Alcohol Care in NHS Hospitals:Needs better integration with the
wider care system
Professor Colin DrummondNational Addiction Centre
Institute of Psychiatry, Psychology and NeuroscienceKing’s College London
Danish National Conference on Alcohol, Jan 2020
Alcohol related hospital admissions England 2003-2017
0
200.000
400.000
600.000
800.000
1.000.000
1.200.000
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
2014
/15
2015
/16
2016
/17
WhollyPartly
Drivers:-Baby boomers-Increasinginequalities
• 26 wholly alcohol attributable conditions• 124 studies; 1.7m patients• Harmful alcohol use = 20%• Alcohol dependence = 10%• 10x higher than general population• 20-30x higher than NHS (HES) estimate
Proportion of smokers and excessive drinkers offered SBI by PHC last year
(Alcohol Toolkit Survey – Brown et al., 2016, BJGP)(n=15,252)
• 20% smokers (n=3,043)
• 62% visited GP last yr• 52% of smokers
received BI for smoking• (30% of all smokers)• Older, female, less
education, disability,higher dependence,more quit attempts
• 12.4% excessive drinkers(n=1,894)
• 59% visited GP last yr• 6.8% of XSD received BI
for alcohol• (4% of all XSD)• Older, smokers, higher
dependence, male
5
26 25
50
80 80
2,66
30
15
50
0
10
20
30
40
50
60
70
80
90
100
110
120
130
Problem gambling Alcohol dependence Drug dependence Psychosis Psychosis withdependence
Prevalence and treatment for dependence and comorbidity
Prevalence % x 100 Treatment for MH % Treatment for SM %
1.2%(600K)
0.8%(380K)
0.5%(240K)
0.15%(72K)
0.7%(340K)
(Drummond et al, APMS 2014)
6
http://www.clahrc-southlondon.nihr.ac.uk/files/Alcohol%20care%20in%20NHS%20hospitals%20–%20Full%20report.pdf
Alcohol CQUIN –Identification and brief advice
≥ 80% brief
advice
Adult inpatient
≥ 50% Screened
Dependent
Low-risk or non-drinker
≥ 80% Referral
offerReferred
Does not accept referral
IDENTIFY ADVISE ACT
Increasing or high-
risk
Alcohol CQUIN – expected impact
~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.
Smoking
Even if only half of patients get screened.
~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.
The NHS could save >£20M per year from reductions in ill-health caused by drinking.
Alcohol
ALCOHOL RELATED FREQUENT HOSPITAL ATTENDERS
www.slam.nhs.uk
What problem did we address?
• Alcohol-related frequent hospital attenders (ARFA):– 3+ alcohol-related admissions per year– Multiple unmet physical, mental and social care
needs– Rarely access community addiction services– Feel stigmatized and socially excluded– Represent 9% of people with alcohol dependence
but 59% of alcohol admissions– 1.4 million bed days per year = £848 million– Identified 324 ARFA patients in Lambeth and
Southwark, with £5m annual cost15
68
22,9
45,4 40,7
9,1
54,6 59,3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prevalence Spells OBDs
%
Distribution of alcohol admissions in people with alcohol dependence
3+ admissions
1-2 admissions
No admissions
54,369
136,015
404,616 303,313
365,359 1,402,600
962,718
£848 Million
£704 Million
Total = £1.6 BillionTotal = 2.4 Million
16
Total = 600,000
Alcohol Frequent attenders per 100,000 and Index of Multiple Deprivation x10 South London
60
110
160
210
260
310
360
0 50 100 150
ARFA rateARFA rateLineær (ARFA rate)
IMD
ARFA
LEWGRE
SOULAM
CROWAN
BEXSUTBRO
KINRIC
MER
r = 0.74
Health inequalities and the alcohol harm paradox
Alcohol Assertive Outreach Team Colin Drummond, Emily Finch, Barney Hyndman
18
www.slam.nhs.uk
What is Alcohol Assertive Outreach Treatment?
• Minimum weekly contact for 12 months• Small keyworker caseloads ≤15• Persistent, assertive engagement• Home-based or community setting• Working across traditional professional boundaries• Patient-led agenda• Engagement with families, carers and professionals• Supporting patients to attend addiction and health
services• Volunteers provided practical help and support
19
www.slam.nhs.uk
What we did
• Worked with patients and clinicians to adapt anAssertive Outreach Treatment model used in severemental illness training manual
• AAOT much more intensive and prolonged thanstandard alcohol care
• AAOT clinical team for Lambeth and Southwark• Created partnerships with hospital and community
teams• Identified ARFA patients through hospital e-records• Recruited 174 ARFA patients into a trial of AAOT versus
Care as Usual, 87 per treatment group
20
Value in reduced healthcare costsMean inpatient nights pre-post intervention
0,27 0,21
26,8
10,5
0,07 0,191,15
5,2
0,27 0,21
26,8
10,5
0,05 0,18
22,5
14,6
0
5
10
15
20
25
30
SIPS PHC AESOPS ACTAD AAOT
Intervention Baseline Intervention 6 months Control baseline Control 6 months 21
www.slam.nhs.uk
Change in alcohol admissions via Emergency Department in King’s College Hospital
-25
-20
-15
-10
-5
0
5
0
500
1000
1500
2000
2500
3000
2014/15 2015/16 2016/17 2017/18
F10 admissions % change
22
Introduction of AAOT
BMJ Mental Health Team of the Year 2019
Extrapolation from AAOT trial to national ARFA data
• England 54,369 ARFAs• OBDs 1,402,600• Cost £848M• Saving AOT compared to CAU = £13,819/case = £751M• AOT treatment cost = £2,979/case = £161M• Net saving = £10,840/case = £590M• For every £1 spent, net cost saved = £3.66• So potential cost saving overall = £590M in England
Alcohol CQUIN – expected impact
25
~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.
Smoking
Even if only half of patients get screened.
~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.
The NHS could save >£20M per year from reductions in ill-health caused by drinking.
Alcohol
Cost of implementation: BA £10 per case (SIPS ED) = £10 x 900,000 = £9MNet saving = £11M
900
5411
590
0100200300400500600700800900
1000
IBA AOT
Numbers of patients and cost savings for IBA and AOT
Number of patients (1000s) Net cost saving (£M)
26
£12 per patient
£11,000 per patient
Value for healthcare costs
Figure 2. Differential changes in liver morbidity risk related to changes in alcohol consumption in dependent and hazardous/harmful drinkers following intervention
0
100
200
300
400
500
600
700
800
900
1000
0 2 4 6 8 10 12 14 16 18 20 22 24 26
Dependence (ACTAD)Reduction 238 units/dayRisk reduction 4188.2x= -410
Hazardous/Harmful (Cochrane)Reduction 4.44 units/dayRisk reduction 2.92.6x= -0.3
-15 U/day
-410x risk
Conclusions• Alcohol care in acute hospitals is enjoying growth• But focus is on SBI rather than complex needs• Community addiction services shrinking and cater for more
motivated, less complex people• Hazardous/harmful drinkers more numerous but morbidity
and costs relatively small and natural remission high compared to dependence
• Although intervention costs 150 times more for AOT than SBI, risk reductions and cost savings exponentially greater
• Focus needs to shift to High Need High Cost patients with multimorbidity and complex needs
• Need for Integrated Care Pathways between hospital and community
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