Fifty-Fourth Report - Alcohol treatment services

The Department for Health and Social Care, as the lead department, does not have sufficient understanding of total cost of alcohol harm. The harms to individuals and society that alcohol misuse can cause are well-known. Alcohol is linked to over 100 illnesses, can drive mental disorder, self-harm and suicide, and is a major cause of preventable death. The Office for National Statistics reports that in 2019–20 it was linked to 42% of all violent crime, up from 40% the previous year. Moreover, alcohol does most harm in the most deprived communities. Drinking patterns are also changing with the young generally drinking less and older people drinking more. Based on analysis dating back to 2012, the Department put the annual cost of alcohol harm to the NHS at £3.5 billion, and to wider society at around £21 billion (or around £25 billion adjusted for inflation). This analysis is over a decade out of date, and we are concerned that these estimates may not reflect the full scale of harm. The Department’s understanding of the prevalence of dependency also dates back to 2018–19. As overall owner for alcohol policy, it is for the Department to coordinate a cross-government effort to understand how and where costs are rising to inform an effective response. Recommendation 2: The Department should undertake the work necessary to improve its understanding of the up-to-date costs of alcohol harm to the NHS and wider society.

Delays by the Department in finalising the allocation of the Public Health Grant, coupled with short-term funding and reductions to the public health grant, make it difficult for local authorities to plan and commission alcohol treatment services effectively. Since 2015–16, local authorities have seen the grant 6 Alcohol treatment services they receive from central government to help fund public health services fall by £630 million in real terms. This has had inevitable consequences on funding for drug and alcohol treatment services, leaving services, “on their knees” according to Dame Carol Black (author of the government’s independent review of drugs). From 2013–14 to 2020–21, the number of adults in England receiving treatment for alcohol dependency fell by 16%. The additional £533 million of funding for substance misuse services is welcome but is short-term. Numbers in treatment have not yet recovered, but they have at least started to increase. When we took evidence, only a month before the start of the new financial year, the Department had still not awarded its public health grant for 2023–24. As we have said before, for example in our July 2022 report on the rollout of the covid vaccine, departments should always set out annual budgets and funding for their key bodies and programmes in good time. Without funding certainty, local councils struggle to recruit and retain staff and to secure contracts with third party providers. This can cause gaps in local services and pushes directors of public health to take risks by commissioning services without certainty of funding. Recommendation 3: To improve certainty around funding for drug and alcohol treatment services, the Department should: • commit to an earlier date by which it will confirm allocations of the Public Health Grant for 2024–25 and subsequent financial years; and • explain how it can provide greater long-term certainty to local authorities so they can plan and deliver the right investments to make a

We are concerned that a high proportion of people with alcohol dependency are not in treatment and that there are unnecessary barriers to people in need of treatment. Treatment services for alcohol dependency are commissioned by local authorities. They show success rates of around 60% and they deliver an estimated £3 benefit immediately for every £1 invested, and potentially far more in the longer- term. Treatment is also accessible as 98% of peopled referred to alcohol treatment services start treatment within 3 weeks. Yet 82% of dependent drinkers in England are not in treatment. The earlier people get into treatment the better, but too many people are falling through the gaps. Only 23% of people who are referred to treatment for alcohol come from health services. We heard that one of the biggest challenges is that people may not accept they have a problem in the first place as heavy drinking is normalised and public awareness of the associated harms is low. It is not only the drinkers themselves — we also heard that the healthcare workers assessing them often fail to spot early signs of problem drinking. Where people do recognise it, stigma around dependency and a reluctance to receive treatment alongside drug users can prevent them from accessing services. Given the well- established relationship between substance misuse and mental ill health, we were concerned to hear that some people are denied access to mental health services because of their alcohol dependency (and vice versa). Approximately 70% of people entering treatment for alcohol dependency also experience problems with their mental health. Alcohol treatment services 7 Recommendation 4: The Department should set out: • how it is working with local authorities to address the barriers to people with alcohol dependency from getting the treatment they need; and • what it is doing to help improve integrated care for people with co-occurring alcohol and mental health problems and to ensure that they receive

