The divergence of minimum unit pricing policy across the UK: opportunities for public health policy development

Background

Above recommended levels of intake, alcohol use is associated with harm including hypertension, haemorrhagic stroke, liver disease, mental health disorders and cancers, as well as accidents, injuries and assaults.^1–3 The 2015 UK Global Burden of Disease study indicates that 2.9% of disability-adjusted life years and 1.9% of mortality are attributable to alcohol use, ⁴ and the 2013 Health Survey for England found that 23% of men and 16% of women in England drink at levels associated with risk to health. ⁵ This Health Survey for England estimate would now underestimate the proportion of men at risk, as a 2016 guidance update lowered the recommended maximum level of intake for men, and so would reclassify some of those previously considered at low risk, as at-risk drinkers. ⁶

Alcohol’s contribution to both mortality and morbidity rose steadily from 1990 to 2010. While this trend may have started to stabilise over the past five years, ⁴ alcohol-related hospital admissions continue to increase. ⁵ Alcohol was estimated to cost the National Health Service £3.3–3.5 billion/year between 2006–2007 and 2009–2010.^7,8 The wider costs of alcohol use include costs to the criminal justice system, social services, employers, families and carers, among others, but as current alcohol pricing structures do not account for all externalities, much of the cost falls onto taxpayers. In 2012, the Westminster Government estimated that the annual cost of alcohol to UK society was £21 billion. ⁹ Despite these figures, alcohol affordability has risen steadily over many years, and alcohol is now estimated to be >50% more affordable than it was in 1980. ⁵ Alcohol is additionally an important driver of health inequalities.^10,11

In this context, policy changes aimed at reducing the human, social and financial costs of high levels of alcohol use may be beneficial and further government intervention in the market potentially appropriate. This view has been supported by a growing evidence base and recent evidence reviews from the National Institute for Health and Care Excellence and Public Health England.^12,13 Both bodies have concluded that national policy change that impacts on alcohol accessibility by constraining affordability would be the most clinically and cost-effective policy strategy. Both also promote minimum unit pricing (which requires that every unit of alcohol purchased is sold above a ‘floor’ price) as an important option. Minimum unit pricing is favoured over alternative price interventions that have been considered and/or trialled in the UK (Table 1), as retailers are unable to absorb the costs of minimum unit pricing, it encourages producers to limit product strength, and has relatively high impact on higher-risk groups.^12,13

Table 1.

Alcohol price interventions considered and/or trialled in the UK.

	Policy	Experience	Related evidence
Minimum pricing	• Requires that product prices exceed ‘floor’ prices • Floor prices may be based on alcohol content (as in minimum unit pricing) or other measures, such as the type of alcohol product, volume of product and/or product strength	• Social reference pricing (broadly defined as setting minimum prices such that prices do not promote alcohol misuse or alcohol-related harm) applied in Canada since the late 1980s (details of policies have varied over time and across provinces)	• Longitudinal analysis of 1989–2010 data from British Columbia indicate that 10% minimum price increase was associated with 3.4% reduction in consumption when all drink types considered 14 • Modelling studies indicate that minimum unit pricing would (in terms of reducing alcohol-related harm) be a relatively effective strategy in the UK context15,16
Excise tax reform	• Excise taxation is an indirect inland taxation strategy, where tax is levied on the sale of a specific good • Reforms can take various shapes within the constraints of EU legislation • Retailers can choose to absorb the cost	• Excise taxes are currently levied on alcohol products across the UK, under the framework of an EU Directive • Cider and wine sales taxed by volume, at rates set within broad alcohol strength categories • Other alcoholic drinks taxed according to alcohol content • Duty paid per gram of alcohol therefore varies across product types and does not reflect product strength • Options are currently constrained by EU legislation	• Several analyses indicate that increasing excise taxation could help reduce alcohol-related harm13,15,17
Ban on below- cost sales	• Requires that products are sold above the cost of duty + VAT	• Coalition Government 2012 Alcohol Strategy rejected a ban on below-cost sales in favour of minimum unit pricing, on the basis that this would be more effective in terms of alcohol-related harm reduction 9 • Ban on below-cost sales in England and Wales introduced by Coalition Government in 2014	• A 2011 Institute for Fiscal Studies analysis suggested such a policy would affect 1% of off-licence alcohol units sold in the UK 17
Quantity discount ban	• Prohibits product discounts based on the quantity purchased (e.g. ‘two for price of one’, X% discount when buy certain number of bottles) or bulk-buying of a specific product (e.g. would require that each item in a box of six 500 mL bottles of a product cost at least 6× the price of a single 500 mL bottle, but not that a 1 L bottle would cost at least twice as much as a 500 mL bottle)	• Introduced in Scotland in 2011	• Analysis of 2010–2012 data from Scotland indicative that the policy had no impact on alcohol purchasing over the short term 18

EU: European Union.

