Reducing Alcohol Harm: health services in England for alcohol misuse

Transcription

1 Departmet of Health Reducig Alcohol Harm: health services i Eglad for alcohol misuse REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1049 Sessio October 2008

2 The Natioal Audit Office scrutiises public spedig o behalf of Parliamet. The Comptroller ad Auditor Geeral, Tim Burr, is a Officer of the House of Commos. He is the head of the Natioal Audit Office which employs some 850 staff. He ad the Natioal Audit Office are totally idepedet of Govermet. He certifies the accouts of all Govermet departmets ad a wide rage of other public sector bodies; ad he has statutory authority to report to Parliamet o the ecoomy, efficiecy ad effectiveess with which departmets ad other bodies have used their resources. Our work saves the taxpayer millios of pouds every year: at least 9 for every 1 spet ruig the Office.

3 Departmet of Health Reducig Alcohol Harm: health services i Eglad for alcohol misuse LONDON: The Statioery Office Ordered by the House of Commos to be prited o 27 October 2008 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1049 Sessio October 2008

4 This report has bee prepared uder Sectio 6 of the Natioal Audit Act 1983 for presetatio to the House of Commos i accordace with Sectio 9 of the Act. Tim Burr Comptroller ad Auditor Geeral Natioal Audit Office 24 October 2008 The Natioal Audit Office study team cosisted of: Grace Beardsley, Beth Bishop ad Will Palmer, uder the directio of Mark Davies. This report ca be foud o the Natioal Audit Office web site at For further iformatio about the Natioal Audit Office please cotact: Natioal Audit Office Press Office Buckigham Palace Road Victoria Lodo SW1W 9SP Tel: equiries@ao.gsi.gov.uk Natioal Audit Office 2008

5 contents SUmmarY 4 part oe Itroductio 11 part two Plaig ad commissioig of services 17 to reduce alcohol harm part three Provisio of educatio, idetificatio 23 ad advice part four Provisio of specialist alcohol 30 treatmet services appedices 1 Departmet of Health commitmets 36 from 2004 ad 2007 alcohol strategies 2 Iteratioal cotext 38 3 Alcohol misuse ad the respose i 40 Scotlad, Wales ad Norther Irelad 4 The ew Public Service Agreemet 42 (PSA) o alcohol ad drugs 5 methodology 44 6 cost-effectiveess of alcohol treatmets 46 7 Terms used i this report 48 Cover photograph courtesy of The Last Drop/Ja Havicksz Stee/Bridgema Art Library; Photographs o cotets page ad page 23 courtesy of Digital Visio Ltd.; Photograph o pages 4 ad 11 courtesy of Alamy.com ad Photographs o pages 17 ad 30 courtesy of

6 SummARy 1 For a sigificat ad growig umber of people i Eglad, alcohol cosumptio is a major cause of ill-health. More tha 10 millio people (31 per cet of me ad 20 per cet of wome) are ow regularly drikig above the guidelies set by Govermet, ad may of these are likely to suffer ill-health or ijury as a result. Hospital admissios for the three mai alcoholspecific coditios (alcohol-related liver disease, metal health disorders liked to alcohol ad acute itoxicatio) more tha doubled i the 11 years betwee ad from 93,459 to 207,788, although this is i the cotext of a geeral rise i admissios of about a third over the same period. There were 8,758 deaths from alcohol-related causes i the UK i 2006, twice as may as there were 15 years before. 2 The Departmet of Health (the Departmet) estimated i July 2008 that alcohol misuse costs the health service i the order of 2.7 billio per year. Such misuse also imposes wider costs o society, such as crime ad disorder, social ad family breakdow ad sickess absece. The total aual cost of alcohol misuse to the UK ecoomy has bee calculated by the Cabiet Office at up to 25.1 billio. 3 The World Health Orgaizatio has idetified four levels of alcohol misuse, which the Departmet uses i its alcohol strategies ad guidace. These rage from hazardous drikig (above recommeded limits), through to severely depedet alcohol misuse, which requires itesive specialist treatmet (Figure 1). 4 REDucING ALcOHOL HARm: HEALTH SERvIcES IN ENGLAND FOR ALcOHOL misuse

7 summary I Eglad, it is estimated that 18 per cet of the adult populatio (7.6 millio) are drikig at hazardous levels; aother seve per cet (2.9 millio) are showig evidece of harm to their ow physical ad metal health, icludig approximately 1.1 millio people who have a level of alcohol addictio (depedecy). The health service offers differet types of services for these groups, ragig from simple measures to provide iformatio ad raise awareess to acute cliical or metal health itervetios for severe cases. 4 Depedet drikig ca have may causes, icludig family history, psychological factors such as axiety or depressio, the addictive pharmacology of alcohol, ad the eviromet i which people live. For others who drik alcohol above the guidelies, at hazardous ad harmful levels, alcohol misuse may be due to habit, lifestyle, lack of awareess of the health effects ad a absece of obvious symptoms. 5 The Departmet has i recet years emphasised the importace of prevetio ad public health measures, particularly i the Choosig Health White Paper (2004) ad i Lord Darzi s review of the future of the NHS, High Quality Care for All (Jue 2008). I keepig with that aim, there has bee a Natioal Alcohol Strategy i place sice 2004, aimig to ecourage a more sesible drikig culture ad reduce the burde of alcohol harm o society ad the ecoomy. I 2007 Govermet reviewed progress ad set out the ext stage of its Natioal Alcohol Strategy i the report Safe. Sesible. Social, led joitly by the Departmet ad the Home Office. The Strategy emphasises the importace of early itervetios such as brief advice (see box), which have bee show to reduce alcohol cosumptio by people who are drikig more tha sesible amouts, but have ot developed a depedecy o alcohol. 1 The rage of alcohol treatmets ad itervetios Level of alcohol problem Treatmets ad itervetios (examples) Severely depedet Moderately depedet Harmful Hazardous Not yet developed Itesive specialist treatmet (e.g. detoxificatio i hospital, combied with residetial rehabilitatio) Specialist treatmet i geeralist or specialist settigs (e.g. detoxificatio at home, with cousellig) A exteded period of medical advice ( exteded brief advice ) i maistream health or other settigs Short (5 10 miutes) medical advice ( brief advice ) i maistream health or other, o-health settigs (e.g. by a GP) Public health educatio programmes Source: Adapted from Broadeig the Base of Treatmet for Alcohol Problems, Istitute of Medicie, 1990 NoteS Idividual drikers may move betwee categories of alcohol problem over time ad the boudaries betwee categories are ot clear-cut. Likewise, the treatmets are idicative ad may, i some circumstaces, be appropriate for the other categories of alcohol problem. Severely depedet: may have withdrawal fits (delirium tremes: e.g. cofusio or halluciatios usually startig betwee two or three days after the last drik); may drik to escape from or avoid these symptoms. Moderately depedet: likely to have icreased tolerace of alcohol, suffer withdrawal symptoms, ad have lost some degree of cotrol over their drikig. Harmful: showig clear evidece of alcohol-related problems. Hazardous: drikig applies to ayoe drikig over the limits recommeded by the Departmet. Not yet developed: people who curretly have o level of alcohol misuse. Reducig Alcohol Harm: health services i Eglad for alcohol misuse 5

