1. Professor Eileen Kaner
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

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

3. So much evidence Freemantle 1993 - 6 trials in primary care
24% drop in consumption (95% CI 18 to 31%)
Moyer 2002 – 56 trials, 34 relevant to PHC
Consistent +ve effect, NNT 8-12 (smoking is 20)
Cost savings found at 4 years in the USA
Kaner 2007 – 29 trials in PHC & A&E
Consistent positive effects ~7 drinks less/week
Evidence strongest for men, less work on women
No significant benefit of longer versus shorter BI

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

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

6. Practitioners want prioritisation: their ‘to do’ list

7. 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

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

9. 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.

10. 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

11. 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

12. NICE’s flow diagram for how it is all carved up

13. Levels of prevention
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
Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more advanced or irreparable disease

14. Upstream

15. Down stream

16. Primary prevention question 1
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?

17. Primary prevention question 2
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?

18. Primary prevention question 3
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?

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

20. Caveats How robust is the evidence? How specific 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

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

22. Secondary prevention question 5
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?

23. Secondary prevention question 6
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

24. Secondary prevention question 7
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?

25. Secondary prevention outcomes
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.
a reduction in hazardous and/or harmful drinking in adults and young people.
System requirements to enable SBI to occur
Training/support
Materials
Time
Referral routes

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

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

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

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

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