Scotland’s Reform Plan Leaves Alcohol Harm Off the Page

Scotland’s new Programme for Government promises to cut drug and alcohol deaths this parliament, then names almost no prevention tool for alcohol beyond a hospital-team trial. The five-year plan, Programme for Government published on 1 September, puts an extra £250 million National Mission on drugs in writing. On alcohol, the specifics stop at trialling Alcohol Care Teams.

Dr Alastair MacGilchrist OBE, a liver doctor and chair of Scottish Health Action on Alcohol Problems, says that gap will leak straight into the reform bill. SHAAP is a partnership of the Medical Royal Colleges and the Faculty of Public Health in Scotland, based at the Royal College of Physicians of Edinburgh.

A Public Health Emergency With One Detailed Plan

John Swinney’s foreword lists “ending Scotland’s unacceptably high rate of drug-related deaths” among the tests of stronger public services. Alcohol does not appear in that bullet. Later, the document groups both harms as a public health emergency and says ministers will work to reduce drug and alcohol deaths over the parliament.

The drugs half of that sentence is built out. It cites the National Mission, more residential rehab beds, treatment standards, the MAT approach, and the UK’s first safer drug consumption facility. The alcohol half is a pledge to build on “our public health approach to alcohol harm, improving prevention and early intervention,” plus the hospital-team trial.

There is no line on keeping minimum unit pricing in line with inflation, no line on how or where alcohol is sold, and no line on marketing. MacGilchrist, writing as SHAAP chair, called that an oversight in a plan sold as public service reform.

DRUGS AND ALCOHOL IN THE PROGRAMME

A joint Alcohol and Drugs Strategic Plan for 2026 to 2035, agreed with COSLA in March 2026, already sits behind the Programme. SHAAP welcomed it and then asked for money and a separate alcohol budget line, after years in which the two harms have shared a pot.

Alcohol Harm Already Bills Health, Justice and Care

National Records of Scotland counted 1,185 alcohol-specific deaths in 2024, 92 fewer than 2023, a 7% fall and the lowest total since 2019. The age-adjusted rate was 20.9 per 100,000, down from 22.5, a change statisticians did not call significant. Men still accounted for about two thirds of the deaths. Average age at death was 60 for men and 58 for women.

Those 1,185 deaths are only the causes that can only be alcohol, such as alcoholic liver disease. SHAAP says more than one in four alcohol-attributable deaths in Scotland are from cancer, and that alcohol is causally linked to at least seven cancers, as well as heart disease and stroke. That is more than three alcohol-specific deaths a day, before the wider toll is added.

People in the most deprived areas were 4.5 times as likely to die an alcohol-specific death in 2024 as people in the least deprived. For all causes of death, the gap is about two to one. MacGilchrist’s clinic point is blunt: by the time advanced liver disease arrives, the patient has usually already been through a GP surgery, A&E, an ambulance, and often the police or social work.

If we are serious about making our public services sustainable, we have to talk about alcohol.

Dr Alastair MacGilchrist OBE, Chair, SHAAP

ALCOHOL HARM IN SCOTLAND

• The death count: 1,185 alcohol-specific deaths in 2024, down 92 from 1,277 in 2023.
• The inequality: Alcohol-specific mortality was 4.5 times as high in the most deprived areas as in the least deprived.
• The money: SHAAP puts the societal cost at £5-10 billion a year, with about £1.2 billion in direct costs to the economy.
• The children: An estimated 200,000 people in Scotland are living with fetal alcohol spectrum disorder.

The Scottish Government’s June 2026 preventative-budgeting work, as quoted in SHAAP’s pre-budget evidence to Holyrood, defines failure demand as demand that appears after problems have emerged because earlier help was absent, thin or ineffective. Alcohol, SHAAP told the Public Service Reform Committee, is a clean case of that definition.

A Scottish study using meconium biomarkers found evidence of significant prenatal alcohol exposure in about one in seven pregnancies. Parental substance use was a concern in 38% of child protection registrations in 2024-25. Of 11,824 children looked after on 31 July 2025, 46% came from households in the most deprived fifth. Keeping a child safely at home is cheaper than residential care, and the alcohol share of that caseload rarely shows up as an alcohol budget line.

