ATS0015

 

Written evidence submitted by Turning Point to the Public Accounts

 

About Turning Point

  1. Turning Point is a national health and social care provider with specialisms in mental health, substance use and learning disability. We provide services across England from 300 sites and last year we supported over 160,000 people. We employ over 4,500 staff and our turnover is £131m. We are a social enterprise and the majority of our revenue comes from NHS and local authority contracts. Our drug and alcohol services include community drug and alcohol services, inpatient detox, residential rehab, and young people’s services. Our mental health services include Improving Access to Psychological Therapies (IAPT), independent hospitals, discharge to assess (D2A), mental health crisis houses, crisis helplines and outreach services and supported living. Our learning disability services include registered care homes and supported living and we support a number of people with complex needs who have come from long stay hospital (the transforming care cohort).

 

  1. Turning Point also provide secretariat duties for the APPG on Complex Needs and Dual Diagnosis.   In early 2022 the group met to discuss the ongoing increase in alcohol-related deaths, with guest speakers Sir Ian Gilmore, Professor of Hepatology, Director of the Liverpool Centre for Alcohol Research and Chair of the Alcohol Health Alliance; Sarah Quilty, Senior Commissioner at Nottinghamshire County Council; Dr Alison Giles, Interim Chief Executive of the Institute of Alcohol Studies and Jon Roberts, Director at Dear Albert. 

Submission

Summary

  1. It is our view that alcohol causes significant and increased harm to individuals, families, communities and public services. Efforts to reduce alcohol related harm should be national policy priority.  We would like to see a new national strategy to reducing alcohol related harm – something which has been remiss for over ten years. This has led to an uneven and uncoordinated response to public health and alcohol use when there needs to be an integrated, cross-cutting agenda. 

 

  1. There is much more the government can do to reduce risks earlier, through tougher measures on alcohol advertising, promotion and sales, and an approach to alcohol prevention that puts people before profit. Turning Point supports MUP (Minimum Unit Pricing) being implemented within England.

 

  1. Turning Point believe greater emphasis needs to be placed on identifying and providing support to people drinking at harmful or hazardous levels to reduce their consumption. This can be achieved through better screening within primary care and A&E which needs to be properly funded, greater use of digital interventions and an ongoing national public health campaign to raise awareness of the negative impact of alcohol, targeted at harmful and hazardous drinkers.

Increasing levels of alcohol related harm

  1. It is our view that alcohol causes significant and increasing harm to individuals, families, communities and public services and efforts to reduce alcohol related harm should be national policy priority. 

 

  1. In 2021, there were 9,641 deaths from alcohol-specific causes registered in the UK, the highest number on record and 7.4% higher than in 2020 (ONS 2022). Similarly, alcohol treatment services have seen a 27% relative increase in deaths among people in treatment between 2020 and 2021. The increase was the largest among the subgroup of ‘alcohol only’ clients, with a 44% increase in deaths during treatment, from 741 deaths in 2019-20 (1.6%) to 1,064 deaths in 2020-21 (2.3%) (NDTMS 2021).

 

  1. In June 2021, data showed that more than 8.4m people in England were drinking at higher-risk levels, up from 4.8m in February 2020 (OHID 2022). Public Health England’s (PHE) July 2021 report found that the heaviest drinkers before the pandemic increased their alcohol purchasing the most. In March 2022, "increasing and higher risk drinking" was found to have remained at heightened levels. Studies estimate substantial increases in alcohol-related harms and pressure on the NHS, even if drinking patterns were to return to pre-pandemic patterns from 2022 onwards.

 

  1. Before the pandemic, one in 10 people admitted to hospital were addicted to alcohol. One in five patients admitted to hospital beds were using alcohol in a harmful way; while one in 10 were dependent on the substance (Study of Addiction (SSA) at King’s College London, 2019). Deaths from liver disease have increased 400% since the 1970s and is the main reason for the majority of alcohol-related deaths.

 

  1. The strain from alcohol misuse has huge effects on other public services. 17% of domestic violence perpetrators have a history of alcohol dependence and around 1 in 3 offenders in all sexual assault cases were under the influence of alcohol.

 

  1. Half of those starting alcohol treatment during 2020 were parents, and while many don’t currently live with their children, there were 31,000 children living with an adult who started alcohol treatment during 2020. In 2021, 12.1% of alcohol related deaths attributed to mental and behavioural disorders because of the use of alcohol (ONS 2022).

