Services for Alcohol Misusers in Hertfordshire

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SERVICES FOR ALCOHOL MISUSERS IN HERTFORDSHIRE

1.Purpose of report

This report has been prepared in response to a request made at the previous meeting of the Joint Commissioning Partnership Board and in response to recommendations contained within the recently published ‘Models of care for alcohol misusers’ (MoCAM) (Department of Health (DH) / National Treatment Agency for Substance Misuse (NTA), June 2006) that commissioners undertake local needs assessments. This report will form part of that assessment process.

The purpose of the report is to outline and assess the current provision of services for alcohol misusers in Hertfordshire. The report will also consider research papers and aim to identify any gaps in provision and to outline possible strategy to improve services in the future. The report will aim to summarise relevant key points contained within ‘Models of care for alcohol misusers’ (MoCAM) and ‘Alcohol misuse interventions: guidance on developing a local programme of improvement’ (Department of Health,14 November 2005). Both of these documents have been written specifically to assist with the development of local alcohol treatment systems for the care of hazardous, harmful and dependent drinkers.

2.Summary

2.1Good economic reasons for alcohol misuse interventions

It is estimated that alcohol misuse is now costing around £20 billion a year in England, including alcohol-related health disorders and disease, crime and anti-social behaviour, loss of productivity in the workplace, and problems for those who misuse alcohol and their families, including domestic violence.

Total healthcare costs related to alcohol misuse have a middle estimate of £1.6 billion, the annual cost of other primary care services reaches a total of almost £0.5 billion and around £0.5 billion (35%) of accident and emergency (A&E) attendance and ambulance costs may be alcohol related. It is estimated that evidence-based alcohol treatment in the UK could result in net savings in the ratio of £5 saved for every £1 spent.

A recently published report by the East of England Public Health Authority (ERPHO) estimated that in-patient costs for the East of England come out at around £17 million and alcohol-related emergency ambulance journeys for Beds and Herts SHA £9 million.

2.2Commissioning a local alcohol treatment system

MoCAM states that commissioning a framework of alcohol screening, brief interventions and treatment is a PCT responsibility.

Directly in relation to commissioning best practice, aside from making detailed reference to ‘Alcohol misuse interventions: guidance on developing a local programme of improvement’, MoCAM also references to:

• ‘National standards, local action: Health and social care standards and planning framework 2005/06–2007/08’,which lays out a set of general commissioning principles for local services

2.3Local strategy

2.3.1Treatment and assessment

There are two central themes in this report relating to local strategy.

Firstly to present a view on how to make best use of our existing combined drug and alcohol specialist services in Hertfordshire with consideration to current guidance which contains a refocus on alcohol misuse.

Secondly to reflect research findings that improved screening is the key to filtering more people into treatment and to encourage the delivery of brief interventions in a wider range of settings. Guidance suggests that improved screening, apart from being useful in itself also forms part of the local assessment process. A programme of screening will help to establish accurately the level and type of local need. That information can then be used to shape the development of a range of services which would form a future local alcohol treatment system.

2.3.2Supporting change

The DH reports that efforts to fully engaging primary care providers with the objective of improving screening and of increasing the delivery of brief interventions has been problematic.

To successfully action many of the recommendations contained in this report will require a wide ranging level of commitment from partners across the NHS and will require leadership at a senior level, ‘Alcohol misuse interventions: guidance on developing a local programme of improvement’ recommends that “Directors of Public Health (DPHs) can be key contributors by steering this important programme at a PCT and SHA level in discussion with Directors of Commissioning and Performance Directors”.

2.3.3Crime and disorder

In view of the established links between alcohol misuse and crime, the local Crime and Drug Strategy Unit supports the further development of screening and brief interventions. Increased interventions for alcohol misuse may help Hertfordshire to meet related LAA targets of reducing the public perception of alcohol related crime and disorder and of reducing anti-social behaviour in hot-spot areas. The local Drug Interventions Programme (DIP) work with offenders with alcohol misuse issues, this is in contrast to general practice where arrest referral / DIP teams work mainly or exclusively with class ‘A’ drug misusers.

3.Background Information

3.1The four tiers framework

‘Model of care for alcohol misusers’ (MoCAM) suggests that commissioners should ensure that a range of services for alcohol misusers are available and that services should form a local alcohol treatment system designed to meet local needs. MoCAM outlines four tiers of interventions following a similar framework to that established within ‘Models of care for the treatment of adult drug misusers’ (MoCDM, 2002 and update 2006).

The four tiers of interventions are summarised in MoCAM:

• Tier 1 interventions: alcohol-related information and advice; screening; simple brief interventions; and referral

• Tier 2 interventions: open access, non-care-planned, alcohol-specific interventions

• Tier 3 interventions: community-based, structured, care-planned alcohol treatment

• Tier 4 interventions: alcohol specialist inpatient treatment and residential rehabilitation

MoCAM also provides quite detailed descriptions of each intervention and outlines the evidence base.

