THE CASE FOR BETTER ACCESS TO TREATMENT

Transcription

THE CASE FOR BETTER ACCESS TO TREATMENT
FOR ALCOHOL DEPENDENCE IN ENGLAND
Interviews
In August 2013 the following people
were interviewed for this report
and we are grateful to all participants:
Adrian Brown
St. George’s Healthcare NHS Trust
Joss Gaynor
Adfam
Dr Carsten Grimm
Locala CIC
Dr Linda Harris
Spectrum Community Health
Dr Francis Keaney
South London & Maudsley NHS FT
Dr Jack Leach
Cheshire Substance Misuse Services
Dr Tony Rao
South London and Maudsley NHS FT
Paul Richardson
Royal Liverpool University
Contributors to the report
Acknowledgement of Funding
Lundbeck is grateful for the
advice given by the following
expert reviewers:
This is an independent report initiated and sponsored by Lundbeck Ltd.
Andrew Langford
British Liver Trust
Tom Smith
Alcohol Concern
britis h
liv er
trus t
Lundbeck provided funding for the writing, design and printing
of this document as well as administrative support through Munro
& Forster, who facilitated the production and launch of the report.
The views expressed in this document do not necessarily represent
the views of, and should not be attributed to, Lundbeck.
Lundbeck supports an increase in access levels to treatment
for dependent drinkers.
UK/NAL/1309/0288 | Date of preparation: September 2013
Foreword
The human impact of alcohol dependence cannot be
underestimated. Behind the statistics, people with alcohol
dependence are real individuals, living in real communities.
They are someone’s spouse, partner, father, mother, son,
daughter, brother or sister.
The impact of alcohol dependence is therefore felt far
more widely than by the dependent drinker themselves.
As a society, we also feel the impact, in terms of crime levels
or antisocial behaviour due to binge drinking, for example.
And alcohol dependence affects us as a nation, costing public
health and the health services in England dearly.
Against the backdrop of the farreaching burden of harmful and
dependent drinking, the evidence
set out in this report demonstrates
the potentially enormous benefit
of improving alcohol treatment
rates – for individuals, families,
communities, public health,
the workforce and the NHS.
These are difficult times for
the public sector, particularly
local government who carry the
responsibility of commissioning
the majority of alcohol services
in England and who are now
prioritising services whilst
managing unprecedented cuts
in government funding.
stage, including in those people
who may not obviously be seen to
have a problem. People who are
dependent on alcohol often do not
look like stereotypical alcoholics.
They may be holding down a job
– in fact, someone with alcohol
dependence may be working
alongside any one of us without
our realising.
A range of professionals in health
and social care, and other services,
can play an important role in
recognising alcohol problems,
and helping people to access the
care they need.
However, local authorities,
with their new public health role,
have an important opportunity
to address alcohol problems and
reduce the widespread burden,
by ensuring that alcohol treatment
services are adequately funded.
Local commissioners should
ensure there is effective screening
and intervention for alcohol
misuse, and greater awareness
of treatment services. Of course,
better screening means there
will be a need for timely brief
intervention and structured alcohol
treatment services.
If access to alcohol treatment is to
be improved, another key factor is
recognising harmful drinking and
alcohol dependence at an earlier
At a national level the Government
has an important role to play, firstly
through Public Health England
and its role in tackling stigma,
15:15 THE CASE FOR BETTER ACCESS TO TREATMENT FOR ALCOHOL DEPENDENCE IN ENGLAND
analysing and disseminating
health intelligence about alcohol,
and ensuring resources are made
available for population based
initiatives that reduce health
inequalities, and secondly through
the Government’s drive to ensure
newly established Health and
Wellbeing Boards address the
barriers to accessing alcohol
treatment at a local level.
We are faced with a clear choice.
National and local policymakers can pull together to
tackle the barriers to improving
alcohol treatment rates that are
highlighted in this report, and
the benefit – both economic and
societal – can be felt across the
country. Alternatively, if no action
is taken, alcohol dependence will
continue to exact a toll on people’s
lives and health, and avoidable
costs to society and the NHS will
continue to mount.
Dr Linda Harris
Chief Executive
Spectrum Community Health
3
Recommendations
Increased funding for alcohol
treatment services
Treatment access for
under-represented groups
The enormous burden of alcohol dependence
necessitates adequate funding for alcohol
treatment services. Commissioners should
“invest to save” and increase funding for
alcohol treatment services, to save both
money and lives.
Building on the Department of Health’s
work to examine the in-need population,
Health and Wellbeing Boards should
ensure that there is a clear picture
at local level of which groups of people
are under-represented in alcohol treatment,
and that any specific barriers to treatment
access for these groups are addressed.
Clear responsibility for identifying
and addressing alcohol problems
Commissioners should ensure that
there is clear responsibility around
helping people to access the care
they need, from identification of alcohol
problems through to provision of integrated
care, e.g. through clear care pathways.
