Healthcare Needs Assessment Alcohol treatment services in Suffolk. December 2013

Transcription

1 Healthcare Needs Assessment Alcohol treatment services in Suffolk December 2013

2 Table of Contents 1 Executive summary Introduction What is a needs assessment? Purpose of the document Scope Objectives Method Assumptions in needs assessments for alcohol use disorders Definitions of alcohol consumption and alcohol harm Alcohol consumption Alcohol harm Alcohol consumption in Suffolk The population of Suffolk Alcohol use disorders in Suffolk Health and social effects of alcohol in Suffolk Mortality Hospital admissions Alcohol and crime Alcohol and other social issues Care of persons with alcohol use disorders in Suffolk Model of care Alcohol misuse commissioning in Suffolk Alcohol treatment in primary care in Suffolk Screening and brief interventions in hospital and other healthcare settings Specialist alcohol services Offender health and alcohol Stakeholder consultation Gap analysis Resource considerations Increasing the provision of screening and brief intervention in adults Ensuring appropriate staffing in specialist services Offering a structured psychosocial intervention for harmful drinkers and people with mild alcohol dependence Improving access to relapse prevention medication Page 2

3 11 Conclusions and recommendations Appendix Appendix Page 3

4 Index of Tables and Figures Table 1: Suffolk population by district all ages Table 2: Population of Suffolk by ethnic distribution Table 3: Prevalence of alcohol consumption in Suffolk (%) estimates from the General Lifestyle Survey Table 4: Estimated prevalence of alcohol dependence in Suffolk Table 5: Estimated prevalence of binge drinking in Suffolk Table 6: Deaths directly standardised rate from alcohol specific conditions in males registered in Suffolk from Table 7: Deaths directly standardised rate from alcohol specific conditions in females registered in Suffolk from Table 8: Deaths directly standardised rate from alcohol attributable conditions in males registered in Suffolk in Table 9: Deaths - directly standardised rate from alcohol attributable conditions in females registered in Suffolk in Table 10: Deaths directly standardised rate from chronic liver disease in males registered in Suffolk in Table 11: Deaths directly standardised rate from chronic liver disease in females registered in Suffolk in Table 12: Hospital admissions directly standardised rate from alcohol-specific conditions in males registered in Suffolk in 2010/ Table 13: Hospital admissions directly standardised rate from alcohol-specific conditions in females registered in Suffolk in 2010/ Table 14: Hospital admissions directly standardised rate from alcohol-attributable conditions in males registered in Suffolk in 2010/ Table 15: Hospital admissions directly standardised rate from alcohol-attributable conditions in females registered in Suffolk in 2010/ Table 16: Alcohol related hospital admissions directly standardised rate, all age and sex in PCTs in Suffolk Table 17: Alcohol-related hospital admissions all age and sex for people resident in Suffolk in 2010/ Table 18: Alcohol-attributable fractions for crime Table 19: Alcohol-attributable recorded crime directly standardised rate in Suffolk in 2011/ Table 20: Alcohol-attributable violent crime directly standardised rate in Suffolk in 2011/ Table 21: Alcohol-attributable sexual crime directly standardised rate in Suffolk in 2011/ Table 22: Claimants of incapacity benefit crude rate of working age population, in Table 23: Road traffic accident deaths due to alcohol directly standardised rate, all age and sex in Table 24: Domestic violence reports where alcohol is a factor in Suffolk, in Table 25: Alcohol treatment commissioning responsibilities for various organisations Table 26: No. of newly registered patients that had AUDIT screen and brief intervention in Suffolk PCT GPs from Oct 2011 Sep Table 27: PAT screens at WSH A&E for 2012/ Table 28: Outcome of PAT positive test at WSH Table 29: Top three presenting complaints to A&E for PAT +ve patients Page 4

5 Table 30: Performance of Ipswich Hospital and West Suffolk Hospital against the 2012/13 alcohol CQUIN Table 31: Evidence-based interventions for adults delivered in specialist alcohol services Table 32: SCC commissioned community based specialist alcohol service providers Table 33: Staff matrix at specialist alcohol service providers Table 34: No. of patients in specialist alcohol treatment Table 35: Sources of referral into specialist alcohol services in Suffolk Table 36: No. of open access patients seen in SATS and CRI Lowestoft in 2012/ Table 37: No. of individuals who received different packages of care in specialist alcohol providers in 2012/ Table 38: Residential care referrals made by Phoenix Futures in 2012/ Table 39: Frequency of common interventions in Suffolk Table 40: Treatment exits in Suffolk Table 41: % of planned treatment exits in Suffolk by intervention type in 2012/ Table 42: Waiting times under 3 weeks in specialist alcohol services in Suffolk Table 43: Waiting times by intervention type in Suffolk in 2012/ Table 44: SATS capacity by intervention type in 2012/ Table 45: Socio-demographic and personal characteristics of service users Table 46: Individuals in alcohol treatment living with children in Suffolk Table 47: Individuals in alcohol treatment with housing problems in Suffolk Table 48: No. of chlordiazepoxide prescriptions in Suffolk PCT Table 49: No. of relapse prevention prescriptions in Suffolk PCT Table 50: Alcohol consumption behaviour of individuals in police custody in Suffolk from Sep 2011 to Aug Table 51: Alcohol related calls to G4S FMS from Suffolk PICs from Sep 2011 to Aug Table 52: Individuals seen by WDP Suffolk Table 53: Alcohol treatment requirements in Suffolk Probation Table 54: Project resource impact of increasing the provision of screening and brief intervention 78 Table 55: Projected cost of changing staffing levels Table 56: Projected cost impact of increasing the number of psychological interventions Table 57: Projected cost impact of increasing the number of relapse prevention prescriptions Figure 1: Estimated costs of alcohol related harm to the NHS Figure 2: Flowchart outlining approach to healthcare needs assessment of alcohol treatment services in Suffolk Figure 3: Population density of Suffolk by ward Figure 4: Population pyramid of Suffolk age and sex distribution Figure 5: Deprivation patterning of Suffolk Figure 6: Alcohol related hospital admissions number of episodes, all age and sex in PCTs in Suffolk Figure 7: Alcohol related hospital admissions directly standardised rate, all age and sex in PCTs in Suffolk Figure 8: Models of care for alcohol misuse Figure 9: No. of initial and full screens performed on newly registered patients in Suffolk GPs Figure 10: AUDIT-C scores of PIC detainees in Norfolk and Suffolk Page 5

6 1 Executive summary This document reports on the healthcare needs for the identification and management of individuals in Suffolk with alcohol use disorders. Specifically, this assessment: (1) reviews routinely collected local data and other forms of health intelligence in relation to alcohol treatment services in Suffolk; (2) collects additional information through formal stakeholder consultation with specialist providers and a series of focus groups with service users; (3) performs a gap analysis of current services against recommended best practice guidelines; (4) uses resource modelling to determine the likely cost impact of any proposed changes. The majority of adults in Suffolk consume alcohol and many do so without experiencing adverse effects. However, a growing number of the population consumes alcohol at a level that currently affects their health or wellbeing or the lives of others, and a further group is drinking at a level that is not currently causing such problems, but is at increased risk of doing so in the future. There are no direct, robust and consistent measures available for the number of people within Suffolk who abstain, or who drink at lower risk, increasing risk or higher risk levels. Comparable and consistent measures of alcohol consumption are available from national lifestyle surveys that measure individual dinking levels and this type of survey can be used to derive synthetic estimates. This report uses the General Lifestyles Survey a national survey as its data source. Based on this, it is estimated that 15.1% of the over 18 population in Suffolk drink at increasing or higher risk. This is not significantly different from 15.4% prevalence in the East of England. In many cases alcohol misuse remits without any form of formal intervention or contact with the health or social care system, however it is generally accepted that the more severe the harmful alcohol use is, the greater the need for formal health care intervention. The most severe kind of harmful drinking behaviour is known as alcohol dependence this is characterised by the presence of symptoms such as tolerance to alcohol, craving, relief of withdrawal, and neglect of alternative pleasures. It is estimated that approximately 3.8%, or 22,000 people in Suffolk fall into this category and it is this group of people with the greatest need for specialist alcohol services. This report assesses the health effects of alcohol through both mortality and morbidity indicators. Alcohol-specific and alcohol-attributable mortality in Suffolk as a whole do not differ significantly from the East of England, although there are particular areas in Suffolk with significantly higher mortality these are Ipswich, Forest Heath and Waveney. The rate of alcohol-related hospital admissions has risen over the last 10 years (although not significantly different from the rest of the country). Using the old PCT populations, Great Yarmouth and Waveney PCT has a higher rate of alcohol-related hospital admission than Suffolk PCT. In addition to the health impact of alcohol-related harm, this report also assesses the relationship of alcohol in Suffolk with crime and anti-social behaviour, loss of productivity in the workplace, road traffic accidents, and family and social problems. Page 6

7 In Suffolk, the identification and screening of harmful alcohol use occurs in general NHS commissioned healthcare services. GPs in Suffolk have the opportunity to engage with a direct enhanced service (DES) held by NHS England. The DES is to reward practices for case finding in newly registered patients aged 16 and over. It also aims to deliver a simple brief intervention to help reduce alcohol-related risk in adults drinking at hazardous and harmful levels. Practices are required to screen newly registered patients aged 16 and over using either one of two shortened versions of the WHO AUDIT questionnaire: FAST or AUDIT-C. FAST has four questions and AUDIT-C has three questions, with each taking approximately one minute to complete (hereafter referred to as initial screen ). If a patient is identified as positive, the remaining questions of the ten question AUDIT questionnaire are used to determine hazardous, harmful or likely dependent drinking ( full screen hereafter). This report indicates significant interpractice variability with regards to engagement with screening of newly registered patients in Suffolk GPs. Approximately 25% of GP practices did not screen even one new patient, and of those that did do an initial screen, far fewer full screens and brief interventions are conducted than would be expected based on current epidemiological evidence. The difficulties observed in opportunistic screening for alcohol use disorders observed in primary care is mirrored in hospitals. Both West Suffolk Hospital and Ipswich Hospital have specialist alcohol health care staff (though with different models), to coordinate the screening of alcohol use disorders particularly in A&E and to deliver brief interventions and sign posting and referrals to relevant agencies. In addition, in 2012/13 there was a contractual arrangement between the PCT and the hospital trusts (through a CQUIN) for hospitals to conduct a minimum number of alcohol screens, and referrals to specialist agencies. This CQUIN was not met by the relevant trusts. In fact, according to data from the National Alcohol Treatment and Monitoring Service, less than 5% of all referrals into alcohol specialist services in 2012/13 were from hospitals. This figure is low, considering that in that same time period approximately 12,000 episodes for hospital admissions in Suffolk were related to alcohol. Specialist alcohol treatment in Suffolk is commissioned by Suffolk County Council and delivered by four agencies Suffolk Alcohol Treatment Services (SATS), and CRI Lowestoft deliver open access clinics and structured psychosocial and other structured treatment; while Phoenix Futures and Open Road deliver structured day programmes (Open Road also deliver structured psychosocial treatment). In total, across the four agencies nearly 800 individuals received a structured treatment in 2012/ of these were on a day programme. Using waiting times as a proxy for system capacity, this report observes that waiting times were highest in psychosocial treatment (average of days wait), compared to day programmes (average of <5 days wait). Successful community-based medically assisted alcohol withdrawal is dependent on prior assessment and preparation of the patient and regular monitoring to pre-empt complications and ensure appropriate drug dosages. This report demonstrates that the majority of community-based medically assisted alcohol withdrawal is initiated by the GP without input from specialist services. Based on GP prescribing data, of the estimated 2,000 episodes of underwent community based Page 7

8 medically assisted alcohol withdrawal in the last year, only 55 (3%) of these episodes benefited from specialist provider input in the last year, this means that there is variation in standards of care for such patients across the county. In addition to patient safety concerns that this finding raises, the lack of specialist input for such individuals and the administration of community detoxification regimes without appropriate aftercare could impact upon the clinical effectiveness and success of the treatment. While pharmacotherapy is most frequently used in Suffolk to facilitate withdrawal from alcohol in dependent drinkers; many fewer individuals receive medication such as acamprosate, disulfiram or naltrexone for relapse prevention. Triangulation of available data suggests that only 5% of eligible patients receive this treatment in Suffolk. One possible reason for the low rates of specialist input in prescribing is the lack of a medical lead for SATS (the largest alcohol specialist provider in Suffolk by volume of patients seen). This report explores the potential for the addition of 0.4 wte consultant psychiatrist to the SATS team and finds an initial investment of 44,000 would be required for 100 consultant sessions per year. It is important to note that these medications are expensive. In order to bring current practice up to 30% of eligible patients (i.e. 93 patients per year on relapse prevention medication), the total cost of the drug plus the additional monitoring equates to additional upfront investment of 33,209. Additional savings could be generated from the reduction in relapse rates, however the model presented in this report notes that only 6 fewer patients would relapse than would otherwise have under the current scenario (equating to an investment of 5,534 for each person who did not relapse). In order to improve effective commissioning and delivery of services to the population, this report makes 16 recommendations grouped across four themes. These are: Theme: Joint working in the new commissioning landscape Recommendation 1: This report proposes the formation of a Suffolk alcohol healthcare partnership comprising the local authority, CCGs, healthcare provider partners, the police and crime commissioner, Suffolk Constabulary and lay representatives. The group will be responsible for sharing information between partner organisations, exploration of ways of joint commissioning and further integration of the various services currently provided in Suffolk. It is envisaged that there will be a sub-group of healthcare commissioners to lead on commissioning. Recommendation 2: The Suffolk alcohol healthcare partnership would also be responsible for monitoring the quality of services offered in Suffolk. Page 8

9 Theme: Screening and brief interventions Recommendation 3: CCGs to increase awareness among GPs and practice nurses on the benefits and practice of screening and brief intervention using the AUDIT tool through information distribution in the GP newsletter and discussion at the Local Medical Committee. Public Health to work with services commissioned and provided by the local authority to promote Making Every Contact Count and to ensure alcohol screening is available where appropriate. Recommendation 4: GPs to ensure practice staff are aware of the need for screening of new patients, and highlight the importance of appropriate follow up for patients who are screened and found to be positive. Recommendation 5: CCGs to consider outcome-based commissioning for alcohol screening from hospital trusts. Recommendation 6: CCGs to explore contractual arrangements between hospital trusts and mental health trusts to identify if alcohol screening and reporting would be an appropriate addition to a future contact. Recommendation 7: Community based alcohol specialist providers to monitor service activity and capacity and report on this regularly to the local authority commissioners. Theme: Equity in specialist service provision Recommendation 8: Specialist providers to explore their capacity for delivery of outreach clinic Recommendation 9: Assessment of future tenders for community based alcohol specialist services should take into account access for individuals in geographically isolated locations. This could be in the form of an equality impact assessment. Theme: Improving access to psychosocial interventions Recommendation 10: Specialist providers to estimate the likely requirements needed to improve access to structured psychosocial interventions Recommendation 11: Commissioners to consider likely increase in cost required to meet the NICE guidance and balance against potential savings. As potential savings likely to be seen most demonstrably in the NHS, joint commissioning could be considered as an option for this scenario. Page 9

10 Theme: Ensuring appropriate pharmacological interventions are used Recommendation 12: CCGs to raise awareness of alcohol specialist service provision for community based detoxification programmes through the GP newsletter and discussion at the local medical committee. Recommendation 13: detoxification. Providers to write to GPs to publicise their services in community Recommendation 14: CCGs to consider adoption of standardised clinical protocol for community based detoxification including clear criteria for individuals that are likely to be appropriate and those that may require inpatient detoxification. Recommendation 15: Commissioners to consider the 0.4 wte consultant psychiatrist model presented in this report and determine whether it is able to fulfil considerable cost implications of this. Recommendation 16: Commissioners to consider whether the benefits outweigh the costs of increased prescriptions of anti-relapse medication. Page 10

11 2 Introduction This document reports on the health care needs of the population of individuals who require alcohol treatment services in Suffolk. For a significant number of people in Suffolk, alcohol consumption is a major cause of ill-health. According to the National Audit Office, over 10 million adults in England (31% of men and 20% of women) drink more alcohol than the recommended daily limit, while more than 2.6 million of them are drinking more than twice this (Department of Health 2008). Alcohol is the third leading cause of European disease burden behind smoking and blood pressure, ahead of health problems relating to being overweight and obese. It is directly linked to a range of health issues such as high blood pressure, some cancers, mental ill-health, accidental injury, violence, liver disease, sexually transmitted infection and unwanted pregnancy. Alcohol not only poses a threat to the health and wellbeing of the drinker; it affects families, communities and wider society through domestic abuse, crime, anti-social behaviour, road safety and loss of productivity. Alcohol misuse contributes to 1.2 million incidents of violent crime a year, 40% of domestic abuse cases and 6% of all road casualties (Department of Health 2009). Much alcohol-related harm is preventable and research demonstrates that for every 1 spent on evidence based alcohol services, 5 is saved for the public purse, providing economic and health benefits for individuals and communities (Department of Health 2009). With this in mind, the National Institute for Clinical Excellence (NICE) public health guidance 24 on preventing harmful drinking recommends that chief executives of NHS and local authorities prioritise the prevention of alcohol-use disorders as an invest-to-save measure. There is evidence that people with alcohol dependence cost the health economy twice as much as other people who drink alcohol. Reducing the need for alcohol-related hospital admissions and reducing mortality can be achieved by commissioning services to identify hazardous and harmful drinkers and provide effective brief interventions or treatment early, preventing the development of the physical and psychological co-morbidities associated with alcohol misuse (Department of Health 2009). Reducing the need for alcohol-related hospital admissions and reducing alcohol-related mortality is a priority for commissioners. Alcohol consumption increased steadily between the 1970s and 1990s. Despite a recent plateau in annual consumption levels, evidence for the long-term health consequences of increased alcohol consumption is clear from corresponding annual increases in alcohol-related hospital admissions, which doubled between 2002 and 2010, and in alcoholrelated mortality from liver disease (National Institute for Health and Clinical Excellence (NICE) 2011). Alcohol-related harm, from mental ill health and alcohol related physical complications, is estimated to cost the NHS around 2.7 billion per year; this is equivalent to about 6 million per 100,000 population aged 10 years and above (approximately 40 million in Suffolk). Despite the growing burden of alcohol misuse on the health service, it is estimated that only 2% of NHS expenditure on alcohol-related harm is currently spent on specialist alcohol services (see Figure 1) (NHS Confederation 2010). A whole system approach may enable commissioners to divert Page 11

