- For a significant and growing number of people in England,
alcohol consumption is a major cause of ill-health. More than 10
million people (31 per cent of men and 20 per cent of women) are
now regularly drinking above the guidelines set by Government, and
many of these are likely to suffer ill-health or injury as a
result. Hospital admissions for the three main alcoholspecific
conditions (alcohol-related liver disease, mental health disorders
linked to alcohol and acute intoxication) more than doubled in the
11 years between 1995-96 and 2006-07 from 93,459 to 207,788,
although this is in the context of a general rise in admissions of
about a third over the same period. There were 8,758 deaths from
alcohol-related causes in the UK in 2006, twice as many as there
were 15 years before.
- The Department of Health (the Department) estimated in July
2008 that alcohol misuse costs the health service in the order of
£2.7 billion per year. Such misuse also imposes wider costs on
society, such as crime and disorder, social and family breakdown
and sickness absence. The total annual cost of alcohol misuse to
the UK economy has been calculated by the Cabinet Office at up to
£25.1 billion.
- The World Health Organization has identified four levels of
alcohol misuse, which the Department uses in its alcohol strategies
and guidance. These range from ‘hazardous’ drinking (above
recommended limits), through to ‘severely dependent’ alcohol
misuse, which requires intensive specialist treatment
(Figure 1).
Figure 1 ("The range of
alcohol treatments and interventions") is unavailable in
this version of the executive summary.
In England, it is estimated that 18 per cent of the adult
population (7.6 million) are drinking at ‘hazardous’ levels;
another seven per cent (2.9 million) are showing evidence of harm
to their own physical and mental health, including approximately
1.1 million people who have a level of alcohol addiction
(dependency). The health service offers different types of services
for these groups, ranging from simple measures to provide
information and raise awareness to acute clinical or mental health
interventions for severe cases.
- Dependent drinking can have many causes, including family
history, psychological factors such as anxiety or depression, the
addictive pharmacology of alcohol, and the environment in which
people live. For others who drink alcohol above the guidelines, at
‘hazardous’ and ‘harmful’ levels, alcohol misuse may be due to
habit, lifestyle, lack of awareness of the health effects and an
absence of obvious symptoms.
- The Department has in recent years emphasised the importance of
prevention and public health measures, particularly in the
Choosing Health White Paper (2004) and in Lord Darzi’s
review of the future of the NHS, High Quality Care for All
(June 2008). In keeping with that aim, there has been a National
Alcohol Strategy in place since 2004, aiming to encourage a more
sensible drinking culture and reduce the burden of alcohol harm on
society and the economy. In 2007 Government reviewed progress and
set out the next stage of its National Alcohol Strategy in the
report Safe. Sensible. Social, led jointly by the
Department and the Home Office. The Strategy emphasises the
importance of early interventions such as ‘brief advice’
(see below), which have been shown to reduce
alcohol consumption by people who are drinking more than sensible
amounts, but have not developed a dependency on alcohol.
Brief advice
‘Brief advice’ is the term used for short, structured advisory
interviews, provided when questions about a patient’s drinking
habits have identified that there is misuse. The advice is provided
by a ‘competent practitioner’ such as a GP, nurse or trained
non-medical professional, in about five to ten minutes. Typically,
the advice given includes the risks a patient is running by
drinking too much, setting goals to reduce alcohol consumption, and
providing written materials such as advice leaflets. Brief advice
has been shown to be effective in reducing hazardous and harmful
drinking, as well as being cost-effective. In September 2008 a new
Directed Enhanced Service was announced, providing an additional
incentive of £8 million for GPs to undertake identification and
brief advice with newlyregistered patients. This will begin in
April 2009.
- Beyond the immediate health benefits to individual citizens, a
greater focus on prevention also means that the costs of later,
often more complex treatment are avoided, providing important
savings to the NHS. By supporting early interventions on alcohol
misuse, such as ‘brief advice’, the Department and the National
Health Service (NHS) may avoid or reduce the costs of later, more
intensive and specialist support for people who develop dependency
or suffer from an alcohol-related illness.