There should also be responsibility for
funding across the different parts of the
care pathway.
Effective screening for alcohol misuse
Directors of Public Health should ensure
effective screening for alcohol misuse,
in line with the principle of “making every
contact count”, in order to identify problems
before people become severely dependent.
The Government should ensure that
NHS Health Checks, including alcohol
harm screening, are properly rolled out,
monitored for uptake and assessed for
effectiveness. Uptake of health checks
should be encouraged.
Training on alcohol issues
In order to ensure that “every contact
counts”, the Government and local
authorities should ensure that alcohol
awareness training forms part of the
compulsory training of all front line staff.
All such staff need to feel confident and
capable of screening for alcohol both
formally using a tool, and informally,
be able to develop simple tailored advice
and be aware of local referral pathways
to specialist support.
4
Implementation of NICE guidelines
Commissioners should ensure that alcohol
treatment services follow NICE and other
appropriate guidelines, meet quality
standards and have outcome measures
in place.
Reduced waiting times for treatment
Local commissioners and providers should
continue to reduce waiting times for alcohol
treatment, and ensure that treatment is
appropriate to the level of dependence.
Improved awareness of alcohol
treatment services
greater awareness of alcohol treatment
services among potential service users.
De-stigmatising seeking help
Public Health England, in partnership
with relevant expert voluntary sector
organisations and other stakeholders
such as providers and professional groups,
should explore options to de-stigmatise
‘seeking help’ for alcohol problems,
e.g. through a public health campaign.
Executive summary
Every year, alcohol-related harm is estimated to cost society
£21 billion1 and the NHS in England £3.5 billion.2 Despite this
enormous economic impact, and the burden on individuals
and families, only about 6% of people in England who are
dependent on alcohol receive treatment.2,3,4
The 6% access rate to alcohol
treatment in England is very low,
not only in relation to what is
considered a ‘medium’ level of
access (15%)5, but also compared
to treatment rates in other
European countries (23% in Italy,
for example).6
at an earlier stage, before people
become more severely dependent
and require more specialist
treatment. This makes sense for
individuals and families, and also
in terms of making the best use
of commissioners’ and providers’
resources.
A number of barriers need to be
addressed for access to alcohol
treatment to be improved. For
example, alcohol services have
been historically underfunded
compared to drugs services, which
impacts on service provision and
waiting times. Alcohol services
should receive a level of investment
that is not only comparable
with drugs services, but also
proportionate to addressing the
burden of alcohol dependence.
Clinical Commissioning Groups
(CCGs) as well as local authorities
have an important role in providing
appropriate treatments in a primary
care setting. Improving access to
treatment for alcohol dependence
would lead to significant benefits,
for example in improving public
health7 and saving the NHS
considerable sums of money.8
With the new public health
responsibility for commissioning
alcohol services, now is the right
time to tackle the shamefully low
access rate to alcohol treatment
in England.
Furthermore, low referral rates
could be improved by identifying
and addressing alcohol dependence
5
Introduction
There are 1.6 million people in England2,3 – one in 20
adults – who are dependent on alcohol.9 Yet only around
6% of dependent drinkers in England receive treatment,2,3,4
compared to more than half of people who are addicted to
drugs.9 This means that every year there are huge numbers
of people who, according to the National Institute for
Health and Care Excellence (NICE), “are either not seeking
help, do not have access to the relevant services, or whose
symptoms are not being appropriately identified by healthcare
professionals.”4 Meanwhile, alcohol dependence accounts
for a “substantial proportion” of all alcohol-related harm.7
Research shows that the rate of
alcohol dependence amongst men
and women is higher in England
than in all Western European
countries apart from Norway,9
as well as Bulgaria and Romania
in Eastern Europe.7 And it is just
as much a problem at local as at
national level; in a community of
100,000 people, the Government
estimates that each year 3,000
people show some signs of alcohol
dependence.1
However, there is a danger that
treatment services will fall by
the wayside as Local Authorities,
newly responsible for public
health, struggle to balance their
budgets. But spending money
on treatment services is not
simply a case of competing
health and social care priorities.
6
With evidence showing that for
every £1 invested in specialist
alcohol treatment, £5 is saved on
health, welfare and crime costs,10
we can’t afford not to. Notably,
Local Authority budgets will be a
main beneficiary of these savings.
According to the North American
Rush model of access, which is the
best currently available yardstick,
10% of people with alcohol
dependence entering treatment per
annum is regarded as a low level
of access, 15% a medium level, and
20% a high level of access.5
Alcohol Concern has called
for increased expenditure on
alcohol treatment in order to
provide 15% of dependent drinkers
– the medium level of access –
with alcohol treatment.11
The Department of Health has also
recommended “the provision and
uptake of evidence-based specialist
treatment for at least 15% of
estimated dependent drinkers”
in local populations.12 Similarly,
NICE has called on commissioners
to ensure that at least one in seven
(around 15%) dependent drinkers
can access treatment locally.13
Urgent action is needed not
only to help people with alcohol
dependence access the help that
they require, but also to address
the significant economic and
societal burdens that this illness
creates. Alcohol treatment rates
should therefore be increased to
15% by 2015 (‘15:15’) across all
groups of dependent drinkers.
