Committee Reports > List of Committees > Joint > 2006 > Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs > Report No. 09 - The Inclusion of Alcohol in a National Substance Misuse Strategy

APPENDIX A:

Consultants’ Report and supporting material

Report on : The Inclusion of Alcohol in the National Drugs Strategy

1. Introduction

Although it is commonly acknowledged that alcohol is our favourite drug and that alcohol consumption makes a positive contribution to many aspects of Irish social and economic life, it has become abundantly clear over the past decade that our drinking habits have become highly problematic. As part of our deliberations on the idea of including alcohol in the National Drugs Strategy, we met with representatives of various groups who outlined for us their views on alcohol-related problems, and we also met with representatives from the drinks industry who gave us their perspective on how such alcohol-related harm might best be reduced. While we found it helpful to hear these views, we were particularly struck by the fact that all of the stakeholders in the policy process have been over this ground on numerous occasions and with numerous committees over the past decade. (The main such committees being: the Working Group on the National Alcohol Policy which reported in 1996; the Strategic Task Force on Alcohol which published reports in 2002 and 2004; the Commission on Liquor Licensing which published four reports between 2001 and 2003; and the Joint Committee on Health and Children which published a report on alcohol misuse by young people in 2004.) The arguments have been rehearsed ad nauseam, yet it would appear that to date no sustained, evidence-based policy response has been set in place in this sphere. St Patrick’s Day fell during the period we were considering this issue, and we noted that the media highlighted once again the way in which excessive drinking marred the day’s festivities, giving rise to yet more demands for ‘something to be done’. It was this Groundhog Day sensation, perhaps more than anything else, which helped us to focus on our task, which was to consider whether the most effective way to manage alcohol in this country might not be to include it in the existing National Drugs Strategy - which currently deals only with illicit drugs.

Our aims in this report, therefore, are:

i) To look in a summary way at the prevalence and range of alcohol-related problems currently being experienced in this country;

ii) To review the political and administrative impediments to framing and implementing an integrated, national alcohol policy of the type that has been recommended for some considerable time by public health authorities; and

iii) To look specifically at the suggestion that a practical way forward would be for the National Drugs Strategy, which is well established and well respected, to have its mandate extended to include alcohol.

2. Alcohol Problems in Present-Day Ireland

2.1 Recognising the Diversity of Alcohol-Related Problems

While the term ‘alcoholism’ continues to be used popularly, and was occasionally used during our committee’s debates, we noted that it is no longer the norm in policy and scientific circles to discuss alcohol-related problems as though they only involve people who are alcohol dependent or ‘alcoholic’. Instead, it is now recognised that such problems extend beyond any single disease category and include a spectrum of social and health issues which may be chronic and ongoing or, alternatively, may be of an acute or once-off nature. This change in terminology is not just a matter of semantics but means in practical terms that public policy makers are now being challenged to deal with a complex range of preventive issues, rather than merely expand treatment facilities for those who have become alcohol dependent. It also seems important to note at this juncture that any discussion of alcohol-related problems should avoid creating the impression that these problems are only directly experienced by drinkers themselves: on the contrary, the ‘external’ costs suffered by others - family members, friends, neighbours or work colleagues - are considerable, as is the financial burden on society as a whole.

We benefited from hearing presentations from those directly involved in treating alcohol dependence - one presentation coming from St Patrick’s Hospital in Dublin which has a long history of specialist treatment in this field, and one from the White Oaks Centre which is a relatively new ‘Minnesota Model’ agency based in Donegal. There is evidence that treatment facilities make a positive albeit modest contribution to reducing a society’s alcohol-related problems, and we are therefore anxious that our report should not be interpreted as advocating any reduction in allocation of public funding to the treatment sector. What we found most striking, however, was the very clear evidence which has already been compiled to document the wide range of negative effects which alcohol consumption has on Irish society. Rather than presenting a lengthy and detailed account of all of these alcohol-related problems (since this has been done comprehensively in the two reports from the Strategic Task Force on Alcohol, 2002 and 2004), we will confine ourselves here to a few illustrative points:

•despite the creation of a network of community-based alcohol counselling services, alcohol problems continue to impose a heavy burden on our inpatient mental health system - in 2004 alcoholic disorders accounted for 14% of all mental health admissions (Daly, et al., 2005);

•a national study of the impact of alcohol on Accident & Emergency department attendances showed that over one quarter of all attendances for injuries were related to alcohol (Hope et al., 2005);