8 summary 6 Beyod the immediate health beefits to idividual citizes, a greater focus o prevetio also meas that the costs of later, ofte more complex treatmet are avoided, providig importat savigs to the NHS. By supportig early itervetios o alcohol misuse, such as brief advice, the Departmet ad the Natioal Health Service (NHS) may avoid or reduce the costs of later, more itesive ad specialist support for people who develop depedecy or suffer from a alcohol-related illess. 7 I April 2008, for the first time, alcohol misuse became the subject of a cross-departmetal Public Service Agreemet (PSA), with the Departmet of Health a parter i deliverig the ew PSA 25 o alcohol ad illegal drugs, led by the Home Office. The PSA will be moitored aually util 2011 ad icludes a performace idicator for the Departmet to brig dow the rate of icrease of alcohol-related hospital admissios. I tur, the Departmet is ecouragig the local NHS commissioig bodies, Primary Care Trusts (PCTs), to iclude this idicator i their operatioal plas. 8 I this cotext, the Natioal Audit Office has udertake a study to evaluate: Brief advice Brief advice is the term used for short, structured advisory iterviews, provided whe questios about a patiet s drikig habits have idetified that there is misuse. The advice is provided by a competet practitioer such as a GP, urse or traied o-medical professioal, i about five to te miutes. Typically, the advice give icludes the risks a patiet is ruig by drikig too much, settig goals to reduce alcohol cosumptio, ad providig writte materials such as advice leaflets. Brief advice has bee show to be effective i reducig hazardous ad harmful drikig, as well as beig cost-effective. I September 2008 a ew Directed Ehaced Service was aouced, providig a additioal icetive of 8 millio for GPs to udertake idetificatio ad brief advice with ewlyregistered patiets. This will begi i April the arragemets for plaig ad commissioig health services for alcohol misuse (Part 2); measures to prevet alcohol misuse, ad to idetify misusers ad provide them with simple advice ad help (Part 3); specialist services to treat misusers who are depedet o alcohol, icludig those who have a serious or logstadig depedece o alcohol (Part 4). 9 The report focuses o alcohol misuse ad o health services, based o data gathered i early It cocetrates o the role played by the NHS ad its parters i deliverig o the hospital admissios idicator of the PSA. The report excludes other iflueces ad policy areas which impact o the PSA, such as those that affect the availability of alcohol (such as pricig ad promotio, taxatio ad licesig) or which deal with crime, disorder ad other social effects. 10 The report focuses o Eglad. The admiistratios i Scotlad, Wales ad Norther Irelad are separately resposible for health issues, ad have respoded i differet ways to the differig patters of alcohol harm i their coutries (Appedix 3). I Scotlad, where alcoholrelated harm is higher tha i Eglad, there are plas to ivest approximately 120 millio i tacklig alcohol misuse over the three fiacial years from I Wales, a ew strategy for tacklig substace misuse, icludig alcohol, was lauched o 1 October A Norther Irelad alcohol strategy was published i 2000 ad a further strategy documet coverig alcohol ad drugs was published i Mai fidigs The curret state of services 11 PCTs are ow resposible for settig their ow local health priorities, but our survey foud that a quarter had ot accurately assessed the alcohol problems i their area. Without such assessmets, PCTs caot kow what services they should be providig, ad caot assess whether the services they commissio are sufficiet or cost-effective. All PCTs have ready access to the data held i the Local Alcohol Profiles for Eglad, which are geerally ackowledged to be the most reliable data available o local eed, but aroud 20 per cet of PCTs do ot make use of them, ad aroud a quarter of PCTs surveyed for this report had ot carried out their ow local eeds assessmet for alcohol i the last few years. Sice April 2008, however, PCTs are required to udertake together with local authorities a formal assessmet (Joit Strategic Needs Assessmet) of the future health ad wellbeig eeds of the local populatio as the basis for plaig future services. 6 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

