The second annual lecture, in memory of Lord Ramsbotham, held on 26 November 2024.
This second of a planned annual lecture series in memory of Lord Ramsbotham, former chief inspector of prisons, was held in the House of Lords in the Palace of Westminster.
Introduced and chaired by Mary Glindon MP, the audience heard from Sir Ian Gilmore, professor of hepatology and chair of the Alcohol Health Alliance, who spoke about Alcohol Policy.
Mary Glindon MP
Welcome to the second in a series of annual events on subjects which Lord Ramsbotham engaged with so passionately here in Parliament. I’m Mary Glindon, the Labour MP for Newcastle upon Tyne East and Wallsend, the new title for my new constituency, but I was really honoured and privileged to serve alongside David as a co-chair of the Drugs, Alcohol and Justice Group, which he himself had chaired for many years. And it was great honour to serve with him.
For those of you who didn’t know David, after a distinguished military career, General Ramsbotham served as Chief Inspector of Prisons before becoming a life Peer. He was born on 6th November 1934 and he died on 13th December in 2022, so these lectures are organised at this time of year to fall in between those two dates. And if anyone missed last year’s event – at which our guest speakers were Sir Bob Neill MP, speaking about prisons, and Richard Burgon MP, who was speaking about probation – there are transcripts available on the Centre for Crime and Justice Studies website.
Both of the speakers last year, if you didn’t hear them, were amazing and it was a really good inaugural lecture. But some of you, if you can cast your mind back to 2018, were here in Parliament when we launched our own Alcohol Charter. You might recall that our guest speaker was here on that day, and I think it was in the Commonwealth Room off Westminster Hall, if that reminds anybody. Now, that was a very good event. But you can read the Charter, it’s on the Alcohol Change UK website. We do have Dr Piper here tonight. Hello, Dr Richard Piper, who is the chief executive of Alcohol Change.
Just before I introduce our guest speaker, we also have with us Clive Brooke, who like me is a Labour Party member and a member of the Drugs, Alcohol and Justice APPG, and the PCS union. We’ve got a lot in common. And as a Baron Brooke of Alverthorpe, he was a close colleague of David’s here in the House of Lords. And in that capacity, I would welcome Clive to say a few words, if he doesn’t mind, about David.
Lord Brooke
That’s very kind of you, Mary. I’m Clive Brooke. I had the good fortune to be sharing a room with David Ramsbotham – an amazing experience. He made his name, of course, in the forces, first of all, but then as a Chief Inspector of Prisons. He was courageous, he was independent, he wasn’t cowed by any particular government, whoever was in power, and he expressed his views in the most forthright fashion.
And that’s how he got the name of Rambo. And he would appear fairly frequently, I think, on Tonight – and Jeremy Paxman was absolutely fascinated by him. He really gave all he could. It’s in service of trying to get a better life for people in prison. Up in my room now, most of what he had around has been moved out by his family, understandably. But his successor has got the desk, and showed me there is a great file where the drawer pulls out, and it is absolutely jammed full of letters from prisoners seeking his assistance. And that was the kind of man he was. He was prepared to go out there and listen to anybody and try to help them.
Coming back to the APPG, he was a longstanding joint-chair for many years. He made a great impression, but in particular, what I remembered especially was that we got an alcohol strategy. I spent a lot of years myself working on alcohol and drugs and sugar addictions. But we got a very good – believe it or not, from David Cameron – a very good strategy on alcohol introduced in 2011. Prime Minister May ditched it effectively in 2014, but it was a very good strategy. And then we had a long period – we managed to get a strategy on drugs, and that has been very welcome and has been very helpful indeed. But on alcohol, we still have a great silence. Yet this APPG, under David’s chairmanship there, set up a small inquiry to try to devise a new strategy on alcohol.
And that’s just been mentioned and just been pointed out to you. And I, particularly as a long-term campaigner on alcohol issues, was so grateful to him for giving the lead on that, along with Mary and with Richard, our sort of secretary. Bringing us up to date, we’ve had a commission on alcohol, which our speaker today has chaired.
So that's probably enough from me, but could we just have a moment of silence to remember David and the great work he did. Thank you.
Mary Glindon MP
I just want to say thank you Clive, because that was a most wonderful few words. And it epitomises everything people think about David, when they recall him and the wonderful work he did. So, we couldn’t have had someone better, especially the person who shared the room with them, to give those words tonight. So, thank you very much indeed.
I think the last time you were here, Sir Ian, it was for the Alcohol Alliance breakfast a few weeks ago, at 8:30 in the morning. We were all keen to be there. You frightened the death out of the people who were there, I have to say, by some of the things you told us about. But in a good way, I’d say. Sir Ian Gilmore, professor of hepatology and chair of the Alcohol Health Alliance, I'll give you the floor now.
