their need for community care

48

services e.g. the elderly, those with mental health problems or the homeless. Therefore, this cost of

community care for alcohol misuse is likely to be an underestimate.

Criminal Justice Social Work

5.10 In 1999/2000 the total gross expenditure on social work for adult offenders was £41 million

(Scottish Executive 2001a - Scottish Community Care statistics). It is known that in 1999, of all

crimes and offences committed with a charge proved, 4,888 received a community service order

and 7,340 received a probation order (Justice Statistics Unit, Scottish Executive 2001). From the

totals in Appendix 6 (iii) it was calculated that in each case, offences specifically mentioning alcohol

e.g. drunk and disorderly, accounted for approximately 3% of these (167 community service orders

and 198 probation orders).

5.11 In addition to the offences which specifically mention alcohol there are a number of other

crimes and offences which may not have happened in the absence of alcohol e.g. shoplifting, assault

or vandalism. In Appendix 6 the number of these other crimes and offences attributable to alcohol

has been estimated (see 6.4 for details of this calculation). If it is assumed that alcohol is a causal

factor in 25% of these crimes and offences (after Bennett 1998) then it would lead to a further

1,180 community service orders and 1,786 probation orders (Appendix 6). Hence, 27.6% of all

community service orders (1,347) and 27% of all probation orders (1,984) in 1999 were the

outcome of crimes and offences due to alcohol misuse. The proportion of all community service and

probation orders estimated as being due to alcohol was used as a proxy for the amount of criminal

justice social work expenditure that is associated with cases involving alcohol. Hence, it was

assumed that 27% of criminal justice social work expenditure is due to alcohol misuse.

Children’s Hearing System

5.12 In 1999/2000 there were 63,755 referrals to the Children’s Hearing System in total (Scottish

Children’s Reporter Administration (SCRA) Annual Report 1999-2000). Two percent of these

(1359) were directly due to alcohol and drug misuse by the children. After the initial referral, the

49

Reporter took action on 31% of these referrals - 20% to a hearing and 11% to social work

departments. Unfortunately, figures are not collected separately for alcohol misuse.

5.13 The proportion of these substance misuse referrals due to alcohol misuse by the child is

unknown. It has thus been assumed that 20% are due to alcohol misuse and 80% are due to drug

misuse, as outlined in section 5.9. Therefore it was estimated that 272 referrals are due to alcohol

misuse alone.

5.14 In 1999/2000 there were 14,203 referrals on the alleged grounds of “lack of parental care”.

Some of these referrals would either have been exclusively or partly due to alcohol misuse by

parents. Using the proportion of 24% from the Aberdeen City Council survey on alcohol as a

reason for social work involvement (1997) and assuming that each referral accounts for a similar

amount of social work time, it was estimated that 24% of the 14,203 referrals are due to alcohol

misuse. This amounts to 3,409 referrals in 1999/2000.

5.15 Hence it was estimated that in 1999/2000 there were 3,681 referrals due to alcohol misuse

(i.e. 272 + 3,409) to the Children’s Hearing System, accounting for 6% of all referrals. The total

expenditure on staff and operational costs for the Children’s Hearing Panel in the year 1999/2000

was £12 million (SCRA 2000).

5.16 Additionally, there were other alleged grounds for referrals to the Children’s Hearing System

in which alcohol may be a significant contributory factor. These include an offence or crime

committed by the child or the child being the victim of a schedule 1 offence (e.g. physical injury).

However, the contribution that alcohol may make in these cases is unknown. Hence, the cost of the

Children’s Hearing System associated with alcohol misuse is likely to be an underestimate.

Total Social Work and Children’s Hearing System Costs

5.17 The annual cost (at 2001/2002 prices) of social work and the Children’s Hearing System

associated with alcohol misuse is shown in Table 5.2.

50

Table 5.2: Annual cost of social work services due to alcohol misuse at 2001/2002 prices.

Social work activity Annual resource use Annual cost(£ million)


Children and Families 24% of total expenditure on children andfamilies social work

71.8 84%

Community Care 20% of social work expendituresubstance misuse

2.2 3%

Criminal Justice social work 27% of total expenditure on criminaljustice social work

11.1 13%

Children’s Hearing System(Independent of social workdepartments)

6% of all referrals & thus 6% ofexpenditure

0.8 1%

TOTAL 85.9 100%

5.18 Table 5.2 illustrates that alcohol misuse costs Scottish social work departments and the

Children’s Hearing System, £85.9 million per annum. Of this, social work associated with children

and families accounts for an estimated 84% of the annual cost and criminal justice social work for a

further 13%. In contrast, Community Care and the Children's Hearing System each account for 3%

and 1% respectively.


5.19 Sensitivity analyses (Figure 5.1) estimated the impact on the baseline cost of social work

activity and the Children’s Hearing System of changing the levels of resource use to 100% above

and 50% below baseline values.

51

Figure 5.1: Sensitivity analyses on the cost of social work services in Scotland.

£158

£88£97

£87

£50

£85 £80 £86

£0

£20

£40

£60

£80

£100

£120

£140

£160

£180

Children and families Community care Criminal justicesocial work

Children's HearingSystem

Annual cost of social work in Scotland associated with alcohol misuse (£m)

5.20 Figure 5.1 shows that the annual cost of social work in Scotland associated with alcohol

misuse is most sensitive to changes in the percentage of total expenditure on children and families

social work and criminal justice social work that is associated with alcohol misuse. Doubling the

percentage of total expenditure on children an d families social work would increase the annual cost

of social work associated with alcohol misuse by 84%. Conversely, halving the percentage of total

expenditure would reduce the annual cost of social work associated with alcohol misuse by 42%.

The equivalent percentages for criminal justice social work are 13% and 6% respectively.

5.21 The annual cost of social work in Scotland associated with alcohol misuse is relatively

insensitive to changes in the annual number of referrals to the Children's Hearing System and the

proportion of social work community care expenditure associated with alcohol misuse. Changing

these parameters by 100% above baseline or 50% below baseline would only change the annual

cost of social work in Scotland associated with alcohol misuse by 3% or less.

£m

52

Limitations

5.22 Voluntary and private alcohol services which often work closely with social work departments

have not been costed. The difficulty with assigning costs to these non-statutory agencies is that even

if the total cost of all their services were available, not all these services are purely for those with

alcohol problems; they may additionally provide services for those with drug misuse, homelessness

or mental health problems. The exact proportion of the workload of each service that is specifically

alcohol-related is unknown. Furthermore, these services straddle both the private and voluntary

sector and may sometimes be partly funded by health boards or social work services and this would

lead to double counting e.g. Glasgow Council on Alcohol receives funding from a variety of sources

including Glasgow City Council Social Work Services, Greater Glasgow Health Board, donations

and the Lloyds TSB foundation (Greater Glasgow Health Board 2000).

5.23 Alcohol Focus Scotland co-ordinates a network of 28 affiliated Local Councils on Alcohol

(LCAs) offering free, confidential, advisory and counselling services. LCAs are the main voluntary

groups providing dedicated alcohol services across Scotland. There are many other groups in the

non-statutory sector. For example, Alcoholics Anonymous has 923 local groups in Scotland with a

membership of about 15,000.

5.24 Alcohol Focus Scotland produces a directory of alcohol services for Scotland. Including the

LCAs there are 59 day services and in terms of residential services, there are 13 centres classified

as “rehab” hostels and 35 are specifically for those who are homeless. Additionally, there are four

private alcohol treatment units and two “designated place”. The latter are in Aberdeen and

Inverness and all referrals must be via the police after arrest for offences due to drunkenness.

Presently, the only offence applicable is Drunk and Incapable. Of the 59 non-NHS day services, 44

(75%) including the LCAs do not specify social work services, local authorities or health boards as

their parent body, thus showing the prominence of the voluntary sector for alcohol misuse services.

Thirteen of the 15 “rehab” hostels (87%) specify their parent body as being from the

voluntary/independent sector as do 29 of the 35 homeless hostels (83%). Hence, the private and

voluntary sectors make a significant contribution to the provision of services for those with alcohol

problems. However, due to the inherent problems involved in obtaining costs in this area, no cost

estimate has been made.

53

CHAPTER SIX CRIMINAL JUSTICE SYSTEM AND

EMERGENCY SERVICES RESOURCE USE AND

COSTS

Introduction

6.1 This chapter estimates annual levels of resource use associated with alcohol misuse that are

incurred by the criminal justice system and the corresponding costs.

6.2 The chapter also considers costs incurred by the emergency services as a result of road traffic

accidents and fires associated with alcohol misuse (excluding ambulance service costs which are

included in chapter 4). The cost of the drink drive campaign in Scotland is also included.

6.3 The chapter concludes by estimating the total cost of resource use by the criminal justice

system and emergency services in Scotland associated with alcohol misuse and undertaking

sensitivity analyses to test the robustness of the results to changes in the estimates of resource use to

100% above and 50% below baseline values. Additionally, the limitations of the costings in this area

are noted.

Criminal Justice System Resource Use

6.4 The link between alcohol and crime is complex. Research has shown that alcohol is often

consumed by offenders and victims prior to offences being committed, however there is little

evidence of its precise role (Shepherd 1994). While alcohol is not always a causal factor in crime, it

can both contribute to and be associated with crime. Hayes (1993) clarified this by defining three

relationships which describe the link between alcohol and crime:

s Causal relationships include alcohol-defined offences (offences defined in law by virtue of the

use of alcohol alongside a behaviour which would otherwise be lawful, e.g. drunk-in-charge of a

child), alcohol-induced offences (offences which occur because the offender has drunk alcohol,

54

typically public disturbances) and alcohol-inspired offences (offences committed to obtain

alcohol, typically shoplifting to obtain drink or goods to sell in exchange for drink).

s Contributory relationships include drinking for “dutch courage” to facilitate an offence which

requires an element of courage, alcohol acting as a trigger, or used as an excuse for offending

behaviour.

s Co-existence where offenders engage in two separate activities which have no relationship with

each other. For example, an offender may drink heavily in their private life but this may have

nothing to do with their criminal activity

For costing estimates there is only an interest in those crimes and offences which would not have

happened in the absence of alcohol. This includes all crimes and offences with a causal relationship

with alcohol and may include some where alcohol has been a contributory factor.

