Jon Cox Specialty Registrar in Public Health. Dr Augustine Pereira Consultant in Public Health Medicine

Transcription

1 Jon Cox Specialty Registrar in Public Health Dr Augustine Pereira Consultant in Public Health Medicine Public Health Directorate, Norfolk County Council 1

2 Contents 1. Executive summary Acknowledgements Introduction Why alcohol? Population considered by this needs assessment Objectives of this needs assessment Needs assessment methods Needs assessments approach Relationship with County Drug and Alcohol Strategy Norwich alcohol strategy and action plan Price, supply and availability of alcohol Price of alcohol Supply of alcohol Voluntary license changes in Norwich Young people and access to alcohol Consumption of alcohol Classification of alcohol-related behaviour Estimates of alcohol consumption and risk categories Alcohol consumption and dependency Pre-loading and drinking at home Binge drinking Alcohol consumption in parenthood Alcohol consumption in prisons Alcohol consumption in older people Harm from alcohol: health impacts Health effects of alcohol Classification of disease and mortality due to alcohol misuse Foetal Alcohol Syndrome Disorders Sexual health Alcohol and mental health Health services related to alcohol misuse Norwich SOS bus

3 6.8 A&E attendances Alcohol-specific hospital admissions Cost of selected alcohol-specific hospital admissions Hospital admissions for alcohol-related liver disease Alcohol-specific hospital admissions for people aged less than 18 years Alcohol-related hospital admissions Specialist alcohol treatment Alcohol treatment in Norwich prison Mortality due to alcohol misuse Alcohol-specific mortality Alcohol-specific cause of death Mortality from chronic liver disease Alcohol-related mortality Months of life lost Harm from alcohol: socio-economic impacts Co-sleeping and infant mortality Children and parental alcohol misuse Impact of substance misuse on Children and Family Services Alcohol and anti-social behaviour Housing, homelessness and street drinking Incapacity Benefit / Severe Disablement Allowance for alcoholism Employment in alcohol-related industry Harm from alcohol: crime and disorder impacts Alcohol and violent crime Alcohol and the Night Time Economy Domestic abuse Alcohol-attributable sexual offences Youth offending and access to specialist assessment for substance misuse Alcohol-related youth offending Comparative needs assessment How does the harm from alcohol in Norwich compare with elsewhere National guidance relating to alcohol harm reduction Signs for Improvement commissioning interventions to reduce alcohol-related harm The Government s Alcohol Strategy (March 2012)

4 9.2.3 NICE PH24 Alcohol-use disorders: preventing harmful drinking (June 2010) NICE CG100 Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications (June, 2010) NICE CG 115 Alcohol dependence and harmful alcohol use (Feb 2011) Police Reform and Social Responsibility Act (2011) National Treatment Agency Evidence of effective interventions to reduce the harm from alcohol Alcohol Brief Intervention Alcohol Diversion Scheme Examples of best practice The Ellesmere Port Alcohol Inquiry - Talking Drink: Taking Action Great Yarmouth Community Alcohol Partnership NHS Wigan and Leigh Alcohol treatment services Current alcohol-related services in Norwich Co-sleeping and infant mortality Children and parental alcohol misuse services Young People Specialist Alcohol Treatment Services Norfolk Recovery Partnership Review of Tier 4 inpatient detoxification and residential rehabilitation Acute health services related to alcohol misuse: Substance Misuse Liaison Team NNUH maternity services Treatment of alcohol consumption in older people Services for Offenders Treatment in Norwich prison Alcohol and mental health Cardiff model of data sharing to reduce alcohol-related crime and disorder Alcohol and the night time economy Directly Enhanced Service for primary care alcohol screening Corporate needs assessment Task and Finish focus group discussion Supply of alcohol Young people s access to alcohol Prevention in schools

5 Other preventative activities Education and awareness of safe consumption of alcohol Risk groups for harm from alcohol misuse Use of alcohol identification and brief advice (IBA) Alcohol treatment services Stigma of alcohol treatment services Alcohol treatment service information Alcohol treatment service pathways Partnership working Families TADs Wellbeing Service User focus group discussion Experiences of GPs Expectations of GPs Other practice members of staff Experiences of NNUH acute services Alcohol treatment and recovery services Accessing health services Prevention of alcohol misuse Recovery groups and use of recovery Discussion Price, supply and availability of alcohol Consumption of alcohol Harm from alcohol: health impacts Harm from alcohol: socio-economic impacts Harm from alcohol: crime and disorder impacts Areas not covered by this needs assessment Recommendations Supply and licensing of alcohol Consumption of alcohol Prevention and education Reducing the health impacts of alcohol Reducing the socio-economic impacts of alcohol Reducing the crime and disorder impacts of alcohol Acute healthcare services

6 12.8 Specialist alcohol treatment services All partner organisations Next steps and way forward Glossary Appendices Appendix 1: Questions and case study used in two focus group discussions Appendix 2: Questionnaire used to collect information on current services and information provided describing current services relating to alcohol misuse

