1 London Journal of Primary Care 2011;4:11 15 # 2011 Royal College of General Practitioners GP Commissioning GP-led services for alcohol misuse: the Fresh Start Clinic Johannes Coetzee GP Principle, Bridge Lane Group Practice, London, UK; Martyn Penfold Alcohol Strategy Lead Wandsworth PCT, London, UK Key messages. A dedicated alcohol service, such as the Fresh Start Clinic, within the primary care setting is more likely to produce better results than patients being treated without a pre-agreed structured treatment plan in primary care. A dedicated alcohol service, such as the Community Alcohol Team (CAT) which is a consultant-led service and based in secondary care is better placed to treat patients with more complex needs. Up to 40% of all referrals to the CAT could be managed within the Fresh Start model.. The Fresh Start Clinic removes the stigma attached to alcohol misuse and offers anonymity in a primary care setting.. Daily attendance and breathalysing offer containment and its current location aids concordance with treatment.. Aftercare is of paramount importance. Patients are seen daily during their period of detoxification, 7 days after and at 3 months. We run a weekly support group for patients who have completed their detoxification whilst waiting to engage with local support services, such as alcohol counselling offered by the third sector. Why this matters to me As a GP, I have an interest in mental health and substance misuse, and working with these patients is very rewarding. I particularly enjoy developing and growing new services. I discovered a great unmet need in our practice population and feel proud to have been able to transfer skills I have learnt in secondary care to primary care. The Fresh Start treatment model has improved the quality of life of a significant number of patients beyond expectations. The Fresh Start model would be very easy to implement elsewhere, and I find it hard to believe that this model has not been tried before as it appears to work well. As an alcohol strategy lead within a PCT our biggest objective is engaging GPs in the alcohol harm reduction agenda both as clinicians and providers. Prior to commissioning the Fresh Start Clinic we surveyed GPs as to what role they wanted to play in the identification and treatment of alcohol use disorders. The key message we received was choice for both GP and patient. As a model, Fresh Start does not preclude GPs from directly treating alcohol misuse, but it offers them a safety net for those who are resistant in engaging in treatment within their own general practice. We believe fresh start is an important extension to that choice. The model has been discussed with each of our GP lead locality commissioning groups and with their support a Fresh Start clinic will operate within each of our GP commissioning clusters.
2 12 J Coetzee ABSTRACT Background A growing number of patients are presenting to health services with alcohol misuse disorders. The challenge to the NHS is to deliver the most cost-effective treatment solutions for all forms of alcohol misuse disorders. Setting NHS Wandsworth undertook a 12-month pilot to identify the most effective model for delivering treatment for alcohol dependency within the primary care setting. Question What are the most effective models to treat patients with alcohol dependency in primary care? Methods Model A: This was a locally enhanced services (LES) agreement for screening, brief interventions and treatment. Practices were required to attend training in the management of alcohol withdrawal and had access to specialist nurse support. Model B: A GP-led clinic supported by a full-time specialist nurse prescriber. The clinic was promoted as the Fresh Start Clinic. It offers planned alcohol withdrawal within a pre-agreed structured treatment plan, and signposts to after care. Results There were 76 treatment episodes in the Fresh Start Clinic compared with 6 recorded treatment episodes under the LES. Fresh Start Clinic 1 Waiting time to treatment is 7 days. 2 We achieved a 100% completion rate. 3 Patient satisfaction questionnaires confirmed positive patient experience. 4 Twenty percent of patients completed questionnaires. 5 Fifty seven percent abstinence at 3 6 months follow-up. 6 Fifty percent improvement in mental well being as measured by Beck s Depression Inventory. 7 Improvement in markers of dependency (GGT and MCV). 8 The cost per treatment episode in the Fresh Start Clinic was significantly less. Conclusions The Fresh Start Clinic offers clinically safe and cost-effective treatment to patients suffering from mild to moderate alcohol dependency in a primary care setting and offers choice to both GP s and patients. Keywords: alcohol dependency, alcohol detoxification, assisted withdrawal, community treatment programme, Fresh Start Clinic Introduction The estimated billion a year cost of alcohol misuse spans alcohol-related disorders and disease, crime and anti-social behaviour, loss of productivity in the workplace and problems experienced by those who misuse alcohol and their families. For the NHS alone, the estimated financial burden of alcohol misuse is around 2.7 billion in hospital admissions, attendances to A&E and in primary care. Alcohol-related illness or injury accounts for in excess of 1 million hospital admissions per year. It is suggested that this may rise to nearly 1.5 million by 2014/ Recent studies suggest that alcohol treatment has both short- and long-term savings and analysis from the UKATT Study suggests that for every 1 spent on treatment, the public sector saves 5. 