6.5 Appendix 6 shows the number of crimes and offences which were recorded by police in

Scotland in 1999 together with those with a charge proved and results of proceedings (Justice

Statistics Unit, Scottish Executive 2001). Appendix 6 (i) and (ii) show crimes and offences not

directly related to alcohol (i.e. those that do not specifically mention alcohol). However, some of

these crimes and offences may be attributable to alcohol. A recent Home Office study (Bennett

1998) reported alcohol levels of arrestees in police custody. The study found that 25% of arrestees

tested positively for alcohol. It has thus been assumed on the basis of this study that 25% of all the

crimes and offences listed in Appendix 6 (i) and (ii) are attributable to alcohol.

6.6 Appendix 6 (iii) shows the number of offences which specifically mention alcohol. Most

offences recorded by the police were for being drunk and incapable and drunk driving. In the

majority of cases (91%), the penalty received was a fine. In 149 cases (2%) a custodial sentence

was received. Sentence lengths for those receiving a custodial sentence for alcohol-related offences

are shown in Table 6.1.

55

Table: 6.1 Sentence lengths for persons receiving a custodial sentence in Scottish courts for alcohol-related offences during 1999.

Number of persons who received a custodial sentence in 1999

Offence AllUp to 3months

3 up to 6months

6 months up to2 years

2-4 yearsAverage length ofsentence served

(days)Drunkenness 12 11 1 - - 14Drunk driving 137 63 67 6 1 67Totals 149 74 68 6 1

Source: Criminal Justice Statistics Unit, Scottish Executive

6.7 In addition to Table 6.1, custodial sentences for those crimes and offences attributable to

alcohol misuse listed in Appendix 6 (i) and (ii) are shown in Table 6.2. Prisoners do not serve their

entire sentence and thus the average days served was estimated by the Criminal Justice Statistics

Unit based on the rules of release. Persons sentenced to less than 4 years are automatically released

half way through their sentence. Persons sentenced to 4 years or more are eligible for parole half

way through their sentence, and if they are not granted parole they are released automatically after

serving two-thirds of their sentence. The current average length of time served by life sentence

prisoners is 13 years

56

Table: 6.2 Number of persons who received a custodial sentence in Scottish courts forcrimes or offences during 1999 and the estimated number of persons whoreceived a custodial sentence for crimes or offences attributable to alcohol,stratified by sentence length received and estimated number of days served.

Up to 4 years 4 years and over Life

Main crime or offenceTotal number

of personswho receiveda custodialsentence

Numberattributableto alcohol†

Averagenumberof daysserved





Non sexual violent crimesHomicide 71 4 206 6 1418 9 4745Serious assault 522 104 265 26 1329 - -Handling offensive weapons 510 128 55 - - - -Robbery 458 85 215 30 1192 - -Other 34 8 172 1 1243 - -Crimes of indecencySexual assault 77 10 260 8 1482 1 4745Lewd & indecent behaviour 136 29 227 5 1340 - -Other 32 6 275 2 1563 - -Crimes of dishonestyHousebreaking 1525 381 104 1 1088 - -Theft by opening lockfastplaces

603 151 67 - - - -

Theft of motor vehicle 507 127 70 - - - -Shoplifting 1991 497 48 - 852 - -Other theft 1383 345 58 1 1600 - -Fraud 207 49 84 3 1097 - -Other 599 149 63 1 1118 - -Fire raising vandalism etcFire raising 23 5 246 1 1279 - -Vandalism etc 269 67 47 - - - -Other crimesCrimes against public justice 782 194 41 2 1278 - -Drugs 950 203 163 34 1171 - -Other 12 3 100 1 1150 - -Miscellaneous offencesSimple assault 1324 329 70 2 992 - -Breach of the peace 1082 270 39 1 1279 - -Other 1761 439 45 2 1141 - -Motor Vehicle OffencesDangerous & carelessdriving

121 30 119 - - - -

Speeding 0 - - - - - -Unlawful use of vehicle 940 235 86 - - - -Vehicle defect offences 0 - - - - - -Other 6 2 66 - - - -Totals 15925 3847 124 10

Source: Criminal Justice Statistics Unit, Scottish Executive†25% of crimes and offences attributable to alcohol after Bennett 1998 (see section 6.4)

57

6.8 The total cost of custodial sentences was determined by applying the cost of six months in

prison in Scotland (£14,187 at 1999/2000 prices; Scottish Office 2000) to the total estimated length

of time served for the 149 alcohol offences (i.e. 9,347 days - average sentence length served

multiplied by number of offences). Additionally, the total cost of custodial sentences for the length of

time served for the other estimated 3981 crimes and offences attributable to alcohol (353,059 days)

was added to this. The total cost of custodial sentences for those who had commenced their

sentence in previous years and who were still imprisoned in the study year were also included. This

was estimated to be an additional 202,766 imprisonment days being served in the study year due to

crimes attributable to alcohol by those convicted in previous years. This latter estimate assumes a

constant level of crime associated with alcohol misuse in previous years and a constant level of

alcohol misuse in previous years.

6.9 Of all persons with a charge proved in Scotland in 1999, 97% were disposed in sheriff

summary or district courts (Scottish Office 2000). The average court cost for the sheriff summary

court weighted by percentage of cases disposed at each stage was £166 in 1999/2000 and the

average prosecution cost was £218 (Scottish Office 2000). These costs do not include the cost of

any social work reports. Court costs for district courts are not available as the local authorities that

are responsible for the administration of district courts do not collect costs in this way. Hence, all

expenditure on court proceedings has been estimated using sheriff summary court costs. The overall

cost of proceedings in district courts is likely to be lower than in sheriff summary courts (the

weighted prosecution cost per case was calculated to be £94 while it is £218 in the sheriff summary

court). However, the small proportion of cases heard in the higher courts (sheriff solemn and high

court) would be at a considerably higher cost. Thus, sheriff summary court costs (uprated to

2001/2002 prices) have been applied to the 7,759 alcohol-related offences proceeded against in

Scottish courts. Additionally the number of crimes and offences attributable to alcohol which were

proceeded against has been estimated to be 34,771 (Table 6.3) and the cost of these proceedings

has also been estimated.

58

Table: 6.3 Number of persons proceeded against in Scottish courts in 1999 for crimes or offences attributable to alcohol

Main crime or offence Number of persons proceededagainst

Estimated number of personsproceeded against for crimes oroffences attributable to alcohol

Non-alcohol specific crimes andoffences *Non-sexual violent crimes 5547 1387Crimes of indecency 1083 271Crimes of dishonesty 28315 7079Fire raising vandalism etc 4893 1223Other crimes 13940 3485Miscellaneous offences(excluding drunkenness)

39228 9807

Motor Vehicle Offences(excluding drink driving)

46076 11519

Totals 139082 34771

Drink offencesDrunkenness 523 523Drink driving 7236 7236Totals 7759 7759

Source: Criminal Justice Statistics Unit, Scottish Executive* 25% attributable to alcohol (after Bennett 1998)

6.10 Total police expenditure in Scotland during 1999/2000 was £776 million (Scottish Office

2000) for a total of 940,152 police recorded crimes and offences (see Appendix 6). Of this,

248,992 (26%) were estimated to be crimes and offences attributable to alcohol. By assuming that

each offence incurs a comparable amount of police expenditure, it was estimated that 26% of police

expenditure (uprated to 2001/2002 prices) in Scotland is alcohol-related.

The Emergency Services

6.11 The link between alcohol consumption and accidents is well established. For example, it has

been estimated that alcohol is a factor in 20-30% of accidents (Honkanen 1993) and heavy drinking

is associated with 15% of drownings (Royal Society for the Prevention of Accidents 1998) and

39% of deaths in fires (Tether 1986). The costs of these accidents in terms of morbidity and

mortality have been accounted for in terms of NHS costs, the cost of premature mortality (both

economic output and human costs) and police time. However, these accidents lead to costs being

incurred by other services. Road accident safety campaigns and the fire service incur costs due to

alcohol-related accidents.

59

6.12 Each year, the Department of the Environment, Transport and the Regions (DETR) estimates

the number of injuries in road accidents involving illegal alcohol levels. These are calculated using

information from the road accidents statistical returns about the number of injuries in road accidents

in which one (or more) motor vehicle drivers or riders refuse to give a breath test specimen or fail a

breath test. Additionally, the estimates are calculated using information from the procurators fiscal

about the blood alcohol levels of road users who die within 12 hours of being injured in a road

accident.

6.13 There are no estimates for Scotland on the number of alcohol-related injuries in road

accidents which involve legal alcohol levels. Neither are there any estimates for Scotland on the

numbers of non-injury (“damage only”) road accidents involving illegal alcohol levels.

6.14 In 1998 the DETR estimated that there were 740 accidents which involved drivers with illegal

alcohol levels in Scotland. Of these accidents, 520 (70%) were considered to be “slight”, 170

(23%) were “serious” and 50 (7%) were fatal. These accidents were estimated to involve 1,090

casualties in total.

6.15 Approximately 9% of the fire service’s workload is non-fire activity (e.g. road traffic

accidents). However, the eight Scottish fire brigades do not collect information on the number of

road traffic accidents caused by drink driving that they attend.

6.16 During 2001-2002, the budget for the drink driving campaign in Scotland is £141,000.

Additionally, £70,000 is being spent on research into attitudes towards drink driving (Road Safety

Campaigns Unit, 2001). The UK-wide drink drive campaigns on television are also seen in

Scotland. However, this study is Scotland specific so the cost of this has not been included.