Sir Ian Gilmore
Thank you, Mary, for that generous introduction and for the invitation to address the APPG. One of the privileges of giving a named lecture, particularly in such august surroundings as this, is the opportunity to learn a little about the individual honoured in this way. What came through in the wonderful introductions by Clive and Mary were the three Hs – humour, humility and humanity. And what about being known affectionately as Rambo? Many men would give a lot for that nickname! He was of course a great support to the Drugs, Alcohol and Justice Group and drew on his huge experience through the Prison Service. I had the privilege of meeting him in 2018 when the APPG produced a charter calling for a National Alcohol Strategy. He would have been 90 this month and it is splendid just to have the opportunity to celebrate his life. I know his family were hoping to be here, but I’m sure we’ll send them a transcript of what’s been said about their father.
The APPG is a wonderful and influential Group, and I could improve on it only by making the title the more cumbersome one of “The alcohol and other drugs and justice group”. Because alcohol is of course our favourite drug. I always try to remember to refer to alcohol and other drugs, although having raised the topic I shall almost certainly forget and get it wrong in the next 20 minutes.
A little bit about where I’m coming from. I’m a liver doctor by background, and 80% of liver deaths are caused by alcohol. To use the public health analogy, I spent years pulling drowning people out of the river without ever thinking of walking upstream to find out why they were falling in in the first place. I chaired an RCP working party around the year 2000 on alcohol – can the NHS afford it? Obviously, the answer was, as it is now, no the NHS cannot afford it, but this stimulated my interest in the wider societal impact of alcohol.
I was then lucky enough, a couple of years later, to be invited to join a working party at the Academy of Medical Sciences chaired by none other than your earlier speaker at the APPG today, Sir Michael Marmot. They were looking afresh at the harm from alcohol from a public health and epidemiology perspective. I was frank on day one that I was a clinician without their research experience, but I was happy to be the scribe and sit at the feet of these experts, and I guess that was the start of my late entry into the field of public health, trying to prevent illness rather than waiting for it to appear.
Then, when I was RCP President, for the first time someone other than my mother listened to me and I was able to set up the Alcohol Health Alliance, now in its 18th year and with more than 60 member organisations. We have learnt the strength of bringing in diverse organisations like homeless charities and domestic violence groups, and also the value of having narratives as well as statistics to show the impact on individuals, families and communities. We have also spawned a wonderfully active Commission on Alcohol Harm that is still ongoing, mainly with Peers from this House and chaired by Baroness Ilora Finlay, who should have been giving this address here today and I hope will be invited back.
Now, a little background to alcohol and its place in our community to see if understanding where it has come from may help us in deciding policy for the present and the future. We know that animals from the earliest days have been drinking sweet fermenting fruit juice, and man and woman no doubt caught on very early in history too. However, its impact on those early communities was not recorded until writing became established. It was about the fourth century BC in Sumeria that drinking alcohol is first documented, and beer was clearly as important as gold for bartering purposes in the local economy. Early taverns became an important urban social phenomenon. In Egypt, we know that workers on the pyramids were paid partly in beer, and rich people were interred in their coffins with copious supplies of wine to keep them going in the afterlife.
Around the same time, we know that winemaking was well established in China – indeed the Shang dynasty is thought to have fallen through the drunkenness of its leader Di Xin and the next dynasty tried to ban alcohol completely, except at formal occasions. As a result, formal occasions multiplied and apparently funerals became a riotous excuse to open the wine. In Greece, in the times of Plato, there was much wine and drunkenness but holding your drink became an important sign of manhood. Rome supplied wine to its soldiers in Britain, which they sipped with their meals and were puzzled how the local barbarians got drunk on beer once a year at harvest time.
Commercial brewing, as well as home brewing, developed in this country in Roman times, with remains of breweries found from Somerset to Northumberland. Wine largely disappeared with the Roman oppressors and our inns and taverns were primarily suppliers of beer. The history of distilling spirits is not clear, but it is almost certain that in the UK it started in the monasteries, which were the centres of knowledge and scientific advances. We know that King James IV of Scotland bought several barrels of whiskey from a monastery in 1495. However, gin was to wait a further 200 years – when the farmers had poor-quality harvests, they discovered that the grain made perfectly acceptable gin. The gin craze and the resulting mayhem in London is a talk on its own but suffice it to say that it was the opium of the masses, cheap and strong, probably twice the strength of current spirits. London, with its streets supposedly paved with gold, attracted thousands of newcomers to a population of 600,000, when the next biggest town in England was nearer 20,000. Gin numbed the pain of poverty and homelessness, and death rates at the time of Gin Lane in the 18th century exceeded birth rates. Women seemed particularly prone, highlighted in Hogarth’s depiction of Gin Lane.