7 1. Executive summary Norwich CCG Children & Families Clinical Action Team called for work to reduce alcohol related harm. The Public Health Directorate agreed to conduct an alcohol needs assessment to inform an alcohol strategy for the Norwich CCG area (current registered population size 205,200). The objectives of this needs assessment were to: review the epidemiology of alcohol for Norwich considering aspects of supply, consumption and harm (health, socio-economic and crime & disorder) review current services relating to alcohol misuse compare current service provision against national guidance describe stakeholder and service user perspectives of alcohol treatment and services assess the need for development and make recommendations for improvement An epidemiological/comparative/corporate approach was used utilising quantitative data and focus group discussions. Findings The affordability and availability of alcohol in Norwich has increased. From 2005 to 2012 there has been a 40% increase in the total number of licensed premises and a 67% increase in the number of off-licenses. There are no comprehensive estimates of alcohol consumption locally but national data show spirit consumption amongst women has risen significantly and has doubled amongst 11 to 15 year olds in the last 20 years. In the Norwich CCG population it is estimated there are between 4,000 and 6,000 people with signs of alcohol dependence and 7,710 males and 4,030 females who drink at higher risk. 25% of adults binge drink in Norwich, compared to 17% for Norfolk, 18% for East of England and 20% for England. 1% of young people (aged 13-18) in Norwich said they drank every day. The proportion of ever drunk was lower in Norwich than nationally (65% cf. 80%) in ages years. Health impacts In 11/12 there were an estimated 9,000 A&E attendances related to alcohol for the Norwich CCG population. There were also 801 alcohol-specific hospital admissions costing 928,226. The peak age for admission was 40 to 44 years of age and 5% were for ages less than 20 years. Emergency admissions accounted for three-quarters of the total. The Norwich CCG rate of hospital admissions for alcohol-specific conditions is higher than for England and East of England for both males and females. The rate for males is about double that of females. During the period 06/07 to 10/11, both the Norwich male and female rates have increased 7

8 more rapidly than the rates for England and East of England. For females, the rate increased nearly twice as quickly in Norwich compared to the East of England, and 50% more quickly than the England rate. for hospital admissions for alcohol-related liver disease in ages 20 to 24 years, the proportion of female admissions has been ten times greater than the proportion of male admissions (3% compared to 0.3% respectively) over the last ten years. there were 3,070 alcohol-related hospital admissions in 11/12 for the Norwich CCG registered population which cost 4,542,166. Over the period 05/06 to 09/10, each year there have been about an extra 150 alcohol-attributable hospital admissions. 606 people were in structured treatment for problems with alcohol in Norwich in 11/12. Of these 288 people (48%) successfully completed treatment there has been an average of 15 alcohol-specific deaths per year during for the Norwich CCG population with males accounting for 67% of deaths. Nationally the alcoholrelated mortality rate has increased over this period but it is difficult to determine the trend in alcohol-related deaths locally. Socio-economic impacts Less than 10% of alcohol-dependent parents with children received structured treatment for their alcohol problems in 2011/12. There were 2,165 referrals to children s social care in Norwich in 10/11 and about 40 to 50% of child protection cases involve parental drug or alcohol misuse. 25 to 30% of young people who refer themselves to the Matthew Project after a school visit do so for parental alcohol misuse concerns. It is estimated that last year in Norwich, Children s Services dealt with 1,080 referrals for families involving children affected by parental substance misuse issues. Alcohol-induced antisocial behaviour was a factor in 65% of referrals to Norwich antisocial behaviour action group (ASBAG) in 11/12. Rates of homelessness for the Norwich City Council area are above national average. Housing Advisors in Norwich estimate that each year about 260 cases of homelessness or threatened homelessness have alcohol misuse as an underlying cause. 8

9 Crime and disorder impacts 30,000 people come into Norwich each evening at the weekend. In recent years there has been an increase in the numbers of crime/disorder incidents in central Norwich has been between 4:00am and 6:00am following the introduction of extended licensing which has made alcohol available for longer periods of time. A voluntary agreement has been in place since Aug 2012 for Prince of Wales licensed venues to close by 4:00am. Whilst alcohol-related violent crime and anti-social behaviour is concentrated in the Prince of Wales Road / night time economy area, the whole city is affected. Alcohol-related anti-social behaviour occurs more frequently than violent crime and incidents of anti-social behaviour can often escalate into violent crime. The rate of alcohol-related crime in Norwich has been steadily decreasing since 06/07, in line with the reductions seen nationally. In the Norwich City Council area, 1,203 alcohol-related crimes were recorded in 2011/12, which represents the second highest rate in Norfolk. 9% of all the alcoholrelated crime in Norfolk happens on Prince of Wales Road where the Norwich night time economy is centred. Domestic abuse accounted for 8.2% of the total crime within the county in 11/12 and alcohol is a factor in about a third of cases. Domestic abuse occurs for the first time during pregnancy in a substantial number of cases. About a half of domestic abuse incidents involved children, affecting about 5% of all children. Norwich has the second highest rate of domestic abuse offences involving children in Norfolk. Norwich has the highest rate of sexual crimes attributable to alcohol in Norfolk National guidance A range of guidance is available to support local work to reduce the harm from alcohol including the National Alcohol Strategy (2012) and Signs for Improvement (DoH, 2009). Current services in Norwich aimed at reducing the harm caused by alcohol were mapped and compared to national guidance. Views of stakeholders and service users Focus group discussions were carried out with the Task and Finish group and a Service User group of people recovering from alcohol misuse. Thematic analysis of discussions identified 21 themes. 9