9 summary The role of Primary Care Trusts i addressig alcohol harm PCTs are resposible for determiig local health priorities ad have cotrol of the majority of NHS spedig. PCTs are free to decide for themselves how much to sped o services to address alcohol harm. They have o specific requiremet to provide ay alcohol-specific services, but sice April 2008 they have bee able to choose to iclude a idicator for alcohol-related hospital admissios i their operatig plas. PCTs ad other local bodies, i particular Drug ad Alcohol Actio Teams, may commissio a rage of treatmets ad services to address alcohol harm from various providers, icludig GPs, hospitals ad metal health trusts, volutary ad private orgaisatios. Drug ad Alcohol Actio Teams These Teams are local parterships of professioals from local authorities ad other public bodies such as PCTs, the police, probatio service, ad from private ad volutary sector providers. Their role is to address drug ad alcohol problems i the local area ad they pla treatmets ad commissio services from a rage of providers i all sectors. Drug ad Alcohol Actio Teams are accoutable primarily to the local parterships of which they are part ad evolved from Drug Actio Teams. There are 149 Drug Actio Teams ad Drug ad Alcohol Actio Teams i Eglad. I may areas Drug ad Alcohol Actio Teams have merged or work closely with commuity safety or crime reductio parterships. 12 May PCTs do ot have a strategy for alcohol harm, or a clear picture of their spedig o services to address it. Some 58 per cet of the PCTs respodig to our survey had a alcohol strategy ad 69 per cet were able to provide details of their expediture o alcohol services. Where spedig was kow, it showed PCTs spet a average of 600,000 o commissioig alcohol services i (icludig, for example, the provisio of brief advice from GPs, weekly alcohol cliics, or more ivolved specialist treatmets). This expediture represets a little over 0.1 per cet of a typical PCT s total aual expediture of aroud 460 millio. The wider geeral cost to the NHS of dealig with the cosequeces of alcohol misuse, ragig from the cost of ambulace services to acute surgical procedures such as liver trasplats, is estimated by the Departmet to be i the order of 2.7 billio aually. 13 PCTs have ofte looked to their local Drug ad Alcohol Actio Teams to take the lead i commissioig services to tackle alcohol harm, but these bodies focus primarily o specialist services for depedet users of illegal drugs ad alcohol. They are ot equipped to meet the eeds of the much larger groups of hazardous ad harmful alcohol misusers. The 2004 Natioal Alcohol Strategy recommeded that local Drug Actio Teams should be ecouraged, but ot required, to exted their remit for commissioig ad deliverig treatmet services to cover alcohol misuse for adults as well as drugs misuse (which icludes uder-age alcohol misuse). I 2004, aroud half of Drug Actio Teams offered both drug ad alcohol services. That figure has sice icreased to 81 per cet. Illegal substace use, however, remais Teams overridig cocer with their mai source of fudig (a budget of 385 millio i ) rigfeced for that purpose. Furthermore, may Drug ad Alcohol Actio Teams do ot have the direct liks with or experiece i primary or acute (hospital) care to commissio effective alcohol itervetios i these areas. 14 Local provisio of specialist services is ot based o a good uderstadig of commuities eeds ad there are wide variatios betwee localities. There is also much scope for better itegratio of hospital services with follow-o ad support services, such as psychiatry or self-help groups, to improve recovery rates ad prevet patiets relapsig ito their previous drikig patters. O the costs ad beefits of programmes to address alcohol harm 15 The available evidece suggests that simple, ofte early itervetios such as idetificatio ad brief advice ca brig substatial savigs by reducig the eed for more itesive treatmet later. Locally, however, opportuities to idetify ad advise people who are drikig above sesible levels are ot beig fully exploited. Alcohol screeig questioaires ad the provisio of brief advice offer a quick ad effective meas of idetifyig ad egagig with those who are drikig above the guidelies but who may ot realise the damage they are doig to their health. There is evidece idicatig the cost-effectiveess of such itervetios (Appedix 6). However, idetificatio ad brief advice is oly sporadically provided by GPs ad health workers, ad rarely used i other parts of the health service, such as accidet ad emergecy (A&E) departmets where those sufferig from the cosequeces of alcohol misuse are ofte preset. Reducig Alcohol Harm: health services i Eglad for alcohol misuse 7

10 summary 16 More specialist treatmets, eve though the cost is higher tha for brief advice, have also bee show to be cost-effective, sice they ca also reduce the high costs of treatig serious alcohol-related diseases. For example, specialist cousellig ad detoxificatio ca reduce alcohol cosumptio, ad may prevet liver damage worseig to the poit where a liver trasplat, typically costig 80,000, is eeded. The Departmet recetly commissioed a olie system to collate details of local alcohol-related iitiatives throughout Eglad, kow as the Hub of Commissioed Alcohol Projects & Policies (HubCAPP). However, the programme is still i its ifacy ad its details have still to be commuicated widely. 17 Sice 2006, the Departmet has sought both to clarify its guidace o sesible drikig ad to promote public health, through a series of ew publicity campaigs. Research showed that the Departmet s guidelies are ot fully uderstood by cosumers, who ted to uderestimate the amout of alcohol that their driks cotai. I respose, the Departmet has fuded a further campaig to raise public awareess of alcohol uits i driks, which started i May The public health campaigs ( Kow Your Limits ), which were iitially aimed at bige drikig ad will cost the Departmet more tha 6 millio i , have followed good practice guidace for such publicity work. The Departmet did ot set measurable goals for the iteded impact of these campaigs but aims to cotiue to track reported cosumer awareess ad behaviour chage. The ew Public Service Agreemet 18 The ew PSA performace idicator o alcoholrelated hospital admissios gives PCTs a icetive to address alcohol harm, but it has limitatios ad carries risks. While the idicator will measure alcohol harm ad its cosequeces for the health service, it may ot act as a clear icetive to PCTs to provide, for example, brief advice. Evidece suggests that the idicator will be resposive to provisio of specialist services ad early itervetios (although it is also sesitive to other policies such as programmes to restrict availability ad to reduce alcohol-related crime ad disorder, which are ot covered by this report). 19 While the majority of PCTs have chose to iclude the ew alcohol-related performace idicator i their operatig plas, or i a Local Area Agreemet, more tha a third have ot. I areas with relatively low levels of alcohol harm ad more pressig health priorities it may be appropriate for PCTs ot to adopt the idicator, but such decisios eed to be based o soud evidece. PCTs operatig plas ad Local Area Agreemets are the direct meas by which the Departmet ca ifluece actio locally o alcohol services ad secure progress towards the PSA. As a positive developmet, almost all (46 of 50) of the PCTs showig the highest rate of alcohol-related hospital admissios, have icluded the ew idicator i their operatig pla ad for may of these (32), the idicator is also icluded i the correspodig Local Area Agreemet. Where Local Area Agreemets do ot iclude the alcohol idicator eve though it is i the PCT s operatig pla, PCTs will have to work harder to gai local parters support for work such as the promotio of sesible drikig. 20 Regioal oversight of the NHS s respose to alcohol misuse has to date bee limited. The creatio of a ew etwork of Regioal Alcohol Offices i autum 2008 aims to stregthe the ifluecig role of Strategic Health Authorities ad Regioal Directors of Public Health ad to provide opportuities for sharig best practice betwee PCTs. The Departmet has committed 2.7 millio per year for three years from for Regioal Alcohol Offices with dedicated Regioal Alcohol Maagers, to support commissioers i deliverig the PSA. Regioal Directors of Public Health will assess whether plaed activity is both realistic ad reflects local eed, ad will check performace by PCTs agaist local targets aually. Coclusio o value for moey 21 Where they could provide a figure i respose to the NAO survey, PCTs reported spedig o average approximately 600,000 o services directly iteded to address ad reduce alcohol harm. Some PCT expediture will be o services such as brief advice, which are judged geerally to be cost-effective; although PCT expediture o alcohol services as a whole caot be comprehesively demostrated to be so. Overall, therefore, there is scope to secure better value for moey from PCT expediture o alcohol services, which is ot usually based o a clear picture of eed or of the likely results. Our survey foud that local strategies are lackig, or iadequate, i may areas ad service delivery is fragmeted, with resources allocated based o a icomplete picture of eed. Service provisio has, as a cosequece, varied widely, both i type ad degree of provisio. 8 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

