The ‘wicked’ problem of alcohol - insights from the data

Newcastle upon TyneNorth TynesideNorthumberland

Lynda SeeryPublic Health Specialist

Starting point – what do we know?(Nationally)

Needs Assessment• National Indicator set –

NWPHO• Hospital admissions for

Alcohol-related harm: Understanding the dataset

Service Review• Models of Care for Alcohol

Misusers (MoCAM)• Effectiveness review• QuADS, DANOS• HubCAPP,

www.alcohollearningcentre.org.uk

• National Alcohol Treatment Monitoring System

• The Alcohol Needs Assessment Research Project (ANARP)

Top priority – do we know what is happening locally?

a) Local Needs Assessment?b) Multiple strategies across the patch (all at various stages) - Prevention - Early intervention and treatment - Enforcement and control - Partnershipc) Local Service Review?

How are we measuring progress? - Are we using effective measures? - Short, medium and long term impact – where does the evidence lie?

- Alcohol-related hospital admissions

Analysis of hospital admissions

• complex indicator• requested dataset 1/7/08 – 31/3/09• all admissions with any of the 3 codes

identified within the spell of care (not necessarily primary diagnosis)

– F10 mental & behavioural disorders due to alcohol

– K70 alcoholic liver disease– T51 intoxication

Individual patient record• postcode level• up to 7 identified codes accepted (but some patients have up to

14 attached codes)

• 1.00 - wholly attributable to alcohol (main focus)

• 1411 admissions (707) patients• between 141 – 202 admissions each qtr• Costs = £2.5m• 943/1411 readmissions (66.8%)• 239/707 patients readmitted (33.8%)• 153 males & 86 females• 468/707 patients admitted once (66.2%)• age breakdown

NewcastleProportion of population in each age group. Newcastle population as a whole and Newcastle admissions 1/4/07 - 31/3/09

<15

<15

15-24

15-24

25-34

25-34

35-44

35-44

45-5445-54

55-64

55-64

65-74

65-7475-84

75-8485+ 85+

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Newcastle population Newcastle admissions

North TynesideProportion of population in each age group. North Tyneside population as a whole and North Tyneside admissions

<15

<15

15-24

15-24

25-34

25-34

35-44

35-44

45-5445-54

55-64

55-64

65-74

65-7475-84

75-8485+ 85+

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

North Tyneside population North Tyneside admissions

NorthumberlandProportion of population in each age group. Northumberland population as a whole and Newcastle admission 1/4/07 - 31/3/09

<15

<15

15-24

15-24

25-34

25-34

35-44

35-44

45-54

45-54

55-6455-64

65-74

65-7475-84

75-8485+ 85+

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Northumberland population Northumberland admissions

Segmentation - understanding the patient layers

The ‘patient layers’ fall into the following categories:

• Patients admitted to hospital for 1 day or less (no overnight stay)

• Patients admitted only once

• Patients admitted once for intoxication / patients re-admitted for intoxication

• Patients with multiple re-admissions for alcohol-related harm (harmful and dependent drinkers)

• Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas

• Patients with severe ongoing/end stage illness

Patients admitted once only for 1 day or 8 hours or less

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Newcastle PCT North Tyneside PCT Northumberland CT

Admissions by top 10 alcohol related conditions - North of Tyne 1/4/07 - 31/3/09(patient admitted once for 1 day or less)

Stomach or Duodenum Disorders

Ingestion Poisoning or Allergies

Epilepsy

Syncope or Collapse

Gastrointestinal Bleed

Sprains, Strains, or Minor Open Wounds

Chronic Pancreatic Disease

Chest Pain

General Abdominal Disorders

Poisoning, Toxic, Environmental

Example of intoxication record

Codes listed

T40 (primary diagnosis)

poisoning by drugs, medicaments and biological substances

X620 intentional self harm

T51 intoxication/toxic effects of substances non medicinal as to source

S099 injuries to head

W19 fall

F101 harmful use

‘Frequent users’ or re-admissions to hospital

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Newcastle PCT North Tyneside PCT Northumberland CT

Re-admissions by top 10 alcohol related conditions - North of Tyne 1/4/07 - 31/3/09(239 frequent users accounting for 943 admissions )

Stomach or Duodenum Disorders

Gastrointestinal Bleed

Chronic Obstructive PulmonaryDisease or Bronchitis

General Abdominal - DiagnosticProcedures

Pancreatic Disorders

Drainage of Ascites

Poisoning, Toxic, Environmental

General Abdominal Disorders

Chronic Liver Disorders

Chronic Pancreatic Disease

Example of re-admission recordCodes listed

K703 (primary diagnosis)

Diseases of the liver

F102 Dependence syndrome

I10X Hypertensive diseases

J459 Chronic lower respiratory diseases

R18X Symptoms and signs involving the digestive system and abdomen

Z720 Persons encountering health services in other circumstances

Z867 Persons with potential health hazards related to family and personal history and certain conditions influencing health status

Phase 1• Initial target groups

– patients re-admitted for intoxication

- Patients with multiple re-admissions for alcohol-related harm (harmful and dependent drinkers)

Significant 20

– Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas

North of Tyne 12

  Male Female

Newcastle 44 49

North Tyneside 22 22

Northumberland 17 25

Mapping the services and initiatives• Tier system

– MoCAM (Models of Care for Alcohol Misusers)

– Prevention/Early Intervention – implementing IBAs (across primary care & multi agency)

– Treatment – Community services & emerging alcohol workforce

• Virtual team working across primary care, mental health, acute services, social care, voluntary sector,

– Enforcement – management of environment & night time economy

• requires more cohesiveness and connectivity with community services

– Rehabilitation – very small numbers– Care Pathway

Improvement methodology• Multi agency care plans

– (individuals may have a single dominant condition i.e. alcohol but may be known to different agencies)

• Community Open clinics (walk in, self refer, referred into from any other service) – Professionals available at clinics, clinical & mental health staff,

social care, housing, benefits

• Assertive Outreach • STR workers (Support, time and recovery workers)

• Wider use of IBAs (multi agency)• Emerging workforce (i.e. new roles, liaison, co-ordination,

systems approach to service delivery)

• Flexible approach, learning (i.e. PDSA cycles)

Repeated use of the PDSA cycleChanges that result in improvement

Hunches

Theories

Ideas

Sequential building of knowledge under a wide range of conditions

Very small scale test

Follow up tests

Wide scale tests of change

Implementation of Change

Spread

A P

S D

PDSA stage

• PDSA cycle 1 – hospital admission analysis– learning has allowed us to ask more questions

• PDSA cycle 2– We have filtered through the records and have taken a layer to

examine more closely so we are now beginning the process of assessing the actual records of individuals with multiple admissions to determine those patients who may benefit from more joined up multi agency services

Future work – focused/targeted work• development of a whole system approach to alcohol related

harm - multi stranded work

• establish a North of Tyne Care Pathway

• community services established and adapted to meet the need - targeted work (demographics already known)

• working up from granular level up into communities has the highest potential for positive impact

• multi agency training – raise awareness, develop skills and competencies

• systematic, cohesive approach across locality and wider geographic area

How hard can it be?

•Pace

•Purpose

•Passion

Questions?