Alcohol –the Liverpool CCG perspective HOW BIG IS THE PROBLEM? Dr. Shamim Rose Governing Body Member and Programme Lead for Alcohol Liverpool Clinical Commissioning Group

Alcohol - the historical GP view An illness service was the only way to get referred. With few options available and lack of clarity about what they should do and what they achieve, the role of the GP has been to deal with the symptoms rather than deal with the problems Minimum support was available – fragmented and unclear, mainly advised pt. to go to “AA” meetings. Advice and sick notes were the main trigger for GP attendance. Referral for end stage disease sent directly to the consultants who dealt with irreversible liver disease as fatty liver was reversible and patients were assured by the GP that if they stopped drinking that they would be OK. With few options available and lack of clarity about what they do and what they achieve, the role of the GP has been to deal with the symptoms rather than deal with the problems

Triggers for the Alcohol Pathway Admissions via A/E departments are increasing despite interventions and Liverpool admission rates are higher than neighbours. Funding for drugs services can be allocated for alcohol services if clear benefit can be demonstrated.   This is the final year of a 3 year strategy. Input for a needs assessment – service and knowledge gaps, priorities etc - being sought to inform the next version. The CCG role is primarily to deliver the health services aspects of the Alcohol strategy but also to fully support public health policies and preventative strategies such as localised minimum pricing of a unit of alcohol which was recently dropped by Government. Support and access to services via GPs is variable. A programme of education has been provided and further sessions will be delivered this year. An RCGP eLearning module is available. Advanced training is being organised locally to be delivered in 3 sessions – daytime and evening.

Alcohol pathway group agenda Pathway group has convened and the second was presented to the programme group earlier this month. The third meeting is due imminently. The pathway aims to promote the referral of appropriate patients into a single point of access - LCAS – rather than GPs referring directly to specialist services such as Windsor Clinic   There is a need for guidance to promote the prescribing of medication at the end of the detoxification process but not during. AUDIT tool applied if AUDIT C score 5+ Brief intervention only if AUDIT score 8+ Thiamine to be prescribed if AUDIT score 16+ Referral to LCAS trigger is AUDIT score 16+

Audit and Audit C Scoring What is the AUDIT-C? The AUDIT-C is a 3 question screen that can help identify patients with alcohol misuse. The AUDIT- C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety.

Audit C Questions 1-3 Q1: How often did you have a drink containing alcohol in the past year? Never (0 points) Monthly or less (1 point) Two to four times a month (2 points) Two to three times per week (3 points) Four or more times a week (4 points) Q2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? 0 drinks (0 points) 1 or 2 (0 points) 3 or 4 (1 point) 5 or 6 (2 points) 7 to 9 (3 points) 10 or more (4 points) Q3: How often did you have six or more drinks on one occasion in the past year? Less than monthly (1 point) Monthly (2 points) Weekly (3 points) Daily or almost daily (4 points)

Audit tool questions 4 - 6 What are the AUDIT Questions 4-10? Q4: How often during the last year have you found that you were not able to stop drinking once you had started? Never (0 points) Less than monthly (1 point) Monthly (2 points) Weekly (3 points) Daily or almost daily (4 points) Q5. How often during the last year have you failed to do what was normally expected of you because of drinking? Q6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Audit questions 7 - 10 Q7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0 points) Less than monthly (1 point) Monthly (2 points) Weekly (3 points) Daily or almost daily (4 points) Q8. How often during the last year have you been unable to remember what happened the night before because of your drinking? Never (0 points) Less than monthly (1 point) Weekly (3 points) Q9. Have you or someone else been injured because of your drinking? No (0 points) Yes, but not in the last year (2 points) Yes, during the last year (4 points) Q10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No (0 points) Yes, but not in the last year (2 points) Yes, during the last year (4 points)

Brief Alcohol Intervention What is a Brief Alcohol Intervention for alcohol misuse? Below are the most common components of brief interventions/counselling that have been shown to decrease drinking: 1) Expressed concern from the provider, regarding unhealthy alcohol use 2) Feedback linking the patient's drinking to his/her health issues 3) Education about recommended drinking limits 4) Offer of explicit advice to cut down drinking or abstain 5) Follow-up 2-4 weeks later to assess the patient's response 6) Referral to specialty addictions treatment if indicated The most effective interventions are explicitly patient centred and non- confrontational. Asking the patients' permission to discuss, eliciting their thoughts, and using reflection are several methods recommended for engaging patients in behaviour change. Longer counselling sessions are not necessarily better. Five minutes of advice has been shown to be as effective as 20 minutes.

If brief intervention is not effective Patients who are unable to cut down their alcohol consumption or abstain should be offered referral to an addictions treatment program. For patients who decline treatment, even if they are alcohol dependent, there is evidence that repeated brief interventions are effective. The content of the brief intervention should continue to include explicit advice to decrease drinking or abstain, and may also be focused on how the increased alcohol use impacts the patient's health. These repeated brief interventions may be done during a surgery consultation, or over the phone. A randomized controlled trial of telephone follow up for brief intervention demonstrated that male patients who engaged in 6 calls (using motivational interview techniques) reported significantly cutting down their drinking at 3 months compared with the control group.