•research undertaken in an Irish general hospital indicated that 30% of male patients and 8% of female patients had an underlying alcohol problem (Hearne et al., 2002);

•although all-cause mortality declined substantially between 1992 and 2002, alcohol-related mortality rose significantly (by 61% for chronic conditions and 90% for acute conditions) for the same period, coinciding with a 25% increase in per capita alcohol consumption over this decade (Strategic Task Force on Alcohol - Second Report, 2004);

•alcohol has been identified as playing a significant role in the commission of public order offences, which have been shown to cluster geographically close to pubs in urban areas and, in time, to occur after pub closing times (National Crime Council, 2003);

•it is estimated that alcohol is involved in 40% of road traffic fatalities and at least 30% of all road traffic accidents annually (Strategic Task on Alcohol - Interim Report, 2002);

•alcohol consumption contributes significantly to marital discord and to related child welfare difficulties - one Irish marriage counselling service reported that problem drinking was the primary issue in up to 25% of cases presenting annually (Marriage Counselling Services, 1996);

•a survey of third-level students in Ireland showed that out of every 100 drinking occasions 76 ended up in binge drinking for male students and 60 for female students, and that these binge drinking occasions were associated with a range of adverse consequences, including diminished academic performance, money problems, unprotected sex and accidents (Hope, Dring and Dring, 2005).

2.2 Alcohol Science and Public Policy

Having satisfied ourselves that Ireland has a high prevalence of alcohol-related problems, we then set out to gain an understanding of how modern researchers in the biomedical and social sciences view these problems and of the evidence which exists as to the effectiveness or otherwise of the various policy measures open to government in this regard. In doing this we reviewed national and international literature, including National Alcohol Policy - Ireland (1996), the Strategic Task Force on Alcohol reports (2002 and 2004) which have already been referred to, and a variety of World Health Organisation (WHO) documents which summarise research findings and offer a template for national alcohol policies. In general, we found that there is a remarkable consistency to the research findings which have accumulated over the past forty years, and that the policy implications of these findings have also been spelt out with increasing clarity over this time period. This is not to say, however, that what is now referred to as ‘alcohol science’ offers easy or comfortable solutions to the political system. Fundamentally, what this science confirms is that the problems we are currently experiencing are a direct and understandable reflection of our national drinking habits, and that the only realistic or effective solutions will be those which lean towards the use of social measures aimed at changing these drinking habits. The most recent WHO review of the research literature Alcohol: No Ordinary Commodity (Babor et al., 2003) starts by identifying the three major problematic features of this drug:

•alcohol is a toxic or poisonous substance: it has the potential to affect in a negative way virtually every organ and system in the human body, and is implicated in many illnesses - including cirrhosis of the liver, several forms of cancer and cardiovascular conditions;

•alcohol is an intoxicant: it makes its consumers drunk, thereby impairing their emotional and psychomotor performance and significantly increasing the risk that they suffer accidents or become involved in violence towards others or self-harm;

•alcohol is a drug of dependence: it has the potential to create dependence or addiction, not merely in those who are genetically so predisposed but - depending on their level and pattern of consumption - in all its consumers.

Bearing in mind that alcohol has these characteristics, it is not surprising that researchers have demonstrated that when a society increases its consumption of this drug it can expect an increase in a range of problems such as those discussed above. This is precisely what has happened in Ireland. The first report of the Strategic Task Force on Alcohol (2002) summarised the changes which have taken place in Irish drinking habits during the Celtic Tiger years, showing (Appendix 1) that between 1989 and 1999 - when consumption in other EU countries was generally remaining static if not declining - our per capita consumption increased by 41%. The main policy implication to emerge from alcohol science is that societies cannot expect to reduce the prevalence of related problems without reducing per capita consumption and, on this basis, the Strategic Task Force on Alcohol identified as one of its fundamental objectives the lowering of per capita alcohol consumption (which had peaked in 2001 at 14.4 litres of pure alcohol) to the EU average of 9 litres.