- In April 2008, for the first time, alcohol misuse became the
subject of a cross-departmental Public Service Agreement (PSA),
with the Department of Health a partner in delivering the new PSA
25 on alcohol and illegal drugs, led by the Home Office. The PSA
will be monitored annually until 2011 and includes a performance
indicator for the Department to bring down the rate of increase of
alcohol-related hospital admissions. In turn, the Department is
encouraging the local NHS commissioning bodies, Primary Care Trusts
(PCTs), to include this indicator in their operational plans.
- In this context, the National Audit Office has undertaken a
study to evaluate:
- the arrangements for planning and commissioning health services
for alcohol misuse (Part 2);
- measures to prevent alcohol misuse, and to identify misusers
and provide them with simple advice and help (Part 3);
- specialist services to treat misusers who are dependent on
alcohol, including those who have a serious or longstanding
dependence on alcohol (Part 4).
- The report focuses on alcohol misuse and on health services,
based on data gathered in early 2008. It concentrates on the role
played by the NHS and its partners in delivering on the hospital
admissions indicator of the PSA. The report excludes other
influences and policy areas which impact on the PSA, such as those
that affect the availability of alcohol (such as pricing and
promotion, taxation and licensing) or which deal with crime,
disorder and other social effects.
- The report focuses on England. The administrations in Scotland,
Wales and Northern Ireland are separately responsible for health
issues, and have responded in different ways to the differing
patterns of alcohol harm in their countries (Appendix 3). In
Scotland, where alcoholrelated harm is higher than in England,
there are plans to invest approximately £120 million in tackling
alcohol misuse over the three financial years from 2008-09. In
Wales, a new strategy for tackling substance misuse, including
alcohol, was launched on 1 October 2008. A Northern Ireland alcohol
strategy was published in 2000 and a further strategy document
covering alcohol and drugs was published in 2006.
Main findings
The current state of services
- PCTs are now responsible for setting their own local health
priorities, but our survey found that a quarter had not accurately
assessed the alcohol problems in their area. Without such
assessments, PCTs cannot know what services they should be
providing, and cannot assess whether the services they commission
are sufficient or cost-effective. All PCTs have ready access to the
data held in the Local Alcohol Profiles for England, which are
generally acknowledged to be the most reliable data available on
local need, but around 20 per cent of PCTs do not make use of them,
and around a quarter of PCTs surveyed for this report had not
carried out their own local needs assessment for alcohol in the
last few years. Since April 2008, however, PCTs are required to
undertake together with local authorities a formal assessment
(Joint Strategic Needs Assessment) of the future health and
wellbeing needs of the local population as the basis for planning
future services.
The role of primary Care trusts in
addressing alcohol harm
PcTs are responsible for determining local health priorities and
have control of the majority of NHS spending. PcTs are free to
decide for themselves how much to spend on services to address
alcohol harm. They have no specific requirement to provide any
alcohol-specific services, but since April 2008 they have been able
to choose to include an indicator for alcohol-related hospital
admissions in their operating plans. PcTs and other local bodies,
in particular Drug and Alcohol Action Teams, may commission a range
of treatments and services to address alcohol harm from various
providers, including GPs, hospitals and mental health trusts,
voluntary and private organisations.
-
Many PCTs do not have a strategy for alcohol harm, or a clear
picture of their spending on services to address it. Some 58 per
cent of the PCTs responding to our survey had an alcohol strategy
and 69 per cent were able to provide details of their expenditure
on alcohol services. Where spending was known, it showed PCTs spent
an average of £600,000 on commissioning alcohol services in 2006-07
(including, for example, the provision of brief advice from GPs,
weekly alcohol clinics, or more involved specialist treatments).
This expenditure represents a little over 0.1 per cent of a typical
PCT’s total annual expenditure of around £460 million. The wider
general cost to the NHS of dealing with the consequences of alcohol
misuse, ranging from the cost of ambulance services to acute
surgical procedures such as liver transplants, is estimated by the
Department to be in the order of £2.7 billion annually.
