ATS0011

Written evidence submitted by Alcohol Health Alliance UK

The Alcohol Health Alliance

The Alcohol Health Alliance UK (AHA) is pleased to submit evidence for the Public Accounts Committee’s inquiry into alcohol treatment services. Representing over 60 organisations including charities, medical royal colleges, and treatment providers all working together to reduce alcohol harm, the AHA has a unique and varied set of experience and expertise to offer.

Summary

1. Alcohol consumption and harm rates are at record highs and persistently increasing.
2. Alcohol harm has significant costs and puts substantial pressure on public services.
3. Funding pressures during the shift to local authority commissioning of services has resulted in more joint delivery of alcohol and drug services, to the detriment of alcohol.
4. Workforce issues present a significant problem.
5. Alcohol treatment provides good value for money. Effective interventions such as IBA, ACTs and assertive outreach should be rolled out more widely.
6. Evidence-based population-level measures are necessary to reduce the need for alcohol treatment.

Recommendations

1. Ongoing alcohol-specific treatment funding.
2. A workforce plan.
3. Greater rollout of effective treatment interventions
4. An independent review of the current state of alcohol harm, treatment, and evidence-based policies (including population-wide prevention measures).

Trends in alcohol consumption and harm from drinking

Health harms

Alcohol is a major cause of preventable premature death,[1] and the leading risk factor for death and illness among people aged 15-to-49 in England.[2] It plays a causal role in more than 200 different diseases and injuries, and is linked to 7 cancers including two of the most common (breast and bowel).[3] Alcohol-specific deaths are at record high levels, up 27.4% between 2019 and 2021.[4] The total number of deaths attributed to alcohol is estimated to be almost 29,000 annually, or 79 deaths every day.[5] Since 2001, alcohol and drug-related mortality is the only cause category where the age-standardised mortality rate has statistically significantly increased.[6]

Alcohol also places a significant stress on the health service - there were almost 980,000 hospital admissions where the primary reason or a secondary diagnosis was linked to alcohol in 2021 – this is more than 1 in 20 of all hospitalisations.[7] Almost 40% of ambulance time estimated to be spent dealing with alcohol-related incidents.[8] Alcohol use disorder doubled the risk of major depression in adults.[9] AS well as increasing the risk of mental disorder, alcohol use disorder is also the impact of other mental health disorders.[10]

Alcohol has also been identified as both a determinant and an outcome of socioeconomic inequality: in England, the death rate from alcohol in the most deprived decile is double that in the least deprived.[11] Premature death from alcohol-related liver disease is almost 5 times higher in the most deprived areas of England than the most affluent.[12]

Rising consumption

Alcohol consumption has increased in recent years. Over the course of the COVID-19 pandemic, the number of people drinking at higher risk levels. 17.7% of the English population now drink over the Chief Medical Officers recommended low-risk guidelines of 14 units a week, compared to 12.4% in February 2020.[13] Between March 2020 and March 2021, Public Health England (PHE) reported a 58.6% increase in the proportion of survey respondents drinking at increased risk or higher risk levels.[14] If alcohol consumption does not return to 2019 levels, modelling indicates there could be an additional 9,914 premature deaths.[15]

The cost-of-living crisis may further exacerbate this trend. Research commissioned by The Forward Trust indicates that of the 2.1 million people reporting increased alcohol intake in recent months, 61% claimed stress over rising prices was the most significant trigger.[16]

Social harms

Alcohol also has a significant impact beyond the individual drinker. An estimated 1 in 5 children in the UK live in a household where at least one parent has an alcohol use disorder. These children are 6 times more likely to experience domestic violence, 3 times more likely to consider suicide, and twice as likely to go on to develop an addiction themselves.[17] In 61% of care applications in England, alcohol and/or drugs was thought to be a factor.[18]

Alcohol is a significant driver of crime, including violent crime, and was involved in 34% of violent crime across England and Wales. [19]On average, over half (53%) of a police officer’s workload is alcohol-related.[20]

Cost

Alcohol-related harms thus have major associated costs. The OECD estimates that alcohol accounts for around 3% of health expenditure in the UK,[21] putting the total healthcare cost of alcohol at £8.3bn.[22] Almost 20% of all working years of life lost in England are directly linked to alcohol,[23] further demonstrative of its massive economic burden. With approximately £11.4 billion arising from alcohol-related crime, [24] the total societal cost of alcohol is estimated to be at least £27 billion every year.[25]