 

  1. Alcohol-related harm is often much more pronounced in areas of high deprivation, even though the average consumption is usually lower in these areas. On average, people on low income drink less than people on higher income. Perhaps this is unsurprising since affordability is a major factor in consumption habits. However, people living in deprived areas are more likely to die or experience admission to hospital on account of an alcohol-related cause. For the eighth consecutive year, the North East had the highest rate of alcohol related deaths of any English region. 

Alcohol-related brain damage:

  1. Alcohol-related brain damage (ARBD), or alcohol-related brain injury (ARBI), is an umbrella term for the damage that can happen to the brain as a result of long-term heavy drinking. Over time, drinking too much alcohol can change the way the brain works and its physical shape and structure. 

 

  1. It has been the case that ARBD was seen in people in their 50s and 60s, but symptoms are now being seen in people in their 30s and 40s. Women tend to develop ARBD at a younger age than men and after a shorter history of heavy drinking.

The changes in the brain are caused by a number of different factors; key ones are:

 

  1. Although alcohol related dementia can be mistaken for Alzheimer’s Disease, it is not inevitably progressive. Stopping drinking and accessing treatment can lead to successful recovery and much of the brain damage can be reversed.

 

  1. Turning Point services see people with symptoms of dementia who have been long term heavy drinkers. A multi-agency, multi-disciplinary approach involving family, carers, adult safeguarding teams, Turning Point clinical staff and our safeguarding leads in services is the most effective way of supporting people and providing treatment and support. Assessment of capacity in line with the Mental Capacity Act is often required to inform discussions of best interest for the individual.

 

  1. In Turning Point’s Rochdale and Oldham Active Recovery services, our safeguarding lead and clinical lead supported by colleagues from Risk and Assurance have worked alongside families and adult social care to support individuals drinking heavily over long periods who have symptoms of dementia or other issues with mental capacity. The service has seen successes with this approach and are building relationships particularly with adult safeguarding teams to ensure these successes can be replicated.

Regulating the alcohol market

  1. There is much more the government can do to reduce risks earlier, through tougher measures on alcohol advertising, promotion and sales, and an approach to alcohol prevention that puts people before profit. Turning Point supports MUP (Minimum Unit Pricing) being implemented within England.

 

  1. Although the pandemic has had an impact on alcohol consumption it is by no means the only factor leading to increased use. Consumption and harm are in part driven by the price of alcohol, promotion by alcohol producers and retailers, and availability. Alcohol is now 74% more affordable in England than it was in 1987. Research has found that alcohol tax and pricing according to the type of product can shift consumption from higher strength beverages to lower strength beverages, which may reduce the overall amount of alcohol consumed (Babor, 2010). Sales bans, restricting hours of sale and limiting outlet density can help reduce harm, if enforced properly.

 

  1. In England, MUP is predicted to save 525 lives annually at full effect. If implemented, Minimum unit pricing (MUP) would set a baseline price at which a unit of alcohol can be sold. Minimum unit pricing works by targeting the cheapest and strongest products on the market without impacting prices in pubs and bars.

 

  1. According to the Alcohol Health Alliance, several barriers exist in England to introducing the above (as some measures are already in place in Scotland). Barriers include the government’s reluctance to overregulate alcohol, the government’s focus on alcohol as an issue linked to crime rather than health, the influence of the Treasury over alcohol policy and the money it brings in, and the power of the alcohol lobby. As stated by a World Health Organisation expert panel, ‘alcohol use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms’ (WHO, 2000)

Treatment

  1. More people are entering treatment because of increased capacity within services resulting from investment in the sector on the back of the drug strategy and this includes people with alcohol problems. 

Residential services

  1. Inpatient detoxification and residential rehabilitation services (known as Tier 4 services) are a vital and important part of our alcohol treatment system. At present demand for residential treatment is outstripping supply and it is particularly difficult to access residential treatment in some parts of the country.  Anecdotally, Turning Point has seen waiting times increase. Many rehab units are looking to expand their capacity however the additional OHID funding for tier 4 has gone to community funders rather than the rehab units themselves. This means rehab services are currently waiting for additional funding to ‘trickle through’ in order to expand. Residential treatment is much more expensive than community-based treatment and it is therefore both appropriate and reasonable that its use is reserved for people whose circumstances/level of complexity mean they cannot safely be treated in the community or for those who have exhausted all community treatment options.

 

  1. Nationally, funding for drug and alcohol treatment reduced by 24% between 2014 and 2019. During this period, funding for inpatient detoxification and residential rehab was particularly impacted with commissioners taking the view that community service provided better value for money. As a result, access to these services was rationed although many providers increased the availability of community detoxification. 

