Background
Whilst only a small proportion of the population experience substance use disorders, the burden of related harm is substantial and far-reaching. Alcohol and drug treatment offers an effective policy approach to improving health and social outcomes for individuals, their families and society. Due to the harm and economic pressures resulting from substance use disorders in England, most alcohol and drug treatment is publicly funded. Since 2014, England’s local authorities’ spending on treatment for substance use disorders has reduced during a period of sustained public sector austerity. Parallel to this disinvestment there have been reported reductions in numbers of people accessing support, reductions in the proportion of people successfully completing treatment and increases in associated harm. This research was designed to examine the impact of disinvestment from alcohol and drug treatment services in England between 2013/14 and 2018/19.
Methods
Following the completion of a systematic review of the existing evidence of how disinvestment from alcohol and drug treatment has impacted on treatment delivery and outcomes, this multimethod study focused on England comprised three sequential phases. Phase One used linear mixed effect modelling of matched annual administrative treatment, hospital admissions and mortality data to examine whether disinvestment from alcohol and drug treatment services was associated with changes in treatment numbers and health outcomes. These results informed the following two phases which focused specifically on the perspectives of England’s 151 local authority-based alcohol and drug treatment commissioners. Phase Two involved semi-structured telephone interviews to understand their experiences of changes in funding, related commissioning, and service provision. Thematic analysis then informed the design of Phase Three: a bespoke online survey to assess the extent to which these reported experiences were shared by a larger sample of commissioners.
Results
After adjusting for inflation, between 2013/14 and 2018/19, £212.2 million was disinvested from treatment for substance use disorders, representing a 27% decrease. Less than 1% was disinvested from alcohol treatment, yet 35% from drug treatment, with substantial regional variation in changes in investment and relative treatment numbers. This disinvestment was related to fewer people accessing (0.303, p<0.001) and successfully completing (-0.205, p<0.001) treatment. However, disinvestment was not found to be significantly related to increases in alcohol-specific hospital admissions or mortality, not drug-related deaths. Interviews with 14 commissioners identified parallel changes in commissioning practice, service structure and public policy. Survey responses representing 55% (n.83) of local authorities confirmed losses of additional funding streams and reductions across all service provision. Challenges presented by the local authority environment included competing priorities and a significant reduction in the size of specialist commissioning teams (-58% t(55)=-5.607 p<0.001). Most areas had moved to integrated community alcohol and drug treatment services in response to budget cuts, but this is perceived as contributing to fewer people accessing alcohol treatment. Regular re-tendering has further compounded reductions in people successfully completing treatment.
Conclusion
Significant and sustained disinvestment from alcohol and drug treatment services in England has contributed to fewer people accessing treatment for substance use disorders and fewer people successfully completing treatment. Commissioners report that whilst changed practices have helped to moderate the effects, continued disinvestment has resulted in unavoidable negative impact on the availability of treatment for people in need of support, and the effectiveness of treatment, for those engaged in services.