Modelling studies factoring in the changes in consumption seen during the pandemic suggest that if alcohol use does not return to pre-COVID-19 levels, the NHS could face surplus costs of up to £1.2 billion.[26]

How the commissioning and provision of alcohol treatment services have changed since the transfer of responsibility for public health

The Health and Social Care Act 2012 radically reformed the way in which health care in England is commissioned and managed. Responsibility for commissioning alcohol treatment services now sits with upper-tier and unitary local authorities in England. Funding for alcohol services comes from the ring-fenced public health grant that each local authority receives to provide a wide range of public health interventions and services.[27] In addition to the public health grant, the government will invest an additional £533 million to “rebuild local authority commissioned substance misuse treatment services in England.”[28]

When sufficiently funded, local authority responsibility for public health allows for a reduction alcohol harm by bringing different levers into one arena, e.g., data on local levels of alcohol-related harm, thorough needs assessments. local strategy and alcohol pathways, licensing legislation, hospital-based services, specialist treatment, and employment, training and housing support.[29] However, local authorities have undergone cuts to public health budgets in most years after assuming responsibility from the NHS.[30] This significant reduction in funding available to commission alcohol services has been the biggest change reported since the transfer of responsibility as detailed below. Smaller budgets have led several local authorities to combine alcohol and other drug treatment services, resulting in the deprioritisation of alcohol treatment compared to drugs, a reduction in alcohol specialisation, and increased barriers to alcohol users approaching services.[31]

Spending on, access to, and outcomes from treatment

Spending

The overall Public Health Grant, from which treatment budgets are drawn, was £850 million lower in 2019 than in 2015/16, representing a 24% cut in real terms per head.[32] In the four years from 2016/17, local authority drug and alcohol treatment services faced real-terms budget cuts of 15%.[33] There has been considerable regional variation in spending cuts, with some areas experiencing cuts of 40% between 2014/15 and 2017/18 (compared with a national average of 14%).[34] We very much welcome the increase in funding outlined in the government’s 10-year Drug Strategy.[35] However, the investment is not enough to tackle the massive unmet need for alcohol treatment. The silence on alcohol dependence is also concerning, especially given the need for alcohol-specific funding (expanded on below).

This has led primarily to the reduction in workforce (across commissioning, strategy development and implementation, and service delivery), leading to insufficient resources to develop services, improve pathways, increase harm reduction work, and weaker system partnership working. Compounding this issue, is the short-term and late notice of annual funding amounts, which in turn limits the ability of local authorities to secure the necessary workforce, in time, or on a sustainable basis.[36]

Cuts have also meant fewer specialist addictions psychiatrists, clinical psychologists, and nurses, and a greater reliance on doctors without specialist training and volunteers with limited training, increasing pressure elsewhere in the NHS and the wider system. Dame Carol Black’s independent review of drugs found that the number of training places for addiction psychiatrists has plummeted from around 60 to around 5, meaning there is little to no capacity to train the next generation of specialists. Even with additional funding, there is therefore a lot of work to do to build up capacity and expertise in the market.[37]

If locally commissioned alcohol treatment services are to be efficient, effective, and responsive to increased demand, the amount of money local authorities receive via the public health grant needs to be sufficient to do the job, with focus given to areas of highest need, and with additional monies available to invest in preventative activity. 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, which will hopefully prepare local authorities and NHS services for a likely increase in demand following the COVID-19 pandemic.[38]

Access

From 2013/14 to 2019 there was a 20% decline in the number of people entering alcohol treatment, despite the number of people in need remaining stable.[39] Numbers entering treatment have begun to increase and there was a 10% rise in people seeking treatment for alcohol only (i.e. not other drugs) 2021/22, however numbers remain lower than 2013/14.[40]

The most recent figures suggest there are 602,391 adults with alcohol dependence in need of specialist treatment in 2018/19. With only 107,428 in treatment for alcohol in 2020/21, this means over 80% of adults are not receiving the help they need.[41] Almost two thirds of those starting treatment for alcohol were self-referred, indicative of a lack of referrals through the health and social care system,[42] and thus more is needed to improve pathways into alcohol treatment.