6.17 An estimated 85 people died in 76 house fires in Scotland during 2000. Misuse of alcohol

was a major contributory factor in 41 of these fires (54%) (Scottish Executive 2001b). It has been

noted that alcohol affects the fire risk in several ways: an increase in the risk of fire outbreak, a

reduction in the ability to react when fire is discovered, and an adverse effect on both the potential

for self-escape and the ability to assist other occupants (Squires and Busuttil 1997).

60

6.18 Information is not recorded on the number of fires attended by the fire service where alcohol

has been a major contributory factor in the cause or extent of a fire, unless the fire results in a

fatality. For this reason it has not been possible to estimate the cost to the fire service of attending

fires associated with alcohol misuse.

Total Criminal Justice and Emergency Services Costs

6.19 The annual cost (at 2001/2002 prices) of criminal justice system resource use associated with

alcohol misuse is shown in Table 6.3.

Table 6.4: Annual cost of criminal justice system resource use associated with alcohol misuse at 2001/2002 prices.

Criminal justice system resource use andemergency services associated with:

Annual resourceuse



Custodial sentences 565,172 days inprison

46.1 17%

Court time and legal costs for prosecutions 42,530 offencesproceeded against

19.8 7%

Police time 26% of allexpenditure

201.8 75%

Drink driving campaign Drink drivingcampaign and

research

0.2 0%

TOTAL 267.9 100%

6.20 Table 6.3 illustrates that resource use by the Scottish criminal justice system associated with

alcohol misuse costs an estimated £267.9 million per annum. Police time accounted for 75% of the

annual cost while custodial sentences account for a further 17%. Court time and legal costs account

for 7% of the annual cost. The cost of the drink driving campaign as a percentage of total costs is

negligible.


6.21 Sensitivity analyses (Figure 6.1) estimated the impact on baseline criminal justice system costs

of changing the levels of resource use to 100% above and 50% below baseline value.

61

Figure 6.1 : Sensitivity analysis on the annual cost of criminal justice system resource use attributable to alcohol misuse.

£288.0 £268.0£314.0

£470.0

£245.0 £258.0 £268.0

£167.0

-£70

£30

£130

£230

£330

£430

£530

£630

Custodial sentences Court time & legalcosts

Police time Drink drivecampaign

Annual cost of criminal justice system resource use due to alcohol misuse (£m)

6.22 Figure 6.1 shows that the annual cost of resources used by the criminal justice system

associated with alcohol misuse is most sensitive to changes in the amount of police time associated

with alcohol misuse. A doubling of the amount of police time would increase the annual cost of

resource use by the criminal justice system associated with alcohol misuse by 75%. Conversely,

halving the annual amount of police time would reduce the annual cost of the criminal justice system

associated with alcohol misuse by 38%. The total cost is also relatively sensitive to custodial

sentences associated with alcohol misuse. Doubling the number of days spent in prison would

increase the annual cost by 17% and halving the amount of days would decrease the total by 9%.

The annual cost of resources used by the criminal justice system associated with alcohol misuse is

relatively insensitive to changes in the annual number of prosecutions associated with alcohol misuse.

Limitations

6.23 It was not possible to estimate the cost of alcohol-related road traffic accidents and fires

attended by the fire service (see sections 6.10-6.17).

62

6.24 The Scottish Courts Service confirmed that the costs of custodial sentences benefit from

economies of scale, due to the initial costs of admitting an offender to prison. Hence, the unit cost of

imprisonment decreases with longer custodial sentences. Almost a quarter (24%) of all custodial

sentences attributable to alcohol (Tables 6.1 and 6.2) are for crimes and offences where less than

three months is actually served. However, information on these initial costs was not available.

6.25 An additional cost not included in this chapter is that resulting from property damage, both

intentional (such as arson) and unintentional (such as that arising from road accidents). Damage

arising from minor incidences would not necessarily be reported to the police or insurance

companies. Under-reporting of this damage, the proportion of damage due to alcohol and the

variation in value of the assorted property damaged makes a cost valuation in this area difficult.

63

CHAPTER SEVEN WIDER ECONOMIC COSTS

Introduction

7.1 This chapter estimates the wider economic costs to Scottish society arising from lost

productivity as a consequence of increased unemployment, higher absenteeism from work and

premature death among those in the working age population arising from alcohol misuse.

7.2 Ideally, the impact of working days lost on Scottish output and employment would be

estimated using The Input Output Tables for Scotland. However, this would require estimates not

only of the number of working days lost due to alcohol-related illness, but also stratified by industrial

sector. Since these data are not available, it was not possible to estimate the impact on Scottish

output and employment by this method.

7.3 These wider costs have predominantly been estimated using the “human capital approach”

although the “willingness to pay approach” (WTP) has been adopted to estimate the cost of

premature mortality. The human capital approach involves applying the annual average wage in

Scotland (New Earnings Survey, ONS 2000b) plus on-costs (i.e. costs paid by employers in

respect of their employees e.g. employers’ national insurance) to lost working time associated with

morbidity and mortality due to alcohol misuse. The inclusion of on-costs enables an employee’s

work time to be valued at the total cost paid for it by an employer. The WTP approach is a

standard valuation method which is used to assess the value which people (collectively) put on

reducing risks, in this case, the value of reducing the risks of mortality.

Unemployment

7.4 Data on the number of people unemployed in Scotland due to alcohol misuse is not available.

Nevertheless, the unemployment rate among those with an alcohol dependency was calculated using

the prevalence rate for alcohol dependency stratified by employment status (after Meltzer et al

1995). It was calculated that 10% of males and 3% of females who are alcohol-dependent are

unemployed in Scotland. By subtracting this unemployment rate from the general unemployment rate

64

in Scotland (i.e. 7% and 2% for men and women respectively (Labour Force Survey, ONS

2000a)), it was estimated that the excess unemployment rate for alcohol-dependants was 3% in men

and 1% in women. Hence, due to the increased tendency for persons that are alcohol-dependent to

be unemployed, it was estimated that 3,398 men and 138 women are unemployed in Scotland per

annum as a result of alcohol dependency.

Absenteeism from work

7.5 The average number of days absent from work due to sickness in the UK is 4 for men and 6

for women per annum (Labour Force Survey, ONS 2000a). However, data are not routinely

collected on absenteeism from work due to alcohol misuse and there are relatively few published

studies investigating the relationship between alcohol consumption and time off work. Nevertheless,

the evidence suggests that alcohol-dependent people take up to four times this number (Institute of

Alcohol Studies 1997). Some of this may be attributable to work-related accidents as up to 25% of

these are thought to be associated with alcohol (Alcohol Concern 2000). It was estimated that

there are 134,374 alcohol-dependent individuals in employment in Scotland (after Meltzer et al

1995 and adjusted in accordance with the unemployment rate among alcohol-dependent individuals

estimated in 7.3 and for the percentage of people in the Scottish population who are economically

inactive (Labour Force Survey, ONS 2000a)). It was conservatively assumed that each of these

individuals take three times the national amount of sick leave and thus it was estimated that an

additional 1,164,344 sick days per annum are lost from the work place in Scotland due to alcohol

dependency.

Premature Mortality of the Working Population

7.6 Estimating the costs of premature mortality in the working population1 is a three step process.

The first step involves estimating the number of people who died as a result of alcohol misuse in

Scotland. The second involves estimating the number of working year lives lost due to premature

1 The costs of premature mortality for the non-working age population are estimated in chapter 8

65

death from alcohol-related causes. The third involves applying appropriate WTP values for each

year of life lost.

7.7 Step 1 - Premature mortality attributable to alcohol misuse was calculated from the annual

number of deaths with an alcohol-related cause in 1999 (the most recent year for which data were

available) obtained from the General Register Office in Scotland. The annual number of deaths was

obtained for each alcohol-specific ICD 9 code and stratified by age and sex. The number of deaths

caused by conditions associated with alcohol misuse was also obtained. The proportion of deaths

attributable to alcohol misuse in these conditions was calculated by combining current estimates of

relative risk associated with certain levels of consumption with the percentage of individuals known

to be consuming alcohol at that level in Scotland (Appendix 3).

7.8 In 1999, 1,032 people died directly from alcohol-related causes in Scotland (General Register

Office, Scotland 2001 - see Appendix 1). A further 609 deaths were estimated to be indirectly

attributable to alcohol. Hence, an estimated 1,641 deaths were associated with alcohol misuse

during 1999, accounting for 3% of deaths in Scotland in that year.

7.9 Step 2 - The number of working years lost for those who died prematurely as a result of

alcohol misuse in the study year was estimated by calculating the mean age of death for each cause

and subtracting it from the usual retirement age (65 years). The estimated number of working years

was adjusted in accordance with the percentages of people in the Scottish population who are either

economically inactive or unemployed (Labour Force Survey, ONS 2000a). After accounting for

unemployment, the number of people who are economically inactive in the Scottish population and

the age of death being higher than the retirement age, it was estimated that there were 12,546

working years of life lost as a result of 766 deaths per annum attributable to alcohol misuse.