10 Recommendations A series of recommendations are made which are summarised below: Supply challenge the presumption of approving license applications introduce an alcohol license saturation policy to prevent new licenses being issued in areas with an existing high-density of licenses reduce the direct and indirect supply of alcohol to children Awareness, education and prevention develop a local programme to help awareness of personal alcohol consumption levels and the potential impact on children based on national social marketing work ensure the consistent use of identification and brief advice across primary care, secondary care, criminal justice, social care, housing support settings to identify individuals at risk of alcohol misuse, provide brief advice and refer appropriately Harm reduction recognise the risk groups identified in this needs assessment and understand the opportunities to intervene to reduce harm from alcohol misuse reduce alcohol consumption in those people drinking above the recommended safe limits for consumption and reduce dependency on alcohol provide extended brief intervention to higher risk or alcohol dependent individuals who are not ready for change Treatment services ensure the provision and uptake of evidence-based specialist treatment for at least 15% of estimated dependent drinkers continue to develop and improve alcohol treatment services and implement the recommendation of the DAAT commissioned Tier 4 detoxification service review increase the identification, provision of brief advice and appropriate referral of patients at risk of harm from alcohol misuse in acute healthcare settings Partnership working co-ordinate the work of all partners to reduce alcohol-related harm work with other local behaviour change and health promotion opportunities such as Norwich Health City improve information sharing between partner organisations to help understand the needs of people entering and leaving structured treatment for alcohol misuse 10

11 2. Acknowledgements Many individuals contributed to this needs assessment. Particular thanks are given to members of the: Wellbeing service recovery group Norwich Alcohol Task and Finish group Norfolk Public Health intelligence team Children & Families, Clinical Action Team, Norwich CCG and to the following individuals for their contributions to the work: Fraser Bowe, Norfolk YOT, Norfolk County Council Stephanie Butcher, Norfolk Constabulary Jon Shalom, Norfolk Constabulary Ian Streeter, Licensing Team, Norwich City Council Nicki Bramford, Family Intervention Project, Norwich City Council Kadhim Alabady, Norfolk Public Health Directorate Carolyn Spence, Norfolk Public Health Directorate Claire Gummerson, Norfolk DAAT Rashad Richmond, Norwich CCG Naomi Selim, The Matthew Project 11

12 3. Introduction In the UK, the consumption of alcohol has increased in recent years with an associated increase in health-related effects. The Norwich Clinical Commissioning Group (CCG) Health & Wellbeing profile identified an increasing trend in alcohol related admissions into hospital over the last 10 year period. Alcohol related liver disease patterns demonstrated wide variation in disease burden between wards. Analyses of data for females aged showed an association between alcohol-related admissions and teenage conceptions. The referral routes to alcohol services commissioned by Norfolk Drug and Alcohol Action Team (DAAT) were perceived to be less well understood by the primary care practitioners. Public Health (Norfolk County Council) was approached by Norwich CCG Children & Families Clinical Action Team in May 2012 to support work on undertaking a health needs assessment for alcohol related harm and to develop a strategy to reduce alcohol misuse and harm caused by alcohol consumption in the Norwich CCG area. This was supported by Norwich City Council partners as well. To begin exploring this work, Norwich CCG hosted a multi-agency alcohol workshop on 13 June 2012 which was organised by Public Health. This event confirmed wide support for a Norwich alcohol needs assessment and strategy. Public Health agreed to lead a Norwich multi-agency project (Public Health lead is J. Cox). The project is planned to produce the following key outputs: a Norwich alcohol needs assessment a Norwich alcohol strategy and action plan 3.1 Why alcohol? Alcohol misuse has become a serious, high-profile problem and topic of public debate. As well as a range of illnesses, excessive alcohol consumption is linked to adverse social consequences, most notably, alcohol-related crime (including vandalism, public disorder, and assault), family dysfunction and domestic violence, and traffic accidents. Harm from alcohol misuse is widespread, for example it is estimated that 2-3 times more children live with a dependent drinker than with a problem drug user. Alcohol-related harm is estimated to cost society between 17.7 billion and 25.1 billion per year 1. It costs the NHS in England up to 2.7 billion a year to treat the chronic and acute effects of drinking 2. It is also estimated that up to 35% of all emergency department attendances and ambulance costs are alcohol-related. In 2008/09 there were more than 945,000 hospital admissions for alcohol- related harm 3. For a population the same size as Norwich Clinical Commissioning Group, each year: 1 Safe, sensible, social consultation on further action. Department of Health, The cost of alcohol harm to the NHS in England: An update to the Cabinet Office (2003) study. Department of Health,

