What proportion of England’s problem drinkers are actually in treatment? And are increasing rates of unmet need the result of austerity-driven funding cuts? Mike Ashton investigates.
It matters, because the more of the in-need population we treat, the smaller the alcohol-dependent population and the less the related harm. Drug and Alcohol Findings conducted an examination for England in 2014 when the figures were most reliable (see https://findings.org.uk/ for the full story and references).
Then, about 112,000 drinkers were in specialist treatment. We found rationales for this representing just 7.5 per cent of harmful or at least mildly dependent drinkers, and up to 43 per cent of those who score in surveys as at least ‘moderately’ dependent. In between was a 19 per cent estimate based on a formula constructed for the Department of Health. This aimed to exclude drinkers who, despite a high risk to health, scored as non-dependent in surveys, but to include lower-risk drinkers dependent enough not to remit, even after an extended brief intervention.
The population in need of treatment becomes constricted further if we take into account whether prospective patients actually want or intend to take a treatment route to curbing their drinking, and/or are making what to them seems a rational choice to continue to drink to excess.
Could do better
Though the question of what proportion of the in-need population is in treatment has several answers, what seems sure is that England could be doing better – not least because Scotland seems to be treating proportionately three times as many of its problem drinkers. An estimate for Leeds is that raising treatment access to that level would cut the alcohol-dependent population by nearly a fifth over five years, and save a further 65 lives.
Since 2014, however, things seem to have got worse (Fig 1). Initiated in 2010, the government’s austerity policies are prime targets for the underlying reason why alcohol treatment numbers have been falling despite sustained levels of need – the chart shows numbers falling consistently since 2013-14. The highest line is the number of patients whose presenting substance use problems included alcohol, the lowest those with alcohol as their sole presenting substance use problem. In between are actual or estimated numbers of patients treated primarily for their drinking problems, the basis for the calculations above.
These figures must be married with trends in estimated treatment need to assess whether need is increasingly failing to be met. The methodology which yielded the 19 per cent estimate for 2014 has been used to estimate the alcohol-dependent population in England from 2010-11 to 2017-18. In 2017-18 the estimate was just 1.6 per cent lower than in 2013-14, yet over the same period the patient caseload fell by about 17 per cent – from equivalent to just over 19 per cent of the in-need population to 16 per cent (see chart). The drop was within margins of uncertainty, but was consistent each year from 2013-14. With a presumed substantial pool of unmet need, even if there had been no fall in the proportion of the in-need population being treated, a diminishing caseload would still have been of concern.
Another statistic used to indicate need for treatment is hospital admissions of patients diagnosed with mental or behavioural disorders due to drinking (Fig 2).
As with the alcohol-dependent population, the treatment caseload as a proportion of admissions has fallen each year since 2013-14, from about 32 per cent to 22 per cent in 2018-19, suggesting that treatment has been capturing smaller and smaller proportions of the in-need population since austerity took hold.
So concerned were Public Health England (PHE) at the ‘fall … in the context of high levels of unmet need’ that in 2018 they mounted an inquiry. It spotlighted ‘financial pressures and service reconfiguration’, but also made it clear that the prime service-reconfiguration suspect – integration of alcohol with drug services – was itself mainly driven by ‘reduced local substance misuse budgets’. This change is said to have led to a defocus on alcohol and a less specialist response to problem drinking, as well as possibly deterring drinkers from services which looked and felt like they were for drug users.
For one well-informed commentator, the time for PHE’s cautious pointing to austerity was past: ‘Some in the field may feel the answer is obvious – continued cuts to treatment budgets (put at 26 per cent for adult and 41 per cent for youth services) have inevitably led to less resources and a changing landscape with very few alcohol-only services remaining, described as a “crisis” in alcohol treatment.’
These views and that of PHE’s inquiry were reinforced by an Alcohol Change UK survey of alcohol services and allied professionals in England in 2017. Key findings were that most respondents could not say there was sufficient local access to these services, and that the main reason was the funding squeeze. The same year a survey of substance use services in England warned that ‘the capacity of the sector to respond to further cuts has been seriously eroded’. Instead of targeting the ‘comprehensive and high quality services’ needed to actualise the government’s recovery agenda, providers were now concerned about being able to maintain the basics of safety and quality.
Need and demand
Austerity might increase unmet need by obstructing the main routes for converting need into demand for and entry into treatment (Fig 3). That this has been at least partly the case was suggested by a report on alcohol treatment in England in 2011-12 from what was the National Treatment Agency for Substance Misuse (NTA). It was concerned at how few people had successfully been referred to specialist treatment by GPs or A&E departments, despite the fact that around one in five people seeing a GP is drinking at risky levels and about a third of emergency attendances are alcohol-related. If there was cause for concern then, there was even more later: from a peak of 15,900 in 2009-10, by 2013-14 these two sources accounted for 15,132 treatment starts of people primarily treated for their drinking; as a proportion of all treatment starts, the trend was consistently down from 23 per cent in 2008-09 to 19 per cent in 2013-14 (see chart).
Since 2014-15 reports instead record patients with alcohol problems unaccompanied by problems with use of illegal drugs – the ‘alcohol-only’ caseload. However, the trends described above continued. The concurrence between the raw numbers (black lines) and the percentage these represented of all new referrals (orange lines) shows that GPs and A&E departments were not just referring fewer and fewer patients in absolute terms, but also relative to other referral sources. By 2018-19 these accounted for just 12 per cent of all new alcohol-only referrals compared to 23 per cent of patients with a primary alcohol problem in 2008-09.
In the end, PHE’s grounds for concern seem a stronger foundation for policy responses than attempts to assess the met-need versus total-need fraction. For numbers in treatment to be falling when there is some hard-to-pin-down, but perhaps substantial, degree of unmet need suggests something is increasingly going wrong in access to treatment for problem drinking in England.