NIHR Signal Licensing decisions by local authorities can reduce alcohol-related hospital admissions

Published on 15 January 2016

This NIHR-funded study found that local authorities in England that were more active in the use of their alcohol licensing powers saw a greater reduction in alcohol-related hospital admissions. The more active local authorities were in reducing access to alcohol, the greater the drop in admissions. Local authorities have two main powers that can be used to address public health issues over alcohol – they can refuse licence applications and implement “cumulative impact areas”, sometimes known as “saturation zones” or “stress areas” (see Definitions tab). Authorities that did both, between 2007 to 2012, had a 5% greater fall in alcohol-related admissions between 2009 to 2015 compared to those who did neither. A trial to test the observed association would provide stronger evidence of effect. Nevertheless, the results from this large study may encourage authorities and their Directors of Public Health to consider more active licensing enforcement.

Licensing decisions by local authorities can reduce alcohol-related hospital admissions

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Why was this study needed?

Alcohol abuse costs the NHS in England about £3.5 billion pounds a year. In 2013/14, 114,920 adults received treatment for alcohol dependency, and about 1 million for alcohol related problems. It is estimated that around nine million adults in England drink at levels that pose some risk to their health. But alcohol abuse is not just a healthcare issue. In Leeds in 2008/9 it was estimated that alcohol abuse cost the city £438 million, only £56.8 million of which was in health and social services, the rest was on crime, lost productivity and wider societal costs.

A recent study in Scotland showed an association between the number of alcohol outlets and alcohol-related hospitalisations. Local authorities have powers to address public health concerns over alcohol consumption. They can refuse individual licence applications and implement “cumulative impact areas”. These are areas where the authority can restrict new alcohol outlets, both off- and on-licence, because of concerns over the impact of already existing outlets (see Definitions tab).

The NIHR funded this study to examine whether authorities that were more active in licensing enforcement, through the use of cumulative impact areas and refusing licence applications, had fewer alcohol-related hospital admissions. Both powers are aimed at limiting the ease of access to alcohol, so the authors hypothesised that more active authorities would see fewer admissions.

What did this study do?

Three hundred and nineteen eligible local authorities in England were rated according to how active they had been in licensing enforcement from 2007 to 2012. They were rated as passive, low, medium or highly active. Broadly speaking, authorities that had neither assigned cumulative impact areas nor refused any licensing applications over the five years were scored as passive, up to those who had implemented both throughout each of the five years, who were considered highly active.

Activity ratings were compared to alcohol-related hospital admissions from 2009 to 2015. Alcohol-related admissions include alcohol liver disease, ethanol poisoning, oesophageal cancer and diseases caused by high blood pressure. Public Health England use this disease list to monitor trends in alcohol related harm. Admissions were only counted when the primary diagnosis was alcohol-related. Accident and Emergency admissions were not included.

Data on alcohol-related crime rates, population size and deprivation were used to control for confounding factors. Studies of association such as this cannot prove causality, but can identify patterns worthy of further investigation.

What did it find?

  • Authorities with more active licensing enforcement witnessed a greater reduction in alcohol-related hospital admissions. The most active authorities had an additional annual average reduction of 2% in alcohol-related admission rates, or about eight admissions averted per 100,000 people in 2015, compared with what would have been expected had they been passive since 2007.
  • Larger reductions in admission rates were observed in authorities with more active licensing enforcement, indicating an “exposure–response” association.
  • A little over a third (37%) of authorities had some form of active alcohol policy in 2007/2008. Just 19% of local authorities were coded as have a medium level of licensing enforcement activity, and 16% were coded as having high activity.

What does current guidance say on this issue?

NICE 2010 guidelines on preventing alcohol-use disorders says that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is an effective way of reducing alcohol-related harm. They recommend that revising legislation on licensing should be considered to ensure that licensing departments can take into account the number of alcohol outlets in a given area and times when it is on sale and the potential links to local crime and disorder and alcohol-related illnesses and deaths.