Directors of Public Health in Local
Authorities are now responsible
for commissioning alcohol services
from public health budgets, with
CCGs responsible for providing
treatment for alcohol dependence
and complications such as liver
disease. The reconfiguration of
responsibilities for alcohol services
presents a timely opportunity to
address the problem of low access
to alcohol treatment in England.
This report sets out evidence to
demonstrate the wide-ranging
burden of alcohol dependence,
and examines why alcohol
treatment rates are so low
in England, looking at the
barriers that are preventing an
improvement in treatment rates.
The report also outlines evidence
to show the potential benefit
for public health, families, wider
society and the NHS of improved
treatment rates, and makes
recommendations aimed
at increasing alcohol treatment
rates across the country.
The findings of this report were
informed by interviews conducted
by telephone during August 2013.
Interviewees included experts in
the field of alcohol dependence,
treatment providers and the third
sector. Extensive desk-based
research was also undertaken.
7
Alcohol dependence and the burden it creates
Alcohol dependence and misuse place a significant burden
not only on the health and quality of life of individuals and
their families, but also on public health, wider society and
communities, the workforce and the NHS.
At a time when public services are facing budgetary
pressures, investment in access to alcohol treatment
services is vital to ease that pressure and ensure that people
stay well and are able to contribute to the economic recovery
by staying in work.
What is alcohol dependence?
Alcohol dependence is defined by NICE as being “characterised by craving,
tolerance, a preoccupation with alcohol and continued drinking in spite of
harmful consequences (for example, liver disease or depression caused
by drinking).”3 NICE explains that alcohol dependence may be diagnosed
as mild, moderate or severe.3 Both genetic and environmental factors are
important in the development of alcohol dependence, with genetic factors
accounting for an estimated 60% of the risk of developing the disorder.14
The term ‘alcohol misuse’ can include dependent drinkers as well as those
who are not dependent but consistently drink above recommended limits.15
The consumption of more than 40g of alcohol per day in women and more
than 60g per day in men is considered to be a ‘high risk’ level
of drinking16 or ‘heavy drinking’.17
A wide-ranging burden
Burden on public health
Alcohol is toxic to most organs of the body and is a causal factor in more
than 60 types of disease and injury.18 Alcohol misuse has been linked to
disorders including high blood pressure, heart disease, liver disease,
stroke, depression and some cancers. Cancer Research UK has noted that
the more alcohol a person drinks, “the higher the risk of developing cancer
and other diseases.”19
Excessive alcohol consumption is also seen as “a major source
of morbidity and premature death in the UK”20 and the number
of alcohol-related deaths has doubled since 1991.9 There were around
15,500 deaths from alcohol-related causes in England in 2010,2 compared
to 1,625 deaths related to drug misuse.21 Alcohol is also “strongly linked to
health inequalities”, with those from deprived groups suffering far greater
alcohol-related harm than people from higher socio-economic groups.22
This considerable burden on public health is highly relevant for
Directors of Public Health, who are now responsible for commissioning
alcohol services.
8
Burden on society
and communities
The Government’s 2012 Alcohol
Strategy estimates that alcoholrelated harm costs society
£21 billion annually.1 Alcohol
contributes to around 1.2 million
incidents of violent crime,
and people injured from drink
driving constitute 6% of all road
casualties.10 Alcohol dependence
is linked with increased criminal
activity,3 and the annual cost of
alcohol-related crime in England
is estimated at £11 billion (at
2010-11 costs).23 At a community
level, increased criminal activity is
clearly undesirable, not least from
a community safety perspective.
Burden on families
NICE notes that alcohol dependence
has considerable adverse effects
on family members3; this has clear
relevance for local authorities’
services for children and families.
Alcohol contributes to 40% of
cases of domestic violence10 and
parental alcohol misuse is present
in a number of cases of child abuse
and neglect; the NSPCC notes that
it was present in 22% of Serious
Case Reviews in England between
2007 and 2009.24 It is estimated that
in England, 780,000 to 1.3 million
children under 16 have parents
whose drinking is classed as
harmful or dependent, with around
26,000 babies under one having a
parent who is a dependent drinker.24
Around 31,000 (33%) adults in
alcohol treatment are parents
with childcare responsibilities
and a further 20% are parents
with a child who lives elsewhere.1
And a report by the Children’s
Commissioner for England noted
that, “Overall, parental alcohol
misuse is seen as a much bigger
problem than parental drug misuse.
