Making it work together
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
Source: Scottish Health Survey 1995 and 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)
% drinking >50 units
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)
% drinking >14 units
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)
Source: Scottish Health Survey 1995 and 1998
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
Source: Calculated from CMRGP rates from ISD, Scotland
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%
Source: Calculated from CMRGP rates from ISD, Scotland
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)
Annual number of inpatient episodes
per 10,000 population
Non-psychiatric episodes Psychiatric episodes
Source: ISD, SMR01 & SMR04 databases
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
Non-psychiatric episodes Psychiatric episodes
Source: ISD, SMR01 & SMR04 databases
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
Source: ISD, SMR01 & SMR04 databases
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
Source: ISD, SMR01 & SMR04 databases
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
Annual number of inpatient episodes
Non-psychiatric episodes Psychiatric episodes
Source: ISD, SMR01 & SMR04 databases
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
Non-psychiatric episodes Psychiatric episodes
Source: ISD, SMR01 & SMR04 databases
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%
Source: ISD, SMR04 database
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%
Source: ISD, SMR01 database
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)
Percentage ofannual cost
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.
Sensitivity Analyses
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
Numberattributableto alcohol†
Averagenumberof daysserved
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
Annual cost(£ million)
Percentage ofannual cost
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.
Sensitivity Analyses
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:
Annual cost(£ million)
Percentage ofannual cost
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
Sensitivity Analyses
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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in Canada, 1992, Addiction, Vol. 93, No. 7, pp991-1006
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prevalence and regional variation, Alcohol and Alcoholism, Vol. 35, Suppl.1, pp8-10
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Medical Science Law, Vol. 37, No.4, pp321-325
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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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middle-aged British Men, Stroke, Vol. 27, No. 6, pp1033-1039
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Now or Pay Later, Journal of Substance Abuse, Vol.5, pp281-287
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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
291.1 Alcoholic psychosis 2
291.2 Alcoholic psychosis 2
291.8 Alcoholic psychosis 3
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
95
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
CommunityServiceOrders
Probations Custodialsentences
Fines Cautions oradmonitions
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
CommunityServiceOrders
Probations Custodialsentences
Fines Cautions oradmonitions
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