3.2Current specialist provision in Hertfordshire – alcohol services

Hertfordshire currently commissions one specialist alcohol specific service:

• Hertfordshire Alcohol Problems Advisory Service (HAPAS) in WelwynGarden City

3.3Current specialist provision in Hertfordshire – combined services

Hertfordshire also currently commissions a range of specialist services to alcohol misusers within a framework of combined drug and alcohol provision:

• Hertfordshire Partnership NHS Trust (HPT), Community Drug and Alcohol Teams (CDAT) at 6 locations across the county, Stevenage, St Albans, Watford, Hemel Hempstead, Hertford, Ware and Cheshunt

• Turning Point / HertsReach / Vale House: from service delivery locations in St Albans, Watford, Hemel Hempstead, Welwyn Garden City and Hertford. The Turning Point criminal justice; Drug Interventions Programme (DIP) team based at Welwyn Garden City also work with alcohol misusing clients

• Hertsmere Substance Misuse Service (HSMS) in Borehamwood

• Cambridge Drug and Alcohol Service in Royston

• Drugsline in Stevenage

• Chrysalis Drug Project in Hertford

Referrals for placements to providers offering assisted alcohol withdrawal (detoxification) and residential rehabilitation are made via the HPT CDAT services. Some of the assessment carried out by CDAT teams result in specialist placements for clients outside of Hertfordshire.

The commissioned services listed above can provide, or refer for, interventions ranging from brief interventions to psychosocial treatments and prescribing. The majority of the interventions described in MoCAM can be provided within this existing framework of specialist commissioned services.

3.3.1Defining the role of combined drug and alcohol services

Locally, each combined services detailed above should currently be able to screen or treat clients with alcohol problems whether or not a drug misuse problem is also apparent.

Nationally, clear failings have been identified with the level of care offered by combined services where a dual drug and alcohol problem had been identified; ‘The National Treatment Outcome Research Study’ (NTORS, 2000) found that drug treatment services were having little or no impact on drug service users’ drinking behaviour, despite half having identified alcohol problems.

National evidence also indicates that alcohol misuse among those in drug treatment is common and poly drug and alcohol use is common, if not the norm (Gossop, 2005).In terms of making the most of our current provision, especially in the instance where the alcohol problem is identified as a secondary need MoCAM states:

“Drug users in treatment should have their alcohol use and treatment needs routinely and continually assessed, and it is good practice for drug users in treatment to have their alcohol problems treated in the same setting where possible. Referrals to specialist alcohol treatment, and guidance from specialist alcohol workers, should be a routine feature in the treatment and care of drug misusers. Where drug misusers are already attending a combined drug and alcohol treatment service, where external referral may not be needed, it is vital that the management of alcohol misuse is clearly identified for action as part of the service user’s formal care plan.”

Critically, MOCAM draws attentions to one specific group of service users:

“Just over 40 per cent of drug misusers in drug treatment in 2004 were hepatitis C virus infection positive. Alcohol use and misuse is the single biggest contributory factor to those with hepatitis C virus infection developing fatal liver disease. These individuals and others suffering from liver disease, or other medical conditions exacerbated by alcohol, should all receive alcohol interventions or treatment.”

Within our local system level ‘models of care’ framework, managers of specialist providers have been advised of this guidance and of the general need for a broader approach to care planning as outlined within MoCDM update 2006.

Alcohol misuse interventions: guidance on developing a local programme of improvement, states that commissioners should:

“Identify links with drug treatment commissioning to ensure clients with dual drug and alcohol problems receive appropriate interventions for their alcohol use while in drug treatment. The use of the pooled drug treatment budget can facilitate this.”

3.4Other specialist services

In addition to the commissioned services, The LivingRoom in Stevenage also offers services to alcohol dependant clients as do various AA groups held across the county.

The work of The LivingRoom is actively supported by the commissioning team and is included in training initiatives and within the system level models of care management arrangements.

3.5Numbers of clients currently in treatment with specialist services

In the period April to July 2006, 1204 primary substance alcohol clients are recorded as being in specialist treatment in Hertfordshire. Of this number 729 are male and 475 are female. These are the most recent figures available.

Not all commissioned organisations are required to submit comprehensive data to commissioners and to the NTA. For example drug and alcohol service offering tier 2 interventions are not required to submit comprehensive treatment data, so the actual numbers of primary alcohol clients in treatment in Hertfordshire may be higher than the recorded figure of 1204. Recently some services have been re-tendered locally which in time should lead to more accurate reporting. Generally the recording of secondary misuse substances could also be improved. It is likely that Hertfordshire would fit the National profile where a high percentage of primary problem drug clients will have a secondary alcohol problem.

There is no information available about the numbers of people attending AA meetings but there are regular daily meeting across the county.

3.6Local hospital and primary care initiatives

Locally, a trial has recently started in WatfordGeneralHospital where drug and alcohol workers from Turning Point will be delivering screening and brief interventions in A&E. Equally trials have taken place elsewhere in certain GP settings across the county where workers from HAPAS and Vale House have delivered screening and brief interventions. Funding for these initiatives has come through the Crime and Drug Strategy Unit.