11 summary 22 The ew PSA idicator o alcohol is a way of ecouragig local NHS orgaisatios to focus o alcohol harm. The adoptio of the idicator locally is, however, optioal. Therefore, the idicator has o direct accompayig sactios or rewards for PCTs. However, the Departmet does pla to publish bechmarkig iformatio o all PCT performace idicators, icludig the alcohol idicator, aually. 23 There is evidece, however, that well-plaed ad targeted services ca produce results which are good value for moey. With a icreased emphasis placed by the Departmet o the promotio of public health, NHS trusts eed to uderstad how to traslate this wider objective ito practical, well-evideced resourcig decisios. The evidece base o cost-effectiveess will be stregtheed by forthcomig studies, icludig a study of brief itervetios the Screeig ad Itervetio Programme for Sesible drikig commissioed by the Departmet, ad the Natioal Istitute for Health ad Cliical Excellece (NICE) review of prevetio, early idetificatio ad cliical guidelies for the maagemet of alcohol misuse. The resultig recommedatios are due to be published i 2009 ad 2010 respectively, providig the NHS with additioal tools to uderstad the relative cost-effectiveess of differet services to reduce ad prevet health harm from alcohol misuse. Recommedatios a The cotributio of the NHS ad its parter orgaisatios to measurable progress relies primarily o the actios of PCTs. Our evidece suggests that, to date, PCTs plaig ad commissioig of health services to reduce alcohol harm have ot bee tailored to local eeds. I 2009, at the ed of the first year of the ew PSA, Strategic Health Authorities should assess the progress made by PCTs i each regio towards the PSA alcohol idicator, takig local actio if agreed progress has ot bee made. b While atioal systems collect detailed data o local patters of alcohol misuse, some PCTs do ot use these sources, ad few PCTs collect iformatio from their local parters to supplemet these atioal datasets. The Departmet should provide a framework to allow PCTs to assess alcohol misuse withi a PCT area; thus eablig regular reviews of performace by Strategic Health Authorities ad Regioal Directors of Public Health, ad allowig PCTs themselves to compare their provisio of alcohol services agaist peer PCTs with similar patters of alcohol misuse. c The ew PSA idicator o alcohol eeds to act as a icetive for PCTs to address effectively the alcohol misuse problems i their local area. To stregthe the rigour of PCTs local prioritisatio ad commissioig decisios cocerig alcohol, the Departmet should deepe ad develop the evidece available to PCTs o the causes ad forecast treds of alcohol-related hospital admissios ad alcohol health costs. It also eeds to develop further evidece for the lik betwee the PSA alcohol idicator ad early itervetios. d Historically, primary care data have ot give a clear picture of alcohol misuse due to cofusig codes for recordig diagoses ad itervetios resultig i icosistet recordig of activity i primary care. New codes for idetificatio, screeig ad brief advice were issued i May ad October 2008, ad the Departmet should set a review poit to assess how effectively these codes are operatig to geerate accurate ad comparable iformatio. e Curretly there is o cosistecy i how the level ad cost of alcohol services is recorded locally. To secure greater cosistecy, the Departmet should emphasise to PCTs the importace of followig the guidace set out i the NHS costig maual. Strategic Health Authorities will be able to use this stadard method to compare provisio across their PCTs as part of their performace maagemet of PCTs. f Moey spet o idetificatio ad brief advice ca be cost effective, helpig to pre-empt the eed for more expesive services to treat loger-term alcohol harm, but curretly such services are sporadic. The Departmet should explore the feasibility of providig PCTs with a toolkit to assess locally the relative costs ad beefits of differet services to tackle alcohol harm, particularly those that focus o early prevetio. The toolkit should aim to show the effect that such prevetive measures ca have i reducig the eed for specialist treatmet i the future, based o existig guidace ad the best available estimates of cost effectiveess. Reducig Alcohol Harm: health services i Eglad for alcohol misuse 9

12 summary g PCTs have ofte see Drug ad Alcohol Actio Teams as the bodies primarily resposible for commissioig services to tackle alcohol harm. These Teams, however, focus o specialist treatmet of illegal substace misuse. PCTs eed to be clear about the purpose of fudig they provide to Drug ad Alcohol Actio Teams, for example i commissioig specialist services. The majority of specialist alcohol treatmets are provided by combied drug ad alcohol services ad so there is a risk that, without a clear specificatio, alcohol treatmet could be overlooked. At a atioal level, the Departmet, workig with the Home Office, eeds to udertake a cosultatio with represetatives of local commissioers i order to provide clear guidace o the remit ad local accoutability of Drug ad Alcohol Actio Teams i relatio to alcohol, icludig how this fits withi the Teams existig accoutabilities for illegal substace misuse. PCTs should also promote the commissioig of brief advice for the large body of hazardous ad harmful drikers, whether provided i geeral practice, A&E departmets or other other parts of the public sector. h Where PCTs do commissio services, they rarely assess the quality of what is delivered. Regioal Directors of Public Health ad Strategic Health Authorities eed to get PCTs to assess the quality of the services they commissio agaist the Departmet s commissioig guidace, icludig Models of Care for Alcohol Misuse, MoCAM (2006) ad criteria set out i the Departmet s World Class Commissioig programme. i Our survey of PCTs showed that ot all are workig well with other public bodies such as the police, priso ad probatio staff, ad social services to idetify ad help people who are misusig alcohol ad whose health may be at risk. Such orgaisatios are ofte well placed to idetify alcohol misuse withi those sectios of the commuity that do ot come ito regular cotact with the health service. PCTs should help educate ad trai NHS staff ad agree with local parters outside the health service how they ca be supported i developig skills to idetify alcohol misuse. j Curretly there is o systematic meas of promotig good evidece-based practice o alcohol harm across PCTs. Regioal Directors of Public Health should develop a professioal etwork of PCTs, Drug ad Alcohol Actio Teams ad health care professioals with a iterest i explorig ad promotig ew ways to tackle alcohol misuse. These etworks should record details ad outcomes of local alcohol-related itervetios ad treatmets usig the existig olie database of alcohol iitiatives (HubCAPP). 10 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