As minimum unit pricing has yet to be implemented in any country, modelling studies currently constitute much of the related evidence base. A recent study that compared alternative pricing strategies with minimum unit pricing for England in 2014–2015 concluded that content-based taxation or minimum unit pricing would be more effective than increasing taxation under the current system, or taxation based on product value, in terms of impact on harmful drinking and health inequalities. ¹⁵ Another recent study estimated that minimum unit pricing would have a 40–50 times greater effect on each of consumption, hospital admissions and deaths, than a ban on below-cost sales. ¹⁶ There are relevant empirical data from British Columbia, Canada, which has applied social reference pricing (which sets a minimum price per product type and volume rather than per volume/strength) to alcohol products for many years. A recent evaluation found that a 10% increase in the minimum price of any given alcohol product reduced consumption relative to other products by 14.6%–16.1%. ¹⁴

Introduction of minimum unit pricing policy in the UK

Based on the earlier contributions to this evidence base, and in keeping with national health strategy documents that have for many years highlighted the importance of investment in preventive healthcare, and promotion of healthy lifestyles including healthy levels of alcohol consumption,^19,20 the Westminster Government’s 2012 alcohol strategy committed to minimum unit pricing for England and Wales. ⁹ In the same year, the Scottish parliament – led by the Scottish National Party with a newly elected parliamentary majority – voted in favour of minimum unit pricing legislation, which was then enacted (but is yet to be implemented – see below). ²¹ A minority Scottish National Party government had been defeated on the issue in 2010, and re-introduction of a minimum unit pricing bill was noted as a ‘priority’ in the party’s 2011 election manifesto, which also commented on the evidence base, and support from the medical and policing professions. ²²

Subsequent policy movements

Although widely supported by these professional communities, many third-sector organisations, and some parts of the alcohol industry (e.g. the Scottish Licensed Trade Association and the C&C Group), ²³ both the Scottish and Westminster Government 2012 policies were met with opposition from the industry and alcohol exporters. ²⁴ The policy for England and Wales was subject to considerable industrial lobbying during its consultation phase, ²⁴ and the Coalition Government at Westminster dropped the policy in 2013, in favour of a ban on low-cost sales, introduced in 2014. ²⁵ In its consultation response, the Government stated that it would be a mistake to implement minimum unit pricing without empirical evidence, before going directly on to note that banning below-cost sales (for which no empirical evidence existed at the time, and which modelling suggested would have little impact),^16,26 would be used to stop cheap and harmful alcohol sales. ²⁵ The policy change was widely viewed as submission to industrial interest. ²⁷ No Westminster Government has since re-established minimum unit pricing policy. A recent Home Office statement notes that the option remains ‘under review’. ²⁸

Initial opposition to the Scottish minimum unit pricing legislation came from the major European Union exporters of alcohol products, resulting in the European Commission commenting that the policy was potentially disproportionate to Scotland’s alcohol problem, and risked violating European Union competition law. ²⁹ A subsequent Scotch Whisky Association-led petition for judicial review – arguing that the legislation was outwith the legislative competence of the Scottish Government and incompatible with European Union law – was dismissed by the Scottish Court of Session, ³⁰ but heard on appeal at the European Court of Justice. The European Court ruled that as minimum unit pricing threatened to constrain the market, it would only be justified if health could not be protected equally effectively by taxation measures that would be less restrictive in terms of limiting competition. ³¹ This posed a challenge as the existing evidence base had not yet demonstrated this specifically. The Scottish Government therefore commissioned specific research on this question, which demonstrated that minimum unit pricing would have greater impact on the most at-risk groups than an increase in alcohol taxation to levels that would lead to the same overall reduction in mortality. ³² Thus when the case – returned to the Scottish Court – was heard again in October 2016, the Court ruled in favour of the Government, citing evidence that the alternatives would be less effective than minimum unit pricing. ³³ The Scotch Whisky Association has appealed and the case is to be heard by the UK Supreme Court.

Divergence of policy progress in Scotland versus Westminster

In the above description of the recent evolution of minimum unit pricing policy in Scotland and Westminster, several between-jurisdiction differences in the policy contexts and processes are noted, which may have been relevant to the differential outcomes. For example, the Scottish Government has political capital invested in its minimum unit pricing policy, which featured prominently in its election campaign, whereas reversal of policy decisions may have been politically relatively easy for the Coalition Government at Westminster, as no specific party was required to accept responsibility. The Scottish Government appeared relatively resistant to industrial lobbying, ²⁴ widely believed to be a major contributor to failure of the Westminster policy. ²⁷ It framed the issue primarily as a health concern embedded within society, ³⁴ rather than a need to manage the irresponsible actions of some deviant individuals or population sub-groups as suggested in the Westminster Government’s strategy, ³⁵ and engaged positively with the evidence generation process. ³² By contrast, actions of the Westminster Government – which argued that further review of the evidence for minimum unit pricing was required, while adopting a less well-evidenced policy banning low-cost sales – appeared to hijack and undermine the evidence review process, a tactic now routinely employed by those with vested interests.^36–38 These and additional factors that may have contributed to the different outcomes reached by the two governments are detailed further in Table 2.

Table 2.

Minimum unit pricing policy in Scotland and Westminster – differential context and process factors.