[…] it appears to be a problem
that (largely because of social
acceptance of alcohol and stigma
attached to its misuse) remains in
fact largely hidden and which, as a
result, means that children often
come to the attention of services
much later.”25
Burden on the workforce
Lost productivity due to alcohol is
estimated at around £7.3 billion
per year (at 2009–10 costs, UK
estimate).23 It is thought that
alcohol dependent employees
miss around 11 million working
days through alcohol per year,
with sickness absence because
of alcohol estimated at around 17
million missed working days per
year among both alcohol dependent
and non-alcohol dependent
employees.26 And that is not
counting the cost of presenteeism,
where employees may be physically
at work, but under-performing due
to the effects of alcohol.
Burden on the NHS
Alcohol-related harm is estimated
to cost the NHS in England £3.5
billion per year.2 Alcohol-related
hospital admissions have risen
year-on-year for the last ten
years.22 Of over 1.2 million such
admissions in England in 201112, more than 300,000 were for
“diseases or injuries that were
wholly attributable to alcohol
consumption or ‘alcohol-specific’”.27
The most common diagnoses were
mental and behaviour disorders
due to alcohol use; notably, there
was a 150% increase between
2002-12 in the number of people
aged 60-74 admitted to hospital
in England with mental and
behavioural disorders associated
with alcohol use.28 Meanwhile,
almost 50,000 of the admissions
were with alcoholic liver disease.27
The Chief Medical Officer has
commented that England is one
of the few EU countries where
liver disease is on the increase.29
Liver disease is now the fifth most
common cause of death in the UK,30
with alcohol-related liver disease
accounting for over a third (37%)
of all liver disease deaths.1
According to the Government’s
Alcohol Strategy, the annual cost
to the NHS of managing this could
be around £1 billion.1
9
Treatments and treatment rates for alcohol dependence
Treatments and interventions
It is important to put measures
in place to help prevent and
reduce alcohol harm, and a great
deal has already been written
on various methods of doing so.
However, until political decision
makers take decisive steps it is
likely that the need for treatment
will grow in the future.
The World Health Organization
has pointed to “good evidence that
treatment can reduce the health
burden attributable to substance
use and possibly the amount
of alcohol and drugs consumed
in a country, even if treatment
alone cannot completely solve
the alcohol or drug problem”.31
Depending on the type and severity
of alcohol dependence, a range
of effective treatments exist.
They include assisted withdrawal,
which may be managed in a
community setting, or in an inpatient or residential setting for
those who are severely dependent.
Psychological and psychosocial
interventions are provided,
such as cognitive behavioural
therapy focused specifically on
alcohol misuse. Pharmacological
interventions may also be
prescribed to help reduce drinking,
achieve and maintain abstinence,
and avoid relapses.
Both abstinence and reduction
goals should be considered as
part of a comprehensive treatment
approach for patients with alcohol
10
dependence.32 Research shows
that offering patients the option
of reduced-risk drinking “brings
patients into treatment who would
not be inclined to be treated;
[and] it engages patients into
treatment early in the course
of their disorder”.33
Similarly, the British Liver Trust
notes that offering reduced
drinking as an option may recruit
less severely dependent problem
drinkers into treatment, who
may be put off by abstinencefocused services aimed at more
dependent drinkers; at the same
time, people with more severe
dependence may also benefit
from having a range of options.30
Enabling patients to have a choice
over their treatment goals could,
therefore, contribute to narrowing
the treatment gap in England.
Under the auspices of Public
Health England, data is collected
on structured alcohol treatment
at the more specialist end of
intervention, for people with
“multiple or more severe needs”.34
In 2011-12, data showed that
51% of people in structured
alcohol treatment in England
accessed structured psychosocial
interventions, while 10% received
inpatient treatment, 11% a
prescribing intervention, 9%
structured day programmes, 4%
residential rehabilitation and 40%
interventions logged as ‘other
structured intervention’.35
Low treatment rates
Only around 6% per year of
dependent drinkers in England
receive treatment.2,3,4 In 2011-12,
there was a slight increase in
the number of people entering
specialist treatment for alcohol
problems in England, but a slight
decrease in the number who were
in treatment compared to the
previous year. Whilst it is positive
that the decrease is attributed
to the number of successful
treatment completions,2 significant
progress is required to enable
more people to receive the help
they need.
The 6% treatment rate is well
below the 15% rate regarded
as ‘medium’ level of access
to treatment according to the
North American Rush model
of access,5 which is the best
currently available benchmark.
Furthermore, the treatment rate
in England is low compared
to other countries. In 2012,
a European Commissionfunded study ranked England
fifth out of six countries in
terms of the percentage of the
in-need population accessing
specialist treatment for alcohol
dependence – below Italy (23.3%),
Spain (18.1%), Austria (11.2%)
and Switzerland (9.4%-15.6%).6
Although factors such as data
collection variations need to be
taken into account when making
comparisons between countries,
these figures nonetheless indicate
that increasing the rate of access
to treatment in England to 15%
is a modest goal.
