Head of Quality and Governance for NHS APA members Inclusion, Kieran Doherty, reflects on the latest ONS alcohol data from an alcohol treatment perspective.
This is not a good news blog. There is no positive twist coming at the end. The fact is that the outlook remains grim in regard to alcohol treatment and that there is no evident plan to address the issues that have led to this ongoing rise in alcohol-related deaths.
The recent Office of National Statistics (ONS) alcohol mortality statistics of 7,565 deaths related to alcohol in the UK in 2019 will not come as a surprise to anyone with an interest in alcohol from a Public Health perspective, or indeed anyone working in the alcohol treatment field.
The Alcohol Change Report in November 2018 highlighted that UK Alcohol deaths had increased by 11 percent between 2006 and 2017. And, as these latest figures show, it has increased once again. Given what we know about drinking patterns so far during the coronavirus pandemic, according to the Alcohol change UK survey, there is little reason to be optimistic that these numbers will do anything other than increase.
However, deaths are only one part of this bad news story as we must also acknowledge the wider health and societal impact of alcohol on morbidity, families, and criminal justice.
So as things stand the outlook is grim, but why have we ended up in this situation in regard to alcohol treatment?
Alcohol treatment services in the UK have been decimated by decisions made on how services are funded and commissioned. Moves to competitive tendering and the brutal reductions in local authority budgets mean that alcohol services have been squeezed to near extinction. The changes to local authority commissioning in the context of reduced budgets and the consequent move to commissioning integrated Substance Misuse services rather than separate alcohol and drug treatment services has led to alcohol treatment becoming the Cinderella service within the Cinderella service, which is addiction.
"From an alcohol perspective we have lost both capacity and skilled specialism."
There are a number of direct consequences as a result of this. Firstly, from an alcohol perspective we have lost both capacity and skilled specialism; there are less people now, both with and without professional qualifications, who describe themselves as alcohol workers or specialists. This includes Community Support Workers, Recovery Workers, Counsellors, Social Workers, Nurses, Medics and Psychologists.
The Dame Carol Black report confirms that “a prolonged shortage of funding has resulted in a loss of skills, expertise and capacity across the substance misuse sector”. This has undoubtedly been more acute in the alcohol field where this skills and capacity drain has been catastrophic.
To give context to this when I first started in the alcohol field in 1988, I worked in a community alcohol team. The service had one day a week of a Consultant Addiction Psychiatrist; three days from a specialist staff grade Doctor; a full-time Psychologist; six Community Nurse Specialists and administrative support. We worked as part of an alcohol network with a shopfront homelessness service, a residential alcohol service and a women’s alcohol centre. We were networked into general and psychiatry provision and had working links with social care services, probation, and mutual-aid networks.
We were located close to the community drug service and jointly worked when required. I appreciate that services nationally even then were patchy and that we are unlikely to see the likes of this again. However, things should be better than they are now.
Given the above, there is clear evidence that the number of people entering treatment for primary alcohol problems has dropped significantly. The PHE Enquiry in November 2018 looked into the fall in numbers accessing alcohol treatment and indicated that between 2013 and 2017 there was a 19 percent drop in people entering specialist alcohol treatment.
Services are also seeing people with alcohol problems present with increased complexity, and fewer non-dependent or low-dependent drinkers. This increasingly complex patient cohort means that not only are we dealing with more acute cases, but we are also missing early intervention with low and non-dependent drinkers. Early intervention is going to be vital in reducing alcohol-related deaths.
This report also highlighted that one of the reasons that people with alcohol problems don’t access services is that they believe that services are essentially drug-dependency based services with often a lack of alcohol specific treatment pathways or specialist workers.
Commissioned Specialist alcohol services are now a rarity. Community alcohol teams; Councils on Alcohol; Alcohol counselling services and regional alcohol treatment units have disappeared almost entirely in the UK over the past 20 years.
Whether you agreed with what was offered by these services is not the point. Overall capacity and alcohol specialism has been stripped out both in community services but also in “in patient” provision.
"If we are going to address alcohol needs and reduce morbidity, mortality, and social impact we will need a well-trained and supervised workforce delivering evidenced-based interventions."