In addition to research on the relationship between population drinking habits and the prevalence of a range of related health and social problems, international researchers have also carried out extensive research so as to establish what works and what doesn’t work in relation to the broad array of preventive strategies (Edwards et al., 1994; Babor et al., 2003). We were struck during the course of our deliberations by the great disparity between those preventive strategies for which there was popular support and those for which there was evidence of effectiveness (Appendix 2). The strategies which appeared to us to be most popular were those which involved education (both education of the general public and of school-going children), the provision of alternative or alcohol-free recreational activities for young people and the expansion of treatment systems for those with alcohol dependence; unfortunately all of these approaches emerge from the evaluative research as having little or no positive effect. It should come as no surprise that prevention strategies based upon alcohol education have consistently been demonstrated to have no impact on drinking behaviour; such strategies have to compete not just with a culture which is broadly supportive of heavy drinking, but also with multi-billion Euro advertising and promotions campaigns by the drinks industry. Neither perhaps should we be surprised that there is no evidence to support the provision of alcohol-free recreational opportunities as a preventive measure, since young people already have access to a much wider range of social and recreational opportunities than has ever been the case previously. Finally, we have already indicated that we see it as necessary to fund treatment systems for those who are alcohol dependent, but would regard it as a counsel of despair to base an entire national alcohol strategy around provision of care for this group of extreme or end-state problem drinkers.

There are, on the other hand, some strategies which are demonstrably effective in improving public health and public order; these include the use of fiscal measures to increase the price of alcoholic beverages, restrictions on the numbers of retail outlets and on days and hours of sale, tougher drink driving countermeasures, and bans or restrictions on alcohol advertising and promotion. It is particularly noteworthy, for instance, that the first drop in alcohol consumption in more than sixteen years took place in 2003 and was clearly attributable to an increase in excise duty on spirits (Strategic Task Force on Alcohol -Second Report). Implementation of these evidence-based strategies has in the past been perceived as politically difficult for two main reasons. Firstly, they are clearly threatening to the drinks industry, an industry which not only contributes to the economic well-being of the country but also has well-established links to Irish political life; secondly, since they are aimed at the drinking population in general, rather than at subgroups within this population (such as ‘alcoholics’, alcohol ‘abusers’ or young drinkers), they might prove to be electorally unpopular. We have noted, however, that public support is growing for alcohol control measures which politicians might previously have deemed unpopular, as evidenced particularly (Appendix 3) in the recent attitudinal survey published by Alcohol Action Ireland (2006).

Given these political difficulties, it is not surprising that only limited gains have been achieved in translating research findings into policy measures. Alcohol scientists have long recognised that one of the major stumbling blocks in this regard is that, in public policy terms, alcohol is an issue which cuts across many different sectors of government, and that different sectors do not necessarily operate from an agreed policy agenda. The most obvious disagreements arise where those governmental sectors which have responsibility for health and welfare favour evidence-based strategies such as those mentioned above, while those sectors concerned with revenue, industry and employment favour strategies which make for a buoyant drinks industry. For more than thirty years (Bruun et al., 1975) the WHO has recommended that, in order to counter this tendency towards intersectoral fragmentation, national governments should create management structures which facilitate the drafting and implementation of integrated, national alcohol policies based upon research findings.

3. Alcohol Policy in Ireland: What Has Been Done to Date?

In reviewing alcohol policy developments in Ireland, we found that the main ideas deriving from alcohol science have been known here for more than two decades and have on several occasions been recommended in policy documents originating within the health sector. Some of the main documents which have discussed this approach to alcohol policy are:

•The Psychiatric Services: Planning for the Future (1984): this document dealt generally with the development of the public mental health services, while specifically recognising the huge burden which alcohol-related problems were imposing on these services. It argued that there were limits to what could be achieved in this regard by curative services and that alcohol problems could best be prevented by a cross-sectoral body from all the relevant government departments;

•National Alcohol Policy - Ireland (1996): this document, which was drafted within the Health Promotion Unit of the Department of Health, dealt solely with alcohol policy issues, drawing heavily on the WHO’s European Alcohol Action Plan and making clear recommendations as to which strategies might best reduce alcohol-related problems in Ireland;

•The Strategic Task Force on Alcohol -Interim and Final Reports (2002 and 2004): these two reports, which again emanated from the Health Promotion Unit, were even sharper in their presentation of evidence-based strategies for the reduction of alcohol-related harm, and were drafted against the background of dramatic increases in our alcohol consumption.

