Alcohol Policy UK

Statistics for alcohol treatment in England 2013-14

Public Health England (PHE) have released annual alcohol treatment figures in England for 2013-2014. PHE say the 'treatment system is working well' with total numbers, recovery rates and waiting times all improving.

Headline findings include:

• 114,920 adults (18 and over) received alcohol treatment in 2013-14, up 5% from 109,683 the year before
• 80,929 adults started treatment during the year, up from 75,773 in 2012-13
• 93% of people waited less than three weeks to start treatment, up from 89% in 2012-13
• 43,530 people successfully completed their treatment, up from 40,908 in 2012-13

Other key findings include:

• A further 34,237 clients in adult treatment cited alcohol misuse as an adjunctive problem to a range of other primary problematic substances
• Clients’ median age starting treatment was 43, and 64% of clients in treatment were male
• Most clients were white British (87%) with no other ethnic group accounted for more than 3% of clients in treatment with a primary substance of alcohol
• 42% of clients starting treatment were self-referrals and 17% were referrals from GP’s. Onward referrals from other substance services accounted for 7%. Referrals from the criminal justice system accounted for 7%
• Where reported, 4% of clients had an urgent housing problem (NFA) on presenting to treatment; a further 10% had other housing problems

See here for the full report, PHE commentary, statistical bulletin and tables.

Whilst numbers in alcohol treatment have been on a small upward trend since the first national report in 2010, the total number represents less 10% of those with some level of alcohol dependency (depending on population estimate). However most drinkers who develop some level of dependency will not access treatment and will recover without any formal help. However in 2010 Alcohol Concern highlighted the significant gap between investment in drug versus alcohol treatment, and more recently warned of the impact of the commissioning changes on local services.

The figures are taken from the National Drug Treatment Monitoring System (NDTMS). See recent years alcohol treatment statistics here or the first national treatment statistics report 2008-09, which recorded 100,098 in treatment.

PHE, who have assumed responsibility for alcohol treatment from the former National Treatment Agency for Substance Misuse (NTA), last year released updated JSNA guidance to support drug and alcohol treatment delivery. Comprehensive NICE alcohol guidance is also available including Public Health Guidance for local authorities.

PHE sets out alcohol priority in 'evidence to action' plan including call for minimum pricing

Public Health England (PHE) has published its 7 priorities for the next 5 years, with 'reducing harmful drinking' listed after action on smoking and obesity.

Download 'From evidence into action: opportunities to protect and improve the nation’s health' [pdf]

The document highlights PHE's role in actioning change to address 'an epidemic of largely preventable long-term diseases' amid a growing burden on the future of the NHS.

PHE says it has 'looked to the evidence to identify where we should focus our efforts', which involves both promoting healthier behaviours and mobilising support for broader action on improving the public’s health.

Public support is seen as particularly relevant in terms of minimum unit pricing (MUP) which public opinion appears split over. PHE says it will continue to set out the evidence base for MUP and also look at the potential of including public health as a fifth licensing objective. 

Under its alcohol priority section, PHE says over the next 18 months it will:

• use alcohol as the trailblazer for a new whole system approach that establishes what works and is clear on the return on investment, enabling government, local authorities and the NHS to invest with confidence in evidence based policies, prevention and treatment interventions
• produce an independent report for government on the public health impacts of alcohol and on evidence-based solutions
• produce a framework on liver disease outlining public health actions to tackle liver disease, including alcohol
• expand the Longer Lives web tool to include indicators on alcohol treatment and recovery, and to identify variations in performance
• launch Liver Disease Profiles [see here] to support local authority health and wellbeing boards to understand liver disease and its risk factors in their area and, in turn, design effective local population level interventions
• continue to set out the evidence base for the introduction of a minimum unit price for alcohol
• consider the evidence for the inclusion of health as a licensing objective

 

PHE, Government & alcohol policy

PHE's current year priorities had only outlined a limited specific focus on alcohol, and also identified alcohol as a 'low priority' within its social marketing plans. Of course PHE have supported local action with the updating of the Local Alcohol Profiles and the recent Liver Disease Profiles, and have taken over the former NTA's remit around substance misuse treatment - see national alcohol treatment data here.