7.10 Step 3 – The WTP approach involves assessing the monetary value which people put on

reducing the risks associated with mortality. Unfortunately, there are no published studies which

assess the value that people put on reductions in mortality risk from alcohol misuse. However,

substantial evidence exists concerning the value that people attach to changes in mortality risks in

other contexts. The Department of the Environment, Transport and the Regions (DETR) for

66

example, produce WTP-based values for the prevention of road fatalities (commonly referred to as

the value for preventing a statistical fatality-VPF). More general WTP values – referred to as values

of statistical life (VOSL) – are widely used in many European countries and internationally. The

WTP component of the VPF figure has been estimated to be £1,031,100 at 1999 prices. This

equates to a life year valuation of £27,022 at 2001/02 prices. This valuation (rather than the VOSL

values) was applied to the 12,546 working years of life lost since it is a UK estimate and is more

conservative than the VOSL values. The cost of these working years of life lost for those who died

prematurely and who are therefore absent from the workforce in subsequent years was discounted

at 6% (The Treasury 1997). Hence, the cost of premature mortality in the working age population

was estimated to be £201.5 million (discounted). There are different views on the discount rate

which should be applied when discounting life years lost. One argument is that the pure time

preference rate of 1.5% should be used since life years have a broadly constant utility value over

time. Using this rate the cost of premature mortality in the working age population was estimated to

be £297.6 million. However, the conservative rate of 6% has been used in this analysis since the

Treasury is yet to produce further formal guidelines on this issue.

Total Wider Economic Costs

7.11 Table 7.1 summarises the annual wider economic costs to Scottish society.

Table 7.1: Annual indirect cost to Scottish society due to alcohol misuse.

Source of lostproductivity:

Annual lost productivityresulting from:



Unemployment 3536 unemployed individuals 84.0 21%Absenteeism fromwork

1164344 days absent from work 119.0 29%

Premature mortality(WTP)

766 deaths resulting in 12546working years of life lost

201.5 50%

Total Cost 404.5 100%

7.12 Table 7.1 illustrates that lost productivity attributable to alcohol misuse costs Scottish society

at least £404.5 million per annum. Lost productivity attributable to premature mortality accounts for

50% of these wider economic costs. Lost productivity attributable to absenteeism from work

accounts for 29% and excess unemployment for a further 21%.

67


7.13 Sensitivity analyses (Figure 7.1) estimated the impact on baseline indirect costs of changing

the activity levels of the resource categories to 100% above and 50% below baseline values.

Figure 7.1: Sensitivity analysis on wider economic costs.

£524

£606

£363 £345£304

£489

£0

£100

£200

£300

£400

£500

£600

£700

Unemployment Absenteeism Premature mortality

Annual wider economic costs of alcohol misuse

(£m)

7.14 Figure 7.1 shows that the annual indirect cost attributable to alcohol misuse is most sensitive

to changes in premature mortality and the annual number of sick days lost from the work place due

to alcohol dependency. A doubling of the annual number of premature deaths due to alcohol

dependency would lead to a 50% increase in wider economic costs attributable to alcohol misuse.

Conversely, a 50% reduction in the annual number of premature deaths due to alcohol dependency

would lead to a 25% decrease in the wider economic costs attributable to alcohol misuse.

7.15 Additionally, doubling the annual number of sick days lost from the work place in Scotland

due to alcohol dependency would lead to a 29% increase in the annual indirect cost attributable to

alcohol misuse. Conversely, a 50% reduction in the annual number of sick days lost from the work

place due to alcohol dependency would lead to a 15% decrease in the annual indirect cost

attributable to alcohol misuse.

£m

68

7.16 Figure 7.1 also shows that the annual indirect cost attributable to alcohol misuse is less

sensitive to changes in the annual number of people who are unemployed because of alcohol

dependency. Doubling the annual number of people who are unemployed because of alcohol

dependency would lead to a 21% increase in the annual indirect cost attributable to alcohol misuse.

Conversely, a 50% reduction in the annual number of people who are unemployed because of

alcohol dependency would lead to an 10% decrease in the annual indirect cost attributable to

alcohol misuse.

Limitations

7.17 Reduced productivity in the workplace due to alcohol misuse has not been quantified. Those

in employment with alcohol problems may experience either intoxication or hangovers in the

workplace. Consequently, while they might not take time off work, there may still be productivity

losses resulting from a reduction in the quality or quantity of work produced or both. It is extremely

difficult to estimate this reduction in productivity, since it is dependent on occupation and a

measurable output. Therefore, the cost of reduced productivity has not been quantified due to the

inherent measurement problems concerned in making such a calculation.

7.18 It was recognised in section 2.9 that alcohol consumption patterns differ by social class.

Applying the average annual wage could overestimate the economic cost since alcohol misuse

problems are generally more severe in deprived population groups, who tend to receive lower

wages than the average wage (Harrison and Gardiner 1999). However, the relationship between

alcohol consumption and social class is not straightforward and data are not available to reflect this

issue in the analysis.

7.19 Additionally, there are a number of other limitations pertaining to the wider economic costs.

Firstly, the only information available on absenteeism and unemployment was in alcohol dependants.

Second, UK average annual sickness absence days have been used as Scotland-specific figures are

not published. Third, there may be further hidden costs caused, for example, by non-attendance at

work through hangover effects or due to other alcohol-attributable conditions. Furthermore, there

69

has been no accounting for early retirement in those misusing alcohol due to lack of available

information. However, to counterbalance this is the argument that in countries which have

unemployment, the impact of premature death on labour resources or excess unemployment among

those with an alcohol problem may not be sizeable (Godfrey 1997).

70

CHAPTER EIGHT HUMAN COSTS

Introduction

8.1 There are significant human costs associated with alcohol-related illness in terms of mortality

and morbidity. The cost of premature mortality has already been estimated for the working

population in chapter seven. This chapter estimates the cost of mortality for the non-working

population. In addition, the human costs associated with alcohol-related illness (i.e. the pain and

suffering and hence reduced quality of life) are considered.

The Health and Social Impact of Alcohol Misuse

8.2 Alcohol misuse can impact on health and thus mortality and morbidity in a number of different

ways. The acute and long-term effects have been described in chapter 3 (see Tables 3.1 and 3.2),

however the medical consequences of alcohol misuse do not reflect its true toll on health. Excessive

alcohol misuse can cause a range of problems where social and health issues are inextricably linked

with a cost to society and the individual.

8.3 There is substantial evidence on the reduction in quality of family life associated with alcohol

misuse. For children, the effects of parental misuse of alcohol can even begin prenatally, resulting in

foetal alcohol syndrome. This is a specific pattern of foetal malformation with growth deficiency,

craniofacial anomalies and limb defects often with mental retardation. Later in life, the children of

parents with alcohol problems have been found to be more susceptible than other children to

specific illnesses, such as mental illness, substance abuse, injuries and poisoning (Woodside et al

1993). These children have also been reported as having high rates of health, behavioural and

emotional problems, such as truancy and poor school performance, anti-social behaviour, difficulty

in forming relationships and psychiatric problems including depression (Velleman 1993).

Furthermore, it is estimated that alcohol is involved in 30% to 60% of all child protection cases in

the UK (Institute of Alcohol Studies 1997). In Scotland, Alcohol Focus Scotland (formally the

Scottish Council on Alcohol) has estimated that 86,000 children live with parents or carers who

misuse alcohol.

71

8.4 Heavy drinking is a common factor in family break-up, and marriages where one or both

partners have an alcohol problem, are twice as likely to end in divorce compared to marriages

where alcohol problems are absent (Velleman 1993). Alcohol is a factor in up to 50% of cases of

domestic violence (British Medical Association 1989) and it is thought that up to 70% of men who

assault their partners are under the influence of alcohol when the assault takes place (Jacobs 1998).

Women exposed to alcohol abuse in the household are more likely to perceive themselves as less

healthy and more likely to feel depressed (Ryan et al 1997).

8.5 Alcohol misuse is widespread among the homeless population. In a survey of Glasgow hostel

residents for the single homeless, hostel managers reported that 37% of the 2,028 residents had an

alcohol problem. The Rough Sleepers Unit has highlighted that 50% of the rough sleeper population

are alcohol-reliant (as opposed to 30% who are drug users) and that between 30% and 50% of

rough sleepers have a serious mental health problem (Rough Sleepers Unit 1999). These individuals

possibly become homeless as a result of an alcohol problem or turn to alcohol in an attempt to

alleviate the problems created by their homelessness.

8.6 Another important consequence of alcohol misuse is the harmful effects on the sexual health of

users. The use of alcohol may lessen inhibitions and while under the influence of alcohol, individuals

are more likely to engage in risk-taking behaviour. A UK study found that young women were

more likely to have unprotected sex while under the influence of alcohol (Farrow and Arnold 2000).

Unprotected sex could result in unwanted pregnancies or infection with sexually-transmitted

diseases.

The Cost of Premature Mortality for the Non-Working Population

8.7 The total number of life years lost for those who died prematurely as a result of alcohol misuse

in 1999 was estimated by calculating the mean age of death for each cause and subtracting it from

the life expectancy figures for men and women (General Register Office for Scotland 2000b). The

number of lost life years in Scotland directly due to alcohol misuse was estimated to be 20,581

years. If the deaths indirectly due to alcohol misuse are included, this estimate becomes 28,003 lost

72

life years. Using the DETR derived value for a year of life (£27,022, see Chapter 7), the total value

of life years lost was estimated to be £418.2 million (discounted). This estimate however includes

the value of working years lost which has already been estimated (£201.5 million for 12,546

working years lost). Subtracting the latter value from the total gives an estimated valuation of

£216.7 million (discounted at 6%) for the 15,457 years lost by those in the non-working population.

Using a 1.5% discount rate (as discussed in section 7.10), the estimated valuation is £354.8 million.

The Human Costs of Morbidity due to Alcohol Misuse

8.8 Morbidity involves a reduction in health-related quality of life. In order to gauge the extent of

morbidity in its many forms, it needs to be described and assessed in ways that are comparable and

consistent. Generic systems, such as quality of life scales/instruments, can be used to describe

morbidity by assessing life expectancy weighted for health-related quality of life. The EuroQoL

(EQ-5D) questionnaire is one such generic, health-related quality of life instrument. The EQ-5D has

five standard dimensions of health: mobility, self-care, usual activities, pain/discomfort and anxiety

and depression. The advantage of such an instrument is that all health states are described using the

same standard descriptions and can thus be compared. The EQ5D uses a single cardinal scale to

describe health states as perceived by the general population where 0 represents a scale that is as

bad as being dead and 1 represents the best of health.

