Delivering Healthy Ambitions Better for Less Tackling alcohol abuse Actions for implementation

Introduction This presentation describes four evidence-based interventions that can impact on reducing alcohol related harm and admissions as part of an integrated care pathway: 1.Identification and Brief Advice (IBA) 2.Alcohol health worker in an acute setting 3.Improving services for dependent drinkers 4.Behaviour change and social norms Presents a summary of the main actions for implementation and case study examples Accompanying Better for Less pack and data report provide the background

Identification and Brief Advice (IBA) Identification and Brief Advice ‘heads the list of effective and cost-effective evidence-based treatment methods’ Clinically significant reductions in drinking and alcohol- related problems can follow from brief interventions IBA can be implemented through targeted widespread use of the Making Every Contact Count Framework for adults who: –have existing medical conditions –live in areas of deprivation or high risk segmentation group postcode areas –have been identified as drinking at increasing risk –are attending NHS or NHS commissioned services, or services offered by other public institutions IBA should use recognised evidence- based resources, be based on FRAMES principles, and take minutes Professionals in the following areas should be trained: –primary healthcare –emergency departments –other healthcare services (hospital wards, outpatient departments, occupational health, sexual health, needle and syringe exchange programmes, pharmacies, dental surgeries, antenatal clinics and VCS and private sector) –criminal justice –social services –higher education –other public services

Identification and Brief Advice (IBA) Consistent, accredited training is essential A free e-learning course accredited by the Royal College of Nursing is available from E-learning for healthcare: lfh.org.uk/projects/alcohol/index.html lfh.org.uk/projects/alcohol/index.html It is included in the Royal College of General Practitioners certificate for the management of alcohol in primary care: stance_misuse/alcohol_certificate.aspx A new, free e-learning tool for pharmacists is now also available: arning/IBA/ arning/IBA/ Nurses are as effective as doctors in producing behaviour change The most positive effects have been observed with adolescents, adults, older adults and pregnant women Identification and Brief Advice ‘heads the list of effective and cost-effective evidence-based treatment methods’ Clinically significant reductions in drinking and alcohol-related problems can follow from brief interventions

Case study: Rotherham Local Enhanced Service (LES) Identification and Brief Advice (IBA) Each GP has agreed the minimum number of IBAs required, totalling 13,000 across LES practices (compared to 17,367 annual DES ‘new registrants’) Will take continued support, feedback and in-house training by a primary care team of alcohol specialist nurses/workers working with practice managers, lead GPs and practice nurses to achieve The alcohol read code template is now also included in the QOF lifestyle template and the NHS lifestyle check will also support this work Increased identification inevitably impacts upon specialist treatment services. This increase in referrals has likely contributed to Rotherham's highest in the region Prevalence Service User Ratio of 8.92% The support team, substance misuse medical advisor and specialist services substance misuse consultant have worked closely with GPs and created a supportive environment for alcohol services at a strategic level and on the ‘frontline’ Effective care pathways have ensured that, through the LES, GPs have access to support across the three tiers of intervention – found to be essential The RCGP alcohol certificate course is commissioned for local primary care practitioners alongside a range of in house primary care training events

Alcohol health worker in an acute setting Appointing an alcohol health worker in an acute setting is a High Impact Change identified by the Department of Health Alcohol health workers offer an effective and efficient approach to case management and improving patient care The Royal College of Physicians advocates the appointment of an alcohol health worker in major acute hospitals to work with a named consultant / senior nurse alcohol lead and provide: –medical management of patients with alcohol problems within the hospital –liaison with community alcohol and other specialist services –education and support for other healthcare workers in the hospital –case finding and delivery of brief advice A case finding approach should be considered in all areas, with regular analysis of high intensity acute service users with alcohol related hospital admissions Appropriate, agreed and confidential information sharing protocols and multi-agency case reviews can enable more effective case management and client care