There is concerning local variation in reported spending on, and outcomes from, alcohol treatment. In 2021–22, the amount local authorities reported spending on alcohol treatment varied from £4,000 per 100,000 people to over £1 million, with median spending of £313,000. In her independent review, Dame Carol Black did not disaggregate local authority spending on drugs and alcohol because of a lack of robustness in the reported expenditure data, so these numbers, while the only figures available, will mask actual spending on alcohol treatment services. However, spending will vary according to local priorities in public health and is a decision for the local authority, so some variation is to be expected. More alarming are the local variations in both the proportion of dependent drinkers in treatment and the success rates from those treatments as these variations focus on local responses to alcohol dependency. While nationally, 82% of alcohol dependent people are not in treatment, locally authorities report treatment gaps of between 58% and 93%. It is still early days but we hope that the Department’s arrangements for focusing national efforts for health improvement through the Office for Health Improvement and Disparities (OHID), can give impetus to the uptake of alcohol treatment. Nationally, the proportion of patients successfully completing treatment is around 60%; locally, this ranges from 29% to 90%. We look to OHID to identify the exemplars and to share best practice. Recommendation 5: Working with local and national partners, the Department should: a) identify ways to increase uptake of treatment services in areas where the proportion or alcohol dependent people in treatment is lower; and b) seek to understand why success rates are particularly low or high in some areas and to identify opportunities to share best practice.

There has been a marked reduction in the size of treatment workforce, in particular, of addiction psychiatrists. Dame Carol Black’s independent review on drugs highlights that a prolonged shortage of funding has depleted the treatment and recovery workforce and resulted in a loss of skills, expertise, and capacity in the sector. This is very worrying given the marked rises in alcohol-related mortality and morbidity. Of particular concern, given the high incidence of co-occurring mental ill health and dependency, is what one stakeholder called the “dying specialty” of addiction psychiatry, which has seen the number of training posts fall from 69 in 2011 to 27 in 2019. The Department assures us that it is working with Health Education England to ensure it is training the right numbers of people though it takes a very long time to train addiction psychiatrists. In the meantime, it hopes it can boost numbers through training to allow people to switch specialty and by persuading former addiction psychiatrists to return to the profession. We welcome 8 Alcohol treatment services the Department’s ambition to rebuild the professional workforce (including psychiatrists, doctors, nurses, and psychologists) and look forward to hearing how its commitment to secure an additional 800 mental health and clinical professionals is progressing. Recommendation 6: The Department should update us on how it is progressing with the implementation of its substance misuse workforce strategy as set out in the 10-year drug strategy. Alcohol treatment services 9 1 Alcohol harm Introduction

On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) on alcohol treatment services.1 We also took evidence from Alice Wiseman, Director of Public Health, Gateshead Council, and Board Member and Alcohol Policy Lead, Association of Directors of Public Health, Professor Dame Carol Black, author of the government’s independent review of drugs, Clare Taylor representing Turning Point and Collective Voice, and Professor Sir Ian Gilmore, director of the Liverpool Centre for Alcohol Research and Chair of the Alcohol Health Alliance.

When we asked if government’s drug strategy adequately dealt with alcohol, Dame Carol told us that she thought it began to deal with it. She hoped that of the circa 50,000 new treatment places that came with her independent review, 20,000 would be for alcohol- dependent people.13 She went on to explain that it was neither enough on alcohol nor on drugs but that the aim was to demonstrate to HM Treasury that both alcohol and drug treatment services could be improved with the funding available. Sir Ian told us that alcohol treatment services had always been a priority but explained that Alcohol Health Alliance wanted an approach to tackling alcohol harm that included prevention as the most important part.14 Sir Ian told us of his career as a liver specialist that he had “spent years pulling drowning people out of the water without walking upstream to see why they were falling in”. He went on to say “if you want to make an impact, there is no doubt that you need to go upstream”. Dame Carol, Ms Taylor and Ms Wiseman also commented on the importance of prevention strategies.15

