ATS0003

Written evidence submitted by Royal College of Psychiatrists

Introduction to organisation and reason for submitting evidence:

The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom. We work to secure the best outcomes for people with mental illness, intellectual disabilities and developmental disorders by promoting excellent mental health services, supporting the prevention of mental illness, training outstanding psychiatrists, promoting quality and research, setting standards and being the voice of psychiatry.

The College represents and leads the Faculty of Addictions Psychiatry who are clinical leaders of NHS and third sector addiction treatment in the UK.

In 2021 we established the Public Mental Health Implementation Centre (PMHIC) to work in partnership with other organisations to support the improved implementation of evidence-based public mental health interventions. This includes the treatment and prevention of mental disorders, prevention of associated impacts, and promotion of wellbeing and resilience.

Summary:

The Royal College of Psychiatrists welcomes the opportunity to submit evidence to the Public Accounts Committee to support their inquiry into Alcohol Treatment Services. We address a range of areas relevant to this inquiry which have a clear impact on psychiatry and mental health. Critical areas covered in our submission include:

• Levels of alcohol use
• Impacts of alcohol
• Economic cost of alcohol misuse
• Risk factors
• Comorbidity of alcohol and mental disorder
• Effective interventions to treat alcohol use disorder
• Numbers of people receiving treatment for alcohol use disorder
• The implementation gap for treatment for alcohol use disorder
• Workforce and commissioning.

Our final section outlines essential areas for development, key recommendations and questions for the committee.

ALCOHOL TREATMENT SERVICES FOR PEOPLE WITH MENTAL HEALTH CONDITIONS

Levels of alcohol use

1. Before COVID-19, alcohol misuse levels were relatively stable in England.1–3
1. The estimated prevalence of alcohol dependent adults in England in 2018/19 was 1.37% (95% CI 1.12, 1.73) – some of the highest estimates were seen in the North West of England.4 However, this is based on 2014 prevalence figures which found that 16.6% of adults in England were harmful drinkers, 1.9% were harmful/ mildly dependent drinkers and 1.2% were dependent on alcohol.2
2. In 2018/19, there were 602,391 adults with alcohol dependence based on 1.37% prevalence – using same figures there were 7.3m harmful drinkers.2,4
3. 15.4% binge drank on heaviest drinking day (2015-18).3
4. 22.8% of adults drank over 14 units a week (2015-18).3
5. Drinking in early pregnancy 4.1% (2018/19).3

2. COVID-19 was temporarily associated with increased consumption of alcohol during the lockdowns; a sharp increase in purchasing was seen across all occupational social grades at the announcement of lockdown (23 March 2020) – the highest volume sales were seen among higher social grades.5,6

Since the COVID-19 lockdowns, a gradual reversion of behaviour to pre-COVID trends has resulted in figures returning more like those observed in 2019 to 2020.7

• 21 % of adults drank over 14 units a week (2021).8
• 15% of adults drank more than 3-4 units (up to and incl. 6-8) on a day (2021).8

3. However, the discontinuation of surveys monitoring level of alcohol consumption[1] prevents appropriate monitoring.

4. Long-term trends indicate that alcohol has become more affordable over the past three decades. Since 1987, alcohol has become 72% more affordable in the UK. During the last ten years, alcohol has also become 14% more affordable (since 2010 based on affordability of alcohol index).

Impacts of alcohol

5. Mortality and reduced life expectancy: Alcohol-related mortality is also a growing area of concern with 2020 data in England suggesting an increasing and worsening trend of alcohol-related mortality at 37.8 per 100,000 people.11
1. Men and women with substance use disorders (including alcohol) have shortened life expectancy and increased risk of mortality compared to national figures, with pronounced differences in some groups.12,13
2. For example, the life expectancy at birth of women and men with alcohol use disorder is reduced by more than 10 and 17 years, respectively, compared to the UK population.13

6. Mental disorder, self-harm and suicide:
1. Alcohol consumption is associated with self-harm and emotional/behavioural problems in children and young people14 with parents who misuse alcohol and can also be closely linked to drug misuse and smoking.15
2. Alcohol consumption is associated with increased suicide and self-harm in adults.16
3. Alcohol use disorder doubled risk of major depression in adults17 and persistence of depression and/or anxiety was shown to be higher in those with remitted or current alcohol dependence compared to those with no lifetime alcohol use disorder.18
4. Smoking prevalence is particularly high among adults undergoing treatment for substance misuse (alcohol and non-opiates) in England – an estimated 64.6% in 2019/20.19 The smoking rate for adults who drink harmfully (over 15 units/week) is estimated to be 20% with over 15,000 smokers also in treatment for alcohol dependence.20,21.