12 resources between and different healthcare settings to improve access to opportunistic screening, brief interventions and specialist alcohol treatment in the community. Figure 1: Estimated costs of alcohol related harm to the NHS Source: NICE (2011). Commissioning guide to services for the identification and treatment of hazardous drinking In addition to the health impact of alcohol-related harm, there are also correlations with crime and anti-social behaviour, loss of productivity in the workplace, and family and social problems. A whole system approach to commissioning alcohol services will draw on the contribution of partners in health, social care, criminal justice, housing and education, among others. Data from the National Alcohol Treatment Monitoring System (NATMS) show that only 10% of harmful or dependent drinkers aged 18 years and over are currently receiving specialist alcohol treatment (National Treatment Agency for Substance Misuse 2010). NICE recommends that this figure be increased to 15% where possible. The small proportion of dependent drinkers in specialist alcohol treatment may be due to the delay between developing alcohol dependence and seeking treatment, the limited availability of alcohol treatment services, and under-identification by health and social care professionals (NICE 2011a). The Department of Health has set out a number of High Impact Changes which outline key areas for investment to reduce alcohol attributable harm. These include identification and brief advice (IBA), community based interventions and increasing the capacity and quality of specialist treatment (Department of Health 2009). With the move of the Director of Public Health (DPH) from the NHS to local authority, the DPH will take responsibility for commissioning alcohol misuse prevention and treatment services in collaboration with clinical commissioning groups. Such commissioning requires robust intelligence on the extent and characteristics of the population s alcohol consumption and an assessment of the most effective means for service delivery. This healthcare needs assessment aims to fulfil those requirements. Page 12

13 2.1 What is a needs assessment? Needs assessment is a systematic method of identifying the unmet health and healthcare needs of a population (Jordan & Wright 1997). The broad aims of a healthcare needs assessment are to provide information in order to plan, negotiate and change services to meet healthcare need. For the purpose of this document need is defined as the capacity of people to benefit from alcohol treatment services. Within this context, it is important to distinguish health needs from both the supply and demand for health. It is known that not all dependent drinkers currently access alcohol treatment services. A health care needs assessment will attempt to examine whether this lack of demand is due to issues on the supply side or whether it represents a genuine estimate of health care needs (University of Birmingham 2013). Health needs can be: Perceptions and expectations of the profiled population (felt and expressed needs) Perceptions of professionals providing the services Perceptions of managers of commissioner/provider organisations, based on available data about the size and severity of health issues for a population, and inequalities compared with other populations (normative needs) Priorities of the organisations commissioning and managing services for the profiled population, linked to national, regional or local priorities (corporate needs) 2.2 Purpose of the document The primary purpose of this needs assessment is to provide a comprehensive picture of alcohol healthcare need in the population and the service provision to meet those needs in Suffolk. 2.3 Scope The specific health care needs that are being assessed are the identification and management of individuals aged 18 years and above who may be drinking harmfully or are dependent on alcohol. This needs assessment is restricted to the assessment of the health care needs of alcohol treatment services. Primary prevention strategies that are aimed at the general public, and other measures taken to prevent exposure to the harmful effects of alcohol by those who are not harmful drinkers do not form part of this needs assessment. 2.5 Objectives The specific objectives of this healthcare needs assessment are as follows: To review of available data that profiles the Suffolk population and the health care needs in relation to alcohol treatment services. Page 13

14 An examination of previous HNA, and strategies produced by Public Health Suffolk, local partners, and national bodies to understand existing and planned priorities for services. The assessment and analysis of the qualitative and quantitative data that are currently collected in relation to alcohol treatment in Suffolk. Assessment of current service model to determine the likely cost impact of any proposed changes. To identify key gaps in the current service and make recommendations for action to ensure the delivery of a sustainable, high-quality service for residents of Suffolk. 2.6 Method The needs assessment has been undertaken broadly in accordance with guidelines developed by NICE (NICE 2005). This approach utilises a cohesive suite of assessments in order to facilitate the commissioning of appropriate alcohol services across the area. A joint steering group was set up to coordinate and deliver the needs assessment for alcohol treatment services in Suffolk. This steering group comprise representatives from: Suffolk County Council NHS Great Yarmouth and Waveney Clinical Commissioning Group NHS Ipswich and East Clinical Commissioning Group NHS West Suffolk Clinical Commissioning Group CRI Suffolk Recovery Services Lowestoft Open Road Suffolk Phoenix Futures Suffolk Alcohol Treatment Service Westminster Drug Project Suffolk Suffolk Constabulary Norfolk and Suffolk Probation Trust Health Watch Suffolk A full Terms of Reference outlining the roles and responsibilities of the group is included in Appendix 1 of this report. A flow chart outlining the approach taken for this healthcare needs assessment is presented below in Figure 2. Epidemiological assessment this approach has considered two components to determine alcohol related health needs: (i) the prevalence of the problem; (ii) services available to deal with the problem. Page 14

15 Corporate assessment the views of local service users and providers concerning the current service provision were used to identify any gaps or areas of duplication which would improve service delivery at the local level. A questionnaire based on the national alcohol needs assessment was developed and circulated to providers. Suffolk family carers conducted qualitative research in the form of focus groups to inform this assessment. Notes of all focus groups were taken and grouped thematically. All findings are presented in this report anonymously. Comparative assessment evidence of effectiveness and best practice for reducing alcohol related harm has been used to compare current service provision with recommendations and alternatives from other areas. This includes recommendations from policy guidelines such as NICE, with regards to the provision of alcohol services. Figure 2: Flowchart outlining approach to healthcare needs assessment of alcohol treatment services in Suffolk 2.7 Assumptions in needs assessments for alcohol use disorders As in standard needs assessment methodology described above, this assessment of alcohol treatment services does not take account of natural remission: that is the proportion of people with alcohol dependence who will recover without formal specialist or other interventions. Furthermore, while there is evidence of natural remission of alcohol dependence over time, we have no way of knowing at present what proportion of people who eventually recover without specialist intervention would have had the course of the disorder shortened by a timely specialist intervention had it been available and accessible. Another assumption is that the treatment Page 15

16 provided is universally effective. This is clearly unlikely to be the case, but it is not possible to assess this within the scope of this needs assessment. Further, not everyone who is offered treatment, assuming it is widely available, would want or accept treatment. Not everyone whom a health professional would wish to refer to specialist treatment would necessarily be willing to accept referral as they may not be in an action stage of motivational readiness to change (Prochaska et al.1998). This subgroup is sometimes referred to as the potential demand for treatment. Page 16

17 3 Definitions of alcohol consumption and alcohol harm The Department of Health currently recommends that men should not regularly drink more than 3 to 4 units of alcohol per day and women 2 to 3 units (1 unit is equivalent to 8 grams of alcohol). The recommended maximum weekly totals are 21 units for men and 14 units for women. Additionally, the British Liver Trust recommends that people abstain from alcohol for a minimum of two consecutive days per week. These recommended limits have been set at what is considered sensible for the population as a whole. However alcohol consumption can never be completely risk free and there is no entirely safe level of consumption. For some alcohol attributable conditions, such as certain cancers, the risk of harm begins to increase at levels below the recommended limits. For some vulnerable groups, such as pregnant women, current guidance advises no consumption at all. 3.1 Alcohol consumption The majority of adults in Suffolk consume alcohol and most do so without experiencing adverse effects. However, a growing number of the population consumes alcohol at a level that currently affects their health or wellbeing or the lives of others, and a further group is drinking at a level that is not currently causing such problems, but is at increased risk of doing so in the future. The risk of harm from alcohol consumption has been studied in detail. There is a clear correlation between increasing levels of alcohol consumption per drinking occasion, per week, per annum, or per lifetime and a range of health, social and psychological adverse consequences. The greater the amount of alcohol consumed by a population, the greater the adverse consequences. However, the relationship between consumption and harm is complex. For some health conditions (e.g. the risk of breast cancer), the increase in risk of harm is approximately linear and even low levels of alcohol consumption have an increased risk compared to abstaining. For other conditions (e.g. alcoholic liver disease), the risk is curvilinear, with the risk of disease increasing steeply with increasing alcohol consumption. In other cases (e.g. heart disease) there may be a small protective effect of moderate amounts of alcohol, such that moderate consumers are at lower risk than abstainers. However, this protective effect is likely to have been overestimated (Ofori-Adjei, Cassewell, Drummond et al., 2007). Risks related to drinking can also be contextual. For example, consumption of any alcohol before driving a vehicle or operating machinery can be particularly hazardous. Consumption of any alcohol in pregnancy may be harmful. Therefore, overall it is difficult to recommend a level of alcohol consumption which is universally without risk for all individuals. There are many ways in which the impact of alcohol use, and the individual behaviour associated with alcohol consumption can be defined. Page 17

18 Public Health England (PHE) uses the following definitions: Lower risk drinking is defined as consumption of fewer than 22 units of alcohol per week for males and less than 15 units of alcohol per week for females. Increasing risk drinking is defined as consumption of between 22 and 50 units of alcohol per week for males and between 15 and 35 units of alcohol per week for females. Higher risk drinking is defined as consumption of more than 50 units of alcohol per week for males and more than 35 units of alcohol per week for females. Binge drinking is defined as consumption of at least twice the daily recommended amount of alcohol in a single drinking session. Another helpful way of categorizing use of alcohol for the purpose of assessing the level of need for treatment is that applied by the World Health Organisation s International Classification of Mental Disorders (10th Revision; 1992). Within this system Alcohol Use Disorders (AUDs) are classified into three categories: Hazardous Alcohol Use, Harmful Alcohol Use and Alcohol Dependence. These can be viewed as increasing levels of risk and harm associated with alcohol consumption. Drinkers not meeting the criteria for an AUD have been described variously as sensible drinkers or low risk drinkers. This is the classification system employed by NICE. Page 18

19 Hazardous drinking: This is defined as drinking above a level that may cause harm in the future, but is not currently causing clear evidence of harm. Some would limit this definition to the physical or mental consequences (as in harmful use). Others would include the social consequences. This group of drinkers can also be defined as scoring eight or more on the Alcohol Use Disorders Identification Test (AUDIT). Harmful drinking: Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol related accidents or physical illness such as acute pancreatitis. Clearly this category includes a wide range of problems and exists on a wide spectrum of severity, from alcohol-related injuries through to life threatening chronic alcoholic liver disease, or absenteeism after an isolated drinking binge through to job loss. This group of drinkers can also be defined as scoring 15 or more on the AUDIT. Alcohol dependence: A cluster of behavioural, cognitive and physiological factors that typically include desire to drink alcohol and difficulties in controlling its use. This is usually defined as the individual having three or more of a range of symptoms of alcohol dependence including: tolerance, alcohol withdrawal, craving, relief of withdrawal, neglect of alternative pleasures, and persistence of drinking despite negative consequences. Someone who is alcohol dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. This group of drinkers can be defined as scoring 20 or more on the AUDIT. It is important to note that while these categories of alcohol use disorders are presented as being exclusive, in reality, harms related to drinking and alcohol dependence each exist on a continuum of severity with no clear cut points at which they can be said to be absent or present, moderate or severe. Nonetheless, both of these definitions represent the sliding scale of alcohol attributable harm and it should be noted that they measure the pattern of alcohol consumption in slightly different ways. For the most part, the NICE definitions will be used within this needs assessment. However, PHE terminology will be referred to where tools have used this method of measurement. 3.2 Alcohol harm The estimated impact of alcohol on a particular outcome is calculated using an Alcohol Attributable Fraction (AAF). Attributable fractions are the proportion of conditions that are attributable to the exposure to a specific risk factor (in this case alcohol) in a given population. They can be used to Page 19

20 estimate the number of deaths, hospital admissions and crimes that are attributable to alcohol consumption. AAFs range between 0.26 and 1 and the lower the AAF, the less attributable the harm is considered to be to the use of alcohol. An AAF of one indicates that the harm is wholly attributable to alcohol, also known as alcohol specific harm. In the case of alcohol specific hospital admissions, this will account for one whole admission e.g. from alcoholic liver cirrhosis. An AAF of less than one indicates that the harm is partially attributable to alcohol, also known as alcohol related harm. In the case of alcohol related hospital admissions, alcohol is seen to account for part of a whole admission e.g. stroke. Alcohol attributable harm is harm caused either wholly or partly by the use of alcohol. It can be calculated by taking the sum of all alcohol specific and related harm. The total number of alcohol attributable hospital admissions will therefore not represent the total number of individuals admitted, but the sum of all whole and part admissions which can be attributed to alcohol. Page 20

21 4 Alcohol consumption in Suffolk 4.1 The population of Suffolk Suffolk covers an area of more than 3,000 square kilometres, bordering Norfolk to the north, Cambridgeshire to the west and Essex to the south with a population of 730,233. Suffolk has a two tier structure of local government. Suffolk County Council is the upper-tier administrative authority and is run by 75 elected councillors representing 63 divisions. It is responsible for major services which are provided county wide which in addition to public health also include business and trading standards, education, transport and streets, social care, and public safety. Seven district councils sit beneath the county council. Their responsibilities include (but are not limited to) local planning and building control, council housing, and environmental health. The table below shows the population of Suffolk in mid-2011 by lower tier local government district (estimates based on 2011 Census figures). Table 1: Suffolk population by district all ages (2011 census) Local authority All Ages Babergh 87,901 Forest Heath 60,038 Ipswich 133,729 Mid Suffolk 97,076 St Edmundsbury 111,443 Suffolk Coastal 124,590 Waveney 115,356 The county town is Ipswich which has the highest population density; other areas of high population density include Lowestoft, Bury St Edmunds, and Felixstowe. The figure below illustrates the population density of Suffolk at the ward level. Page 21

22 Figure 3: Population density of Suffolk by ward In Suffolk, the mean age of the population is 41.7 years (median 42) and peak age groups appear to be between the ages of years. The population pyramid below shows the distribution of the Suffolk population by sex and age groups. Page 22

23 Age Group Figure 4: Population pyramid of Suffolk age and sex distribution Female Male % of Total Population Suffolk is characterised by a predominantly White British population as seen in the table below. The proportions of ethnic minorities vary considerably by district with the highest percentages being found in Ipswich. Over 100 languages were recorded in the latest census as being used in Suffolk. Table 2: Population of Suffolk by ethnic distribution Ethnic group Number Proportion (%) White 693, Mixed 12, Asian 13, Black 6, Other 2, Suffolk is a relatively wealthy county with some pockets of deprivation, particularly notable in Waveney (Lowestoft) Suffolk Coastal (Felixstowe), Babergh (Sudbury), St Edmundsbury (Haverhill, and northern part of Bury St Edmunds) and in the Ipswich area of Suffolk. The map below shows deprivation by ward. Page 23

24 Figure 5: Deprivation patterning of Suffolk 4.2 Alcohol use disorders in Suffolk All alcohol consumption There are no direct, robust and consistent measures available for the number of people within Suffolk who abstain, or who drink at lower risk, increasing risk or higher risk levels. Comparable and consistent measures of alcohol consumption are available from national lifestyle surveys that measure individual dinking levels and this type of survey can be used to derive synthetic estimates; here we use the General Lifestyle Survey (2008) as the primary data source. The General Lifestyle Survey asks household respondents aged 16 and over across Great Britain a range of questions including those related to alcohol use. Respondents are asked how often over the last year they have drunk normal strength beer, strong beer, wine, spirits, fortified wines and alcopops; and how much they usually drink on any one day. This information is combined to give an estimate of the respondent s weekly alcohol consumption (averaged over a year) in units of alcohol. The General Lifestyle Survey dataset contained a respondent s Lower Super Output Area of residence and this was used to identify their local authority of residence. Local authority level data were appended to each individual record in the dataset. Using the local authority information in Page 24

25 particular variables on age, sex, deprivation and hospital admissions, a final model was used to predict the probability of being an abstainer, a lower risk drinker, an increasing risk drinker, and a higher risk drinker according to age, sex, ethnicity and so on. Overall prevalence estimates for each drinking category were then obtained by summing the predicted number of abstainers, lower risk, increasing risk and higher risk drinkers within all sex/age/ethnicity groups in each local authority as shown in the table below. Table 3: Prevalence of alcohol consumption in Suffolk (%) estimates from the General Lifestyle Survey District Abstain (%) Lower (%) Increasing (%) Higher (%) Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney The figures presented above should be taken with caution the survey sample size is small, particularly at the lower super output area, and confidence intervals are likely to overlap. This means that there is no statistically significant difference between the local authorities Alcohol dependence Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example, liver disease or depression caused by drinking). Alcohol dependence is also associated with increased criminal activity and domestic violence, and an increased rate of significant mental and physical disorders. Although alcohol dependence is defined in ICD-10 and DSM-IV in categorical terms for diagnostic and statistical purposes as being either present or absent, in reality dependence exists on a continuum of severity. However, it is helpful from a clinical perspective to subdivide dependence into categories of mild, moderate and severe. People with mild dependence usually do not need assisted alcohol withdrawal. People with moderate dependence usually need assisted alcohol withdrawal, which can typically be managed in a community setting unless there are other risks. People who are severely alcohol dependent will need assisted alcohol withdrawal, typically in an inpatient or residential setting. The most reliable estimates of alcohol dependence come from the report Adult psychiatric morbidity in England, 2007: results of a household survey. The prevalence of people with a score of 16 or more on the Alcohol Use Disorders Identification Test (AUDIT) in people aged 16 years and over is estimated at 3.8%. Page 25

