Professor Eileen Kaner

1. NICE work if you can get it:Screening & brief intervention as a Public Health strategy to reduce hazardous & harmful drinking in England. Professor Eileen Kaner

2. Overview of the presentation • Why do we need guidelines? • Despite lots of evidence SBI is not routinely delivered • Needs top-down prioritisation • General policies are not enough • Specific guidance on ‘what should happen’ • Policy makers need to consider impact & cost • Their interest is ‘why should we prioritise this’ • How might it happen with minimal disruption

3. So much evidence • Freemantle 1993 - 6 trials in primary care • 24% drop in consumption (95% CI 18 to 31%) • Moyer 2002 – 56 trials, 34 relevant to PHC • Consistent +ve effect, NNT 8-12 (smoking is 20) • Cost savings found at 4 years in the USA • Kaner 2007 – 29 trials in PHC & A&E • Consistent positive effects ~7 drinks less/week • Evidence strongest for men, less work on women • No significant benefit of longer versus shorter BI

4. So little practice • Majority of GPS may be missing up to 98% of excessive drinkers in PHC (Kaner et al. 1999) • NAO 2008 report on recent activity • 58% PCTs have an alcohol strategy • 69% provided data on expenditure • Spend is ~£600,000 on alcohol • About 0.1% of PCT annual expenditure of £460M

5. General policies • Alcohol harm reduction strategy 2004 • Choosing Health White paper 2004 • Prison Service Alcohol strategy, 2004 • DH Local Implementation guidance 2005 • Models of Care for Alcohol misuse 2006 • National Probation Service / NOMS 2006 • Safe, Sensible, Social – next steps 2007 • BMA tackling the alcohol epidemic 2008 • Safe, Sensible, Social: further action, 2008 • Healthcare Commission on choosing health, 2008

6. Practitioners want prioritisation: their ‘to do’ list

7. National Institute for Health and Clinical Excellence (NICE) • Independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health • Topics referred by government initially • NICE produces guidance in three areas of health: • public health – Prevention goes beyond NHS • health technologies – Drugs and interventions • clinical practice – Appropriate delivery of care

8. Like buses! • Three separate referrals on alcohol to NICE • Prevention • Physical treatment • Mental Health Management • These came to separate parts of NICE • Complex agenda • Is carving it up the best way to deal with it?

9. Prevention guidelines due March 2010 • Scope: The prevention of alcohol-use disorders in people 10 years and older, covering: • interventions affecting the price, advertising and availability of alcohol; • how best to detect alcohol misuse both in and outside primary care; • brief interventions to manage alcohol misuse in these settings.

10. Clinical Management guidelinesdue May 2010 • Scope: The assessment and clinical management in adults and young people 10 years and older covering: • acute alcohol withdrawal including delirium tremens; • liver damage including hepatitis and cirrhosis; acute and chronic pancreatitis; • management of Wernicke’s encephalopathy

11. Dependence guidelinesdue January 2011 • Scope: The diagnosis and management of alcohol dependence and harmful alcohol use in people 10 years and older covering: • Identification and assessment • pharmacological and psychological/psychosocial interventions, • prevention and management of neuropsychiatric complications of alcohol dependence or harmful alcohol use

13. Levels of prevention • Primary prevention – strategies that aim to deter people from drinking heavily (whole population approaches, media campaigns, labelling) • Secondary prevention – early identification of clinical risk or harm and intervention to modify it • Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more advanced or irreparable disease

14. Upstream

15. Down stream

16. Primary prevention question 1 • Price: What type of price controls are effective and cost effective in reducing alcohol consumption and/or alcohol-related harm in adults and young people?

17. Primary prevention question 2 • Availability: Which interventions are effective and cost effective at managing alcohol availability to reduce levels of consumption and/or alcohol-related harm in adults and young people?

18. Primary prevention question 3 • Promotion: Which strategies for the control of alcohol promotion are effective and cost effective in reducinglevels of consumption and/or alcohol-related harm in adults and young people?

19. Primary prevention outcomes • Expected outcomes: achange in the levels of alcohol consumption across the population • alcohol sales, availability, marketing activity • From these we can assume a subsequent impact on alcohol-related health or social problems across the population

20. Caveats • How robust is the evidence? • Difficult work methodologically • How specific is the evidence? • To adults &/or young people • How relevant is it to England? • Can we make inferences from other countries

21. Secondary prevention question 4 • Context – targeting for practitioners: What key factors increase the risk of hazardous and harmful drinking? When are individualsmost vulnerable to excessive drinking?

22. Secondary prevention question 5 • Identification/screening: Are alcohol screening questionnaires, biochemical markers or clinical indicators an effective and cost effective way of identifying adults and young people who are at risk due to drinking?

23. Secondary prevention question 6 • Brief Intervention: Are brief interventions effective and cost effectivein managing hazardous and harmful drinking among adults and young people? And across all groups within our population

24. Secondary prevention question 7 • Implementation: What arethe key barriers to that influence practitioners’ ability to help adults and young people manage their drinking behaviour? What are the key facilitators?

25. Secondary prevention outcomes • list of the key factors (contexts) associated with an increase in alcohol–related risk or harm - who may be at risk. • an efficient way of identifying adults and young people who are at risk due to their drinking. • a reductionin hazardous and/or harmful drinking in adults and young people. • System requirements to enable SBI to occur • Training/support • Materials • Time • Referral routes

26. Caveats • Imperfect evidence • Methodological flaws • Realistic evaluation of complex problems • How relevant is SBI evidence to England specifically • Volume of evidence • Summary of published reviews for BI – blunt approach • But are young people, BME groups adequately covered? • Making reasonable extrapolations • How far can you extend beyond published studies?

27. The NICE way of working • Evidence produced by independent contractors • Considered by large/diverse committee (PDG) • Initial evidence – goes out to public consultation • Feedback responded to – public process • Final evidence presented to PDG • PDG develops recommendations • Recommendation consultation • Field work & testing with practitioners • Final guidance published

28. Challenges • NICE made up of different organisational cultures • Public health works differently to chronic condition etc. • 3 groups with ownership over the 3 scopes • Overlaps & gaps • prevention and early treatment eg harmful drinkers • can we separate • physical and mental health management? • planned & unplanned detoxification? • Can this formal (rigid) process capture complexity • The continuum of risk/harm/dependence • Remitting nature of alcohol related problems

29. Bringing it all together • Different timescale for the 3 sets of guidance • Integrated care pathways will be challenging • What impact will the consultation & field work testing processes have on the science • Will the ‘plain English’ editing strengthen/dilute the content • Making policy-level recommendations • If a general election is called, NICE goes into ‘purdah’

30. Nice work if you can get it.And you can get it - if you try.George & Ira Gershwin 1937But it takes a lot of time and workAnd sometimes a little diplomacyEileen Kaner 2009