NICE work if you can get it: Screening & brief intervention as a Public Health strategy to reduce hazardous & harmful drinking in England. Professor Eileen Kaner

Overview of the presentation Why do we need guidelines? Why do we need guidelines? Despite lots of evidence SBI is not routinely deliveredDespite lots of evidence SBI is not routinely delivered Needs top-down prioritisationNeeds top-down prioritisation General policies are not enough General policies are not enough Specific guidance on ‘what should happen’ Specific guidance on ‘what should happen’ Policy makers need to consider impact & costPolicy makers need to consider impact & cost Their interest is ‘why should we prioritise this’ Their interest is ‘why should we prioritise this’ How might it happen with minimal disruption How might it happen with minimal disruption

So much evidence Freemantle trials in primary care Freemantle trials in primary care 24% drop in consumption (95% CI 18 to 31%)24% drop in consumption (95% CI 18 to 31%) Moyer 2002 – 56 trials, 34 relevant to PHC Moyer 2002 – 56 trials, 34 relevant to PHC Consistent +ve effect, NNT 8-12 (smoking is 20)Consistent +ve effect, NNT 8-12 (smoking is 20) Cost savings found at 4 years in the USACost savings found at 4 years in the USA Kaner 2007 – 29 trials in PHC & A&E Kaner 2007 – 29 trials in PHC & A&E Consistent positive effects ~7 drinks less/weekConsistent positive effects ~7 drinks less/week Evidence strongest for men, less work on womenEvidence strongest for men, less work on women No significant benefit of longer versus shorter BINo significant benefit of longer versus shorter BI

So little practice Majority of GPS may be missing up to 98% of excessive drinkers in PHC (Kaner et al. 1999) Majority of GPS may be missing up to 98% of excessive drinkers in PHC (Kaner et al. 1999) NAO 2008 report on recent activity NAO 2008 report on recent activity 58% PCTs have an alcohol strategy58% PCTs have an alcohol strategy 69% provided data on expenditure69% provided data on expenditure Spend is ~£600,000 on alcoholSpend is ~£600,000 on alcohol About 0.1% of PCT annual expenditure of £460MAbout 0.1% of PCT annual expenditure of £460M

General policies Alcohol harm reduction strategy 2004 Alcohol harm reduction strategy 2004 Choosing Health White paper 2004 Choosing Health White paper 2004 Prison Service Alcohol strategy, 2004 Prison Service Alcohol strategy, 2004 DH Local Implementation guidance 2005 DH Local Implementation guidance 2005 Models of Care for Alcohol misuse 2006 Models of Care for Alcohol misuse 2006 National Probation Service / NOMS 2006 National Probation Service / NOMS 2006 Safe, Sensible, Social – next steps 2007 Safe, Sensible, Social – next steps 2007 BMA tackling the alcohol epidemic 2008 BMA tackling the alcohol epidemic 2008 Safe, Sensible, Social: further action, 2008 Safe, Sensible, Social: further action, 2008 Healthcare Commission on choosing health, 2008 Healthcare Commission on choosing health, 2008

Practitioners want prioritisation: their ‘to do’ list

National Institute for Health and Clinical Excellence (NICE) Independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health Topics referred by government initially NICE produces guidance in three areas of health: public health – Prevention goes beyond NHS health technologies – Drugs and interventions clinical practice – Appropriate delivery of care

Like buses! Three separate referrals on alcohol to NICE Three separate referrals on alcohol to NICE PreventionPrevention Physical treatmentPhysical treatment Mental Health ManagementMental Health Management These came to separate parts of NICE These came to separate parts of NICE Complex agendaComplex agenda Is carving it up the best way to deal with it?Is carving it up the best way to deal with it?

Prevention guidelines due March 2010 Scope: The prevention of alcohol-use disorders in people 10 years and older, covering: interventions affecting the price, advertising and availability of alcohol; how best to detect alcohol misuse both in and outside primary care; brief interventions to manage alcohol misuse in these settings.

Clinical Management guidelines due May 2010 Scope: The assessment and clinical management in adults and young people 10 years and older covering: acute alcohol withdrawal including delirium tremens; liver damage including hepatitis and cirrhosis; acute and chronic pancreatitis; management of Wernicke’s encephalopathy

Dependence guidelines due January 2011 Scope: The diagnosis and management of alcohol dependence and harmful alcohol use in people 10 years and older covering: Identification and assessment pharmacological and psychological/psychosocial interventions, prevention and management of neuropsychiatric complications of alcohol dependence or harmful alcohol use

Levels of prevention Primary prevention – strategies that aim to deter people from drinking heavily (whole population approaches, media campaigns, labelling) Primary prevention – strategies that aim to deter people from drinking heavily (whole population approaches, media campaigns, labelling) Secondary prevention – early identification of clinical risk or harm and intervention to modify it Secondary prevention – early identification of clinical risk or harm and intervention to modify it Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more advanced or irreparable disease Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more advanced or irreparable disease

Upstream

Down stream

Primary prevention question 1 Price: Price: What type of price controls are effective and cost effective in reducing alcohol consumption and/or alcohol-related harm in adults and young people?