Thankfully, mutual aid services continue to provide a clear and consistent offer to people with alcohol problems. However, while mutual aid should be an important integrated element of provision, it should be in addition to commissioned services not in place of commissioned services.
If we are going to address alcohol needs and reduce morbidity, mortality, and social impact we will need a well-trained and supervised workforce delivering evidenced-based interventions. Look at Improving Access to Psychological Therapy (IAPT) services; every single worker has done a designated training course and works to clear treatment protocols based on NICE guidance. Workers are well-trained and well-supervised in that they receive both clinical supervision and case management supervision.
The alcohol and wider addiction field needs a clear workforce strategy with minimum standards with regards to the disciplines needed, training requirements, and supervision. If it can be done in IAPT why can’t it be done for alcohol and drug treatment services? We should have a national IAPT project: Improving Access to Alcohol Treatment.
The PHE guidance, published in February 2018, on alcohol and drug prevention, treatment and recovery: why invest? estimates the social and economic costs of alcohol related harm amount to £21.5 billion while harm from illicit drug use costs £10.7 billion. PHE estimate that there is a £3 return for every £1 spent on alcohol treatment.
We know that alcohol treatment is cost effective; we also know what works from a treatment perspective. The impact of lack of investment and inconsistent commissioning means that it is just not delivered in a consistent and systematic way.
"The alcohol and wider addiction field needs a clear workforce strategy with minimum standards with regards to the disciplines needed, training requirements, and supervision."
For a start, there should be a minimum standard for the commissioning of alcohol treatment services in each area irrespective of what form of commissioning was in place.
If I were to design an alcohol service, it would have a number of key elements including:
An open access referral system with both phone referrals and a dedicated website which offers self-screening, referral and access to online interventions both for brief interventions and for relapse prevention.
All workers will have a qualification or be working toward a qualification and have supervision and case management.
Workers in the service linked to primary care supporting GPs and other practice staff to do brief interventions and provide support to those who require episodes of brief treatment.
Workers to be attached to general hospitals providing support both within A&E departments and across the various wards to ensure support and pathways for people with alcohol problems who end up in hospital.
Similar clear pathways with secondary care inpatient and community mental health services.
The services will deliver specialist addiction talking therapy provision that includes time limited interventions including psycho-education, goal setting, problem solving and relapse prevention.
The service will be trauma informed and there would be pathways to IAPT for ongoing treatment for depression, anxiety, PTSD, and so on.
The service will offer detoxification for those with an alcohol dependency. This would include advice on alcohol reduction regimes; medication assisted community detoxification and a pathway for inpatient detoxification.
There will be pathways to support local authority services, linking with safeguarding and developing joint working protocols.
Similarly, there will be links with criminal justice services, housing providers and homelessness services again with joint working protocols.
In conclusion, let me be clear there is no obvious light at the end of the tunnel, the cavalry is not coming. When I expressed my frustration at the rise in deaths with colleagues in the field I was greeted with “well, at least we have the Carol Black review”. And much as I welcome the Carol Black review and fully agree with everything I have seen from it so far, as far as I am aware it does not cover alcohol.
“Well, there is the £80m in additional monies that has been announced.” Again alcohol was not explicitly in its remit.
“Well, there is a new alcohol strategy coming.” The proposed national alcohol strategy was due in 2019. It is now 2021 and, in reality, there is no indication that it is coming anytime soon.
To undo some of the damage that has been done to provision of specialist alcohol treatment, both a substantial change in commissioning and a significant funding uplift with a clear plan to rebuild a skilled workforce is required.
There are services who provide very good, accessible, and innovative offers to their alcohol clients. However, it appears that these are the exceptions rather than the rule.
Pending a change in national strategy I would encourage all services to work with commissioners on consolidating and strengthening alcohol pathways and building the alcohol skills of their staff.
I can see nothing that suggests there is intent and desire in government to commit to a change in strategy with associated funding. With the current pandemic and the ongoing Brexit project that is unlikely to change soon.
So, within services let’s continue to do what we can with the resources we have. Being flexible, being innovative, listening, putting people at the centre of what we do, while supporting those individuals and bodies that lobby for change in regard to the commissioning and funding of alcohol treatment with the hope that, at some point, there is a coordinated plan to address this Public Health scandal.