DAAP AGM 30 November 2005

1. DAAP AGM 30 November 2005 Models of Care for Alcohol Misusers Trevor McCarthy Senior Policy Officer: Alcohol

2. Alcohol: It’s a drug Jim, but not as we know it. Alcohol: It’s a drug Jim, but not as we know it.

3. Treatment for Problem Drinkers • Physical health • Psychological adjustment • Vocational adjustment • Social adjustment • Interpersonal adjustment • Legal status and criminal activity • Poly-drug use, where relevant • HIV / Hepatitis risk taking, where relevant Raistrick D & Heather N 1998: Review of the effectiveness of Treatment for Alcohol Problems. Unpublished report for DoH. Commissioning Standards. SMAS.1999

4. National Alcohol Harm Reduction Strategy for England: 4 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

5. NTA Work to supportAlcohol Harm Reduction Strategy for England • Consult & develop Models of Care for Alcohol Misusers (MoCAM) – informed by national key stakeholder group • Commission ‘Review of the Effectiveness of Treatment for Alcohol Problems’ (includes BI & cost effectiveness) • Ambition: in partnership with Healthcare Commission develop criteria congruent with NHS standards for new review & inspection function • Complementary work e.g. Alcohol Needs Assessment Research Project (ANARP) and local Toolkits [DH] • Develop draft implementation strategy with DH

6. What is MoCAM? • A framework describing what should be commissioned in each local area • Evidence based guidance • Consensus based: professionals and service users • Mainstreaming alcohol interventions to develop integrated local alcohol treatment systems

7. What is different? • Alcohol is more pervasive: higher levels of prevalence than drugs & more front line contact • No significant new money allocated • Regional performance management not yet defined • Links to crime and disorder qualitatively different • UKATT isn’t NTORS – different evidence base • Alcohol’s profile is on the rise

8. Typology of drinkers Severely-DependentProblem Drinkers Moderately-DependentProblem Drinkers Harmful Drinkers Hazardous Drinkers Low-Risk Drinkers Abstainers N.B. ‘Drinking patterns are not fixed for life’: Strategy Unit Interim Report 2004

9. What is in Models of Care for Alcohol Misusers • 4 Tiered model: following Models of Care • Local systems for screening and assessment • Adopting a stepped care approach • Emphasis on care plans in structured care • More explicit co-ordination of care for people with multiple issues e.g. mental health, drug problems, homeless, domestic violence (young people)

10. Stepped care approach to alcohol treatment • the least intrusive and expensive intervention that is likely to be effective is the first line of treatment, and more intensive services are offered only if the initial step proves inadequate Sobell & Sobell 2000 • Stepped care as a helpful concept which: • Broadly describes existing service organisation • Can inform commissioning strategies • Applied flexibly would allow service users choice

11. Alcohol Treatment System The 4 Tiers Tier I: Mainstream Targeted screening Information and brief advice Referral “Shared care” Tier 2: Mainstream or Specialist Open access or outreach Brief interventions & treatment assessment and referral “Shared Care” Tier 3: Community Specialist Comprehensive assessment Care planned treatment Managed withdrawal Psycho-social treatments Tier 4:Residential Specialist In-patient managed withdrawal & psycho-social treatment Residential rehabilitation

12. Implications for Tier 1: all frontline workers • Capacity building for Tier I: all staff enabled to: • Identify hazardous & harmful drinkers & those drinking over sensible limits • Provide information on low risk drinking • Provide brief advice to reduce alcohol harm • Make referrals for more intensive treatment

13. Alan Cartwright. 1999.NDSAG Conference. Role Adequacy Role Support Therapeutic Commitment Therapeutic Process

14. Alan Cartwright. 1999. NDSAG Conference. Non Facilitative Behaviour Poor Alliance Role Insecurity Resistant Service User

15. New Quality requirementscould look like … Quality Criteria for Commissioners & Providers, ideally to be reviewed or inspected by Healthcare Commission New Commissioning Alcohol Treatment Systems Criteria • Commissioning • Performance monitoring • Meeting needs of a diverse population

16. Quality requirements for providers could be … • Screening & Brief Interventions • Assessment • Care planning • Evidence-based treatment • Meeting needs of people with complex needs • Exiting treatment: aftercare and support • Managing alcohol services In line with NHS Standards for Better Health 2004

17. Which Drinkers? • NSFs Mental Health; Coronary Heart Disease; Older People; Diabetes & the Cancer Plan • Mental Health(Dual Diagnosis Good Practice Guide 2002; National Suicide Prevention Strategy) • Sexual Health(young people and risk) • Health Inequalities(HImPs, LSPs)

18. MoCAM consultation • Phase 1: over 100 responses January 2005 • Phase 2: over 100 responses – including key stakeholders and series of events: providers, commissioners, users and carers • Most responses very favourable to MoCAM draft overall • Most responses tended to have one main area where they wanted more focus; some consensus emerged • Concern expressed about availability of resources for service provision and enhancement

19. Consultation responses • Considerable variation from one liners to erudite essays – most completed pro-forma response sheet • Significant consensus for increased emphasis for family members and others affected and Domestic Abuse • Understandable concern about resources to enhance service provision and delivery • Evident that most of the responses represented a considerable amount of work, frequently involving several contributors

20. Essential equipmentfor Commissioners:

21. Commissioners’ In-Tray late 2005 / early 2006: • MoCAM – final text • MoCAM Alcohol Treatment Pathways guidance • Review of the Effectiveness of Treatment for Alcohol Problems • Summary of the Review • ANARP Toolkit

22. What next ? • Implementation strategy will be crucial • Small amounts of new monies until 2008 / 2009 • Defend existing alcohol treatment services • Prioritisation or resources in next Spending Review • Build commissioning structures and monitoring • Increase alcohol competence in mainstream workforce • Build support for families and users • Encourage local alcohol champions Pssst. Don’t tell anybody we told you this but … Tackling alcohol misuse will improve health.

23. Do you need Glasses? There are, it has been said, two types of people in the world. There are those who, when presented with a glass that is exactly half full, say: this glass is half full. And then there are those who say: this glass is half empty. The world belongs, however, to those who can look at the glass and say: ‘What’s up with this glass? Excuse me? Excuse me? Excuse me? This is my glass? I don’t think so. My glass was full! And it was a bigger glass!’ TERRY PRATCHETT: The Truth

24. Principles for Strategic Implementation of MoCAM “Brains first and then Hard Work.” THE HOUSE AT POOH CORNER A. A. Milne London 1928

25. Here’s hoping… “Help me to hope. But help me not to hope too much” MAGGIE GEE: My Cleaner. Saqi 2005

26. In 1969 I gave up women and alcohol and it was the worst 20 minutes of my life.

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