-
PCTs have often looked to their local Drug and Alcohol Action
Teams to take the lead in commissioning services to tackle alcohol
harm, but these bodies focus primarily on specialist services for
dependent users of illegal drugs and alcohol. They are not equipped
to meet the needs of the much larger groups of ‘hazardous’ and
‘harmful’ alcohol misusers. The 2004 National Alcohol Strategy
recommended that local Drug Action Teams should be encouraged, but
not required, to extend their remit for commissioning and
delivering treatment services to cover alcohol misuse for adults as
well as drugs misuse (which includes under-age alcohol misuse). In
2004, around half of Drug Action Teams offered both drug and
alcohol services. That figure has since increased to 81 per cent.
Illegal substance use, however, remains Teams’ overriding concern
with their main source of funding (a budget of £385 million in
2006-07) ringfenced for that purpose. Furthermore, many Drug and
Alcohol Action Teams do not have the direct links with or
experience in primary or acute (hospital) care to commission
effective alcohol interventions in these areas.
Drug and alcohol action teams
These Teams are local partnerships of professionals from local
authorities and other public bodies such as PcTs, the police,
probation service, and from private and voluntary sector providers.
Their role is to address drug and alcohol problems in the local
area and they plan treatments and commission services from a range
of providers in all sectors. Drug and Alcohol Action Teams are
accountable primarily to the local partnerships of which they are
part and evolved from Drug Action Teams. There are 149 Drug Action
Teams and Drug and Alcohol Action Teams in England. In many areas
Drug and Alcohol Action Teams have merged or work closely with
community safety or crime reduction partnerships.
- Local provision of specialist services is not based on a good
understanding of communities’ needs and there are wide variations
between localities. There is also much scope for better integration
of hospital services with follow-on and support services, such as
psychiatry or self-help groups, to improve recovery rates and
prevent patients relapsing into their previous drinking
patterns.
On the costs and benefits of programmes to address alcohol
harm
-
The available evidence suggests that simple, often early
interventions such as identification and brief advice can bring
substantial savings by reducing the need for more intensive
treatment later. Locally, however, opportunities to identify and
advise people who are drinking above sensible levels are not being
fully exploited. Alcohol screening questionnaires and the provision
of brief advice offer a quick and effective means of identifying
and engaging with those who are drinking above the guidelines but
who may not realise the damage they are doing to their health.
There is evidence indicating the cost-effectiveness of such
interventions (Appendix 6). However, identification and brief
advice is only sporadically provided by GPs and health workers, and
rarely used in other parts of the health service, such as accident
and emergency (A&E) departments where those suffering from the
consequences of alcohol misuse are often present.
-
More specialist treatments, even though the cost is higher than
for brief advice, have also been shown to be cost-effective, since
they can also reduce the high costs of treating serious
alcohol-related diseases. For example, specialist counselling and
detoxification can reduce alcohol consumption, and may prevent
liver damage worsening to the point where a liver transplant,
typically costing £80,000, is needed. The Department recently
commissioned an online system to collate details of local
alcohol-related initiatives throughout England, known as the ‘Hub
of Commissioned Alcohol Projects & Policies’ (HubCAPP).
However, the programme is still in its infancy and its details have
still to be communicated widely.
- Since 2006, the Department has sought both to clarify its
guidance on sensible drinking and to promote public health, through
a series of new publicity campaigns. Research showed that the
Department’s guidelines are not fully understood by consumers, who
tend to underestimate the amount of alcohol that their drinks
contain. In response, the Department has funded a further campaign
to raise public awareness of alcohol units in drinks, which started
in May 2008. The public health campaigns (‘Know Your Limits’),
which were initially aimed at binge drinking and will cost the
Department more than £6 million in 2008-09, have followed good
practice guidance for such publicity work. The Department did not
set measurable goals for the intended impact of these campaigns but
aims to continue to track reported consumer awareness and behaviour
change.
The new Public Service Agreement
-
The new PSA performance indicator on alcoholrelated hospital
admissions gives PCTs an incentive to address alcohol harm, but it
has limitations and carries risks. While the indicator will measure
alcohol harm and its consequences for the health service, it may
not act as a clear incentive to PCTs to provide, for example, brief
advice. Evidence suggests that the indicator will be responsive to
provision of specialist services and early interventions (although
it is also sensitive to other policies such as programmes to
restrict availability and to reduce alcohol-related crime and
disorder, which are not covered by this report).