An inquiry by Public Health England found that reduced budgets were a key driver in the drop in treatment numbers post-2013.[43] This was echoed in an Alcohol Change UK survey that found a lack of funding as the most common threat to service provision, with only 12% of respondents believing resources in their area were sufficient.[44]

Stakeholders responding to the PHE inquiry reported a number of possible factors associated with service reconfiguration and reduced capacity that contributed to falling treatment numbers, listed below.[45]

-          A loss of focus on the specific needs of alcohol users;

-          Prioritisation of limited resources on opioid substitute treatment;

-          Barriers to alcohol users approaching the service, including a perception that the service focused on the needs of drug users;

-          Barriers to alcohol users engaging in treatment after initial contact, including a lack of alcohol specific treatment pathways within integrated services and a loss of alcohol treatment expertise among staff; and

-          Referral pathways and multi-agency working had become less effective.

These indicate a prioritisation of drug treatment over alcohol, despite the fact that more people die from alcohol every year than other drugs.

The same inquiry found that numbers of people accessing alcohol treatment increased where there was: [46]

-          Leadership commitment to alcohol treatment and a strategic approach by local authorities to alcohol harm reduction;

-          Commitment to service improvement (as opposed to just cost-saving);

-          Intention by commissioners to increase numbers in alcohol treatment to meet unmet need;

-          Commissioners work with providers to ensure alcohol-specific needs were addressed in service models and service cultures were appropriate for alcohol users;

-          Very accessible services, in a wide range of non-stigmatising settings;

-          Services actively promoted and clearly identifiable as being for alcohol users;

-          Alcohol-specific treatment pathways/interventions;

-          Staff with alcohol-specific competences and roles; and

-          Quick access to treatment.

Outcomes

Treatment outcomes are directly linked to funding. Alcohol treatment provides very good value for money: in England, every £1 invested in alcohol treatment is predicted to yield £3 of social return, increasing to £26 over 10 years.[47]Every 5% reduction in yearly spending on alcohol treatment is associated with an extra 60 alcohol-related hospitalisations per 100,000 people in the population.[48]

For those that were able to access alcohol treatment, 62% completed the programme successfully and were discharged as ‘treatment completed.’[49] The alcohol treatment landscape is complex and covers a broad range of community and in-patient services provided by the NHS, voluntary sector and private sector. Though far from exhaustive, the following section looks at outcomes for some specific treatment options.

Intervention and brief advice

Intervention and brief advice (IBA) is a cost-effective intervention to reduce consumption before the point that treatment for dependence is needed.[50] IBA requires initial screening, structured brief advice or extended brief interventions for those identified as high risk, and referral to specialist services for those identified to be most at risk of dependent drinking.[51] With three quarters of people with liver disease being diagnosed at a late stage when it is too late for lifestyle changes or intervention, early intervention is crucial.[52]

There is a clear need for greater rollout of IBA. Research has found that less than 10% of those who drink “excessively” reported having received any advice on their alcohol consumption over a period of a year.[53] Out of 1.8 million registered adult patients, less than 10% had an Alcohol Use Disorders Identification Test (AUDIT) or Fast Alcohol Screening Test (FAST), and almost half had no recorded alcohol consumption data at all.[54]

With screening and briefing estimated to save £1.23 for every £1 spent,[55] this intervention should be incorporated more thoroughly into primary care, dentists, and routine screening such as breast screening. Some local authorities have innovatively rolled out IBA via digital tools and to places such as hairdressers and driving instructors.[56] However, as increased screening is likely to lead to more referrals, there must be capacity in treatment services to facilitate a higher number of patients.

Other primary care interventions have also shown positive outcomes. A pilot placing Addictions Nurses in GP practices in the most disadvantaged areas of Glasgow found positive outcomes including increased engagement with alcohol services, reduced use of GP, emergency department and hospital admissions among the targeted population.[57]

Alcohol Care Teams

Alcohol care teams (ACTs) are teams of specialists, mainly location in acute UK hospitals. There is clear evidence that they reduce acute hospital admissions, readmissions and mortality, improve the quality and efficiency of alcohol care, and have 11 key evidence-based, cost-effective and aspirational components.[58]