13 PART ONE Itroductio 1.1 This report evaluates work by the Departmet of Health (the Departmet) ad the Natioal Health Service (NHS) to address the health effects of alcohol misuse. I April 2008 the Departmet became a parter i a ew joit Public Service Agreemet (PSA) led by the Home Office to reduce the harm caused by alcohol ad drugs. This Part of our report describes the backgroud to the itroductio of the ew PSA ad outlies the scope of our research. With a ew PSA, ad i recogitio of the Govermet s aim for a icreased focus o public health issues geerally, this report evaluates: the arragemets for plaig ad commissioig health services for alcohol misuse (Part 2); measures to prevet alcohol misuse, to idetify those who may have a alcohol problem, ad to advise ad help them (Part 3); specialist services to treat misusers who have a serious or logstadig depedece o alcohol (Part 4). Alcohol misuse ad public health 1.2 Alcohol misuse causes or cotributes to a wide rage of serious health problems ad accidets that require health care. These health problems iclude high blood pressure, heart disease, liver ad kidey disorders ad a umber of cacers. Misuse ca be fatal, cotributig to sudde deaths through acute alcoholic poisoig or accidets while people are itoxicated, as well as deaths due to log-term abuse of alcohol. Health effects of alcohol Some alcohol-related coditios such as liver disease ad high blood pressure may ot show ay symptoms causig the patiet to seek treatmet, util serious damage has already occurred. I , there were 811,443 NHS hospital admissios i Eglad with either a primary or secodary diagosis wholly or partly related to alcohol, icludig alcoholic liver disease, the toxic effects of alcohol or metal or behavioural disorders due to alcohol. This figure accouts for six per cet of all hospital admissios ad has icreased by almost three-quarters (71 per cet) from 473,529 i , although some of the reported icrease will be due to more detailed recordig of diagoses ad to more people beig admitted to hospital for ay reaso. Nearly three-quarters of all attedaces at hospital accidet ad emergecy (A&E) departmets betwee 12 ad 5am o weeked ights are alcohol-related, ofte lead to disruptive behaviour, ad place a heavy burde o A&E resources ad capacity to meet govermet targets o waitig times. more tha 6,500 people died of alcohol-related causes i Eglad ad Wales i Evidece suggests that rates of disease associated with alcohol are icreasig: the most commo alcohol-related cause of death, alcoholic liver disease, killed 4,160 people i 2005, a icrease of 20 per cet (from 3,464) sice The brai adapts to heavy alcohol use ad depedet drikers who suddely stop drikig may suffer serious withdrawal effects, such as seizures ad delirium. These symptoms ca be miimised with medicatio ad medical supervisio. Note: Alcohol-related fatality figures cout oly deaths for which specific alcohol-related coditios were recorded as the uderlyig cause (icludig metal ad behavioural disorder due to use of alcohol, alcoholic liver disease ad poisoig by exposure to alcohol). Source: The Iformatio cetre, Statistics o Alcohol: Eglad 2007; ad Departmet of Health Safe, Sesible, Social Cosultatio o further actio (2008) REDucING ALcOHOL HARm: HEALTH SERvIcES IN ENGLAND FOR ALcOHOL misuse 11

14 part oe 1.3 The reasos for a idividual s drikig patters leadig to alcohol misuse are complex ad varied. Researchers have oly limited uderstadig of how ad why people s drikig habits develop ad chage over time. Factors cotributig to alcohol misuse iclude habit ad family history, psychological factors such as axiety or depressio, the addictive pharmacology of alcohol, lifestyle issues ad the eviromet i which people live. Some researchers believe that some people may have a geetic predispositio to alcohol misuse, but the evidece is ot coclusive. The availability ad price of alcohol are also importat factors. 1.4 Alcohol misuse results i sigificat costs to the NHS, estimated by the Departmet as beig i the order of 2.7 billio 1,2 i Most of these costs are bore by the frot-lie ad maistream NHS. Ambulace services ad accidet ad emergecy services, take together, bear almost a third (30 per cet) of these estimated costs, while hospital services accout for over a half (56 per cet) of the total (Figure 2). Specialist alcohol treatmet services, provided by o-nhs orgaisatios, accout for oly two per cet of the total estimated costs. The total costs of alcohol misuse to the UK ecoomy, icludig health effects ad other aspects such as crime, have bee estimated by the Cabiet Office at up to 25.1 billio. Patters of alcohol misuse 1.5 The 2007 Natioal Alcohol Strategy 3 ad Departmet s guidace 4 idetifies four mai categories of alcohol misusers who may beefit from some kid of itervetio or treatmet: hazardous drikers who are drikig at levels over the sesible drikig limits, either regularly or through less frequet sessios of heavy drikig, but have so far avoided sigificat alcoholrelated problems; harmful drikers are drikig above sesible levels, usually more tha hazardous drikers ad show clear evidece of some alcohol-related health problems; moderately depedet drikers are likely to have icreased tolerace of alcohol, suffer withdrawal symptoms, ad have lost some degree of cotrol over their drikig. They may recogise they have a problem with drikig but do ot have severe depedece; 2 Aual estimated costs of alcohol harm to the NHS, Hospital A&E Ambulace services Primary care Specialist treatmet services Other health care costs Depedecy drugs ,000 1,200 1,400 1,600 millios Source: Departmet of Health Improvemet Aalytical Team report, The cost of alcohol harm to the NHS i Eglad: A update to the Cabiet Office (2003) study. July NOTES Hospital icludes ipatiet visits (both directly ad partly attributable to alcohol misuse) ad outpatiet attedaces. Other health care costs iclude alcohol-related cousellig, commuity psychiatric urse visits ad health visits. The expediture o Depedecy Drugs is estimated to be at least 2.14 millio per aum. 1 Departmet of Health: Improvemet Aalytical Team, The cost of alcohol harm to the NHS i Eglad: A update to the Cabiet Office (2003) study (July 2008). 2 The estimated cost to the health service of 2.7 billio for alcohol misuse is based upo a wide defiitio of alcohol-related issues ad a umber of assumptios which are the applied to a average cost. Therefore, the actual cost is likely to be subject to variatio each year. The Departmet s view is that this estimate should oly be used as a broad idicatio of cost to the NHS. 3 Departmet of Health, Home Office, Departmet for Educatio ad Skills, Departmet for Culture, Media ad Sport, Safe. Sesible. Social. The ext steps i the Natioal Alcohol Strategy (Jue 2007). 4 e.g. Departmet of Health, Models of care for alcohol misusers (MoCAM) (Jue 2006). The descriptio of types of driker used here is adapted from MoCAM guidace. 12 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