These reports all made the same points as are broadly to be found in the international research literature and in the various framework documents produced by WHO, but we concluded that individually and collectively they have made little or no discernible impact on the way in which we have responded at national level to the management of our alcohol-related problems. The National Alcohol Policy report of 1996, which might have been expected to provide a focal point for ongoing policy work in this sphere, appeared to us to have sunk more or less without trace, with many members of our committee being unaware of its existence. We know that politicians are frequently subject to criticism for what is described as a lack of political will in relation to alcohol and for their alleged closeness to the drinks industry, and we also know that criticisms of this nature are commonly advanced so as to explain why research findings are not automatically translated into policy measures. However, in considering our national failure to implement the recommendations of reports such as those mentioned here, we have identified a somewhat more mundane reason for this failure: it is our view that successive policy reports on alcohol and alcohol-related problems in this country, however scientifically valid and socially laudable they may have been, have not led to ongoing implementation, largely because no permanent management structures have been established to give effect to their recommendations. The ideal of an integrated national alcohol policy, such as has been advocated by WHO for several decades, may never be fully attained; indeed we have been tempted to conclude that repeated demands for such an integrated policy may be an example of the best being the enemy of the good, in the sense that there has not been sufficient exploration of other potentially useful policy structures which fall short of this ideal.

This leads us directly on to the purpose of the present report, which is to consider whether it might not represent practical progress in this sphere if alcohol were to be added on the National Drugs Strategy - a strategy which has the kind of permanent structures already alluded to but which are missing in the case of alcohol.

4. The National Drugs Strategy : What Is It?

4.1 Background to the Strategy

It became clear to us during the course of our deliberations that not all of those who made representations on this topic fully understood what the National Drugs Strategy is or how it had originated; therefore, it seems useful at this point to outline the underlying rationale and main features of this strategy. While problems relating to alcohol have been a perennial issue for the Irish political system, problems relating to illicit drugs have a much shorter history, dating from the late-1960s and in the case of heroin - the drug which has most exercised policy makers here - only from 1979/1980. It can readily be understood that, as is also true of alcohol, public sector management of illicit drugs is a complex business, involving a wide range of sectoral interests. Various attempts had been made over the years to create a co-ordinated policy response to drugs, but it was only in 1996 that the groundwork was laid for the present system in The First Report of the Ministerial Task Force on Measures to Reduce the Demand for Drugs. This report, which was written by a group comprising of Ministers of State, acknowledged the sense of crisis then being experienced by Irish society and its political leaders in relation to drugs. The criminal justice system was struggling to cope with a high volume of drug-related crime, the healthcare system with a range of difficulties directly or indirectly associated with drug use; and in those urban communities where heroin use was commonplace all of the statutory authorities - housing and educational authorities, as well as criminal justice workers and healthcare providers - were finding it difficult to organise coherent and comprehensive responses to this problem. In drafting their recommendations for the creation of new structures aimed at the management of drug issues (Appendix 4) , the Ministers of State drew explicitly on ideas which had just been formulated in the context of wider approaches to Irish public sector reform under the banner of the Strategic Management Initiative (SMI)

4.2 The SMI Approach to Cross-Cutting Issues

The introduction of SMI to the public service in Ireland may be generally understood as reflecting similar developments in other countries which were concerned to bring about reform of public sector management systems. As part of this initiative, an early report Delivering Better Government (1996) had argued that many important policy issues were what was described as cross-cutting issues: that is, they were issues which could not be effectively managed from within the functional remit of any single governmental sector, since they were relevant to a wide range of central government departments and executive bodies. It was argued that conventional public sector management systems often dealt badly with these cross-cutting issues, because individual sectors were more inclined towards ‘territorial protection’ than towards cooperation and consensus-building with other sectors. So as to improve public sector management of cross-cutting issues and create what is popularly known as ‘joined-up government’, Delivering Better Government recommended the following structural innovations:

•the establishment of Cabinet Sub-Committees to take ultimate responsibility for policy formulation and implementation in key cross-cutting areas;

•the nomination of ‘lead’ departments at central government level which would ensure that appropriate actions are being taken and required outcomes achieved;

•the allocation of specific co-ordinating roles to Ministers or Ministers of State;

•the creation of dedicated cross-cutting structures or teams which would provide detailed, ongoing management of these issues.

These SMI recommendations (Appendix 5) provided the model for the National Drugs Strategy which was created in the wake of the First Report of the Ministerial Task Force on Measures to Reduce the Demand for Drugs, and which has evolved with relatively minor changes over the subsequent decade. The structures set in place, which are intended to combine ‘top-down’ co-ordination of relevant policy issues with ‘bottom-up’ or community level participation in the policy process, consist of the following:

•the Cabinet Committee on Social Inclusion;

•the Inter-Departmental Committee on Drugs (made up of high-level representatives of key government departments involved in the drug policy arena);

•the Department of Community, Rural and Gaeltacht Affairs, which has been identified as the lead department for the National Drugs Strategy;

•the Minister of State within the lead department, who has been allocated specific governmental responsibility for this strategy ;

•the National Drugs Strategy Team, which is a dedicated team consisting of senior civil servants from relevant departments, along with representatives from an Garda Siochana, the HSE, FAS, and the community and voluntary sectors;

•Local Drugs Task Forces sited in areas with a high prevalence of drug problems;

•Regional Drugs Task Forces.

