Public Health England.
Public Health England, 2014.
In England a record 114,920 adults were in specialist alcohol treatment in 2013/14 and nearly 4 in 10 left as planned free of dependence. A good record, but probably still most dependent drinkers who might have benefited from treatment did without it, partly because relatively few found their way there via GPs and emergency departments.
Summary The featured report presents and comments on data from the National Drug Treatment Monitoring System on adults (aged 18 and over) who received specialist treatment for alcohol problems in England between 1 April 2013 and 31 March 2014. This account draws on the data source as well as the featured report. For the treatment of under-18s see this analysis instead.
Headline findings were that, compared to last year, more people were in treatment during the year – up from 109,683 to 114,920, the highest number since this figure was first published 2008/09. The total included slightly more who initiated treatment during the year (for the first time or returning), up from 75,773 to 80,929, again the highest since 2008/09 chart. These numbers should be set in the context of estimates that 1.6 million people in England may have some degree of alcohol dependence, of whom 250,000 are moderately or severely dependent and may benefit from structured alcohol treatment.
Despite the increase in numbers entering treatment, 93% of people waited under three weeks for it to begin, up from 89% in 2012/13 and continuing the steady improvement since 2008/09.
43,530 patients successfully completed treatment, continuing the steady upward trend since 2008/09. Of these, 58% were not drinking at all when they left. 38% of all patients in treatment at some time during the year successfully completed it, continuing the yearly increases from 26% in 2008/09. Of all treatment leavers, successful completers constituted 59%, also up steadily since bottoming at 48% in 2009/10. In contrast, the proportion of patients who ‘dropped out’ of treatment was (as in the previous year) 26% of all those leaving, down from a peak of 33% in 2009/10.
In 2013/14, 70% of all people in alcohol treatment were aged 30 to 54 and nearly two-thirds (64%) were men. Despite the general growth in the caseload, as a proportion of the total and in numbers, 18–24-year-olds have become less prominent, numbering 4768 in 2013/14 after falling each year from a peak of 6328 in 2009/10.
At 42% of all entrants during the year, self-referral was the most common route to treatment. Next at 17% was referral from primary care surgeries. Referrals from hospital accident and emergency departments accounted for just under 2% of all treatment entrants, 1268 patients.
2013/14 was the first full year for a new classification of the settings patients were treated in and the type of interventions they received there. Some individuals will have been treated in several settings and/or received several types of interventions. 101,782 drinkers equating to 89% of all in treatment during the year were treated in non-residential community settings, including day programmes and services offered by community drug and alcohol teams. Nearly all these patients were recorded as participating in psychosocial therapies such as cognitive-behavioural therapy or motivational interviewing and (usually in addition) 16% were prescribed medications. Prescribing was near universal in inpatient units, which offered assessment, stabilisation and/or assisted withdrawal to 8885 patients, about 8% of all the total number in treatment. GPs treated 4948 patients and 3903 were treated in residential rehabilitation centres.
The data for 2013/14 indicates that the alcohol treatment system in England is performing well. However, a challenge remains to ensure alcohol treatment services are accessible and appropriate. While the system has absorbed increased numbers, commissioners face a greater challenge to maintain these gains while improving outcomes from the system and making sure all who need help are steered towards treatment.
Short waiting times demonstrate that it is easy for people with problems to access specialist treatment, and the data shows this treatment is effective – people who seek specialist help do get better.
Treatment is one important component in the range of responses to alcohol-related harm. Other parts of the system need to rise to the challenge of harmful alcohol use. The NHS has a key role in reducing alcohol-related harm – for instance, by improving the availability of alcohol care teams so they can seize the opportunities that emergency department attendances and hospital admissions present to engage people and encourage them to change their behaviour. Similar opportunities need to be grasped at any point in the social care and criminal justice systems to help people address the effect of harmful alcohol use on themselves and others.
The continuing challenge for local authorities and their strategic partners will be to ensure a coordinated strategic approach to the interventions that are proven to prevent and address alcohol-related harm, ie, licensing, health-improvement messages, hospital alcohol services and specialist treatment, remembering that is everybody’s business to change attitudes and behaviour to reduce alcohol harm.
commentary One of the concerns of this and previous years’ reports was that while those receiving treatment are doing reasonably well and progressively better, many who might benefit from treatment do not receive it. Depending on the criteria, England’s performance in ensuring problem drinkers enter treatment can look anywhere from poor to excellent. Explained in this hot topic entry, treatment can be seen as capturing numbers equivalent to just 7% of harmful drinkers up to a creditable 40% or more of those also at least moderately dependent. The lower figure can be justified as the percentage of all those who might benefit from treatment, the higher as perhaps closer to those likely to need extended and structured treatment to sustainably overcome their dependence. The report seems to limit the need for or benefit from structured treatment to the 250,000 drinkers in England it says are at least moderately dependent, but there is an argument for extending briefer forms of structured treatment – sometimes seen as extended brief interventions – to dependent drinkers further down the severity scale.
Another reason why the gap between need and access to help is not as large as it appears is that structured specialist treatment is not the totality of support available to problem drinkers. But whatever its dimensions, figures from Scotland suggest the gap might be narrowed much further; there it seems the proportion of possibly dependent drinkers who enter treatment is over three times the figure in England.
One reason for the treatment–need gap is what – in its last report on alcohol treatment before being absorbed by Public Health England – the National Treatment Agency for Substance Misuse (NTA) saw as the low numbers successfully referred to specialist treatment by GPs or accident and emergency departments, despite estimates that one in five patients seen by GPs is drinking at risky levels, and that 35% of emergency attendances are alcohol-related. An ambition for the coming years was “that these two key routes will become more active in identifying and referring people who need treatment”.
If there was cause for concern in 2011/12, there is more cause now. Referrals from GPs fell from 14,330 in that year to bottom at 13,541 the following year, only partially recovering to 13,864 in 2013/14 chart. From 22%, since 2008/09 the proportion of all treatment entrants accounted for by GPs seems to have fallen each year, ending at 17% in 2013/14. Accident and emergency department numbers and proportions are both up, but from a very low base, peaking in 2013/14 at 1268 patients equating to 1.6% of all referrals, still a small proportion of the potential. From a peak of 15,900 in 2009/10, in 2013/14 these two sources accounted for 15,132 treatment starts in 2013/14; as a proportion of all treatment starts, the trend has consistently been down from 23% in 2008/09 to 19% in 2013/14. Almost uniformly in what the NTA would see as the wrong direction since figures became available, these trends suggest screening and intervention rates and/or quality in these two prime settings for identifying dependent drinkers have yet to approach their potential.
In contrast, hospitals – identified as a referral source only since 2011/12 – have since then rapidly increased their referral rates by 46% to account for 4711 patients, perhaps aided by the widespread deployment of alcohol liaison nurses.
The record of hospitals and the surge in self-referrals to treatment – up by almost a quarter over the three years since 2011/12 – suggests that trends in GP and accident and emergency department referrals are not due to any diminution in the demand for treatment. It could however be that some self-referrals were prompted by advice, information, screening and brief interventions conducted in surgeries and departments and in other settings.
Thanks for their comments on this entry in draft to James Morris of the UK Alcohol Academy. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 20 December 2014. First uploaded 12 December 2014
DOCUMENT 2013 Alcohol treatment in England 2012–13
DOCUMENT 2013 Alcohol treatment in England 2011–12
REVIEW ABSTRACT 2009 Continuing care research: what we have learned and where we are going