13 4,000 people will be admitted to hospital with an alcohol-related condition; 2,000 people will be a victim of alcohol-related violent crime; over year olds will be drinking weekly; over 26,000 people will binge-drink; over 43,00 people will be regularly drinking above the lower-risk levels; over 6,000 will be showing some signs of alcohol dependence; and over 1,000 will be moderately or severely dependent on alcohol Population considered by this needs assessment This needs assessment considered everyone who is directly or indirectly affected by alcohol misuse, or at risk of harm from alcohol within the Norwich Clinical Commissioning Group (CCG) population (current registered population size 205,200). Examples of indirect effects include people affected by alcohol related community anti-social behaviour, family or social networks including alcohol misuse or victims of alcohol-related crime. 3.3 Objectives of this needs assessment The objectives of this needs assessment were as follows: Review the epidemiology of alcohol for Norwich considering aspects of supply, consumption, harm (health, socio-economic and crime & disorder) Review current services relating to alcohol misuse Compare current service provision against national guidance Describe stakeholder and service user perspectives of alcohol treatment and services Assess the need for development and make recommendations for improvement 3.4 Needs assessment methods A multi-agency Task and Finish group was established which met monthly from September 2012 to January The purpose of this group was to help produce the needs assessment and to provide advice and expertise to the work. Membership of the group is shown below: Name Jon Cox Augustine Pereira Thomasin Keeble* Organisation Public Health, Norfolk County Council Public Health, Norfolk County Council Public Health, Norfolk County Council 4 The Government s Alcohol Strategy. HM Government, March

14 Rachael Metson Michael Stephenson Jo Sapsford Bob Cronk Adele Godsmark Barry Gibson Edward Brown Peter Burnham Anne-Louise Schofield Shaun Norris Kevin Hanner Euan Williamson Denise Grimes* Tracy Williams Lindsay Springall Mary Taylor Alison Dow Norwich City Council Norwich City Council Norwich City Council Norwich City Council Children s Services, Norfolk County Council Children s Services, Norfolk County Council Norfolk Constabulary Norfolk County Council Norfolk County Council Norfolk County Council Norfolk Community Health & Care NHS Trust NHS Norfolk & Waveney Trust Alcohol Disorders Service Children & Families, Clinical Action Team, Norwich CCG Children & Families, Clinical Action Team, Norwich CCG Children & Families, Clinical Action Team, Norwich CCG Children & Families, Clinical Action Team, Norwich CCG * not a permanent member 3.5 Needs assessments approach A health needs assessment is a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities. Needs assessments can be broader than health and can include dimensions such as socio-economic, as is the case with this assessment. Here need is defined as the ability to benefit from an intervention and as a concept it is distinct from demand and supply. Thus an essential part of any needs assessment is the identification of costeffective interventions that can provide population benefits. Needs assessments are classically structured as follows: definition of the problem 14

15 epidemiological needs assessment corporate needs assessment (stakeholder views) comparative needs assessment current service provision identification of unmet needs recommendations for change Epidemiological needs assessment The epidemiological needs assessment scope is shown in Table 1. This section aimed to describe the risk factors, impacts and outcomes associated with alcohol misuse in the population. The epidemiological needs assessment was structured as follows: Supply of alcohol Consumption of alcohol Harm from alcohol: o Health impacts o Socio-economic impacts o Crime and disorder impacts Comparative needs assessment Comparison of epidemiological need in Norwich was made against that of Norfolk and England to help place the picture of harm from alcohol in Norwich in context. A service mapping exercise was undertaken to help understand the wide range of services currently provided relating to harm from alcohol. This included those services commissioned by the DAAT and also by other commissioners such as Norwich City Council. Current services were compared to national policies and guidance to help understand areas that needed to be address locally. Corporate needs assessment The views of stakeholders were used in this needs assessment. Stakeholder views were obtained from two focus group discussions (one with the Task and Finish group and a second with a service user group). 3.6 Relationship with County Drug and Alcohol Strategy The framework for the development of a County Drug and Alcohol Strategy aims to ensure that clear county priorities and objectives are identified whilst enabling and supporting locality partnership working and action. A Norwich alcohol action plan will be developed to address Norwich specific issues arising from the needs assessment, whilst taking account of the county strategy. 15

16 Table 1 Components of the planned epidemiological needs assessment. 16

17 Public Health is working closely with the Drug and Alcohol Action Team (DAAT) team to ensure that the Norwich alcohol work is aligned with county strategy developments. Additionally, this work will support future drug and alcohol locality needs assessments by helping to address DAAT objectives for the development of these. The Norwich model of locality work will help inform locality working with other CCGs and Local Authorities. Alongside the development of the Norwich Alcohol Strategy and Action Plan, the integrated nature of drug and alcohol-related needs and service delivery are considered where possible. The Norwich Alcohol strategy and action plan will take account of the consultation on the Norfolk drug and alcohol commissioning intentions which is expected around January Norwich alcohol strategy and action plan Recommendations from needs assessment will form the basis of the Norwich alcohol strategy and action plan. 17