4.3 How the National Drugs Strategy Works

Over the decade of its existence, these structures have facilitated the emergence of a policy process in which:

i) policy objectives are explicitly stated;

ii) actions necessary for the attainment of objectives are identified, as are agencies which have specific responsibility for working towards the attainment of these objectives;

iii) key performance indicators are established and so also are time-frames.

In 2001, following a national consultation process, a very detailed policy framework, Building on Experience: National Drugs Strategy 2001 -2008, was published, and in 2005 a mid-term review of the strategy was published. This mid-term review offered evidence of mixed outcomes in terms of the implementation of the strategy, but on the whole it provided impressive evidence that the structures have succeeded in keeping all the major stakeholders - statutory and non-statutory - involved in an ongoing process of working towards a set of agreed objectives. It can reasonably be concluded, therefore, that following a lengthy period in which Irish drug policy was characterised by fragmentation, and by what has sometimes been described as an ‘epileptic’ style of management activity (this metaphor refers to long periods of almost total inactivity interspersed with occasional bursts of frenzied activity), the creation of the National Drugs Strategy has brought consistency and coherence to this complex arena. Since 2001 the work of the strategy was based around four inter-connected ‘pillars’, supply reduction, prevention (which includes education and awareness campaigns), treatment and research, and, following its mid-term review, a fifth pillar - rehabilitation - was added.

It is noteworthy that Eoin Ryan, the then Minister of State with responsibility for the drugs strategy, commented in his foreword to Building on Experience that during the public consultation process leading up to the drafting of this report members of the public (particularly outside of Dublin) identified alcohol as their major source of concern. This grassroots’ concern with alcohol issues, and an accompanying sense of frustration that alcohol is not part of the National Drugs Strategy, continues to be reflected in the developing work of the Regional Drugs Task Forces - most explicitly (Appendix 6) perhaps in Shared Solutions: First Strategic Plan of the Western Region Drugs Task Force (2005).

5. Should Alcohol be Included in the National Drugs Strategy?

5.1 Moving Beyond Passivity

We have satisfied ourselves that alcohol, despite its legal status, is a drug which is implicated in a wide range of health and social problems currently prevalent in Ireland. We have also satisfied ourselves that despite the existence of scientific consensus as to their cause and their prevention, successive governments have failed to set in place any ‘joined-up’ or ‘cross-cutting’ management structures aimed at reducing the prevalence of alcohol-related problems in this country. As stated at the outset, we were particularly struck by the fact that more than ten years of debates, reviews and committees have failed to produce ongoing, evidence-based policy on this topic, so that the alcohol policy arena here is characterised by a palpable sense of passivity: alcohol problems in this country are viewed as though they were natural disasters, which are inevitable and completely beyond the reach of public policy. Our primary aim, therefore, in presenting this report is to challenge this passivity.

5.2 Summarising the Arguments

We have been persuaded that the National Drugs Strategy, while clearly no panacea for what appear to be intractable problems, has succeeded in creating a practical, integrated policy framework for reducing the harm associated with illicit drugs. In these circumstances, it would appear that there are only two reasonable options open to us: either to recommend the creation of another policy process - a National Alcohol Strategy - comparable to and parallel with the National Drugs Strategy or, alternatively, to recommend that the existing drugs strategy be extended to include alcohol. The arguments in favour of the latter option seem compelling. The process of putting together an entirely new alcohol strategy would undoubtedly be a lengthy and contentious political and administrative affair, which might ultimately come to nothing. On the other hand, the process of adding alcohol to the agenda of the existing National Drugs Strategy could proceed with relative speed, and would mean that the knowledge and experience gained over the past decade in managing illicit drug problems could now be applied in the sphere of alcohol-related problems. There would, also, be economies of scale to be derived from having a single policy structure for alcohol and illicit drugs, and the five-pillar model of the National Drugs Strategy, which has already been referred to, would appear to offer an ideal framework for a comprehensive policy approach to alcohol issues.