26 The 2007 adult psychiatric morbidity survey also estimated that the proportion of people with mild, moderate and severe alcohol dependence are around 84%, 14% and 2% respectively. People with mild dependence are classed as those scoring 15 or less on the Severity of Alcohol Dependence Questionnaire (SADQ), those with moderate dependence have a SADQ score of between 15 and 30, and those people who are severely alcohol dependent have a SADQ score of more than 30. The proportion with mild dependence will also include some people who are classed as harmful drinkers. The synthetic estimates for the different sub-groups of alcohol dependence in the Suffolk population are presented in the table below. Table 4: Estimated prevalence of alcohol dependence in Suffolk Alcohol dependence Prevalence (%) Estimated number of people Mild ,479 Moderate ,079 Severe Binge drinking The individual-level measure of binge drinking was generated from the data collected in the HSE about the quantities of all the different types of alcoholic drinks (beer, wine, spirits, sherry and alcopops) consumed on a respondent s heaviest drinking day in the previous week. The measures were combined to give the number of units of alcohol consumed on the heaviest drinking day. Binge drinking was then defined separately for men and women: men were defined as having indulged in binge drinking if they had consumed 8 or more units of alcohol on the heaviest drinking day in the previous seven days; for women the cut-off was 6 or more units of alcohol. Based on this, the binge drinking estimates for Suffolk local authorities were identified and presented in the table below. Table 5: Estimated prevalence of binge drinking in Suffolk Local authority Prevalence (%) Babergh 17.3 Forest Heath 18.0 Ipswich 17.0 Mid Suffolk 15.5 St Edmundsbury 16.5 Suffolk Coastal 15.6 Waveney 15.5 England 20.0 Page 26

27 5 Health and social effects of alcohol in Suffolk 5.1 Mortality Alcohol-specific mortality These are deaths from conditions where alcohol is causally implicated in all cases of the condition, for example, alcohol-induced behavioural disorders and alcoholic liver cirrhosis. By definition, for these conditions, the alcohol-attributable fraction equals one because no cases would be expected to arise in the absence of alcohol. The tables below shows deaths from alcohol-specific conditions, classified by underlying cause of death (ICD-10), registered in the respective calendar years in males and females of all ages. Table 6: Deaths directly standardised rate from alcohol specific conditions in males registered in Suffolk from Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Table 7: Deaths directly standardised rate from alcohol specific conditions in females registered in Suffolk from Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Men are more likely to die than women from an alcohol specific cause by a ratio of 2.23 to 1. For both males and females, the greatest number of deaths from alcohol specific causes was observed in Ipswich (37 in total). This corresponds to the highest death rate (standardised for age and sex) for alcohol specific mortality. Page 27

28 Alcohol specific mortality for men was higher than the East of England average in Forest Heath, Ipswich and Waveney. For women, only Ipswich noted a mortality rate that was higher than the East of England average Alcohol-attributable mortality Alcohol-attributable or related conditions include all alcohol-specific conditions (see Section 5.1.1), plus those where alcohol is causally implicated in some but not all cases of the condition, for example, as for hypertensive diseases, various cancers and falls. The tables below shows the deaths from alcohol-attributable conditions, classified by underlying cause of death (ICD-10) registered in the respective calendar year 2010, in males and females of all ages. Table 8: Deaths directly standardised rate from alcohol attributable conditions in males registered in Suffolk in 2010 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Table 9: Deaths - directly standardised rate from alcohol attributable conditions in females registered in Suffolk in 2010 DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Mortality from chronic liver disease Half of all cases of cirrhosis are due to alcohol excess. As such mortality secondary to chronic liver disease is a good indicator of the severity of ill health due to problem drinking. The tables below shows the deaths from chronic liver disease, including cirrhosis, classified by underlying cause of death (ICD-10: K70, K73-K74), registered in the respective calendar years , in males and females of all ages. Page 28

29 Table 10: Deaths directly standardised rate from chronic liver disease in males registered in Suffolk in Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Table 11: Deaths directly standardised rate from chronic liver disease in females registered in Suffolk in Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Hospital admissions Person-specific admissions were originally adopted as one measure of the number of individuals being adversely affected by alcohol. However, an additional indicator (admission episodes for alcohol-attributable conditions) was subsequently developed as a measure of pressures from alcohol on health systems, for which the alcohol-attributable fractions have been applied to estimate the number of admissions rather than the number of people Alcohol-specific hospital admissions The tables below show the persons admitted to hospital where the primary diagnosis or any of the secondary diagnoses contain one of the listed conditions specific to alcohol misuse for the year 2010/11 in males and females resident in Suffolk, all ages. Page 29

30 Table 12: Hospital admissions directly standardised rate from alcohol-specific conditions in males registered in Suffolk in 2010/11 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Table 13: Hospital admissions directly standardised rate from alcohol-specific conditions in females registered in Suffolk in 2010/11 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Alcohol-attributable hospital admissions The tables below show the persons admitted to hospital where the primary diagnosis or any of the secondary diagnoses contain one of the listed conditions attributable to alcohol misuse for the year 2010/11 in males and females resident in Suffolk, all ages. Table 14: Hospital admissions directly standardised rate from alcohol-attributable conditions in males registered in Suffolk in 2010/11 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Page 30

31 Table 15: Hospital admissions directly standardised rate from alcohol-attributable conditions in females registered in Suffolk in 2010/11 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England All alcohol related hospital admissions This section looks at historical trends with regards to all alcohol related hospital admissions (rather than people) for Suffolk PCT and Great Yarmouth and Waveney PCT areas. Caution should be interpreted with regards to this data there have been significant changes to hospital coding over the last ten years and this could account for some of the observed increase seen in the number of individuals admitted due to an alcohol-related condition. The table and figures below show the directly standardised hospital admission rate, and the number of episodes for alcohol related conditions in Suffolk PCT and Great Yarmouth and Waveney PCT from 2002/03 to 2011/12. Table 16: Alcohol related hospital admissions directly standardised rate, all age and sex in PCTs in Suffolk Year Suffolk PCT Great Yarmouth & Waveney PCT DSR Number DSR Number 2002/ / / / / / / / / / Page 31

32 Age-standardised hospital admission rate Number of hospital admission episodes Figure 6: Alcohol related hospital admissions number of episodes, all age and sex in PCTs in Suffolk NHS Suffolk NHS Suffolk annual targets NHS Great Yarmouth and Waveney / / / / / / / / / /12 Financial year Figure 7: Alcohol related hospital admissions directly standardised rate, all age and sex in PCTs in Suffolk NHS Suffolk NHS Great Yarmouth and Waveney / / / / / / / / / /12 [A] Financial year Page 32

33 5.2.4 Admissions episodes for alcohol-attributable conditions This indicator, previous known as national indicator 39, was developed as a measure of pressures from alcohol on health systems. Alcohol attributable fractions have been applied in this instance to estimate the number of admissions rather than the number of people. The table below shows the number of admissions (male and female) from people resident in Suffolk to hospital where the primary diagnosis or any of the secondary diagnoses contain an alcohol-attributable condition for the year 2010/11. Table 17: Alcohol-related hospital admissions all age and sex for people resident in Suffolk in 2010/11 Local authority DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Alcohol and crime The role of alcohol in crime and public disorder is currently a high profile topic for public debate. Personnel in criminal justice agencies and emergency services are confronted daily with the results of alcohol-related crime, particularly violent crime. The many victims of this type of crime include those involved in street fights, victims of muggings, domestic violence and sexual assault. The severity of alcohol related crime can vary widely from relatively low level offences such as rowdy drunkenness to violent assault. At the lower end of the scale alcohol-related disorder is intimidating but more serious forms of alcohol related violence have long-term effects on people's lives. Statistics on actual levels of alcohol-related crime are difficult to obtain. It is estimated that 60% of violent incidents are not reported to the police and police forces have different practices when it comes to categorising crime as being alcohol-related unless the crime is alcohol-specific. This report calculates the recorded crime attributable to alcohol using the UK Prime Minister s Strategy Unit s alcohol-attributable fractions (Table 18) and applying them to the total number of recorded crimes. The alcohol-attributable fractions were taken from the Home Office New English and Welsh Arrestee Drug Abuse Monitoring System arrestee survey ( ) and were based on urine tests of arrestees. Page 33

34 Crime category Alcohol-attributable fraction Violence against the person 0.37 Sexual offences 0.13 Robbery 0.12 Burglary 0.17 Theft of motor vehicle 0.13 Theft from a motor vehicle 0.13 Table 18: Alcohol-attributable fractions for crime Alcohol-attributable recorded crimes Alcohol-attributable crimes are an aggregate of six offences - violence against the person, sexual offences, robbery, burglary dwelling, theft of a motor vehicle, theft from a motor vehicle. The table below refers to the annual counts of the relevant recorded crime offences, by location of incident in 2011/12, multiplied by the relevant alcohol-attributable fraction. Table 19: Alcohol-attributable recorded crime directly standardised rate in Suffolk in 2011/12 DSR per 1,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Alcohol-attributable violent crime Estimates of violent crime attributable to alcohol are annual counts of the violence against the person offences by location of incident in 2011/12, multiplied by the relevant alcohol-attributable fraction. Page 34

35 Table 20: Alcohol-attributable violent crime directly standardised rate in Suffolk in 2011/12 DSR per 1,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Alcohol-attributable sexual crime Conservative estimates of sexual assault suggest that approximately one-half of those cases involve alcohol consumption by the perpetrator, victim, or both. Alcohol contributes to sexual assault through multiple pathways, often exacerbating existing risk factors. Beliefs about alcohol s effects on sexual and aggressive behaviour, stereotypes about drinking women, and alcohol s effects on cognitive and motor skills contribute to alcohol-involved sexual assault. This report estimates the level of sexual crime attributable to alcohol by using the annual counts of sexual offences by location of incident in 2011/12, multiplied by the relevant alcohol-attributable fraction. Table 21: Alcohol-attributable sexual crime directly standardised rate in Suffolk in 2011/12 DSR per 1,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Alcohol and other social issues Incapacity and severe disablement To qualify for Incapacity Benefit or Severe Disablement Allowance, claimants have to undertake a medical test of incapacity for work which is called the Personal Capability Assessment. Therefore, the medical condition recorded on Incapacity Benefit or Severe Disablement Allowance claim form does not itself confer entitlement to incapacity benefits, so for example, the decision for a Page 35

36 customer claiming Incapacity Benefit on grounds of alcoholism would be based on their ability to carry out the range of activities in the Personal Capability Assessment; or on the effects of any associated mental health problems. The following table presents the number of claimants of Incapacity Benefit or Severe Disablement Allowance whose main medical reason to not work is alcoholism and the crude rate per 100,000 of the working age population in Table 22: Claimants of incapacity benefit crude rate of working age population, in 2011 Crude rate per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Deaths from road traffic accidents due to alcohol The effect of small doses of alcohol on driving has been widely studied. It is generally acknowledged that driving performance begins to deteriorate at blood alcohol levels of 20 to 30 mg / 100 ml. Impairment in performance is progressive and linearly related to blood alcohol concentration. This next table shows the deaths from land transport accidents, classified by underlying cause of death (ICD-10: V01-V89), multiplied by an alcohol-attributable fraction (alcohol-attributable fraction) of registered in the respective calendar years , persons, all ages (i.e. this model assumes that 35% of all road traffic accident deaths are due to alcohol). Table 23: Road traffic accident deaths due to alcohol directly standardised rate, all age and sex in DSR per 100,000 Number Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney East of England Page 36

37 5.4.3 Alcohol and domestic violence Domestic violence is often misunderstood as physical violence or hitting only, rather than the range of violent and abusive behaviour it encompasses. This may include: emotional, sexual, physical, financial or psychological abuse. For this reason some people prefer to use the phrase domestic abuse or will use both violence and abuse. The Home Office defines domestic violence as any threatening behaviour, violence or abuse between adults who are or have been in a relationship, or between family members. It can affect anybody, regardless of their gender or sexuality. The violence can be psychological, physical, sexual or emotional. Strong links have been found between alcohol use and the occurrence of domestic violence. Evidence suggests that alcohol use increases the frequency and severity of domestic violence. Alcohol consumption as a direct cause of domestic violence has often been contested either on the basis of additional factors (e.g. low socio-economic status, impulsive personality) accounting for the presence of both, or because frequent heavy drinking can create an unhappy and stressful partnership that increases the risk of conflict and violence. However evidence is available to support relationships between alcohol and domestic violence that include: Alcohol use directly affects cognitive and physical function, reducing self-control and leaving individuals less capable of negotiating a non-violent resolution to conflicts within relationships. Excessive drinking by one partner can exacerbate financial difficulties, childcare problems, infidelity, or other family stressors. This can create marital tension and conflict, increasing the risk of violence occurring between partners. Individual and societal beliefs that alcohol causes aggression can encourage violent behaviour after drinking and the use of alcohol as an excuse for violent behaviour. Experiencing violence within a relationship can lead to alcohol consumption as a method of coping or self-medicating. Children who witness violence or threats of violence between parents are more likely to display harmful drinking patterns later in life. The table below uses Suffolk Police data recording systems to identify the proportion of domestic violence reports where alcohol is a factor. The police recording systems are based around the home office crime recording practices and categorisation of crime. In the case of domestic violence the category will be violent crime (of all sorts, from non wounding to serious actual bodily harm and grievous bodily harm offences). For each crime the recording officer and crime assigner will decide if the incident is domestic violence related, and if it is alcohol related. There is some subjectivity as to whether the crime is considered alcohol related or not. For example one officer might consider an offender to be intoxicated while another may not depending on the tolerance levels of the attending officer. There will of course be incidents that are reported to have been in the past (probably a large proportion of domestic violence offences) and therefore there is no evidence (an officer was not there to arrest the offender and therefore make a judgment about their level of intoxication) to report it as alcohol related. However again, some officers will report it as alcohol related (if in the victims account they have said the offender was intoxicated without any evidence) and others will not. Page 37

38 Table 24: Domestic violence reports where alcohol is a factor in Suffolk, in Q1 Q2 Q3 Q4 All No. of reports where alcohol is a factor Total no. of DV reports % of reports where alcohol is a factor The table above indicates that across all quarters, there is consistency in the proportion of domestic violence reports where alcohol is a factor (at approximately 30%). While there is no directly comparable data, national studies suggest that this figure is more likely to approach 40%, suggesting that the alcohol as a contributory factor to domestic violence is less of a problem in Suffolk then the rest of the country. Page 38

39 6 Care of persons with alcohol use disorders in Suffolk 6.1 Model of care A wide range of interventions of different intensity have been developed and researched to respond to the wide range of alcohol use disorders and risks. Population approaches These include regulating availability and access to alcohol, raising public awareness, improving enforcement and supporting families. Many of these measures are part of the Suffolk alcohol harm reduction strategy. Some of these include: A trading standards program to reduce the level and frequency of underage sales of alcohol. It features education and training for vendors, the establishment of the Explore card as a valid proof of age identification and a poster campaign to help reinforce the messages around underage sales and the purchase of alcohol for minors. The Suffolk Crime and Disorder Partnership (CDRP) training scheme for local entertainment outlets and public houses to train door staff to intervene early in alcohol related violence. While important, it is not within the scope of this health care needs assessment to evaluate these population level interventions. The health care needs assessment will focus on individual based approaches to alcohol use disorders, specifically alcohol treatment services. Individual based approaches A useful way of conceptualising alcohol interventions for individuals is laid out in the Department of Health Models of Care for Alcohol Misuse (MoCAM). This is a four-tiered model that assumes that in general terms, less severe alcohol use disorders are likely to respond to less intensive interventions and more severe alcohol use disorders will require more intensive interventions (See Figure 8). However, this is not a hard and fast rule: some people with more severe alcohol dependence will respond to less intensive interventions, and indeed many recover without any formal intervention. Equally some harmful drinkers will require more intensive interventions, including specialist treatment. Nevertheless, MoCAM is a useful starting point to describe interventions and the target group for whom they are largely intended. Tier 1 services: - Provided by mainstream services - Targeted screening - Information and brief advice to hazardous drinkers - Referral - Shared care with those providing higher tiers Page 39

40 Tier 2 services: - Provided by those with defined competency in alcohol misuse treatment. These could be trained mainstream services or alcohol specialists. - Open access support - Alcohol specific assessment - Shared care with those providing higher tiers - Mutual aid e.g. Alcoholics Anonymous Tier 3 services: - Community based specialised alcohol misuse assessment - Comprehensive assessment - Care planning and co-ordination - Range of psycho-social therapies and support within a care plan - Range of interventions for assisted withdrawal (detoxification) and other drug based interventions. - Shared care services and training for Tier 1 and 2 providers Tier 4 services: - Alcohol treatment in a residential or in-patient setting - Comprehensive assessment - Care planning and co-ordination - Range of psycho-social therapies and support within a care plan - Range of interventions for assisted withdrawal (detoxification) and pharmacotherapies - Shared care and training for Tier 1 and 2 providers Figure 8: Models of care for alcohol misuse Page 40

