A&E and Alcohol Services Peter Rice, Consultant Psychiatrist, NHS Tayside

“Society is changing. There’s a reduction in trauma e.g. car accidents, but much more chronic illness” (Senior Nurse) Inequalities, Health and the Accident and Emergency Response NHSGGC Anne Bryce 2010

British Liver Trust / ONS 2009 UK MORTALITY TRENDS

Male Cancer Deaths in Scotland

Liver Cirrhosis Death Rates 1950 – 2006 : An International Comparison

Chronic Liver Disease Mortality by Deprivation, Scotland (Men)

Attendees at NHSGGC A&E units more often come from the poorest communities in Glasgow, including marginalised groups such as asylum seekers and refugees, where chronic ill-health, reduced personal resources and problematic lifestyle behaviours are both the cause and consequence of an experience of poverty, social exclusion and poor social support. Inequalities, Health and the Accident and Emergency Response NHSGGC Anne Bryce 2010

“Problems are upstream….A&E can only pull them out the water, patch up and return to the community” (A&E Manager Inequalities, Health and the Accident and Emergency Response NHSGGC Anne Bryce 2010

What works? International Review of Policy Measures Authored by Public Health Academics Sponsored by WHO

StrategyMeasureEffect Price ControlsTaxation graduated by strength Controlling cheapest price High ? High TreatmentBrief Interventions Intensive treatment for dependence High High/Mid AvailabilityEnforced age limits Restricted hours Retail monopolies Outlet Density High Mid Safer Environment Enforcement of licensing codes Server Training Mid MarketingLimiting exposure to advertisingLow Education and Information Integrated campaigns Classroom Education Only Public Campaigns / Warning Labels Low Nil

Alcohol Statistics Scotland 2011 RECENT AFFORDABILITY TRENDS On trade Beer Off trade beer

SCOTTISH ALCOHOL CONSULTATION A Minimum Price for Alcohol - No discounts for multiple purchase - Separate areas and checkouts in stores - Age limit of 21 in off sales - Social responsibility fee - More support and treatment

- Coronary Heart Disease - Children’s Dental Care - Childhood Obesity - Suicide Prevention - Smoking Cessation - Breastfeeding and……. Achieve agreed number of screenings using the setting- appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines by 2010/11 HEALTH IMPROVEMENT TARGETS 2008

SCOTTISH ALCOHOL BILL Principle of social responsibility levy. - Ban on discount for multiple purchase. - Confining promotional material to alcohol display area. - Compulsory age verification policy (under 25) - Licensing boards to consider ban on off-sales to under 21s. - Minimum price per unit of Alcohol

“Staff can’t do everything that is asked of them. Some staff are able to do this well because of their interest and personality, others not….Like ABI (Alcohol Brief Intervention) we will consider what part of the intervention we can do and try to tailor to the department – like raising a concern with the attendee and giving them information” (Senior Nurse) Inequalities, Health and the Accident and Emergency Response NHSGGC Anne Bryce 2010 “No time for staff to undertake brief interventions. May be possible through fracture clinic but not in ED” (A&E Manager ) WHAT IS A&E’s ROLE ?

1000 pts in study across 14 sites. Intervention delivered by A&E staff with option of onward referral Treatment group 10 min BI / Control group written handout Treatment group reduced consumption at 3/12 but effect not sustained.

SCREENING TOOLS Brief Reliable Deliverable Paddington Alcohol Test (PAT) Fast Alcohol Screening Test (FAST)

MESSAGES SO FAR There’s a lot of it about You don’t win them all A&E Staff can be influential, but so can others Brief Interventions can start change process But less likely to be effective as dependence increases.

Scottish Alcohol Needs Assessment 2009

DOES THE SERVICE MEET THE (POTENTIAL) DEMAND ? Ratio of Service Capacity : Demand

Trends in Consumption and Mortality Mortality and Consumption go together. Mortality changes quickly. Recent fall in consumption. - Rise in excise duties - Falling incomes - Destocking