What are the implications?

The association between licensing enforcement and drop in alcohol-related hospital admissions does not prove causality. The exposure-response relationship could be because authorities with the most active enforcement are also the most proactive in adopting other alcohol policies. These may range from late night levies, where authorities charge premises that have a late-night alcohol licence, to alcohol screening and brief interventions.

The authors made a number of efforts to correct for confounding factors. For example baseline deprivation, population size and alcohol-related crime data were used to correct for the fact that alcohol policies tend to be introduced in areas with greater levels of alcohol-caused harm. The study also looked at the trends over five years, rather than taking a “snapshot” in time, adding credibility to the observed association. The authors were unable to use A&E data, because they weren’t collected in HES (Hospital Episode Statistics, a database of admissions to NHS hospitals in England). Nevertheless the results indicate a potential, longer-lasting benefit of licensing enforcement.

These results contribute to the evidence of effectiveness of population-level alcohol licensing policies. They are the first to show that the intensity with which alcohol licensing policies are implemented is associated with a fall in alcohol-related hospital admissions. Ideally the next step would be to trial different approaches in a random selection of authorities. The results may encourage authorities and their Directors of Public Health to consider a more active approach to licensing enforcement.

Citation

de Vocht F, Heron J, Angus C, et al. Measurable effects of local alcohol licensing policies on population health in England. J Epidemiol Community Health. 2015 Nov 10. [Epub ahead of print].

This project was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR).

Bibliography

Her Majesty’s Stationery Office. Police Reform and Social Responsibility Act. London: Her Majesty’s Stationery Office; 2011.

Her Majesty’s Stationery Office. Licensing Act. England and Wales. London: Her Majesty’s Stationery Office; 2003.

Home Office. Amended guidance issued under Section 182 of the Licensing Act 2003. London: Home Office; 2012.

Jones L, Bates G, McCoy E, et al. The economic and social costs of alcohol-related harm in Leeds 2008-09. Liverpool: Liverpool John Moores University; 2011.

NICE. Alcohol-use disorders: prevention. PH24. London: National Institute for Health and Care Excellence; 2010.

Public Health England. Alcohol treatment in England 2013-14. London: Public Health England; 2014.

Richardson EA, Hill SE, Mitchell R, et al. Is local alcohol outlet density related to alcohol-related morbidity and mortality in Scottish cities? Health Place. 2015;33:172-80.

Why was this study needed?

Alcohol abuse costs the NHS in England about £3.5 billion pounds a year. In 2013/14, 114,920 adults received treatment for alcohol dependency, and about 1 million for alcohol related problems. It is estimated that around nine million adults in England drink at levels that pose some risk to their health. But alcohol abuse is not just a healthcare issue. In Leeds in 2008/9 it was estimated that alcohol abuse cost the city £438 million, only £56.8 million of which was in health and social services, the rest was on crime, lost productivity and wider societal costs.

A recent study in Scotland showed an association between the number of alcohol outlets and alcohol-related hospitalisations. Local authorities have powers to address public health concerns over alcohol consumption. They can refuse individual licence applications and implement “cumulative impact areas”. These are areas where the authority can restrict new alcohol outlets, both off- and on-licence, because of concerns over the impact of already existing outlets (see Definitions tab).

The NIHR funded this study to examine whether authorities that were more active in licensing enforcement, through the use of cumulative impact areas and refusing licence applications, had fewer alcohol-related hospital admissions. Both powers are aimed at limiting the ease of access to alcohol, so the authors hypothesised that more active authorities would see fewer admissions.

What did this study do?

Three hundred and nineteen eligible local authorities in England were rated according to how active they had been in licensing enforcement from 2007 to 2012. They were rated as passive, low, medium or highly active. Broadly speaking, authorities that had neither assigned cumulative impact areas nor refused any licensing applications over the five years were scored as passive, up to those who had implemented both throughout each of the five years, who were considered highly active.

