PAC report: Government not taking alcohol harm sufficiently seriously

 - Deaths rose 89% over last two decades and sharply since start of pandemic 

 - Estimated £25 bn/year cost to NHS and wider society out of date and may not reflect full scale of harm 

 - Alcohol linked to over 100 illnesses and 42% of violent crime but no strategy in place since 2012 

An estimated 10 million people in England regularly exceed the Chief Medical Officers’ low-risk drinking guidelines, including 1.7 million who drink at higher risk and around 600,000 who are dependent on alcohol. But in a report today the Public Accounts Committee says a “staggering” 82% of those 600,000 dependent drinkers in England are not in treatment despite success rates of around 60% and evidence that, on average, every £1 spent on treatment immediately delivers £3 of benefit and significantly more in the longer term. 

There has been an alarming increase in alcohol-related deaths, which rose by 89% over the past twenty years, with sharp rises since 2019. But the number of people receiving treatment for alcohol dependency has generally been falling. The Department for Health and Social Care’s understanding of the total cost of alcohol harm for the NHS and wider society is based on analysis dating back to 2012. That puts the estimate at £25 billion a year (adjusted for inflation) but the Committee is concerned that this more than decade-old analysis may not reflect the full scale of harm. The Committee is “surprised and disappointed” that the Department is not taking a more proportionate and serious approach to addressing the problem. Despite the widespread harm, there has been no alcohol-focused strategy since 2012 and the latest plans for one were abandoned in 2020. 

Alcohol is linked to over 100 illnesses, can drive mental disorder, self-harm and suicide, and is a major cause of preventable death. In 2019-20 it was linked to 42% of all violent crime, up from 40% the previous year. 

The Committee says DHSC must secure a consensus and act on the best available evidence on preventative measures around price, availability, and marketing.  It must also address the key issues of funding uncertainty for local authorities; barriers to accessing treatment; local variations in outcomes and severe and worsening healthcare workforce shortages. 

Dame Meg Hillier MP, Chair of the Committee, said: “The harms from alcohol are appalling and the benefits of every £1 spent on treatment are immediate and obvious. It is linked to over 100 illnesses, mental disorder and suicide and to 42% of violent crime. It also costs the NHS and wider society at least £25 billion a year with inflation – and possibly more. But the Government has had no alcohol strategy in place since 2012 and abandoned its latest effort in 2020 – just as deaths from alcohol began to rise sharply over the terrible, unacceptable toll it was already taking. What more does DHSC need to see to act decisively on this most harmful intoxicant? In doing so it must give local authorities the certainty and stability over funding to maintain and improve the treatment programmes that are proven to work, and stop dithering over the evidence on industry reforms.”  

Lead PAC Member on this inquiry Dan Carden MP said: “Today’s report lays bare the lack of political will to address alcohol harm. The Government’s record on alcohol harm is one of policies scrapped and promises broken.  

“Alcohol harm is a deepening public health crisis that affects us all and it is wrong and unfair to believe that it is only alcohol dependent drinkers who are affected. 

“Shamefully, it has been 11 years since the last Government UK Alcohol Strategy. The measures set out in the 2012 strategy were, and remain, effective evidence-led health policies that prevent death, improve public health and alleviate pressures on our public services. The abject failure to deliver on promised initiatives has certainly contributed to tragic yet preventable levels of alcohol harm felt across the UK. 

“In recent years, there has been a concerted and somewhat successful effort from the Government to implement strategies aimed to tackle obesity, gambling, tobacco, and illicit drugs. Arguably the most harmful and legal drug, alcohol, remains unchallenged. During the Public Accounts Inquiry, the Department provided no credible justification as to why alcohol remains a conspicuous outlier. 