2 Currently, only 1 in 18 dependent drinkers accesses structured treatment each year. 3 The current level of funding for treatment of alcohol misuse disorders falls significantly below the estimated need. The current drive to promote screening will undoubtedly increase demand on already over-stretched services. Although evidence suggests that waiting times to specialist treatment are coming down in most areas, the average waiting time to treatment is 6 8 weeks. Evidence from local audits suggests that in 2009 fewer than 4% of dependent drinkers were accessing structured treatment. 4 Within the context of World Class Commissioning, the challenge is to deliver services that improve the patient experience and outcome, with an emphasis on measurable outcomes that deliver both health gain and cost benefits. This is of particular importance as the NHS needs make 20 billion efficiency savings over the next few years. Interventions that are demonstrably lower cost and higher impact will make an important contribution to this objective. The Fresh Start Clinic offers clinically safe and cost effective treatment to patients suffering from mild to moderate alcohol dependency in a primary care setting and offers choice to both GPs and patients. Methods In 2008, in Wandsworth, the Community Alcohol Treatment (CAT) team was the only service available to treat patients with alcohol dependency. Evidence from a local audit showed that up to 40% of referrals to
3 GP-led services for alcohol misuse 13 the CAT were adults presenting with moderate alcohol dependency. 4 In 2008/2009, NHS Wandsworth undertook a 12- month pilot designed to identify the most clinically and cost-effective model for delivering treatment for mild to moderate alcohol dependency within a primary care setting. The pilot was driven by evidence from a local audit of both patient and GP experiences. In total, 94.5% of patients reported having discussed concerns about their alcohol use with their GP. Only 27% of patients were offered treatment by their GP with 73% being either referred to the CAT team by their GP or being advised to self-refer. 4 The audit also identified high rates of relapse and retreatment within primary care. It also indicated that although many GPs are treating alcohol dependency to varying degrees, there are underlying concerns regarding the quality and effectiveness of treatment provided. The majority of GPs indicated that their preferred treatment model would be primary-care-led clinics for alcohol misuse or referral to the CAT for more severely dependent patients The pilot involved two different models of primarycare-led treatment. The PCT s objective was to identify the most clinically and cost-effective model of primary-care-based treatment for alcohol misuse, as well as improving the patient experience. Model A Model A is a locally enhanced services (LES) agreement for screening, brief interventions and treatment. The practices were self-selecting and six took part with a combined list size of around patients. The total population of Wandsworth is The LES consisted of six general practices of a possible 52. This involved screening for alcohol misuse and the offering of alcohol detoxification in primary care. All practices were required to attend training in the management of alcohol withdrawal and had access to the support of a specialist alcohol nurse. Model B Model B is a structured clinic supported by a GP with previous experience in the treatment of substance and alcohol misuse. The GP holds the RCGP Diploma in Substance Misuse Part 2 from RCGP and had access to a full-time specialist nurse prescriber. Patients referred to the CAT who were identified as mild to moderate dependent drinkers were seen in the Fresh Start Clinic. The clinic was advertised as the Fresh Start Clinic in an attempt to remove stigma and thereby improve access in the primary care setting. The operating principles are based on those used in specialist services. It offers planned alcohol withdrawal for patients suffering from mild to moderate alcohol dependency (drinking up to 28 units of alcohol per day) within a pre-agreed structured treatment plan. Abstinence prescribing is offered. Follow-up key working sessions and an open group are offered with signposting to aftercare. Patients are followed up by either a face-to-face or telephone consultation at 3 months. The pilot for these two models ran for a period of 12 months, with each model being measured against the criteria of quality, outcomes and cost-effectiveness. The data submitted by the practices operating within the LES framework did not provide the level of detail required for comparison against the core criteria. Level of screening across the six practices was positive. The rate of identification of moderate to severe alcohol dependency and subsequent treatment was very low with only eight recorded episodes of alcohol withdrawal during the 12-month period. Results There were 76 treatment episodes in the Fresh Start Clinic compared with eight under the LES. It was difficult to measure the quality of screening and Box 1 Outcomes Model A (LES) Model B (Fresh Start Clinic) Treatment episodes (n =8) (n = 76) Quality Difficult to assess Positive patient feedback Lost working days 19.2 Outcomes Uncertain 100% completion rate 57% abstinence at 3 6 months 50% improvement in mental well being Improvement in serum GGT and MCV levels Not applicable Waiting time to treatment 7 days
