1. Why we need to get to grips with alcohol in Wessex

2. Prescribing Observatory for Mental Health Audit: How can we manage alcohol use in Mental health Services? Dr Shanaya Rathod/Dr Julia Sinclair

3. To improve outcomes for patients with co-morbid alcohol use – Implementation of NICE guidance Screening Brief interventions ?Consider – Develop and pilot a pathway within SHFT – Links with AHSN to evaluate and disseminate across Wessex Aims

4. Prevalence UK Psychiatric patients CMHT (London) -44% harmful alcohol use or recent substance use (Weaver 2003) Psychiatric IP - 49% harmful alcohol use (1/12) (SW London) and 27% drug use (1/12) (Barnaby 2003) Psychiatric IP-50% men and 29% women (Oxfordshire)harmful alcohol use (1/12) (Sinclair 2008)

5. Barriers to effective care Definitions of ‘dual diagnosis’ – suggest “co-morbidity” Low levels of ‘Alcohol specific Health literacy’ in staff Culture – Details of patients addictive behaviours often poorly documented (e.g Farrell 1988, WRISS 2001a, 2001b) – Seen as not part of core role “refer on”

6. Context

7. NICE CG115: “Staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They should be competent to initially assess the need for an intervention or, if they are not competent, they should refer people who misuse alcohol to a service that can provide an assessment of need” NICE PH24: “Brief interventions for adults should be delivered by Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with people who may be at risk of harm from the amount of alcohol they drink.” Alcohol specific health literacy

8. Quality improvement programme Prescribing in substance misuse: alcohol detoxification Baseline audit March 2014

9. Method Participants: 43 Mental Health Trusts participated 174 clinical teams 1,197 adult patients Audit data collected: Demographic, diagnosis, type of service Documentation of alcohol misuse, physical and neurological assessments Medication prescribed to treat alcohol withdrawal, dosage and details of regimen Specialist advice sought during alcohol detoxification and for continuing management

10. Clinical service providing care for alcohol detoxification Baseline N=1,197 Clinical service providing care Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) Sub-sample of patients whose admission for alcohol detoxification was unplanned N = 735 (61%) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of sub-sample) n (% of total sample) Acute adult psychiatric ward - detoxification overseen by a non-specialist adult psychiatrist 139 (30%)694 (94%)833 (70%) Acute adult psychiatric ward - detoxification overseen by a specialist in alcohol/substance misuse 321 (69%)24 (3%)345 (29%)

11. Initial assessment: Documentation of past history of alcohol detoxification Baseline N=1,197 Documentation of previous detoxifications Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) Sub-sample of patients whose admission for alcohol detoxification was unplanned N = 735 (61%) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of sub-sample) n (% of total sample) 1-4 previous alcohol detoxifications 224 (48%)270 (37%)494 (41%) 5 or more previous alcohol detoxifications 34 (7%)40 (5%)74 (6%) First known alcohol detoxification 130 (28%)175 (24%)305 (25%) Not documented74 (16%)250 (34%)324 (27%)

12. Initial assessment: Standardised assessments/rating scales used Baseline N=1,197 Standard assessments/rating scales Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) CIWA-Ar (prior to starting detoxification regimen)170 (14%) CIWA-Ar (during detoxification regimen)170 (14%) SADQ113 (9%) AUDIT80 (7%) APQ11 (1%) LDQ7 (1%) None of the above 690 (58%) Other 65 (5%)

13. During admission: Documented brief intervention Brief intervention Total sample All patients who were admitted for alcohol detoxification N = 1,197 Documented 505 (42%) Not documented 692 (58%)

14. Discharge: Medication for relapse prevention prescribed at the point of discharge Baseline N=1,197 Type of drug Sub-sample of patients who were admitted under non- specialist care N= 848 (71%) Sub-sample of patients who were admitted under specialist care N=349 (29%) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of type of drug) n (% of total sample) Acamprosate 115 (14%)133 (38%)248 (21%) Naltrexone 4 (<1%)10 (3%)14 (1%) Disulfiram 14 (2%)45 (13%)59 (5%) Nalmefene 000 Not on any of the relapse medication above 720 (85%)178 (51%)898 (75%) Baclofen 2 (<1%)0 Not applicable17 (2%)017 (1%)

15. Initial assessment: Documented drinking history Proportion of patients who had a documented assessment of drinking history at admission Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a.A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation 1.3.4.5). b.A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).