A PHE Alcohol Self-Assessment Stocktake tool is also available to support local strategy and PHE have been involved in the Local Alcohol Action Areas, though no public reports from these so far.

Beyond PHE's work, the controversial Responsibility Deal has been the main focus of Government alcohol policy given the minimum pricing u-turn. With the upcoming general election next year, the 'APPG' parliamentary group recently released a manifesto urging political parties to adopt ten key alcohol policies. A leaked report earlier in the year suggested Labour will be committing to MUP.

Recent Findings alcohol bulletins: training requires follow-up, motivational interviewing, implementing new therapies, mindfulness effective supplement, IBA & more

Recent bulletins from the drug and alcohol bank:

Post-workshop follow-up helps retain therapy training gains

Selecting key research and reviews for the drug and alcohol treatment matrices revealed that this review from 2005 remains a unique and valuable resource. It concludes that retaining psychosocial therapy skills after the popular workshop training format requires follow-up consultation, supervision or feedback. Rather than simply dispatching staff to one-off workshops, the implication is that services must invest much more to be confident the investment will pay off for clients.

Learning motivational interviewing: coach, don’t just train

The first review to amalgamate findings on training clinicians in motivational interviewing for substance use problems finds training does develop competence, especially when reinforced by supervision or coaching feeding back trainees’ actual performance. There may be no need for initial training to be face-to-face; books and videos can do as well.

Implementation of new therapies will fail unless tailored to the organisation

Detailed, frank and compelling account of what it takes in the real world (when implementers have to grapple with counsellors and organisations over which they have no control) to introduce a new therapy programme for problem substance use. Key lesson is that each organisation is different: being there, learning about that unique context, and taking it in to account, is what’s needed to give implementation a chance

Mindfulness therapy effective supplement to usual treatment

Promising signs – but from a single study at a single treatment agency – that integrating Buddhism-inspired mindfulness elements with CBT creates a more effective supplement to usual (in the US context) 12-step based aftercare than a purely cognitive behavioural approach, helping patients sustain gains from initial intensive treatment.

Do brief interventions work in real-world trials?

The probation arm of the largest such study yet conducted in Britain found that the proportion of offenders drinking at risky levels fell just as much after a terse warning as after a structured brief intervention – an example of the lack of impact of brief interventions in trials which approximate real-world practice?

New evidence on protecting vulnerable youngsters

Britain’s National Institute for Health and Care Excellence assesses new evidence relevant to its public health guidance on interventions to reduce substance misuse among vulnerable young people. Highlights include a study showing that intensive community nursing support for disadvantaged expectant and new mothers can have a long-term preventive impact on smoking, drinking and cannabis use by their children.

'Alcohol and childhood don't mix' - DrinkWise call for more action to protect children

Drink Wise North West have launched a campaign aiming to highlight the impact of alcohol on children and actions that should be taken. As part of the campaign DrinkWise have released a report and film clips warning that the normalisation of alcohol is 'teaching our children to drink'. 

Read the report 'Alcohol and childhood don't mix' [pdf] here. Its key findings state:

• 15 children are ending up in hospital every day because of alcohol – hundreds as young as 11
• 2.1 million children in England are affected by other people’s drinking
• 250,000 children suffer mental distress due to others’ drinking
• 170,000 children are neglected because of others’ drinking 
• 10-15 year olds view more alcohol ads on TV than adults over the age of 25
• Alcohol is 61% more affordable today than in 1980 – children drink more when alcohol is cheaper
• Children who are exposed to a lot of alcohol advertising, are more likely to drink heavily and to start drinking at an earlier age
• By the age of 15, 44% of girls and 39% of boys have already been drunk at least twice
• Children in the UK drink more and start drinking earlier than most other European countries

The issue of alcohol and young people remains a high profile policy area despite an overall downward trend in children and young people's drinking since 2003 - though the UK remains above the European average for prevalence and likelihood of binge drinking.

Alcohol Concern and others like Balance North East have been campaigning for tougher regulation on alcohol advertising. Last year Drinkaware warned against parents being drunk in front of their children and other issues include access to alcohol over the internet and questions over the impact of school based alcohol education.