The 65p Minimum Is Two Years Out of Date

Minimum unit pricing began at 50p on 1 May 2018. Parliament voted to keep it and lift it to 65p from 30 September 2024. Public Health Scotland’s evaluation, as set out by SHAAP, found the policy cut alcohol-specific deaths by 13.4%, about 156 a year, and cut wholly alcohol-attributable hospital admissions by 4.1%, about 411 a year, against a no-MUP path through 2020. Gains were largest for men and for people in the most deprived areas.

That 13.4% is a counterfactual, not the 7% fall from 2023 to 2024, and the two should not be stacked. SHAAP still treats MUP as the proof that a population measure can move deaths. It also says a cash floor rots. By the 2024 uprating, inflation had taken the original 50p down to about 62p in real terms. University of Sheffield modelling, cited in the Holyrood filing, found that 65p against a frozen 50p is likely to save an extra 800 lives in its first five years.

MacGilchrist now says the floor should already be 70p if it is to hold the ground won in 2024. SHAAP wants primary law that lifts the price automatically each year with inflation, which it says would protect the gain at no cost to the public purse. On 1 October 2026, Wales raised its minimum unit price from 50p to 65p, matching the Scottish rate set two years earlier.

THE MINIMUM UNIT PRICE CLOCK

1. 1 May 2018: Scotland sets the first minimum unit price at 50p.
2. 30 September 2024: The floor rises to 65p after a parliamentary vote to keep the policy.
3. 1 October 2026: Wales moves from 50p to 65p, the rate Scotland has used since 2024.

Drinkers still meet that floor as a tax on ordinary supermarket bottles, which is one reason a frozen 65p is politically quieter than a duty rise. The same week the Programme was published, Monica Lennon MSP put down questions on whether the coming alcohol prevention plan would include marketing limits and automatic uprating. Alcohol Focus Scotland posted the exchanges.

Thanks to @MonicaLennon7 for asking Parliamentary questions on whether the upcoming alcohol prevention plan will include marketing restrictions and on plans to introduce automatic uprating of minimum unit pricing. 🙌 pic.twitter.com/Ure5bSZRaP

— Alcohol Focus Scotland (@AlcoholFocus) September 18, 2026

Those questions sit where the Programme does not. WHO still lists action on price, availability and marketing as “best buys,” with an estimated return of more than nine times the cost, and as “quick buys” that can show an effect inside a year. Brief interventions are classed as a quick buy over two to three years.

Treatment Capacity Fell as Drug Services Took Priority

Access to specialist alcohol treatment fell about 40% over a decade. Alcohol Focus Scotland, working from Public Health Scotland figures, put referrals at 32,556 in 2013/14 and 19,617 in 2021/22. That drop is 12,939, or 39.7%, which the field reports as 40%. PHS did not find a matching fall in need. Stakeholders told that review that alcohol work was pushed down the list after Medication Assisted Treatment standards concentrated effort on drugs.

The start of the referral slide lined up with a real-terms cut of about 20% in Alcohol and Drug Partnership funding. Audit Scotland’s 2024 review of services found the National Mission on drugs had “in part been at the expense of focus on alcohol deaths and alcohol services,” in the Auditor General’s words as quoted by SHAAP. Most of the combined budget was going on residential rehab and NHS specialist care at crisis point, leaving little for prevention.

The cash totals can mislead if they are read as an alcohol recovery. Combined alcohol and drug funding distributed through the main channels rose from £70.5 million in 2014/15 to £161.6 million in 2023/24, a 75% real-terms increase. Audit Scotland also logged an 8% real-terms fall in ADP funding between 2021/22 and 2023/24, on £161 million distributed in 2023/24. The 2025-26 Budget put £60 million into the National Mission on drug deaths and £20.9 million into local prevention, treatment, recovery and the consequences of problem alcohol and drug use combined, which SHAAP called a real-terms cut.