As almost 6% of hospital admissions in England are alcohol-related,[59] ACTs are a proactive way to drive down readmissions, and can bridge the gap between secondary and community care.[60] They are cost-effective across all four elements of alcohol-related harm: crime and social disorder, families and family networks, the workplace, and health.[61] Implementation of an alcohol specialist nurse service in Nottingham improved the health outcomes and quality of care for detoxification and alcohol-related cirrhosis patients, resulting in a saving of 36.4 bed days per month in detoxification patients and a reduction in bed days used in the cirrhotic group from 6.3 to 3.2 days per month.[62]

Although there has been an increase in the number of trusts in England with an alcohol specialist nurse service, many hospitals are not resourced to provide the optimal seven-day service, [63] which is estimated to save £179,000 per annum per 100,000 population.[64] To provide a seven-day service, trusts should ideally have a minimum of four nurses, with liver and mental health expertise.[65]

The NHS Long Term Plan set aside £27 million to support the implementation of specialist ACTs in 25% of hospitals with the highest rates of alcohol-dependence related admissions, estimated to prevent 50,000 admissions over five years.[66] The implementation of this plan thus far is unclear, and the delivery aim of 25% hospitals falls far short of a national roll out: every acute hospital must have an alcohol care team.

RADAR

Another example of good practice is the RADAR unit that has been serving Hospital Trusts in Greater Manchester since 2012. It takes referrals directly from A&E, admitting patients to a specialist inpatient alcohol detoxification unit with 24-hour medical cover and multidisciplinary team support.[67] An independent evaluation found that this service led to both excellent outcomes and substantial cost savings.[68]

Assertive outreach

Assertive outreach delivers effective results for high-need, high-cost repeat attenders.[69] In 2015/16, just 9% of people with alcohol dependence accounted for 59% of inpatient alcohol-related hospital admissions.[70] These 54,369 patients accounted for 365,000 admissions and more than 1.4 million bed days, at an estimated cost of £858 million.[71]

Assertive outreach interventions targeting this group can offer considerable cost savings, improved health and qualify of life. A randomised controlled trial of an alcohol assertive outreach team showed an increase in abstinent days from 14% to 68%, and inpatient bed days reduced from 26.8 to 1.2.[72] The rollout of assertive outreach to care for over 50,000 high need, high-cost patients across England was estimated to have an implementation cost of around £161 million and provide savings of around £575 million.[73] This translates as a £3.42 return on every £1 spent on assertive outreach.[74]

Alcohol intoxication management services

Alcohol intoxication management services have been found to effectively divert those who have consumed high amounts of alcohol away from emergency services, improving ambulance response times and reducing emergency department attendance.[75]

Residential rehabilitation

Residential treatment is an evidence-based intervention which is effective in both treatment and cost. Each successful completion in residential rehabilitation provides net savings of £43,904 per year, and over two thirds of people in residential rehabilitation complete their treatment journeys.[76]

However, placements in residential rehab in England have fallen by around 15% year on year for the last six years. In 2020-21, less than 1% of the treatment population in England and Wales received residential rehab as an intervention (the European average is 11%).[77] There is also significant regional disparity in the provision of residential treatment: in the North East, there are seven areas with no access to residential rehab at all. As a region, there are only 19 placements made within a treatment population of some 20,000 people. Residents in South East England are 13 times more likely to access residential rehab than those from the NE.[78]

Liver screening

78% of alcohol-specific deaths are due to alcohol-related liver disease (ARLD).[79] Many of those accessing alcohol services are at high risk of developing cirrhosis and may have undetected ARLD. Yet non-invasive tests for liver fibrosis (i.e. transient elastography and enhanced liver fibrosis testing) are not widely embedded in high-risk community services including alcohol services.[80] Earlier detection of ARLD can stimulate a change in high-risk drinking behaviour and save lives.[81]

Integrated care

Alcohol dependence often co-occurs with other mental and physical health conditions, and the complex relationship between these must be accounted for in effective treatment provision. Two-thirds of new starters into alcohol treatment between 2021 and 2022 also required mental health treatment,[82] a quarter of whom were not yet receiving any treatment.[83] Out of all alcohol-related hospital admissions, 23% are for mental and behavioural disorders due to the use of alcohol.[84] Individuals with a mental health condition concurrent with problematic alcohol use also experience a greater burden of physical illness, further highlighting the need for timely and integrated treatment.[85]