7. Violence:
1. Alcohol is associated with 53% of violent crime in England and Wales.22
2. Alcohol is associated with increased risk of violence perpetration including domestic abuse and rape by penetration which is also related to alcohol and drug misuse. For example, 60% of men in perpetrator programmes have alcohol and/or drug problems.23 39% of victims from rape reported that the perpetrator(s) were under the influence of alcohol.24

8. Economic cost of alcohol misuse:

• Annual wider costs in England were estimated to be £20–£55 billion.25
• Tax revenue from alcohol sales in the UK during 2017 were £11.6 billion.26
• Economic burden of alcohol equated to 1.3%-2.7% of annual GDP.27
• Annual economic impact of alcohol misuse is 1.5% of GDP with 39% being direct costs and 61% due to losses in productivity.28

Risk factors

9. Alcohol increases risk of mental disorder.
1. For example, alcohol use during pregnancy increased the risk of conduct disorder, hyperkinetic disorder and intellectual disability (foetal alcohol spectrum disorder.).1,29.

10. Mental disorder increases risk of alcohol use.
1. Alcohol use in young adulthood alcohol was associated with early onset of persistent conduct problems and adolescent onset of conduct problems.30
2. 36.3% of 11–16-year-olds in England who consumed alcohol were at risk of developing any mental disorder, 39.7% emotional disorders and 41.8% behavioural disorders.1,31.

Comorbidity of alcohol and mental disorder

11. Substance/alcohol misuse and mental health often co-occur. There is a well-established bi-directional relationship between alcohol consumption and some mental health conditions (e.g., anxiety and depression).1,32,33 In other words, alcohol use disorder both increases risk of mental disorder and is also the impact of other mental disorders.1
1. In 2016/17, approximately 11,035 adults in England had concurrent contact with mental health services and substance misuse services for alcohol misuse.34

12. Some groups are more vulnerable to having a co-existing mental health diagnosis and alcohol use. They may face multiple synergistically interacting disadvantages[2]; for instance, people living in poverty, people who are homeless or people who have a history of violence or offending.32,36.

Effective interventions exist to treat alcohol use disorder

13. Effective interventions exist to treat alcohol use disorder.37

1. Brief interventions were effective for adolescents (meta-analysis)38 while interventions for college students were effective for college students (meta-analytic review39; systematic review/meta-analysis40). Parenting programmes were also effective (systematic review).41.
2. Screening and extended brief interventions for 16-and 17-year-olds at risk of alcohol use, and screening, brief interventions and extended brief interventions for adults reduced alcohol consumption.37,42.
3. Brief intervention in primary care was effective (systematic review of reviews).43,44.
4. Key service components within whole system commissioning of alcohol services include:

• Opportunistic screening and effective brief interventions for adults who are hazardous and harmful drinkers.42
• Timely access to assessment (including in the general hospital and mental health context), assessment and treatment planning, medical assisted withdrawal as an inpatient (depending on risk profile).37.
• Recovery interventions, including residential recovery and peer support interventions are also effective; however, concerns have been previously raised about the quality of residential detox and recovery services as well as the loss of specialist alcohol services.45
• Services for children and young people vulnerable to alcohol related harm.46
• Whole system commissioning of high-quality alcohol services37 including alcohol care teams in general hospitals47 and assertive approaches to managing frequent attenders.48

14. Pharmacotherapy is effective for medically assisted withdrawal and for preventing relapse. Also, psychological treatments (e.g., psychotherapy) have proven to reduce alcohol consumption and dependence.49 Residential treatments have also shown improvements in substance use over time.50

15. Many interventions are cost effective and result in economic savings, for example:
1. Screening and brief intervention in primary care for alcohol misuse results in net returns of £12 for each £1 spent.51
2. Prevention of alcohol related harm by reducing affordability: several effective interventions (with strong evidence) exist to reduce alcohol misuse and harmful drinking including alcohol minimum prices and taxes, public policies to restrict alcohol availability and reduced sales hours.52

• The minimum unit pricing of alcohol in Scotland and Wales is one example of an effective intervention.15,53.
• Over 10 years, a minimum price of 40p and 50p per unit could result in savings of £3.1 billion and £7.1 billion respectively.54
• Over 5 years, a minimum price of 60p per unit would save £3.2 billion.27

16. The Royal College of Psychiatrists developed guidance55 for clinicians (addiction specialists and non-specialist community psychiatric teams) managing people with alcohol problems during COVID-19 to be used alongside existing guidance[3] prior to the pandemic, for instance focussing on:

1. Timely assessment using existing screening questionnaires (e.g., AUDIT)
2. Providing advice (brief intervention) for individuals drinking at harmful levels but not indicative of dependency on alcohol including diarising drinking and seeking social support to reach goals.
3. For those dependent on alcohol, a need to manage alcohol withdrawal and considering the best setting and support to be offered given there are restrictions on inpatient/rehabilitation services.

