1. Implementing an alcohol referral pathway The experience of an ambulance service Cathryn James/ Tom Heywood

2. Context In Quarter 1 of 2013/14 YAS attended 10,178 999 calls where alcohol was suspected. This equates to 5.9% of all 999 calls (may be higher). The ambulance costs are estimated at £231 per patient. Over a third of frequent callers to YAS have alcohol misuse issues.

3. Background This pathway promotes the ‘Make Every Contact Count’ approach, a nationwide initiative to help people stay healthy and reduce system-wide costs to the NHS. Inappropriate frequent calls put an additional unnecessary strain on the 999 service. Ambulance clinician’s role in terms of public health are yet to be realised. Lack of evidence? The only ambulance trust to have this pathway.

4. Aims and objectives The aim was to explore the ways in which an ambulance service could improve the health of their patients that present to the 999 service due to alcohol misuse. The objective was to develop a pathway for ambulance clinicians so they can identify alcohol misuse and offer referral to specialist services.

5. NICE Guideline QS11: Alcohol dependence and harmful alcohol use quality standard Statement 1. Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol. Statement 2. Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice. Statement 3. People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment.

6. How does the pathway work? Clinicians identify a patient who may benefit by using CAGE tool screening. Gain patient consent to refer (over 18 only). Refer 24/7 via YAS clinical hub (single point). Referral faxed to the appropriate provider.

7. Referral data Sheffield and Rotherham were pilot sites in October 2011 From April 2012- October 2013 there were 120 patient referrals, an average of 6 per month. Pathway implemented YAS wide from 2nd December 2013 YAS wide up to the 17 April 2014 there has been 113 patient referrals.

8. Resources Current YAS management set up resource Additional YAS clinician time to make referral Additional time and resource at YAS clinical hub (single point) Continued management of current pathway Proposed Patient information leaflet/ advice card/ details of services available Educational material and dedicated training for YAS clinicians

9. Costs The costs to resource the pathway to date have been incorporated within the current YAS budget. We are presently trying to quantify an overall cost per referral. No immediate YAS benefits, however we believe there benefits to wider NHS and social care community.

10. Benefits Better patient experience/ care. Reduce overall burden to the NHS and social care system. Referral can act as a gateway to manage other issues. YAS does not receive immediate benefit.

11. Evaluation Patient stories Need for feedback on outcomes from providers! YAS are currently trying to quantify the impact on frequent callers Research opportunities Invited to present a poster at the NICE shared learning awards at the National conference in May

12. Patient story A message for ambulance crews ‘Someone in my state wouldn’t often seek help themselves or are often not in a state to do so. I would like to give a message to all ambulance crews to take every opportunity to try and refer patients with alcohol problems; it might seem as if it will fall on stony ground but on every occasion they should try (please don’t be put off). The input from the crew was invaluable for me and could be for others too.’

13. Future YAS data collection Extend CAGE questionnaire to ask where the patient accessed their last drink from. Hot spots for alcohol related calls. YAS data on frequent callers.

14. Next steps Further development is underway for the pathway to include children/ young people (NICE quality statement 12) Expand pathway for substance/drug misuse YAS staff education/ training; opportunity to develop Identification and brief intervention training for YAS staff More robust data collection and clinical outcomes

15. Next steps continued.. Move from faxed referrals to a secure electronic process. Ensure a smooth handover of service providers in next commissioning round. Patient leaflets/information. To develop identification and brief advice (IBA) specifically for ambulance services.

16. Any questions? Future working partnerships? Contacts. Thomas Heywood thomas.heywood@yas.nhs.ukthomas.heywood@yas.nhs.uk Tel. 07825101616 Cathryn James cathryn.james@yas.nhs.ukcathryn.james@yas.nhs.uk Tel. 07789865053