Case study: Bradford Royal Infirmary and Piccadilly Project Alcohol health worker in an acute setting Partnership between NHS Bradford and Airedale, Bradford teaching Hospitals NHS Foundation Trust and VCS alcohol services Commissioned through the joint commissioning team; one post funded initially but two further posts now secured Patients receive co-ordinated care in the hospital for immediate medical care needs and ongoing support in the community through local alcohol service the Piccadilly Project Patients are involved in their own care and develop an agreed plan Families/carers can also receive support and be referred to the Family Support Service for ongoing support Early evidence suggests they are successfully screening and intervening with a ‘treatment-naive’ population - 64% of referrals have had no previous involvement with alcohol or substance misuse services All other statistics are similar nationally – The Bradford mean age is 48 (nationally 41), the Bradford percentage of white British referrals is 91% (nationally 87%) and the Bradford female to male split is 79%:21% (nationally 64% male) VCS ‘in-reach’ work in the hospital is improving partnership working and ensuring smooth pathway progression The retention rate from the BRI to the Piccadilly Project is 54% - evidence has shown that meeting with the alcohol worker prior to discharge further increases retention. The retention rate to the Community Drug and Alcohol Team has increased to 62.5% Patient satisfaction has been monitored and positive feedback received on the service, staff, and the difference the interventions have made to patients lives.

Case study: Wakefield Integrated Substance Misuse Service Alcohol health worker in an acute setting Variety of data developed to support multi-agency case reviews of high- intensity users Ensures all pieces of the clinical jigsaw are shared between clinicians in different organisations Enables more effective case- management and secondary care Uses a SUS/HES/tariff calculation to calculate the cost of admission Temporal analysis shows the day and time of most A&E attendances Data shared with stakeholders as part of a wider ‘balanced scorecard’ approach to outcome monitoring across the treatment system Better reflects the range of outcome measures that indicate the ‘balance’ in the substance misuse treatment system

Improving services for dependent drinkers A dependent drinker costs the NHS twice as much other drinkers The largest and most immediate reduction in admissions can be delivered by intervening with this group through the provision of specialist treatment Department of Health guidance states that for the greatest impact, local areas should ensure provision and uptake of specialist treatment for at least 15% of dependent drinkers North West PHO estimated alcohol treatment figures in the recent local alcohol profiles for England using population based estimates. For 2008/9, 3% of the Yorkshire and the Humber population aged was in treatment, slightly higher than the national figure of 2.7% Estimates will be reviewed quarterly through the directors of public health – this will help us review progress against the 15% ambition Areas should consider the following when developing care pathways to ensure the most effective, quality care for patients: –attention to definition of cases –determination of the proportion of cases that will seek and engage in treatment at any time –treatment planning needs to take cognizance of natural history –the treatment effectiveness question –economic benefits

Behaviour change and social norms Social norms strongly influence the way people behave A social norms approach is an evidence-based approach and shown to reduce alcohol use of those drinking above lower risk limits Behaviour change and social norms Areas should consider an agreed approach to social marketing and behaviour change across partnerships and co-ordinate work across lifestyles issues A social norms approach can be run cost-effectively using existing surveys and segmentation to help define issues and embedding the process in existing community engagement projects and perception work Key aspects of the approach are specific data, local involvement and positive imagery Local guidelines for implementation have been developed in partnership with Bradford University, University of Leeds and the National Social Norms Institute, please visit:

Case study: Unitcheck (University of Leeds) Behaviour change and social norms Unitcheck is helping young people take the first steps to reducing their alcohol intake Website aims to change the habits of at- risk young drinkers by providing a quick check on the number of units they are drinking, information on the health impacts, and a comparison to their peers 5% of students surveyed were found to be regularly drinking at weekly levels associated with health risk During the trial, results showed a reduction in drinking per occasion of approximately one unit A three-month follow up showed this reduced intake had continued Unitcheck is now being rolled out to four other UK universities Modification and promotion to community groups, organisations and health professionals nationally and internationally is now being considered For further information visit:

Further information and resources Accompanying resources This presentation should be read in conjunction with: Delivering Healthy Ambitions Better for Less – Tackling alcohol abuse rForLess/16%20BETTER%20FOR%20LESS%2 0Tackling%20Alcohol%20Abuse.pdf Alcohol related harm in Yorkshire and the Humber Data Profile Report =90991 Further information Dianne Draper Health Policy Manager Sarah Morrow Regional Alcohol Manager