15 part oe severely depedet drikers may have withdrawal fits (delirium tremes: e.g. cofusio or halluciatios usually startig betwee two or three days after the last drik); ad may drik to escape from or avoid these symptoms. 1.6 Patters of drikig vary accordig to geder, age ad other factors such as lifestyle ad icome. For example, me are more likely tha wome to drik more tha sesible amouts, while youg people aged are more likely tha older people to bige drik. Helpig people reduce their drikig ad restore their health 1.7 There is a rage of itervetios ad treatmets for people who are misusig alcohol (see Figure 3 overleaf), suitable for differet types of alcohol misuse. Structured brief advice from a traied professioal is appropriate as a first-stage itervetio, particularly for people who are drikig too much but who are ot depedet. Other, more complex treatmets such as detoxificatio ( dryig-out ) uder medical supervisio ad rehabilitatio ad psychosocial cousellig services are used to treat depedecy o alcohol. Itervetios ad treatmets may be provided i primary care (e.g. GP practices ad health cetres), secodary care (acute hospitals), specialist tertiary care (metal health services or residetial rehabilitatio) ad at home. People who are depedet o alcohol ofte eed psychological ad social treatmets such as cousellig, group therapy ad support for their families. 1.8 There is evidece that itervetios ad treatmets ca be effective ad justify their cost; the evidece available to date is discussed i Appedix 6. May such itervetios have bee show to be cost-effective, whereby the costs of providig them are outweighed by the overall savigs i the full social cost which will result from reduced alcohol cosumptio, such as the reduced costs to the crimial justice system due to a fall i alcohol-related crime ad disorder. A study i 2005 foud, for example, that et savigs of 5 to the public sector could result from every 1 spet o some specialist treatmet services. 5 There are local examples of iovative services which have demostrated their costeffectiveess. A specialist alcohol health worker service at St Mary s Hospital, Paddigto, has reduced re-attedace rates at the accidet ad emergecy departmet 6 [Case Example 2, p25]. The public service respose to alcohol harm 1.9 The Departmet is resposible for the health aspects of alcohol policy i Eglad, as set out i Safe. Sesible. Social. The ext steps i the Natioal Alcohol Strategy, produced joitly by the Departmet, the Home Office, the Departmet for Educatio ad Skills, ad the Departmet for Culture, Media ad Sport (DCMS) i The Departmet s resposibilities, as set out i the 2007 Natioal Alcohol Strategy ad a previous Strategy published i , iclude: coductig ad dissemiatig research o alcohol services; providig guidace to local commissioers of health services, primarily PCTs, o developig ad implemetig strategies ad programmes to reduce alcohol harm; improvig medical ad urse traiig o alcohol; icreasig the public s awareess of the risks associated with excessive cosumptio of alcohol ad how to get help, where the Departmet works with the alcohol idustry. Further details of the Departmet s specific commitmets ad the actios desiged to meet them are give i Appedix 1. The respective roles of the Departmet, Regioal Directors of Public Health (i the regioal Govermet Offices ad Strategic Health Authorities) ad of Primary Care Trusts are show i Figure 4 o page 15. Figure 5 o page 16 shows the Departmet s ifluece o local provisio of health services for alcohol misuse, which takes two mai forms: providig guidace to PCTs, directly, via Strategic Health Authorities ad Regioal Directors of Public Health, or via the Natioal Treatmet Agecy for Substace Misuse (NTA) for specialist treatmet; overseeig Strategic Health Authorities review of PCT operatig plas Most recetly, the Departmet was made a parter with the Home Office i a ew PSA o alcohol ad illegal drug misuse. The Agreemet, which came ito effect i April 2008, will be moitored aually util It icludes two ew idicators that relate to alcohol, oe of which will measure the umber of alcoholrelated hospital admissios. The ew PSA is described i Appedix 4 of this report ad its local implicatios are explaied i paragraph UKATT Research Team (2005). Cost-effectiveess of treatmet for alcohol problems: Fidigs of the UK Alcohol Treatmet Trial. British Medical Joural, 331: Barrett, B., Byford, S., Crawford, M., Patto, R., Drummod, C., Hery, J., Touquet, R. (2006) Cost-effectiveess of screeig ad referral to a alcohol health worker i alcohol misusig patiets attedig a accidet ad emergecy departmet: A decisio-makig approach. Drug ad Alcohol Depedece, 81, Prime Miister s Strategy Uit, Alcohol Harm Reductio Strategy for Eglad (March 2004). Reducig Alcohol Harm: health services i Eglad for alcohol misuse 13