8.9 Several studies have assessed the quality of life of alcohol-dependants. For example, one

study concluded that alcohol-dependent individuals experience a specific pattern of impairment in

health-related quality of life with three main characteristics: a relative lack of impairment in the

physical and functioning dimensions, a profile of health-related quality of life similar to that of patients

with depression, and a positive relationship between the severity of alcohol-dependence and the

degree of impairment in quality of life (Daeppen et al 1998). A review of several studies on alcohol-

dependent individuals found their quality of life to be very poor and that important factors affecting

their quality of life are psychiatric co-morbidity, social environment and disturbed sleep (Foster et al

1999).

73

8.10 As has been noted throughout this study, the health outcomes of alcohol misuse are disparate

(Tables 3.1 and 3.2) and although alcohol misuse often leads to a reduced health-related quality of

life, measurement of this is hampered. Different studies have used different quality of life instruments

to measure different health outcomes. Consequently, comparisons between studies are fraught with

difficulties. Moreover, a literature search did not find any UK-based studies evaluating individuals’

willingness-to-pay to avoid the symptoms associated with alcohol-related illnesses. Consequently, it

has not been possible to value the human cost of morbidity associated with alcohol misuse.

74

CHAPTER NINE COMPARISONS AND CONCLUSIONS

Introduction

9.1 This chapter:

s Summarises the costs of alcohol misuse in Scotland;

s Compares the results of this study with those of similar studies conducted in the UK and other

countries;

s Compares the cost of alcohol misuse with the estimated cost of other conditions;

s Identifies the main uncertainties and limitations in the estimates presented;

s Presents the key conclusions.

Summary of the Cost of Alcohol Misuse in Scotland

9.2 This study used a prevalence-based approach and estimated the total annual societal cost

associated with alcohol misuse in Scotland to be £1,070.6 million. The distribution of the estimated

costs between the different statutory agencies and society is shown in Figure 9.1

Figure 9.1: Distribution of the annual societal cost of alcohol misuse in Scotland.

Human costs£261.7 (20%)

Wider economic costs

£404.5million(38%)

Criminal justice system

£267.9 million(25%)

Social work services

£85.9 million(8%)

NHS Scotland£95.6 million

(9%)

75

9.3 Of the wider economic costs, 50% was due to premature mortality, 29% to absenteeism from

work and 21% to the higher unemployment rate among alcohol dependants than the general

population.

9.4 Eighty four percent of social work services costs is accounted for by expenditure on children

and families. Criminal justice social work accounts for a further 13% while community care and the

Children's Hearing System collectively account for the remaining 4%.

9.5 Most of the healthcare costs are attributable to inpatient care, accounting for 57% of the total

annual cost of healthcare. Accident and emergency attendances and ambulance transportation both

contribute a further 10%. Primary healthcare contributes less than 7% to the total annual NHS

Scotland cost, of which GP consultations account for 64% (i.e. 4% of the total annual cost).

9.6 Police time associated with alcohol misuse accounts for 75% of the cost of the Scottish

criminal justice system. Custodial sentences and prosecutions account for the remaining 17% and

7% respectively.

9.7 In addition to these costs, the human cost of alcohol misuse was estimated to be £217 million

(discounted) per annum for 15,457 lives lost in the non-working population. This did not include an

estimation of the cost of morbidity and thus reduced quality of life due to alcohol misuse.

9.8 In terms of the statutory agencies, alcohol misuse imposes a greater burden on the criminal

justice system than both the health service and social work services. However, the greatest burden is

on the individual and society as a whole in terms of lost productivity arising from unemployment,

absenteeism from work and premature mortality. The wider economic cost is consistent with the

burden placed on the health service, since it is those of working age who have more alcohol-related

GP consultations and hospital admissions than those in other age groups. The finding that alcohol-

related hospital admissions are higher among those who live in areas of deprivation, may also be

consistent with the estimated 24% of children and families social work caseload being alcohol-

related. There seems a prima facie argument that families from more deprived socio-economic

circumstances account for a higher proportion of social workers' case load than other members of

76

society, although further studies are needed to substantiate this. Some work has shown that alcohol

appears to be similar to other psychoactive substances in that problem use is associated with social

structural factors such a poverty, disadvantage and social class (Harrison and Gardiner 1999).

Where pockets of disadvantage exist and alcohol consumption and related harm are high, there may

be a case for introducing a range of community level initiatives.

9.9 The local authorities which incurred the greatest expenditure on community care services for

drug and alcohol misuse in 1999/2000 were, in order of decreasing expenditure, Glasgow City,

Aberdeen City, North Lanarkshire, City of Edinburgh, Highland and Renfrewshire. If this

community care expenditure is considered per capita, the order becomes Glasgow City, Inverclyde,

Aberdeen City, Shetland Islands and Perth and Kinross. Hence, Glasgow City and Aberdeen City

local authorities have the highest reported expenditure on substance misuse both overall and in terms

of per capita. However, it should be noted that expenditure and use of both health and social work

services may only be an indication of service provision and not be informative about service

requirements. For example, Fife social work services has noted that alcohol services are running at

capacity with waiting lists for some services (Fife Social work services 2001). Notwithstanding this,

these particular regions of Scotland appear to be where the burden of alcohol misuse is greatest.

9.10 Several health boards have recognised that alcohol misuse is a serious problem in their area

and have already developed their own strategies for dealing with this (e.g. Greater Glasgow and

Lanarkshire; (Greater Glasgow 2000, Lanarkshire Health Board 2000)). Greater Glasgow's

strategy, in particular, includes proposals for future treatment and support services, since the

availability of specialist social work services is patchy (Greater Glasgow 2000). There is now a

priority to increase the level of services provided for chronic problem drinkers in Greater Glasgow.

9.11 Alcohol misuse is showing concerning trends in the younger age groups with significant

increases since 1990 in those aged 11-15 years reporting drinking something alcoholic at least once

a week (WHO 1998). This is reflected in the increasing referrals to the Children's Hearing System

for drug and alcohol misuse (although the exact proportions of each are unknown) and has been

causing increasing concern in social work services departments. Aberdeenshire council social work

services has reported that increases in alcohol-related offences and alcohol-related hospital

77

admissions suggest that alcohol misuse is becoming more widespread, especially among young

people (Aberdeenshire Social work services 2001). Eilean Siar social work services noted that they

have a high incidence of alcohol misuse and that under-age drinking is a problem (Eilean Siar Social

Work Services 2001). Additionally, there were 486 non-psychiatric hospital admissions by those

under 16 years directly due to alcohol in 1999/2000.

9.12 It was estimated that 26% of all crimes and offences recorded by the police are associated

with alcohol misuse, and this is likely to be specifically due to misuse at the time of an offence. A

report produced by the Home Office noted that “many of the problems the police deal with are not

a result of dependent drinkers but are ordinary drinkers who have ‘binged’ and cannot control their

behaviour” (Deehan 1999). Acute alcohol misuse is additionally associated with accidents and thus

accident and emergency admissions, fires and fire service resource use, property damage and

inefficiency at work. Hence, the cost of alcohol misuse impacts significantly on Scottish society.

The Portman Group has recently extended their sensible drinking campaign to Scotland with its

initiative entitled “If you do do drink, don’t do drunk” aimed at encouraging younger drinkers to

avoid drinking excessively.

Comparison with Other Cost of Alcohol Misuse Studies

9.13 There is no previously published study on the cost of alcohol misuse in Scotland. One in-

house study by Argyll and Clyde Health Board (Smith et al 1996) estimated some healthcare costs

for Scotland by extrapolating from a study in their own area. The population covered by Argyll and

Clyde Health Board represents 8% of Scotland's population. Moreover, Argyll and Clyde has some

of the highest hospitalisation rates of all the health boards (see Figure 4.8). Thus, their cost estimate

for hospitalisations and accident and emergency attendances was high at £154 million (the total

number of episodes and unit costs used were not reported making comparisons with this study

difficult). Other studies have been completed within the UK, for Northern Ireland and England and

Wales (McDonnell and Maynard 1985). Estimates on the cost of alcohol misuse specifically to the

NHS have also been undertaken by the Royal College of Physicians (2001). Similar studies have

also been conducted for other countries. The results of these studies are summarised in Table 9.1

78

Table 9.1: Total annual societal cost of alcohol misuse in different OECD countries. *Includes human costs of £441 million.

CountryYear

ofstudy

Annual cost inyear of study

Equivalent annualcost at 2000

prices

Cost per capita Reference

Canada 1992 US $9 billion £7 billion £222 Single et al 1998France 1996 US $13 billion £10 billion £168 Reynaud et al 1999England andWales

1983 £1615 million £ 4 billion £76 McDonnell et al 1985

Japan 1987 Yen 6604 billion £82 billion £646 Nakamura et al 1993N Ireland 1997 £778 million* £844 million £498New Zealand 1991 $1045 million £373 million £97 Devlin et al 1997U.S. 1992 US $148 billion £134 billion £482 Harwood et al 1998

9.14 The study estimating the annual cost associated with alcohol misuse in Northern Ireland

estimated that GP visits, inpatient psychiatric and non-psychiatric episodes cost £13 million, £4

million and £9 million respectively. Comparable costs for Scotland were £4 million, £19 million and

£36 million respectively. The population of Scotland is approximately three times that of Northern

Ireland so the GP cost for Northern Ireland appears very high in comparison with that calculated for

Scotland. The difference is explained by different methodologies. While the Scottish estimate is

based on GP consultation rates for alcohol misuse and the application of unit costs, the cost for

Northern Ireland is based on an assumption that alcohol misuse accounts for 14% of all GP costs.

This draws attention to the fact that comparisons between studies should be made with the

appropriate caution.

