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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