16. Initial assessment: Documented physical examination Proportion of patients who had a documented physical assessment at admission Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a.A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation 1.3.4.5). b.A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).

17. Initial assessment: Documented assessments for the signs and symptoms of Wernicke’s encephalopathy Proportion of patients who had documented assessments of the signs and symptoms of Wernicke’s encephalopathy

18. Implementation of NICE guidance Screening Brief interventions How to improve outcomes for patients with co-morbid alcohol use?

19. Requesting help with alcohol problem New Presentation Periodic Review Full screen AUDIT AUDIT Score 8-15 Increasing-risk Consider joint working with Specialist services Full Assessment Extended Brief Advice AUDIT Score 16-19 Higher-risk AUDIT Score 20+ Possible Dependence AUDIT Score 0-7 Lower-risk Alcohol Care Pathway No action Positive Result Negative Result FAST AUDIT - C Initial Screening Tools Brief Advice Units of alcohol

20. 2. Need to Actively Manage Alcohol Use as integral part of care Assessment Drinking reduction Detox Relapse Prevention

21. Ways to Optimise Treatment Identification – CQUIN? Make management an integral part of the treatment plan Engender a culture of therapeutic optimism within the service Staff training in basic competencies Actively manage both conditions Drink diaries and motivational interviewing are effective tools – core part of MHS Don’t forget pharmacotherapy www.warc.soton.ac.uk Wessex Alcohol Research Collaborative

22. To improve outcomes for patients with co-morbid alcohol use – where ever they present – Implementation of NICE guidance in MH Services Screening Brief interventions Active management of co-morbid alcohol use Consider? – Develop and pilot a pathway for MH services – Links with AHSN to evaluate and disseminate across Wessex AHSN working together

23. Why we need to get to grips with alcohol in Wessex Alcohol care in England’s Hospitals, an opportunity not to be wasted

24. Alcohol care in England’s hospitals: An opportunity not to be wasted. Jason Mahoney Head of Alcohol and Drugs, South East PHE Centres

25. Public Health England Protecting and improving the nation’s health and wellbeing and reducing health inequalities. www.gov.uk/phe 25 Alcohol care in England’s hospitals

26. Why alcohol concerns us What we can do about it How to do that So, what next? 26Alcohol care in England’s hospitals

27. 27Alcohol care in England’s hospitals

28. 28Alcohol care in England’s hospitals

29. 29Alcohol care in England’s hospitals

30. Percentage change in standardised UK mortality rates (age 0-84) normalised to 100% in 1970 Liver Circulatory Ischaemic heart Cerebrovascular Neoplasms Respiratory Endocrine/metabolic Diabetes 30Alcohol care in England’s hospitals Liver disease deaths compared with the other major killers

31. PHE Fingertips Wessex PHE Centre Local Authorities compared to England Liver disease Alcohol specific hospital admissions Under 75 mortality rate – alcoholic liver disease http://fingertips.phe.org.uk/profile/liver-disease/ 31Alcohol care in England’s hospitals

32. 32Alcohol care in England’s hospitals

33. 33Alcohol care in England’s hospitals Reducing consumption prevents ill health Regularly consuming 25g (3 units) daily Regularly consuming 50g (6 units) daily Regularly consuming 100g (12 units) daily Cancers Increase over standard risk Mouth and throat 96%211% 545% Colon 5% 10% 21% Oesophagus 39% 93% 259% Rectum 9% 19% 21% Liver 19% 40% 81% Larynx 43%102% 286% Breast 25% (f) 55% (f) 141% (f) Cardiovascular Hypertension 43%104% 315% Ischaemic stroke -10% 17% 337% Haemorrhagic stroke 19% 82% 370% Cardiac arrhythmias 51%123% Oesophageal varices 26%854% Unspecified liver disease 26%854% Acute and chronic pancreatitis 34% 74% 219%