-
While the majority of PCTs have chosen to include the new
alcohol-related performance indicator in their operating plans, or
in a Local Area Agreement, more than a third have not. In areas
with relatively low levels of alcohol harm and more pressing health
priorities it may be appropriate for PCTs not to adopt the
indicator, but such decisions need to be based on sound evidence.
PCTs’ operating plans and Local Area Agreements are the direct
means by which the Department can influence action locally on
alcohol services and secure progress towards the PSA. As a positive
development, almost all (46 of 50) of the PCTs showing the highest
rate of alcohol-related hospital admissions, have included the new
indicator in their operating plan and for many of these (32), the
indicator is also included in the corresponding Local Area
Agreement. Where Local Area Agreements do not include the alcohol
indicator even though it is in the PCT’s operating plan, PCTs will
have to work harder to gain local partners’ support for work such
as the promotion of sensible drinking.
- Regional oversight of the NHS’s response to alcohol misuse has
to date been limited. The creation of a new network of Regional
Alcohol Offices in autumn 2008 aims to strengthen the influencing
role of Strategic Health Authorities and Regional Directors of
Public Health and to provide opportunities for sharing best
practice between PCTs. The Department has committed £2.7 million
per year for three years from 2008-09 for Regional Alcohol Offices
with dedicated Regional Alcohol Managers, to support commissioners
in delivering the PSA. Regional Directors of Public Health will
assess whether planned activity is both realistic and reflects
local need, and will check performance by PCTs against local
targets annually.
Conclusion on value for money
-
Where they could provide a figure in response to the NAO survey,
PCTs reported spending on average approximately £600,000 on
services directly intended to address and reduce alcohol harm. Some
PCT expenditure will be on services such as brief advice, which are
judged generally to be cost-effective; although PCT expenditure on
alcohol services as a whole cannot be comprehensively demonstrated
to be so. Overall, therefore, there is scope to secure better value
for money from PCT expenditure on alcohol services, which is not
usually based on a clear picture of need or of the likely results.
Our survey found that local strategies are lacking, or inadequate,
in many areas and service delivery is fragmented, with resources
allocated based on an incomplete picture of need. Service provision
has, as a consequence, varied widely, both in type and degree of
provision.
-
The new PSA indicator on alcohol is a way of encouraging local
NHS organisations to focus on alcohol harm. The adoption of the
indicator locally is, however, optional. Therefore, the indicator
has no direct accompanying sanctions or rewards for PCTs. However,
the Department does plan to publish benchmarking information on all
PCT performance indicators, including the alcohol indicator,
annually.
-
There is evidence, however, that well-planned and targeted
services can produce results which are good value for money. With
an increased emphasis placed by the Department on the promotion of
public health, NHS trusts need to understand how to translate this
wider objective into practical, well-evidenced resourcing
decisions. The evidence base on cost-effectiveness will be
strengthened by forthcoming studies, including a study of brief
interventions – the Screening and Intervention Programme for
Sensible drinking – commissioned by the Department, and the
National Institute for Health and Clinical Excellence (NICE) review
of prevention, early identification and clinical guidelines for the
management of alcohol misuse. The resulting recommendations are due
to be published in 2009 and 2010 respectively, providing the NHS
with additional tools to understand the relative cost-effectiveness
of different services to reduce and prevent health harm from
alcohol misuse.
Recommendations
- The contribution of the NHS and its partner organisations to
measurable progress relies primarily on the actions of PCTs. Our
evidence suggests that, to date, PCTs’ planning and commissioning
of health services to reduce alcohol harm have not been tailored to
local needs. In 2009, at the end of the first year of the new PSA,
Strategic Health Authorities should assess the progress made by
PCTs in each region towards the PSA alcohol indicator, taking local
action if agreed progress has not been made.