SHAAP’s fear for reform is mechanical. If alcohol treatment is not classed as a frontline service, workforce and ADP cuts will show up as A&E attendances, police cells and court time, which cost more per contact. On 23 September 2026, National Records of Scotland reported 1,133 drug-use deaths for 2025, up 116, or 11%, on the year before. That is a different year from the 1,185 alcohol-specific deaths of 2024. It is also the file that already has the detailed plan.

What Prevention Would Cost the Taxpayer

Portfolio Efficiency and Reform Plans attached to the 2026 Spending Review set out £1.5 billion of cumulative recurring savings over the review period. The Programme also promises a Prevention Unit, a Scottish Prevention Investment Framework, and Social Impact Partnerships starting at £200,000, with a £10 million fund later in the term if the pilots work. SHAAP’s filing says savings of that scale cannot be found by redrawing organograms. They need less demand coming through the door.

Several of the alcohol tools it lists raise money or cost the Treasury nothing. A social responsibility levy on large retailers would, in SHAAP’s words, apply a polluter-pays rule to windfall profits from minimum unit pricing and send the cash to local prevention and treatment. Index-linking MUP is a law change, not a spending line. Separating alcohol from drugs in the budget is bookkeeping with teeth, after Audit Scotland found alcohol lost out in a combined pot.

SHAAP’S PREVENTION STEPS

• Index-linked MUP: Automatic yearly uprating so the 65p floor does not fade the way 50p did.
• Retailer levy: A charge on large alcohol sellers, steered to prevention and treatment.
• Frontline treatment: Reverse the 40% fall in access and the 20% ADP cut, instead of meeting the same people in A&E.
• Brief interventions: Short GP and clinic conversations estimated to save £1.23 for every £1 spent.
• A visible alcohol line: Ring-fenced prevention spending across health, justice and social care, not a shared drugs-and-alcohol total.

Alcohol Care Teams, the one named new alcohol service in the Programme, already have a cost argument. They cut readmissions and sit between acute wards and community care. SHAAP wants the Invest to Save logic pointed at that kind of work, rather than at back-office mergers that leave the same drinkers cycling through the expensive doors.

On 5 August 2026, MacGilchrist warned that alcohol had been downgraded as a political priority after the ministerial brief expanded to mental wellbeing, public health, sport, alcohol and drugs. Maree Todd now holds that combined post. After the 2024 death figures, she said the fall was welcome and that the harm remained a public health priority. Alison Douglas, chief executive of Alcohol Focus Scotland, said there was no room for complacency, with deaths still more than double the level of 30 years ago.

Prisons, FASD and the Children Already in the System

On 19 June 2026, Scotland’s prison population stood at 8,515, against a design capacity of 7,805. The count hit a record 8,603 on the morning of 26 May 2026. The Scottish Prison Service’s 2025-26 accounts, published on 28 September 2026, put the average daily population at 8,278, the highest average in a reporting year. Linda Pollock, the service’s chief executive, said staff had delivered through a record population.

Alcohol is not the only driver of that crush, and the Programme already promises earlier action on crime and a sustainable prison population. SHAAP’s point is narrower: custody, community sentences and release are all points where alcohol problems can be picked up, and they are not used that way with any consistency. Cutting treatment to hit an efficiency target moves the same people into cells that already overflow.

The unpaid bill is also in classrooms and care plans. Fetal alcohol spectrum disorder is lifelong. SHAAP puts 200,000 people in Scotland in that group, with costs in health, education, social care and justice that never appear as an alcohol line. The 38% of child protection cases flagged for parental substance use is the same failure demand, counted in a different ledger.

Reform language in the Programme is about a Prevention Unit, fewer public bodies, and two strategic health boards in place of 14 territorial ones. MacGilchrist’s case is that those wiring diagrams will not close the gap if the demand that fills the beds, the cells and the care placements is left untouched. Wales has now copied a 65p floor Scotland has used since 2024. Holyrood has not yet said when that floor will move again, or whether a levy, a marketing limit or a standalone alcohol budget will appear in the prevention plan ministers still owe.