4 14 J Coetzee outcomes under the LES. There have been relatively few treatment episodes and results should be interpreted with caution. Discussion The CAT is a consultant-led service supported by specialist nurses and is located at a Springfield Hospital. The CAT was the only resource available to patients prior to the existence of the Fresh Start Clinic and treated patients suffering from mild/moderate to severe dependency. The Fresh Start Model is a primary-care-led, Tier 3 service separating mild to moderate dependent drinkers from severely dependent drinkers. This service complements the CAT by allowing it to focus on patients with more complex needs. A secondary consequence of the Fresh Start Clinic has been to make a significant contribution to the reduction in waiting time to treatment with the CAT from an average of 13 weeks to a maximum of 4 weeks. The Fresh Start treatment model confirms that patients with mild to moderate alcohol dependency could be safely treated in the community. Patients suffering from mild to moderate alcohol dependency were often understandably not seen as a priority by the CAT and as a result they had little access to treatment. However, in general practice these patients usually present in crisis when seeking help. Being seen within 7 days of referral to the Fresh Start Clinic, shows the patients they are being taken seriously. The CAT does not collect data on health outcomes as patients are not followed up after treatment. We are unsure if data can be provided to show an improvement in mental and physical well-being. The CAT offered 37 detoxifications during the period of the LES and the Fresh Start pilot. The main measures of effectiveness used by the CAT are treatment completions and re-treatment rates. Funding for alcohol services has been historically low. Funding for the LES was made available for a short period. The LES would have been extremely costly if uptake had been greater. GPs were paid 1.50 for every patient screened and 10 for every brief intervention offered. A payment of 200 was made for every completed detoxification. Each practice was also paid a one-off signing on fee of The biggest challenges for commissioners were, in the first instance, engaging GPs with the screening and treatment agenda, with only 6/49 practices opting to sign up to the LES. For most, the remuneration offered was not seen as an incentive and we believe that many GPs are reluctant to increase the level of identification of alcohol use disorders without improved pathways and reduced waiting times into specialist alcohol services. In the longer term, significantly increased levels of primary care engagement within the LES framework for alcohol misuse would present PCTs or future commissioning frameworks with a significant cost pressure, both to fund and to monitor in terms of its quality and effectiveness. The CAT is a cost-intensive service with high management overheads and infrastructure costs. The cost per treatment of moderately dependent drinkers would therefore be significantly higher if compared with the cost per treatment episode in the Fresh Start Clinic. There are GP-led clinics commissioned elsewhere using the GP with a special interest model, but we are not aware of any that operate to a similar treatment planned model or that operate on the basis of robustly monitored outcomes. The Department of Health published Models of Care for Alcohol Misusers (MoCAM) in 2006 which describes the overall outcomes sought (to the individual, to others directly affected by their behaviour and to the wider community) and an improvement in the health and social functioning of the alcohol misuser. 5,6 We measured the outcomes as recommended by MoCAM, namely:. a reduction in alcohol consumption this may be an abstinence goal or a moderation goal. 57% abstinence at 3 months the majority of patients who relapsed, re-engaged with the service working towards harm reduction. reduction in alcohol dependence. extended brief interventions are offered to harmful and hazardous drinkers. amelioration of alcohol-related health problems such as liver disease or psychological problems. markers of dependency (serum GGT and MCV levels) are taken at the point of entry and at 3 months. Our results show a significant improvement in these. Beck s depression inventory (BDI) is completed at the point of entry and at 3 months. The average pretreatment BDI score was 33 compared with a score of 11.5 post treatment (n = 10). general improvement in health and social functioning. the average number of sick days taken over the previous 12 months with alcohol-related absence was 19 days. We intend to audit these in future. From a commissioning perspective, Fresh Start offers a comparatively low-cost, high-impact model for delivering effective treatment for alcohol misuse. It also offers significant cost benefits to the wider health economy. In 2011/2012, NHS Wandsworth intends to expand the number of Fresh Start Clinics within the borough to three. A second-stage pilot has commenced
5 GP-led services for alcohol misuse 15 which will widen the menu of services available to patients through the Fresh Start Model. This includes interventions for harmful/hazardous drinkers. We are in the process of developing a shared care framework for risk stratifying patients presenting with abnormal liver function tests. ACKNOWLEDGEMENTS Dr Eva Katona, Consultant Psychiatrist CNWL for her help and support in setting up the service. Antoinette Pang, Specialist Nurse Fresh Start Clinic. Local supporting Services Partners Bridge Lane Group Practice for their enduring support. ETHICAL APPROVAL Not required. CONFLICTS OF INTEREST None. REFERENCES 1 Department of Health. Alcohol Ready Reckoner V UKATT Research Team. Cost effectiveness of treatment for alcohol problems; findings of the randomised UK alcohol treatment trial. BMJ Online Alcohol Concern. Investing in Alcohol Treatments Reducing Cost and Saving Lives NHS Wandsworth. Auditing Patient Experiences of Alcohol Treatment Services in Wandsworth. London: NHS Wandsworth, Department of Health. Signs for Improvement commissioning interventions to reduce alcohol related harm. London: DOH, Department of Health. Models of Care for Alcohol Misusers. London: DOH, 2006 ADDRESS FOR CORRESPONDENCE Johannes Coetzee Bridge Lane Group Practice 20 Bridge Lane London SW11 3AD UK Submitted 28 February 2011, comments to authors 28 March 2011, revised 12 April 2011, accepted for publication 14 April Read and comment on this article online at