Alcohol and its impact on the health of the nation Don Lavoie, Alcohol Policy Team

1. Alcohol and its impact on the health of the nationDon Lavoie, Alcohol Policy Team

2. Safe. Sensible. Social

3. Government goal To minimise the health harms, violence and antisocial behaviour associated with alcohol, while ensuring that people are still able to enjoy a drink safely and responsibly

4. Government strategy • Taking steps to cut alcohol-related crime • Cutting alcohol-related hospital admissions • Creating greater awareness of the risks of drinking excessively • Targeting those groups who cause most harm to themselves and others • Working together to create an environment that promotes sensible drinking • Providing more help for people who want to drink less

5. Alcohol in England • 85% of adults drink alcohol • 26% (around 10 million) of adults in England drink more than the Government's lower-risk guidelines • Almost 2.6 million adults drink at higher-risk • 1.6million men drink 50+ units/week • 1 million women drink more 35+ units/week.

6. “Risk Based” categories of drinking

7. Point of Clarification • Opportunistic alcohol case Identification and the delivery of Brief Advice (IBA) is the same as • Screening and Brief Interventions for alcohol misuse (SBI)

8. Why a focus on alcohol-related harm? • In 2007/08 there were 863,000 NHS hospital admissions in England with a diagnosis wholly or partly related to alcohol.

9. Why a focus on alcohol-related harm?

10. Why a focus on alcohol-related harm?

11. Risks

12. Alcohol Improvement Programme

13. National Alcohol Improvement Programme Alcohol Interventions Improvement Programme Learning Centre Collects, co-ordinates and disseminates learning and good practice. Tools: SIPS toolkits, HuBCAPP, e-learning resource Enabling change Priority support to Early Implementation PCTs. Tools: Learning sets, collaboratives, etc NHS Planned delivery on RA-RHAs Start delivering RA-RHAs Receive priority support from AIIC Implement High Impact Changes Implementation Early Implementation PCTs PCTs (Unplanned) delivery on targets through implementation of elements of the high impact actions learning learning learning Support Influence Review Support Priority access learning NST(DH) Supports 18 struggling PCTs P.A. Strategic reports & follow-up visits Regional co-ordinators (DH/SHA) Responsibility to ensure delivery of targets Support learning DH Policy Team Role: Work with outside bodies to facilitate frontline delivery. Develop policy, Develop Guidance, Commission, co-ordinate and contract manage support projects and channel expertise Social Marketing Insight, evidence, products and interventions NWPHO Provide local data on need and key evidence Trailblazers (SIPS), ANARP Effectiveness review, HES data,etc Evidence

14. National Alcohol Improvement Programme • NWPHO providing local health profiles to assist PCTs to understand their needs and develop planning • NATMS is now collecting information from service providers on the number of patients receiving specialist alcohol treatment • SIPS Trailblazer Research Programme is improving the evidence and refining the materials needed to conduct effective IBA • The National Support Team (NST) on Alcohol is visiting 18 PCTs this year and 18 PCTs next year who have high level of alcohol related hospital admissions to assist them in making improvements • Regional Offices have been established in the RPHGs to ensure delivery of targets • 20 Early Implementation PCTs have been selected to “go further a little bit faster” in implementing improvements to reduce alcohol related admissions • Alcohol Learning Centre gathers learning and practice from all sources and makes it available to the NHS and its partners.

15. Campaigns and Social Marketing

16. Units campaign

17. Harmful Drinkers Direct Marketing Pilot

18. Signs for Improvement &High Impact Changes

19. Signs for improvement Commissioning interventions to reduce alcohol-related harm

20. Signs for improvement • This guidance is designed to direct commissioners to the resources and guidance, which will assist them in commissioning interventions to reduce alcohol-related harm in their local community. • It offers ways to improve commissioning, looking at each World Class Commissioning competency and all stages in the commissioning cycle.

21. High Impact Changes • Work in partnership • Develop activities to control alcohol misuse • Influence change through advocacy • Improve the effectiveness and capacity of specialist treatment • Appoint an Alcohol Health Worker • IBA - Provide more help to encourage people to drink less • Amplify national social marketing priorities

22. High Impact Changes(actions that prepare the way) • Work in partnership • Develop activities to control alcohol misuse • Influence change through advocacy • Improve the effectiveness and capacity of specialist treatment • Appoint an Alcohol Health Worker • IBA - Provide more help to encourage people to drink less • Amplify national social marketing priorities

23. High Impact Changes(actions you can commission) • Work in partnership • Develop activities to control alcohol misuse • Influence change through advocacy • Improve the effectiveness and capacity of specialist treatment • Appoint an Alcohol Health Worker • IBA - Provide more help to encourage people to drink less • Amplify national social marketing priorities

24. Work in partnership • What does this mean? • PCTs and their local partners will wish to prioritise alcohol in relation to local need and co-ordinate action to maximise the impact on alcohol-related harm. • They should investigate their alcohol-related needs within their • Joint Strategic Needs Assessment (JSN) • and reflect their plans within the • NHS Operational Plan using the Vital Signs alcohol indicator (VSC26) and • Local Area Agreement (LAA) indicator (NIS39)

25. Work in partnership • What is the evidence that this works? • Work by Tether, Robinson and colleagues set out the rationale for co-ordinated action at local level. • The existence of multi-agency groups such as: • Local Strategic Partnerships (LSPs) • Crime and Disorder Reduction Partnerships (CDRPs) • Drug and Alcohol Action Teams (DAATs) offer opportunities to reduce alcohol related harm and co-ordinate local initiatives.

