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ALCOHOL & NICE a rapid overview

ALCOHOL & NICE a rapid overview. Trevor McCarthy January 2014. New Commissioning Arrangements. Public Health England & Health and Well Being Boards Aspiration to align NHS + Public Health + Social Care outcomes Public Health have not been involved in drug commissioning (untainted)

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ALCOHOL & NICE a rapid overview

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  1. ALCOHOL & NICEa rapid overview Trevor McCarthy January 2014

  2. New Commissioning Arrangements • Public Health England & Health and Well Being Boards • Aspiration to align NHS + Public Health + Social Care outcomes • Public Health have not been involved in drug commissioning (untainted) • Alcohol is a Top 3 priority for Public Health (after smoking & obesity) Trevor McCarthy January 2014

  3. NICE NICE NICEso good they named it 3 times (so far) • New Labour 1st policy white paper: The New NHS: Modern, Dependable 1997 • 1999: National Institute for Clinical Excellence • 1 April 2005 + Health Development Agency →National Institute for Health & Clinical Excellence • Health and Social Care Act 2012 → 1 April 2013:National Institute for Health and Care Excellence (new responsibilities for social care) Trevor McCarthy January 2014

  4. Understanding the evidence base … science isn’t hard – academics around the world explain hugely complicated ideas to ignorant eighteen-year-olds every September – it just requires motivation. BEN GOLDACRE Bad Science 2009 Trevor McCarthy January 2014

  5. What are guidelines? Trevor McCarthy January 2014 • Clinical guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. • Guidelines provide recommendations for effective practice in the management of clinical conditions where variations in practice are known to occur and where effective care may not be delivered uniformly.

  6. NICE guidance Trevor McCarthy January 2014 • NICE has produced guidance in three areas: • Public health – guidance on promoting health and preventing illness • Health technologies – use on medicines, treatments and procedures • Clinical practice – guidance on appropriate treatment and care of people with specific diseases and conditions in the NHS. • Forthcoming: social care

  7. Hierarchy of Evidence 1 • 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias • 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias • 1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias Trevor McCarthy January 2014

  8. Hierarchy of Evidence 2 • 2++ High quality systematic reviews of case control or cohort or studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal • 2+ Well-conducted case control or cohort studies - low risk of confounding or bias and a moderate probability that the relationship is causal Trevor McCarthy January 2014

  9. Hierarchy of Evidence 3 • 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal • 3 Non-analytic studies, e.g. case reports, case series • 4 Expert opinion (in the absence of evidence – then expertise is OK) Trevor McCarthy January 2014

  10. So – What is NICE for? • Fairness: vs ‘postcode lottery’ • Effectiveness – scientific validation • Cost effectiveness (no longer able to make recommendations re: cost of medications) • Hierarchy of evidence • Not set in stone – evidence updates (e.g. PH24) • Countering: advertising; anecdotes; special interest groups; experts; prejudice; inequity Trevor McCarthy January 2014

  11. The way I see it, it is my civic duty to live fast, die skint and leave a dirty big fat bastard of a corpse Rab C Nesbitt. BBC. Series 10 Episode 2 - 12 October 2011 Trevor McCarthy January 2014

  12. Remember this? (10 years ago) Trevor McCarthy January 2014

  13. AHRSE 2004 - 4 key strands • Improved, better-targeted, education and communication • Better co-ordination and enforcement of existing powers against crime and disorder • Encourage industry to promote responsible use & take a role in reducing alcohol-related harm • Better identification & treatment of alcohol problems Trevor McCarthy January 2014

  14. Trevor McCarthy January 2014

  15. MoCAM: framework describing what should be commissioned in each local area • Evidence based guidance & consensus based – professionals & service users • Mainstream alcohol interventions to develop integrated local alcohol treatment systems • Tier I: all frontline staff able to identify drinkers, provide info, brief interventions • Tier II: all staff deliver extended brief interventions, referrals and joint working Trevor McCarthy January 2014

  16. 2007Review of AHRSEcommitment made in 2004 Trevor McCarthy January 2014

  17. Safe, Sensible Social • Aimed to: • Build on progress made in implementing 2004 strategy & • To minimise health harms, violence & antisocial behaviour associated with alcohol, while ensuring that people are able to enjoy alcohol safely and responsibly. Trevor McCarthy January 2014

  18. March 20121.1 Over the last decade we have seen a culture grow where it has become acceptable to be excessively drunk in public and cause nuisance and harmto ourselves and others. Trevor McCarthy January 2014

  19. No-one. Not researchers; not commissioners; not practitioners; not drinkers. No-one else suggests that our alcohol problem arose in the 10 years preceding this (when the current Prime Minister’s party were mainly in opposition). Policy is always political: this is the least substantial, most politicised alcohol strategy yet. Trevor McCarthy January 2014

  20. Uniquely Insulting Tone • PM foreword: more powers for hospitals not just to tackle the drunks turning up in A&E • 3.12 we will work with the police to tackle the issue of serving alcohol to drunks • 3.16 staff can refuse to treat drunks who are abusive in A&E • Drunks. Not People with alcohol related health problems. Not People who need help. Not People who have a right to treatment and respect. Trevor McCarthy January 2014