Why are treatment rates low?
A range of factors are thought to contribute to alcohol
treatment rates in England remaining low, not least historical
underfunding compared to drug services, which impacts
on service provision and waiting times. At the same time,
there are low referral rates to alcohol dependence treatment,
which could be improved with better identification and
earlier treatment of alcohol problems. There is no single
solution, however; both supply and demand issues need to be
addressed if the treatment access rate is to be raised to 15%.
Treatment access issues
for some groups
Only around 6% of people who
are alcohol dependent in England
currently receive treatment.2,3,4
For the treatment rate to be raised
to 15%, it is also important to
understand who may be in need
of treatment but is not accessing
it. The Department of Health
has commissioned research to
examine the in-need population
in detail,36 but there are already
some indications as to who is not
receiving treatment.
For example, there is geographic
inequity in access rates to
specialist treatment services
for dependent drinkers across
England, which according to
research by Alcohol Concern range
from as low as 0.5% in Dudley to
6.4% in Ealing.10
Furthermore, some experts
interviewed for this report believe
that issues around parenting and
childcare create specific access
barriers to treatment for women,
and NICE has referred to the need
for specialist alcohol services to be
“sensitive to the particular needs of
women”.37 NICE has also discussed
the under-representation of
people from ethnic minority
groups in specialist alcohol
treatment services37 and has
noted that homeless people who
misuse alcohol may find it hard to
attend planned appointments.37
Meanwhile, specific access
barriers for older people may
include lack of transportation and
mobility problems.38
Younger people’s access to alcohol
treatment may also need to be
explored further. Between 2002
and 2012, hospital admissions
for alcohol-related liver disease
increased by 117% among under30s in England.39 Against this
backdrop, the highest levels of
alcohol dependence have been
identified in younger people –
for men in 25-34-year-olds (16.8%)
and for women in 16-24-yearolds (9.8%).40 However, “just 16%”
of people in alcohol treatment
in 2011-12 were aged 18-29.2
Although the data on younger
people who are alcohol dependent
and those who are in treatment do
not match exactly in terms of age
groups, they suggest that younger
people may be under-represented
in treatment.
With regard to levels of alcohol
dependence, there is some
anecdotal evidence from experts
that those receiving treatment
tend to be at the more severe end
of need; this indicates that, whilst
there may be some good practice
in identifying and treating lower
levels of dependence, there are
also gaps in early identification and
intervention before people become
severely dependent. Alcohol
Concern has noted a 24% rise in
the number of people in England
with moderate to severe alcohol
dependence between 2000 and
2007,40 which also suggests that
lower levels of dependence are not
being addressed at an earlier stage.
The issue of problems not being
identified early on is highlighted
by the 2013 National Confidential
Enquiry into Patient Outcome and
Death (NCEPOD) report on patients
who died with alcohol-related
liver disease. The report concludes
that there may be opportunities
for earlier intervention, which
could prevent more serious
problems developing, and
recommends alcohol misuse
screening for all patients who
present to hospital services.41
11
Improving treatment rates: supply-side barriers
Similarly, one reason why
only around 6% of dependent
drinkers receive treatment in
England is thought by NICE to
be under-identification of alcohol
misuse by health and social
care professionals, “leading to
missed opportunities to provide
effective interventions.”3 A 2013
research report also found that,
“Opportunities are also being
missed to identify and treat
alcohol dependence as early
as possible.”22
Alcohol problems are not always
obvious, however. For example,
NICE notes that the prevalence
of alcohol-use disorders
among older people may be
under-detected “because of
a lack of clinical suspicion or
misdiagnosis.”37 This is despite
an increasing proportion of
older people drinking above
recommended levels37 and
older people being “uniquely
vulnerable to alcohol problems”
because of changes related to
the ageing process.38
More broadly, the charity Adfam
explains that many people who
misuse alcohol are able to stay
in employment and continue
to function fairly normally for
“considerable periods of time”,
which “can add to the confusion
about both the existence and
severity of the problem.”42
Nonetheless, if treatment access
rates are to be improved, it is
important that alcohol problems
are identified in people who may
not be seen as having a problem
because they do not look like
a stereotypical alcoholic.
12
Underfunding of alcohol
treatment services
Alcohol treatment services have
been historically underfunded
in England compared to drugs
services. Alcohol Concern has
calculated an annual spend
of £217 million on alcohol
treatment for an estimated 1.6
million dependent drinkers –
£136 per dependent drinker.10 In
comparison, the annual spend on
drug treatment for the estimated
332,000 dependent drug users
is £436 million – £1,313 per
dependent drug user.10 It is
essential that alcohol services
receive a level of investment that
is not only comparable with drugs
services, but also proportionate
to addressing the huge burden
of alcohol dependence outlined
earlier in this report.