34. Evidence into action: PHE Priorities 34 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PHE_Priorities.pdf Reducing harmful drinking A reduction in the number of hospital admissions due to alcohol. Alcohol care in England’s hospitals

35. Alcohol as a public health priority Reducing harmful drinking: What works? - Social Marketing - Licensing - Identification and Brief Advice - Alcohol care teams / hospital settings - Specialist alcohol treatment 35Alcohol care in England’s hospitals

36. 36Alcohol care in England’s hospitals

37. RCP 2001 Dh 2009 BSG, Alcohol Health Alliance UK 2010 HM Govt 2012 University of Stirling 2013 10+ years of recommendations Alcohol care in England’s hospitals 2001 “a dedicated alcohol health worker or an alcohol liaison nurse in each major acute hospital” 2009 “High impact change 5: Appoint an alcohol health worker” 2010 “a multidisciplinary Alcohol Care Team in each district hospital” 2012 “We encourage all hospitals to employ Alcohol Liaison Nurses“ 2012 “Multidisciplinary alcohol care teams should organise systematic interventions” 2013 “Every acute hospital should have a specialist, multi-disciplinary alcohol care team tasked with meeting the alcohol-related needs of those attending the hospital and preventing readmissions.” 37 Alcohol care in England’s hospitals

38. NICE quality and productivity proven case study: 38Alcohol care in England’s hospitals

39. 39Alcohol care in England’s hospitals Commissioning of services

40. Broad service types 40Alcohol care in England’s hospitals Services are diverse, but fall into three broad categories: multi-disciplinary alcohol care teams – Supporting patient care from within the hospital and liaising with community services in-reach alcohol care teams – based in the community to support the care of hospital patients high impact user (HIU) services - identify and assertively engage with a relatively small number of those patients who attend A&E or are admitted most frequently

41. What’s recommended Hospital alcohol services, led by a senior clinician with dedicated time for the team and providing evidence-based interventions. Teams will facilitate identification of alcohol misusers in hospitals and appropriate packages of care provided by multi-disciplinary teams. Whether teams are large or small, set within the hospital or in-reach, they should be able to provide: case identification/Identification and Brief Advice (IBA) comprehensive alcohol use Assessment contribution to nursing and medical care planning psychotherapeutic interventions medically assisted alcohol withdrawal management discharge planning including referral to community services 41Alcohol care in England’s hospitals

42. 42 Report recommendations Every district general hospital should consider having effective specialist alcohol provision Existing services should be maintained and developed Alcohol Care Teams to support training for colleagues in all clinical areas Ensure that existing services are adequately integrated across primary and secondary care and that new services are implemented where there are none Local partners should consider employing assertive out-reach or in-reach services for high impact service users in all major hospitals and existing services should be evaluated to assess their impact on hospital and community services System planning should ensure that community services are accessible and available to ensure continuation of detoxification with psychosocial interventions outside of the hospital Alcohol care in England’s hospitals

43. 43 What PHE will do next We will develop pro-forma service specifications for each of the broad service types We will develop a core minimum dataset for alcohol care teams We will develop a pro-forma evaluation template to help ensure that service evaluations are comparable. We will re-run the survey of hospital services Alcohol care in England’s hospitals

44. So, what could you do? Is there an alcohol care team at the local hospital? How is it funded? Has it been evaluated? Does it reflect the recommendations? 44Alcohol care in England’s hospitals

45. Thank you Jason Mahoney Head of Alcohol and Drugs, South East PHE Centres Jason.Mahoney@phe.gov.uk 07787 005 689 45Alcohol care in England’s hospitals

46. Why we need to get to grips with alcohol in Wessex James Linde Alliance Alcohol Related Liver Disease Priority Setting Partnership Beccy Maeso, Senior Programme Manager, NIHR Evaluation, Trials and Studies Coordinating Centre

47. James Lind Alliance (JLA) Alcohol Related Liver Disease Priority Setting Partnership Beccy Maeso

48. The James Lind Alliance (JLA) Involving patients and clinicians in setting priorities for research Finding out what research is important to: Patients / service users Carers / relatives Clinicians / healthcare professionals