Despite the prominence of dual diagnosis, treatment for each condition is often dependent on a patient recovering from one condition first.[86] A rapid evidence review found that the lack of uniformity in service delivery for people with dual diagnosis, and inconsistencies in regional and UK policy and guidance, mean there is still a long way to go to address this issue.[87] More alcohol training for non-alcohol specialists is needed to prevent stigmatisation across different services, as well as anti-stigma campaigns for both public and practitioner audiences to reduce the normalisation of alcohol as a form of self-medication for dealing with stress and distress.[88]Psychological treatments such as psychotherapy have proven to reduce alcohol consumption and dependence.[89]

Recovery is also much wider than treatment alone: employment opportunities and housing status are important for improving recovery outcomes. Between 2020 and 2021, 1 in 10 of those starting treatment for alcohol problems said they had a housing problem.[90] Housing First is an effective evidence-based model for people with complex needs who sleep rough, which should be scaled up and rolled out more widely.[91] Individual placement and support (IPS) has an established evidence base in the mental health sector, and recent research has shown this is also successful in getting people in drug and alcohol treatment back into work.[92]

NICE quality statements have reinforced two principles that would help to integrate care. Firstly, ‘everyone’s job’ indicates that both commissioners and service providers should be responsible for providing services for people with a dual diagnosis or complex needs. Secondly, ‘no wrong door’ underlines that service providers should not turn away people with co-occurring conditions and that treatment for any of the conditions should be available at every point of contact, known as Making Every Contact Count.[93]

New NHS Integrated Care Systems (ICS) provide opportunities for co-ordination across health and care services,[94] and ICS budgets should be used to properly fund alcohol treatment.[95] As Local Authorities can use their voice to influence at Integrated Care Board level, they should be seen as allies for drug and alcohol treatment providers and commissioners.[96]

The role of prevention

Alcohol treatment is provides an essential service, it is effective and it provides good value for money. However, it is only one part of the holistic, evidence-based approach to alcohol harm that is needed from the Government. As a witness to the independent Alcohol Harm Commission noted “we’ll never treat ourselves out of this situation we’re in … we have to start with prevention.”[97]

Preventative policies limit the burden on treatment services, with only 1 in 5 people with alcohol dependence currently receiving the treatment they need, effective prevention also helps to reduce the level of unmet need.[98] Population-level measures to limit the affordability, availability and promotion of alcohol have been recommended as cost-effective by Public Health England (now the Office for Health Improvement and Disparities)[99] and the World Health Organization.[100]

Increasing alcohol duty is most cost-effective measures to tackle alcohol harm, reduce cancer and deaths, as well as providing other public health benefits such as reducing obesity.[101] Cuts and freezes to alcohol duty almost every year over the last decade costing the Treasury a total of £8.6 billion[102] – much-needed revenue which could have been reinvested into the healthcare system. The new alcohol duty system expected to come into effect on 1 August 2023 will bring public health benefits but the overall level of duty continues to be set too low. With the current revenue from alcohol duty (£12.6 billion) approximately less than half of the costs of alcohol to society (at least £27 billion), [103] the new system will only serve its purpose if the rate is high enough and is not eroded over time due to inflation.

Reducing the availability of alcohol through licensing regulations can lead to a reduction in assault incidence.[104] Conversely, the relaxing of licensing restrictions led to an increasing alcohol-related overnight attendance in a London hospital.[105] In Scotland, alcohol-related hospitalisations, deaths and crime rates are directly linked to the density of licensed premises.[106]

Exposure to alcohol marketing encourages children and young people to start drinking at an earlier age and engaging in riskier drinking habits,[107] and can also trigger relapses in those with alcohol dependence. Alcohol marketing restrictions reduce the overall burden on health services by bringing down alcohol consumption. Several European countries already have alcohol marketing restrictions in place, especially around sports sponsorship by alcohol companies, including France, Norway and the Republic of Ireland.[108] The Scottish Government is also currently consulting on alcohol marketing restrictions. Including health information on labels also has the potential to decrease intentions to purchase and consume alcohol, as well as actual consumption.[109]

Concluding remarks

Despite record rates of alcohol harm and persistently high levels of unmet treatment need, there has been very little evidence-based alcohol policy from the government. The last alcohol strategy was in 2012, and many of the recommendations were either not implemented or of unclear status. Following on from the success of Dame Carol Black’s review of drugs, an independent review of alcohol harm looking at prevention, treatment and recovery would help us understand the scale of the problem and identify evidence-based policies to inform a comprehensive alcohol strategy. 

February 2023