On discussing the merits of preventative measures, the Department told us that what works and does not work on alcohol was very well researched but that the right approach for some areas was highly contested. By way of example, it referenced alcohol pricing and the introduction of minimum unit pricing in Scotland, commenting that the results were 7 HM government departments, From harm to hope: A 10-year drugs plan to cut crime and save lives, 6 December 2021 8 C&AG’s Report, para 2.17 9 C&AG’s Report, paras 1.6 & 1.8, Figure 2 & 4 10 Q 2 11 C&AG’s Report, para 2.3 12 Qq 29–32; HM government departments, From harm to hope: A 10-year drugs plan to cut crime and save lives, 6 December 2021 A 10-year drugs plan to cut crime and save lives 13 Qq 1, 3 14 Qq 1, 3, 6, 20–21, 102 15 Qq 1, 4, 6, 7, 20, 21, 102, 118 Alcohol treatment services 11 unclear.16 Ms Wiseman told us that in her view the evidence on what was needed was clear and Sir Ian commented that there was “international evidence that would break the benches here with its weight”. Both told us that tackling alcohol harm needed preventative action on price, availability, and promotion.17 Understanding the cost of harm

Alcohol harm impacts not only drinkers themselves but also their families and wider communities. It is linked to over 100 illnesses, can drive mental disorder, self-harm, and suicide, and is a major cause of preventable death. The Office for National Statistics reported that alcohol was linked to 42% of all violent crime in 2019–20, up from 40% in 2018–19, and there is evidence that it does most harm in our most deprived communities with five times as many liver deaths as the most affluent communities.18 Despite rises in ill health and deaths associated with alcohol, the Department last calculated the cost of alcohol harm in 2012. At the time, the Department of Health estimated the annual cost of alcohol-related harms to be around £21 billion, broken down as: £11 billion from alcohol-related crime; £7 billion from lost productivity through unemployment and sickness; and £3.5 billion to the NHS. The Department told us it recognised that it would not be advisable to rely on this data to accurately reflect levels of alcohol harm today and that work is underway to produce new cost figures.19As with the cost of harm, the Department’s understanding of the prevalence of alcohol dependency is also out of date. The NAO’s report shows that the estimate of 600,000 dependent drinkers in England dates back to 2018–19, based on survey research from 2014.20

The NAO’s report shows that drinking patterns have changed considerably since 2012 when the cost of alcohol related harms were last calculated, with young people generally drinking less.21 The Department told us that we had also seen more liver disease over that period.22 We suggested that, 11 years on and given the change in underlying assumptions, the Department might want to update its calculation of the cost of harm. It would be helpful if decision makers had access to the exact costs of alcohol to the NHS (and more widely) to support effective decision making around an appropriate response. As overall owner for alcohol policy, it would be for the Department to coordinate a cross government efforts to do this. 16 Q 115 17 Qq 1, 3, 6, 113–118 18 Qq 5, 23, 73; Office for National Statistics, Nature of crime: violence, (Table 9a) 3 September 2020 19 C&AG’s Report, paras 1.5 & 1.11, Figure 2 20 Alcohol dependence prevalence in England - GOV.UK (www.gov.uk). The prevalence, trends and amenability to treatment report published by the University of Sheffield provides analysis and information on the methodology and sources of these estimates. 21 C&AG’s Report, para 1.4 and Figure 1 22 Q87; C&AG’s Report, para 1.5 12 Alcohol treatment services 2 Treatment services Impacts of funding uncertainty on commissioning alcohol treatment services