17. The Commissioning Quality Standards (CQS) for alcohol and drug treatment and recovery56 explicitly states “plans to improve integrated care for people with co-occurring mental or physical health problems.”

1. Mental health is referred to under standard 1 (partnership and governance), standard 3 (whole and integrated systems) and standard 4 (evidence-based support).

18. Updated alcohol treatment guidelines are due to be published this year by the Office for Health Improvement & Disparities (OHID) - the Royal College of Psychiatrists have made significant input to these.

Numbers receiving treatment for alcohol use disorder

19. Hospital admissions

In terms of hospital admissions, 280,000 estimated admissions in 2019/20 where the main reason was attributable to alcohol. 2% higher than 2018/19 and 8% higher than 2016/17.57

England admissions11 for:

• Alcohol specific conditions in 2020/21: 318,596
• Alcohol related conditions (narrow) in 2020/21: 247,972
• Alcohol related conditions (broad) in 2020/21: 814,595
• Alcohol specific conditions (under 18s) for 2018/19 to 2020/21: 10,569

20. More than 1 in 4 (29%) of all adults in substance misuse treatment between April 2021-March 2022 were in alcohol treatment; this is a 10% increase from the previous year (from 76,740 to 84,697).58.

21. There is a need for more information about numbers receiving structured treatment provided by primary care (e.g., brief interventions) and NHS and third sector organisations – both are large providers.

22. Most prescriptions[4] for treatment for alcohol dependence are prescribed in primary care rather than NHS hospitals; in 2020/21, over 163,000 prescriptions were prescribed in primary care compared to just over 3,000 in NHS hospitals.59

The implementation gap for treatment for alcohol use disorder

23. Only a minority of people with mental disorder in the UK receive treatment with far less coverage of interventions to address associated impacts such as alcohol use disorder.
1. Only 6% of people received treatment for alcohol dependence in 2014 (medication or counselling).2 There is also a gender gap relating to treatment for mental or emotional problems (26.9% men compared with 47.3% women).2
2. According to data from the National Drug Treatment Monitoring System and Estimates of Alcohol Dependence in England, 82% of dependent drinkers were not in treatment in 2020/21.3

Trend in population coverage of treatment for alcohol use disorders

24. Additionally, years of cuts to substance misuse services - 28.2% in real terms between 2013/14 and 2021/22 on current prices60 - and the COVID-19 pandemic has resulted in the alcohol treatment gap widening; the Royal College of Psychiatrists estimated that over 8 million adults would be considered ‘higher risk’ drinkers in September 2020.61

Workforce and commissioning

25. This inquiry should be seen in the context of Dame Carol Black’s review of drugs (2020/21)62. The review aimed to inform the government’s approach on tackling the harm that drugs cause. We are largely supportive of the review report including its recommendations to improve workforce capacity, commissioning standards and move towards integrated commissioning.

26. The Government’s response to the review came in the form of a ten-year Drug Strategy which aims to tackle drugs and prevent crime. We were pleased to see this strategy backed by an additional £780m investment.

27. Dame Carol Black’s review highlighted key challenges and considerations affecting the workforce which the committee should recognise:

• Drug and alcohol treatment services are commissioned by local authorities. Reduced funding and frequent retendering have led to a high turnover of staff and a depletion of skills, with the number of addiction psychiatrists, psychologists, nurses and social workers in the field falling significantly. Many addiction services are now run by the voluntary sector although a significant number continue to be provided by NHS trusts – mainly in partnership with voluntary sector agencies.

• Job security and access to professional development are more readily available within NHS mental health services, so are more attractive to many healthcare workers compared to drug treatment services.

• Most drug and alcohol or recovery workers are not registered professionals yet make up most of the workforce. These workers are not always properly trained or supervised and 10% of them are volunteers.

• Similar issues affect peer workers. We recognise that people with lived experience, working as peer supporters or mentors, have a critical role to play in any well-developed drug and alcohol treatment service.

• The number of training places for addiction psychiatrists has plummeted meaning there is no capacity to train the next generation of specialists.  

