As a liver doctor, I have spent my career caring for men and women suffering the consequences of alcohol harm. By the time someone comes to me with advanced liver disease, they have usually been in contact with public services many times over: the GP surgery, A&E, an ambulance crew, perhaps the police, perhaps social work. Each of those contacts, as well as costing money, is an opportunity to intervene to help that person before it is too late. Sadly, most of these opportunities are missed – very few of them are designed to recognise and stop the alcohol harm at the root of the problem.
This is why I want to make a case that may not be obvious to everyone following the debate on public service reform in Scotland. If we are serious about making our public services sustainable, we have to talk about alcohol.
The problem reform is trying to solve
Scotland’s public services are under enormous strain. The Scottish Government is looking for £0.5 billion in efficiency savings, and its own projections show health and social care spending rising from around 40% of devolved public spending by the end of this decade to almost 55% by the mid-2070s.
You cannot close a gap like that by merging a few agencies or trimming back office costs. The only lasting way to relieve the pressure is to reduce the demand coming through the door. The Scottish Government has a useful term for this. It calls it “failure demand”: demand for services that arises after problems have emerged, because earlier intervention was absent, insufficient or ineffective.
Alcohol harm is about as clear an example of failure demand as you will find.
Alcohol touches almost every public service
In 2024, 1,185 people in Scotland died from causes directly attributable to alcohol, most of them from liver disease. It is partially responsible for at least seven types of cancer, as well as heart disease and stroke. More than one in four deaths linked to alcohol in Scotland is from cancer.
But deaths are only the tip of the iceberg. For every person who dies, many more live with alcohol problems day in, day out, and the years before an alcohol death are usually marked by poor health, time out of work and real damage to families. By the time I see somebody losing their health because of alcohol, they have often already lost their driving licence, their job, their marriage.
That harm lands on almost every part of the public sector. It fills hospital beds and A&E departments. It takes up police time and court time. Scotland’s prisons held 8,515 people in June this year, against a design capacity of 7,805, and alcohol is a factor in a large share of violent crime and domestic abuse. Parental substance use was a concern in 38% of child protection registrations in Scotland last year and keeping children safely at home costs far less, in every sense, than taking them into care. An estimated 200,000 people in Scotland are living with Foetal Alcohol Spectrum Disorder, a lifelong condition caused by alcohol exposure in the womb, with consequences for health, education, social care and the justice system.
Taken together, alcohol is estimated to cost Scottish society between 5 and 10 billion pounds every year. And the burden is not shared equally. People in our most deprived communities are over four times more likely to die from alcohol than those in the least deprived.
A striking gap in the Programme for Government
Against that backdrop, I read the Scottish Government’s new Programme for Government, published on 1 September, with real interest. It describes drug and alcohol misuse as a public health emergency and commits to reducing drug and alcohol deaths over the course of this Parliament. Those are the right words, and I welcome the commitment to trial Alcohol Care Teams in hospitals, specialist teams that we know reduce repeat admissions, thereby reducing some of the pressure on our beleaguered NHS.
But when it comes to alcohol, that is where the specifics end. There is a general line about “building on our public health approach to alcohol harm, improving prevention and early intervention”, but not one concrete prevention measure behind it. Nothing on keeping minimum unit pricing up to date. Nothing on how and where alcohol is sold. Nothing on alcohol marketing. By contrast, the drugs commitments in the same section are detailed and practical.
That matters, because the measures that do the most to reduce alcohol harm are not treatments. They are population-level policies that stop harm developing in the first place.
I would argue this is a significant oversight. Helping people to live longer, healthier lives should be reason enough for government to act. But even if you set health aside entirely and look at this purely as a question of public finances, the case for action on alcohol is overwhelming. A Programme for Government that is built around reforming public services, yet says almost nothing about one of the biggest preventable pressures on those services, has missed something important.
We already know what works
The good news is that alcohol is one of the areas of public policy where the evidence is strongest, where the answers are often cheap or even revenue-raising.
The World Health Organisation identifies action on the price, availability and marketing of alcohol as “best buys”, or in other words, the most cost-effective ways proven to reduce the burden of disease. Estimates suggest these measures return more than nine times what they cost. The WHO also identifies several of them as “quick buys”, capable of making a measurable difference within a year.
Scotland knows this better than most. Minimum unit pricing, introduced in 2018, has been independently evaluated and is estimated to prevent hundreds of deaths and hospital admissions every year, at almost no cost to the public purse.
But its effectiveness erodes over time because of inflation. That is why the minimum price had to be increased from 50p per unit in 2018 to 65p in 2024. But in the 2 years which have passed since then inflation has raised prices by 7%, meaning that to preserve its effectiveness going forward, the minimum unit price should already be at 70p. The solution which SHAAP advocates is to ‘index-link’ the minimum price level, with automatic uprating every year in line with inflation. This would protect those gains without costing the taxpayer a penny.
In the consultation response SHAAP submitted to the Scottish Parliament’s Public Service Reform Committee in August, we set out a number of other practical steps:
- A social responsibility levy on large alcohol retailers. Supermarkets have benefited financially from minimum unit pricing. A levy would ask the businesses profiting from alcohol sales to contribute to the costs of the harm, with the money directed to prevention and treatment.
- Treating alcohol services as frontline services. Access to alcohol treatment in Scotland has fallen by 40% in a decade, alongside a real terms cut of around 20% in funding for the local partnerships that commission it. Cutting treatment services to achieve supposed efficiency ‘savings’ has the opposite effect: People simply turn up in crisis instead, at A&E, in police cells and in court, all of which cost far more.
- Using the Invest to Save Fund. Short conversations about drinking in GP surgeries and other health settings, known as brief interventions, save around £1.23 for every £1 spent. Alcohol Care Teams reduce readmissions. Investing to prevent Foetal Alcohol Spectrum Disorder has a modelled return of £3.56 for every £1 spent. These are exactly the kind of proven, cost-saving interventions an invest-to-save approach should back.
- Earlier help in the justice system. Police custody, community sentences and release from prison are all points where alcohol problems can be picked up and treated. Doing that consistently across Scotland would help reduce reoffending and ease pressure on an overcrowded prison estate.
- Giving alcohol its own place in the budget. At the moment, alcohol and drugs are largely funded and reported together, and Audit Scotland has found that alcohol has lost out as a result. Separating them, and creating a budget line for alcohol harm prevention that cuts across health, justice and social care, would let us see whether spending is actually shifting from crisis towards prevention.
Prevention is reform
The deeper problem is structural. The costs of alcohol harm are spread across health, justice, social care and education, but no single part of government owns the job of preventing it. Each department ends up paying for harm that could have been prevented by investment somewhere else. That is the problem reform is supposed to fix.
Prevention is sometimes treated as a nice-to-have, something to fund once the immediate pressures ease. But the immediate pressures will not ease unless we reduce the demand that creates them. When it comes to alcohol, the evidence is clear, many of the tools are already in our hands, and several of them would raise money rather than cost it.
Given the pressure on Scotland’s public finances and the scale of harm alcohol continues to cause, the real question is not whether we can afford to act on alcohol. It is whether we can afford not to.
Dr Alastair MacGilchrist OBE is Chair at Scottish Health Action on Alcohol Problems (SHAAP)