Activity ratings were compared to alcohol-related hospital admissions from 2009 to 2015. Alcohol-related admissions include alcohol liver disease, ethanol poisoning, oesophageal cancer and diseases caused by high blood pressure. Public Health England use this disease list to monitor trends in alcohol related harm. Admissions were only counted when the primary diagnosis was alcohol-related. Accident and Emergency admissions were not included.

Data on alcohol-related crime rates, population size and deprivation were used to control for confounding factors. Studies of association such as this cannot prove causality, but can identify patterns worthy of further investigation.

What did it find?

  • Authorities with more active licensing enforcement witnessed a greater reduction in alcohol-related hospital admissions. The most active authorities had an additional annual average reduction of 2% in alcohol-related admission rates, or about eight admissions averted per 100,000 people in 2015, compared with what would have been expected had they been passive since 2007.
  • Larger reductions in admission rates were observed in authorities with more active licensing enforcement, indicating an “exposure–response” association.
  • A little over a third (37%) of authorities had some form of active alcohol policy in 2007/2008. Just 19% of local authorities were coded as have a medium level of licensing enforcement activity, and 16% were coded as having high activity.

What does current guidance say on this issue?

NICE 2010 guidelines on preventing alcohol-use disorders says that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is an effective way of reducing alcohol-related harm. They recommend that revising legislation on licensing should be considered to ensure that licensing departments can take into account the number of alcohol outlets in a given area and times when it is on sale and the potential links to local crime and disorder and alcohol-related illnesses and deaths.

What are the implications?

The association between licensing enforcement and drop in alcohol-related hospital admissions does not prove causality. The exposure-response relationship could be because authorities with the most active enforcement are also the most proactive in adopting other alcohol policies. These may range from late night levies, where authorities charge premises that have a late-night alcohol licence, to alcohol screening and brief interventions.

The authors made a number of efforts to correct for confounding factors. For example baseline deprivation, population size and alcohol-related crime data were used to correct for the fact that alcohol policies tend to be introduced in areas with greater levels of alcohol-caused harm. The study also looked at the trends over five years, rather than taking a “snapshot” in time, adding credibility to the observed association. The authors were unable to use A&E data, because they weren’t collected in HES (Hospital Episode Statistics, a database of admissions to NHS hospitals in England). Nevertheless the results indicate a potential, longer-lasting benefit of licensing enforcement.

These results contribute to the evidence of effectiveness of population-level alcohol licensing policies. They are the first to show that the intensity with which alcohol licensing policies are implemented is associated with a fall in alcohol-related hospital admissions. Ideally the next step would be to trial different approaches in a random selection of authorities. The results may encourage authorities and their Directors of Public Health to consider a more active approach to licensing enforcement.

Citation

de Vocht F, Heron J, Angus C, et al. Measurable effects of local alcohol licensing policies on population health in England. J Epidemiol Community Health. 2015 Nov 10. [Epub ahead of print].

This project was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR).

Bibliography

Her Majesty’s Stationery Office. Police Reform and Social Responsibility Act. London: Her Majesty’s Stationery Office; 2011.

Her Majesty’s Stationery Office. Licensing Act. England and Wales. London: Her Majesty’s Stationery Office; 2003.

Home Office. Amended guidance issued under Section 182 of the Licensing Act 2003. London: Home Office; 2012.

Jones L, Bates G, McCoy E, et al. The economic and social costs of alcohol-related harm in Leeds 2008-09. Liverpool: Liverpool John Moores University; 2011.

NICE. Alcohol-use disorders: prevention. PH24. London: National Institute for Health and Care Excellence; 2010.

Public Health England. Alcohol treatment in England 2013-14. London: Public Health England; 2014.

Richardson EA, Hill SE, Mitchell R, et al. Is local alcohol outlet density related to alcohol-related morbidity and mortality in Scottish cities? Health Place. 2015;33:172-80.