• The addiction research workforce is important for ensuring the UK is aware of emerging treatments, recovery supports and drug trends. The Review recommends that Government research funders, professional bodies and scientific societies should actively commission research on addiction and support the careers of addiction researchers. 

28. Following the review RCPsych established the following areas of crucial importance:

• Chronic staff shortages and a disconnect between services have led to many patients not getting the lifesaving care they desperately need. The Royal College of Psychiatrists’ addictions workforce report in 2020 found a 58% fall in the number of higher trainee places, with five regions in England having no opportunities for such training.63 

• Addiction psychiatry has fewer structural safeguards to maintain trainee numbers than in the case of other specialities. For example, LA commissioned services are contractually required to provide interventions for people with drug and alcohol use disorders which require the clinical competencies of consultant addiction psychiatrists. However, the commissioning process does not explicitly protect training capacity and capability within services. The funding available to adult addiction services in England has reduced in real terms and this has in turn put pressure on monies available for medical posts including training posts. 

• We need to ensure that Mental Health Trusts and their ICS commissioners are encouraged to be active partners (especially around governance and training) in developing addiction care pathways.

• We need to reduce the barriers for access to mental health services for those with comorbid addictions. Dame Carol Black’s review highlighted: Trauma (physical, sexual or psychological) and mental ill-health are the drivers and accompaniment of much addiction. They are co-morbidities rather than separate problems for a ‘dual diagnosis’. Commissioners of substance misuse services and NHS mental health services must ensure that individuals do not fall between the cracks.

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Areas for development/recommendations

29. Overdue need for the publication of an updated, comprehensive National Alcohol Strategy.

• A national Drugs Strategy64 exists but an updated alcohol strategy is required. The last Alcohol Strategy65 was published in 2012 (with an update due to be released in 2018) – this is in urgent need of updating and should be co-produced with people with lived experience. This has already been called for by the Commission on Alcohol Harm.66

30. Identify implementable interventions by different sectors.

31. Nationally assess the current size of unmet need for treatment and prevention, including for higher risk groups.

• This is required to inform size, impact, and cost of unmet need for treatment and prevention as well as impacts and associated economic benefits of improved coverage. Specifically, there is a need to resume regular surveys of alcohol misuse since these were discontinued and mean that size of need is currently not possible to accurately assess.3,9.

• Additionally, Health and Wellbeing Boards have a statutory duty to use the local needs assessment to inform their Integrated Care Strategy to support coordinated prevention and treatment for people with alcohol use disorder by primary care, secondary care and third sector organisations including for people with mental disorders to ensure services are fit-for-purpose and provide appropriate and relevant solutions to local needs.67 Needs assessments are currently of poor quality and do not sufficiently take inequalities into account.

• Therefore, Integrated Care Boards should have oversight of local commissioning of services to ensure that these are properly funded, integrated and meet local needs.

32. Agree acceptable levels of coverage of interventions to treat alcohol use disorder.

• This coverage must consider population scale preventable suffering, impacts and costs of implementation failure, the UN Sustainable Development Goal of universal health coverage as well as the economic savings of interventions. For instance, primary care-based screening and brief intervention for all hazardous and harmful or mild dependent drinkers aged 16 years and older in England would result in net savings[5] of £1693 million after 7 years (£869 million in crime-related savings, £501 million in productivity-related savings, £323 million in NHS savings).68.

33. A recovery-focussed, stigma-free approach to alcohol treatment for people with mental health conditions which needs to address multiple determinants.20 This would ultimately align with NICE guidelines recommendations for when people with co-existing severe mental illness and substance misuse first contact community health services.69

34. We welcome the additional investment in drug and alcohol use disorder services in England in 2022/23 of up to £85.7 million additional grants by the Department of Health and Social Care70; however, the Government’s commitment to delivering the recommended funding from the Dame Carol Black review in full is essential in a context where £283m has been taken out of budgets for substance misuse services between 2013/14 and 2021/22 in real terms. Alongside this, the following areas need to be delivered in concert:

• Specifically, the Royal College of Psychiatrists has previously recommended an allocation of £90 million of capital funding for drug and alcohol use disorder services by 2024/25. This will help to prepare local authorities and NHS services for a likely increase in demand to services following the COVID-19 pandemic. 71

• Delivery of a workforce strategy to ensure sufficient investment in addiction psychiatrists and multidisciplinary teams. Health Education England have confirmed there will be 273 additional training posts in core and higher psychiatry training in August 202372 and we await further details of the regions and specialties to receive these extremely welcome posts in due course.

Questions for the Committee:

1. How much of the treatment funding allocations associated with the drug strategy have been allocated for alcohol treatment?