From our consultations with representatives of the drinks industry, we realise that what we are proposing may well be distasteful to the industry; however, we view this as a practical way forward in what should be a national effort to reduce the harm associated with alcohol consumption, and we regard it as farfetched to represent our proposal as a form of neo-prohibitionism. Drinks industry representatives have contributed to the policy debate over the past decade and, in the spirit of social partnership, we envisage that the industry will continue to do so if or when alcohol is included within the National Drugs Strategy. We are, however, completely satisfied that public disquiet about the prevalence of alcohol problems in our society has now reached a point (as reflected, for instance, in the already mentioned work of the Regional Drugs Task Forces and in the recently published survey from Alcohol Action Ireland) where the political system is justified in taking this step, a step which might previously have been regarded as extreme or lacking in public support. We also believe that the inclusion of alcohol in the National Drugs Strategy can facilitate and enhance ‘community mobilisation’ - the process whereby voluntary organisations could work actively at local level to prevent alcohol-related harm, as they already do in relation to illicit drugs - and that many vintners and off-licence traders are interested in and committed to this process.

5.3 Our Recommendation

As stated at the outset, our intention in this report was to deal with just one question: Should alcohol be included in the National Drugs Strategy? It quickly became clear to us that there has been regular and intense policy debate about alcohol in this country for at least the past decade, but that this debate has failed signally to produce an effective policy response to problems stemming from the consumption of alcohol. In our effort to answer the single question with which we were concerned, we also decided that no useful purpose would be served by presenting detailed accounts of the prevalence of diverse types of alcohol-related problems currently being experienced here. Detail of this kind has been convincingly produced in previous reports and might only serve to distract from the relatively straightforward question which we set ourselves. Having considered the issues, we are unequivocally of the view that alcohol should be included in the drugs strategy.

We have just one recommendation: that alcohol should be included in the National Drugs Strategy. We believe that this recommendation can be acted upon quickly and that, if done so, this will :

•finally anchor this important policy issue within a well-established structure which guarantees ongoing policy work at the highest governmental level;

•create a framework for ‘bottom-up’ or community mobilisation activity in relation to alcohol, comparable to that which has taken place in relation to the illicit drugs for many years;

•create greater clarity at the research/policy interface and, in particular, challenge the dominance and popularity of policy measures which lack research support as to their effectiveness;

•satisfy public demand for a coherent policy response to alcohol-related problems.

References:

Alcohol Action Ireland (2006). Alcohol in Ireland - Time for Action: A Survey of Irish Attitudes. (Dublin: Alcohol Action Ireland).

Babor, T. et al. (2003). Alcohol: No Ordinary Commodity - Research and Public Policy. (Oxford University Press).

Bruun, K. et al. (1975). Alcohol Control Policies in Public Health Perspective. (Helsinki: Finnish Foundation for Alcohol Studies).

Building on Experience: National Drugs Strategy 2001-2008 (2001). (Dublin: Stationery Office).

Commission on Liquor Licensing - Final Report (2003). (Dublin: Stationery Office).

Daly, A. et al. (2005). Activities of Irish Psychiatric Units and Hospitals 2004. (Dublin: Health Research Board).

Delivering Better Government: Second Report to the Government of the Co-ordinating Group of Secretaries - A Programme of Change for the Irish Civil Service (1996). (Dublin: Stationery Office).

Edwards, G. et al. (1994). Alcohol Policy and the Public Good. (Oxford University Press).

Hearne, R., Connolly, A. and Sheehan, J. (2002). Alcohol abuse prevalence and detection in a general hospital. Journal of the Royal Society of Medicine, 95, 84-87.

Hope, A. et al. (2005). Alcohol and Injuries in the Accident and Emergency Department: A National Perspective. (Dublin: Health Promotion Unit).

Hope, A., Dring, C. and Dring, J. (2005). College Lifestyle and Attitudinal National (CLAN) Survey (The Health of Irish Students). (Dublin: Health Promotion Unit).

Joint Committee on Health and Children (2004). Report on Alcohol Misuse by Young People. (Dublin: Stationery Office).

Mid-Term Review of the National Drugs Strategy 2001-2008 (2005). Dublin: Stationery Office.

Marriage Counselling Services (1996). Annual Reports. (Dublin and Cork Counselling Centres).

National Alcohol Policy - Ireland (1996). (Dublin: Stationery Office).

National Crime Council (2003). Public Order Offences in Ireland. (Dublin: Stationery Office).

Strategic Task Force on Alcohol - Interim Report (2002). (Dublin: Department of Health and Children).

Strategic Task Force on Alcohol - Second Report (2004). (Dublin: Department of Health and Children).

Shared Solutions: First Strategic Plan of the Western Region Drugs Task Force (2006). (Dublin: Department of Community, Rural and Gaeltacht Affairs).