Of course, we have to admit, in these days of talk of reparation, in the 18th and 19th centuries we were not slow to use alcohol as a means of protecting and indeed extending the British Empire, and to this day this is seen in the alcohol problems visible in the indigenous populations in, for example, the United States, Australia and Canada. We learned in the 18th and 19th century that prohibition did not work, hence the ineffectual gin acts, and of course it was learned the hard way in the 1930s in the United States. However, there were some interesting by-products of prohibition in the USA – for example during prohibition domestic violence fell by over 50%.
Where are we today and what can we learn from the past? Firstly, I think we can learn that culture is not immutable – we can do something about the heroic culture around drinking and the normalisation of alcohol, which makes it currently the centre of every celebration. That normalisation is not necessarily in our genes – how much is being fed by the global producers, the constant advertising, the social media cultivating the concept of normality? For example, wine o’clock for women – women holding down a job, rushing home, getting children to bed and encouraged to feel they have earned and deserve a liquid reward. I am sure the drinks industry is not far away from these social media groups that encourage it.
But what a change in culture we’ve seen in smoking, that shows it is possible – albeit it has taken far too long. It was 1962 that Richard Doll, who at 90 was a member of the Academy of Medical Sciences working party of 2005 that I mentioned, produced his seminal work on smoking and lung cancer, but it took another 50 years to ban smoking in public places. But we have seen a change – it isn’t considered manly or heroic to smoke – people don’t say that so and so can really take his fags – and nowadays we see smokers at work huddled in the rain outside their offices having a cigarette in a way that almost reflects guilt. But we are not seeking to shame drinkers, but to understand the intrinsic dangers of the product and remove them.
Another change in culture that is closer to home is the move in the last 20 years to home drinking. This has been almost entirely driven by the availability of cheap supermarket drink. I remember as a teenager a bottle of beer could be bought from the side window of the pub, but it would cost a few pennies more than inside. It used to be, only 20 years ago, that most drinks were taken in bars or restaurants but now 80% of all drinks are consumed at home – with the one exception of beer that is about 50:50. Why would somebody spend the best part of £10 on a drink in a pub when they can buy the whole bottle of wine or large pack of beer for the same price and have it at home before going out? Price changes culture.
I am not going to spend 20 minutes bamboozling you with statistics, but it is worth stating the economic as well as social cost is underlined by alcohol being the leading cause of death, ill-health and disability for 15-49-year-old men in the UK – people who should be at their most productive. The most recent estimate of costs of alcohol to the UK are £35 billion, and the biggest contributor is crime and disorder – £27 billion.
I don’t need to tell this group of that strong link between alcohol and crime, with 44 per cent of violent crime linked to alcohol – and 40 per cent of people in prison say they were drunk at the time of the offence. Almost two-thirds, 63 per cent, of people in prison have a measurable alcohol-use disorder, with almost half of those, 31 per cent, seriously dependent on alcohol. The risk of death from alcohol is three times higher for those who have been in prison than for the general population. There are also other alcohol-related harms. For example, there is an increased prevalence of people in custody with foetal alcohol spectrum disorder.
An area that interests me and I hope you can tell me more about is the possible role of the Courts. The Family Drug and Alcohol Courts in England are focussed, quite rightly, on protecting children, but the Alcohol Courts in Scotland seem to have developed a wider brief in finding solutions for the perpetrators too.
Looking after the individual was central to David Ramsbotham’s philosophy, and this is exemplified by the title of his 2019 report on Probation – “People are not things”.
There are so many parallels with the heath issues of smoking and unhealthy foods that we joined forces with ASH and the Obesity Health Alliance last year and produced the report “Holding us Back” – advocating for a coherent health policy approach on the common barriers and solutions to these public health challenges. Clearly there are differences – we are not trying to eliminate alcohol from society as we would like to do for tobacco, and food is essential to life. But we have to acknowledge that the harm is preventable and furthermore felt disproportionately in the poorest and most vulnerable in society. You will have heard that earlier today from Michael Marmot. They must all be the substrate for joined-up Government, with health inequalities at its core.
We followed-up this year with a second report, “Killer tactics”, looking at the commonality of the methods used by the producers and retailers. These common industry tactics include: to deny or play down the evidence of harms linked to their products; to position themselves as part of the solution; to distort the science about their products; to distort messaging about health risks and harms; to use legal threats to interfere with the implementation of effective policies to protect public health; to use Corporate Social Responsibility to signal their virtue at the expense of public health and wellbeing; to use proxies to communicate their messages without always being transparent about their funding; and to give gifts, benefits and hospitality to MPs attempting to win their favour.