41 Within these four tiers are two broad types of treatment: screening and brief interventions, and more specialist alcohol treatment. Opportunistic screening and brief interventions (SBI): this refers to the use of screening or case identification tools (such as the AUDIT questionnaire) applied opportunistically in nonspecialist settings (e.g..primary care, A&E departments, maternity services, criminal justice agencies) followed by a brief intervention usually delivered by a non-specialist health or social care professional. Interventions delivered in this context can vary from five minutes of structured advice, to an extended brief intervention of 20 to 40 minutes involving motivational principles. SBI is largely intended for hazardous and harmful drinkers who are not seeking help for an alcohol use disorder. Specialist alcohol treatment: this refers to a wide range and intensity of interventions from, for example, one or more sessions of Motivational Enhancement Therapy through to intensive residential rehabilitation lasting up to 12 months. What these interventions have in common is that they are provided for patients actively seeking help for an alcohol use disorder, and the interventions are provided by specialist staff trained to provide them. Specialist treatment is primarily targeted at people with alcohol dependence, and the more intensive forms (e.g. inpatient or residential treatment) are generally reserved for people with more severe alcohol dependence and/or significant psychiatric co-morbidities or social problems. 6.1 Alcohol misuse commissioning in Suffolk The new commissioning landscape The commissioning of specialist care for persons with alcohol use disorders in Suffolk have altered with the passage of the Health and Social Care Act From April 2013, the National Treatment Agency (NTA) ceased to exist and decision making and budgetary accountably passed to local authorities with a devolved public health ring-fenced budget. Consequently the Public Health Directorate at Suffolk County Council has assumed lead responsibility for the commissioning of specialist alcohol services for the residents of Suffolk as part of its responsibility to improve public health, with the Health and Wellbeing Board (HWB) playing a strategic coordinating role. The intention of this transfer of fiscal responsibility is to enable the design of services to meet local needs, working in partnership where it makes sense for them. Within Suffolk there are three clinical commissioning groups (CCG) the Ipswich and East CCG, West Suffolk CCG, and Health East (Great Yarmouth and Waveney CCG). These are the NHS commissioning bodies for Suffolk, with responsibility for the design of local health services including acute hospital services, mental health services, ambulance services, continuing care and arranging emergency and urgent care services. All GP practices in Suffolk belong to a CCG. These CCGs are required by the Health and Social Care Act 2012 to consult the HWB to ensure that their commissioning plans take proper account of local strategic health priorities. CCGs do not hold budgets for commissioning local specialist alcohol services, although GPs and others will often have a role and interest in alcohol misuse interventions. They have a Page 41

42 responsibility for overlapping issues principally acute hospital care and mental health and may assume some wider responsibilities for alcohol misuse commissioning, for example, the Government s Alcohol strategy suggests that CCGs might consider commissioning Alcohol Liaison Nurses in hospitals. Prison health services (including alcohol treatment) are the responsibility of the offender health team at NHS England. The table below, derived from the NHS England guidance Commissioning fact sheet for clinical commissioning groups (July 2012) shows the respective organisations and their commissioning responsibilities with respect to the care for alcohol misuse disorders. Table 25: Alcohol treatment commissioning responsibilities for various organisations Public Health Directorate, Suffolk County Council Clinical commissioning groups in Suffolk East Anglia Area Team, NHS England Alcohol health workers in a Alcohol misuse services, Brief interventions in primary variety of healthcare settings, prevention and treatment care acute hospital admissions Commissioning for outcomes In addition to the new commissioning landscape described in the table above, the Drug Strategy (2010) introduced the concept of Payment by Results (PbR) to the drug and alcohol field, and in April 2012, eight sites nationally began a two year pilot which will be evaluated in While there is no indication that payment by results will be a mandatory element of alcohol services commissioning, other areas have begun to adopt this concept prior to the results of the pilot sites being completed. It is therefore important that Suffolk is prepared for this new agenda if it is to continue to the provision of good quality services. It could be argued that an element of PbR has already been introduced into the wider substance misuse system, with areas experiencing cuts and increases in funding for specialist drug services over the last two years from the NTA, dependent on local performance figures. Any nationally mandated change to the way alcohol services are commissioned are likely to use the agreed outcome themes for the PbR pilot sites. These are: Freedom from alcohol dependence Reduced offending Improved health and wellbeing As yet, no consistent definitions have been developed nationally with respect to the above outcome themes. Nonetheless, the necessity to evidence a recovery focussed system is becoming increasingly important. Appropriate data collection, continuing clinical audit, and a move away from payment for numbers treated alone will assure commissioners that providers are able to demonstrate that they are delivering recovery focused care, and can also serve as a self-audit tool to ensure quality in the local system. Page 42

43 NICE recommends that an integrated, whole system approach to commissioning high quality alcohol services could deliver the following outcomes: Improving outcomes for people, including better health, wellbeing and relationships, by increasing access to evidence-based interventions underpinned by NICE guidance Reducing alcohol-related harm through delivering interventions that make people aware of the potential risks of alcohol misuse Improving quality of life for the community by reducing alcohol-related crime and antisocial behaviour, and preventing family breakdown Reducing the need for alcohol-related hospital admissions by commissioning services that identify and provide early intervention for hazardous and harmful drinkers, and provide recovery focused treatment for people with alcohol dependence Promoting recovery through integrated treatment that involves family and carers, and includes coordinated care and re-integration support Reducing alcohol-related morbidity and mortality through integrated whole system commissioning of alcohol services Improving people s experiences of alcohol treatment and care A whole system approach to commissioning high quality services may also contribute to the following outcomes in the NHS outcomes framework: Domain 1 preventing people from dying prematurely: reducing premature mortality from the major causes of death under 75 mortality from liver disease Domain 2 enhancing quality of life for people with long-term conditions: enhancing quality of life for carers and enhancing quality of life for people with mental illness 6.2 Alcohol treatment in primary care in Suffolk Within Suffolk, this is delivered through general practices each of which belong into one of three different CCGs. A map showing the CCG geographies in Suffolk is presented in the figure below. Each CCG is responsible for the commissioning of healthcare services to meet the reasonable needs of the person for whom they are responsible (i.e. principally for patients registered with their member practices, together with any unregistered patients living in their area), except for those services that the East Anglia Area Team of NHS England, or Suffolk County Council are responsible for commissioning. Primary healthcare provides for many individuals in Suffolk, the first point of contact in the healthcare system, and it is estimated that approximately 80% of the adult population consult their GP at least once each year. GPs are therefore best placed to identify, manage and signpost individuals with alcohol misuse disorders. Studies indicate that people with alcohol-use disorders commonly present to primary care, often with problems associated with their alcohol use, but they less often seek help for the alcohol problem itself. Further, alcohol use disorders are seldom identified by health and social care professionals. One recent study found that UK GPs routinely identify only a small proportion of people with alcohol-use disorders who present to primary care (less than 2% of hazardous or harmful drinkers and less than 5% of alcohol-dependent drinkers) (Cheeta et al., 2008). This has important implications for the prevention and treatment of alcohol-use disorders. Failure to identify Page 43

44 alcohol-use disorders means that many people do not get access to alcohol interventions until the problems are more chronic and difficult to treat. Further, failure to address an underlying alcohol problem may undermine the effectiveness of treatment for the presenting health problem (for example, depression or high blood pressure). Screening and brief intervention delivered by a non-specialist practitioner is a cost-effective approach for hazardous and harmful drinkers (NICE, 2010a). In many cases alcohol misuse remits without any form of formal intervention or contact with the health or social care system, let alone specialist alcohol treatment. Studies of what has been referred to as spontaneous remission from alcohol misuse find that this is often attributed, by individuals, to both positive and negative life events, such as getting married, taking on childcare responsibilities, or experiencing a negative consequence of drinking such as being arrested, having an accident or experiencing alcoholic hepatitis. It therefore follows that not everyone in the general population who meets the criteria for a diagnosis of an alcohol-use disorder requires specialist treatment. Often a brief intervention from a GP may be sufficient to help an individual reduce their drinking to a less harmful level. The NICE quality standard on alcohol dependence and harmful alcohol use states: Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice (quality statement 2). Commissioning opportunistic screening and brief interventions for adults, underpinned by NICE guidance and quality standards, is likely to contribute to the overarching outcome of reducing alcohol-related harm and alcohol-related hospital admissions by: Targeting the delivery of screening and brief interventions to selected populations at an appropriate time and in an appropriate setting Reducing alcohol consumption in those drinking at hazardous and harmful levels by providing brief advice or extended brief interventions Improving identification and referral to specialist treatment of people with alcohol dependence and harmful drinkers who have not responded to brief interventions Brief interventions for hazardous and harmful drinkers include: A session of structured brief advice on alcohol for adults who have been identified via screening as drinking a hazardous or harmful amount An extended brief intervention for adults who have not responded to structured brief advice or who may benefit from an extended brief intervention for other reasons. This could take the form of motivational interviewing or motivational-enhancement therapy For Suffolk, this quality standard is fulfilled in GP practices through a direct enhanced service (DES) held by NHS England. The DES is to reward practices for case finding in newly registered patients aged 16 and over. It also aims to deliver a simple brief intervention to help reduce alcoholrelated risk in adults drinking at hazardous and harmful levels. Page 44

45 Practices are required to screen newly registered patients aged 16 and over using either one of two shortened versions of the WHO AUDIT questionnaire: FAST or AUDIT-C. FAST has four questions and AUDIT-C has three questions, with each taking approximately one minute to complete (hereafter referred to as initial screen ). If a patient is identified as positive, the remaining questions of the ten question AUDIT questionnaire are used to determine hazardous, harmful or likely dependent drinking ( full screen hereafter). Following identification, the practice delivers a brief intervention to those identified as drinking at hazardous or harmful levels. Dependent drinkers should be referred to specialist services. The recommended brief intervention is the basic five minutes of advice developed for use in the UK context called How Much Is Too Much? The table below indicates the total numbers of newly registered patients aged 16 years and above, and the outcome of the initial screen for GP practices within the old Suffolk PCT borders for a 1 year period from 1 st October 2011 up to an including 30 th September Expected figures are based on current epidemiological evidence available from the NICE full guidance on alcohol dependence and harmful alcohol use (Clinical Guidance 115). Table 26: No. of newly registered patients that had AUDIT screen and brief intervention in Suffolk PCT GPs from Oct 2011 Sep 2012 No. of new patients that had initial screen No. of new patients that went on to have a full screen No. of new patients who received brief intervention No. of new patients referred to specialist services Observed Expected Of the 67 practices included for this analysis, 24 practices did not report any newly registered patients who received an initial alcohol screen. 43 practices reported at least one 1 new patient receiving an initial alcohol screen (ranging from 1 patient to 1,105 patients receiving an initial alcohol screen). The figure below shows the number of initial screens and full screens performed by each practice who reported at least one initial screen for Oct 2011 to Sep Page 45

46 Number Figure 9: No. of initial and full screens performed on newly registered patients aged 16+ in Suffolk GPs Practice No. of new patients with initial screen No. that go on to have full screen This analysis finds that for the time period assessed: 24 Suffolk practices did not report any patient receiving an initial alcohol screen. Given the requirements of the DES that all newly registered patients aged 16 years and above should receive an alcohol screen, it would be reasonable to assume that either these practices did not sign up to the DES or are not compliant with the DES. As a whole, fewer patients than expected subsequently went on to receive a full screen. NICE guidelines suggest that based on current disease epidemiology, practices should expect 24.2% of people with an initial screen to satisfy the requirements for a full alcohol screen. There is significant inter-practice variation in the proportion of patients who do go on to receive a full screen. Of those who do receive a full screen, only 30% of patients subsequently go on to receive a brief intervention. NICE guidelines suggest that based on current disease epidemiology and likely uptake rate of a brief intervention, 62% of patients who receive a full screen should go on to receive a brief intervention. The number of patients referred to specialist services is smaller than expected based on current epidemiology. The following caveats should be considered with respect to the above analysis: Only newly registered patients are included in the DES. Other patients who have received alcohol screening and brief interventions will not be included for this analysis. New patients may have received screening and brief interventions but not been reported as part of the DES. Page 46

47 Waveney practices are not included. Data is only available for the old Suffolk PCT area. These limitations do not as a whole negate the findings of this analysis of the alcohol DES data for Suffolk. Fewer than expected hazardous and dependent drinkers are identified and this has a subsequent impact on the numbers of patients receiving brief interventions and referral to specialist alcohol services. 6.3 Screening and brief interventions in hospital and other healthcare settings Around one in eight bed-days in hospitals and estimates of up to a third of all A&E attendances are due to alcohol-related conditions. At any one time, general medical or surgical inpatient beds are likely to be occupied by problem drinkers, making them in theory promising places in which to identify and counsel these patients. The published literature on alcohol interventions delivered in hospital settings presents a mixed evidence-base for the effectiveness of such interventions. There is a substantial body of international evidence on the effectiveness of brief interventions delivered to lower risk and increasing risk drinkers in A&E settings (summarised in the Review of the Effectiveness of Treatment for Alcohol Problems, Raistrick et al, 2006) but the evidence for the effectiveness of brief interventions delivered to higher risk and dependent drinkers in general hospital settings (admitted patients) is less robust. The Department of Health s recent guidance on commissioning interventions for problem drinkers - Signs for Improvement (Department of Health, 2009) does, however, clearly advocate the appointment of Alcohol Health Workers or Alcohol Liaison Nurses to deliver specialist interventions to patients admitted with identified alcohol-related health problems (High Impact Change 5). Signs for Improvement identifies the remit of these workers as: Medical management of patients with alcohol problems Liaison with community alcohol and other specialist services Education and support for other healthcare workers in the hospital Implementation of a case-finding strategy and delivery of brief advice within the hospital Although Signs for Improvement identifies the deployment of Alcohol Health Workers as having a predictable medium-term impact on the reduction of alcohol-related hospital admissions, there is little evidence for this in terms of the published research. Evidence for the efficacy of Hospital Alcohol Liaison work within this evaluation has therefore been gleaned largely from unpublished research and internal evaluation evidence. One such piece of evidence, recently submitted for publication (Ryder et al, 2010), outlines a series of five studies undertaken at the Queen s Medical Centre in Nottingham aimed at identifying (and quantifying) the impact on primary and secondary healthcare services of a Hospital Alcohol Liaison Service introduced at the hospital in This service was set up to provide interventions to inpatients with alcohol-related illness focusing on higher risk and dependent drinkers. By using Page 47

48 comparator data pre and post introduction of the service, positive impacts from the work of the Alcohol Liaison Nurse Service were identified as follows: A reduction in the number of patients admitted for alcohol detoxification (diverted to supervised outpatient detoxification) resulting in an estimated saving of 36.4 bed days per month In a sample of patients with significant alcoholic liver disease with previous admissions to hospital, bed days used fell from 6.3 per month to 3.2 per month with 51% of these patients having fewer bed days post intervention by the Alcohol Liaison Nurse. In addition, these patients demonstrated a significant reduction in self-reported alcohol intake In a comparison of two groups of patients admitted with an alcohol-related diagnosis, patients seen by an Alcohol Liaison Nurse demonstrated a greater reduction in self-reported alcohol intake than patients seen only by a physician and this reduction was observed to remain at the lower level after one year. A comparison of patient attendances at primary care following a short alcohol-related admission to hospital pre and post introduction of the Alcohol Liaison Service indicated a lower level of attendance by patients seen by Alcohol Liaison Nurses than those seen by a physician only. Alcohol-related violent incidents against hospital staff fell in the second six months following the introduction of the Alcohol Liaison Service. Further analysis of these incidents indicated the fall to be due to better management of withdrawal from alcohol on the Admissions Unit. With the above in mind, hospitals in Suffolk operate a number of different schemes to provide support to patients attending A&E and inpatients. West Suffolk Hospital since 2010 has in place an alcohol support liaison worker (ASLW). Funding for this initially came via a group called the Respect Yourself Respect Alcohol (RARY). This group comprised consisted of the Suffolk Constabulary, Forest Heath and Babergh District Councils, MIND, Suffolk Family Carers, Suffolk Probation Services, Volunteer Centre and the West Suffolk Hospital. Following the first year of the project, full funding for the ALSW has been provided by the WSH. The purpose of the ALSW is to oversee the implementation of the Paddington Alcohol Test (PAT) screening tool in the West Suffolk A&E department. The ALSW is responsible for: Implementation of the PAT screening tool in A&E groups Training of A&E nursing staff and junior doctors to perform PAT in triage Assist the hospital in development of an alcohol treatment care plan The table below outlines the activity of the WSH A&E with respect to the use of the PAT in 2012/13. Table 27: PAT screens at WSH A&E for 2012/13 No. of patients No. of patients No. of patients Result not recorded screened in A&E referred to SATS signposted to SATS Page 48

49 All patients who are PAT positive go on to receive one of the following outcomes depending on their consent. If the patient answers yes to the question Do you feel your current attendance is related to alcohol?, the patient will be referred for further intervention. If the patient answers no, the patient is provided a Think About Drink leaflet. In the 3 month period from Dec 2012 Feb 2013, a total of 444 patients tested PAT positive. The table below shows the onward management of this group of patients following a PAT positive test. Table 28: Outcome of PAT positive test at WSH Outcome No. of patients Leaflet 395 Advice 158 GP 35 AA 31 Specialist provider 4 Not known 4 Self-discharged 3 The table below lists the most common presenting complaints to A&E for PAT positive patients Table 29: Top three presenting complaints to A&E for PAT +ve patients Presenting complaint % of PAT +ve patients Generally Unwell 24.9 Fall 22.2 Psychiatric 11.3 In Ipswich Hospital Trust, the model employed differs. Ipswich Hospital employs a Band 7 Clinical Nurse Specialist Alcohol Misuse. Funding for this was the result of a bid by Suffolk PCT in partnership with Ipswich Hospital Trust for DH Health Programmes funding and lasts one year duration. The programme commenced October This role is based within the gastroenterology department at Ipswich Hospital. The primary role of the clinical nurse specialist alcohol misuse is to provide clinical expertise in assessment, care planning, delivery and evaluation of interventions to people with alcohol/substance misuse problems, who have been referred to or admitted to the Trust. Key responsibilities include: To undertake assessment/joint assessments of people with co-existing mental health and alcohol/substance misuse problems Where appropriate, initiate community/home alcohol detox to patients referred to the Gastroenterology department Provide post detox support to patients discharged from the Gastroenterology department Participate in the promotion and delivery of structured group work Respond to requests for consultation regarding patients of the Gastroenterology department Page 49