See here for a Joseph Rowntree Foundation report Young People, Alcohol and Influences. Further alcohol-related reports and guidance related to children and young people can be found here on the Alcohol Learning Centre, including the CMO guidance. See here a post on IBA for young people and all Young People tagged Alcohol Policy UK posts.

Liver disease profiles highlight alcohol's role in premature deaths - time for a national strategy?

New liver disease profiles have been released by Public Health England (PHE) detailing the local and regional impact of liver disease. PHE highlight liver disease is the only major cause of mortality increasing in England, despite it decreasing in Europe. Liver deaths in England increased 40% between 2001 and 2012.

Alcohol specifically accounts for 37% of all liver disease deaths, although over 90% are due to one of the three main risk factors: alcohol, viral hepatitis and obesity. One in ten people who die in their forties die of liver disease, whilst 90% of people who die from liver disease are under 70 years old.

The profiles however highlight stark disparities across England, largely reflecting health inequalities. Blackpool has the highest death rate among men with 58.4 deaths per 100,000 as the North West and North East top the regions, as shown by a recently published regional map of alcohol-related liver disease.

A PHE blog by Professor Julie Verne on preventable liver disease highlights

• Over a decade the number of people dying with an underlying cause of liver disease in England rose by 40% from 7,841 to 10,948
• Most liver disease deaths are from cirrhosis (a hardening and scarring of the liver) or its complications – people die from liver disease at a young age with 90% under 70 years old and more than 1 in 10 in their 40s
• Liver disease is the third biggest cause of premature mortality and lost working life behind ischaemic heart disease and self-harm
• Most liver disease is preventable – only about 5% of deaths are attributable to autoimmune and genetic disorders
• It’s a disease of inequalities. People who live in the most deprived fifth of areas in England are more likely to die from liver disease than those who die in the most affluent fifth.
• Liver disease, and death from it, is associated with stigma mainly because of the risk factors. This sometimes makes it hard for the patients to access care and hard for the families especially in bereavement
• 70% of patients with liver disease die in hospital...

A 'national liver strategy'?

Change4Life 2012 campaign warns of alcohol effects

Earlier this year a report from the all-party parliamentary hepatology group said the Government's failure to tackle rising liver disease was a scandal resulting in a "shameful waste of lives". The group called for minimum pricing and action to ensure better care coordination and early identification. In 2013 a review of patients who died with alcohol-related liver disease by a patient care and death review group also called for improvements in alcohol brief intervention (IBA), access to treatment, alcohol care teams and improved hospital pathways.

In 2009 the Department of Health said it would deliver a National Liver Strategy to combat the rise of liver disease. By 2012, more reports indicated it was soon coming, but never appeared. Of course a liver strategy would need to reflect a number of areas being led on by PHE, and recognise health inequalities - something set out in the Public Health Outcomes Framework. Health groups though will continue to argue real longer term outcomes will also depend on action on price, availability and marketing of alcohol and junk food.

PHE are working to produce a framework outlining its scope of activities to tackle liver disease led by Professor Julia Verne. In her PHE blog she writes:

The challenge will be significant. Liver disease develops silently and obvious signs and symptoms may only appear when changes are irreversible, therefore the identification of people with risk factors for liver disease in primary care is a critical first step in the pathway.

See reports in the Telegraph, Guardian, and BBC and here for more about alcohol-related liver disease (ARLD).

Alcohol Concern's 'alcohol harm map' says 10 million alcohol-related NHS contacts a year

Alcohol Concern have released an updated version of its alcohol harm map and says total alcohol-related NHS contacts hit almost 10 million in England during 2012-13. Although rising alcohol-related hospital admissions passed one million in 2010, the 10 million figure includes around 2.7 million outpatient and 6.3 million A&E visits.

The alcohol harm map allows the user to click on a region and select a local authority or CCG area to identify various data on local alcohol misuse. This includes population prevalence, hospital costs, alcohol-related deaths and other conditions. 