Limited provision of alcohol
treatment services
Given the historical under-funding
of alcohol treatment services, it is
perhaps unsurprising that NICE
views “the limited availability
of specialist alcohol treatment
services in some parts of England”
as one of the reasons why only
around 6% of dependent drinkers
receive treatment.3 Anecdotal
evidence from experts also
suggests that the provision and
capacity of treatment services
may vary across the country.
Some believe that a range of
types of alcohol treatment are
provided, whilst other experts
perceive issues regarding access
to psychosocial treatment,
detoxification and rehabilitation
services. Similarly, NICE notes
“a lack of structured intensive
community-based assisted
withdrawal programmes”,
and “limited access to psychological
interventions such as cognitive
behavioural therapies specifically
focused on alcohol misuse.”3
Waiting times
The limited provision of alcohol
treatment services means that
people wait longer to receive
treatment. Although waiting times
have improved, with 85% of people
waiting fewer than three weeks
to start specialist treatment in
2011-12, compared to 82% in
2010-11, the body which compiled
these statistics admits that “there
remains plenty of room for further
improvement.”2 Indeed, several
experts interviewed for this report
consider waiting lists to be a major
barrier to treatment access. It is
important that people are able to
enter treatment swiftly, while they
are ready to do so.
Furthermore, there are indications
that waiting times are exacerbated
by bureaucracy. With regard to
treatment for alcohol dependence,
the Government comments that,
“Service users are often frustrated
at having several assessments
before they go into treatment.”43
Dr Carsten Grimm, a GP and
clinical lead of the alcohol
treatment service in Kirklees,
notes that in some areas service
users have to “fail” in a treatment
tier before being able to access
treatment in the next tier (alcohol
treatment is categorised in Tiers
1-4, Tier 1 being the lowest).
Although the extent to which this
process is followed is unclear,
appropriate care should not be
delayed in this way.
Improving treatment rates: demand side barriers
Service integration issues
Where alcohol dependence has
been identified, it is crucial that
people are given the help they
need. However, there is anecdotal
evidence from experts that people
with both alcohol dependence
and mental health problems find
it difficult to access treatment
because neither alcohol services
nor mental health services
are willing to take them on as
patients; some people with a
dual diagnosis are understood to
have been ‘bounced’ between the
two services. The extent to which
the buck is being passed in this
way is unclear; nevertheless, an
integrated approach with clear
responsibilities for care is essential
to meet people’s treatment needs.
Low referral rates to alcohol
treatment services
Evidence indicates that there is
significant room for improvement
in the extent to which healthcare
professionals identify alcohol
problems and refer people to
treatment services. GPs and A&E
are perhaps the most obvious
‘gateway’ professionals who may
come into contact with dependent
drinkers. Yet only 1% of referrals
to specialist alcohol treatment in
2011-12 were by hospital A&E
departments, and whilst 19%
of referrals were by GPs, it is
recognised that “this is not an
especially high figure given
that around one in five people
seeing a GP drinks above lowerrisk levels.”2 A survey of GPs
in England found low levels
of motivation for addressing
problem or dependent drinkers’
alcohol issues, with busyness,
lack of training or contractual
incentives cited as key barriers.
It is also of concern that “GPs
were significantly less motivated
to work with dependent drinkers
than with problem drinkers”.44
More broadly, a range of health
and social care professionals
could help in addressing alcohol
problems. For example, Dr
Paul Richardson, a consultant
hepatologist, highlights the need
for clinicians in secondary care to
identify people who would go on
to develop severe medical and/or
social problems if action was not
taken. At Royal Bolton Hospital,
a multi-disciplinary Alcohol Care
Team has been developed to
try and reduce alcohol-related
admission; the initiative features
as a recommended example
in NICE’s QIPP Collection.45
Professionals such as staff
in medical wards, community
care, housing services and day
centres could also play a role in
recognising alcohol problems;
appropriate training would be
required to ensure they felt
confident and capable of doing so.
Indeed, NICE comments that “the
provision of care for people who
misuse alcohol is not solely the
responsibility of the agencies and
staff who specialise in alcohol
treatment. Staff across a wide
range of health, social care and
criminal justice services who are
not exclusively working with people
who misuse alcohol but regularly
come into contact with them in
the course of providing other
services also have a crucial role
to play in helping people to access
appropriate care.”37
13
Low awareness of alcohol
treatment services
Issues around visibility and
awareness of alcohol services
among healthcare professionals
such as GPs could be a barrier
to treatment access, as several
expert interviewees noted. It was
thought that reasons for low
awareness/visibility could include
the fragmented organisation of
alcohol services or even the names
of services not clearly denoting
what they do. Interviewees also
highlighted that awareness of
alcohol services among potential
service users could be a barrier
to accessing treatment. Indeed,
research confirms that a lack of
awareness about available services
may contribute to delays in problem
alcohol users seeking help.46
14
Lack of clarity around definitions
of dependence
Referral rates for alcohol treatment
could also be affected by varying
interpretations of the term ‘alcohol
dependence’; several interviewees
thought that a lack of clarity
in definitions could be a barrier
to treatment. According to the
charity Adfam, family members
have reported that their difficulties
have been compounded by a lack
of clarity among professionals,
including alcohol practitioners,
on what is meant by an ‘alcohol
problem’.42 A clear understanding of
alcohol dependence, and potentially
alcohol problems more broadly, is
fundamental in enabling people to
receive the help they need.