18 4. Price, supply and availability of alcohol 4.1 Price of alcohol It s cheaper to get drunk than go to the cinema 5 In the past 20 years, the price of alcohol has been rising at around the same rate as for other consumer products. However, incomes have risen much faster. As a result, alcohol is more affordable than it was in Estimates of the increase in affordability of alcohol range from 44% 6 to 75% over this period. 7 There is strong evidence demonstrating a clear link between consumption and the price of alcohol. A bottle of supermarket vodka, containing 26 units (more than a man s weekly recommended limit) can be purchased for Since 1987, for example, beer and wine have become 139% and 124% more affordable respectively when bought from an off license. 9 In some cases, alcohol products are sold below cost. Overall, 80% of alcohol is purchased by 30% of the population. 10 This suggests that the current low pricing policy in supermarkets mainly benefits those drinking at hazardous and harmful levels. in some parts of England, alcohol is being sold by supermarkets for as little as 12p a unit in some parts of England, a 2 litre bottle of strong cider, containing 15 units - more than a woman s weekly recommended limit, can be purchased for as little as 1.85 a bottle of supermarket vodka, containing 26 units more than a man s weekly recommended limit, can be purchased for In some cases, alcohol products are sold below cost. 4.2 Supply of alcohol In 1953, there were around 61,000 on-licence premises in England and Wales. By 2003, this figure had increased to an estimated 78,500. The number of off-licence premises has risen even more rapidly, from 24,000 in 1953 to more than 45,000 today Binge - Drinking to get drunk: Influences on young adult drinking behaviours. Alcohol Concern, The Health and Social Car Information Centre (2011), Statistics on Alcohol: England, The NHS Information Centre (2009) Statistics on alcohol: England. Leeds: The Health and Social Care Information Centre 8 The Four Steps to Alcohol Misuse 2011, alcohol price report Balance, the North East Alcohol Office 9 Booth A, Meier P, Stockwell T (2008) Independent review of the effects of alcohol pricing and promotion. Part A: systematic reviews. Sheffield: School of Health and Related Research 10 Booth A, Meier P, Stockwell T (2008) Independent review of the effects of alcohol pricing and promotion. Part A: systematic reviews. Sheffield: School of Health and Related Research 11 The Four Steps to Alcohol Misuse 2011, alcohol price report Balance, the North East Alcohol Office 12 Alcohol Concern Cymru Briefing (2012) Full to the Brim? Outlet density and alcohol-related harm, London, Alcohol Concern. 18

19 Norwich: the supply of alcohol is controlled locally by the licensing authority. From 2005 to 2012 there has been a 40% increase in the number of licenses in the Norwich City Council district (Figure 1) and there were a total of 542 licenses in the district in November The largest increase since 2005 has been in the number of licenses for off-site consumption which have increased by 67% from 88 to 147 licenses. There has been a smaller increase of 32% in the number of on-site licenses. Total: 40% growth Both: 24% growth Off: 67% growth On: 32% growth Number of licenses Total: 40% growth Both: 24% growth Off: 67% growth On: 32% growth Figure 1 Trend in the number of licenses in Norwich City Council district, 2005 to Voluntary license changes in Norwich On 4 August 2012 on-licensed premises in Norwich voluntarily ceased selling alcohol after 4:00am. This voluntary reduction in the availability of alcohol was enabled by the prospect of enforceable Early Morning Restriction Orders described in the national alcohol strategy. The impact of this change in availability of alcohol on the Constabulary and health services is being assessed in a separate piece of work led by Public Health. 4.4 Young people and access to alcohol Research 14 shows that the most common ways for young people aged 11 to 15 years to access alcohol were being given it by friends (24% of those surveyed) or parents (22%); asking someone else to buy alcohol (18%); or taking alcohol from home with permission (14%). 13 Licensing Team, Norwich City Council, One on every corner: The relationship between off-license density and alcohol harms in young people. Alcohol Concern,

20 For older pupils surveyed, home was still an important source of alcohol. 36% of 15 year olds had been given alcohol by parents and 25% had taken it from home but they were much more likely to have obtained it from friends (50%) or to have asked someone else to buy it for them (41%) than younger pupils. Greater off-licence density may increase the volume of alcohol in the home, as well as friends' and family s access to alcohol and the number of opportunities for passers-by to purchase alcohol on behalf of a minor. 20

21 5. Consumption of alcohol 5.1 Classification of alcohol-related behaviour Increasing alcohol consumption is associated with increased risk of harm. The term alcohol misuse disorders describes a range of conditions and behaviours; these can affect the physical and mental health of individuals. The Alcohol Use Disorders Identification Test (AUDIT) can be used to assess a person s alcohol misuse which is based on these conditions and behaviours. Alcohol-related behaviour is categorised as: hazardous drinking (approximates to increasing risk) harmful drinking (approximates to higher risk) alcohol dependence Alternatively, alcohol consumption can be described in risk categories based on the number of units consumed each day or over the course of a week (Table 2). Table 2 Risk categories for consumption of alcohol. These categories indicate the right setting for treating people and the types of interventions that are appropriate for the individual. When alcohol dependence is indicated, further screening is needed to determine dependency level. Most commonly a Severity of Alcohol Dependence Questionnaire is used with three levels of dependency; mild, moderate and severe. The level of alcohol dependency when combined with other factors will the most appropriate treatment (eg as an inpatient or in the community) to be determined, and what psychosocial treatments and prescriptions are needed. The associated factors that are taken into account can include: 21