  21. The prevention paradox • The majority of alcohol related harms are associated with people whose drinking is hazardous & harmful • Dependent drinkers are likely to experience and be linked with greater degrees of harm • But there is so much drinking that the hazardous & harmful drinkers harm outweighs that of dependent drinkers Trevor McCarthy January 2014

  22. Motivational Government • All the alcohol strategies have taken whole population Public Health approaches • Bear down on overall consumption to reduce levels of problems • Strategies decorated with headline criminal justice initiatives • Good luck persuading ‘pre-contemplative’ drinkers to moderate by calling them ‘Drunks’ Trevor McCarthy January 2014

  23. Trevor McCarthy January 2014

  24. NHS White Paper July 2010 Trevor McCarthy January 2014

  25. No top down re-organisation of the NHS? “The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK,” Mark Pearson: OECD Coalition health bill will undermine NHS, says OECD thinktank Guardian 23 November 2011 Trevor McCarthy January 2014

  26. NICE: Alcohol Prevention Guidance NICE Public Health Guidance 24 Published June 2010 12 recommendations Trevor McCarthy January 2014

  27. Policy Recommendations (1-3) 1 Price: Consider minimum price per unit. 2 Availability: Consider licensing legislation; protecting public’s health as an objective; availability and alcohol-related harm & immediate sanctions on premises in breach Consider reducing personal import allowances 3 Marketing: Minimise young’s exposure to alcohol advertising - consider complete ban Trevor McCarthy January 2014

  28. Practice Recommendations (4-8) 4 Licensing • Resources - screening & brief interventions 6 Supporting children & young people 10 - 15 7 Screening people aged 16 & 17 years 8 Extended brief interventions - 16 & 17 Trevor McCarthy January 2014

  29. Practice Recommendations (9-12) 9 Screening adults 10 Brief advice for adults 11 Extended brief interventions for adults 12 Referral Trevor McCarthy January 2014

  30. Recommendation 5 (highlight) Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective. Trevor McCarthy January 2014

  31. NICE: Alcohol Use Disorders:Physical Complications NICE Clinical Guideline 100 Published June 2010 38 clinical recommendations 7 research recommendations Trevor McCarthy January 2014

  32. NICE: Alcohol Use Disorders:Diagnosis, assessment and management of harmful drinking and alcohol dependence NICE Clinical Guideline 115 Published February 2011 Comprehensive treatment recommendations 6 research recommendations Trevor McCarthy January 2014

  33. CG 115: PRINCIPLES OF CARE • Building a trusting relationship and providing information • Working with and supporting families and carers • All interventions for people who misuse alcohol should: • Be delivered by appropriately trained & competent staff • Be the subject of routine outcome monitoring … to inform decisions about continuing psychological & pharmacological treatments. Trevor McCarthy January 2014

  34. CG 115: Identification & Assessment • Risk assessment to inform care plan inc. risk to self (inc. unplanned withdrawal, suicidality and neglect) & risk to others. • NHS funded services – staff who care for people who potentially misuse alcohol should be competent to ID harmful drinking & dependence & to assess need for intervention … if not competent(?) refer to service that can assess. • Assessment in specialist alcohol services: do not refuse treatment to service users who do not agree to a goal of abstinence. Trevor McCarthy January 2014

  35. CG 115:Interventions for alcohol misuse • For all people … motivational intervention as part of initial assessment. • Care coordination & case management • For harmful drinking & mild dependence offer psychological intervention (CBT, behavioural therapies (MI / MET) or social network & environment-based therapies SBNT) focus on alcohol-related cognitions, behaviour, problems & social networks. • Assessment & interventions for assisted alcohol withdrawal & Drug regimens • Interventions after successful withdrawal Trevor McCarthy January 2014

  36. NICE commissioning guide: August 2011 Trevor McCarthy January 2014

  37. NICE PH24 – the immediate response from Andrew Lansley Health Minister* “Regarding NICE's recommendations on minimum pricing for units of alcohol, it is not clear that the research examines specifically the regressive effect on low income families, or proves conclusively that it is the best way to impact price in order to impact demand.” Published 2 June 2010 • http://www.dh.gov.uk/en/MediaCentre/Statements/DH_116534 *The Prime Minister disagreed. CAMRA disagreed. NICE disagreed. Trevor McCarthy January 2014

  38. Merchants of Doubt “Doubt is our product,” ran the infamous memo written by one tobacco industry executive in 1969, “since it is the best means of competing with the ‘body of fact’ that exists in the minds of the general public.” Merchants of Doubt Naomi Oreskes & Erik M Conway 2010 Trevor McCarthy January 2014

  39. Prejudice Based Policy You cannot reason people out of positions they didn’t reason themselves into. Bad Science BEN GOLDACRE Trevor McCarthy January 2014

  40. The presence of those seeking the truth is infinitely to be preferred to those who think they’ve found it.TERRY PRATCHETTMonstrous Regiment Trevor McCarthy January 2014

  41. If you can’t make decisions in life, you’re a bloody menace. You'd be better becoming an MP! Trevor McCarthy January 2014

  42. Trevor McCarthy January 2014

  43. Commissioning Alcohol Services & Pavlov’s Cash Register • Performance related pay • Payment by Results • Performancerelated pay • Payment byResults • Focus on what works and what is most important • N.B. It’s not the pay ……………………….. Trevor McCarthy January 2014

  44. The poor end up paying for the mistakes of the entitled This Week BBC July 2009 Trevor McCarthy January 2014

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