The data is drawn from a number of sources, mainly Hospital Episode Statistics (HES) which also inform the 'attributable fractions' data set used by the Local Alcohol Profiles for England (LAPE). NHS data bods might note 'admissions' are usually only used to describe actual hospital ward admissions, not A&E attendances. Of course describing each admission or visit as a 'contact' as we have done may be less than ideal since most admissions or visits are likely to include multiple staff contacts.

The alcohol harm map was produced in partnership with the pharmaceutical company Lundbeck Ltd, makers of the drug Nalmefene. See here for more information on the alcohol harm map data set, or see the annual Statistics on Alcohol for England 2014 report for the ONS take.

Alcohol numbers - tricky business?

Identifying exact alcohol figures for alcohol to the NHS and wider society is complex territory. £21 billion is often quoted as the total cost, with NHS proportion estimated at £2.7 billion, though this stemmed from a 2004 Cabinet Office analysis. Critics often point out that overall consumption has been falling since 2004, but alcohol-related admissions have continued to rise as a lag effect from previous decades of rising consumption.

Alcohol Concern Chief Executive Jackie Ballard said the NHS was "now facing an intolerable strain from alcohol-related illnesses" and that "we need to ensure adequate alcohol care pathways are prioritised and appropriate services are put in place to ease this burden." She also called for minimum pricing as the "the first and most effective" action the Government can take to prevent alcohol misuse.

See reports from the Telegraph, Daily Mail and Sky. See all Alcohol Policy UK reports relating to stats and figures here. 

Minimum pricing would be '50 times' more effective than below cost ban as Scotland continue to fight EU battle

Minimum pricing Vs Below Cost Ban

The Sheffield Alcohol Research Group (ScHARR) have published new research comparing the impact of Minimum Unit Pricing (MUP) with the current below cost ban. Published in the BMJ, the analysis estimates a 50 pence MUP would have approximately a 50 times greater effect.

In England a 'below cost ban' recently came into place as an MUP substitute following the Government's u-turn, but ScHARR have estimated just 0.7% of units sold are likely to have been affected. It is also unclear if any retailers have actually adjusted any retail prices following the ban, although some staff discounts on alcohol have reportedly been stopped.

On why MUP would have such a greater effect the paper states:

'[For MUP] a greater proportion of the market is affected and to a greater extent and this is especially true for harmful drinkers. It is this more specific targeting of harmful drinkers that sets the minimum unit pricing policies aside from for example general price or tax increases across the board.

The Independent picked up on the news by highlighting the missed opportunity to save lives - the analysis suggests the below cost ban will only prevent 14 deaths and 500 hospital admissions in England each year, compared to saving 624 deaths and 23,700 admissions annually from a 45p MUP.

Earlier this year ScHARR also published work which is said shows MUP is a targeted measure, as it would have negligible effects on low income moderate drinkers’ alcohol consumption and spending, therefore would not 'punish responsible drinkers'. Further work by Sheffield recently suggested supermarkets subsidise tax increases on the cheapest drinks to keep customers attracted in store.

Of course the modeled impacts of MUP have often been questioned by opponents. ScHARR have however also published a mathematical description of the alcohol policy analysis model.

Scotland's minimum pricing battle: SHAAP Brussels report  

SHAAP (Scottish Health Action on Alcohol Problems) have published a briefing Alcohol Policy in Scotland: Proceedings from Brussles event [pdf] following a recent meeting over Scotland's current battle to implement MUP.

The briefing contains articles by a range of health roles and industry roles, as well as an explanation of the current position by Donald Henderson, Head of Public Health Policy, Scottish Government. He explains Scotland are 'in the middle of a process where member states have to submit observations' [following the current appeal stage] and that 'sometime next year we will have both an Advocate General opinion and possibly the full court’s opinion and response'.

 

SHAAP are campaigning for people to sign in support for Scotland's Alcohol Minimum Pricing legislation.

News & updates Sept 2014: liver disease maps and drink data, alcohol and young people, 'hugger mugger' warnings, breathalysing on the door & more

Selected media stories since the August roundup:

Alcohol data

The Huffington Post picked up on regional information about alcohol-related liver disease published by the Health & Social Care Information Centre. It highlights areas of the North West and North East of England have the highest rate of emergency hospital admissions for alcohol-related liver disease in the country. 