9.15 Inpatient costs were also estimated by the Royal College of Physicians and calculated to be

£500 million in 1998/1999 by assuming that 7% of all inpatient episodes are alcohol-related. This

cost increases to £2.9 billion if it is assumed that 40% of acute specialties are alcohol-related. As the

population of the whole UK is 12 times that of Scotland, the estimated cost of £54.3 million for

Scotland is in line with the UK cost estimates.

9.16 Table 9.1 also shows the results of several other prevalence-based cost of illness studies

which estimated the total societal cost of alcohol misuse in a number of OECD countries. The results

have been converted to sterling and up-rated to 2000 prices. Clear differences emerge when

looking at the costs per capita, which may be accounted for by differences in the costs included,

methodologies, societal infrastructure and alcohol consumption levels. (In this study the cost per

79

capita is estimated to be £209). However, there are some similarities between the studies. For

example, the Canadian study estimated that 3% of deaths were attributable to alcohol misuse which

is the same percentage found in this study.

9.17 The proportion of costs due to productivity losses are high and are reported to be 78%,

67%, and 55% in the Japanese, New Zealand, and Canadian studies respectively (Nakamura et al

1993, Devlin et al 1997 and Single et al 1998). However, in this study the wider economic costs

account for only 38% of the total societal cost due to the inclusion of human costs. This is

comparable with the study completed in Northern Ireland which estimated human costs and where

the “social cost to industry” was estimated to be 31% of total societal costs.

Comparative Analysis with Different Cost of Illnesses

9.18 As well as looking at other studies which have estimated the costs of alcohol misuse, it is

interesting to look at studies which have estimated the costs of other illnesses. Figure 9.2

summarises the prevalence-based direct cost of different conditions in Scotland, estimated from UK

studies and uprated to 2001/2002 prices (Gray and Fenn 1993, Drummond et al 1993, Anderson

et al 1994, Guest 1999, Hart and Guest 1995, ABPI 1999, Gerard et al 1989, Guest 1998, Gray

et al 1995, Blau and Drummond 1991, Blumhardt and Wood 1996, Guest and Morris 1997, Wade

1994, Dale 1989, Kind and Sorensen 1993, Knapp 1997). The direct costs do not include

estimations of wider economic costs or human costs.

80

Figure 9.2: Direct annual costs associated with different conditions at 2001/2002 prices.

£90£93

£121£118

£449£382

£155

£55£25

£11£5£4

£61

£0 £100 £200 £300 £400 £500MigraineMultiple sclerosis

Benign prostatic hyperplasiaCritical limb ischaemiaPneumoniaDepression

Chronic obstructive pulmonary diseaseDiabetes

StrokeSchizophreniaAlzheimer's diseaseDrug misuseAlcohol misuse

Annual direct cost (£ million)

9.19 Figure 9.3 summarises the annual wider economic costs of different illnesses to Scottish

society, estimated from UK studies and uprated to 2001/2002 prices (Kind and Sorensen 1993,

Knapp 1997, Das Gupta and Guest 2001, Gray et al 1995).

Figure 9.3: Indirect annual costs associated with different conditions in Scotland at 2001/2002 prices.

£411

£405

£235

£156

£<1

£0 £40 £80 £120 £160 £200 £240 £280 £320 £360 £400 £440

Insulin-dependantdiabetes mellitus

Bipolar disorder*

Schizoprenia

Alcohol misuse

Depression

Annual indirect cost (£ million)(* also known as manic depression)

81

9.20 Various methodological differences exist between the studies summarised in Figures 9.2 and

9.3, which make direct comparisons difficult. Notably in Figure 9.2 only the alcohol and drug misuse

figures include criminal justice costs. Sixty percent of the direct costs attributable to alcohol misuse

are criminal justice costs, increasing to 62% if criminal justice social work is also included.

Nevertheless, these graphs illustrate that alcohol misuse imposes a substantial burden on Scottish

society which is greater than many prevalent illnesses, such as stroke, chronic obstructive pulmonary

disease (COPD) and diabetes.

9.21 It is also interesting to compare this study with one completed recently on Scottish Executive

expenditure on tackling drug misuse (Scottish Executive 2000c). The total cost for tackling drug

misuse was estimated to be £333 million at the end of 1999. However, when adjusted for inflation

and the extra £100 million to be received over three years announced in September 2000, this

estimate increases to £382 million for 2001/2002. In this study, the direct cost of resource use

associated with alcohol misuse (excluding wider economic costs and human costs) was estimated to

be £449 million in Scotland and thus 17% higher than that for drug misuse. Some cost estimates

were comparable between the two studies. For example, the cost of criminal justice social work

was based on an assumption that 30% of crime was drug-related, suggesting a cost of £11.6 million.

In this study, a proportion of 32% was assumed and thus the estimated cost was £13.7 million.

Other costs differed markedly between the two studies. For example, the drug misuse study

estimated the healthcare cost to be £36.3 million (this includes a £15.3 million ringfenced allocation

to health boards for 2001/2002) whereas this study estimated the cost to be £95.6 million.

Comparisons should be made with appropriate caution due to the different methodologies used,

notwithstanding the fact that budgets for drugs and alcohol misuse services are often not separately

defined. When announcing additional funding to tackle drug misuse in August 2001, the Scottish

Deputy Justice Minister commented “because of the increasing evidence that drug users also have

long-term problems with alcohol, we have asked Health Boards and Drug Action Teams to include

in their priorities for this funding, services which also address the misuse of alcohol”.

9.22 This study has estimated that there are at least 1,641 premature deaths due to alcohol misuse

in Scotland annually. In comparison, the annual number of deaths due to asthma, insulin-dependent

diabetes and depression in Scotland (estimated from UK studies) are 133, 166 and 217

82

respectively (Kind and Sorensen 1993, Gray et al 1995, National Asthma Campaign 1999). The

annual number of lost life years associated with alcohol misuse in Scotland was estimated to be

28,003. This compares with 3,167, 3,417 and 3,333 annual lost life years for asthma (National

Asthma Campaign 1999), malignant melanoma (Department of Health 1996) and

bronchitis/emphysema (Department of Health 1996) respectively for Scotland (estimated from UK

studies). Hence, these estimates highlight the disproportionate impact that alcohol misuse has on

premature mortality.

Uncertainty and Limitations

9.23 There is considerable uncertainty surrounding some of the resource use estimates that have

been used in this analysis, due to the lack of robust published studies. In particular, there is a lack of

published information about the resources provided by social work services and the criminal justice

system in managing cases that are alcohol-related. Nevertheless, attempts have been made to

estimate resource use wherever possible and the impact of these assumptions has been tested by

sensitivity analyses.

9.24 Alcohol-related expenditure by NHS Scotland is sensitive to the annual number of inpatient

episodes and day cases, outpatient visits, accident and emergency attendances and ambulance

journeys. The annual number of inpatient episodes and day cases directly related to alcohol were

obtained from the inpatient databases of the Information and Statistics Division of the NHS

Scotland, which consists of data from all Scottish NHS Trusts. Therefore, this estimate was

considered to be robust. However, the number of inpatient episodes attributable to conditions where

the incidence of alcohol misuse is raised was calculated by combining current estimates of relative

risk associated with certain levels of consumption with the percentage of individuals estimated to be

consuming alcohol at that level in Scotland. Nevertheless, this methodology has been widely used in

other studies to estimate the cost associated with alcohol misuse (Single et al 1992).

9.25 The annual number of outpatient visits, accident and emergency attendances and ambulance

journeys was estimated from several data sources. However, even if these estimates were out by

100%, it would only introduce a margin of error on the total annual healthcare cost attributable to

alcohol misuse of the order of 10%.

83

9.26 The annual cost of social work services in Scotland associated with alcohol misuse was most

sensitive to changes in the percentage of total expenditure on children and families social work

related to alcohol misuse. The Aberdeen City Council survey found that 24% of total expenditure on

children and families social work was associated with alcohol misuse, since alcohol was cited as a

factor in 24% of children and families social work involvement. Basing the cost estimate on this

figure could lead to a substantial margin of error in the annual cost of social work services in

Scotland associated with alcohol misuse. The area covered by Aberdeen City Council may not be

representative of Scotland as a whole and alcohol was only cited as a factor and not the cause of

social work involvement. Nevertheless, in the absence of robust published data, there remains some

uncertainty surrounding this estimate.

9.27 The annual cost of resources used by the criminal justice system associated with alcohol

misuse is most sensitive to changes in the amount of police time. However, 26% of all crimes and

offences recorded by the police in 1999/2000 were estimated as being caused by alcohol and in the

absence of any robust published data it was assumed that this would result in 26% of police time

being spent on alcohol-related crimes. Nevertheless, there remains some uncertainty surrounding this

estimate, which could result in a substantial margin of error in the annual cost of resource use by the

criminal justice system.

9.28 The wider economic costs attributable to alcohol misuse were sensitive to changes in

premature mortality and the annual number of sick days lost from the work place due to alcohol

dependency and the annual number of people who are unemployed. The latter two parameters were

estimated from other studies and may therefore represent some uncertainty. However, the annual

number of premature deaths due to alcohol misuse, which was obtained from the General Register

Office in Scotland, may be an underestimate rather than an overestimate (see Chapter Two, section

2.24).

9.29 Costs have not been quantified in a number of areas where it is known that alcohol misuse will

certainly incur resource use. These costs include the cost of alcohol-related nurse consultations, the

cost of voluntary organisations dealing with those with alcohol problems, fire service resource use

84

due to alcohol-related fires and road traffic accidents, property damage and the human costs of

morbidity, reducing the quality of life for those with alcohol problems and their friends and families.

