Research and analysis

PHE inquiry into the fall in numbers of people in alcohol treatment: findings

Published 1 November 2018

1. Introduction

There has been a fall in the numbers of people in treatment for alcohol problems in England in the past few years. Analysis of data from the National Drug Treatment Monitoring System (NDTMS) shows that the numbers of people entering treatment who were only dependent on alcohol fell from 65,110 to 52,383 between the years 2013 to 2014 and 2016 to 2017. This is a 19% fall, compared with a 5% fall in the numbers of people entering treatment for all other substance groups, including those who were dependent on a combination of alcohol and non-opiate drugs.

This fall in numbers has occurred in the context of high levels of unmet need, with an estimated 4 in 5 alcohol-dependent adults not accessing alcohol treatment. Find national and local levels of unmet need for alcohol treatment on Public Health England’s (PHE) public health dashboard.

In response to this fall in treatment numbers, Public Health England conducted a rapid inquiry in 2018 to better understand what was behind the fall in numbers of people in treatment for alcohol dependence^{[footnote ]} in England. This report sets out findings from the inquiry as well as recommendations and next steps.

Since the inquiry took place, the 2017 to 2018 treatment statistics show another fall in people entering treatment to 50,656.

2. The inquiry process

The inquiry included a ‘deep dive’ followed by a wider consultation.

The deep dive involved visits to 14 local authorities across 6 PHE regional centres, including 9 local authorities where there had been a fall in numbers in alcohol treatment and 5 where there had been an increase between 2013 to 2014 and 2016 to 2017. Local areas were selected on the basis of large changes in numbers in alcohol (but not drug) treatment, and to make sure local authorities from as many different PHE regional centres were represented in the sample.

In each area, 3 focus groups were held with:

• commissioners and providers of treatment services
• service users
• partner services

Standardised open questions were used in the meetings.

In the wider consultation, PHE centre teams had structured conversations with commissioners in 69 local authorities where there had been a greater than 10% fall in numbers in alcohol treatment during the review period. The aim was to highlight the fall in numbers, test the findings of the deep dive and identify other factors which might lie behind the falling trend.

The deep dive and wider consultation referred to an analysis of local NDTMS data and 270 stakeholders participated throughout the course of the inquiry. Most of the stakeholders said that the process had been helpful in providing a space to discuss the issues and think about solutions. This report’s findings and recommendations are based on these conversations.

3. Main findings

These findings were first identified through the deep dive and broadly confirmed by the wider consultation. With one exception, we found that there were consistent features associated with a decrease in alcohol treatment numbers. There was also a clear contrast between these areas and the areas that had seen an increase in treatment numbers.

3.1 Main findings about the fall in alcohol treatment numbers

Our analysis suggests that the context in which treatment is currently commissioned and provided, including financial pressures and service reconfiguration, has affected alcohol treatment numbers more than treatment numbers for other substances.

All services visited for the deep dive which had seen a fall in numbers had been reconfigured. In 7 of the 9 services visited for the deep dive, treatment provision had moved from several separate alcohol and drug services to one integrated substance misuse service. Within the wider consultation, 40 of the 69 areas had moved to an integrated substance misuse system. The majority of the remaining local areas (at least 23 of which were already integrated systems) reported further service reconfiguration or a reduction in service capacity and increased caseloads.

The main, but not only, motivation for service re-configuration was reduced local substance misuse budgets. All but one of the areas participating in the deep dive which had seen a fall in numbers reported budget reductions between 15% and 35%. The wider consultation confirmed this picture and cost savings were often cited as the main reason for service reconfiguration.

The inquiry gives a snapshot of rapidly changing service configurations. For example, in 4 areas we visited new service providers had been contracted since numbers in treatment had fallen and they were implementing new service models. In most of the areas, commissioners and service providers were already addressing some of the issues they had identified. In particular, they were increasing the level of staff alcohol specialism and the number of alcohol specific interventions in integrated services.

The inquiry found that alcohol treatment can be delivered effectively by integrated substance misuse services, and integration can improve cost effectiveness, streamline commissioning and service delivery, and improve treatment pathways for service users. Integration does not necessarily lead to a fall in alcohol treatment numbers, as some services which have seen an increase in numbers have shown.