Stigma and readiness
for treatment
Research shows that stigma acts
as a barrier to accessing treatment
for problem alcohol users;46 this
was confirmed by several experts
who were interviewed for this
report. Dr Tony Rao, Consultant
Old Age Psychiatrist and Visiting
Researcher, commented that
stigma is even more of a problem
for older people, who may view
drinking as a moral weakness.
Furthermore, several experts note
that people with drinking problems
may feel that there is stigma
attached to using services which
also treat drug problems; the
charity Adfam has also recognised
this issue.42
Some experts note that potential
service users’ readiness for
treatment could be a barrier
to treatment, although services
are seen as responsible for
engaging people. The role of
family support in helping people
access treatment was also noted;
Joss Gaynor of Adfam explained
that families are crucial agents
of change, and that working with
the family means that they can
support the treatment process.
Why should treatment rates be increased?
Alcohol dependence imposes considerable burdens on
public health, families and wider society, as well as the
workforce and the NHS. Improving treatment rates for alcohol
dependence could, therefore, have a positive impact in all
of these areas, several of which have direct relevance for
local authority budgets.
Evidence shows that for every £1 invested in specialist alcohol treatment,
£5 is saved on health, welfare and crime costs.10 And treatment for alcohol
dependence has proven results; well over half (57%) of people exiting
treatment in 2011-12 were no longer dependent on alcohol.35 If access
to treatment was much better and there was improved identification of
alcohol problems and early intervention, the potential benefits would be
more widely felt.
Allowing treatment rates to remain low, or even to worsen, would be
a missed opportunity not only to improve the lives of individuals and
families affected by alcohol dependence, but also to tackle the associated
economic and societal costs. The potential positive impact of improving
access to treatment means that we can’t afford not to take action now.
Benefit to public health
Research shows that alcohol
dependence treatment “not only
helps the individuals affected,
but also substantially improves
public health in general.”7
The Government’s 2012 Alcohol
Strategy also notes that successful
treatment of alcohol dependence
has “been shown to prevent
future illnesses.”1 Similarly, NICE
reports that commissioning highquality alcohol services using an
integrated, whole-system approach
can increase access to evidencebased interventions, which could
improve outcomes for people, such
as better health, wellbeing and
relationships.47
Benefit to society and communities
The National Audit Office recognises the cost-effectiveness of many
interventions for alcohol misuse, and acknowledges that the cost of
providing the interventions is outweighed by ‘full social cost’ savings
resulting from lower alcohol consumption – for example, lower criminal
justice system costs resulting from a reduction in alcohol-related crime
and disorder.49 A US study highlighted by NICE in 2013 also demonstrates
that the use of alcohol treatment for people with alcohol dependence
results in a reduction in social costs;50 the study examined social costs
associated with health care, arrests, and motor vehicle accidents.51
Alcohol treatment experts have
indicated that improving alcohol
rates could have a significant
public health benefit. One NHS
Medical Director, commented that,
“The impact on public health of
improving treatment rates would
be great, for example in reducing
the stress, psychological distress,
mental health issues and chronic
illness that go along with alcohol
dependence.”
At a local level, communities could also benefit from the effects of
improved treatment rates for alcohol dependence, particularly with regard
to community safety. NICE notes that commissioning high-quality alcohol
services using an integrated, whole-system approach could improve
“quality of life for the community by reducing alcohol-related crime and
anti-social behaviour”.47
In addition, given the current
shortage of donated livers for
transplantation,48 any intervention
that decreased the need for a
donated organ would reduce the
burden of need.
The public health benefit of
increasing treatment rates is
of direct relevance for Directors
of Public Health who are now
responsible for commissioning
alcohol services.
15
Benefit to families
Joss Gaynor of the charity Adfam, which works with families affected
by drugs and alcohol, explains that, “Treatment is a real opportunity for
families to stay together and for children to stay with parents. It could and
should improve the lives of families and enable families to work together
towards recovery.”