9.30 Any cost of illness study, such as this, is limited by the availability of information. A recent

information scoping report for alcohol misuse in Scotland produced by the Information and Statistics

Division, Scotland (Graham et al 2000) identified gaps in information provision, such as the extent of

social work activity in response to alcohol-related issues and the lack of data on those attending

voluntary agencies. The report concluded that “reliable information on which to base decisions

cannot easily be met with the current disparate information landscape”.

Conclusion

9.31 It is important to note that the costs estimated in the study often reflect past levels of resource

use. Moreover, cost of illness studies such as this provide information about patterns of resource use

associated with a particular condition, thereby enabling a greater understanding of the framework in

which decisions about resource allocation are made. However, cost of illness studies, unlike cost

effectiveness and cost utility studies, are unable to directly inform decisions about whether resource

allocation for particular treatments or strategies are effective.

9.32 It should be emphasised that the costs in this study do not represent the absolute amount of

expenditure on alcohol misuse in Scotland, but are estimates often based on assumptions rather than

documented statistics. By its very nature, alcohol is often associated with many social, psychological

and health problems, but it is often impossible to identify its exact contribution to an outcome in the

presence of many other confounding factors. It is also problematic to identify whether alcohol

misuse is the cause of a problem or whether the problem itself has resulted in the misuse of alcohol.

Additionally, there are several areas where alcohol misuse would incur a cost, but due to a lack of

information it has been impossible to make an estimation.

9.33 The present analysis demonstrates that alcohol misuse imposes a substantial burden on

Scottish society, costing an estimated £1,070.6 million per year at 2001/2002 prices. Nine percent

of this is accounted for by NHS Scotland expenditure, 8% by social work services resource use,

25% by criminal justice system resource use and 38% by wider economic costs. Additionally, the

85

human cost of premature mortality for those in the non-working population accounts for a further

20%. In terms of the statutory agencies, it has been estimated that alcohol misuse imposes the

greatest burden on the criminal justice system followed by the health service and social work

services.

86

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Medical Science Law, Vol. 37, No.4, pp321-325

The Treasury (1997) Annex G: The cost of capital discount rates and required rates of return, In:

Appraisal and evaluation in central government, Volume 77, London: HMSO

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an enquiry into alcohol and crime published on behalf of the All Party Group on Alcohol Misuse by

Alcohol Concern, London

Tether, P and Harrison, L (1986) Alcohol-related fires and drownings, British Journal of

Addiction, Vol. 81, No. 3, pp425-431

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The epidemiologically based needs assessment reviews, Volume 1 (eds. Stevens A and Raftery

J), Radcliffe Medical Press, pp111-255

Wannamethee, SG and Shaper, AG (1996) Patterns of Alcohol Intake and Risk of Stroke in

middle-aged British Men, Stroke, Vol. 27, No. 6, pp1033-1039

Woodward, M, Coughey, K and Cohen, R (1993) Medical Costs of Children of Alcoholics - Pay

Now or Pay Later, Journal of Substance Abuse, Vol.5, pp281-287

World Health Organisation (1998) Cross National - Health Behaviour in School Aged Children

(HBSC)

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Vol. 80, pp486-489

93

APPENDIX 1: DEATHS DUE TO ALCOHOL BY SEX AND SPECIFIC

CAUSE (ICD CODE 9*) FOR SCOTLAND 1999

ICD 9 CODE

NUMBER OF DEATHS

291.0 Alcoholic psychosis 2




303.9 Alcoholic dependence syndrome 264

571.0 Alcoholic fatty liver 28

571.1 Acute alcoholic hepatitis 24

571.2 Alcoholic cirrhosis of liver 122

571.3 Alcoholic liver damage unspecified 464

305.0 Alcohol 85

357.5 Alcoholic polyneuropathy No deaths registered

425.5 Alcoholic cardiomyopathy 17

535.3 Alcoholic gastritis 8

577.1 Chronic pancreatitis 9

655.4 Maternal care for suspected damage to the foetus from alcohol No deaths registered

760.7 Foetal alcohol syndrome No deaths registered

779.8 Foetus & newborn baby effected by alcohol 2

E860 Accidental poisoning by alcohol not elsewhere classified No deaths registered

Total deaths 1032

Source: General Register Office, Scotland

*All deaths coded by underlying cause

94

APPENDIX 2: READ CODES FOR CONDITIONS DIRECTLY

ATTRIBUTABLE TO ALCOHOL MISUSE FOR CMR

GP RATES

Read Code Description

E230. Acute alcoholic intoxication

E2300 Acute alcoholic intoxication - unspecified

E2301 Acute alcoholic intoxication - continuous

E2302 Acute alcoholic intoxication - episodic

E2303 Acute alcoholic intoxication - in remission

E230z Acute alcoholic intoxication NOS

Eu100 Acute alcohol intoxication

Eu101 Harmful use of alcohol

E23.. Alcohol dependence syndrome

E231. Chronic alcoholism

E2310 Chronic alcoholism unspecified

E2311 Chronic alcoholism-continuous

E2312 Chronic alcoholism-episodic

E2313 Chronic alcohol.- in remission

E231z Chronic alcoholism NOS

E23z. Alcohol dependence syndrome NOS

Eu102 Alcohol dependence syndrome

E01y0 Alcohol withdrawal syndrome

Eu103 Alcohol withdrawal state

E010. Alcohol withdrawal delirium

Eu104 Alcohol withdrawal delirium

E013. Alcohol withdrawal hallucinos.

E014. Pathological alcohol intoxic.

E015. Alcoholic paranoia

Eu105 Psychotic disorder due to alcohol

E011. Alcohol amnesic syndrome

Eu106 Amnesic syndrome due to alcohol

E012. Other alcoholic dementia

Eu107 Residual psychosis due alcohol

E01y. Other alcoholic psychosis

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Read Code cont. Description cont.

E01yz Other mental / behavioural disturbances due to alcohol

Eu10y Alcoholic psychosis NOS

E01z. Unstable mental/behavioural disturbances due alcohol

Eu10z Cerebral degeneration -alcoholism

F11x0 Cerebellar ataxia - alcoholism

F1440 Alcoholic polyneuropathy

F375. Alcoholic myopathy

F3941 Alcoholic cardiomyopathy

G555. Alcoholic gastritis

J610. Alcoholic fatty liver

J611. Acute alcoholic hepatitis

J617. Alcoholic hepatitis

J6170 Chronic alcoholic hepatitis

J6120 Alcoholic fibrosis and sclerosis

G8523 Oesophageal varices alcoholic cirrhosis of liver

J612. Alcoholic cirrhosis of liver

J6130 Alcoholic hepatic failure

J613. Alcoholic liver damage unspecified.

J6710 Alcohol-induced chronic pancreatitis

L2553 Maternal care, suspected damage to foetus from alcohol

PK83. Foetus and newborn maternal use of alcohol

PK80. Foetal alcohol syndrome

Q0071 Foetus and placenta/breast alcohol

96

APPENDIX 3: CONDITIONS IN WHICH THERE IS A RAISED

INCIDENCE DUE TO ALCOHOL MISUSE

Condition Source of relative risk(at 50g alcohol a day)

Oropharyngeal cancer (C10) Corrao et al 1999Nasopharyngeal cancer (C11) Corrao et al 1999Oesophageal cancer (C15) Corrao et al 1999Colorectal cancer (C18-C20) Corrao et al 1999Liver cancer (C22) Corrao et al 1999Laryngeal cancer (C23) Corrao et al 1999Breast cancer (C50) Corrao et al 1999Hypertensive diseases (I10-I13) Corrao et al 1999Subarachnoid haemorrhage (I60) Corrao et al 1999Intracerebral haemorrhage (I61) Corrao et al 1999Sequelae of cerebrovascular disease (I69) Corrao et al 1999Stroke not specified as haemorrhage orinfarction (I64)

Corrao et al 1999 and Wannamethee S and ShaperAG 1996

Other non-traumatic intracranealhaemorrhage (I62)

Corrao et al 1999

Portal vein thrombosis (I81) Due to cirrhosis (44% of which is alcohol-relatedaccording to episode statistics from Information andStatistics Division 2001)

Oesophageal varices (I85) Due to cirrhosis (44% of which is alcohol-relatedaccording to episode statistics from Information andStatistics Division 2001)

Injuries (S00-T14) Yates DW et al 1987, and Primohamed M et al 2000

97

APPENDIX 4: UNIT RESOURCE COSTS AT 2001/2002 PRICES

Resource Unit cost Source

GP consultation* £17 Netten and Curtis 2000Psychiatric inpatient day £154 Scottish Health Service Costs 2000General medical inpatient day £228 Scottish Health Service Costs 2000General surgical inpatient day £326 Scottish Health Service Costs 2000Rehabilitation inpatient day £189 Scottish Health Service Costs 2000Day patient general psychiatry £64 Scottish Health Service Costs 2000Day patient psychiatry of old age £78 Scottish Health Service Costs 2000Outpatient attendance medical £88 Scottish Health Service Costs 2000Outpatient attendance psychiatry £79 Scottish Health Service Costs 2000Accident and emergency episode £51 Scottish Health Service Costs 2000Biochemistry test £14 Flynn et al 1999Haematology test £10 Bruce et al 1999

*Unit cost of a GP consultation unavailable for Scotland

98

APPENDIX 5: WORKING PARTY ON SOCIAL WORK CASELOAD

AND ALCOHOL MISUSE

The proportion of some social work services in Scotland which is associated with alcohol was

obtained by consensus from "A Working Party on Social Work Caseload and Alcohol Misuse"

which was convened specifically for this study. During a meeting the Working Party reviewed some

of the methodology and assumptions underlying the analysis. Members of the Working Party were:

Alistair Baird, Aberdeen City Council Social Work Department

Kay Barton, Head Substance Misuse Division, Scottish Executive Health Department

Iona Colvin, Glasgow City Council Social Work Department

Mary Cuthbert, Alcohol and Tobacco Issues Branch,

Ray de Souza, City of Edinburgh Council Social Work Department

Tom Leckie, Social Work Inspectorate, Scottish Executive

Isobel McCarthy, South Lanarkshire Council Social Work Department

99

APPENDIX 6 (i): CRIMES AND OFFENCES IN SCOTLAND 1999 ATTRIBUTABLE TO ALCOHOL MISUSE

(AM)

Total number of: Estimated numbers attributable to alcohol misuse

Estimatedpercentage

associated withalcohol misuse†

Crimesrecorded

by thepolice

Chargesproven

CommunityServiceOrders

Probations Custodialsentences

Fines Cautions oradmonitions

Crimesrecorded bythe policeassociatedwith AM

Communityservice ordersassociated with

AM

Probationorders

associatedwith AM

Custodialsentencesassociatedwith AM

Non sexual violentcrimesSerious assault(including homicide)

25% 7200 1230 196 129 593 228 35 1800 49 32 148

Handling offensiveweapons

25% 7901 2080 286 249 510 741 256 1975 72 62 128

Robbery 25% 5075 658 40 97 458 32 16 1269 10 24 115Other 25% 3264 197 14 37 34 36 72 816 4 9 9Crimes of indecencySexual assault 25% 1933 126 6 20 77 15 1 483 2 5 19Lewd & indecentbehaviour

25% 2383 314 8 82 136 59 21 596 2 21 34

Other 25% 1666 461 5 28 32 270 125 417 1 7 8Crimes of dishonestyHousebreaking 25% 53826 3018 251 507 1525 459 173 13457 63 127 381Theft by openinglockfast places

25% 50224 1661 163 254 603 423 145 12556 41 64 151

Theft of motor vehicle 25% 29818 1642 165 295 507 412 187 7455 41 74 127Shoplifting 25% 32008 7649 197 797 1991 3501 1076 8002 49 199 498Other theft 25% 81109 5260 265 557 1383 2223 658 20277 66 139 346Fraud 25% 18608 1988 162 106 207 1150 268 4652 41 27 52Other 25% 10596 2457 246 290 599 947 315 2649 62 73 150

100

APPENDIX 6 (ii): CRIMES AND OFFENCES IN SCOTLAND 1999 ATTRIBUTABLE TO ALCOHOL MISUSE

(AM)

Total number of: Estimated numbers attributable to alcohol misuse

Estimatedpercentage

associated withalcohol misuse†

Crimesrecorded

by thepolice

Chargesproven




Crimesrecorded bythe policeassociatedwith AM

Communityservice ordersassociated with

AM

Probationorders

associatedwith AM

Custodialsentencesassociatedwith AM

Fire raisingvandalism etcFire raising 25% 2325 106 12 31 23 15 18 581 3 8 6Vandalism etc 25% 77243 4007 136 228 269 2334 505 19311 34 57 67Other crimesCrimes against publicjustice

25% 18528 4622 231 501 782 1820 1200 4632 58 125 196

Drugs 25% 31870 6400 438 446 950 4043 503 7968 110 112 238Other 25% 126 25 1 2 12 8 2 32 0 1 3MiscellaneousoffencesSimple assault 25% 53989 10812 709 872 1324 5819 1763 13497 177 218 331Breach of the peace 25% 71028 14396 224 589 1082 9434 2913 17757 56 147 271Other 25% 18243 8354 509 715 1761 3694 923 4561 127 179 440Motor VehicleOffencesDangerous & carelessdriving

25% 13964 3369 43 37 121 3057 105 3491 11 9 30

Speeding 25% 125336 14179 0 1 0 14151 25 31334 0 0 0Unlawful use ofvehicle

25% 77846 16638 409 268 940 13838 1143 19462 102 67 235

Vehicle defectoffences

25% 52913 2004 0 1 0 1867 133 13228 0 0 0

Other 25% 72525 6405 5 3 6 6190 188 18131 1 1 2Totals 921547 120068 4721 7142 15925 76766 12769 230387 1180 1786 3981

101

APPENDIX 6 (iii): CRIMES AND OFFENCES IN SCOTLAND 1999 DIRECTLY DUE TO ALCOHOL MISUSE

(AM)

Total number of:

Percentageassociated withalcohol misuse

Crimesrecorded

by thepolice

Chargesproven




Drunk and incapable 100% 7101 400 0 10 12 306 71Drunk in charge of achild

100% 84 30 0 3 0 16 11

Drunk and attemptingto enter licensedpremises

100% 101 4 0 1 0 2 1

Disorderly on licensedpremises or refusingto quit

100% 244 17 1 0 0 16 0

Drunk in or attemptingto enter sports ground

100% 254 27 0 0 0 24 3

Drunk driving* 100% 10821 6899 166 184 137 6349 59Totals 18605 7377 167 198 149 6713 145

*Drunk driving comprises driving or in charge of motor vehicle while unfit through drink or drugs, blood alcohol content above

limit and failing to provide breath, blood or urine specimens.

†25% of crimes and offences attributable to alcohol after Bennett 1998 (see section 6.4)

APPENDIX 7: ORGANISATIONS AND PEOPLE CONTACTED IN THECOURSE OF THE STUDY

Scottish Executive

Kay Barton, Head, Substance Misuse Division, Health Department

Allan Brown, Chair, Road Safety Campaign for Scotland

Gillian Blair, Justice Statistics Unit

Julie Bright, Justice Statistics Unit

Mary Cuthbert, Alcohol and Tobacco Policy Team Leader, Substance Misuse Division, HealthDepartment

Steven Gillespie, Community Care Statistics

Joseph Jobling, Assistant Statistician, Development Department, Economic Advice and Statistics

Tom Leckie, Inspector, Community Care, Social Work Inspectorate

Gavin Lewis, Economics and Information, Health Department

Lindsay Liddle, Alcohol and Tobacco Policy Team, Substance Misuse Division, HealthDepartment

Fiona Murray, Director, Road Safety Campaign for Scotland

Julie Rintoul, Statistician, Community Care Statistics

Dr Jennifer Steedman, Economic Adviser, Health Department

Charles Stewart, Senior Assistant Inspector, Fire Services Inspectorate

Sandy Taylor, Justice Statistics Unit

Fred Thorne, Justice Statistics Unit

Ann Thomson, Local Government Finance Statistics

Social Work

Alistair Baird, Aberdeen City Council Social Work Department

Iona Colvin, Social Work Department, Glasgow City Council

Ray de Souza, Social Work Department, City of Edinburgh Council

Larry Harrison, Reader in Social Work, University of Hull

Isobel McCarthy, Social Work Department, South Lanarkshire Council

Stephen McGill, Senior Officer for Research, Glasgow City Council

Phil Quinlen, Social Work Department, Glasgow City Council

102

103

Information and Statistics Division, Scotland

Matthew Armstrong, Primary Care Information Unit

Margaret Davies

Joan Forrest, Primary Care Information Unit,

Lesley Graham

Neil Graham, Maternity and Neonatal Manager

David Murphy, Senior Information Analyst, Hospital and Community Information Unit

Gordon Thomson, Hospital and Community Information Unit

Health Education Board Scotland

Sally Haw, Substance Misuse

Children’s Hearing System

Nuala Scott, Research Officer, Scottish Children’s Reporter Administration

General Register Office, Scotland

Caroline Capocci, General Register Office, Scotland

Carole Welch, General Register Office, Scotland

Fire and Police Services

Julie Black, Dumfries and Galloway Fire Brigade

Alison Cameron, Fire Control Officer, Highlands and Islands Fire Brigade

The Fire Master, Cental Scotland Fire Brigade

Constable Alaistair McLean, Accident Prevention Unit, Central Scotland Police Force

Jean Livingstone, Group Control Fire Officer, Lothian and Borders Fire Brigade

Derek Lowe, Sub Officer, Support Command, Fife Fire and Rescue Service

Chief Inspector Marshall, Central Scotland Police Force

Ian Robertson, Commander Personnel, Tayside Fire Brigade

Michael Rooney, Station Officer, Strathclyde Fire Brigade

Neil Simpson, Assistant Divisional Officer, Grampian Fire Brigade

104

Health Promotion

Sybil Alexander, Health Promotion Officer, Ayrshire and Arran Health Board

Paul Ballard, Health Promotion Manager, Tayside Health Board

Harry Black, Health Promotion Manager, Fife Health Board

Carolyn Chalmers, Alcohol Development Officer, NHS Orkney

George Clark, Senior Health Promotion Specialist, Social Inclusion Manager, Lothian Health Board

Sue Drummond, Alcohol Development Officer, Highland Health Board

Christine Duncan, Senior Health Promotion Officer, Dumfries and Galloway Health Board

David Eva, Director of Finance, Shetland Health Board

Marie Forsyth, Information Officer, Drug and Alcohol Action Team, Ayrshire and Arran Health

Board

Colin Gilmour, Health Promotion, Western Isles Health Board

Elizabeth Hill, Substance Misuse Co-ordinator, Tayside Health Board

Douglas Hosie, Finance Department, Lanarkshire Health Board

Michael Hutchinson, Health Promotions Advisor Alcohol, Health Promotions, Aberdeen

Trevor Lakey, Health Promotion Manager, Greater Glasgow Health Board

Jan Irvine, Health Promotions, Argyll and Clyde Health Board

Teresa Martinez, Senior Health Promotions Officer – Substance Use, Forth Valley

Hazel McLean, Health Promotion Administrator, NHS Orkney

Julie Murray, Drug and Alcohol Development Officer, Borders Health Board

Janet Owens, Health Promotion, Grampian Health Board

John Thomas, Health Promotion Manager, Lothian Health Board

Janice Thomson, Alcohol Development Officer, Argyll and Clyde Health Board

Other

Alcoholics Anonymous

Alcohol Focus Scotland

Institute of Alcohol Studies

The Portman Group

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