James Morris, The Alcohol Academy

Local alcohol systemsDo ‘NICE’* examples exist?

*(based)

PHE EM Alcohol Event26 February 2014

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1) What is a ‘NICE’ based treatment system …2) do they exist?NICE system definition: Exist?

Part of a system that meets the 13 Quality Standards (QS11)?

Part of a system where QS11 is met to a high degree, across all groups and fully in accordance with the 612 page CG115

Broadly speaking, some services will be NICE compliant

Probably not…

So…

A high quality NICE based treatment system meeting all QS to a high level… probably a pipe dream in the real world

However, alcohol has been increasingly prioritised over recent years

Much more guidance and resourcesSome examples of key service elements,

innovation, progress etc..

Examples of NICE based systems – or elements of…

Lambeth ‘Alcohol Brief Treatment’ (ABT) service in Primary Care

Lambeth is a deprived London borough with approx 300k residents

Treatment services typically see severely dependent, complex need substance misusers

So ABT pilot of 2 ‘alcohol brief treatment’ roles to offer psychosocial interventions to:Provide ‘evidence-based

psychological interventions’ to mildly dependent drinkers ONLY (i.e.PbR cluster 1) within GP services

Leadership on improving IBA & referral

Lambeth ‘ABT’ rationale

• Most alcohol dependence is mild or moderate, therefore psychosocial rather than physiological

• Mild dependence requires much less intensive treatment and does not typically require medically assisted withdrawal

• However those with mild dependence are less likely to be ‘treatment seeking’ and may not have even contemplated their drinking as problematic or harmful

Severity of alcohol dependence in Lambeth

Lambeth estimates*

= 11,800

= 1,400

= 140

*2013 Alcohol Segmentation report

14%

2%

84% Mild

National prevalence, APMS 2007

“Significant resource-impact recommendations• this report focuses on recommendations that are

considered to have the greatest resource impact and therefore require the most additional resources to implement or can potentially generate savings. They are:”

Should brief treatment be a key priority?

NICE CG115

See page 15: CG115 Alcohol dependence and harmful alcohol use: costing report

Should ‘brief treatment’ be a key priority?

The business case - NICE Says:National proportion of people with mild alcohol

dependence provided with evidence-based specialist treatment is estimated at 1.13%

Increasing …access to psychological interventions [for harmful/mildly dependent drinkers] will decrease development of moderate or severe dependence.

Harmful alcohol use is also associated with increased criminal activity and domestic violence and employee absenteeism. Implementing the guidance is expected to reduce the significant costs to society

Lambeth ABT pilot evaluation

Main outcomes recorded*:AUDIT scores (alcohol risk level)Number of drinking daysTOPs outcomesPhysical and Mental healthOverall health

Feedback from GP partners and service users

*Outcomes recorded at review stage (average 6 weeks in) and at exit (average 4 months after start)

First year activity based on 266 referralsTreatment Completed (planned exit) 62Treatment Delivered (uncompleted) 27Current clients 31New referrals 17Brief Advice (no further help wanted) 11Out of Borough referral 16Referred to Shared Care 30Referred other services 5Transferred shared Care 4Did not attend appointment 41No Response 11Declined treatment 11

Total 266

AUDIT outcomes at start (25), review* and end* of treatment (12) - average

Audit Screening Tool Score (40 poor, 0 better)

25

22

12

0

5

10

15

20

25

30

Initial Full AUDIT Score (0..40) (n=62) Second Full AUDIT Score (0..40) (n=54) Final Full AUDIT Score (0..40) (n=62)

*Review stage typically at 6 weeks in and at exit at typically 4 months after start

Units per day at start (14), review (8) and end of treatment (5) - average

average of 14 units consumed per day at the start of treatment to an average of 5 units consumed per day on completing treatment

TOPs Units of Alcohol consumed Each Day

14

8

5

0

2

4

6

8

10

12

14

16

Start TOP Units (n=62) Review TOP Units (n=55) Exit TOP Units (n=62)

Drinking days per month 21 at start to 10 - average

TOPs number of Drinking Days (0…28) - 0 good, 28 poor

21

14

10

0

5

10

15

20

25

Start TOP Drinking Days (n=62) Review TOP Drinking Days (n=55) Exit TOP Drinking Days (n=62)

Overall Health Rating improvement 11 to 15

TOPs Overall Health Rating (0 poor, 20 better)

11

13

15

0

2

4

6

8

10

12

14

16

Start TOP Overal Score (0..20) (n=62) Start TOP Overal Score (0..20) (n=55) Exit TOP Overal Score (0..20) (n=62)

ABT implications..

ABT forms a key part of NICE required ‘evidence based psychological interventions’ for a large ‘unmet’ population

Not necessarily ‘new’ approach but few if any examples of targeting mild dependence

Cross-over with ‘higher risk’/Extended Brief Intervention (EBI) approach

No mainstream funding commitment

Durham Community Alcohol Service (CAS): a whole system example?

County Durham have had a dedicated alcohol commissioner who has secured significant investment in a ‘whole systems’ approach

Three core locality teams and a number of additional services including hospital, Older Adults, Peer Mentoring, Couples Counselling, Mutual Aid, etc.

NICE based systems: what next?

Funding for alcohol investment

will remain scarce – ‘do more with less’?Overlooked areas e.g. SBNT, pharmacology etc?Better use of peer support?Investing more ‘upstream’ e.g. mild dependence

in non-treatment settings?More good examples out there to highlight?

How/where?Support from PHE?

Audience examples & discussion?

We know Birmingham is and has been undertaking significant work and has a long established alcohol services

Other areas or examples to highlight?

Any questions?

Thank you www.alcoholacademy.net www.alcoholpolicy.net

Contact:Alcohol AcademyJames Morris, director

James@alcoholacademy.net0208 296 0134