NICE also recognises the potential benefit that alcohol treatment can
deliver for families. For example, implementing the NICE guideline on
alcohol-use disorders, which aims among other things to “improve access
and engagement with treatment and services for people who misuse
alcohol”,37 would lead to a reduction in domestic violence associated with
harmful alcohol use.8 NICE has also noted that commissioning high-quality
alcohol services using an integrated, whole-system approach could prevent
family breakdown.47
A German study has shown that alcohol treatment can also result in
families being better off financially. The study concluded that monthly
family costs which were directly related to a family member’s alcoholism
dropped from an average of £529.91 to £113.90 after twelve months of
treatment – or a reduction from 20.2% to 4.3% as a proportion of the total
pre-tax family income. In addition, there was a reduction in time spent
caring for the family member with alcohol dependence, from an average
of 32.2 hours to 8.2 hours per month.52
Benefit to the workforce
Increasing alcohol treatment rates
may also have a positive impact on
the workforce, which benefits the
economy at both local and national
level. For example, NICE states
that implementing its guideline
on alcohol-use disorders will
lead to a reduction in employee
absenteeism associated with
harmful alcohol use.8 In addition,
research by the Chartered Institute
of Personnel Development (CIPD)
shows that where employers
help staff with alcohol and/or
drug problems through referral
to specialist treatment or
rehabilitation support, over 60%
of those people continue working
for the organisation after
overcoming their problems.53
Benefit to the NHS
The Government’s 2012 Alcohol Strategy clearly states that, “Increasing
effective treatment for dependent drinkers will offer the most immediate
opportunity to reduce alcohol-related admissions and to reduce NHS
costs.”1 With each alcohol dependent person costing the NHS around £1800
per year,8 the impact of increasing treatment rates could be considerable.
Research shows that specialist treatment results in savings of almost
£1138 per dependent drinker over a six-month period. Furthermore, it has
been estimated that as many as 1,200 alcohol-related hospital admissions
could be averted “for every additional £1m invested in appropriate levels of
accessible, evidence-based treatment”.12 Meanwhile, Alcohol Concern has
called for investment in alcohol services to be doubled, which would save
the NHS £1.7billion.10
And whilst increasing the number of people who receive specialist
treatment would increase treatment costs, NICE notes that “investing in
cost-effective interventions will probably generate sufficient savings to
outweigh the additional costs of increasing the number of people that
access services.” For example, “considerable potential savings” could result
from a reduction in disease burden, with the cost of hospital admissions
which are wholly attributable to alcohol estimated at around £1450 per
person, and the indicative cost of admissions which are partially attributable
to alcohol thought to be around £1750 per person. NICE estimates that
fully implementing its guideline on alcohol-use disorders in England would
result in a saving of around £9.3 million, with estimated savings of around
£18,600 for a population of 100,000.8
16
Recommendations
Increased funding for alcohol
treatment services
Treatment access
for under-represented groups
The enormous burden of alcohol dependence
necessitates adequate funding for alcohol
treatment services. Commissioners should
“invest to save” and increase funding for
alcohol treatment services, to save both
money and lives.
Building on the Department of Health’s
work to examine the in-need population,
Health and Wellbeing Boards should
ensure that there is a clear picture
at local level of which groups of people
are under-represented in alcohol treatment,
and that any specific barriers to treatment
access for these groups are addressed.
Clear responsibility for identifying
and addressing alcohol problems
Commissioners should ensure that there
is clear responsibility around helping
people to access the care they need, from
identification of alcohol problems through
to provision of integrated care, e.g. through
clear care pathways. There should also be
responsibility for funding across the different
parts of the care pathway.
Effective screening for alcohol misuse
effective screening for alcohol misuse,
in line with the principle of “making every
contact count”, in order to identify problems
before people become severely dependent.
The Government should ensure that
NHS Health Checks, including alcohol
harm screening, are properly rolled out,
monitored for uptake and assessed for
effectiveness. Uptake of health checks
should be encouraged.
Training on alcohol issues
In order to ensure that “every contact
counts”, the Government and local
authorities should ensure that alcohol
awareness training forms part of the
compulsory training of all front line staff.
All such staff need to feel confident and
capable of screening for alcohol both
formally using a tool, and informally,
be able to develop simple tailored advice
and be aware of local referral pathways
to specialist support.
Implementation of NICE guidelines
Commissioners should ensure that
alcohol treatment services follow NICE
and other appropriate guidelines, meet
quality standards and have outcome
measures in place.
Reduced waiting times for treatment
Local commissioners and providers should
continue to reduce waiting times for alcohol
treatment, and ensure that treatment is
appropriate to the level of dependence.
Improved awareness of alcohol
treatment services
greater awareness of alcohol treatment
services among potential service users.
De-stigmatising seeking help
Public Health England, in partnership
with relevant expert voluntary sector
organisations and other stakeholders such
as providers and professional groups, should
explore options to de-stigmatise ‘seeking
help’ for alcohol problems, e.g. through
a public health campaign.
17
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THE CASE FOR BETTER ACCESS TO TREATMENT

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