- While national systems collect detailed data on local patterns
of alcohol misuse, some PCTs do not use these sources, and few PCTs
collect information from their local partners to supplement these
national datasets. The Department should provide a framework to
allow PCTs to assess alcohol misuse within a PCT area; thus
enabling regular reviews of performance by Strategic Health
Authorities and Regional Directors of Public Health, and allowing
PCTs themselves to compare their provision of alcohol services
against peer PCTs with similar patterns of alcohol misuse.
- The new PSA indicator on alcohol needs to act as an incentive
for PCTs to address effectively the alcohol misuse problems in
their local area. To strengthen the rigour of PCTs’ local
prioritisation and commissioning decisions concerning alcohol, the
Department should deepen and develop the evidence available to PCTs
on the causes and forecast trends of alcohol-related hospital
admissions and alcohol health costs. It also needs to develop
further evidence for the link between the PSA alcohol indicator and
early interventions.
- Historically, primary care data have not given a clear picture
of alcohol misuse due to confusing ‘codes’ for recording diagnoses
and interventions resulting in inconsistent recording of activity
in primary care. New codes for identification, screening and brief
advice were issued in May and October 2008, and the Department
should set a review point to assess how effectively these codes are
operating to generate accurate and comparable information.
- Currently there is no consistency in how the level and cost of
alcohol services is recorded locally. To secure greater
consistency, the Department should emphasise to PCTs the importance
of following the guidance set out in the NHS costing manual.
Strategic Health Authorities will be able to use this standard
method to compare provision across their PCTs as part of their
performance management of PCTs.
- Money spent on identification and brief advice can be cost
effective, helping to pre-empt the need for more expensive services
to treat longer-term alcohol harm, but currently such services are
sporadic. The Department should explore the feasibility of
providing PCTs with a toolkit to assess locally the relative costs
and benefits of different services to tackle alcohol harm,
particularly those that focus on early prevention. The toolkit
should aim to show the effect that such preventive measures can
have in reducing the need for specialist treatment in the future,
based on existing guidance and the best available estimates of cost
effectiveness.
- PCTs have often seen Drug and Alcohol Action Teams as the
bodies primarily responsible for commissioning services to tackle
alcohol harm. These Teams, however, focus on specialist treatment
of illegal substance misuse. PCTs need to be clear about the
purpose of funding they provide to Drug and Alcohol Action Teams,
for example in commissioning specialist services. The majority of
specialist alcohol treatments are provided by combined drug and
alcohol services and so there is a risk that, without a clear
specification, alcohol treatment could be overlooked. At a national
level, the Department, working with the Home Office, needs to
undertake a consultation with representatives of local
commissioners in order to provide clear guidance on the remit and
local accountability of Drug and Alcohol Action Teams in relation
to alcohol, including how this fits within the Teams’ existing
accountabilities for illegal substance misuse. PCTs should also
promote the commissioning of brief advice for the large body of
hazardous and harmful drinkers, whether provided in general
practice, A&E departments or other other parts of the public
sector.
- Where PCTs do commission services, they rarely assess the
quality of what is delivered. Regional Directors of Public Health
and Strategic Health Authorities need to get PCTs to assess the
quality of the services they commission against the Department’s
commissioning guidance, including Models of Care for Alcohol
Misuse, MoCAM (2006) and criteria set out in the Department’s World
Class Commissioning programme.
- Our survey of PCTs showed that not all are working well with
other public bodies – such as the police, prison and probation
staff, and social services – to identify and help people who are
misusing alcohol and whose health may be at risk. Such
organisations are often well placed to identify alcohol misuse
within those sections of the community that do not come into
regular contact with the health service. PCTs should help educate
and train NHS staff and agree with local partners outside the
health service how they can be supported in developing skills to
identify alcohol misuse.
- Currently there is no systematic means of promoting good
evidence-based practice on alcohol harm across PCTs. Regional
Directors of Public Health should develop a professional network of
PCTs, Drug and Alcohol Action Teams and health care professionals
with an interest in exploring and promoting new ways to tackle
alcohol misuse. These networks should record details and outcomes
of local alcohol-related interventions and treatments using the
existing online database of alcohol initiatives (HubCAPP).