The Department is responsible for allocating the annual ring-fenced Public Health Grant (PHG) to local authorities each year. The PHG fell by £630 million (in 2021–22 prices), from £3.96 billion to £3.32 billion, over the period from 2015–16 to 2021–22.23 This has had inevitable consequences on funding for drug and alcohol treatment services, leaving services “on their knees” according to Dame Carol, author of the government’s independent review of drugs. Dame Carol told us that drug and alcohol services took one of the greatest reductions of all services affected by reductions in the PHG.24 The amount local authorities reported spending on drug and alcohol services fell by 27% in real terms from 2014–15 to 2021–22. Over the period from 2013–14 to 2020–21, the number of adults in England receiving treatment for problems with alcohol (and no other drugs) fell by 16%.25

We heard from Ms Wiseman that local government welcomes the additional £533 million boost to funding for substance misuse treatment services provided through the 10-year drug strategy, and that it was good to have it ringfenced. However, Ms Wiseman cautioned that it did not take them back up to previous levels of funding and that wider local government cuts have impacted other services which help people in recovery such as services providing housing and employment support. The additional funding is short- term and covers the three years from 2022–23 to 2024–25. Ms Wiseman confirmed that she did not know whether, after 2024–25, her local authority would still have money to pay for any new staff recruited during these three years.26 Government has also made smaller pots of funding available in these years to help local authorities provide specialist drug and alcohol treatment to people who sleep rough and to prison leavers. The NAO reported that the numbers of people in treatment for alcohol dependency had not yet recovered to 2013–14 levels (90,000), but did increase to 85,000 in 2021–22, 10% more than in 2020–21.27

When we asked the Department why, at 2 March 2023, it had not yet awarded its PHG for 2023–24, the Department acknowledged that it was very late but not unusually so. The Department explained that over the last three years they have allocated it on 7 February, 16 March and 17 March and acknowledged the “excellent job” local government does managing their services with the level of uncertainty that the annual budgets bring.28 We warned the Department about such delays in our July 2022 report on the rollout of the covid vaccine. In that report, we said departments should always set out annual budgets and funding for their key bodies and programmes in good time, and use supplementary estimates to manage uncertainties as they arise later in the financial year.29 We heard from Ms Taylor and Ms Wiseman that not knowing the PHG has a significant impact on 23 C&AG’s Report, paras 2.4 & 2.10, Figure 7 24 Q 13; Dame Carol Black, Independent report, Review of drugs part two: prevention, treatment, and recovery, 8 July 2021 25 C&AG’s Report, paras 2.17 & 3.2, Figure 9 & 11 26 C&AG’s Report, para2.13, Qq 56–57, 64 27 C&AG’s Report, paras 2.11–2.12, 3.2, Figure 11 28 Qq 66–67 29 Committee of Public Accounts, The rollout of the COVID vaccine programme in England, Eleventh Report of the Session 2022–23, HC 258, 13 July 2022 Alcohol treatment services 13 planning, recruiting specialist staff and workforce retention.30 Ms Wiseman told us that they can also face problems attracting providers to run the services if there is no secure funding base to offer. This can cause gaps in local services and pushes directors of public health to take risks by commissioning services without certainty of funding.31 Accessing treatment services

There is convincing evidence that alcohol treatment services are accessible, successful, and cost effective. As the NAO’s report sets out, data from the National Drug Treatment Monitoring System show that around 60% of those leaving treatment for problems with alcohol (and no other substance) do so having successfully completed treatment and that 98% of patients start treatment within 3 weeks of a referral.32 In 2018 guidance to local commissioners, providers and healthcare professionals, making the case for investment in drug and alcohol treatment services, Public Health England advised that alcohol treatment would deliver £3 return on investment for every £1 invested, totalling £26 over 10 years.33 Despite this, government analysis shows that only 18% of dependent drinkers in England are in treatment.34