49. What is the JLA? Established in 2004 Royal Society of Medicine – Dr John Scadding James Lind Library - Sir Iain Chalmers INVOLVE – Sir Nick Partridge Since April 2013: part of NETSCC JLA Advisers The Guidebook

50. Who was James Lind? James Lind (1716-1794) A pioneer of clinical trials

51. Alcohol Related Liver Disease Priority Setting Partnership Bring patients and clinicians together to Identify uncertainties about the effects of treatments Agree by consensus a prioritised “top 10” list of uncertainties for research Publicise the methods and results of the PSP Draw the results to the attention of research funders independently of the JLA More info jla.southampton.ac.uk

52. How do we do it? The priority setting process: Set up steering group Invite partners Gather uncertainties Prioritise uncertainties Promote priorities to researchers and funders

53. Set up steering group Patient, carer and clinician representatives Resources and expertise Regular meetings Publicising the project Overseeing the process Responsible for dissemination of results JLA chair – a neutral facilitator Protocol

54. Gather uncertainties What are treatment uncertainties? no up-to-date, reliable systematic reviews of research evidence addressing the uncertainty about the effects of treatment exists up-to-date systematic reviews of research evidence show that uncertainty exists

55. ARLD steering group

56. Gather uncertainties Survey Patients and carers Clinicians Research recommendations UK Database of Uncertainties about the Effects of Treatments (UK DUETs) www.library.nhs.uk/duets

58. Check the uncertainties Prepare the dataset Remove out of scope submissions Categorise eligible submissions Format the submissions PICO questions: Patient/Population, Intervention, Comparator, Outcome “Lumping and splitting” Verify the uncertainties Identify research recommendations Prepare the long list

59. Prioritise uncertainties – step 1 (interim stage) From a long list to a short list Top 10 uncertainties chosen by partners As individuals On behalf of members On behalf of colleagues Representing an organisation

60. Prioritise uncertainties – step 2 (final) Priority setting workshop Patients, carers and clinicians A day of democratic discussion and ranking Nominal Group Technique Prioritise the remaining uncertainties Agree the top 10

61. Final priority setting

62. JLA Priority Setting Principles The principle of patients, carers and clinicians working together Methodological transparency Declaration of interests Working with UK Database of Uncertainties about the Effects of Treatments www.library.nhs.uk/duets www.library.nhs.uk/duets

63. Next steps Promote priorities to researchers and funders NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC) Dissemination of findings Publications Conferences

64. Current Partnerships Anaesthesia Depression Hip and knee replacement for osteoarthritis Inflammatory bowel disease Intensive care Late stillbirth Mesothelioma Neuro-oncology Palliative and end of life care Parkinson’s disease Spinal cord injury Common Shoulder problems Alopecia Renal Transplantation Surgical Treatment for Early Hip and Knee Osteoarthritis Endometrial Cancer Teenage and Young Adult cancer Mild to moderate hearing loss Alcohol related liver disease Non alcohol related liver and gall bladder diseases Cavernoma

65. Completed Partnerships Asthma Urinary incontinence Vitiligo Prostate cancer Schizophrenia Type 1 diabetes ENT aspects of balance Life after stroke Eczema Tinnitus Cleft lip and palate Lyme disease Pressure ulcers Sight loss and vision Dementia Dialysis Multiple sclerosis Hidradenitis suppurativa Acne Pre-term birth Childhood disability

66. What difference does it make? Asthma Funding has been awarded by NIHR HTA programme to fund research to provide better evidence on the effects of breathing exercises for asthma

67. Prioritised areas from PSP uncertainties Non-pharmacological interventions to reduce weight gain in people with schizophrenia prescribed antipsychotic medication Management of sexual dysfunction due to antipsychotic drug therapy Training to recognise the early signs of recurrence in schizophrenia (joint research call between NIHR and Australian National Health and Medical Research Council)

68. For more information… email jla@soton.ac.ukjla@soton.ac.uk More info www.jla.nihr.ac.ukwww.jla.nihr.ac.uk @lindalliance @LindAlliance

69. Questions ?