16 part oe 3 The delivery of services for educatio, idetificatio ad treatmet of alcohol misusers Idetificatio ad brief advice Treatmet Ipatiet treatmet ad residetial rehabilitatio Higher GPs (ad other primary care workers) Icludes: Comprehesive assessmet for complex cases Referral 1 Psychiatric therapy to address alcohol misuse ad co-existig coditios Medically assisted ipatiet withdrawal Alcohol misusers Other NHS, e.g.: A&E departmets Psychiatric services Ateatal cliics Geeral hospital Referral Delivered i: Specialised service ipatiet facility, residetial rehabilitatio uits, hospital Commuity-based, structured treatmet Icludes: Psychiatric therapy to address alcohol misuse ad co-existig coditios Severity or complexity of misuse No-NHS, e.g.: Social services Probatio ad priso services Educatio services Occupatioal health Structured day programmes Medically assist relapse prevetio Delivered i: e.g. at home or at specialised services, (NHS, volutary or idepedet) ow premises i the commuity Self-referral Referral Ope access alcohol-specific itervetios Icludes: Educatio campaigs (ru by the Departmet, local ad regioal NHS bodies ad other govermet departmets) Iformatio, advice ad support Telephoe ad web-based services Exteded period of medical advice ( exteded brief advice ) Mutual aid groups, e.g. Alcoholics Aoymous Delivered i: e.g. GP practices, A&E departmets, probatio services Lower Source: Natioal Audit Office, based o Departmet of Health (2006) Models of care for alcohol misuse (MoCAM) NOTE 1 Referral occurs i various forms, such as a formal referral of a patiet by a GP directly to a NHS service or a A&E worker idetifyig a alcohol misuser ad providig them with the cotact details for a alcohol treatmet service. 14 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

17 part oe 4 Body Cetral, regioal ad local health service roles o alcohol harm Role Cetral Departmet of Health Sets the overall priorities for the NHS through the Operatig Framework ad accompayig Vital Sigs performace framework. Sets atioal strategy for the NHS s respose to alcohol harm, workig with other govermet departmets, ad iflueces local delivery e.g. through World Class Commissioig, the Natioal Istitute for Cliical Excellece (NICE) ad workig with medical schools to improve traiig ad providig guidace ad advice. O a atioal level, rus campaigs, works with the idustry ad udertakes research ad developmet. Regioal Regioal Govermet Office Joit role of the Regioal Director of Public Health: i Strategic Health Authority, reviews ad challeges Primary Care Trusts operatig plas (icludig the use of the alcohol PSA idicator, described below); Strategic Health Authority i regioal Govermet Office, acts as the Departmet s represetative i the regio, workig o alcohol as a public health issue with regioal represetatives of other govermet departmets ad ifluecig local authorities. Local Primary Care Trust (PCT) Commissios ivolvig plaig, fudig ad performace maagig local health services to prevet ad treat alcohol harm. Source: Natioal Audit Office UK alcohol cosumptio 1.11 The UK market i alcoholic driks is worth more tha 30 billio per aum, ad geerates aual tax reveues of over 13 billio. Globally, alcohol cosumptio causes 1.8 millio premature deaths each year (3.2 per cet of the total) 8 ad is the third leadig prevetable cause of ill-health i Europe, after smokig ad high blood pressure. I Eglad, harmful alcohol use is a public health ad social issue which has a sigificat impact right across society. For example, there has bee a large icrease i NHS alcohol-related hospital admissios amog the age group ad the rate of admissios icreases with age. Deprived areas suffer higher levels of alcohol-related mortality, hospital admissios, crime, absece from work, school exclusios, teeage pregacy ad road traffic accidets liked to greater levels of alcohol cosumptio Patters of alcohol misuse i other coutries are ofte differet from those i the UK, reflectig social ad cultural iflueces. Direct comparisos are complicated by differet ways of measurig alcohol cosumptio ad differet guidelies o sesible drikig. O the most recet figures, for 2004, average levels of alcohol cosumptio i the UK are slightly higher tha those for Germay, the Netherlads ad Filad, but lower tha for Frace ad Luxembourg. However, oe recet survey foud that UK bige drikig rates were oly exceeded i Europe by Irelad ad Filad. Most Wester coutries have a similar overall burde of disease attributable to alcohol, though the prevalece of particular alcohol-related coditios varies. Overall, certai types of heart disease such agia ad heart attacks are the most importat cause of death from alcohol misuse, accoutig for 112 deaths per 100,000 populatio i both the UK ad the US (Appedix 2 ad see Appedix 3 for a UK compariso) Developed ecoomies have adopted a rage of policies to tackle alcohol harm, beyod immediate health service itervetios. Measures adopted, (such as restrictig the availability of alcohol through taxatio or licesig, striget laws o drik-drivig ad miimum legal drikig ages) have bee show to be effective. Research i the US, for example, shows that the miimum legal drikig age of 21 i all states has bee the most effective of a rage of measures to reduce alcohol cosumptio ad harm amog high school ad college studets. Health itervetios to reduce alcohol harm have bee broadly similar i other coutries to those i the UK ad have faced the same barriers that we idetify i the remaider of this report, such as a lack of icetives for healthcare professioals to scree patiets for alcohol misuse ad advise them o its health effects. Sice geetic ad historical cultural factors may cotribute to a perso s alcohol depedecy, differet coutries may require differet solutios to reduce their idividual alcoholrelated problems. 8 World Health Orgaisatio. Alcohol: Facts ad Figures ( accessed 01/09/2008). Reducig Alcohol Harm: health services i Eglad for alcohol misuse 15

18 part oe Methodologies 1.14 To support our fidigs we carried out fieldwork from November 2007 to Jue 2008 comprisig: a survey of all Primary Care Trusts ad Drug Actio Teams; a survey of some 1,450 GPs; aalyses of the available quatitative data o alcohol harm ad its effects o the NHS; a review of existig literature ad documetatio; iterviews ad focus groups with alcohol misusers ad their families; case study visits; iteratioal comparisos research; a expert pael meetig; ad iterviews with key stakeholders. A more detailed descriptio of the methodologies used is at Appedix 5. 5 The Departmet iflueces the provisio of local alcohol services by PCTs Health harm from alcohol Social harms ad uderage alcohol misuse Social harms of alcohol misuse Departmet of Health Home Office Other govermet departmets Natioal Istitute for Health ad Cliical Excellece (NICE) Natioal Treatmet Agecy for Substace Misuse (NTA) Strategic Health Authorities (SHAs) Regioal Director of Public Health Regioal Govermet Office Guidace o what itervetios are effective (for PCTs, DAATs ad LAs) Guidace o commissioig alcohol services Review of PCT operatig plas, icludig optioal alcohol idicator Review of Local Area Agreemet, icludig optioal alcohol idicator Drug ad Alcohol Actio Team (DAATs) Primary Care Trust (PCT) Local authority (LAs) Commissioers From PCTs From PCTs, DAATs, LAs Primary Care Services (e.g. GPs) NHS hospital trust (acute care) Specialist NHS statutory providers (e.g. metal health trusts) No-NHS providers (e.g. volutary ad private services) Service providers Potetial fudig Guidace/review Source: Natioal Audit Office 16 Reducig Alcohol Harm: health services i Eglad for alcohol misuse

