James Morris, The Alcohol Academy Local alcohol systems Do ‘NICE’* examples exist? *(based) PHE EM Alcohol Event 26 February 2014

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1 ) What is a ‘NICE’ based treatment system … 2) do they exist? NICE system definition: Exist? Part of a system that meets the 13 Quality Standards (QS11)? Part of a system where QS11 is met to a high degree, across all groups and fully in accordance with the 612 page CG115 Broadly speaking, some services will be NICE compliant Probably not…

So… A high quality NICE based treatment system meeting all QS to a high level… probably a pipe dream in the real world However, alcohol has been increasingly prioritised over recent years Much more guidance and resources Some examples of key service elements, innovation, progress etc..

Examples of NICE based systems – or elements of…

Lambeth ‘Alcohol Brief Treatment’ (ABT) service in Primary Care Lambeth is a deprived London borough with approx 300k residents Treatment services typically see severely dependent, complex need substance misusers So ABT pilot of 2 ‘alcohol brief treatment’ roles to offer psychosocial interventions to: Provide ‘evidence-based psychological interventions’ to mildly dependent drinkers ONLY (i.e.PbR cluster 1) within GP services Leadership on improving IBA & referral

Lambeth ‘ABT’ rationale Most alcohol dependence is mild or moderate, therefore psychosocial rather than physiological Mild dependence requires much less intensive treatment and does not typically require medically assisted withdrawal However those with mild dependence are less likely to be ‘treatment seeking’ and may not have even contemplated their drinking as problematic or harmful

Severity of alcohol dependence in Lambeth Lambeth estimates * = 11,800 = 1,400 = 140 *2013 Alcohol Segmentation report 14% 2% 84% Mild National prevalence, APMS 2007

“Significant resource-impact recommendations this report focuses on recommendations that are considered to have the greatest resource impact and therefore require the most additional resources to implement or can potentially generate savings. They are:” Should brief treatment be a key priority? NICE CG115

See page 15: CG115 Alcohol dependence and harmful alcohol use: costing report Should ‘brief treatment’ be a key priority?

The business case - NICE Says: National proportion of people with mild alcohol dependence provided with evidence-based specialist treatment is estimated at 1.13% Increasing …access to psychological interventions [for harmful/mildly dependent drinkers] will decrease development of moderate or severe dependence. Harmful alcohol use is also associated with increased criminal activity and domestic violence and employee absenteeism. Implementing the guidance is expected to reduce the significant costs to society

Lambeth ABT pilot evaluation Main outcomes recorded*: AUDIT scores (alcohol risk level) Number of drinking days TOPs outcomes Physical and Mental health Overall health Feedback from GP partners and service users *Outcomes recorded at review stage (average 6 weeks in) and at exit (average 4 months after start)

First year activity based on 266 referrals Treatment Completed (planned exit)62 Treatment Delivered (uncompleted)27 Current clients31 New referrals17 Brief Advice (no further help wanted)11 Out of Borough referral16 Referred to Shared Care30 Referred other services5 Transferred shared Care4 Did not attend appointment41 No Response11 Declined treatment11 Total 266

AUDIT outcomes at start (25), review* and end* of treatment (12) - average *Review stage typically at 6 weeks in and at exit at typically 4 months after start

Units per day at start (14), review (8) and end of treatment (5) - average average of 14 units consumed per day at the start of treatment to an average of 5 units consumed per day on completing treatment

Drinking days per month 21 at start to 10 - average

Overall Health Rating improvement 11 to 15

ABT implications.. ABT forms a key part of NICE required ‘evidence based psychological interventions’ for a large ‘unmet’ population Not necessarily ‘new’ approach but few if any examples of targeting mild dependence Cross-over with ‘higher risk’/Extended Brief Intervention (EBI) approach No mainstream funding commitment

Durham Community Alcohol Service (CAS): a whole system example? County Durham have had a dedicated alcohol commissioner who has secured significant investment in a ‘whole systems’ approach Three core locality teams and a number of additional services including hospital, Older Adults, Peer Mentoring, Couples Counselling, Mutual Aid, etc.

NICE based systems: what next? Funding for alcohol investment will remain scarce – ‘do more with less’? Overlooked areas e.g. SBNT, pharmacology etc? Better use of peer support? Investing more ‘upstream’ e.g. mild dependence in non-treatment settings? More good examples out there to highlight? How/where? Support from PHE?

Audience examples & discussion? We know Birmingham is and has been undertaking significant work and has a long established alcohol services Other areas or examples to highlight? Any questions?

Thank you Contact: Alcohol Academy James Morris, director