Primary prevention question 2 Availability: Availability: Which interventions are effective and cost effective at managing alcohol availability to reduce levels of consumption and/or alcohol-related harm in adults and young people?

Primary prevention question 3 Promotion: Promotion: Which strategies for the control of alcohol promotion are effective and cost effective in reducing levels of consumption and/or alcohol-related harm in adults and young people?

Primary prevention outcomes Expected outcomes: a change in the levels of alcohol consumption across the population Expected outcomes: a change in the levels of alcohol consumption across the population alcohol sales, availability, marketing activityalcohol sales, availability, marketing activity From these we can assume a subsequent impact on alcohol-related health or social problems across the populationFrom these we can assume a subsequent impact on alcohol-related health or social problems across the population

Caveats  How robust is the evidence?  Difficult work methodologically  How specific is the evidence?  To adults &/or young people  How relevant is it to England?  Can we make inferences from other countries

Secondary prevention question 4 Context – targeting for practitioners: Context – targeting for practitioners: What key factors increase the risk of hazardous and harmful drinking? When are individuals most vulnerable to excessive drinking?

Secondary prevention question 5 Identification/screening: Identification/screening: Are alcohol screening questionnaires, biochemical markers or clinical indicators an effective and cost effective way of identifying adults and young people who are at risk due to drinking?

Secondary prevention question 6 Brief Intervention: Brief Intervention: Are brief interventions effective and cost effective in managing hazardous and harmful drinking among adults and young people? And across all groups within our population

Secondary prevention question 7 Implementation: Implementation: What are the key barriers to that influence practitioners’ ability to help adults and young people manage their drinking behaviour? What are the key facilitators?

Secondary prevention outcomes list of the key factors (contexts) associated with an increase in alcohol–related risk or harm - who may be at risk. list of the key factors (contexts) associated with an increase in alcohol–related risk or harm - who may be at risk. an efficient way of identifying adults and young people who are at risk due to their drinking. an efficient way of identifying adults and young people who are at risk due to their drinking. a reduction in hazardous and/or harmful drinking in adults and young people. a reduction in hazardous and/or harmful drinking in adults and young people. System requirements to enable SBI to occur System requirements to enable SBI to occur Training/supportTraining/support MaterialsMaterials TimeTime Referral routesReferral routes

Caveats Imperfect evidence Imperfect evidence Methodological flawsMethodological flaws Realistic evaluation of complex problemsRealistic evaluation of complex problems How relevant is SBI evidence to England specificallyHow relevant is SBI evidence to England specifically Volume of evidence Volume of evidence Summary of published reviews for BI – blunt approachSummary of published reviews for BI – blunt approach But are young people, BME groups adequately covered?But are young people, BME groups adequately covered? Making reasonable extrapolations Making reasonable extrapolations How far can you extend beyond published studies?How far can you extend beyond published studies?

The NICE way of working Evidence produced by independent contractors Evidence produced by independent contractors Considered by large/diverse committee (PDG) Considered by large/diverse committee (PDG) Initial evidence – goes out to public consultation Initial evidence – goes out to public consultation Feedback responded to – public process Feedback responded to – public process Final evidence presented to PDG Final evidence presented to PDG PDG develops recommendations PDG develops recommendations Recommendation consultation Recommendation consultation Field work & testing with practitioners Field work & testing with practitioners Final guidance published Final guidance published

Challenges NICE made up of different organisational cultures NICE made up of different organisational cultures Public health works differently to chronic condition etc.Public health works differently to chronic condition etc. 3 groups with ownership over the 3 scopes3 groups with ownership over the 3 scopes Overlaps & gaps Overlaps & gaps prevention and early treatment eg harmful drinkersprevention and early treatment eg harmful drinkers c an we separatec an we separate physical and mental health management? physical and mental health management? planned & unplanned detoxification? planned & unplanned detoxification? Can this formal (rigid) process capture complexity Can this formal (rigid) process capture complexity The continuum of risk/harm/dependence The continuum of risk/harm/dependence Remitting nature of alcohol related problems Remitting nature of alcohol related problems

Bringing it all together Different timescale for the 3 sets of guidanceDifferent timescale for the 3 sets of guidance Integrated care pathways will be challengingIntegrated care pathways will be challenging What impact will the consultation & field work testing processes have on the scienceWhat impact will the consultation & field work testing processes have on the science Will the ‘plain English’ editing strengthen/dilute the contentWill the ‘plain English’ editing strengthen/dilute the content Making policy-level recommendationsMaking policy-level recommendations If a general election is called, NICE goes into ‘purdah’If a general election is called, NICE goes into ‘purdah’

Nice work if you can get it. And you can get it - if you try. George & Ira Gershwin 1937 But it takes a lot of time and work And sometimes a little diplomacy Eileen Kaner 2009