 

  1. The number of people receiving treatment in inpatient and residential settings fell between 2014 and 2019, hitting a low in the first year of the pandemic. In 2014-2015, 25,847 people received inpatient treatment and in 2019-20 the figure had fallen 49% to 15,161. The number dropped again because of the pandemic with 13,214 people treated in those settings in 2020-21. In 2021-22 it has increased to 14,105 people. However, this is still 45% lower than the peak of people receiving treatment in these settings in 2014-15.

 

  1. Residential detoxification and rehabilitation is generally ‘spot-purchased’ and prior to the publication of the drug strategy, most residential providers would suggest that there have been more residential beds available than there have been people to fill them for well over 10 years.  During the pandemic, a number of residential facilities closed as they had become financially unsustainable. At Turning Point, we took a conscious decision to keep our inpatient detox unit in Manchester, ‘Smithfield’, open throughout the pandemic. As a result of increased investment linked to the drug strategy the number of referrals has increased significantly (and we have seen this at Smithfield) although in some parts of the country, particularly in the South East and the South West there is now a significant problem with under supply.

 

  1. What is also clear, and has been the case for some time, is that the percentage of clients accessing tier 4 treatment varies significantly from local authority to local authority and this continues to be the case post-pandemic which means that where you live will determine the likelihood that you will be able to access residential treatment.

 

  1. The situation in regard to tier 4 provision could be improved if:
  1. Office for Health Improvement and Disparities (OHID) collated and regularly published statistics on the number of clients accessing tier 4 treatment and the associated cost by local authority, thus introducing greater scrutiny/transparency
  2. Tier 4 budgets were once again separated from local community treatment budgets (removing any perceived conflict of interest) and administered at a local, regional or national level in such a way as to provide a balance between simplicity of pathways and over treatment.

Early intervention

  1. Of the referrals we receive for community alcohol treatment, just under half are alcohol dependent and just over half are harmful or hazardous drinkers, which means the service user’s drinking is causing them harm but they are not physically dependent. Around 1/3 of our alcohol clients also have problems related to use of other substances as well as alcohol. We believe greater emphasis needs to be placed on identifying and providing support to enable people drinking at harmful and hazardous levels to reduce their consumption. This can be achieved through better screening within primary care and A&E which needs to be properly funded, greater use of digital interventions and an ongoing national public health campaign to raise awareness of alcohol harm targeted at harmful and hazardous drinkers.

Severity of alcohol dependency of service users

Number of Referrals

Percentage

Severe alcohol dependence

2128

12%

Moderate dependence

2119

12%

Mild physical dependency

3539

19%

Total dependent

7786

43%

 

 

 

Non-dependant (harmful or hazardous drinkers)

10461

57%

Total

18247

100%

*Count of initial inward referrals to Turning Point services where referral date is in calendar year 2022 and Drug Group is Alcohol or Alcohol & Non-Opiate. Severe is SADQ >= 31, moderate is 16-30 and mild is < 16.

 

  1. YouGov survey data reported in the Guardian suggest 18.1% of adults in England were drinking at “increasing or higher risk” in the three months to the end of October 2021, which equates to 8 million people. That is much higher than in February 2020, before the pandemic, when 12.4% or about 6 million people drank at these levels. In October 2019, 11.9%, or about 5 million people, were drinking at this level. In total there were 107,428 adults in treatment for alcohol in 2019/20. In England there are an estimated 602,391 dependent drinkers and government analysis suggests only 18% are accessing treatment.

 

  1. It would seem that a far smaller proportion of “increasing or higher risk” drinkers are accessing support. Most dependent drinkers will be known to their GP, and it is likely that they are not accessing treatment because they don’t want to stop drinking or they don’t feel they are able to. Identification of people who are drinking at harmful or hazardous levels and encouraging them to access support services is more problematic. 

 

  1. NICE’s new draft quality standard for the diagnosis and management of alcohol-use disorder encourages health professionals to correctly gather information on people’s alcohol drinking habits to ensure those who need help are not missed. In particular, NICE is asking to ensure that systems are in place for the use of validated alcohol questionnaires (called AUDIT) when asking people about their alcohol use.  The AUDIT tool picks up 90% of patients with an alcohol problem and the benefit is primarily in identifying increasing or higher risk drinkers who may not be known to services. It is much better than simply asking a patient how much they drink when many people under-estimate their consumption or are reluctant to admit the amount to a healthcare professional.  However, the AUDIT tool takes 10 minutes to complete, and the reality is that if a patient has come in for something else, there simply is not time to go through the questions. We must acknowledge the pressures on primary care. There are particular points when use of the AUDIT tool works well. We would like to see greater use of the AUDIT tool as part of new patient assessments, chronic disease reviews or as a self-assessment while people are waiting in A&E but this needs to be properly funded.  