In line with our current research, future improvements in delivering increased screening and brief interventions is likely to involve an up-skilling of staff whose work place is normally surgeries, hospitals and other medical settings rather than by importing specialist drug and alcohol workers into those settings.

3.7Numbers of clients currently in GP treatment – primary care

GPs will often refer patients with problematic alcohol needs to local CDAT services.

There is no ready source of data about the collective caseload of GPs. However, research conducted for this report, of a single GP caseload in Hemel Hempstead, revealed that 1035 or approx. 13% of patients drink above the recommended limits and 136 or approx. 3% were heavy or binge drinkers.

4.Research findings – primary care and secondary care

‘Alcohol Needs Assessment Research Project’ (ANARP) (DH 2005) found:

Only 24% of referrals to alcohol services come from primary care, whereas 36% are self-referrals. This suggests:

• Primary care does not perform the same gatekeeping role for alcohol services as it does for some other medical disorders/diseases.

• There is considerable potential for growth in the screening, identification and referral of individuals with patterns of hazardous, harmful and dependent use of alcohol in both primary and secondary care (including general hospitals and mental health services).

• Screening, identification and referral could be extended to agencies outside of the NHS including criminal justice agencies and social services.

The emphasis on the need to improve screening is a strong recommendation throughout MoCAM and ‘Alcohol misuse interventions: guidance on developing a local programme of improvement’. These recommendations are based on the extensive national ANARP research.

• ANARPfound that 23 per cent of the population (aged 16–64) drink hazardously or harmfully, which equates to approximately 7.1 million people in England. A further 1.1 million people in England are dependent on alcohol.

• A recent trial found that brief intervention can reduce weekly drinking by between 13% and 34%.

MoCAM describes in detail what is meant by each intervention including suggesting a range of screening ‘tools’ for use in primary healthcare and A&E settings. Research continues to identify a DH approved best option, alongside research to identify best practice for implementation and training.

• Evidence suggests that hazardous and harmful drinkers receiving brief interventions were twice as likely to moderate their drinking 6 to 12 months after an intervention when compared to drinkers receiving no intervention.

To summarize research findings: brief interventions are most effective for harmful and hazardous drinkers who will not benefit from referral to specialists services. Dependant drinkers should normally be referred to specialist services following screening. Harmful and hazardous drinkers should receive brief interventions in a specialist setting where a problematic drug problem is also apparent.

5.Conclusion and recommendations

Hertfordshire has a robust framework of specialist services but currently lacks a coherent broad based strategy around screening and brief interventions for alcohol misusers. Hertfordshire benefits from a criminal justice DIP model that allows the team to work with alcohol misusing offenders.

5.1Building on the expertise of our combined drug and alcohol services

The emphasis and learning from national research is clear; that most providers of drug services can improve the care planning and treatment of alcohol misusing clients. Locally, it is likely that improvements could also be made, lines of communication between the commissioning team and providers are open and effective and it is possible for commissioning team to continue to stress the importance of focused alcohol treatment and to ensure that care plans fully identify and address alcohol misuse issues.

A proactive approach by commissioners is supported within MoCDM update 2006 which quotes a research finding that, “care planning is frequently ad hoc and should be a routine activity monitored by local drugpartnerships, in order to deliver the vision of integrated careenvisaged in current national guidance. It also recommends thatthere should be performance indicators that focus on effectivecare planning and aftercare outcomes”.

Funding via the pooled treatment budget will continue to be directed for dual drug and alcohol care across all specialist services currently commissioned in Hertfordshire. Services should be absolutely clear of their responsibilities as detailed throughout this report which reflects explicit guidance for the DH and NTA.

Encouraging the recording of secondary substance misuse issues will be prioritised.

5.1.1Recommendation:

We recommend that the Board supports commissioners’ proactive initiatives to monitor the quality of alcohol assessment and care planning (in general) within all commissioned specialist services and to suggest improvements where necessary. The objective of this scrutiny would be to ensure that alcohol problems are properly identified, that brief interventions are appropriately delivered according to need, that care plans address alcohol misuse issues and that care plans lead to appropriate treatment and positive outcomes for clients.

5.2Screening and brief interventions

‘Alcohol misuse interventions: guidance on developing a local programme of improvement’suggests a range of steps under the heading “making it happen locally”. At this stage we recommend supporting the following measures as suggested within the guidance:

5.2.1Recommendations:

• Local champions – to aid development of screening and brief interventions:

Identify local champions to support implementation, such as a regional and local public health lead, a GP with a specialist interest, a hospital consultant, a substance misuse consultant, voluntary services, service users and a lead PCT commissioner.

• New post:

For rapid progress, local organisations may consider appointing and training an Alcohol Intervention Specialist(s) (G or H Grade Nurse or equivalent), with responsibility for co-ordinating and implementing arrangements for screening, the provision of information and brief interventions within a setting(s) identified locally, and identifying pathways to specialised treatment.

• Strategy should be to broaden access to screening and brief interventions for hazardous and harmful drinkers who:

1) Attend primary care as new registrations or with a pre-existing condition where alcohol may contribute to the harm, or are perceived by their General Practitioner (GP) as being at an increased risk of developing health conditions because of excessive drinking