The First Report of the Ministerial Task Force on Measures to Reduce the Demand for Drugs (1996). (Dublin: Department of the Taoiseach).

The Psychiatric Services: Planning for the Future (1984). (Dublin: Stationery Office).

APPENDIX 1

APPENDIX 2

Table 3: Alcohol Policy Effectiveness

APPENDIX 3

Alcohol in Ireland

Time for Action

A Survey of Irish Attitudes

Alcohol Action Ireland

Executive Summary

This report has been commissioned by AAI, in order to determine the views of the Irish public in relation to a wide range of alcohol policy measures. The findings confirm that most people are aware of our problem with alcohol and accept that tackling the problem will involve a change in our cultural attitude towards and acceptance of alcohol misuse and drunkenness. Only a small minority (26%) of people believe that the government is doing enough to tackle the problem.

The key findings of the survey are;

•82% of people believe that our current alcohol consumption levels are a problem and 85% feel that our cultural attitude to alcohol needs to change.

•Anecdotally we know that most families in Ireland have some experience with problem or dependent drinkers — the survey reveals that 66% of Irish people know someone with a problem.

•Significant numbers of people (44%) have been injured, harassed or intimidated as a result of someone’s use of alcohol.

•The majority of people (51%) believe the Government is not doing enough to address alcohol problems and 85% believe an agency should be set up to specifically tackle alcohol-related problems.

•The potential support for the Government to introduce effective control measures, in relation to alcohol have been either underestimated or ignored. For example a majority of respondents (54%) would support an increase in taxation if it was specifically put to initiatives that led to a reduction in alcohol-related harm.

•60% believe that A&E staff should be able to refer patients with persistent alcohol-related problems.

•Over two thirds of people (71%) believe that alcohol advertising should only be permitted after 9pm and less than one third (29%) are opposed to an outright ban on alcohol advertising.

•Nearly 90% support the introduction of random breath testing for drink driving.

•Over 70% believe that proposals to allow alcohol to be sold by phone/internet, as per the ‘café bar legislation’, would make it easier for under 18’s to buy alcohol.

•A majority (57%) of Irish people have been concerned about someone’s use of alcohol.

The Irish pattern of drinking large quantities of alcohol at one sitting inevitably leads to a wide variety of alcohol related harms and it is therefore unsurprising that almost half (44%) of all people have been injured, harassed or intimidated by someone’s use of alcohol.

Tackling the problem will inevitably involve a wide range of policy changes and interventions at both the individual level and the wider population level. The findings suggest that there would be widespread public support for the Government if more effective measures were taken to lessen the harm caused by alcohol to the health and social well-being of Irish people.

There are a number of measures that could be introduced to bring about changes in our alcohol consumption levels and consequent levels of harm. AAI believes that we should establish a structure or body that will operate at national and regional level to implement the recommendations of the Strategic Task Force on Alcohol. This body would then be responsible for drawing up a National Alcohol Strategy similar to the National Drugs Strategy. This would set out specific actions, targets and deadlines for the achievement of those targets. The body would also oversee the implementation of those recommendations and provide resources at a regional and community level.

In addition we should:

•Reduce the number of outlets selling alcohol and reduce the opening hours.

•Ensure that any system of Random Breath Testing introduced here will be highly visible, well publicised and most importantly well resourced.

•Introduce statutory regulations on advertising and marketing of alcohol products restricting alcohol advertising to after 9pm.

•Provide the necessary resources to allow the Gardai enforce all existing laws on serving alcohol to underage and intoxicated people, opening and closing hours, and public drunkenness.

•Use taxation as a means of reducing demand for alcohol by increasing prices in line with inflation. The taxation system could also be used as a way of promoting low alcohol or no alcohol alternatives through a reduction of tax on these products.

•Provide Early Intervention programmes in all social, health and justice services to ensure that all those working in such settings would be in a position to detect high risk drinking in individuals at an early stage and provide the appropriate response.

APPENDIX 4

APPENDIX 5

must be underpinned by legislative change. There can be little doubt that the secretive aspects of the Civil Service owe much to the presence of the official Secrets Act, based on an Act of 1911. In order to start the process of cultural change and to give it the necessary legislative underpinning the Group recommend that:

•In accordance with the programme outlined in A Government of Renewal, the Freedom of Information and Privilege and Compellability of Witnesses legislation be enacted as soon as possible

•In that context, the Official Secrets Act and other statutory provisions which restrict access to information be reviewed.