Global alcohol consumption data published by WHO has been used to create an interactive online map showing per capita consumption of wine, beer and spirits by country. 

The Spirits Business reported on new National Diet and Nutrition Survey data on Scots drinking compared to the rest of the UK. Meanwhile, industry figures criticised recent council reports that include “flawed” data that amount to “meaningless propaganda”, according to the Morning Advertiser.

Alcohol and young people

The Morning Advertiser reported that almost 90% of 18-24 year olds agree that education on the effects of alcohol should be integrated into the National Curriculum. Mentor UK's 'ADEPIS' has produced a number of resources for schools, including a toolkit for helping schools review their alcohol and drug policies.

Research reported in the Telegraph suggests students will spend more than £200 on alcohol and getting into bars and clubs during their first week of University. Meanwhile Manchester University claims its new NUS Alcohol Impact scheme has already attracted interest from 'other institutions wishing to get involved' in trying to create a 'social norm of responsible alcohol consumption among students' - our recent analysis of the scheme here.

Meanwhile a Drinkaware poll reported in the Journal, found that nearly a quarter of parents admitted to supplying their own children with up to nine units of alcohol in one sitting. However, parents in Wales are over-estimating the number of young people who drink alcohol, according to Alcohol Education Trust research reported on ITV.com.

300 young people were referred to an alcohol intervention in Durham in Operation Aries - a crackdown on underage drinking over the summer that also saw 200 litres of alcohol confiscated; 80% was purchased by adults, reports the BBC. More here.

Parental drinking habits can affect children before they are born: new research claims that children of mothers who drink as little as four units of alcohol in a day even once while pregnant are at greater risk of developing mental health problems, reports the Guardian.  See more on this from NHS Choices.

Police Alcohol Harm initiatives

In Plymouth, officers have started breathalysing offenders arrested for alcohol related offences. By aiming to ascertain their level of intoxication, police were attempting to identify repeat alcohol related offending, reported the Plymouth Herald. The BBC reports that pub and club goers are to be breathalysed before being allowed into night time venues in Loughborough.

ACPO launched a week-long campaign from 19 September highlighting the realities faced by those dealing with drunkenness and alcohol-related incidents. Police chiefs such as in Worcestershire and Darlington, supported the campaign.

Devon and Cornwall Police kicked the campaign off by tweeting every incident dealt with by officers in the force area overnight on the Friday and Saturday on Twitter to raise awareness of the issue (see @DC_Police #alcoholharm). The last two tweets give a flavour:

Before we say good night, we hope you can see dealing w/ #alcoholharm at weekends has a significant impact on communities & police resources. 

Friday final figures were 43 in custody and 374 incidents between 8pm-3am. Saturday we have 59 in custody and 493 incidents.

Greater Manchester Police tweeted videos of 'hugger mugger' incidents (see video), where drunk people are vulnerable to being robbed during apparently friendly encounters.

Also..

Holidaymaker's insurance claims for accidents are being rejected due to drinking in some cases - but insurers have come under pressure from the Financial Ombudsman Service (FOS) who said it expected a "high standard of proof" that the amount consumed made a policy invalid. See BBC report.

Nalmefene (Selincro) NICE approval prompts debate over "pill" to reduce alcohol problems

Debate over the use of Nalmefene (Selincro) has opened up following NICE draft guidance which says it should be available as an option for some dependent drinkers. Nalmefene is the first drug available intended to help eligible problem drinkers cut down, whereas existing NICE approved medications are licensed for use to support abstinence.

Below we explore some key considerations for the alcohol field in the wake of the recent attention and forthcoming full NICE guidance on Nalmefene.

Understanding 'alcohol dependency' in a treatment context

Some of the debate stems from poor journalism or misunderstanding around the use of the drug and in particular, alcohol dependency itself. Whilst many people perceive alcohol dependency only in terms of 'alcoholism', recognising a spectrum of dependence ranging from mild to severe is favoured by most addiction experts.