50 Lead on staff development within the Emergency department, following national guidelines and targets. Develop treatment plans for clients in collaboration with the Gastroenterology department Accept referrals on behalf of the service, using triage skills to determine priority into pathways Formal evaluation of the programme has yet to be conducted. Ongoing reporting indicates that Referrals to the alcohol specialist nurse come mainly from A&E and EUA Patients referred have a clear alcohol history and most referrals are appropriate From October 2012 up till July 2013 (9 months duration), there have been 240 referrals All referrals are seen within 1 day All referrals receive a full AUDIT screen and comprehensive assessment Of those referrals, 49 patients have been diagnosed as dependent drinkers and have received onward referral to community specialist alcohol services 1 clinic per week has been commenced for patients who have been referred by A&E but subsequently discharged. Clinic has been commenced in April 2013, with a total of 20 patients seen in a 4 month period. For 2012, alcohol screening was included as part of the Making Every Contact Count (MECC) initiative. MECC was piloted within the region to encourage and help individuals make healthier lifestyle choices to achieve positive long term behaviour. Both Ipswich Hospital and West Suffolk Hospital were signed up to a Commissioning for Quality and Innovation (CQUIN) payment for alcohol with the PCT and used as a commissioning lever to embed practice. The relevant alcohol CQUIN and the performance against that CQUIN is shown in the table below. Table 30: Performance of Ipswich Hospital and West Suffolk Hospital against the 2012/13 alcohol CQUIN Organisation Expected target Observed Ipswich Hospital Trust West Suffolk Hospital FT 1,100 PAT surveys in Q1, 11,000 PAT surveys by year end 200 referrals by year end starting July 2012 Q1-33% of front line A&E staff trained in PAT administration, Q2 - a total of 67% of front-line A&E staff trained in PAT administration, Q3-500 PATs completed, Q4-500 PATs completed PAT target not met. Only 1,238 PAT surveys were conducted by end of year. Referral target not met. 128 referrals were made to SATS by end of year. No targets were met. Data was not reported. The table above indicates that in both Ipswich and West Suffolk Hospital, the CQUIN was not met. This suggests significant room of improvement with regards to both screening, referral and data collection and reporting in the hospital trusts. Page 50

51 6.4 Specialist alcohol services Commissioning an integrated specialist community-based alcohol service, underpinned by NICE guidance and quality standards, is likely to contribute to the overarching outcomes of reducing alcohol related harm, alcohol-related hospital admissions and mortality, by: increasing the proportion of people in the local population with alcohol dependence who enter and complete treatment in a setting appropriate to their need increasing the proportion of dependent drinkers who achieve their treatment goals including abstinence (or a reduction in alcohol consumption for service users who do not agree to a goal of abstinence) preventing unnecessary hospital admissions or re-admissions because of acute alcohol withdrawal or other alcohol-related physical complications reducing the proportion of dependent drinkers who receive medically assisted alcohol withdrawal in an inpatient setting, who could withdraw safely in the community reducing complications arising from unplanned acute alcohol withdrawal reducing length of hospital or inpatient stay for medically assisted alcohol withdrawal preventing the development of and subsequently reducing the numbers of people diagnosed with alcohol-related physical complications, alcohol-related liver disease and pancreatitis increasing the number of dependent drinkers who achieve and maintain abstinence and reducing rates of relapse to heavy drinking. The table below summarises the range of interventions recommended by NICE for the treatment of adults with alcohol dependence and adults who are harmful drinkers but who have not responded to brief interventions. The table identifies packages of care that are recommended for the treatment of these groups. Page 51

52 Table 31: Evidence-based interventions for adults delivered in specialist alcohol services Intervention Harmful drinking or mild Moderate dependence Moderate dependence and Severe dependence dependence complex needs Initial assessment Comprehensive? assessment Psychological interventions Care coordination Mutual aid, peer support and reintegration Supporting families and carers Community detox??? Residential detox Not appropriate? Residential Not appropriate Not appropriate?? rehabilitation Relapse? prevention medication Aftercare? Ticks () indicate treatments expected for this group Question marks (?) indicate treatments that may occasionally be considered for people in this group Context The model of specialist service delivery in Suffolk is in accordance with the Models of Care guidance. There are currently four organisations commissioned by Suffolk County Council to provide specialist alcohol treatment services in the community as part of an integrated package of care. Suffolk Alcohol Treatment Service (SATS) is part of the Norfolk and Suffolk NHS Foundation Trust and covers East and West Suffolk (but not Waveney) and is commissioned to provide both brief alcohol interventions and structured alcohol treatment. The service is configured to target principally alcohol clients but may see other groups. It has sites in Bury St Edmunds and Ipswich. Individuals are assessed for treatment need by SATS and those requiring a structured day programme are referred to Phoenix Futures. Phoenix Futures is a voluntary organisation aimed principally at alcohol clients, commissioned to deliver structured day programmes as part of a package of care. Individuals cannot present directly to Phoenix Futures but must go via an assessment at SATS. CRI Lowestoft operates in the Waveney district of Suffolk. It provides open access services, brief interventions and structured treatment, and is the only alcohol treatment provider in that area. The Page 52

53 service is configured to target both drug and alcohol clients. All individuals requiring alcohol treatment in Waveney are assessed by CRI Lowestoft. Individuals assessed by CRI Lowestoft as requiring structured day programmes and other psychosocial interventions are referred to Open Road. Open Road is a voluntary organisation offering services to both drug and alcohol users commissioned to deliver structured psycho-social interventions and structured day programmes. Table 32: SCC commissioned community based specialist alcohol service providers SATS Phoenix Futures CRI Lowestoft Open Road Type of NHS Voluntary Voluntary Voluntary organisation Catchment area County wide Ipswich & St Waveney County wide except Waveney Edmundsbury Primary role of service Alcohol only Alcohol only Alcohol only Drugs and alcohol Principal funding bodies Suffolk County Council Suffolk County Council Suffolk County Council Approximate total budget Not provided 188,000 For Waveney service is 74,000 p.a. (Alcohol is 17%) Staff dedicated to alcohol treatment (w.t.e.) Treatments offered 38, Open access services, structured psychosocial interventions, structured alcohol specific pharmacological interventions Structured day programmes, referrals to residential care Open access alcohol services The NICE quality standard on alcohol dependence and harmful alcohol use states: Structured psychosocial interventions People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff (quality statement 4). There should therefore be an adequately trained multidisciplinary team with an appropriate mix of skills taking into account the different competencies required for delivering interventions. NICE guidelines suggest that the team should include specialist alcohol misuse workers, community mental health nurses, and psychologists. The table below displays a matrix of the various staffing levels by total wte staff dedicated to alcohol treatment at the various specialist community alcohol services in Suffolk. Page 53

54 Table 33: Staff matrix at specialist alcohol service providers SATS Phoenix Futures CRI Lowestoft Open Road Counselling 1.0 psychologists Managers Occupational 1.0 therapists Outreach workers Project workers Registered 1.0 general nurses Registered 2.0 mental nurses Administrative staff Social workers 1.0 Support workers 1.0 Volunteer counsellors Other (specify) General volunteers Student Social worker placements Routes of referral The NICE quality standard on alcohol dependence and harmful alcohol use states: 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 (quality statement 3). To means that in order to ensure appropriate referral to specialist alcohol services: Alcohol treatment pathways identify the referral procedures for harmful drinkers who have not responded to brief interventions, repeat referrals, people with alcohol dependence who are identified via screening, and people with alcohol dependence who are identified in other settings such as A&E and community care services The thresholds for referral, assessment and treatment are consistent between settings and providers, so there is treatment to suit every person s needs and to facilitate smooth transition between partner services. Relevant staff are aware of treatment pathways and procedures to refer people for assessment, including locally agreed waiting time targets. The table below shows activity for all persons in alcohol treatment in the community by specialist provider. Note that the sum of the numbers for the various providers will not add up to the county Page 54

55 total. This is because a person may be in treatment at more than one service (and so will be counted in each). Table 34: No. of patients in specialist alcohol treatment Specialist provider 2011/ /13 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Suffolk Alcohol Treatment Service Phoenix / NORCAS CRI Lowestoft The table and figure below shows the activity by route of referral for new patients presenting for alcohol treatment. Note that 2009/10 and 2010/11 refer only to the Suffolk PCT population, whereas 2011/12 and 2012/13 refer to all new patients who are registered in Suffolk. Table 35: Sources of referral into specialist alcohol services in Suffolk Referral source 2009/ / / /13 Community based care services Children and Family Services Health and Mental Health Services Of which: A&E Not available Not available 0 0 Hospital Not available Not available GP Not available Not available Other Not available Not available Substance Misuse Services Criminal Justice Self, Family and Friends Other No Referral Source Recorded/Inconsistent Page 55

56 Figure 10: Distribution of referral sources (by %) to specialist alcohol services in Suffolk in 2012/ Community services Family Services A&E Hospital GP Other Substance healthcare Misuse Criminal Justice Self Other In 2012/13, self-referrals (31%), general practitioners (17%), and substance misuses services (7%) make up the greatest proportion of referrals to specialist alcohol services in the community in Suffolk. Together they account for 55% of all referrals in the time period examined. The self-referral rate for Suffolk was lower than the East of England (31% self-referral in Suffolk compared to 51% for East of England). No referrals were recorded as originating from A&E in the time period specified. This may be artefactual A&E may have advised the patient to present to an alcohol specialist service but unless a written referral for the patient is made by A&E it is not coded as originating from A&E Screening and brief intervention in specialist community-based services Screening and assessment is a vital stage in determining the most clinically and cost-effective treatment for harmful drinkers and people with alcohol dependence. The NICE quality standard on alcohol dependence and harmful alcohol use states: Adults accessing specialist alcohol services for alcohol misuse receive an assessment that includes the use of validate measures (quality statement 5) In Suffolk, initial screen are carried out for all individuals who attend open access clinics run by SATS and CRI Lowestoft. Where appropriate, individuals may also receive brief advice and intervention, or where they score as alcohol dependent go on to receive structured treatment. The table below lists the numbers of individuals screened and those who go on to receive a brief intervention (i.e. those assessed as harmful or only mildly dependent drinkers) in 2012/13. Page 56

57 Table 36: No. of open access patients seen in SATS and CRI Lowestoft in 2012/13 SATS CRI Lowestoft No. of patients screened 641 Not available through open access drop in Brief intervention Management of care Individuals who are identified as moderately or severely dependent by either a referring clinician, or through open access drop in will undergo comprehensive assessment at SATS or CRI Lowestoft. The comprehensive assessment of the patient is structured in a clinical interview and assesses multiple areas of need covering the following areas: Alcohol use, including: o Consumption: historical and recent patterns of drinking, and if possible, additional information (for example, from a family member or carer) o Dependence Alcohol-related problems Other drug misuse, including over-the-counter medication Physical health problems Psychological and social problems Cognitive function Readiness and belief in ability to change Where the healthcare professional deems it appropriate, individuals are subsequently offered a package of care this package of care usually consists of a range of psychological (and occasionally pharmacological interventions), peer support, or take the form of structured day programmes. Structured day programmes are only offered by Phoenix Futures and Open Road and can only be accessed by individuals following a comprehensive assessment at either SATS or CRI Lowestoft. All other structured psycho-social packages of care are offered by SATS and CRI Lowestoft. The table below outlines the number of individuals who received different packages of care at the different community based specialist alcohol services in 2012/13. Page 57

58 Table 37: No. of individuals who received different packages of care in specialist alcohol providers in 2012/13. SATS Phoenix CRI Lowestoft Open Road Futures Care planned individual or group therapy abstinence oriented Day programmes Where structured outpatient programmes are considered unsuitable for the patient, due either to complex care needs or severity of alcohol dependence, individuals may be referred on to residential care. This necessitates the coordination of care with other agencies. The table below shows the number of residential care referrals made by Phoenix Futures in 2012/13. Table 38: Residential care referrals made by Phoenix Futures in 2012/13 Referred for residential care 93 Placed in residential care 68 Average wait for CCA Average length of time between CCA completion and placement 1.5 weeks 1 week after funding agreed As part of a treatment journey a client may receive more than one intervention while being treated at a provider and may attend more than one provider for subsequent interventions. The table below lists the frequency of common interventions carried out in specialist alcohol services in the community in Suffolk in 2011/12 and 2012/13. Table 39: Frequency of common interventions in Suffolk 2011/ /13 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Structured psychosocial Structured day programmes Other structured treatment Non alcohol specific intervention Community prescribing Referred to residential treatment Referred to inpatient treatment Structured psychosocial interventions, and other structured treatment which can include peer support and mutual aid, care coordination, aftercare and reintegration support are the most frequent interventions offered to patients. Page 58

59 6.4.5 Treatment exits In order to ensure that individuals who access treatment fully benefit from the treatment, improve the likelihood of treatment efficacy and reduce the risk of relapse, it is vital that treatment exits are planned to ensure appropriate aftercare. Aftercare reduces the risk of relapse by developing coping strategies to help the person maintain their treatment outcomes, and promoting reintegration support helps mitigate against risk factors for relapse such as unstable employment, housing or relationships. The table below shows the proportion of planned exits for individuals in community-based specialist alcohol services in 2011/12 and 2012/13. Table 40: Treatment exits in alcohol specialist services in Suffolk 2011/ /13 Completed planned exit 272 (53.5%) 225 (41.6%) Unplanned exit 203 (39.2%) 230 (42.5%) Transferred not in custody 40 (7.7%) 86 (15.9%) Transferred in custody 3 (0.6%) 0 (0%) The proportion of unplanned exits in 2012/13 increased slightly from 39% the previous year to 43%. It should be noted that this is significantly higher than the East of England 27% unplanned exits. The following table breaks the 2012/13 data down by intervention type to identify the proportion of planned exits for each intervention Table 41: % of planned treatment exits in Suffolk by intervention type in 2012/13 Q1 Q2 Q3 Q4 No. of % No. of % No. of % No. of % exits planne d exits planne d exits planne d exits planne d Structured psychosocial Structured day programmes Other structured treatment Non alcohol specific intervention Page 59

60 6.4.6 System capacity System capacity refers in this case, to the ability of specialist alcohol services to perform its care function effectively, efficiently and sustainably. Waiting times are a good indicator both of the quality of care and patient experience, and also the capacity of specialist alcohol services to deliver specialist care to its population. The table below shows the proportion of patients who waited 3 weeks and under from assessment to first intervention, where there is a valid waiting time entered for that patient. An intervention in this case can be a psychosocial intervention, structured programme, or residential treatment. Table 42: Waiting times under 3 weeks in specialist alcohol services in Suffolk 2011/ /13 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Number of valid waiting times Number of waiting times under 3 weeks % of waiting times under 3 weeks 57% 60% 63% 44% 52% 63% 65% 65% The proportion of patients with a waiting time of under 3 weeks has been fairly constant over the last 3 quarters (60% of patients). The table below shows the average waiting time in days and the proportion of waiting times by wait time category (under 3 weeks, 3 6 weeks, 6 9 weeks, and greater than 9 weeks), for different structured interventions in 2012/13. Table 43: Waiting times by intervention type in Suffolk in 2012/13 Structured Structured day Other structured Rx psychosocial Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Avg waiting time (days) n/a n/a <3 weeks n/a n/a 3-6 weeks n/a n/a 6-9 weeks n/a n/a >9 weeks n/a n/a Structured day programmes had the greatest had the shortest waiting times, with an average wait time of 5 days and 100% of patients seen within 3 weeks. In contrast, both structuredpsychosocial interventions and other structured treatment performed poorly on waiting times. For structured psycho-social interventions the average waiting time ranged from 28 days up till 58 days, and for other structured treatment the average waiting time ranged from 15 to 28 days. Page 60

61 Another way of examining capacity within the system to cope with increased demand is to look at the capacity utilisation of that service. This is a metric used to measure how much out of the potential maximum number of places the service is being used. Displayed as a percentage, capacity utilisation levels give insight into the overall slack that is in the service at a given point in time and is a useful measure for demand for the service. A high capacity utilisation proportion could indicate high demand for the service. The table below shows the capacity utilisation for different services provided by SATS in 2012/13 Table 44: SATS capacity by intervention type in 2012/13 Number of places available Number of places utilised Capacity utilisation (%) Drop in service % Care planned % individual or group therapy abstinence oriented Care planned individual or group therapy controlled drinking % Across the different interventions offered by SATS, the capacity utilisation ranged from 63 68% in 2012/13. This could suggest that the service has capacity to cope with any additional demand Alcohol client information These next set of data show a snapshot of socio-demographic and other characteristics of adults in alcohol treatment in Suffolk in 2011/12 benchmarked against the East of England. Page 61

62 Table 45: Socio-demographic and personal characteristics of service users Category Indicator Suffolk East of England Sex % adults in alcohol treatment who are male Age % adults in alcohol treatment aged % adults in alcohol treatment aged Ethnicity % adults in alcohol treatment of white ethnicity Alcohol use % adults in alcohol treatment consuming behaviour more than 600 units of alcohol per month % of adults in alcohol treatment only Substance misuse Other personal characteristics Health seeking behaviour misusing alcohol % adults in alcohol treatment also misusing opiates and/or crack cocaine % adults in alcohol treatment also misusing cannabis % adults in alcohol treatment who are parents % adults in alcohol treatment living with at least 1 child % adults in alcohol treatment with a housing problem % adults in alcohol treatment who selfreferred % adults in alcohol treatment referred from the criminal justice system Of particular interest are two groups of individuals parents living with their children, and those with a housing problem. Children living with a dependent drinker are at greater risk for having emotional problems, and research indicates that they are four times more likely than other children to suffer an alcohol use disorder in later life. The NICE quality standard on alcohol dependence and harmful alcohol use states that: Families of people who misuse alcohol have their own needs identified, including those associated with risk of harm and are offered information and support (quality statement 7). Further, evidence shows that treatment is more likely to be sustainable where families, partners, carers and children are closely involved in the treatment. The table below shows the number and proportion of individuals in alcohol treatment living with at least one child. Page 62

