At last there is hope of some commonsense in health statistics, and with it the possibility of creating a more rational debate about alcohol and its place in society.
The Department of Health has published a new framework of public health outcomes. Alcohol is addressed in the ‘Health Improvement’ domain, along with a new basis for counting the number of alcohol-related hospital admissions – a crucial indicator: “the preferred option is for an indicator based on just alcohol-related primary diagnoses”.
This apparently obscure statistical change is important, because exaggerated and distorted “medical statistics” have been used to beat-up the industry over recent years, and to justify the Medical Temperance ‘whole population’ approach to reducing alcohol-harms.
Remember those lurid headlines that read “Over a million alcohol–related hospital admissions a year” OR “Drinking-related hospital cases double in ten years”?
How are such numbers arrived at? When a person is admitted to hospital he might be suffering from a number of medical conditions.
The figure of a million alcohol-related admissions a year is based on all the conditions recorded for every patient, not just the one he was admitted for – whether or not the primary diagnosis that led to admission was alcohol-related. Confused? Here’s an example:
A patient is admitted to hospital for a hip replacement operation. This is not an alcohol-related condition. But the patient also suffers from high blood pressure which could be caused by alcohol, amongst other things.
Although it is a hip replacement the patient is admitted for, the high blood pressure will also be recorded in the patient’s notes and ‘coded’ by hospital clerks.
So this ‘admission episode’ will be ‘fractioned-out’ between the primary diagnosis – ‘hip replacement’ – 0.7, and the ‘supplementary diagnosis’ – ‘high blood pressure’ – 0.3. So, in NHS-speak 0.3 is the ‘alcohol attributable fraction’ of one hospital admission episode.
The figure of a million alcohol-related hospital admissions is arrived at by adding up all these fractions derived from all hospital admissions, whether for alcohol-related reasons or not!
In future the way alcohol-related hospital admissions are counted will be based only on the ‘primary diagnosis’ that led to the patient’s admission in the first place. Alcohol-related hospital admission episodes, as previously counted, totalled 1,057,000 for 2009/10.
Take out all the supplementary diagnoses that resulted in alcohol attributable fractions and that figure reduces to 194,800!
This figure is then divided between primary diagnoses that are ‘wholly attributable’ to alcohol (68,400 of the total) and those that are ‘partly attributable’ – alcohol may be part of the reason for admission, or may not - (126,500 of the total).
So hospital admissions that we can definitely say are for an alcohol-related cause only, are just 54% of the total. So when you drill down the figures they reduce from a million to 194,000 to 68,000!
But it gets worse! Examine the statistical tables closely and you find a footnote that reads: “Admissions do not represent the number of inpatients, as a person may have more than one admission within the year.”
This is a reference to what medics call “frequent flyers” - people who turn up drunk or injured at A&E department’s week-in, week-out. So we know how many “admission episodes” there are, but not how many people generated them.
But this is crucial information. From the point of view of the average member of the public the impression is precisely that ‘hospital admissions’ = ‘people admitted to hospital’ when in fact it doesn’t.
However, in Scotland a parliamentary question in 2009 discovered that about a third of alcohol-related hospital admissions were repeat admissions – frequent flyers.
Clearly the number of patients admitted is significantly less than the number of admissions. So we’re actually looking at quite a small cohort of problem drinkers.
The 'whole population' approach
The point I’m getting at here is that Medical Temperance bases its view of how to reduce alcohol-harms on the ‘whole population’ approach - the idea that “we all need to drink less”; that the only way to reduce alcohol-harms is to suppress the mass market in alcohol.
And this approach has the ear of Government. But it turns out that actually relatively small, discrete categories of person are responsible for generating a large percentage of alcohol-related hospital admissions, and this blows a big hole in the ‘whole population’ approach and has profound implications for alcohol policy.
The whole population approach relies on stoking a continuous moral panic about alcohol. This in turn relies upon a litany of perverse statistics, collected by arcane methods of incredible complexity, the bogus nature of which are only now becoming apparent.
Instead of pathologising normal, social drinking, we need to identify and treat that small minority of people who have a genuinely unhealthy relationship with alcohol. Straight statistics would be a helpful start.
- Paul Chase is head of compliance at CPL Training