But in most areas where there had been a fall in numbers, some stakeholders felt that service reconfiguration and reduced capacity had generated some unintended consequences including:

• a loss of focus on the specific needs of alcohol users
• a 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
• referral pathways and multi-agency working had become less effective

Stakeholders said that there were other factors which had contributed to the fall in numbers including:

• reduced capacity in wider local health and social care services, particularly in areas with high levels of socio-economic deprivation
• a national service provider being placed into formal administration in some areas
• poor data quality exaggerating the decrease in some areas
• the delivery of early or brief interventions preventing peoples’ problems escalating to a point where they needed treatment for dependence

3.2 Main findings about increases in alcohol treatment numbers

Among the services which had seen an increase in treatment numbers, 2 had been reconfigured to be integrated substance misuse treatment systems, 2 had already been integrated and had then undergone further reconfiguration and one was an alcohol specific service, which had also been reconfigured during the review period. Two of the 5 services where there had been an increase in numbers reported a significant budget reduction.

While 3 of the services had shown an increase in numbers from the beginning of their reconfiguration, 2 had achieved an increase in numbers following changes initiated by service providers and proactive performance management by commissioners.

Stakeholders in areas which had seen an increase in numbers described many common features, including:

• leadership commitment to alcohol treatment and a strategic approach by the local authority to alcohol harm reduction
• a commitment to service improvement, as opposed to just cost saving
• an intention by commissioners to increase numbers in alcohol treatment to meet unmet need
• commissioners working with providers to ensure alcohol-specific needs were addressed in service models and that service cultures were appropriate for alcohol users
• very accessible services, in a wide range of non-stigmatising settings and in-reach arrangements with partner agencies
• services actively promoted and clearly identifiable as being for alcohol users
• having alcohol-specific treatment pathways and interventions
• staff with alcohol specific competences and roles
• quick access to treatment (including medically assisted withdrawal) following initial contact
• a proactive, motivational and empathetic approach to engaging service users
• commissioners addressing referral pathway issues at a strategic level
• service providers maintaining good partnership arrangements, which lead to effective referral pathways

4. Issues which affected the numbers in alcohol treatment

This section has more detail about the issues which stakeholders said had affected numbers in alcohol treatment in their areas.

4.1 Good leadership and a comprehensive strategic approach to reducing alcohol harm

In all areas which had seen an increase in alcohol treatment numbers, senior local authority alcohol and drug treatment commissioners showed strong leadership and worked collaboratively with partners including clinical commissioning groups, NHS trusts, police and crime commissioners, adult social care, children’s services and housing. They described a comprehensive local strategic approach to reducing alcohol harms including licensing interventions, social marketing campaigns and promoting identification and brief advice (IBA) within health and social care services. Alcohol treatment was commissioned and developed in the context of this broader approach to reducing alcohol harms. There were multi-agency partnership meetings where a local strategic approach to alcohol treatment was developed and monitored.

In all areas which had seen an increase, commissioners had started new contracts with service providers with a clear intention to improve treatment access for alcohol users, based on local levels of unmet need. Service specifications included consistently monitored targets for the number of people in alcohol treatment, and requirements to respond to alcohol-specific needs.

Areas which had seen a fall in numbers often reported a lack of local leadership and a lack of strategic planning between local partners. However, in at least one of these areas, there were indications that strong leadership and a joint strategic approach was helping to reverse the fall in treatment numbers.

Several commissioners in areas which had seen a fall said that monitoring had focused more on operational tasks associated with service reconfiguration and on successful treatment completion, than the number of people in alcohol treatment.

Many areas which had seen falls in numbers also reported a reduction in the commissioning team’s capacity to analyse treatment data.

4.2 Addressing the needs of alcohol users within service models and cultures

In some areas which had seen a fall in numbers, stakeholders said that a lack of focus on the specific needs of alcohol users had contributed to a culture that was orientated to drug users. Examples of this included managers referring to the service as a drug service, or waiting rooms with no visible information on alcohol.

Stakeholders in several areas noted that the integrated service was delivered from the site of the former drug service and said it was still seen as a drug service locally. Some service staff reported that the majority of the clinical discussions focused on drug users. In contrast, in areas which had seen an increase, and in areas trying to address the fall in numbers, commissioners, service providers and peer supporters had taken steps to create a culture which was equally orientated to alcohol and drug users.

4.3 Prioritising opioid substitute treatment

Stakeholders in some areas said that there were not enough resources for alcohol treatment after accounting for opioid substitute treatment. Others reported that treatment for opioid users was intentionally prioritised, based on an inaccurate perception that risks are lower for alcohol users.