When we asked Ms Wiseman what was preventing people from accessing treatment, she explained that there was a big issue with people being able to accept that they have a problem in the first place. We heard that drinking alcohol in our communities is widespread and public awareness of the associated harms very low. Ms Wiseman told us of NHS workers questioning patients about their alcohol use as part of wider healthcare assessments but failing to recognise high-risk drinking. She explained that they sometimes missed opportunities to refer patients presenting with a different condition for alcohol treatment services and suggested workforce development could help to raise awareness.35

Even once people accept they may have a problem, issues with stigma can prevent them from accessing help. For example, we heard that people often feel a sense of shame at being unable to “drink responsibly”.36 Dame Carol described the particular challenge for people early in their alcohol-dependency journeys in overcoming the stigma of attending treatments alongside a drug-dependent person.37 We heard there was some evidence that alcohol had possibly lost out to drugs as far as treatment was concerned and that a separate ‘alcohol-only’ treatment offer aimed specifically at clients with alcohol dependency could make services more accessible and encourage more people into treatment sooner.38 Dame Black suggested that GP services and outreach could be used more to deliver services.39

Most people entering treatment for alcohol dependency in England self-refer. In 2021– 22, only 23% of referrals were from health services.40 Our expert witnesses thought much more could be done to identify people early and direct them towards treatment. Ms Taylor 30 Qq 11, 65 31 Qq 64, 86 32 C&AG’s Report, paras 3.8–3.9, Figure 14 33 Q 1; Public Health England, Guidance Alcohol and drug prevention, treatment and recovery: why invest?, 12 February 2018 34 C&AG’s Report, para 3.3 and Figure 12 35 Qq 33–34 36 Q 33 37 Q 3 38 Qq 17, 20–21; C&AG’s Report, para 3.4 39 Qq 3, 7 40 Q 26; C&AG’s Report, para 3.7 and Figure 13 14 Alcohol treatment services wanted to see better partnership working across primary and secondary care to help with early identification of people drinking to excess and to ensure there are effective pathways into treatment. Sir Ian thought that alcohol care teams in hospitals were good news, noting that most patients coming into hospital would be seen and assessed. He cautioned that there was a long way to go and he feared many, particularly the most vulnerable, would still fall through gaps because the signposting to treatment, the training of alcohol workers and the links with the charitable sector were not yet good enough.41

Dame Carol, Sir Ian, Ms Taylor and Ms Wiseman all raised concerns about the relationship between mental ill health and alcohol. Sir Ian told us that an estimated 70% of people entering treatment for alcohol dependency have co-occurring mental health problems.42 The relationship between substance misuse and mental ill health is well- established yet, as Dame Carol pointed out in her report, too many people are denied access to mental health services because of their alcohol dependency (and vice versa). The Department agreed it was an incredibly difficult issue and told us it was working with NHS England on a national action plan for drug, alcohol and mental health to try to move things forward.43

Sir Ian and Ms Wiseman spoke of the cost effectiveness of in-patient and residential treatment services. We heard examples of how the lack of in-patient and residential services in some areas of the country meant patients were left either bouncing between community treatment services or having to travel long distances. Ms Wiseman told us that some areas run community rehabilitation models as an alternative which work well for some people going through treatment as they can live at home. The Department told us that £10 million of the additional funding has been ringfenced to help with the provision of these services resulting in an extra 1,800 people getting in-patient treatment in 2022–23.44 Local variations in spending, unmet need, and treatment outcomes

In 2021–22, the amount individual local authorities reported spending on alcohol treatment varied from £4,000 per 100,000 people to over £1 million, with median spending of £313,000. Three local authorities reported spending £0 on alcohol treatment services.45 In her independent review Dame Carol did not disaggregate local authority spending on drugs and alcohol because of a lack of robustness in the reported expenditure data. So the reported spending, while the only figures available, will mask actual spending on alcohol treatment services.46 However, poor data notwithstanding, spending will vary according to local priorities in public health and is a decision for the local authority.