 

  1. At Turning Point, we are increasing the use of digital interventions to support people who are drinking at harmful or hazardous levels. Non-dependent clients can access our digital platform where they can work through modules online in their own time and out of opening hours which can be of particular use for those that have work or childcare responsibilities during the day. Alongside this, they will also have reviews with their keyworker to monitor progress.

 

  1. We recognize that not all 8 million people who are drinking at harmful or hazardous levels will access support services.  We also see the potential for the application of lessons from health psychology/behavioral economics into a national campaign targeting people drinking at increasing or higher risk.

Reducing alcohol related deaths

  1. Engagement with treatment services remains the biggest single protective factor against alcohol related deaths. However, the increase in the numbers of people who have died in treatment clearly indicates that services need to change the way they are working. At Turning Point we have developed a drug and alcohol related deaths quality standard and we would like to see a similar quality standard adopted across all alcohol treatment services.  The standard includes measures such as:

Identifying people with liver disease

  1. Alcoholic liver disease accounts for the majority of alcohol-specific deaths. A FibroScan is a simple and non-invasive procedure used to accurately assess the health of the liver and gives the opportunity to identify poor liver health at an early stage. Fibro scanning can also be used in outreach activities and can extend service reach people who have not previously engaged in treatment but who are at higher risk (for instance; rough sleepers, military personnel, those with poor mental health).

 

  1. Broader commissioning of harm reduction, including Fibro scanning, can facilitate rapid referrals and ultimately reduce the burden on active and primary care services.

 

  1. Funding is necessary to field staff and the necessary equipment required to carry out Fibro scanning work. Presently, only some commissioners fund fibro scanning when such harm reduction activities should be rolled out nationally. Turning Point have received funding for FibroScans in some service areas under OHID universal funding – however this has not been the case for all areas.

 

  1. The earlier we can identify and stage liver disease, the earlier we can support individuals to reduce alcohol related harmful behaviour. FibroScan offered with psychosocial intervention will support positive harm reduction behaviour change.

 

  1. Our ambition is to offer FibroScan to all new alcohol treatment presentations and to existing service users within the next 12 months. The use of FibroScan has been recognised by Turning Point and resulted in our national alcohol pathway being updated to include the offer of a FibroScan exam at the earliest opportunity. 

Case study: FibroScan in Leicester

  1. The use of FibroScan technology by the Turning Point Leicester City service was initially funded by Leicester City Council with the aim to increase the number of Leicester City residents accessing alcohol treatment and to support positive behaviour change to reduce harmful drinking behaviour. Funding was initially agreed as part of an 8 month pilot for use of a FibroScan with 2 specific cohorts:

 

  1. Results from Specialist Alcohol and Liver Care clinic within Primary Care from (August 2021 – March 2022):
  1. Results from use of FibroScan within Structured Treatment, Alcohol Dependent Cohort (August 2021 –July 2022)

Service accessibility and under-served communities

  1. Services need to be accessible to all parts of the community they serve, and this may involve targeted outreach, working in partnership with local community organisations or faith groups and developing tailored treatment offers.  People may have language barriers and employing a diverse workforce to reflect the community makeup is essential.

 

  1. Alcohol use can not only harm the individual, but also has significant impact on the physical, psychological, and mental welfare of their family and loved ones. The stigma and shame associated with substance use often means families and carers suffer in silence, creating severe isolation which can result in depression and other associated health problems. It is therefore imperative that alcohol treatment providers cater for the needs of people affected by alcohol use within their community, family, and friend groups.

Case study: engaging the Sikh community in Leicester

  1. Within our substance use services in Leicester and Leicestershire & Rutland, we have transformed service engagement with minority communities. Our Guajarati/Urdu-speaking outreach workers have significantly increased numbers in treatment from British-Asian communities.

 

  1. Working alongside community/faith-based partners the Sikh Recovery Network (SRN), Spinney Hill Recovery (SHR) and community leaders, they have opened doors to culturally sensitive mainstream treatment such as co-delivered bilingual (Punjabi/English) peer-led alcohol recovery groups at the local Gurdwara.

 

  1. Turning Point also supported SRN to establish an annual Sikh Recovery Day Celebration in September 2022 and delivered Sikh 12-Step workshops exploring how the principles of 12-Step recovery fit the Sikh religion.