Sex differences Why is the AUDIT-C cut-off higher for men than women? The recommended cut-off for women is based on studies of women, which used in-depth interviews to assess their drinking patterns and problems due to drinking. Women develop problems due to drinking at lower levels of alcohol consumption than men (e.g. breast cancer and liver disease). This reflects their lower total body water as well as possible differences in metabolism and susceptibility to disease. Alcohol use in the past was more stigmatized for women compared to men, so women may be more likely to under- report their drinking.

Liverpool CCG plans Clinician led- The pathway into alcohol recovery is to be co- owned by GP’s in the CCG and the Local Authority/Public Health which is now led by Doctors. Referrals will by made via GP practices directly or by patient self referrals once identified that there is a need for intervention. Patient Focused -We will empower our patients to engage in improving their overall quality of  life, to interact in their care plans, and to ensure that no decisions will be  made without fully involving patients, both in the planning and monitoring of  services Outcome Led - Depending upon what the results are, we will modify our efforts and channel more resources where the outcomes are favourable and measurable. Partnership and Collaboration -We believe in working in unity, both within our organisation and externally with  our partners.  We listen to, communicate with, and work effectively with all our  partners including membership practices, Trusts, the Local Authority, and  Commissioning Support Services. From the Vision and Values Patient Focused and Outcome Led  We will empower our patients to engage in improving their overall quality of  life, to interact in their care plans, and to ensure that no decisions will be  made without fully involving patients, both in the planning and monitoring of  services. Partnership and Collaboration We believe in working in unity, both within our organisation and externally with  our partners.  We listen to, communicate with, and work effectively with all our  partners including membership practices, Trusts, the Local Authority, and  Commissioning Support Services. Locally Focused We will work through locality and neighbourhood groups to implement and  deliver services that meet the needs of our communities. Progressiveness We encourage innovation and continuous improvement in all services we  commission.  We will target our resources in the most effective way to ensure  we offer value for money in the services we provide, and equity for patients. Accountability  We accept responsibility for our actions.  We make and support business  decisions through experience, evidence and good judgement, and we will  deliver against our promises. Integrity and Respect

Alcohol – How big the problem is

Alcohol – variation in practice There is substantial variation in the difference between admissions and LCAS referral. We know that there is variation in the levels of identified demand There is also a difference in how practices deal with this You probably can’t see this very well – although there is a general trend between admissions and LCAS referral, there is substantial variation We have asked for the figures regarding self referrals being matched up to registered GP in order to define stats.

Alcohol as a health and wellbeing issue in general practice It is a partnership between GP’s, local authority/Public Health and providers Commissioning of services with the main onus being on the Local Authority in conjunction with Public Health. Delivery of services Actively identify drinkers (who are willing to change) Prescribe initial treatment Proactive referral to correct supporting services Informed management of end stage disease

Current LCAS Provision Liverpool Community Alcohol Service – commissioned by Local Authority LCAS run 70 clinics a week across the city. GPs and commissioners are not clear about what services are provided and from where.   LCAS provide support to housebound patients but this is not well known. Community detox services This is provided via LCAS. It involves daily dosing, plus psychological support. It is unclear how hospital services access community detox. The group agreed that there was limited support for patients post detox and services that have been decommissioned should be reviewed.

Drivers for change Clinical pathway to set out expectations is the only way forward. Looking at the gateway for all patients and those seeking advice and counselling. Not only the patient themselves but the relatives. Clear understanding of the outcomes and benefits of the various supporting services GPs as referrers to a supporting service. CCG as commissioner of that service Formal (mandatory) inclusion in undergraduate and training curricula about the unification of alcohol pathway utilisation. The pathway will be one with one gateway with several methods of entry. Exit points with a gateway for re-entry. There is a concern around high rates of DNA’s and low referrals to LCAS. Maintenance treatment in the form of psychological counselling and prescription medication for symptoms and opioid receptor blockers currently prescribed by Consultants should really be prescribed in Primary Care post detox. Clear understanding of the outcomes and benefits of the various supporting services GPs as referrers By understanding what a patient will get from a supporting service the GP is more likely to refer CCG as commissioner As a commissioner the CCG needs to be clear what supporting services are delivering, whether the intervention is cost effective and whether there are service gaps that need to be filled

The future......... There is currently no identified service pathway for persons with alcohol related brain damage. There is evidence that persons with Wernicke’s encephalopathy are potentially reversible. By the time Korsakov’s psychosis sets in – it is irreversible. Mental Health Providers and Local Authority need to be working on this to ensure a pathway is available to avoid further “street drunks living in retail doorways.” AKA People with dementia observed during the last stages of severe chronic alcoholism. Clear understanding of the outcomes and benefits of the various supporting services GPs as referrers By understanding what a patient will get from a supporting service the GP is more likely to refer CCG as commissioner As a commissioner the CCG needs to be clear what supporting services are delivering, whether the intervention is cost effective and whether there are service gaps that need to be filled