19 PART TWO Plaig ad commissioig of services to reduce alcohol harm 2.1 This Part of the report examies the plaig, commissioig ad oversight of services to reduce alcohol harm. Local PCTs, which cotrol the majority of NHS spedig, ca directly commissio services to reduce alcohol harm. Such services rage from straightforward educatio ad advice from GPs, to more specialist treatmet provided i hospitals or metal health trusts, or by private or volutary orgaisatios. PCTs ca also work with local Drug ad Alcohol Actio Teams to commissio specialist treatmet services for depedet drug ad alcohol users. Primary Care Trusts (PCTs) ad alcohol misuse 2.2 The 2004 ad 2007 Natioal Alcohol Strategies set out the Govermet s curret ad proposed iitiatives o alcohol misuse ad highlighted both existig guidace ad examples of good practice for healthcare orgaisatios. I 2007, the Departmet published geeral commissioig guidace for PCTs 9 but did ot clarify their resposibilities i relatio to other local public bodies, particularly with referece to alcohol services. More recetly, the Departmet has prepared Supplemetary guidace: Alcohol to assist PCTs i implemetig the guidace for alcohol misuse, which will be published i autum Before April 2008, there were o cetrally defied measures of local PCT performace i reducig alcohol harm. The operatig framework which applied to all PCTs for the three fiacial years to icluded 36 atioal targets o health issues such as cardiovascular (heart) disease, cacer, smokig ad sexual health, but made o specific referece to alcohol. 2.3 PCTs foud it difficult to provide us with details of their spedig o services to reduce alcohol harm. Most PCTs i our survey (71 per cet) could provide a overall estimate, but had difficulty providig details of expediture for ay particular type of services or settig. Nearly a third (29 per cet) could ot estimate their total spedig figure for such services. PCTs told us that there were various reasos why they could ot give spedig details, icludig difficulty estimatig the proportio of alcohol-related spedig withi services caterig for both alcohol ad drug misuse, ad for large cotracts with metal health trusts. 2.4 Per capita spedig o alcohol services is markedly less tha o services for users of illegal drugs. Where PCTs were able to provide spedig figures i respose to our survey, they reported spedig a average of 600,000 i o alcohol services. Research for the Departmet published i 2004 estimated that i a total of 217 millio was spet by PCTs ad Drug ad Alcohol Actio Teams o specialist alcohol treatmet services, approximately 197 for each of the 1.1 millio depedet drikers, although the authors suggested that the expediture figure was likely to be a overestimate. For the estimated 250,000 depedet drug users, the total amout of cetral ad local fudig spet o drug treatmet i the same period was 436 millio, or 1,744 per head. The 2004 Natioal Alcohol Strategy cocluded from this that there had bee a lack of focus o alcohol treatmet, especially i cotrast to drugs services. This view was echoed, i research commissioed for the Departmet, by people workig i alcohol-specific services Departmet of Health, Commissioig framework for health ad well-beig (March 2007). 10 Departmet of Health, Alcohol Needs Assessmet Research Project (ANARP): The 2004 atioal alcohol eeds assessmet for Eglad (November 2005). REDucING ALcOHOL HARm: HEALTH SERvIcES IN ENGLAND FOR ALcOHOL misuse 17

20 part two 2.5 From the fiacial year owards, the Departmet has provided a additioal 15 millio aually for alcohol services to PCTs budget allocatios, uder the Choosig Health programme. PCTs were ot required to sped the allocatio o alcohol services however, our ow survey coverig the secod year ( ) idicated that PCTs had spet at least 11 millio of this moey o alcohol services. Nevertheless, over half of the PCTs (58 per cet) reported spedig some of this moey (a total of aroud 4 millio) o services other tha alcohol. The relatioship betwee spedig ad eed 2.6 Our survey showed little correlatio betwee PCTs spedig o alcohol services ad the extet of alcohol problems i their local populatio (Figure 6). Although patters of alcohol misuse ad health effects vary a great deal i differet parts of Eglad ad alcohol problems are geerally much higher i more deprived locatios tha i more affluet parts of the coutry, PCTs spedig does ot reflect the patter of eed. The maps i Figure 7 show the geographical distributio of eed ad spedig patters. 2.7 We foud various reasos for these local variatios i spedig, icludig allocatios based o the patters of previous years rather tha o a recet evaluatio of eed. Where spedig had bee sigificatly icreased, this was ofte due to a local champio such as a NHS doctor or maager with a particular iterest i the health effects of alcohol, who had maaged to secure extra resources. 2.8 Spedig data is complex ad we would either expect or recommed a exact correlatio betwee eed, however measured, ad PCTs spedig patters, for the followig reasos: Figures provided by PCTs are ulikely to be directly comparable, sice PCTs have various differet ways of recordig ad presetig data o alcohol services ad there is o stadardised retur required by the Departmet; 6 PCT expediture patters for services to reduce alcohol harm PCT expediture o alcohol services per capita, Idex of Alcohol Harm Source: Natioal Audit Office NOTES 1 The PCT expediture figure icludes dedicated alcohol-specific fudig from PCTs to Drug ad Alcohol Actio Teams. 2 The Idex of Alcohol Harm, developed for the Natioal Audit Office by the North West Public Health Observatory (NWPHO) which compiles the Local Alcohol Profiles for Eglad, combies a umber of idicators of alcohol harm. A score of 1 idicates the lowest level of alcohol harm ad 152 the highest (see Appedix 4). 18 Reducig Alcohol Harm: health services i Eglad for alcohol misuse