Response to the Newcastle 2016 Public Health Thematic Briefing: Drugs and Alcohol – Commissioning for recovery
Posted by Graeme Wilson on 17th Jul 2013 at 5:57PM
As a team engaged in the study of alcohol use and health, we welcome this substantial initiative to prevent, and support recovery from, substance misuse. It is encouraging to see the prioritisation of multi-agency working to address broader issues associated with, or arising from, alcohol problems and to create pathways to support for those suffering problems but not engaged with specialist services. This is particularly important in helping those with co-morbid physical or mental health conditions, which can undermine attempts to treat alcohol problems on their own. The document also recognises the continuum of needs in proposing to commission various forms of support that research shows to be valued by particular sectors but difficult to access, such as peer support groups not specific to substance use, a recovery community and ongoing support in the wake of detox or rehabilitation.
From the perspective of public health in relation to alcohol, there are some risks to having a combined strategy to address both alcohol and drug misuse. Such an approach starts from a focus on addiction rather than prevention, and so is oriented towards recovery from dependent substance use. In England 26 to 39 per cent of men and 17 to 27 per cent of women drink alcohol at levels that are hazardous or harmful to health  and 8.7 per cent of men and 3.3 per cent of women are dependent on alcohol . There is therefore a broader impact on public health from alcohol than just that arising from dependence, as witnessed for instance in the current record rates of liver disease. A focus on commissioning for recovery from dependence may also encourage this large community of heavy drinkers to think the issue is about people with severe problems in mental health services rather than about them, and that services are therefore not appropriate to themselves and their needs. Heavy drinkers are also likely to be reluctant to access services for those using illicit substances. However it is also clear that there are strong links between problematic drug users and problematic alcohol users, and within the specialist sector the substances may need to be looked at together.
At many points it is emphasised that commissioned services must be demonstrably evidence-based and effective. We strongly support a commitment to building and translating the evidence base, supporting service providers in keeping pace with best practice and ensuring that knowledge is disseminated and acted upon across a very wide workforce. There is substantial evidence for the effectiveness of preventive methods such as screening and brief interventions in reducing harm from alcohol consumption among the general population. Prevention and early intervention to tackle drinking before it becomes dependent are acknowledged in this document as important, but are not consistently included and emphasised. For instance, the Summary of needs analysis does not cover the needs of heavy drinkers not accessing specialist services. The importance of brief intervention capacity across the workforce is discussed under section 5.10, but as an adjunct to pharmacological support. Section 5.15 states that problems with alcohol and drug use in pregnancy are particularly complex and therefore require specialist support. This is certainly the case if an individual’s alcohol problems are severe, but the more widespread impacts on pregnancy from relatively low levels of alcohol consumption can be practically and effectively addressed with interventions delivered by non-specialist practitioners. Commissioning to address harmful drinking before it escalates to dependence will reap substantial public health benefits in the longer term.
We note that the document distinguishes between the needs of those younger than 18 and those older. This is an important distinction when planning commissioning as the evidence base for screening and brief intervention with young people in the UK is still developing. However patterns of need change across the life course and it will also be important to respond to emerging trends at different stages of adulthood, recognising that not all services suit all users with similar levels of need. For instance, although there is a clear intention in the document to tackle problem drinking in licensed premises, this will not address the burgeoning trend towards heavy drinking at home among parents and working professionals. In particular, rates of problematic or unhealthy drinking are increasing among adults in later life, when changing health states mean that risks from alcohol are greater and at lower levels of consumption than in earlier life. Newcastle has an ageing population, and as a city aspires to be at the forefront of age awareness. An emphasis on flexibility and diversity in service provision will facilitate support for this sector, who may for instance benefit most from out-of-hours provision. Commissioning a bespoke alcohol service or services for older people would address a clear gap in current provision, and it would be good to see this sector‘s needs recognised in the diagram of services on page 18.
Finally, the overall focus in this document on services to identify and support individuals is positive. However, tackling the identified problem of Newcastle’s ‘party city’ culture is important in protecting public health; although valuable initiatives such as tackling alcohol pricing and harmful advertising are mentioned, these might be most effectively deployed if woven into a more coherent community-level strategy.
1. Health and Social Care Information Centre (2013) Statistics on Alcohol: England, 2013.
2. NHS Information Centre for Health & Social Care (2009) Adult psychiatric morbidity in England, 2007: Results of a household survey.
Dr Graeme B Wilson
on behalf of the alcohol research team at Institute of Health and Society, Newcastle University
17th July 2013