“With thousands of families broken by alcohol, the highest alcohol-specific deaths on record, 84% of alcohol dependent people in need of treatment not receiving it and the enormous cost to the public purse, the Government must now remove the barriers of inaction and act on the recommendations set out in this report.”/ENDS

PAC report conclusions and recommendations 

6.       We are concerned that the Department is not taking alcohol harm sufficiently seriously. It is unacceptable that deaths from alcohol rose by 89% in the last two decades.  The harm caused by alcohol misuse is getting progressively worse and alcohol-related hospital admissions were steadily rising until interrupted by COVID. However, despite the increase in harm there has been no alcohol-focused strategy since 2012 and the latest plans to publish one were abandoned in 2020. We welcome commitments in the 10-year drugs strategy to establishing a world class treatment and recovery system but this needs to be delivered to people with real needs and to take seriously the impact of alcohol and not just drugs. While downstream measures are important, to tackle the significant costs to the NHS and wider society, we heard from experts in the field of the need for a whole system approach which includes preventative measures around the price, availability and marketing of alcohol. The Department does not share their assessment of the evidence but has not set out what it will do.  

Recommendation 1: In the absence of a formal strategy, the Department should 

a) set out how it will tackle the significant costs to the NHS and society of alcohol harm, with targets and performance measures and 

b) publish its assessment of the available evidence of effective strategies to tackle alcohol harm. 

7.       The Department for Health and Social Care, as the lead department, does not have sufficient understanding of total cost of alcohol harm.  The harms to individuals and society that alcohol misuse can cause are well-known. Alcohol is linked to over 100 illnesses, can drive mental disorder, self-harm and suicide, and is a major cause of preventable death.  The Office for National Statistics reports that in 2019-20 it was linked to 42% of all violent crime, up from 40% the previous year. Moreover, alcohol does most harm in the most deprived communities. Drinking patterns are also changing with the young generally drinking less and older people drinking more.  Based on analysis dating back to 2012, the Department put the annual cost of alcohol harm to the NHS at £3.5 billion, and to wider society at around £21 billion (or around £25 billion adjusted for inflation). This analysis is over a decade out of date, and we are concerned that these estimates may not reflect the full scale of harm. The Department’s understanding of the prevalence of dependency also dates back to 2018-19. As overall owner for alcohol policy, it is for the Department to coordinate a cross-government effort to understand how and where costs are rising to inform an effective response.  

Recommendation 2: The Department should undertake the work necessary to improve its understanding of the up-to-date costs of alcohol harm to the NHS and wider society. 

8.       Delays by the Department in finalising the allocation of the Public Health Grant, coupled with short-term funding and reductions to the public health grant, make it difficult for local authorities to plan and commission alcohol treatment services effectively. Since 2015-16, local authorities have seen the grant they receive from central government to help fund public health services fall by £630 million in real terms. This has had inevitable consequences on funding for drug and alcohol treatment services, leaving services, “on their knees” according to Dame Carol Black (author of the government’s independent review of drugs).  From 2013-14 to 2020-21, the number of adults in England receiving treatment for alcohol dependency fell by 16%. The additional £533 million of funding for substance misuse services is welcome but is short-term. Numbers in treatment have not yet recovered, but they have at least started to increase. When we took evidence, only a month before the start of the new financial year, the Department had still not awarded its public health grant for 2023-24. As we have said before, for example in our July 2022 report on the rollout of the covid vaccine, departments should always set out annual budgets and funding for their key bodies and programmes in good time. Without funding certainty, local councils struggle to recruit and retain staff and to secure contracts with third party providers.  This can cause gaps in local services and pushes directors of public health to take risks by commissioning services without certainty of funding. 

Recommendation 3: To improve certainty around funding for drug and alcohol treatment services, the Department should: 

- commit to an earlier date by which it will confirm allocations of the Public Health Grant for 2024-25 and subsequent financial years; and 

- explain how it can provide greater long-term certainty to local authorities so they can plan and deliver the right investments to make a difference in their areas. 