4.4 Accessible services for alcohol users

All stakeholder groups thought that alcohol users are less likely to access integrated services because of their own attitudes and the characteristics of the service. Users’ attitudes included a fear of stigma, preconceptions about drug users and a sense that their treatment needs were different. Service characteristics included services that people believed was a drug service, waiting rooms or buildings perceived or experienced as intimidating and services with a reputation for antisocial behaviour.

Some stakeholders felt that services were often less accessible after reconfiguration. Some services had seen a reduction in the number of satellite sites and in-reach sessions in partner agencies. Stakeholders felt that this had a greater impact on alcohol users who were more likely to attend an appointment at a local or familiar setting, than in a central service which they perceived as more focused on drug users.

In some areas the loss of outreach and home visits had affected the most vulnerable people with the highest needs. In some areas, a lack of community outreach was also thought to have affected some black, Asian and minority ethnic communities, particularly those new to the local area. Service user groups also repeatedly highlighted the social isolation experienced by alcohol users and that they were often unaware of local treatment services.

The loss of alcohol treatment sessions in GP surgeries was frequently raised. The reasons for this included reduced capacity of the treatment service to resource them, GP surgeries starting to charge for the use of rooms by treatment services and a loss of confidence or support from GPs.

Services which had seen an increase in treatment numbers said they had been very proactive in promoting their service through a range of communication methods, including through partner agencies. They used local alcohol-related campaigns and training as opportunities to promote their services. They also ensured they were easily identifiable as alcohol services.

Accessibility was a marked feature of the services which had seen an increase in numbers. They offered appointments and activities in a range of non-stigmatising settings and provided in-reach in several partner agencies. Service hubs were welcoming and well-managed.

4.5 Engaging alcohol users in treatment following initial contact

Service users said that the approach and attitude of staff was the most important feature in engaging people in treatment. Service users and alcohol specialists agreed that quick access to treatment and a proactive, motivational and empathetic engagement approach is particularly effective with alcohol users. Seeing recovery in other people and having contact with peer mentors early in treatment were also seen as important, particularly by service users. All these were common features in areas where there had been an increase in numbers.

In contrast, in some services which had seen a fall in numbers, there were longer waiting times for alcohol users than for drug users, more emphasis on self-referral and a requirement for service users to demonstrate motivation. Many services had introduced ‘pre-treatment’ or ‘pre-detox’ groups which varied in nature and duration. In some cases, service users experienced these groups as barriers to accessing treatment, and some services had stopped running them for that reason.

Managers, alcohol specialist staff and service users all felt that the loss of alcohol specialist roles and competences could stop service users engaging in treatment. Some managers said that fewer alcohol specialist staff had transferred over into new service configurations and several had struggled to recruit skilled staff, particularly nurses.

In most areas, staff were expected to be competent to treat both alcohol and drug users. Stakeholders said that without sufficient training and support, staff who were previously drug specialists were not always competent to deliver effective alcohol treatment interventions (and the other way round). Some stakeholders also felt that alcohol specialists had less time to deliver effective alcohol interventions where they were required to carry mixed caseloads. Service users said that it was very important to them that staff members who first assessed them had good understanding of alcohol harms and dependence and that this had a very significant impact on their willingness to engage with treatment.

Some integrated services had initially offered a single ‘one size fits all’ treatment pathway for all service users (except for the prescribing interventions), which they found had deterred alcohol users from engaging. These services revised their treatment pathways and interventions to improve engagement for alcohol users.

The deep dive found that 5 of the services which had seen a fall in numbers, and 2 of the services which had seen an increase, had re-introduced some alcohol specialism at the assessment and the early stage of treatment as a way of addressing the needs of alcohol users. This involved introducing alcohol specific pathways or increasing the number of alcohol specialist roles. The 2 areas which had seen an increase after making changes thought that alcohol specialism had been an important factor in achieving this. In the areas which had seen a fall in numbers, it was too early to see whether these changes would help to reverse the falling trend, but most stakeholders in those areas thought that the changes were helping to engage alcohol users.

Most areas reported that individual psychosocial interventions for people in alcohol and drug treatment had been greatly reduced or were no longer offered to alcohol users. Treatment was usually in a group work format, and some service users found this difficult to engage with at first.

While all stakeholders agreed that integrated alcohol and drug treatment and recovery groups can work well for alcohol users later in the treatment process, most thought that it was important that service users had the option of alcohol specific interventions at the start of treatment. A specialist initial phase and then integrated alcohol and drug interventions later seemed to be the preferred model of the majority of stakeholders, particularly service users.