I am sure many of those tactics are familiar to you. But I fully understand that the drinks industry’s first responsibility is to their shareholders and the fault is ours – including governments – by allowing them to have a seat at the table when public health policy is being developed.
I never cease to be amazed at the effective and co-ordinated response from the Scotch Whisky Association when a few pence of duty are put on a bottle of Scotch – huge swathes of Scotland will become unemployed, children going to school in bare feet, and not mentioning that over 95% of their product is exported and unaffected. But we could learn a lot from them, particularly if we had only a fraction of their resources.
Without doubt the most successful intervention in this field I ever made was to resign – resign from co-chairing an alcohol committee at Public Health England when they chose to partner with a largely industry-funded organisation in a campaign. After the consequent publicity, PHE abandoned the partnership and introduced a policy, akin to the WHO one, on how they would, and would not, work with industry actors. However, government works in strange ways and before long PHE was dissolved and moved into OHID – the Office for Health Improvement and Disparities – within the DHSC and that policy did not survive the journey. We continue to press OHID to embrace that policy.
To finish on a positive note – there are solutions, but they need a systems-wide approach of the kind being launched tomorrow by the Medical Council on Alcohol, supported by the Alcohol Health Alliance. This system-wide approach needs to use the evidence-base of what works to reduce harm – endorsed by the WHO –tackling the big three.
The first and most important is price. The affordability of alcohol is directly linked to consumption levels and alcohol-related harm rates – the cheaper alcohol is, the more is consumed and the more harm is caused. One way to reduce the affordability of alcohol is through minimum unit pricing, or MUP. MUP sets a floor price based on the amount of alcohol in a drink, thereby increasing the price of the cheapest, strongest products. Since MUP has been in place in Scotland and Wales, household purchases have dropped by 7.7% and 8.6% respectively – particularly among the households who purchased the most alcohol. A 50p minimum unit price is predicted to prevent 36,000 crimes annually in England when at full effect. To be honest, I was surprised that MUP had the effect it did in Scotland and Wales. When it was first mooted a decade before it was implemented in Scotland in 2018, it had been suggested by the then England CMO Liam Donaldson at 50p, and when the rigorous evaluation was going on in Scotland of its efficacy, that figure was nearly 15 years out of date.
In the absence of national MUP, various local authorities have tried schemes – for example Ipswich pioneered a “reducing the strength” scheme. These are voluntary arrangements where retailers specifically remove cheap, high-strength drinks – the same ones most affected by MUP. In the following year, Ipswich saw a 23.5% fall in reported incidents of street drinking, a drop in anti-social behaviour and crime around participating stores, and an overall fall in crime. This sort of local initiative can be very effective but is prone to be dependent on local champions and the policy has a tendency to fall away as those champions fall away too.
Second is availability. The availability of alcohol correlates directly with levels of crime. For example, across Scotland, neighbourhoods with the most alcohol outlets had crime rates over four times higher than neighbourhoods with the least. Limiting the hours of sale is a highly cost-effective policy to help reduce crime. The state of Queensland in Australia introduced several limits for alcohol availability in nightlife in 2016, including stopping alcohol sales in licensed venues by 3am and mandatory use of ID scanners in nightclub precincts. Analysis of data between 2016 and 2019 found a 49% drop in assaults between 3am and 6am on Friday and Saturday nights.
Local Authorities need to be able to better control the availability of alcohol in their areas. To do so, public health should be added as a fifth licensing objective to further support public health bodies’ position as a responsible authority in reducing social and health harms.
Marketing is the third big area where the evidence for harm-reduction is strong. England sticks out as an exception to most countries in our lax approach. Some examples are the special offers encouraging bulk buying at the end of supermarket aisles – banned in Scotland and Ireland. In these countries, you have to make a positive decision to buy alcohol and go into a special area in the supermarket. Is it right that you can buy whisky at a petrol station at 2am? And there are so many examples, such as billboards near schools, product placement on TV – go just over the English Channel and there is a ban on broadcast advertising of alcohol products and of sports sponsorship.
It needs a Government Alcohol Strategy – sadly lacking for 12 years now. It needs the support of you all and I am grateful to you for giving me the opportunity to seek your support and commitment during this Lord Ramsbotham Annual Lecture. David was key in the APPG in 2018 when it called for an Alcohol Strategy. With a new government that appears to recognise the importance of prevention in producing longer and healthier lives, in his memory let’s push now for