26. Develop activities to control alcohol misuse • What does this mean? • Make use of all the existing laws, regulations and controls available to all the local partners to minimise alcohol related harm. • What is the evidence that this works? • Citysafe, Liverpool’s Community Safety Partnership has helped to reduce assaults, robbery and antisocial behaviour by over 28% in the city centre compared with the previous year. • Sheffield Community Safety Partnership has introduced a number of new initiatives to reduce violent crime. Sheffield saw a reduction in serious violent crime of approximately 30%.

27. Influence change through advocacy • What does this mean? • Find high-profile champions to provide leadership within partner organisations and a focus for action to reduce alcohol harm • What is the evidence that this works? • The Community Trials Project set a number of key elements in making progress on alcohol harm: • Community leadership • Making local alliances • Working with local politics • Making the case for additional resources

28. Improve the effectiveness and capacity of specialist treatment • What does this mean? • Dependent drinkers represent a very high-risk group for alcohol-related hospital admissions. Providing evidenced based, effective treatment as well as increasing treatment opportunities for dependent drinkers may offer the most immediate opportunity to reduce alcohol-related admissions. Reviewing care pathways, access times and blockages into treatment offer opportunities to improve the local treatment system.

29. Improve the effectiveness and capacity of specialist treatment • What is the evidence that this works? • Models of Care for Alcohol Misusers (MoCAM) • The Review of the Effectiveness of Treatment for Alcohol Problems • The UK Alcohol Treatment Trial (UKATT) showed: • treatment saved nearly £1138 per dependent drinker treated and reduce hospital stays. • 25% of patients reported no continuing alcohol-related problems at follow-up • 40% of patients reported being much improved, reducing their alcohol problems by 66% (UKATT Research Team, 2005)

30. Appoint an Alcohol Health Worker • What does this mean? • The Royal College of Physicians have advocated the appointment of a dedicated Alcohol Health Worker or an Alcohol Liaison Nurse in each major acute hospital, to work with a named consultant/senior nurse alcohol lead, to provide a focus for: • Medical management of patients with alcohol problems within the hospital • Liaison with community alcohol and other specialist services • Education and support for other healthcare workers in the hospital • Implementation of case-finding strategy and delivery of brief advice within the hospital.

31. Alcohol Health Worker • What is the evidence that this works? • Over an 18 month period, the intensive care management and discharge planning delivered by an Alcohol Liaison Nurse in the Royal Liverpool Hospital had been shown to prevent 258 admissions or re-admissions – about 15 admissions per month. • Economic analysis of such an appointment in a general hospital suggested that the post saved ten times more in reducing repeat admission than its cost.

32. Identification & Brief Advice • What does this mean? • Identification and Brief Advice (IBA) is opportunistic case finding followed by the delivery of simple alcohol advice. These are effective interventions directed at patients drinking at increasing or higher-risk levels who are not typically complaining about or seeking help for an alcohol problem. • IBA can be effectively implemented in a number of settings including: • Primary Care – targeted at increasing and higher risk groups • A&E Departments – possibly with the use of alcohol liaison Nurses or Alcohol Health workers • Specialist settings – e.g. maxillofacial clinics, fracture clinics, sexual health clinics • Criminal Justice settings such as Probation and Arrest Referral Schemes (evidence to support this setting is still emerging)

33. Identification & Brief Advice • What is the evidence that this works? • There is a very large body of research evidence supporting IBA in Primary Care including 56 controlled trials (Moyer et al., 2002) and a Cochrane Collaboration Review (Kaner et al., 2007). • For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002). This compares favourably with smoking where only one in twenty will act on the advice given (Silagy & Stead, 2003). This improves to one in ten with nicotine replacement therapy. • Patients who received IBA in A&Es made 1/2 fewer visits to the ED during the following 12 months (Crawford et al., 2004).

34. Benefits of IBA • IBA would result in the reduction from higher-risk to lower-risk drinking in 250,000 men and 67,500 women each year (Wallace et al, 1988). • Higher risk and increasing risk drinkers who receive brief advice are twice as likely to moderate their drinking 6 to 12 months after an intervention when compared to drinkers receiving no intervention (Wilk et al, 1997). • Brief advice can reduce weekly drinking by between 13% and 34%, resulting in 2.9 to 8.7 fewer mean drinks per week with a significant effect on recommended or safe alcohol use (Whitlock et al, 2004). • Reductions in alcohol consumption are associated with a significant dose-dependent lowering of mean systolic and diastolic blood pressure (Miller et al, 2005). • Brief advice on alcohol, combined with feedback on CDT levels, can reduce alcohol use and %CDT in primary care patients being treated for Type 2 diabetes and hypertension (Fleming et al, 2004).

35. The Numbers

36. IBA in A&E • A study at St Mary’s Paddington showed that patients who received an intervention (Crawford et al, 2004): • Were drinking at significantly lower levels • Made ½ fewer visits to A&E • Saved 40 admissions per year

37. Amplify national social marketing priorities • What does this mean? • Social marketing is the systematic application of marketing, alongside other concepts and techniques, to achieve specific behavioural goals, for a social good. For alcohol, the goal is to reduce alcohol-related hospital admissions by influencing those drinking at higher risk to reduce their use of alcohol to within lower risk levels. • What is the evidence that this works? • Evidence supporting social marketing exists in areas such as smoking, sexual behaviour and nutrition. But direct evidence concerning alcohol is still emerging.

38. In summary We can make our country a healthier, safer place to live, but only if we all work together. We must forge a clearer national understanding of what is and isn’t acceptable drinking behaviour and act to reduce the harm caused by alcohol to individuals, families and communities.

39. Useful Links • Alcohol Learning Centre http://www.alcohollearningcentre.org.uk/ • Materials, Units Calculator and Drink Check http://www.alcoholstakeholders.nhs.uk/ • Primary Care Framework http://www.primarycarecontracting.nhs.uk/204.php • SIPS Research Programme http://www.sips.iop.kcl.ac.uk/index.php