Most people with alcohol problems though, including mild or even moderate dependency, are usually a long way from common ideas of the 'alcoholic'. This causes challenges such as barriers to early recognition of 'alcohol problems' or acceptability of interventions and support. The concept of a 'pill to help reduce drinking' therefore seems controversial given a common belief that 'all "alcoholics" need to go for abstinence'.

However, alcohol services reflecting NICE treatment guidance will support those with alcohol dependency to aim for reduced drinking if they chose to do so. Evidence of some dependent drinkers returning to non-dependent drinking does exist, albeit less severely dependent drinkers seem more likely to achieve this (and multiple factors will be influential).

What this means for Nalmefene?

Nalmefene is therefore aimed at 'mildly dependent' drinkers, whilst those with severe dependence (i.e physically dependent) and those with other complicating factors are not eligible. One further complication is the measures used in the research trials to define eligible drinkers. The studies identify those qualifying as having a sufficient 'Drinking Risk Level' (DRL) when having a significant score on the Severity of Alcohol Dependence Questionnaire (SADQ) and drinking more than:

• 5 units in a drinking day if female
• 7.5 units in a drinking day if male

In addition to fulfilling a criteria for dependence, drinkers in the trials were advised to cut down and had not reduced two weeks later to be eligible (but many did). Yet some media headlines inferred anyone drinking 'two glasses' of wine was being lined up for the treatment - see this example from the Telegraph. However most media reports also highlighted some of the concerns or considerations voiced by addiction or public health specialists. In particular, concerns over an expectation that it is the pill alone that 'works', when there is only evidence to support its use alongside psychosocial support. One of a number of issues previously explored here in this guest post.

Dr Niamh Fitzgerald, Lecturer in Alcohol Studies at the University of Stirling, has also highlighted other areas for consideration. In this Science Media Centre article, she cautions over 'what the introduction of Nalmefene will mean in practice'. The studies informing the NICE approval were conducted with people recruited through specialist services, not those visiting their GP. There is therefore a gap in evidence for its use in Primary Care settings where efforts to implement simpler psychosocial approaches such as IBA have been mixed at best.

Other public health roles highlighted the role of environmental factors in addressing alcohol misuse. Policies such as minimum pricing, or tighter controls on availability or advertising which don't require NHS spending on medications and would reach a broader group of harmful drinkers. Other questions such as the nature of pharma funded trials and the various policy implications have been raised in relation to Nalmefene.

Whilst a consensus may be that Nalmefene could be a 'helpful option' for certain problem drinkers, there may be significant efforts needed to ensure it is used only as intended - for instance only alongside psychosocial support, for properly eligible drinkers and in tested settings. Calls to further study its use and effects therefore seem well warranted.

Latest from the IBA blog: Are GPs doing enough?; IBA in non-health settings; 5 insights for alcohol interventions; IBA for young people? Primary Care case study

The alcohol IBA blog was set up to promote understanding and the delivery of IBA through news, links and ideas on IBA. 

Recent posts are highlighted below:

• Should we ease off GPs not doing alcohol IBA (properly)? Primary Care is the key setting for IBA...but.. is there any point in organising good IBA training, resources and pathways if there’s no interest in taking them up? .. read more here.

• Delivering alcohol IBA in non-health settings? In this guest post Dr Fizz Annand takes a quick look at recent research exploring alcohol brief intervention as ‘IBA’ in non-health settings...read more here.

• Mind the credibility gap: 5 insights to give ‘binge drinking’ public health interventions more punch  In this guest post John Isitt reports on some of the key lessons learned from local work to reach at-risk drinkers beyond IBA... read more here.

• IBA for young people: a promising picture?  A common question about IBA is ‘does it work for young people?’ – a straightforward answer isn’t easy, though we are getting closer...read more here. 

• IBA Primary Care case study: a rare new example A new case study provides a rare but valuable insight into a local effort to properly implement IBA and supporting pathways into a busy GP practice.. read more here.

The blog also has specific 'About IBA' and 'IBA tools' pages and also aims to highlight other resources such as INEBRIA and the Alcohol Learning Centre IBA pages.

Please get in touch if you have any IBA projects or ideas to share.