22 serious co-morbid mental health issues or learning disability serious physical illness vulnerability pregnancy resident children at risk 5.2 Estimates of alcohol consumption and risk categories In 2007, 72% of men and 57% of women in England had an alcoholic drink on at least 1 day during the previous week. 15 In addition, 41% of men and 35% of women exceeded the daily recommended limits on at least 1 day in the previous week. 10% of the population consume 45% of all the alcohol consumed in England. 16 Norfolk: although the amount most people drink poses a relatively low risk to their health, an estimated 24% of males and 15% of females drink a hazardous or harmful amount in Norfolk. 17 Norwich: in 2010, 15.8% of people in Norwich were estimated to abstain from drinking alcohol which is a slightly higher proportion than for the East of England (15.3%). 18 Office for National Statistics lifestyle estimates (2010) for Norwich City Council area indicate there are around 22,000 males and 15,000 females who exceed the 21 and 14 recommended limits for men and women (increased risk drinkers). There are around 5,103 males who drink more than 50 units a week and there are 2,634 females who exceed the 35 units a week (higher risk drinkers). Applying the same estimates to Norwich CCG population indicates that there are about 7,710 males and 4,030 females drinking at higher risk. Of those who drink, the proportion drinking at higher risk levels in Norwich is the second highest in the East of England, and is higher than the proportion for England. 5.3 Alcohol consumption and dependency Although over one million people in England are dependent on alcohol, only around 6% of these currently receive treatment. This means that every year there are over 940,000 people who are either not seeking help, do not have access to the relevant services, or whose symptoms are not being appropriately identified by healthcare professionals. 19 Norfolk: based on these national estimates, there are likely to be over 16,000 people dependent on alcohol in Norfolk but only 1,000 of these receive treatment. 15 Robinson S, Lader D (2009) General household survey 2007: smoking and drinking among adults. London: Office for National Statistics 16 Meier et al. Policy options for alcohol price regulation: the importance of modelling population heterogeneity. Addiction, , East of England Lifestyle prevalence estimates (Ipsos MORI), Office for National Statistics Lifestyle Estimates, Drummond et al. Alcohol needs assessment research project: the 2004 national alcohol needs assessment for England. London: Department of Health,

23 Norwich: for Norwich CCG there are about 4,000 people with at least mild to moderate alcohol dependency based on national estimates discussed above. Using estimates from The Government s Alcohol Strategy (2012), in Norwich CCG there are about 6,000 people with signs of alcohol dependence. Norwich: a recent survey of young people s (aged 13-18) drinking in Norwich in the previous month 20 showed that: 32% had not drunk at all 38% of respondents had drunk once or twice 18% had drank three-five times 7% had drank more than six times 1% drank every day The survey asked whether respondents had ever drunk so much alcohol that they were really drunk. Proportions of responses were as follows: never: 45% yes (once): 14% yes (two or three times): 18% yes (four to ten times): 12% yes (more than ten times): 10% The survey showed that for those aged 14 and under in Norwich 39% reported being really drunk at least once. The proportion of people aged years who reported having been drunk at least once was lower in Norwich (65%) compared to 80% found by a national study carried out by the Joseph Rowntree Foundation in Pre-loading and drinking at home In the UK, sales from off-licensed premises now account for nearly 50% of all alcohol consumption. 22 Since 1992, the volume of alcoholic drinks brought into the home in the UK has increased from 527ml per person per week to 706 ml in 2008 whilst the amount of alcohol sold by the on-trade has dropped by 40% between 2001 and N-DAP (2012) Young People, Drugs and Alcohol Survey Bremner, P. et al (2011) Young People, Alcohol and Influences 22 Scottish Health Action on Alcohol Problems (2007) Price, Policy and Public Health, 23 NHS, Statistics on alcohol,

24 5.5 Binge drinking Binge drinking is usually thought of as drinking excessive amounts of alcohol (more than 8 units for men or 6 for women) quickly to get drunk. Estimates of binge drinking and increased risk consumption in England are shown in Figure 2 and Figure 3. These suggest that consumption at higher risk levels in females has increased more rapidly than in males. These estimates suggest that binge drinking became more prevalent in 2006 but unfortunately a more recent time series is not available. Figure 2 Trends in the proportion of binge drinking for males and females in England, 1998 to 2006 (>8/6 units on any day in the last week). 24 Figure 3 Trends in the proportion of increased risk drinking, 1993 to 2002 (>21/14 units per week). Contrary to popular belief, amongst men binge drinking is most prevalent in ages 45 to 64 years. 31% of men drink above the safe consumption guidelines for ages 45 to 64 years whereas the equivalent figure is 23% for people aged 16 to 24 years. The pattern is different for women with 24 Smith and Foxcroft. Drinking in the UK an exploration of trends. Joseph Rowntree Foundation,

