Alcohol Improvement Programme Heart of Birmingham PCT, NHS South Birmingham, Birmingham DAAT Max Vaughan Alcohol Commissioning Manager Birmingham DAAT

Alcohol Improvement Programme Heart of Birmingham PCT, NHS South

Birmingham, Birmingham DAAT

Max VaughanAlcohol Commissioning Manager

Birmingham DAAT

Scope Questions to be answered

Whether all patients need to attend A&E for alcoholrelated incidents and could an alternative model bedeveloped and suitably placed to promote access?

If patients are seen out with of A&E is this a “safe place”for observation and clinical management?

Do all admissions require an acute hospital bed or couldthey be managed elsewhere for example, a

commissionedservice provided on or near an available NHS site)?

What would be the treatment pathways to and from analternative site? Would these pathways be clinically safe?Are there any physical or environmental concerns relatingto an alternative model of provision?

Can ambulance services categorise alcohol relatedincidents and potentially divert patients to designateddrop-off points accordingly?

How will ambulance staff diagnose an alcohol-relateddisorder?

Whether alcohol interventions could be better placedwithin a dedicated unit?

Where will this dedicated unit be located and what will bethe pathways to admission?

Are there any alternative models of care? What will these look like and how will they interface withexisting service provision?

Are these models financially viable? What is the “break-even” point whereby the cost of a newmodel of care pays for itself through reduced admissions

METHODS

The approach incorporated the following components:

• Review of the available literature

• Analysis of management information

• Interviews with stakeholders

• Physical and environmental assessment of alternative venues

Available Evidence

• Quality of data• Do interventions in A&E, impact on NI39 ?• Women increase• Poly drug use increase• Related Blood Borne diseases increase• WMPHO – HES data

Alcohol-specific admissions for HOBPCT and SBPCT rate per 100,000 population, 2007/2008

Alcohol-related admissions for HOBPCT and SBPCT rate per 100,000 population, 2007/2008

The number of admissions by individuals by Birmingham residents, 2007/2008

Number of times a patient was admitted

Number of patients Total number of admissions

1 846 846

2 390 780

3 168 504

4-5 121 273

6-10 74 544

>10 20 306

Frequent Fliers• Admissions increase = acute issues increase• Operational tracking data better than systems

data• Staff ‘fatigue’• Case management techniques needed• Older age group• Mental Health issues• Homelessness

Options for Alcohol Improvement Programme Investment !

• Brief interventions

• External diversion

• Internal diversion

Option 1BRIEF INTERVENTIONS

“a treatment strategy in which a short, structured therapy is offered (between 5 minutes and 2 hours) and typically on a single occasion. Aimed at helping a person stop or reduce their substance misuse”

(Cochrane Drug and Alcohol Group,http://www.cdag.cochrane.org/en/glossary.htm

Barriers to Brief Interventions• Alcohol misuse can be perceived as having a lower

significance in comparison to illicit substance misuse.

• A lack of willingness or awareness from clinical staff Poor liaison between the acute sector and services in the community

• Cultural issues of operating in a hospital environment relating to a lack of support from clinicians

• Practical issues relating to delivering BI including ensuing adequate time to access patients in a positive environment

Alcohol Liaison Nurse

• Screening at A&E and on key wards

• Links to community based provision

• Clinical services

Option 2 External diversion

Advantages DisadvantagesBelief that this option will substantially impact on NI39 as alcohol-related patients will physically not be in contact with an acute hospital

Significant activity and resources will be utilised in this clinic and this will not be included in official statistics. This will overstate the cost-effectiveness of this option

Offers an opportunity to make better utilisation of physical space

Clinical concerns about the increased levels of risk were raised – for example, to ensure quality of care in the event of an emergency scenario. Availability of a “crash team” considered unlikely but necessary

Offers an opportunity to develop an “expert” response to a key area of need. For example, to develop a nationally recognised centre of excellence

Pathways in the event of an emergency remain unclear. For example, if specialist clinical support is required back at City Hospital – how will this be facilitated? A scenario was raised whereby patients on trolleys would be “ferried” to and from City Hospital.Costs will be expensive to offer clinical expertise over a 24 period including extra security costs

Concerns were raised over ensuring the security of a clinic which houses intoxicated patients together in one area

There may be a perverse incentive in that this option may face resistance from an acute trust that receives £55 per A&E attendancePatient expectations revolve around accessing A&E services. Concerns also that if a clinic gets a reputation as an “alcohol” clinic this may reduce patients’ willingness to attend

Key service delivery issues for diverting alcohol-related patients to a non-acute clinic

Entry to Accident & Emergency

Admission to Medical

Assessment Unit

Admission as an In-patientCURRENT PROCESS

Admission to an Alcohol Medical Assessment Unit

“Internal” diversion

More likely to dischargeNEW PROCESS

Option 3 - Treatment pathway for an Alcohol Medical Assessment Unit Model

OPTION APPRAISAL

• Appropriateness • Feasibility • Desirability • Sustainability

The Task !

