Dr Adenekan Oyefeso Reader in Addictive Behaviour St George’s, University of London

1. Alcohol Needs Assessment Research Project(ANARP)The 2004 national alcohol needs assessment for England Dr Adenekan Oyefeso Reader in Addictive Behaviour St George’s, University of London Presentation to West Midlands Public Health Excellence Conference 2006 MORI

2. St George’s Colin Drummond Adenekan Oyefeso Tom Phillips Survjit Cheeta Paolo Deluca Hannah Winfield Jennie Jenner Kathryn Cobain Sue Galea Vivienne Saunders Katherine Perryman Kable Ltd Tom Fuller Deirdre Pappalardo MORI Social Research Institute Oswin Baker Alex Christopolous Authors

3. Before…. After….

4. Context • The National Alcohol Harm Reduction Strategy for England: • Identifies high level of alcohol misuse and alcohol related harm in society • Insufficient focus on alcohol treatment in the past • Limited information on whether service provision meets demand • Four parallel supporting projects have been commissioned: • Review of the effectiveness of alcohol treatment conducted by National Treatment Agency • Service framework for alcohol services (Models of Care for Alcohol Misuse) conducted by National Treatment Agency • Pilot screenings and brief intervention models for alcohol misuse in primary and secondary healthcare (to be commissioned by DH) • National needs assessment (ANARP, this project) (commissioned by DH)

5. ANARP Methods – 8 parallel projects Conducted between September 2004 and February 2005 • A study of available data on the prevalence of alcohol use disorders in England • St George’s, University of London • A study of the identification of alcohol use disorders in primary care • General Practice Research Database • St George’s, University of London • A national survey of alcohol treatment agencies in England • St George’s, University of London; MORI • An analysis of the gap between need and service provision • St George’s, University of London; MORI • A quantitative telephone survey of general practitioners • Kable & MORI • Focus groups with general practitioners • Kable • A quantitative survey with Drug Action Team professionals • Kable & MORI • Focus groups with Drug Action Team coordinators • Kable

6. Definitions of Alcohol Use Disorders used in ANARP • Hazardous Drinking: people drinking above recognised safe levels but not yet experiencing harm (weekly >21/14 units, daily >8/6 units). • Harmful Drinking: people drinking above safe levels and experiencing harm (AUDIT 8-15). • Alcohol Dependence: people drinking above safe levels and experiencing harm and symptoms of alcohol dependence (AUDIT 16+).

7. ANARP Findings I: Prevalence of Alcohol Use Disorders • 26% of the adult population have an alcohol use disorder (AUD) • Includes 38% of men & 16% of women aged 16-64 • 23% of the adult population are hazardous or harmful alcohol users (7.1 million people in England) • 21% of men and 9% of women engage in binge drinking • Prevalence of alcohol dependence is 3.6% overall, 6% among men, and 2% among women (1.1 million people in England) • Important variations • All alcohol use disorders decline with age • Among black and minority ethnic groups, there is lower prevalence of hazardous / harmful use, but similar levels of dependence compared with the white population • Considerable regional variation in prevalence of alcohol use disorders Alcohol dependence is considerably more prevalent than drug abuse

8. ANARP Profile of Alcohol Use Disorders

9. ANARP Findings II: General Practice Research • GPs under-identify alcohol use disorders (AUDs): • Hazardous / Harmful drinkers: only 1/67 males, and 1/82 females identified • Alcohol dependence: 1/28 males, 1/20 females identified • Younger patients less commonly identified than older patients • Large regional variations in identification rates • Low level of referral to specialist services • Main reason given by GPs is waiting lists for specialist services • Demand for specialist services seems to be moderated by mechanisms such as low levels of enquiry and finding alternatives to referral (e.g. Alcoholic Anonymous) • But higher level of awareness of AUDs than previous surveys • Identification of AUDs is about 5 times higher than in previous surveys • A relatively high number of GPs reported the provision of in-house interventions • Majority of patients identified were felt to need specialist treatment • GPs welcome the possibility of more training in alcohol issues

10. ANARP Findings III: Drug Action Team Professionals • Funding for alcohol treatment mainly from PCTs, Local Authorities, Charitable funds • Ranges from £35,000 to £8million per DAT • Much lower than budgets for drugs • Only 60% of DATs have alcohol treatment plans in place, and few are detailed or funded • DAT professionals feel that the alcohol strategy has raised expectations, without impact on the ground : • Lack of specific targets will hamper local action • Lack of robust measures to address alcohol supply • Lack of action since publication of national strategy • Lack of funding • Focus on issues of crime and disorder more than health and social needs • DAT professionals believe the harm resulting from alcohol misuse is far greater than from drug misuse

11. ANARP Findings IV: Alcohol Treatment Agency Survey • Survey identified 696 alcohol treatment agencies in England (43% more than previously known) • 69% community-based, 31% residential • 56% response rate • Over half are non-statutory agencies, one third NHS, and 8% private sector • Estimated annual spend = £217million • Estimated treatment personnel in England = 4,250 • Clients primarily alcohol dependent • 91% of clients in residential agencies • 71% of clients in community agencies • Clients mostly self- or GP-referred • 36% self-referral • 24% GP/primary care referral

12. Primary role of agency service type (% of respondents)

13. Distribution of alcohol treatment agencies by Region (n=696)

14. Alcohol Use Disorder by treatment setting Potential = hazardous drinkers Actual = harmful drinkers Moderate Dep = moderate alcohol dependence Severe Dep = severe alcohol dependence

15. Treatment Interventions Provided by Community Services 45% provide detoxification

16. Treatment Interventions provided by Residential/Inpatient Services 46% provide detoxification

18. Gap between need and access (PSUR) by region

19. Summary of Policy Implications of ANARP • More agencies identified than previously known • Valuable information for service planning, data gathering and service users • Consideration should be given to incorporating alcohol treatment in National Drug Treatment Monitoring System and developing an infrastructure for data collection in alcohol agencies • Level of PSUR is lower than previous international studies • Considerable room for improvement in access to alcohol treatment • Large regional variations in access to alcohol treatment • Potential for improvement in screening, identification and referral • People with alcohol dependence are heavy consumers of health services • There are opportunities to increase identification and referral activity across primary and secondary health care, and in other agencies e.g. criminal justice & social services. • Need for development and implementation of systematic referral criteria/integrated care pathways for AUDs

20. Summary of research implications from ANARP • Better prospective data collection of prevalence of AUDs • In the general population • In primary and secondary care (including general practice, A&E departments, and general hospitals). • Alcohol treatment agencies should be incorporated into the NDTMS • Assessment of alcohol-related need and the impact of alcohol policies • A central monitoring system for indicators of alcohol related harm and prevalence of AUDs would assist in future needs assessment and service planning • Include items on alcohol help seeking in future psychiatric morbidity surveys to understand the true level of demand for alcohol treatment • Methods of improving access to alcohol treatment • Methods of increasing levels of screening, identification, intervention and referral • Across primary and secondary care, criminal justice and social care • Including the impact of screening initiatives on demand for specialist alcohol treatment. • Methods of engaging people with alcohol dependence in treatment • Impacts of Assertive outreach & Intensive case management

21. Summary of research implications from ANARP • Partnership working: Do we all have shared objectives about alcohol service provision? • Improvement in intra-provider cooperation • Improvement in inter-provider cooperation • Improvement in commissioner-provider cooperation • Joined up thinking • What should we do? • What can we do? • How can we reduce the gap?