 

  1. Proactive engagement with the Sikh community via East Park Road Gurdwara has provided us with a deep understanding of community-specific SM issues, notably poppy seed dependence and hazardous/dependent drinking among older men.

 

  1. Grassroots media/networks are key to raising awareness/engagement among minority communities. TP/SRN have recorded a podcast series on SM issues (Spotify/YouTube) and are co-producing a SM series for Punjabi TV.  Community football club GNG FC have agreed to feature TP/SRN logos on all banners/e-mail marketing.

Case study: engaging minority women in Leicester

  1. At Turning Point, our specialist Family, Friends and Carers Recovery Workers are trained to deliver high-impact interventions and support to affected others, including 5-Step. Developed by AFINet, the 5-Step Method is a structured, evidence-based brief intervention for family members affected by a relatives’ alcohol or drug use. Based on theories of stress coping, 5 Step recognises that family members are affected by a unique and complex set of stresses and therefore need help.

 

  1. As part of our integrated substance use treatment service in Leicester, Turning Point is piloting the delivery of tailored 5-Step support to Asian women in the locality.

 

  1. Based on local intelligence and community outreaches, we identified that in the Asian community, women affected by their loved ones’ substance were not accessing available support, primarily due to cultural barriers and stigma around addiction and substance use.

 

  1. To overcome these barriers and gain clients’ trust, delivering the 5 Step intervention in Gujarati and Hindi on a one-to-one basis to Asian women affected by their loved ones’ substance use. There is flexibility regarding meeting locations – be it at home or in informal, neutral locations where they feel comfortable.

 

  1. Since starting the pilot, the women we have worked with are gaining confidence to speak up and are also learning techniques to successfully cope with their loved one’s substance use, thereby limiting the negative impact on their health and wellbeing. Many of the women facing multiple vulnerabilities, e.g., domestic violence, now feel safe enough to disclose it to the service and are more receptive to being connected with local support.  

 

  1. We are also planning to launch an on-site women’s group at the premises of our partner (Spinney Hill Drugs, Alcohol and Addiction Support), a culturally sensitive recovery provider serving the Asian community in Leicester. The group sessions will take place when only women (including staff) are in the building. Play facilities for young children will be available as well as prayer facilities for women attending.

Commissioning and delivery models

  1. Third sector providers currently deliver approximately 2/3 drug and alcohol treatment services across the country. We deliver high quality services (96%) of Turning Point’s CQC regulated services are rated Good or Outstanding) and excellent value for money.  A culture of flexibility and responsiveness means the third sector are very good at engaging with people with complex needs and sometimes chaotic lives, innovating in response to changing circumstances and working in partnership with a broad range of organisations.

 

  1. The large third sector providers combine clinical quality (we employ significant numbers of clinicians and have robust clinical governance arrangement in place- recognised by CQC) with a person-centred ethos that recognises that friends, family, work, education, skills and housing are all key to a person’s recovery.  It is for this reason that we believe that public health commissioning teams are best located within local government. We also believe that integrating treatment services for drugs and alcohol is the right approach, with so many service users having issues with both drugs and alcohol. Bringing together multiple functions/organisations under one roof has resulted in massive efficiency gains and quality improvements in terms of service user experience.  

 

  1. We recognise that NHS organisations play a vital role providing specialist treatment services for clinically complex patients. The NHS also shoulder the burden of much alcohol related harm and there needs to be better joint working between hospitals and community treatment services. Early identification of liver disease is one key example, with joined-up pathways across hepatology and substance use services. 

 

  1. The new Integrated Care Systems (ICSs) aim to promote more joined up services, greater focus on prevention and early intervention.  Addressing alcohol related harm is a good example of where this is needed but ICSs are not well set up to engage with the 3rd sector. It is early days, but our limited experience of funding for initiatives that have been administered through ICSs (social prescribing, alcohol care teams and services for people with co-existing substance use and mental health) is that there is very little flexibility and scope for innovation with spending quite prescribed, short-term and often limited to staff directly employed by an NHS organisation which means it is difficult for areas to involve local VCSE providers. This is problematic considering that 2/3 of drug and alcohol treatment services are delivered by the 3rd the sector.

A national strategy for reducing alcohol related harm

  1. We would like to see a new national strategy to reducing alcohol related harm. There has been no national alcohol strategy for over ten years. This has led to an uneven and uncoordinated response to public health and alcohol use when there needs to be an integrated, cross-cutting strategy which provides an overarching framework for public health teams and integrated care systems, covering community and residential alcohol treatment services, acute, emergency and primary healthcare, and wider social care services.  The strategy should also cover advertising and availability.

February 2023

 

 

 

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