Alcohol Treatment Matrix cell E2: Treatment systems; Generic and cross-cutting issues

2020/21 update funded by

Alcohol Change UK web site. Opens new Window

Alcohol Change UK



Previously also funded by

Society for the Study of Addiction web site Society for the Study of Addiction

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Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

Drug Treatment Matrix

Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

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Treatment systems; Generic and cross-cutting issues

Seminal and key studies on local, regional and national systems for effectively and cost-effectively providing treatment. Explores whether payment by results stifles patient-centred practice or stretches services beyond comfort zones, the surprising results of a randomised trial of service-improvement mechanisms, and the multiple answers to how many drinkers should be in treatment. See the remaining four cells in row 2 of the matrix for more on generic features of medical and psychosocial therapies.


S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Organise chronic care for chronic conditions (2002; alternative free source at time of writing). Implications of truly treating addiction of the kind seen by public treatment services as analogous to a chronic disease include organising long-term monitoring and care and judging services on how the patient fares during treatment, not after they leave. For the benefits of continuing care see cell A2 and how to organise cell D2. For related discussion in this cell click and scroll down to highlighted heading.

K Need for alcohol treatment in England (prepared for Public Health England, 2017). Estimated that nearly 600,000 adults in England were dependent on alcohol in 2014/15, implying that the treatment caseload was equivalent to 19% of the in-need population. For similar estimates for Scotland see a technical report (prepared for the English Department of Health, 2016) from the same research team and a needs assessment (NHS Health Scotland, 2014) from the Scottish NHS. For discussion click and scroll down to highlighted heading.

K Local area strategies in England lack vision, clarity and commitment ([UK] Department of Health, 2011). When from 2006 to 2011 government alcohol policy support teams made more than 480 visits to local strategic partnerships, they found improving attempts to promote public health through alcohol-related interventions, but attempts which were often muddled and uncoordinated and lacked consistent commitment.

K What the treatment system feels like for the patient (2015). Interviews with patients being treated for problem drinking at an NHS addiction service in England revealed that for them the treatment journey was often “fragmented, with input from a number of different staff in different settings and an overall lack of clarity around the role and remit of each”.

K Randomised trial proves that bedside outreach can dramatically improve continuity of treatment after detoxification (2018, free source at time of writing). In Denmark engagement in long-term treatment virtually doubled from 24% to 47% when a nurse from the outpatient alcohol treatment clinic met detoxification patients at the hospital to explain the importance of outpatient treatment, present an ‘attendance contract’, and offer a first appointment, helping to transform an acute-care episode into a programme which could tackle the roots of the problem.

K Service improvement system helped extend access to and retention in treatment (2008). US NIATx programme halved waiting times and extended retention partly by fostering a self-sustaining improvement network linking treatment services and a performance assessment system linked to funding. See also this later extension (2012) to the programme and a similar study (2010) (free source at time of writing) of the NIATx method in Los Angeles treatment services which recorded substantial improvements in waiting times, retention, and ‘no-shows’. These studies showcase the gains possible when a central authority engages services in its quality-improvement mechanisms. Related NIATx study and web site listed below.

K Expert coaching helps services improve patient access and retention (2013; free source at time of writing). Randomised trial tested the improvement-collaborative model promoted by the US NIATx quality-improvement resource (referred to in the listing below of their web site). Arrangements for services to learn from each other were less effective and less cost-effective at improving patient access and retention than assigning each clinic an NIATx-trained quality-improvement ‘coach’. Related NIATx study listed above and web site below. For discussion click and scroll down to highlighted heading.

K Independent evaluation of English payment-by-results schemes finds no overall benefits and increased costs (2017). In England from 2012 the government piloted eight schemes which paid substance use treatment services for achieving desired outcomes, evaluated in this study by comparing changes in scheme versus non-scheme areas from two years before the schemes started to the following two years. It found no overall benefit but some rebalancing to treating alcohol patients as opposed to users of illegal drugs, and even for alcohol patients the key recovery indicator of successful treatment completion and no return within a year appeared adversely affected and costs increased. Similar results in government report ([UK] Department of Health, 2013) on the schemes’ first year. Related US study and review below. For discussion click and scroll down to highlighted heading.

K Pay for results, not for trying (2008). Rather than specifying treatment inputs like numbers of counselling sessions, the US state of Delaware incentivised patient recruitment, engagement, and drug- and alcohol-free treatment completions; the result was more patients, more engaging treatment, and a rapid increase in satisfactory treatment completions. But there were signs too that services did just enough to earn the rewards without seeking to excel in these or in other ways. Related UK study above and review below. For discussion click and scroll down to highlighted heading.

K How much should treatment systems rely on residential rehabilitation? (2007). Rare randomised trial confirmed that unless there are pressing contraindications, intensive day options deliver outcomes equivalent to residential care. Often of course, there are pressing contraindications. See also this informal Effectiveness Bank review.