25 more 16 to 24 year olds (23%) drinking above the lower-risk guidelines than 45 to 64 year olds (20%). Norwich: estimates of binge drinking rates suggest that Norwich district has a significantly higher rate of binge drinkers compared to Norfolk and England (25% binge drink in Norwich, compared to 17% in Norfolk, 18% for East of England and 20% for England) (Figure 4). This may in part be linked to Norwich having a younger age profile. People aged years comprise 19% of the Norwich population compared to 12% for England. 25 Figure 4 Estimates of the proportion of adult population (over 16 years) who report binge drink in Norfolk districts (2007 to 2008). Estimates indicate that binge drinking rates in Norwich are significantly higher than for England, the East of England and for Norfolk districts. Data source: Office for National Statistics. Lifestyle alcohol consumption estimates from Experian Mosaic geodemographic data indicate that binge drinking is widespread across Norfolk (Figure 5). Across Norfolk, binge drinking is more prevalent in urban areas and areas close to military bases (this is because armed forces are a very high alcohol consumption group within English geodemographic population segmentations). 25 Norfolk Insight (2011) Norwich NHS district health profiles. 25

26 Figure 5 Estimates of the proportion of adults (over 16 years) who report binge drinking for Norfolk (2006 to 2008). Darker shades indicate higher estimated proportions of binge drinking. The large rural area north of Thetford has a high estimated binge drinking rate due to the presence of RAF Mildenhall. Data source: Public Health Intelligence mapping of Experian Mosaic geodemographic data. Binge drinking is prevalent across the majority of Norwich CCG area (Figure 6). This is in contrast to the prevalence of anti-social behaviour and alcohol-related crime shown in Figure 24 and Figure 25 which tend to be more restricted to the central night time economy area of the city. 26

27 Figure 6 Estimates of the proportion of adults (over 16 years) who report binge drinking for Norwich (2006 to 2008). Darker shades indicate higher estimated proportions of binge drinking. Data source: Public Health Intelligence mapping of Experian Mosaic geodemographic data. 5.6 Alcohol consumption in parenthood A recent national report 26 found that: 5% of women maintained their intake of alcohol upon discovering they were pregnant after the birth of their first child, 23% of parents continue to drink as much as before their baby was born first parenthood is associated with increasing consumption. 22% of women and 10% of men increase their alcohol intake after their first birth. fathers drink more frequently, with 40% drinking a few times a week and 13% drinking every day. 28% of the mothers drank alcohol a few times a week and 4% admitted drinking every day. 5.7 Alcohol consumption in prisons Norwich: a HMP Norwich prison needs assessment conducted in 2001 showed that: between 25% and 42% of prisoners had severe alcohol problems 26 Over The Limit The Truth About Families And Children. 4Children, October

28 63% of convicted prisoners had moderately hazardous levels of drinking Inadequate detoxification was a key theme amongst prisoners A needs assessment carried out at HMP Norwich in 2011 found that alcohol was the most commonly abused substance. 36% of respondents described their primary substance as alcohol, 32% heroin and 18% cannabis. These are also the three most commonly used substances of those in treatment in the community. The remaining 10% had used stimulants including cocaine and amphetamine. 57% of those who had misused substances described themselves as regular or heavy users. National Drug Treatment Monitoring System data for Norwich prison showed that during the period from July to September 2012, there were 77 prisoners who were primarily treated for alcohol (29% of all the prisoners receiving substance misuse treatment). Alcohol was recorded as a second or third problem substance for a further 90 prisoners (34% of those receiving treatment). This suggests that although alcohol is the most commonly misused substance in Norwich prison, treatment for other forms of substance misuse is more common. 5.8 Alcohol consumption in older people While alcohol consumption among middle and older age groups is lower than for younger age groups, in recent years there has been a small but steady increase in the amount of alcohol consumed by the middle and older age groups. The trend is consistent across different surveys and different consumption measures. 27 Norwich: In Norwich CCG area 32,588 people are aged over 65 years (16% of the registered population). Data from the general household survey suggests 1 in 6 older men and 1 in 15 older women are drinking enough to harm themselves 28 suggesting that about 2,500 men and 1,200 women aged over 65 years are at risk from excess alcohol consumption. 27 Smith, L. and Foxtrot, D. (2009) Drinking in the UK: An exploration of trends Joseph Rowntree Foundation 28 UK National Digital Archive of Datasets. General household survey, UK,

29 6. Harm from alcohol: health impacts 6.1 Health effects of alcohol The House of Commons, Health Committee (2009) states that alcohol harms health through three mechanisms: acute intoxicating effects, occurring after a single binge chronic toxic effects, following years of drinking at harmful levels propensity for addiction leading to physical and psychological dependency Alcohol consumption is associated with many chronic health problems including psychiatric, liver, neurological, gastrointestinal and cardiovascular conditions and several types of cancer. It is also linked to accidents, injuries and poisoning. 29 Alcohol is the number one risk factor for ill health and premature death among males aged years Classification of disease and mortality due to alcohol misuse Thirteen conditions specific to alcohol (alcohol-specific conditions) and 47 conditions related to alcohol (alcohol-related conditions) are recognised (Figure 7). 31 The 47 alcohol-related conditions include the 13 alcohol-specific conditions. This classification is used to define alcohol-specific and alcohol-related conditions for hospital admission and mortality in this needs assessment. 6.3 Foetal Alcohol Syndrome Disorders Norwich: In 2010 there were 2,368 live births in the Norwich CCG area suggesting that at least 2-3 children are born each year in Norwich with Foetal Alcohol Spectrum Disorders. The true figure is likely to be higher due to difficulties with diagnosis Rehm J, Baliunas D, Borges GLG et al. The relation between different dimensions of alcohol consumption and burden of disease an overview. Addiction, Global Status Report on Alcohol and Health, WHO, Jones et al. Alcohol-attributable fractions for England. North West Public Health Observatory, Harwin et al. Children affected by parental alcohol problems. British Medical Association,