4.6 Referral pathways

An important finding of the deep dive was that in all areas which had seen an increase in alcohol treatment numbers, there were active multi-agency partnership forums. Services in these areas were in regular contact with their partner agencies and they said that referral pathways were effective. While referral pathway problems had existed in most areas, they had been more effectively overcome where commissioners had proactively addressed them within the context of strong strategic partnerships. Some stakeholders said that implementing the Preventing ill health: commissioning for quality and innovation (CQUIN) scheme had helped to improve communication between partners and local pathways into treatment for people who were alcohol dependent.

Areas where there had been a fall in numbers more often reported an erosion of effective referral pathways. This was partly due to staff and commissioners having less time to maintain working relationships with partners, or referrers losing confidence in the service following a period of upheaval.

Many stakeholders also said that referrals from mental health services and community rehabilitation companies were low and that they had found it difficult to engage these services in partnership working.

The effectiveness of referral pathways from hospitals was a particular concern and many stakeholders reported very low referral numbers, including from hospital alcohol care teams. Some local authority commissioners and service providers said that they had found it difficult to establish working partnerships with clinical commissioning groups and hospital trusts. As a result, they found it hard to develop or maintain effective referral pathways. Following the introduction of the Preventing ill health: commissioning for quality and innovation (CQUIN) scheme PHE has produced guidance on referral pathways from NHS hospitals to community alcohol treatment services, which can be used to improve referral pathways.

4.7 Reduced capacity in local public services

Six of the 9 areas where there had been a fall in alcohol treatment numbers were areas of higher socio-economic deprivation, 3 of which were in the most deprived tenth of English local authorities according to the index of multiple deprivation. Stakeholders in those areas referred to wider social and economic factors contributing to alcohol dependence, and to difficulties in accessing treatment services and achieving recovery. Some areas reported that reduced capacity across wider public services had impacted on alcohol treatment numbers in several ways, including:

• reduced public transport in rural areas
• reduced effectiveness of referral pathways
• a reduction in joint funding and joint strategic planning

These themes were also raised in the broader consultation.

Four of the 5 areas which had seen an increase in numbers were areas where there was high socio-economic deprivation, one of which was in the most deprived tenth of English local authorities. In those areas, stakeholders talked about the impact of local deprivation on service users but said that partnership working with local health and social care services and referral pathways were still effective.

4.8 Treatment provider placed into formal administration

In several areas, local services were affected because the national service provider which was running the service was placed into formal administration before services were transferred to another provider or to local authorities. The transfer to a new service provider was time consuming and disruptive. Stakeholders felt that this had disproportionately affected the number of people accessing alcohol treatment.

4.9 Data quality

Some stakeholders in some areas thought that changes in treatment numbers may have been exaggerated due to data quality issues. It was not the remit of this inquiry to establish if this was the case.

4.10 Early intervention diverting people from treatment

Some stakeholders thought that delivering face-to-face and online early or brief interventions was preventing peoples’ problems escalating to a point where they needed treatment for dependence. It is beyond the scope of this inquiry to determine whether this is in fact the case. However, early and extended brief interventions are recommended for people scoring below 20 on the alcohol use disorders identification test (AUDIT) questionnaire, rather than those who are dependent drinkers.

If people were being diverted from treatment, local treatment data on consumption could be expected to show a reduction in the proportion of service users drinking between 1 and 199 units, and to a lesser extent those drinking between 200 and 399 units, in the 28 days before treatment entry. A significant reduction in those groups was only reported by services in one of the local areas, where stakeholders thought that alcohol users had been diverted from treatment by early intervention.

5. Conclusions

The commissioning and delivery of alcohol and drug treatment is changing rapidly and further service reconfigurations are likely to take place over the next few years, aiming to improve cost effectiveness. So it’s vital that local authorities continue to prioritise alcohol treatment.

Alcohol misuse costs society £21.4 billion each year, as PHE’s Why invest? guidance shows. Effective alcohol treatment reduces the burden on health and social care services.

There is a risk that the falling trend in the numbers in alcohol treatment will continue unless local areas ensure that their strategic and commissioning plans, service specifications and referral pathways meet alcohol-specific treatment needs. It’s also very important that alcohol treatment expertise is maintained or enhanced.