•The role of the Ombudsman in providing a means of redress for citizens be extended and enhanced

•The process of Oireachtas reform, in particular of the Committee System, be continued in support of the change to greater openness and transparency in public administration. In this regard also, the need for greater clarity in relation to the role and remit of individual Committees is essential.

Measures to increase access to information will need to be complemented by:

•A clear understanding of the relative responsibilities of Minister and Civil Servants in relation to the formulation of policy, on the one hand, and implementation of policy, on the other,

•Adequate protection for those giving evidence before Oireachtas Committees,

•Provision of a statutory framework within which civil servants, whild acting bona fide in the public interest, may legitimately disclose information

Further work will be required to develop and implement the proposals on open and transparent service delivery, and to this end, recommendations are set out in Part 111- Making it Happen.

CROSS-DEPARTMENTAL ISSUES

There are many vital national issues which can no longer be resolved from within the functional remit and skill base of a single Department or Agency. Indeed, many of the most pressing issues which must be addressed require the expertise and commitment of a variety of Departments and Agencies in order to achieve a successful outcome. Increasingly, therefore, effective action necessitates new approaches to understand, developing and managing the linked activities and processes that result in the desired outcome, whether the provision of services to the public or sound policy advice to Ministers and the Government. These new approaches challenge traditional Department and functional boundaries.

The Group are of the view that the existing Civil Service structure is not well geared to meeting this challenge satisfactorily. Each Department’s work is firmly focused on a sectoral and functional basis, there are limited structures for Consultation, co-ordination and co-operation and the current system rewards “territorial protection” at the expense of active co-operation to achieve results. Recognising the essential need for cross-Departmental co-operation, some initiatives have been put in place, such as the Tax Strategy Group and the Task Force on Long-Term unemployment. The Group consider that while these structures have served very well to promote inter-Departmental discussion and co-operation leading to more integrated action, it is essential to go beyond this to a situation where policy is implemented on the basis of teams drawn from different Departments and Agencies in pursuit of stated goals.

In order to identify possible approaches to this complex issue, the Co-ordinating Group established three working groups at Assistant Secretary level to consider more appropriate mechanisms for cross-Departmental action on Child Care, competitiveness and environmental issues. The working group reports made clear that innovative approaches are required which clearly articulate the strategic policy objectives in the different areas and which develop new approaches and mechanisms to implement policy and, critically, to monitor and assess progress.

The development of Strategic Result Areas as set out earlier in this Report, with identify the key issues where cross-Departmental action, commitment and expertise are required to solve problems. Examples of these areas include effective responses to the problem of drugs, the need to increase employment, the need to maintain and enhance Ireland’s competitiveness, to act against poverty and unemployment, and to promote and encourage economic and social development at local level. In this context, the Government decision in relation to the National Anti-Poverty Strategy specifically referred to the use of the Strategic Management Initiative to reflect the Government’s commitment to an anti-poverty strategy and reflected the need to ensure that tackling poverty is a priority across all Departments and Programes. The Group reaffirms this and reiterates the need to have the anti-poverty strategy integrated in the objectives of relevant Government Departments and Agencies.

In order to further strengthen the overall approach to this complex issue, the Group recommend the establishment of Cabinet Sub-Committee for key areas of Government policy, the allocation of specific co-ordinating roles to Ministers and Ministers of State, the systematic sharing of expertise between Departments, the development of project teams and the nomination of a “lead Department” in each area to ensure that action is taken and the required outcomes achieved.

Pending the development of Strategic Result Areas and in order to assist in devising solutions, the Group recommend that a number of cross-Departmental teams be established with co-ordination by a Minister/Minister of State and with a specific lead Department. Among the issues which would benefit from this approach are:

•Child Care

•Drugs

•Employment

•Competitiveness

•Unemployment and Social Exclusion

•Financial Services

•Local Development

The Group recommend that these teams be given a specific remit and detailed objectives over an agreed period and that team members be detached from their Department on a full- or part-time basis, according to the specific skills they bring to resolving these issues within the team framework. A clear obligation would be placed on the team to develop solutions and new approaches. Suitable reward mechanisms will need to be designed for this work.

The Group recommend that the new co-ordinating Group proposed in Part 111 — Making it Happen liaise with Government on the setting up of these pilot teams and that this be done speedily. The new Group will monitor developments and assess progress. The lessons learned and the best practice emerging can then be identified and used to introduce a systematic and innovative process for tackling key issues of national importance and to assist in the development of Strategic Result Areas.