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.
OBVIOUS ANSWERS
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 alcoholonly
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 metneed
versus total-need fraction. For
numbers in treatment to be falling
when there is some hard-to-pindown,
but perhaps substantial,
degree of unmet need suggests
something is increasingly going
wrong in access to treatment for
problem drinking in England.
Mike Ashton is co-editor of Drug
and Alcohol Findings, www.findings.
org.uk
WWW.DRINKANDDRUGSNEWS.COM
SEPTEMBER 2020 • DRINK AND DRUGS NEWS • 9