6. Next steps

National level work

1. PHE will use the findings of the inquiry to inform its work with other government departments and organisations and the PHE-hosted Alcohol Leadership Board and will highlight treatment need and the importance of adequate resources, strategic partnerships and aligned commissioning between the NHS and local authorities.
2. PHE will use the findings of the inquiry to inform the proposed government alcohol strategy due in 2019.
3. PHE has advised NHS England that the NHS long-term plan should include the development of alcohol care teams in every hospital.
4. PHE will continue to produce local and national alcohol dependence prevalence estimates and estimates of unmet need, to support local planning and commissioning.
5. PHE and the Department of Health and Social Care (DHSC) will review how services are supported to put in place evidence-based interventions recommended by the National Institute for Health and Care Excellence (NICE), including the possible need for further evidence-based guidelines.
6. PHE has published guidance to help improve referral pathways between hospitals, and community substance misuse services, and will support its implementation.
7. PHE will engage with the senior managers and clinicians of the larger NHS and voluntary sector service providers to explore actions to address the fall in numbers.

PHE support for local authorities

1. PHE will produce a briefing for commissioners and service providers on how service specifications and service models can help to meet local need for alcohol treatment.
2. PHE will develop the scenario-planning element of its commissioning tool and supporting guidance to provide more detailed information about the impact of reduced funding on alcohol treatment and how to best mitigate the impact where funding reductions are planned.
3. PHE and the Local Government Association (LGA) will explore how a sector-led improvement approach could be used by local authorities to address the fall in numbers in their areas. An explanation of ‘sector-led improvement’ can be found on the LGA website.
4. PHE will develop a tool as part of the alcohol CLeaR system improvement resources, focusing specifically on unmet need for treatment which local authorities could use as part of a sector-led approach.
5. PHE will explore the data quality issues identified in the review and work with local areas to resolve them, producing additional guidance if appropriate.
6. PHE will offer targeted support to local areas with high levels of unmet alcohol treatment need and where the numbers accessing treatment are continuing to fall, to identify ways of increasing numbers in alcohol treatment.

7. Selection methodology for the inquiry

7.1 Selection methodology for the deep dive

Local authorities where there was a fall in numbers in alcohol treatment

1. 2013 to 2014 has been used as the baseline year as that is when there was a peak in alcohol only presentations.
2. Nationally in 2016 to 2017, there had been a 19% fall in the number of alcohol only presentations since then (compared to a fall of 5% in other substances).
3. Local authorities with the largest decreases between 2013 to 2014 and 2016 to 2017 in alcohol only presentations were identified.
4. Any areas that had seen a fall of over 25% in presentations for all other substances since 2013 to 2014 were excluded, as it would be likely that the alcohol only reductions were a part of, or a byproduct of, the general fall in the number of people starting treatment.
5. Local authorities that had seen at least twice the national fall in alcohol numbers were then selected for possible investigation.
6. That gave 20 local authorities with one in each PHE centre region except in the East of England.
7. In addition to one local authority per PHE centre region listed (a total of 8), the 2 local authorities with the highest falls from the 2 PHE regional centres with the highest number of short-listed local authorities have been selected to make up a total of 10.
8. Nine local authorities (of the 10 selected) participated.

Local authorities where there was an increase in numbers in alcohol treatment

1. Local authorities with the largest increases between 2013 to 2014 and 2016 to 2017 in alcohol only presentations were identified.
2. Any areas that had seen an increase of over 25% in all other substances since 2013 to 2014 were excluded, as it would be likely that the alcohol only increases were in part a result of the overall expansion of the local treatment system.
3. Any local authorities that had seen significant reductions in alcohol presentations over the last 1 or 2 years were excluded.
4. Local authorities with small numbers of alcohol only clients were excluded as the annual percentage changes were likely to be too volatile to denote ‘real’ change.
5. This resulted in the identification of 12 local authorities that had an increase of over 10% in alcohol only between 2013 to 2014 and 2016 to 2017.
6. Five local authorities were selected from this shortlist on the basis of the highest increases and representing 5 different PHE regional centres. All 5 participated.

7.2 Selection methodology for the broader consultation

1. All local authorities which had seen a greater than 10% fall in alcohol only presentations between 2013 to 2014 and 2016 to 2017 and were not included in the deep dive above were selected.
2. 84 local authorities were selected.
3. 69 local authorities (of the 84 selected) participated.

1. In this report the term ‘alcohol dependence’ is used to describe the full spectrum of dependence, as defined by the International Classification of Diseases, 10th revision (ICD-10). This includes people meeting criteria for dependence which would not usually require medically assisted withdrawal. The prevalence, trends and amenability to treatment report published by the University of Sheffield provides information on the definition of alcohol dependence used to produce estimates for people in need of alcohol treatment. ↩