9.      We are concerned that a high proportion of people with alcohol dependency are not in treatment and that there are unnecessary barriers to people in need of treatment. Treatment services for alcohol dependency are commissioned by local authorities. They show success rates of around 60% and they deliver an estimated £3 benefit immediately for every £1 invested, and potentially far more in the longer-term.  Treatment is also accessible as 98% of peopled referred to alcohol treatment services start treatment within 3 weeks. Yet 82% of dependent drinkers in England are not in treatment. The earlier people get into treatment the better, but too many people are falling through the gaps. Only 23% of people who are referred to treatment for alcohol come from health services. We heard that one of the biggest challenges is that people may not accept they have a problem in the first place as heavy drinking is normalised and public awareness of the associated harms is low. It is not only the drinkers themselves - we also heard that the healthcare workers assessing them often fail to spot early signs of problem drinking. Where people do recognise it, stigma around dependency and a reluctance to receive treatment alongside drug users can prevent them from accessing services.  Given the well-established relationship between substance misuse and mental ill health, we were concerned to hear that some people are denied access to mental health services because of their alcohol dependency (and vice versa). Approximately 70% of people entering treatment for alcohol dependency also experience problems with their mental health. 

Recommendation 4: The Department should set out: 

- how it is working with local authorities to address the barriers to people with alcohol dependency from getting the treatment they need; and  

- what it is doing to help improve integrated care for people with co-occurring alcohol and mental health problems and to ensure that they receive the support that they need.  

10.   There is concerning local variation in reported spending on, and outcomes from, alcohol treatment. In 2021-22, the amount local authorities reported spending on alcohol treatment varied from £4,000 per 100,000 people to over £1 million, with median spending of £313,000. In her independent review, Dame Carol Black did not disaggregate local authority spending on drugs and alcohol because of a lack of robustness in the reported expenditure data, so these numbers, while the only figures available, will mask actual spending on alcohol treatment services. However, spending will vary according to local priorities in public health and is a decision for the local authority, so some variation is to be expected. More alarming are the local variations in both the proportion of dependent drinkers in treatment and the success rates from those treatments as these variations focus on local responses to alcohol dependency. While nationally, 82% of alcohol dependent people are not in treatment, locally authorities report treatment gaps of between 58% and 93%. It is still early days but we hope that the Department’s arrangements for focusing national efforts for health improvement through the Office for Health Improvement and Disparities (OHID), can give impetus to the uptake of alcohol treatment. Nationally, the proportion of patients successfully completing treatment is around 60%; locally, this ranges from 29% to 90%. We look to OHID to identify the exemplars and to share best practice. 

Recommendation 5: Working with local and national partners, the Department should:  

a.       identify ways to increase uptake of treatment services in areas where the proportion or alcohol dependent people in treatment is lower; and 

b.      seek to understand why success rates are particularly low or high in some areas and to identify opportunities to share best practice. 

11.  There has been a marked reduction in the size of treatment workforce, in particular, of addiction psychiatrists. Dame Carol Black’s independent review on drugs highlights that a prolonged shortage of funding has depleted the treatment and recovery workforce and resulted in a loss of skills, expertise, and capacity in the sector. This is very worrying given the marked rises in alcohol-related mortality and morbidity. Of particular concern, given the high incidence of co-occurring mental ill health and dependency, is what one stakeholder called the “dying specialty” of addiction psychiatry, which has seen the number of training posts fall from 69 in 2011 to 27 in 2019. The Department assures us that it is working with Health Education England to ensure it is training the right numbers of people though it takes a very long time to train addiction psychiatrists. In the meantime, it hopes it can boost numbers through training to allow people to switch specialty and by persuading former addiction psychiatrists to return to the profession. We welcome the Department’s ambition to rebuild the professional workforce (including psychiatrists, doctors, nurses, and psychologists) and look forward to hearing how its commitment to secure an additional 800 mental health and clinical professionals is progressing.  

Recommendation 6: The Department should update us on how it is progressing with the implementation of its substance misuse workforce strategy as set out in the 10 -year drug strategy