The NAO’s report showed considerable local variation in both the proportion of dependent drinkers in treatment and the success rates from those treatments. Nationally, an estimated 82% of alcohol dependent adults in England were not in treatment in 2018– 41 Qq 2–3, 7, 26 42 Qq 2, 13, 76; ATS0003 43 Qq 76, 80; Dame Carol Black, Independent report, Review of drugs part two: prevention, treatment, and recovery, 8 July 2021 44 Qq 24–25, 81–84 45 C&AG’s Report, para 2.18 and Figure 10 46 C&AG’s Report, para 2.17 Alcohol treatment services 15 19, but local authorities reported treatment gaps ranging from 58% to 93%.47 The report showed that the proportion of patients successfully completing treatment nationally was 59% but locally, this ranged from 29% in Sunderland to 90% in Barnsley.48

While noting the variation in performance outlined in the NAO’s report, the Department told us that local authorities broadly did “a great job of commissioning public health services.” The Department told us that it had published a set of guidelines through OHID to give more help to local authorities commissioning these services. We heard that it was working hard to spread good practice and that it hoped that its focus and additional investment would improve performance across the board. The Department thought that completion rates, which had remained stable despite budget pressures, indicated that local authorities had done a very good job of maintaining quality.49 The Department explained that OHID had a budget of around £30 million to run national public health awareness campaigns. It told us that recent campaigns had included obesity, smoking and mental health and gave the example of the beginners’ running campaign, Couch to 5k, as one that had been very successful. The Department noted the success of campaigns around smoking and said it did not think the public had as clear an understanding around alcohol harm. We were told that choosing where to spend the budget for public health campaigns was a decision for Ministers.50 Treatment workforce

Dame Carol’s independent review on drugs highlighted that a prolonged shortage of funding and frequent retendering of treatment services had led to a high turnover of staff and depletion of skills. During the session, Dame Carol explained that the number of addiction psychiatrists, psychologists, nurses and social workers in the field had fallen significantly.51 Given the well-established links between mental ill health and alcohol, experts were particularly concerned about what Sir Ian described as the ‘dying specialism’ of addiction psychiatry.52 In its written evidence, the Royal College of Psychiatrists (RCPsych) told us there has been a 58% fall in the number of trainee places for addiction psychiatrists from 64 in 2011 to 27 in 2019. RCPsych said that chronic staff shortages and a disconnect between services mean many patients were not getting the care they need.53

The Department acknowledged the fall in clinical psychiatrists and mental health practitioners and agreed that services needed access to the full set of professionals.54 The Department noted that it had already committed to securing an additional 800 mental health and clinical professionals in the drug strategy.55 It assured us it was working with Health Education England on a workforce strategy to set out training requirements and focus on attracting professionals back into these roles. The Department told us it would ensure it is training the right numbers of people but recognised that this training 47 C&AG’s Report, para 3.3 and Figure 12 48 C&AG’s Report, Figure 15 49 Qq 79, 100–101 50 Qq 108–112 51 Q 10; ATS0003 52 Q 2; ATS0003 53 ATS0003 54 Qq 103, 125 55 Q 27; HM government departments, From harm to hope: A 10-year drugs plan to cut crime and save lives, 6 December 2021 16 Alcohol treatment services takes a very long time.56 In the meantime, it said it was looking to make it easier for people to specialise in addiction psychiatry later on in their training by adding additional modules and was also looking to persuade former addiction psychiatrists to return to the profession.57

The Department assured us that, as part of its monitoring activity, it would be looking closely at the numbers of people employed. We heard it was keen that the additional funding (£533 million) serve to reintroduce health professionals into treatment services, including clinical psychiatrists and mental health practitioners. The Department said that it had agreed a set of plans with local authorities and thought it had good visibility on performance which it said should give it confidence.58 Ms Taylor told us the extra funding was helpful but cautioned that it was difficult to build up specialist staff without stable funding.59 56 Qq 27, 106, 125–127 57 Q 127 58 Q 103 59 Qq 11, 103, 106, 125 Alcohol treatment services 17