Measurable effects of local alcohol licensing policies on population health in England

Published on 10 November 2015

F de Vocht, Jon Heron, Colin Angus, Alan Brennan, John Mooney, Karen Lock, Rona Campbell, Matthew Hickman,

Journal of Epidemiology & Community Health , 2015

Background English alcohol policy is implemented at local government level, leading to variations in how it is put into practice. We evaluated whether differences in the presence or absence of cumulative impact zones and the ‘intensity’ of licensing enforcement—both aimed at regulating the availability of alcohol and modifying the drinking environment—were associated with harm as measured by alcohol-related hospital admissions. Methods Premises licensing data were obtained at lower tier local authority (LTLA) level from the Home Office Alcohol and Late Night Refreshment Licensing data for 2007–2012, and LTLAs were coded as ‘passive’, low, medium or highly active based on whether they made use of cumulative impact areas and/or whether any licences for new premises were declined. These data were linked to 2009–2015 alcohol-related hospital admission and alcohol-related crime rates obtained from the Local Alcohol Profiles for England. Population size and deprivation data were obtained from the Office of National Statistics. Changes in directly age-standardised rates of people admitted to hospital with alcohol-related conditions were analysed using hierarchical growth modelling. Results Stronger reductions in alcohol-related admission rates were observed in areas with more intense alcohol licensing policies, indicating an ‘exposure–response’ association, in the 2007–2015 period. Local areas with the most intensive licensing policies had an additional 5% reduction (p=0.006) in 2015 compared with what would have been expected had these local areas had no active licensing policy in place. Conclusions Local licensing policies appear to be associated with a reduction in alcohol-related hospital admissions in areas with more intense licensing policies

There are four objectives set out in the 2003 Licensing Act. They are: prevention of crime and disorder; public safety; prevention of public nuisance, and protection of children from harm. It is stated that public health cannot be the primary consideration for a licensing decision, but may only be used to support licensing decisions based on any of the four objectives.

In cumulative impact areas, where there are concerns over the impact of already existing outlets, applicants for a new alcohol licence have to demonstrate how they will avoid threatening the licensing objectives. This is a reversal of the normal burden of proof.

The results of this study may help make the case for the inclusion of protecting or promoting health as a fifth licensing objective of alcohol policy in England.

Expert commentary

Alcohol abuse causes a heavy toll on our communities and creates a complex array of demands on health, social care, and community policing. Local efforts to develop more responsible attitudes to alcohol use are important, and local licensing decisions are one of the few levers we have to influence the pattern of supply. Licensing objectives in my local authority do not routinely include a cumulative health impact criterion, but in areas where this has been adopted, it appears to have a strong association with lower levels of hospital admission - suggesting reduced harm at population level.

This study provides us with a valuable insight into how a cumulative impact approach can help to reduce some of the more severe health consequences of alcohol abuse and reduce demand on the local emergency departments. I will use this evidence locally to revisit the local licensing criteria and to inform the local needs assessment and strategy work. We need innovative tools to reverse the increasing harm from alcohol we have witnessed over the last 15 years and this report adds new impetus to our approach to licensing.

Dr Bob Coates, Consultant in Public Health, Southampton City Council

Author commentary

Local alcohol licensing policies are primarily aimed at reducing acute effects of the consumption of alcohol in public spaces, including alcohol-related criminal offences and anti-social behaviour. This paper describes that additionally, and to some extent unintentionally, these policies also have an effect on population health. More specifically, the stricter the licensing policies, the larger the effect on 2007-2015 local alcohol-related hospital admissions. Although the effect was relatively modest, -2% per year for the most intense compared to the passive areas, if all local council were to implement these policies this implies that annually several thousands of hospital admissions could be averted.

Dr Frank de Vocht, Senior Lecturer in Epidemiology and Public Health Research, University of Bristol

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