2. What is being done to ensure the substance misuse workforce (particularly in addiction psychiatry) can meet the demands of a bigger treatment system?

3. How is planning at H&WB and ICS levels incorporating need for alcohol treatment which is integrated across mental health, acute trusts and primary care as well as in LA commissioned substance misuse treatment services? This includes treatment for those with concurring mental health and SU problems and other inequalities.

4. How can we achieve the ambitions of the new alcohol guidelines to be published this year?

5. Are the plans to expand the residential and inpatient treatment sector effective?

6. How has DHSC progressed on the plans set out in its 10 Year Drug Strategy? We are particularly interested in commitments to:

a)      Deliver world-class treatment and recovery services – rebuild local authority commissioned substance misuse services, improving quality, capacity and outcomes,

b)      rebuild the professional workforce – develop and deliver a comprehensive substance misuse workforce strategy and

c)       ensure better integration of services – making sure that people’s physical and mental health needs are addressed to reduce harm and support recovery.

7. How is DHSC addressing chronic staff shortages through:

a)      increasing and safeguarding the number of training places for addiction psychiatrists?

b)      retaining staff in drug and addiction services – for instance through pay and conditions?

8. Has DHSC brought in Mental Health Trusts and their ICS commissioners to contribute to local and national plans focused on delivering and better integrating treatment and recovery services?

February 2023

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58               Office for Health Improvement and Disparities. Adult substance misuse treatment statistics 2021 to 2022: report. , 2023 (https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2021-to-2022/adult-substance-misuse-treatment-statistics-2021-to-2022-report).

59               NHS Digital. Statistics on Alcohol: Data Tables. 2022. (https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2021/data-tables).

60               Analysis based on total expenditure in Department for Levelling Up, Housing and Communities, Local authority revenue expenditure and financing (https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing) with real terms adjustments in 2021/22 prices using HM Treasury, GDP deflators at market prices, and money GDP December 2022 (Quarterly National Accounts) (https://www.gov.uk/government/statistics/gdp-deflators-at-market-prices-and-money-gdp-december-2022-quarterly-national-accounts)

61               The Royal College of Psychiatrists. Addiction services not equipped to treat the 8 million people drinking at high risk during pandemic, warns Royal College. 2020. (https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/09/14/addiction-services-not-equipped-to-treat-the-8-million-people-drinking-at-high-risk-during-pandemic-warns-royal-college).

62               Home Office, Department of Health and Social Care. Independent review of drugs by Professor Dame Carol Black. , 2020.

63               Royal College of Psychiatrists. Training in addiction psychiatry: current status and future prospects. , 2020 (https://www.rcpsych.ac.uk/members/your-faculties/addictions-psychiatry/training-in-addiction-psychiatry-current-status-and-future-prospects).

64               UK Government. From harm to hope: A 10-year drugs plan to cut crime and save lives. , 2022 (https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives).

65               HM Government. The Government’s Alcohol Strategy. , 2012 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcohol-strategy.pdf).

66               Commission on Alcohol Harm. ‘It’s everywhere’ – alcohol’s public face and private harm. (https://ahauk.org/wp-content/uploads/2020/09/Its-Everywhere-Commission-on-Alcohol-Harm-final-report.pdf).

67               Public Health England. Better care for people with co-occurring mental health and alcohol/drug use conditions: a guide for commissioners and service providers. , 2017 (https://www.gov.uk/government/publications/people-with-co-occurring-conditions-commission-and-provide-services).

68               Campion J, Knapp M. The economic case for improved coverage of public mental health interventions. Lancet Psychiatry 2018; 5: 103–5.

69               National Institute for Health and Care Excellence. Coexisting severe mental illness and substance misuse: community health and social care services. 2016. (https://www.nice.org.uk/guidance/ng58).

70               Office for Health Improvement and Disparities. Additional drug and alcohol treatment funding allocations: 2022 to 2023. 2022. (https://www.gov.uk/government/publications/extra-funding-for-drug-and-alcohol-treatment-2022-to-2023/additional-drug-and-alcohol-treatment-funding-allocations-2022-to-2023).

71               The Royal College of Psychiatrists. Spending Review Representation Autumn 2021. , 2021 (https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/rcpsych-spending-review-2021-representation---final---redacted-version-12102021.pdf?sfvrsn=7a15537_4 ).

72               Health Education England, More doctors joining the NHS as nearly 900 additional specialty training posts announced by HEE, 10 January 2023 (https://www.hee.nhs.uk/news-blogs-events/news/more-doctors-joining-nhs-nearly-900-additional-specialty-training-posts-announced-hee).

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