63 Table 46: Individuals in alcohol treatment living with children in Suffolk 2011/ /13 Parent living with own children 109 (19.8%) 114 (19.3%) Other child contact: Living with children 30 (5.4%) 32 (5.4%) Other child contact: Parent not living with children 147 (26.7%) 159 (26.9%) Not a parent/no child contact 263 (47.7%) 281 (47.5%) Both fields blank or declined to answer 2 (0.4%) 5 (0.8%) Alcohol use disorders are among the issues most frequently affecting the users of homelessness services. More than half of hostels report that a majority of their clients have a problem with alcohol and almost 1 in 3 second stage accommodation projects reported a similar finding. Further, homeless people with alcohol problems may have specific housing and care needs arising from their alcohol use that providers have to address this may result in greater demand for residential care, where ordinarily the severity of their condition does not necessarily necessitate that. The table below outlines the number and proportion of individuals in alcohol treatment in Suffolk with housing difficulties. Table 47: Individuals in alcohol treatment with housing problems in Suffolk 2011/ /13 NFA - urgent housing problem 25 (4.5%) 22 (3.7%) Housing problem 44 (8.0%) 74 (12.5%) No Housing problem 471 (85.5%) 477 (80.7%) Other housing problem* 3 (0.5%) 3 (0.5%) Missing 8 (1.5%) 15 (2.5%) 6.5 Pharmacological interventions Pharmacological interventions for the management and treatment of alcohol misuse can significantly improve the likelihood of positive treatment outcomes including maintaining abstinence and preventing relapse. There are two classes of pharmacological intervention recommended in NICE guidance: Medication to treat medically assisted alcohol withdrawal, such as chlordiazepoxide Medication to promote abstinence or prevent relapse after withdrawal, such as acamprosate, oral naltrexone and disulfiram Medically assisted alcohol withdrawal Withdrawal symptoms are generally thought of as a feature of the later stages of a drinking career, and once they have occurred then subsequent manifestations in terms of both frequency and Page 63

64 severity depend upon a complex interaction of factors, but above all blood alcohol level seems to be important. The characteristics of alcohol withdrawal are well known, and common symptoms of alcohol withdrawal include: nausea, depression, anxiety, craving, confusion, tremulousness and visual hallucinations. For the majority of patients, there are no complications from withdrawal and there comes to be an expectation that all detoxification is risk-free. The danger is that clinicians may not exercise sufficient vigilance when monitoring withdrawal and may find themselves dealing with avoidable problems or, at worst, a fatality. It is the timing of withdrawal symptomatology that is particularly unpredictable - the tremulous state typically peaks within 6-24 hours of stopping or reducing alcohol consumption. Illusionary or transient hallucinatory phenomena superimposed on the tremulous state, but occurring within a similar time-scale, should alert clinicians to a more severe withdrawal and the need to review medication. Guidance from the Royal College of Psychiatrists suggests that there is often an undue emphasis on pharmacological treatment of alcohol withdraw which is unhelpful and distracting because in psychological terms, detoxification reduces the severity of withdrawal and thereby eliminates the negative reinforcement of relief drinking. In practice, a broad spectrum of drinking cues are diminished as the process of detoxification progresses...placing undue emphasis on substancespecific withdrawal fails to recognise the variety of cues and cue complexes that act as sources of reinforcement and contribute to building dependence...(and has) a practical implication for future treatment plans. The NICE quality standard on alcohol dependence and harmful alcohol use states that: People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric co-morbidities (quality statement 8). There is evidence that community-based medical assisted alcohol withdrawal are at least as effective as residential units for planned alcohol withdrawal, are preferred by patients and are less costly than inpatient withdrawal. For the majority of individuals, a community-based detoxification delivered on an outpatient or day patient basis, is ideal. In Suffolk, both SATS and CRI Lowestoft offer either home visits or outpatient-based programme for people with mild to moderate dependence in which contact between staff and the patient averages 2 4 meetings per week over the first week. These outpatient-based community assisted withdrawal programmes consist of a drug regimen (prescribed by the GP) and psychosocial support including motivational interviewing. The main role of the specialist community services are to: Assess and prepare the patient for a medically assisted withdrawal plan in liaison with the patient s GP Monitor during the detoxification Page 64

65 Provision of psychosocial interventions that support people through making changes In 2012/13, approximately 25 patients in CRI Lowestoft underwent community detoxification. Within SATS, in 2012/13 approximately 4 patients per month in East Suffolk and 1 patient per month in West Suffolk had a shared care plan for community detoxification. For SATS this was usually done via home visits by a community detoxification nurse. A significant number of these patients are repeat detoxification patients, although this report is unable to determine the full extent of repeat detoxification. Data from the NATMS pulls data across specialist services and lists 34 activities coded as community prescriptions in 2012/13. The bulk of these are likely to be community detoxification. Evidence suggests that the likelihood of a successful detoxification programme is increased if pharmacological interventions form part of an overall recovery plan. Despite this, reports from both general practitioners, and community based specialist services suggest that a significant number of patients do not have a formal recovery plan or are assessed and monitored by specialist alcohol services while they undergo detoxification. For these individuals, the mainstay of their detoxification programme in the community is a pharmacological intervention led and prescribed by the GP with no input from or shared care pathway into specialist services. The table below shows chlordiazepoxide prescription information in 2012/13 from Suffolk PCT. Table 48: No. of chlordiazepoxide prescriptions in Suffolk PCT Month-Year No. of prescriptions Activity cost ( ) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar All In Suffolk PCT, 2444 prescriptions for chlordiazepoxide were issued in 2012/13 an average of 203 prescriptions each month. Caution should be taken when equating the number of prescriptions issued with the total number of patients undergoing medically assisted alcohol withdrawal in the community. For this particular population of patients, there are likely to be significant number of repeat prescriptions for individuals patients, and prescription data cannot be used to identify the number of patients. Page 65

66 Despite the particular limitations of this data set, as an estimate of prescribing activity, this data demonstrates activity with regards to medically assisted alcohol withdrawal that is far in excess of what is observed in specialist alcohol clinics. This suggests therefore that a majority of patients in Suffolk who undergo community based medically assisted alcohol withdrawal do so through GP services only and do not receive the full package of care that is available to them, including preparation, assessment and structured psychosocial support. Difficulties with community detoxification arrangements in Suffolk include: Variation of care with respect to GP managed detoxification, including different practice with respect to the assessment of appropriate individuals, and management and titration of pharmacological dosages. The lack of a clearly identifiable link in specialist services that could provide specialist input while the GP maintains overall responsibility for patients. The lack of medical staffing in specialist services that would enable the overall management of more medically complex cases (but still suitable for community detox) within the specialist service Relapse prevention medication In addition to standards on medically assisted alcohol withdrawal, the NICE quality standard on alcohol dependence and harmful alcohol use states that: Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance (quality statement 11). While pharmacotherapy is commonly used to assist withdrawal, it is less commonly prescribed to prevent relapse. Clinical opinion suggests that around only 5% of people who withdraw each year receive medication to prevent relapse. However, the expert opinion of the guidance development group suggests that around one third (30% of patients who successfully withdraw) patients may benefit from it. Relapse prevention medication can help to reduce the rate of relapse from around 90% to 82%. The NICE Clinical Guidance 115 recommends that after a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention. In individuals for whom acamprosate or naltrexone are not suitable but still have a goal of abstinence, disulfiram can be used instead. For all of the above, prior to the prescription of relapse prevention medication, individuals should have had a comprehensive medical examination and relapse prevention medication should be seen as just one part of the recovery plan. Page 66

67 Individuals in specialist community services undergoing a structured intervention may have relapse prevention medication recommended for their use to the GP, however no formal mechanism exist whereby the specialist service could start the initial prescription. The table below shows the total number of relapse prevention prescriptions in Suffolk PCT in 2012/13. Table 49: No. of relapse prevention prescriptions in Suffolk PCT Month-Year Acamprosate Disulfiram Naltrexone Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar On average, approximately 50 prescriptions were issued for acamprosate, 45 for disulfiram and 16 for naltrexone were issued in each calendar month in 2012/13, i.e. a total of 111 prescriptions for anti-relapse medications in each month. These prescriptions are a good estimate of the number of patients receiving such medication over the course of a year as it is likely that patients continue to be on such treatments. Because of patients who may move out of region, or in cases where the GP has stopped the prescription, it is difficult to determine the number of new patients put on anti-relapse medication over the course of the year. Aggregate data from quarter 1 was compared to data from quarter 4 of the financial year. On average for the first quarter of 2012/13, a total of 106 relapse prescriptions are issued. This compares with an average of 116 prescriptions in the final three months of Assuming that the GP practice population is relatively stable, and that those who were on anti relapse medication in the preceding years continued their prescriptions, this analysis suggests therefore that there were 10 new patients who commenced anti-relapse medication over the course of the year. This is likely to be an underestimate, even in a stable population, as a number of individuals are likely to have stopped their anti-relapse medication. The NICE Guidance Development Group suggests that 26.24% of individuals who receive community detoxification subsequently manage to withdraw from alcohol successfully. Of these, 30% should be receiving anti-relapse medication. Using these assumptions, an expected figure for the number of patients who should have commenced anti-relapse medication in Suffolk is 190 patients. Even if all prescriptions in the last quarter of the year went solely to new patients this Page 67

68 would still fall far short of the 190 expected patients. The true figure with respect to new prescriptions is likely to be between 10 to 50 new prescriptions. This suggests that the majority of patients who would benefit from anti-relapse medication in Suffolk do not currently receive it. 6.6 Offender health and alcohol The consequences of alcohol problems in offenders affect individuals, their families as well as health and emergency services and wider society. The relationship between alcohol and crime, and in particular violent crime is increasingly being recognised. Offenders are three times more likely to have an alcohol problem when compared to the general population, with higher rates for women offenders. Men most likely to drink to excess are those from deprived areas, with binge drinkers the most likely offend. While offenders tend to be mostly young men from disadvantaged backgrounds, many of whom also have substance misuse problems there is a growing number of women in the criminal justice system. This population of individuals who come into contact with the criminal justice system represent an otherwise hard to reach group so offender-based health services can enable alcohol-related services to be made more accessible and address the substantial health inequalities that exist for this population. This section of the report examines the treatment needs of alcohol misusing offenders within key criminal justice settings in the community namely individuals in police custody and probation Population in police custody Suffolk has three Police Investigation Centres (PICs) for detention in Martlesham (30 cell complex, Bury St Edmunds (24 cell complex), and in Great Yarmouth (30 cell complex). These centres, replacing the previous custody suites, have been held up by inspectors as a benchmark for the quality both of the custody provision and of thoroughly planned and executed joint working. With regards to health needs, the inspectors highlighted that the centres have well equipped medical rooms, good patient care and a reduction in the numbers of people being held in the PICs under the Mental Health Act. After arrest detainees are brought to the PICs by the arresting officer. It is then the responsibility of the custody officer to accept the detainee into custody and at this point a risk assessment is undertaken which includes assessment of the detainees current physical state, drug and alcohol use (including requests for help with issues) and mental health status. Based on the detainee s answers to these questions and the officers observations of the detainee the officer will accept the detainee into custody. Rarely, he or she will not accept the detainee and suggest that an immediate visit to A&E is required to deal with the detainee s condition. Data was obtained from the Suffolk NSPIS custody system administrator for cases with information recorded in the NSPIS system. For alcohol issues, data was obtained from 29,975 Page 68

69 records for September 2011 to August This was 99.2% of the total of 30,208 persons in custody. The table below shows how prevalent significant alcohol problems are in this population 8% of male detainees, and 9% of female detainees reported dependence on alcohol. Table 50: Alcohol consumption behaviour of individuals in police custody in Suffolk from Sep 2011 to Aug 2012 Risk assessment question Male N = 25,270 Female N=4,705 Have you consumed alcohol / 15,268 (60.4%) 2,925 (62%) taken any drugs (prescribed or otherwise) or solvents within the last 24 hours Dependent on alcohol? 2,011 (7.9%) 434 (9.2%) Once accepted into custody the results of the risk assessment will determine the level of observations required and whether some form of health care input is required. At this point also, the detainee may request to see a health care professional if they wish. The forensic medical service, run by G4S Forensic Medical Services, will be called in the first instance for medical input and/or if there is any doubt over the detainee s fitness to be detained, later fitness to be interviewed or fitness to be charged. G4S records indications of the type of service provided at the time of the initial call. The table below shows the count and proportion of issues relating to alcohol intoxication and withdrawal as a percentage of total calls to G4S from Suffolk PICs. Table 51: Alcohol related calls to G4S FMS from Suffolk PICs from Sep 2011 to Aug 2012 Request type Count % of all calls Intoxicated (alcohol) 410 6% Withdrawing (alcohol) 345 5% RTA blood samples 149 2% Multiple services may operate in parallel simultaneously and depending on day and day of week detainees may be referred directly to mental health or drug and alcohol services by custody staff without any input from the forensic medical service. For alcohol, referral services are provided in PICs through Suffolk county council commissioned arrangements with the Westminster Drug Project (WDP) Suffolk. WDP Suffolk provides drug and/or alcohol screening and assessment, and can offer brief interventions, signposting or more tailored support and referrals to SATS. WDP Suffolk receive referrals directly from custody staff who both pass on detainee requests to see a drug and alcohol worker or make suggestions of detainees who may benefit from being offered this service. In addition, drug and alcohol workers attempt to see all detainees in the PIC at the time of their visit to offer the opportunity of self-referral to the detainee (cell door visits). If they have missed seeing someone at the PIC they will follow on and see the person at the court. WDP Suffolk are not funded to provide treatment or follow up for persons who exclusively had alcohol problems, these individuals are signposted to other specialist or community services. Page 69

70 Table 52: Individuals seen by WDP Suffolk 2011/ /13 Number of individuals seen/screened for alcohol misuse in custody settings Number of individuals requiring 38 an alcohol intervention Number that went on to be referred to structured treatment Activity data from the above tables can be compared to a cross-sectional survey undertaken as part of a health care needs assessment for individuals in police custody in Norfolk and Suffolk in Of a total of 394 eligible detainees, 152 (39%) consented to take part in the survey. The three question version of the AUDIT-C was used to assess the level of alcohol dependence amongst the detainees. As the figure below shows, 82 individuals (54%) had AUDIT-C scores suggestive of problem drinking behaviour. Figure 11: AUDIT-C scores of PIC detainees in Norfolk and Suffolk Were this proportion to be applied to the population in custody, it suggests that approximately 15,000 detainees in Suffolk could potentially benefit from a full AUDIT screen, with the majority benefiting from receiving brief advice on harmful drinking behaviour Probation services The Norfolk and Suffolk Probation Trust (NSPT) is responsible for overseeing offenders released from prison on licence and those on community services made by the courts. With regards to alcohol, the NSPT deliver a variety of interventions from brief interventions frequently delivered by offender managers during their routine interaction with offenders, to programmes which deliver Page 70

71 alcohol treatment requirements (ATRs) or alcohol specified activity requirements (ASARs). Introduced by the Criminal Justice Act 2003 and made available to the courts as a possible component of a Community Order (CO) or Suspended Sentence Order (SSO), an ATR can be imposed for between six months and three years as part of a CO and for a maximum of two years as part of an SSO, for offences committed by any adult aged 18 or over. Unlike previous provisions for an offender to receive alcohol treatment under a Community Rehabilitation Order or Community Punishment and Rehabilitation Order, the court does not have to be satisfied that alcohol caused or contributed to the offence in order to impose an ATR. The main goals of ATRs are towards: Abstaining, reducing or controlling drinking levels Reducing related criminal activity Promoting change and improvements in other areas of life There can be considerable variability in how the treatment component can be offered. Usual practice tends to be six hourly sessions typically delivered as a six month sentence. This is consistent with tier 2 services of MoCAM. Table 53: Alcohol treatment requirements in Suffolk Probation Requires ATR (sentenced) Commenced ATR Completed ATR ATR completion rate 2010/ % 2011/ % 2012/ % Page 71

72 7 Stakeholder consultation 7.1 Specialist provider survey In order to better understand the broader issues and challenges faced by front line teams when managing individuals with alcohol use disorders, a provider survey was undertaken. Three broad themes were studied with respect to this report current challenges and issues facing the service, groups of people who are currently poorly served, resources need that will enable the service to see and treat more people with alcohol problems. Providers had the opportunity to respond to this survey by free text responses. Key findings from the survey include a need to consider access to services, particularly for individuals who do not reside in the main urban areas, and greater joinedup working with GPs. Current challenges and issues facing specialist services Suffolk is a largely rural county, with low population density and with long distances for large parts of the population to travel to the main centres of population which have open access services. (x2) The majority of referrals are long term dependent drinkers that have had more than one episode of treatment and are well known to services. This is the most difficult section of the drinking population to treat successfully. Attracting those individuals not needing pharmacological intervention is a problem. Purely psychosocial intervention is harder to sell. Hosting alcohol services in a drug centre there is some verbal feedback that this discourages some alcohol misusers from accessing services Special groups of people with alcohol problems that are currently poorly served by alcohol services in the area Those living outside of the main urban areas there are satellite services but without active promotion of non-dependent services referrals continue to be largely those requiring pharmacological interventions. Even with current satellite areas covered there is an access problem for a significant proportion of the population Individuals who come in via criminal justice routes possible view that lifestyle is not a problem Increasing risk section of drinkers we see a high proportion of physically dependent drinkers Additional resources that would enable specialist providers to see and treat more people with alcohol problems GP s being clearer about referral routes and criteria resources: time and promotional material (x2) Better satellite coverage aimed at non-dependent drinkers resources: recovery workers; venues and/or venue hire; travel costs Page 72

73 7.2 Patient engagement focus groups In July and August 2013, a series of focus group sessions were held to gain qualitative feedback about the patient experience of alcohol treatment services in Suffolk who currently or have previously used a service within the past two years. These sessions were publicised through posters, leaflets and s in liaison with various community groups and organisations such as alcoholics anonymous, community resource centre and homelessness services. The tools used during the session to gain people s views were through general conversation, brief questionnaires, quick tick box task and other materials that enable people to write or draw their comments. Four themes were discussed at focus group sessions, these were: Access to service - How easy do you find it to get to the treatment service location? - How easy do you find to make an appointment or see a recovery worker/health care professional? - How satisfied are you with the hours the service is offered? Service-user and recovery worker/healthcare professional communication - How good are the staff at: - Giving you enough time? - Asking about symptoms? - Listening to you? - Explaining care plan? - Involving you in decisions about your care? - Taking your problems seriously? - Did you have confidence in the recovery worker/professional you saw? Care planning and support - Did the discussion with a recovery worker/professional about managing your alcohol use problem lead to an agreed care plan? - Do you think that this plan has helped improve the care you received? - Did the plan involve family members? - Were you directed to other sources of support outside the agency e.g. GP, voluntary services, websites, etc? Overall satisfaction - How do you feel about the care you received at your treatment service? - What should good alcohol treatment services consist of? Overall 26 individuals were consulted and detailed results of the focus group are provided in Appendix 2 of this report. Page 73