	Scotland		Westminster (England and Wales jurisdiction)
Context
Extent of local alcohol problem	Alcohol sales, alcohol-related hospital admissions and alcohol-related deaths consistently higher in Scotland compared with England and Wales, over many years39,40
	Drinking culture of relatively pronounced reputation
Professional support for policy to reduce harm due to alcohol use	Widespread and strongly acknowledged by Government; documented in 2011 election manifesto 22		Arguably less obvious; debate coincident with transfer of English public health departments from the NHS to civil service, which resulted in loss of political independence for many public health voices 41
Political context	SNP defeated on issue in preceding parliament; issue prioritised in manifesto; risk of policy failure if change of government at end of parliament – hence delay to progress a political risk		No strong party links to policy; policy consultation and response coincident with introduction of Health and Social Care Act, 41 which dominated health-related media and political attention at the time
Nature of government	Majority government; dominant party		As coalition government, no specific party required to accept responsibility for policy reversal; for the same reason, coalition parties may have been more susceptible to industrial influence
Process
Framing of issue	Primarily as a health concern embedded within and across society (Alcohol, etc. (Scotland) bill transferred from the Justice Ministry to the Ministry of Health in the late 2000s) 34		Conceptualised as a problem located within deviant individuals who exhibit irresponsible behaviour associated with excess crime, violence, fear and health service usage, necessitating a response led by criminal justice 35
Tradition of industrial access to decision-makers	Access to major UK parties in Scottish parliament well established; less established relationship with SNP 24		Well established24,27
Response to industrial lobbying	Scottish Government led formulation of response, engaged in legal debate and worked with a responsive academic department, enabling timely production of relevant evidence 32		Withdrew policy citing insufficient evidence (no specifics reported); implemented policy that evidence suggested would have low impact
Engagement with evidence process	Developed constructive relationship with researchers to consider specific questions posed by judiciary, enabling timely policy progress; resultant evidence has been key to policy resistance to legal challenge to date, and has essentially become the political position of the Scottish Government		Requested an evidence review from Public Health England, in response to consultation outcome

NHS: National Health Service; SNP: Scottish National Party.

Opportunities for public health input into minimum unit pricing policy and wider health policy

Considering these various factors in terms of options for public health input into ongoing policy development for England and Wales, the evidence review commissioned by the Westminster Government when it dropped its minimum unit pricing policy has recently been published, and provides a useful tool with which to advocate for government re-engagement with minimum unit pricing policy. ¹³ The Westminster Government is unlikely to re-establish minimum unit pricing policy while the legal process between the alcohol industry and Scottish Government is ongoing, but should the Scottish Government be successful at the Supreme Court, this combined with Public Health England’s recent recommendations would provide an opportunity to push for minimum unit pricing in England and Wales. Given the recent and ongoing cuts to local public health budgets, and the expectation that local public health departments should fund alcohol interventions understood to be less effective and less cost-effective than minimum unit pricing, ¹² both local and national public health professionals should feel confident in their expectation and demand for national action.

Whether this confidence does exist, however, is questioned by one of our identified differences between the two policy contexts – namely the relatively constrained position of English service public health professionals in such public debate following their recent relocation to local authorities and the civil service. ⁴¹ Potentially the restrained nature of Public Health England’s comments on minimum unit pricing policy subsequent to publication of their assessment of the evidence (e.g. Public Health England statements in O’Dowd ²⁸ ) is because of this. Thus, if expert input is a desired part of the policy development process, the new circumstances of English public health professionals may need to be balanced by changes to evidence review and policy development processes. The ease with which the current process can be misused by those with vested interests also favours the development of structures to facilitate rigorous discussion of evidence and defend the evidence review process. The minimum unit pricing experience indicates that more balanced opportunities for stakeholder representation to decision-makers (i.e. via widening access to decision-makers) could be usefully adopted at Westminster, following Scottish precedent. However, more fundamental changes to the evidence review process have been proposed elsewhere, ⁴² noting that reforming the process to promote fair-hearing of evidence should reduce both under- and over-use of evidence, and support democratic decision-making.

Such changes may be particularly wanting in Westminster in view of the renewed threat of Scottish independence, and the potential loss of public health advocacy, precedent in public health action and pre-emptive engagement with relevant legal processes, that Scotland has supplied several times over recent years. A reformed use of evidence would also be helpful in the pending opportunity to impact on decision-making, regulatory and legal processes in the UK, when European Union legislation is repealed. Failure to capitalise on the opportunity to influence such process development would potentially provide industrial and individual interests relatively unbalanced access to the UK policy agenda in future. Under such conditions, it would be likely that both evidence and health would be relatively side-lined in future policy development.

Finally, despite the ongoing discussion about minimum unit pricing policy across the UK, and although it is difficult to predict what it would take for the Westminster Government to revert to a minimum unit pricing policy, any minimum unit pricing policy that does come to be implemented in Scotland or England and Wales will only be implemented because the relevant evidence exists. The case is a positive example of the vital role evidence plays in the policy process, a demonstration of the benefit of relevant and timely evidence, and of the potential benefits to be gained through collaboration with policymakers, who in this case played an important role in the evidence-generation process. As others have previously suggested, ⁴³ promoting such practical application of academic public health resources would likely enhance their impact.