R Embed recovery from addiction in the community (2008). Creating a recovery-friendly environment is the best way to sustain resolution of substance use problems argues this (as we described it) “sweeping, learned but practice-oriented tour-de-force”, shifting the focus from the treatment clinic to the surrounding social systems within which the patient must eventually reshape their life. See also spin-off documents on peer-based addiction recovery support (2009) and recovery-oriented methadone maintenance (2010). For discussion click and scroll down to highlighted heading.

R Evidence for key features of a recovery system ([US] Substance Abuse and Mental Health Services Administration, 2009). Turn to chapter 7 starting page numbered 22 for evidence for key elements of recovery-oriented systems of care for problem substance use, including continuity of care anchored in the community and delivered by an integrated network of services centred on the individual’s need. See also associated implementation case studies ([US] Substance Abuse and Mental Health Services Administration, 2009). For related discussion click and scroll down to highlighted heading.

R Policy strategies for improving outcomes (2011). Two of the world’s most respected addiction researchers also with top-level policymaking experience in the UK and the USA set out the options for improving treatment systems. For related discussion click and scroll down to highlighted heading.

R Funding mechanisms for substance use treatment (Report for the Australian Department of Health, 2014). Chapter 6 comprehensively reviews funding mechanisms including payment-by-results, for which it finds no peer-reviewed evidence that it has improved outcomes after treatment for problem alcohol or drug use. Part 2 makes recommendations for service planning and commissioning which may be applicable to the UK. Related UK and US studies above. For discussion click and scroll down to highlighted heading.

G Evidence-based principles for commissioning alcohol treatment systems in England (National Institute for Health and Care Excellence, 2011). From the UK’s authority on medical and social care, organising and procuring treatment services across an area which implement national guidance and satisfy policy requirements. Reflected in associated quality standards (National Institute for Health and Care Excellence, 2011) and incorporated in more nuts-and-bolts guidance from Public Health England listed below.

G Practical guidance on commissioning integrated alcohol harm-reduction systems in England (Public Health England, 2018). Key strategies and action-prompts for developing an integrated local system to reduce alcohol-related harm, including treatment services which meet NICE standards. One of a suite of commissioning guidance and resources. Supported by ‘return on investment’ resources (Public Health England, 2016) enabling commissioners to estimate the social benefits of various interventions and their impacts on performance indicators. See also associated guidance (Public Health England, 2019) for strategic planners and commissioners.

G Scottish Government on what ‘quality’ consists of in substance use service provision (Scottish Government and Convention of Scottish Local Authorities, 2014). Aims to ensure commissioning of integrated service delivery of sufficient quality to meet the needs and aspirations of a local population. An evaluation ([Scottish] Care Inspectorate, 2017) judged that these principles “are being embedded and beginning to show some impact in more person-centred treatment, care and support”; summaries remain available (1 2). See also earlier guidance (produced for the Scottish Advisory Committee on Drug Misuse, 2008) on implementing an integrated care system, which includes action points to inform development of a plan to address local weaknesses or gaps.

G Impact of funding cuts on commissioning substance use services in England ([UK] Advisory Council on the Misuse of Drugs, 2017). Based on research, financial data and stakeholder surveys and testimonies, the UK government’s official drug policy advisers warn that without significant efforts to protect investment and quality, “loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems”. Supported by a survey (2017) of treatment services in 2016–2017 which found “worrying signs that damage has already been done and the capacity of the sector to respond to future cuts has been eroded”. For related discussion click and scroll down to highlighted heading.

G Organising to address problem drinking in NHS hospitals (undated). Guidance and advocacy from London’s Health Innovation Network on the steps that need to be taken in NHS hospitals to tackle alcohol-related harm, including commissioning and models for service delivery systems.

G Case studies of how local areas in England reorganised to create more responsive and engaging alcohol services ([English] Local Government Association, 2019). From the body representing the local authorities responsible for substance use services in England, practical examples of how their members have reorganised local treatment systems in diverse ways to better meet the needs of their populations.

G Elements and procedures of an effective local treatment system (2016). The Obama administration’s extension of health care and in particular substance use treatment to more of the US population generated a need for guidance on how local areas should set up addiction treatment systems. This clear US guidance covers the types of services to be provided, the links between them, and how to assess need and maintain quality.

G US system-change resources ([US] NIATx, accessed 2020). Web-based service provided by the University of Wisconsin offering practical strategies for commissioners and planners to promote quality-improving change across a treatment system, including engaging services in mutual learning and support, a tactic tested in a study listed above. Objectives include reducing waiting times and improving retention (example study listed above) and increasing admissions and reducing ‘no-shows’. For discussion click and scroll down to highlighted heading.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. Also see hot topics on evidence-based commissioning and recovery as a treatment objective, and William White’s on-line library of papers related to recovery-oriented systems of care.

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