74 Access to service A majority of individuals reported that they were happy with access to the service they use or had accessed in the past. The minority of individuals who reported that access could be improved commented that there needs to be services directed to meet the needs of women, services need to be quicker at seeing people and the wait for rehabilitation is too long. One respondent commented that people can only find out about the service at services, i.e. that there was a lack of information available in public spaces. Significant numbers of respondents found it difficult to access specialist service through their GP. A number reported that GP services need to publicise alcohol services more clearly especially in rural areas. One respondent commented that some GPs do not differentiate between treating individuals for mental health issues and substance misuse disorders. One respondent recommended that specialist workers from agencies could go into practices to sit in practice meetings so that GPs are able to gain information and advice on how to support individuals with alcohol issues. Healthcare professional and client information Respondents here highlighted the need for service providers to develop ways to come together to help, discuss and plan treatment along with both clients and family members. Care planning A majority of the service users who were currently accessing alcohol treatment services reported that they were aware of their care plan and involved in the creation of their plan and this is an important part of making sure their plans helped them with their recovery. Other comments noted that when people finish detoxification courses or rehab there is no aftercare support in the community. One respondent suggested that GP s could be more active and participate in care planning meetings. Other comments The needs of homeless and street drinkers were seen as a significant issue for a number of respondents. One respondent suggested that services could work with homelessness services and actively seek out homeless individuals on streets and provide guidance and support. Page 74

75 8 Gap analysis A gap analysis is a comparison of actual performance with potential performance of the system. The information below triangulates the findings of this needs assessment by comparing the current situation in Suffolk against the NICE quality standard for alcohol dependence and harmful alcohol use QS1 QS2 QS3 QS4 QS5 NICE Quality Standard Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol. Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice. 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. People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff. Adults accessing specialist alcohol services for alcohol Current Status In 2012/13 training was provided to specific groups of staff in hospital A&Es and the NSFT on identification of individuals with alcohol use disorders as part of the Making Every Contact Count CQUIN initiative. This was a contractual arrangement between the PCT and the provider trusts that has not been continued this year. Contractual arrangements for screening and brief interventions are with GPs (for new registrants, and as part of the NHS Health Checks) and hospital A&Es. These appear to be significantly underutilised. In the GP setting in a 1 year time period, a quarter of all practices did not report screening any new registrants for alcohol use. Of the 14,000 patients screened as part of the alcohol DES, only 1,124 subsequently went on to have a full screen, and 44 were referred to specialist service. This is a significant underestimate (by greater than 100%) of the current epidemiological evidence and disease pattern. Open access routes to specialist services exist and >40% of patients are self-referrals. Stakeholder consultation and patient engagement focus groups suggest that there is scope both for increasing publicity of these services to the public and also for increasing the number of referrals from GPs (for individuals who are moderately dependent). Clear referral guidelines need to be in place for individuals who are referred from health care services to prevent duplication of assessment. Issues exist for individuals who are not in the main areas of population and may find it difficult to access specialist clinic locations. At present, the specialist services are run without medical support or lead. This has significant implications in terms of patient safety (particularly for complex cases with additional co-morbidities), administration of community based medically assisted withdrawal and relapse prevention medication, and liaison between the specialist provider with the patient s GP and GP access to specialist input and post-discharge care. Specialist providers report that all individuals receive a comprehensive assessment on entry into Page 75

76 QS8 QS9 NICE Quality Standard misuse receive a comprehensive assessment that includes the use of validated measures. People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities. People needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance QS11 Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance. Current Status community based specialist services in Suffolk. Validated instruments such as the AUDIT tool form part of this assessment. Successful community-based medically assisted alcohol withdrawal is dependent on prior assessment and preparation of the patient and regular monitoring to pre-empt complications and ensure appropriate drug dosages. This report demonstrates that the majority of community-based medically assisted alcohol withdrawal is initiated by the GP without input from specialist services. Based on GP prescribing data, of the estimated 2,000 episodes of underwent community based medically assisted alcohol withdrawal in the last year, only 55 (3%) of these episodes benefited from specialist provider input in the last year, This means that there is variation in standards of care for such patients across the county. In addition to patient safety concerns that this finding raises, the lack of specialist input for such individuals and the administration of community detoxification regimes without appropriate aftercare could impact upon the clinical effectiveness and success of the treatment. Although psychological interventions both in an outpatient setting and as part of a structured day programme are offered by providers, the documented waiting times for psychosocial interventions are a bottleneck in the service. At present the majority of patients who require a structured psychosocial programme wait longer than 3 weeks with an average waiting time of approximately 50 days. In addition, there appears to be a significant underutilisation of relapse prevention medication in GP practices. NICE guidance suggests that 30% of patients who successfully withdraw from alcohol should be placed on an anti-relapse pharmacological therapy alongside structured psychological intervention. This report finds that there is scope for a 100% increase in the number of patients on anti-relapse medication in order to meet this 30% figure. Page 76

77 9 Resource considerations Four key areas that currently do not meet NICE quality standards are likely to pose a significant resource requirement: Increasing the provision of screening and brief intervention in adults (QS1 &2) Ensuring that staff in community based specialist services are appropriately qualified and at a level sufficient to meet the needs of the population (QS3 & 4) Offering a structured psychosocial intervention for harmful drinkers and people with mild alcohol dependence (QS11) Improving access to relapse prevention medication (QS8, 9 & 11) This next section considers what, if any, additional resources are required, and the likely cost impact, of an enhancement in the level of service provision, such that the alcohol service provision in Suffolk meets NICE quality standards. 9.1 Increasing the provision of screening and brief intervention in adults Potential costs associated with screening adults for harmful or hazardous use of alcohol are difficult to quantify. NICE guidelines recommend that screening is provided both to all new registrants, and also on an opportunistic basis. NICE Public Health Guidance suggests that in addition to new patient appointments, alcohol screening could also be carried out when screening for other conditions, at an antenatal appointment, when managing chronic disease, or when carrying out a medicine review. The additional time required to complete the screening is around 3 5 minutes, it may be possible to fit this into new registrations or consultations at little or no extra cost. If a unit cost is applied to screening it varies significantly depending on which professional group completes the audit, ranging from 2.65 for a practice nurse to for a GP. The costs are also heavily influenced by the number of people screened; screening all patients at next attendance will involve screening large numbers compared with screening patients at each new GP registration. This report will only consider screening costs associated with new patient registration. It should be noted that the DES on alcohol screening is held contractually by NHS England, so apart from additional materials and training of staff required to deliver brief interventions, the significant bulk of the enhancement to current service provision level is expected to be cost neutral. In Suffolk, the current scenario is that 14,000 new registrants are screened every year. Of these 250 are identified as hazardous drinkers and go on to receive brief interventions. The recommended practice is that all new registrants should be screened this is likely to be approximately 6.5% of the total practice population, for Suffolk this would be 37,905 initial screens. Page 77

78 Of these, a proportion of individuals will be identified as harmful or hazardous drinkers 24.2%. All of these individuals should be offered brief advice and intervention, however based on current estimates only 62% are likely to accept the brief intervention. Despite the relative cost neutrality of this intervention, reaching the target will likely require some time to achieve. This is due to the need for staff training, and changes in practice. The table below shows the requirements needed in order to reach this target of 100% coverage of new adult patients within 3 years, assuming only minimal population growth in the adult population in Suffolk. Table 54: Project resource impact of increasing the provision of screening and brief intervention Projected activity Current Year 1 Year 2 Year 3 Number of people screened per year 14,000 25,000 30,000 37,905 Number of hazardous drinkers identified and receiving brief interventions each year 350 3,000 4,200 5,687 Cost impact to CCGs in Suffolk Brief intervention material ( 1 / unit) 350 3,000 4,200 5,687 Development and maintenance of training package for practice staff 0 2,000 1,000 1,000 Total investment needed ( ) 5,000 5,200 6, Ensuring appropriate staffing in specialist services Increases in the number of people screened in primary care are likely to lead to greater demand for specialist services. Current capacity modelling does not suggest that services are struggling to cope with demand for the most part. One exception would be structured psychosocial interventions, where the average waiting time for this service is 50 days, and significant proportion of individuals wait more than 4 weeks for the service. This model shows the likely cost impact of the addition of 1.0 wte CBT worker in Year 2. In addition to this, feedback from both the specialist provider survey and also patient engagement focus groups suggest that access for individuals living in rural areas or areas of Suffolk not well served by public transport. Provision of outreach clinics to those groups of individuals could potentially be managed using current staff, however there will be additional costs for transport and provision of clinic space. For the purposes of this model 1 session per week is delivered from a rural GP practice in Year 1. As the service offered is not an NHS commissioned service, the practice is likely to charge rent. Based on other services delivered in primary care (though NHS commissioned) such as AAA screening, the estimated cost impact for that including transport and overhead costs is likely to be 100 per session. Page 78

79 Specialist services currently lack any medical oversight. This has significant clinical governance issues, impacts on the ability of the service to monitor complex cases of medically assisted alcohol withdrawal that could potentially be managed in the community (thus leading to increase in inpatient and residential detoxification programmes), and input and liaison with primary care practices (which could be a potential reason why the vast majority of community detoxification take place in primary care without an appropriate package of care, assessment and monitoring in place by the specialist alcohol service). SATS are currently developing a business case to recruit a consultant psychiatrist to act as a medical lead for the service for 2 sessions per week. This model looks at the impact of costs if this were to go ahead in Year 1. Table 55: Projected cost of changing staffing levels Unit cost Current Year 1 Year 2 Units Cost Units Cost Units Cost Staff costs Addiction psychiatrist (per session) , ,000 Alcohol nurse band 6, per wte 35, , , ,900 Alcohol social worker scale SO1/2, per wte 32, , , ,864 Psychologist (band 8a, per wte) 51, , , ,871 CBT therapist (band 5, per wte) 29, ,072 Administration staff (band 3, per wte) 20, , , ,584 Managerial costs 35, , , ,000 Outreach clinic costs Overheads and travel (per session) Estimated costs of the service 612, , ,291 Additional investment required 54,264 29, Offering a structured psychosocial intervention for harmful drinkers and people with mild alcohol dependence Psychological interventions such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies, focused specifically on alcohol related cognitions, behaviour, problems and social networks may prevent harmful drinkers becoming dependent on alcohol, and prevent those with mild dependence developing more severe dependence. There is a high demand for structured psychological services in Suffolk with long average waiting times for those who require it. Further, the proportion of harmful drinkers and people with mild Page 79

80 alcohol dependence who currently access specialist services who receive psychological interventions is estimated to be only 39%. In this model, it is assumed that 1.13% of people with mild dependence are receiving evidencebased treatment each year, of whom around 39% currently receive structured psychological interventions. The expert clinical opinion of the NICE guidelines development group was that following implementation of the guideline, 100% of people having specialist treatment for mild dependence may receive structured psychological interventions. The average cost of psychological interventions received by people with mild alcohol dependence ( ) is taken from the full NICE guidance and is the mean cost of the three main types of therapy recommended: cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies. Costs are based on staff time and an average number of sessions for each type of therapy. In practice, the duration of these therapies may be shorter than recommended in the guidance and, therefore, the cost impact of implementing the guidance may be lower than calculated here. Three people with mild alcohol dependence were assumed to need to receive a psychological intervention to produce one non-drinker (the number needed to treat [NNT]). This is derived from Alwyn et al. (2004), which considered the cost-effectiveness of adding a structured psychological intervention to a conventional community detoxification programme for problem drinkers and found a NNT of around 3. The annual unit cost of the saving from the reduction in the number of people dependent on alcohol ( 1800 per year per dependent drinker) is taken from the full guideline and is the estimated annual cost to the NHS of alcohol dependency. The table below shows that an initial investment of 94,192 will be required in order to fully implement the guidance a staged process over a number of years may be more financial feasible. There will be an associated saving of 75,600 per year due to a reduction in the number of people with mild alcohol dependence. Note that this cost saving is a cost-saving to the NHS, while it is expected that the majority of psychosocial interventions for these individuals will be commissioned by local authority. Page 80

81 Table 56: Projected cost impact of increasing the number of psychological interventions Current Post-implementation Number of people with mild alcohol dependence Current practice Proportion Units Costs ( ) Proportion Units Costs ( ) 18,479 18,479 Estimated proportion of people with mild alcohol dependence provided with evidence-based specialist treatment each year Proportion of harmful drinkers and people with mild alcohol dependence provided with evidence-based specialist treatment receiving psychological interventions Cost of psychological interventions ( ) per intervention 1.13% % % % , ,009 Additional investment needed ( ) 94,192 Potential savings Increased number of people with mild alcohol dependence receiving psychological intervention Number needed to treat (NNT) to produce one extra non-drinker Potential number of additional nondrinkers Potential savings due to reduced number of people with mild alcohol dependence ( 1,800 per year per person) ,600 Net cost impact 18, Improving access to relapse prevention medication Pharmacotherapy is most frequently used to facilitate withdrawal from alcohol in dependent drinkers; many fewer individuals receive medication such as acamprosate, disulfiram or naltrexone for relapse prevention. While it is difficult to get reliable it can be estimated from prescribing data that about 10 new patients are placed on anti relapse medication in Suffolk each year (assuming a stable population). This model uses the lower end of that estimate to describe current practice and estimates that 16 new patients are placed on anti-relapse medication per year in Suffolk. This corroborates expert opinion that suggest that only 5% of individuals who successfully withdraw are on anti-relapse medication. This is equivalent to 16 individuals for Suffolk. Page 81

82 The NICE Guidance Development Group suggests that 26.24% of individuals who receive community detoxification subsequently manage to withdraw from alcohol successfully. Of these, 30% should be receiving anti-relapse medication. Using these assumptions, an expected figure for the number of patients who should have commenced anti-relapse medication in Suffolk is 93 patients annually. The additional cost of relapse prevention with a pharmacological intervention (acamprosate or oral naltrexone), along with the additional monitoring needed when these drugs are prescribed ( ), was taken from the full NICE guideline. Drug costs were taken from the British national formulary (BNF) 60, September People were assumed to be already receiving a psychological intervention after withdrawal and the incremental cost is the cost of the additional medication and monitoring only. Rates of relapse for people who receive medication after withdrawal (82.15%) and those who do not receive medication after withdrawal (89.56%) were taken from the full NICE guideline. The annual cost of a relapse ( 1800) was taken from the full NICE guideline and is the estimated annual cost to the NHS of alcohol dependency. Table 57: Projected cost impact of increasing the number of relapse prevention prescriptions Proportion of people who successfully withdraw who receive medication for relapse prevention Unit cost / proportion Current Post-implementation Units Cost ( ) Units Cost ( ) Proportion of people who successfully withdraw who do not receive medication for relapse prevention Cost of relapse prevention pharmacological intervention and monitoring ( ) , ,114 Rate of relapse for people who receive medication after withdrawal 82.15% Rate of relapse for people who do not receive medication after withdrawal 89.56% Annual cost of relapse ( ) 1, , ,800 Total cost 505, ,914 Net cost 22,412 Page 82

83 11 Conclusions and recommendations The commissioning landscape Responsibility for commissioning of alcohol treatment services lies within different organisations. Suffolk County Council is responsible for commissioning specialist alcohol services in the community. This is dependent upon adequate referral processes and integrated working arrangements between primary care and other NHS commissioned services such as acute hospital trusts. CCGs are responsible for commissioning alcohol specialist workers in hospitals, and also for admissions and inpatient rehabilitation services. The UK government strategy has prioritised alcohol treatment services as an invest-to-save measure, and yet investment made by one commissioning organisation may result primarily in savings in another organisation, for example investments made in staffing levels or psychological interventions in community based alcohol specialist services by Suffolk County Council are likely to result in considerable cost savings to the NHS. Similarly, increase in service provision with regards to screening in primary care and hospitals are likely to result in increases in demand for community based alcohol specialist services. It is clear therefore that commissioning of any one part of the alcohol system cannot happen in isolation. Suffolk has an established alcohol strategy group and is developing an alcohol strategy. This group has wide representation from a number of teams and is a good example of joint working. Despite this however, no specific group or body exists which focuses primarily on health care commissioning for individuals with alcohol use disorders. Recommendation 1: This report proposes the formation of an alcohol healthcare partnership comprising the local authority, CCGs, and healthcare provider partners, the police and crime commissioner and Suffolk Constabulary. The group will be responsible for sharing information between partner organisations, exploration of ways of joint commissioning and further integration of the various services currently provided in Suffolk. It is envisaged that there will be a sub-group of healthcare commissioners to lead on commissioning. Recommendation 2: The Suffolk alcohol healthcare partnership would also be responsible for monitoring the quality of services offered in Suffolk. Page 83