30 Figure 7 Alcohol-specific conditions (top 13 rows) and alcohol-related conditions classified by International Classification of Disease v.10 (ICD10). Other factors in addition to alcohol contribute to the alcohol-related conditions. Alcohol-specific conditions are wholly attributable to alcohol consumption by definition. 30

31 6.4 Sexual health Young people in particular are more likely to have risky sex when they are under the influence of alcohol. Over 10% of year olds say that after drinking, they have had sex that they later regretted, whilst 8.5% have engaged in unprotected sex after drinking. 33 Such risky sexual behaviour may result in sexually transmitted diseases, teenage pregnancy, and abortion. Norwich: Teenage conception rates are relatively high in Norwich, compared to England and the East of England (Figure 8). Several wards in Norwich have teenage conception rates that place them in the highest 20% of wards nationally. There is a positive association between the rate of teenage conceptions and the alcohol-related hospital admission rate. Figure 8 Teenage conception crude rate (/1,000 females aged 15 to 17 years / year) (2007 to 2009). Wards shown in dark red are amongst the 20% of all wards in England with the highest teenage conception rates. Data source: Public Health Intelligence mapping of ONS teenage conception rates. 33 Hibell et al. Alcohol and other drug use among students in 35 European countries. The ESPAD Report 2003 CAN, Sweden,

32 6.5 Alcohol and mental health There is a complex relationship between substance misuse and mental health problems. Substance misuse is usual rather than exceptional amongst people with severe mental health problems. The 2002 Co-morbidity of Substance Misuse and Mental Illness Collaborative study concluded that 85% of users of alcohol services were experiencing mental health problems. It was also found that 44% of mental health service users either reported drug use or were assessed to have used alcohol at hazardous or harmful levels in the past year % of people treated by community mental health services were estimated to have harmful alcohol use. 35 Norwich: it is not possible to say how many of the people who are receiving mental health services in Norfolk also have substance misuse problems because this is not recorded as part of their initial assessment. However in 2010/11, 3,477 adults accessed specialist mental health services in the Norwich district; suggesting at least 1,530 people were in treatment with a dual diagnosis of mental health and substance misuse problems in Norwich. 6.6 Health services related to alcohol misuse Alcohol places a significant burden on the NHS and the impact is often thought of in terms of alcohol-specific and alcohol-related (or alcohol-attributable). Alcohol-specific hospital admission is caused by conditions related wholly to alcohol (for example, alcoholic liver disease or alcohol overdose). Alcohol-related hospital admission is caused by conditions that are wholly related to alcohol or where alcohol is considered a contributory factor (for example, stomach cancer and injury). 6.7 Norwich SOS bus The Norwich SOS bus has been operating for ten years and has helped nearly 8,000 people (about 60 people per month). 61% of attendances needed support related to the use of alcohol and/or drugs. 6.8 A&E attendances It is estimated nationally that one in four A&E attendances are alcohol related. The national data set relating to A&E services 36 showed that: 70% of A&E attendances between 12:00 and 5:00 a.m. were alcohol related at peak times 55% of attendances were either positive for alcohol consumption or intoxicated 43% were identified as problematic drinkers after screening 34 Weaver T et al. Co-morbidity of substance misuse and mental illness collaborative study (COSMIC), Department of Health/National Treatment Agency, Weaver et al. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 2003: Cabinet Office. Interim Analytical Support. Prime Minister s Strategy Unit,

33 Norwich: in 11/12 there were 37,154 A&E attendances for the Norwich CCG population, of which about 9,000 were related to alcohol based on national estimates Alcohol-specific hospital admissions Norwich: in 11/12 there were 801 alcohol-specific hospital admissions (both elective and nonelective) amongst the Norwich CCG registered population. The peak age for admission was 40 to 44 years of age (Figure 9). There were 307 admissions between 40 to 54 years (38% of all admissions). 39 admissions (5% of total) were for ages less than 20 years of age. The cost of these alcohol-specific admissions was 928,226 (Figure 10) which is similarly distributed to the number of alcohol-specific admissions. Admissions for ages 40 to 54 years cost 328,653, accounting for 35% of the total. Admissions for ages less than 20 years of age cost 42,482 (5% of total). Number of alcohol-specific admissions Figure 9 Number of alcohol-specific admissions for Norwich CCG registered population (11/12). Data source: Public Health Intelligence SUS data analysis Cost of selected alcohol-specific hospital admissions For selected hospital admissions (alcohol-related mental disorders & alcohol-related liver disease) the cost to Norwich CCG almost doubled from 147,000 to 284,000 in two years (Table 3). However this trend did not continue and from 10/11 to 11/12 the cost of these admissions fell to 231,000. Emergency admissions tend to account for three-quarters of the total cost. 37 Alcohol Concern,