84 Screening and brief interventions Despite considerable evidence which indicate that opportunistic screening and brief advice and interventions offered in a healthcare setting can result in individual behavioural change and reduce rates of harmful and hazardous drinking, there exists considerable opportunities for further service development in this area. With regards to GP screening of new patients, considerable variation exists between practices in Suffolk and 25% of all Suffolk practices do not partake of this service agreement. Importantly of those patients who do receive an initial screen, much fewer than expected go on to receive a full screen and brief advice. Alcohol screening has been incorporated into the NHS Health Checks programme from 2013/14, and the directly enhanced service agreement for alcohol new patient registrations continues between NHS England and GP practices. Recommendation 3: CCGs to increase awareness among GPs and practice nurses on the benefits and practice of screening and brief intervention using the AUDIT tool through information distribution in the GP newsletter and discussion at the Local Medical Committee. Public Health to work with services commissioned and provided by the local authority to promote Making Every Contact Count and to ensure alcohol screening is available where appropriate. Recommendation 4: GPs to ensure practice staff are aware of the need for screening of new patients, and highlight the importance of appropriate follow up for patients who are screened and found to be positive. Apart from primary care, screening should also be carried out in the hospital and other healthcare setting. Both West Suffolk and Ipswich Hospital have alcohol health liaison workers who are able to coordinate screening in A&E and on the wards. Nationally, some evidence exists as to the benefit of alcohol liaison workers located in acute trusts. Despite this however, few referrals for specialist services are made directly from the hospital. Recommendation 5: CCGs to consider outcome-based commissioning for alcohol screening from hospital trusts. A CQUIN introduced as part of MECC last year obliged acute trusts to ensure staff in A&E were trained in PAT screening and to deliver brief interventions, and also to increase the number of referrals from A&E to specialist services in the community. Both Ipswich Hospital and West Suffolk Hospital were able to train staff to deliver PAT screening, however were unable to identify a greater proportion of harmful and hazardous drinkers or to refer them on to specialist services. Page 84

85 A similar CQUIN was put in place last year for the Norfolk and Suffolk Foundation Trust, however fulfilment of this CQUIN depended upon staff training only with no requirement to demonstrate delivery of screening or onward referral. For the 2013/14 cycle, no contractual arrangement is in place between acute trusts and the CCGs to deliver screening in those settings. Recommendation 6: CCGs to explore contractual arrangements between hospital trusts and mental health trusts to identify if alcohol screening and reporting would be an appropriate addition to a future contact. Improvements in screening processes are likely to results in greater pick up rate of harmful and hazardous drinking behaviour and correspondingly increase demand for community based specialist services. This report demonstrates that current services are operating at 63 68% capacity. As such there is the capacity to cope safely with an approximately 20% increase in demand for the services. Recommendation 7: Community based alcohol specialist providers to monitor service activity and capacity and report on this regularly to the local authority commissioners. Equity in specialist service provision The survey of specialist providers and patient engagement focus group report significant difficulties for certain groups of the population in accessing alcohol specialist services due to geographical isolation. Service locations tend to be based in the main urban areas and satellite or outreach clinics are not widely used. Evidence presented in this report does not suggest that there would need to be increases in staffing in order to enhance provision of outreach clinics. This report presents a service model of 1 outreach clinic a week in a rural GP practice, and estimates transport and overhead costs to be approximately 100 per session. Recommendation 8: outreach clinic Specialist providers to explore their capacity for delivery of Recommendation 9: Assessment of future tenders for community based alcohol specialist services should take into account access for individuals in geographically isolated locations. This could be in the form of an equality impact assessment. Improving access to psychosocial interventions There is a high demand for structured psychological services in Suffolk with long average waiting times for those who require it. Further, the proportion of harmful drinkers and people with mild alcohol dependence who currently access specialist services who receive psychological Page 85

86 interventions is estimated to be only 39%. The NICE guidance recommends that this should be 100%. At present, SATS employ 1.0 wte psychologist. This report shows that the expected cost increase of the addition of 1.0 wte cognitive behavioural therapist in staffing is approximately 30,000 annually. This would assist in waiting times for access to structured psychological therapy, and enable services to increase the proportion of harmful drinkers and people with mild alcohol dependence provided with evidence-based specialist treatment receiving psychological interventions. Recommendation 10: Recommendation 11: Specialist providers to estimate the likely requirements needed to improve access to structured psychosocial interventions Commissioners to consider likely increase in cost required to meet the NICE guidance and balance against potential savings. As potential savings likely to be seen most demonstrably in the NHS, joint commissioning could be considered as an option for this scenario. Ensuring appropriate pharmacological interventions are used Successful community-based medically assisted alcohol withdrawal is dependent on prior assessment and preparation of the patient and regular monitoring to pre-empt complications and ensure appropriate drug dosages. This report demonstrates that the majority of community-based medically assisted alcohol withdrawal is initiated by the GP without input from specialist services. Based on GP prescribing data, of the estimated 2,000 episodes of underwent community based medically assisted alcohol withdrawal in the last year, only 55 (3%) of these episodes benefited from specialist provider input in the last year. This means that there is variation in standards of care for such patients across the county. In addition to patient safety concerns that this finding raises, the lack of specialist input for such individuals and the administration of community detoxification regimes without appropriate aftercare could impact upon the clinical effectiveness and success of the treatment. This report also finds through the patient engagement focus groups, that a number of respondents found it difficult to access specialist services through their GPs, and that there is a lack of aftercare following detoxification programmes conducted by the GP. Recommendation 12: Recommendation 13: CCGs to raise awareness of alcohol specialist service provision for community based detoxification programmes through the GP newsletter and discussion at the local medical committee. Providers to write to GPs to publicise their services in community detoxification. Page 86

87 Recommendation 14: CCGs to consider adoption of standardised clinical protocol for community based detoxification including clear criteria for individuals that are likely to be appropriate and those that may require inpatient detoxification. Should there be an increase in the number of referrals for the assessment, monitoring and aftercare of community detoxification programmes, specialist services will need to be able to manage this increased demand. In the majority of cases, the GP should be expected to remain the lead clinician in charge of the patients care, with alcohol services providing specialist input as necessary. This will require liaison between specialist services and the GP, and in some cases a point of contact that the GP can ask for advice on treatment protocols. In complex cases that are still considered suitable for community detoxification, there may be also be small degree of clinical risk involved and specialist services may wish to get more involved with the patients care. At present this is hampered by the lack of medical staffing at the specialist services. This report notes that there is a business case in development that would see SATS recruit a consultant psychiatrist to provide medical oversight, and to treat complex cases for 2 sessions a week. Recommendation 15: Commissioners to consider the 0.4 wte consultant psychiatrist model presented in this report and determine whether it is able to fulfil considerable cost implications of this. Pharmacotherapy is most frequently used to facilitate withdrawal from alcohol in dependent drinkers; many fewer individuals receive medication such as acamprosate, disulfiram or naltrexone for relapse prevention. Triangulation of available data suggests that only 5% of eligible patients receive this treatment in Suffolk. It is important to note that these medications are expensive. In order to bring current practice up to 30% of eligible patients (i.e. 93 patients per year on relapse prevention medication), the total cost of the drug plus the additional monitoring equates to additional upfront investment of 33,209. Additional savings could be generated from the reduction in relapse rates, however the model presented in this report notes that only 6 fewer patients would relapse than would otherwise have under the current scenario (equating to an investment of 5,534 for each person who did not relapse). Recommendation 16: Commissioners to consider whether the benefits outweigh the costs of increased prescriptions of anti-relapse medication. Page 87

88 References Alwyn T, John B, Hodgson RJ & Phillips CJ (2004) The addition of a psychological intervention to a home detoxification programme Alcohol and Alcoholism 39: Department of Health (2008) Reducing Alcohol Harm: health services in England for alcohol misuse Online at: Accessed: 2 January 2014 Department of Health (2009) Signs for improvement: commissioning interventions to reduce alcohol related harm Online at: Accessed: 2 January 2014 Jordan J & Wright J (1997) Making sense of health needs assessment British Journal of General Practice 47: Online at: Accessed: 2 January 2014 NHS Confederation (2010) Too much of the hard stuff: what alcohol costs the NHS Online at: Accessed: 2 January 2014 National Institute for Health and Clinical Excellence (NICE) (2005) Health needs assessment: a practical guide. Online at: Accessed: 2 January 2014 NICE (2011) Commissioning Guide. Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults Online at: Accessed: 2 January 2014 NICE (2011a) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence Online at: Accessed: 2 January 2014 National Treatment Agency for Substance Misuse (2010) Statistics from the National Alcohol Treatment Monitoring System (NATMS) Online at: Accessed: 2 January 2014 Oferi-Adjei D, Casswell S, Drummond C, et al. (2007) WHO Expert Committee on Problems Related to Alcohol Consumption Technical Report Series; No 944. WHO: Geneva. Prochaska JO, Velicer WF, DiClemente CC & Fava J (1998) Measuring processes of change: Applications to the cessation of smoking Journal of Consulting and Clinical Psychology 56(4): Online at: Accessed: 2 January 2014 Raistrick D, Heather N, Godfrey C (2006) Review of the effectiveness of treatment for alcohol problems Online at: ms_fullreport_2006_alcohol2.pdf Accessed: 2 January 2014 Page 88

89 Ryder SD, Aithal GP, Holmes M, Burrows M & Wright NR (2010) Effectiveness of a nurse led alcohol liaison service in a secondary care medical unit Clinical Medicine 10(5): Online at: pdf Accessed: 2 January 2014 University of Birmingham (2013) An Introduction to HCNA; The epidemiological approach to health care needs assessment Online at: Accessed: 2 January 2014 Page 89

90 Appendix 1 1 Purpose Healthcare Needs Assessment for Alcohol Treatment Services in Suffolk Terms of Reference The purpose of this group is to oversee and provide strategic steer to the development of Suffolk s Healthcare Needs Assessment (HNA hereafter) for Alcohol Treatment Services. The HNA will provide evidence and intelligence for the development of commissioning plans and service changes in relation to alcohol treatment services in Suffolk. 2 Rationale The UK Government s Alcohol Strategy (2012) strongly encourages local authorities, clinical commissioning groups (CCGs hereafter), and partners to work together to identify and meet local need to reduce levels of harmful drinking in the community. Action undertaken towards this stated ambition must be based on a clear picture of the population need and sound evidence on effective interventions. For Suffolk, this evidence and intelligence will be systematically identified through a healthcare needs assessment that will provide a framework to examine the factors that impact on alcohol treatment services. 3 Roles and responsibilities The group will support this HNA process by: Providing expert knowledge of the local area to map current services and identify apparent barriers and gaps in services Representing the views of different stakeholders on the current services Facilitating access to key sources of local and national information and data Using local context and intelligence to assist interpretation of information and data gathered during the needs assessment and draw conclusions from these Contributing to the formulation of recommendations for service development from the needs assessment 4 Membership Deputy Director of Public Health, Suffolk County Council Dr Amanda Jones Public Health Specialty Registrar Dr Justin Wong (Chair) Drugs and Alcohol Team Coordinator Simon Aalders Page 90

91 Drugs and Alcohol Team Adult Commissioner Michelle Paterson Public Health Information Analyst Tanya Kimber West Suffolk CCG representative Dr Tom McGonigle Ipswich & East CCG representative Dr Ben Solway Great Yarmouth & Waveney CCG representative Dr Maria Karretti Phoenix Futures representative Cynthia Pointon SATS representative Graham Abbott CRI representative Rankin Barr Open Road representative Richard Bergson WDP representative Paul Simmons Suffolk Constabulary representative Robin Pivett Probation Service representative Julia Sharp Suffolk Police and Crime Commissioner representative Claire Swallow Health Watch Suffolk representative Kalam Pearce 5 Meetings There will be two face to face meetings an initial meeting to identify current pathways and processes, and a later meeting to discuss key recommendations. Where a member cannot personally attend a face to face meeting, they are asked to send a representative. In addition to face to face meetings, the group may be called upon to respond via to key issues, concerns and drafts. Page 91

92 Appendix 2 FEEDBACK FROM FOCUS GROUP SESSIONS Report produced by Judith Bourne of Suffolk Family Carers Definition The following terms are used throughout this document to describe those who participated in the focus group as being: A Service User means anyone who is currently accessing health or community or alcohol treatment services and ex- service users who have experienced significant problems attributed to their misuse of alcohol. A Family Carer is someone of any age whose life is restricted because they are looking after another person who cannot manage without help because of illness, age related frailty, mental health need, substance misuse or disability. Family Carers are not paid and do not always live with the person they care for. They may be caring for a friend, neighbour or relative. But people who assist someone in this way may not necessarily identify themselves as being a carer, particularly if they are a parent or a neighbour who frequently helps out. 1. Introduction The focus groups involved gaining qualitative feedback about Service Users and Family Carers experience and views of Alcohol treatment services in Suffolk and who currently or have previously used a service within the past two years. I met with service users and family carers within carers and alcohol treatment services throughout Suffolk and people were also invited to share their experiences by contacting service user and family carer involvement worker at Suffolk Family Carers, directly or via the website, individual contact and through colleagues at DAAT and Suffolk Family Carers teams. The feedback from the focus groups will be used to contribute towards Suffolk Alcohol Needs Assessment 2013, lead by Dr Justin Wong, Specialty Registrar, Public Health, Suffolk County Council. 2. How was the focus groups carried out? To explore service users and family carers views of alcohol services they currently or previously used and what should good alcohol treatment services consist of? I arranged to meet with people on: face to face basis at various venues within Suffolk publicised the sessions through posters, leaflet, s Gained support from commissioned service providers within Suffolk Drugs & alcohol treatment services and ran a session and joined group sessions, during the organisations treatment programmes. Liaised with community groups and voluntary organisations. For example, AA, Al-anon, Community Resource Centre, homelessness services. Page 92

93 Themes for discussion The aim of the focus groups was to provide a flexible, safe, friendly and confidential environment, to put service users and family carers at ease. People had the choice to remain anonymous, participate fully or partially in the focus group and light refreshments were provided at all sessions. In addition, as a way to say thank you for participating in the focus groups, people were given the opportunity to be entered in a prize draw to win gift vouchers. The themes used to create topics for discussion and questions for the focus group were as follows: a. Equality and monitoring information b. Access to service How easy do you find it to get to the treatment service location? How easy do you find to make an appointment or see a recovery worker/health care professional? How satisfied are you with the hours the service is offered? c. Service-user and recovery worker/healthcare professional communication. How good are the staff at: Giving you enough time? Asking about symptoms? Listening to you? Explaining care plan? Involving you in decisions about your care? Taking your problems seriously? Did you have confidence in the recovery worker/professional you saw? d. Care planning and support Did the discussion with a recovery worker/professional about managing your alcohol use problem lead to an agreed care plan? Do you think that this plan has helped improve the care you received? Did the plan involve family members? Were you directed to other sources of support outside the agency e.g. GP, voluntary services, websites, etc? e. Overall satisfaction How do you feel about the care you received at your treatment service? What should good alcohol treatment services consist of? The tools used during the session to gain people s views were through general conversation, brief questionnaires, quick tick box task and other materials that enable people to write or draw their comments. However, several issues arose that prevented people from completing tasks on their Page 93

94 own or as a group discussion; for example, people experience difficulties with reading and writing, the effects of their current alcohol use, mental health, the level of literacy and some people seemed hesitant to share too many details about themselves. They appeared guarded and sometimes anxious, this had an impact on how people participated, consequently, recording feedback during session were relied on me keeping a record whilst continuously reassuring people that I was only recording information and not their personal details. Some of the people I spoke to were concerned about confidentiality and worried that if they commented on their experience of services it would get back to the organisation. ; that they are complaining about, worrying it could have an effect on how they receive the service or even have to leave the service, thus they would be left with no support. One person stated that without the service he does not have any other support within the community, no family contact or help with daily living, therefore he does not want to complaint about how he is receiving a service because the service would stop and it would be more likely he would relapses. It is difficult to get a true impression from service users if the participants possess minimal or no reading and writing abilities thus may become frustrated and/or reluctant to participate when they are faced with written materials. This can be overcome if services enlist ways to find out from service users and family carers what the best ways to communicate with the people are.. 3. What was found Overall 26 people were seen, not all those people completed equality monitoring forms and comments forms to gain a level of their satisfaction with a service they attended, as they preferred not to. Also, 2 people attended a session because they had seen the poster about the focus groups so joined in the session and made enquiries about how to gain support with their alcoholism. However the two people did also provide feedback about accessing alcohol services. A. Equality Monitoring Due to literacy difficulties, their manner and some reluctance the service users who attended the sessions were not able to fully complete forms accurately or they choose not to complete forms. Q1. Ethnicity White English Black Caribbean Page 94

95 Number of Responses Number of Responses The above pie chart shows that there were only two ethnic origins and the majority of the respondents were White English. Q2. Age Rather not say Age Groups Series1 The above chart shows that the majority of the respondents were aged between 46 and 55. Their exact ages were; 46, 39, 47, 40, 48, 51, 46, 32, 38, 53, 24, 24, 43, 56. Q3. Do you consider yourself to have a disability? 5 6 Yes 5 No Rather not say Q4. Gender Male Female Rather not say Gender Page 95

96 Number of Responses Number of Responses Q5. Faith No Religion Christian Cathloic Other Religion Q6. Sexual Orientation 2 1 Bisexual 13 Hetrosexual Rather Not Say Q7. Employment/Training Employment/Training Page 96

97 Q8. Do you have any caring/parenting responsibilities? 2 13 No Other There were two responses of Other one respondent has children but they are in care, and the other cares for their Mother and Sister but did not state they were ill/disabled. Although there was only two people who indicated that they were carers during the feedback from focus group service users expressed a need for people who care for and support them should be involved in care planning activities, (when appropriate and with consent of the service user) especially, as many of the service users view that by having a parent; carers, siblings etc., involvement in their care and this would help towards making their recovery more successful and build a better, and trusting family relationships. During the focus groups service users and some family carers shared their experiences and made comments about Alcohol treatment services in relation to the themes; access to service, Serviceuser and recovery worker/healthcare professional communication, care planning, overall satisfaction with a service provider including other comments in relation to what should good alcohol treatment services consist of? These are summarised below. B. Access to services This next section outlines how service users would like services to ensure it is accessible to them and where applicable, family carers. People were ask to rate the services they had experiences by indicating from very happy to very unhappy. Some service users preferred not to comment. Service Used Number of Service Users NORCAS 3 ACT 1 OPEN ROAD IPSWICH 3 Health Outreach Project 1 (HOP) Page 97

98 Number of Service Users NORCAS ACT OPEN ROAD IPSWICH HOP Service Used A majority of the people reported that they were very happy with the service they use or had accessed in the past. Service provisions Very happy Happy In-between Unhappy Very unhappy Facilities 7 1 Atmosphere Courses/activities facilities atmosphere courses/activities very happy happy inbetween unhappy very unhappy Page 98