• Complete the tables in groups

Options evaluation and appraisal- qualitative analysis of

key success factors Factors Alcohol Liaison

Nurse delivering BI

External diversion to a non-acute

site

Internal diversion to an AMAU

AppropriatenessDo the objectives fit in with the widergoals of the NHS?

Yes - this links in well with

other clinical responses to

address non-alcohol specific

needs

Yes - can potentially better

address lifestyle needs and

mental health issues

Potentially some concernover bottlenecks that

mayreduce patient flow –

mayimpact on 4-hour targets


key success factors

Is there availability of skills, resources (financial and physical) and competencies

ALN staff can be recruited although there is some concern at recruiting and retaining nurses with a drug and alcohol qualification. Limited impact on physical resources unless a follow-up clinic site is required

Availability of an external site problematic. Lack of availability of rooms at Summerfield and Lansdowne sites. Concern over the competencies of ambulance crews with knowledge to divert patients outwith of A&E; concerns at providing 24 hour service 7-day a week with existing workforce availability

Some concern over specialist senior clinical support - for example, sufficiently trained doctors and consultant support. Major issue with available resources to develop separate AMAU

Factors Alcohol Liaison Nurse delivering

BI

External diversion to a non-acute site


Appropriateness


key success factors

Does the option link in with the widercultural elements of the NHS?

Yes - although perceptions

suggest BI bestundertaken by nurses

thanother sectors

Cultural impact ofambulance crews

exploredin that concerns that

teamswill be resistant tochanging existing

workingpatterns

Broadly - although thismay be stretched if

AMAUis seen as impacting on

4hour targets


BI

External diversion to a non-acute site


Appropriateness



Nurse delivering BI


site


FeasibilityWhat is the potential impact of each option at reducing alcohol-related admissions?

Evidence variable but suggests BI does reduce admissions. Some concerns raised at whether the method of calculating admissions will "mask" any improvements

This option will make the largest impact as patients are physically excluded from acute provision. Concern that activity will not be recorded and thus overstate cost-effectiveness

Likely to make a greater impact than BI alone as more expertise is brought to bear on a difficult client group



Nurse delivering BI

External diversion to

a non-acute site

Internal diversion to

an AMAUFeasibilityWhat are the timing issues? Will an

impactbe seen in the short term or longer

term?

Impact can be seen in the

short term as recruiting an

ALN should beStraightforward

Long-term impact. Building

new physical structuresplus possibility of

planningpermission for a new

usewill prevent short-tomedium term gains

Medium term as disruption

will be affected throughbuilding new AMAU.Possible knock-on

effectson existing MAU in

terms ofreduced patient flows

etc



Nurse delivering BI


site


Desirability What are the perceived clinical risks? Few as based in acute

wards will mitigate anyclinical risk

Potentially huge if crashteam required. Unclear

whathappens if a patientsrequires referral back to

anacute setting for otherInterventions

Low as based within acute

setting so most emergency

requirements will be to hand



Nurse delivering BI

External diversion to

a non-acute site

Internal diversion to

an AMAU

Desirability What are the health and safety issues for

staffin terms of security?

Low as sits within existing

arrangements

High as intoxicated clients

are located together.Concern over theperception of the clinic

inthe public's mind may

fosterillusion of a "drunk tank"

Moderate/high as intoxocated patients areplaced together as withexternal option. May bemitigated by being

withinA&E environment


key success factors

Sustainability Is this option sustainable in the longer-

termand can it run after Alcohol-improvementinvestment has been completed?

Easily sustained in thelonger term

Dependent on the initialsuccess at diverting

patientsaway from an I/P

admission

Medium term once AMAUhas been accepted as analternative option


BI

External diversion toa non-acute site

Internal diversion toan AMAU

The Scores!

• Alcohol Liaison Nurses 127

• External diversion 73

• Internal diversion 103

Tre

atmen

t Path

ways

Figure 6: Proposed Model to deliver enhanced brief interventions for acute hospital settings

Medical Assessment Unit In-patient wards DischargeAccident & Emergency

Patient arrives at A&E

Patient admitted to MAU

Patient admitted to a ward

Patient treatment “journey”

Screening and provision of BI at

A&EALN BIs ALN Extended BIs

Discharge back to community

Follow-up of key segments

Patients discharged here do not become an in-patient

Extended interventions,

lifestyle, detoxification

Interventions become more targeted and enhanced as patient progress through the various “touch points”

Year Number of BIs Reduced A&E attendance Reduced I/P attendance

Annual total DH Estimate Cautious est. %

Year 1 792 396 238 (30%) 25

Year 2 792 396 317 (40%) 35

Year 3 792 396 396 (50%) 45

TOTAL 2,376 1,188 951 - 105

Estimate of the impact of one ALN over three years at one site (based on City Hospital)

The Proposed Approach The study suggests that there are financial gains to the NHS by

employing two ALNs in a single hospital.

The Proposed Model • 1. two ALNs within each acute setting.• 2. enhanced brief interventions through their “treatment journey” • 3. track patients from the MAU• 4. following-up patients at discharge• 5. (a) screening and brief interventions and (b) clinical management • 6. Times ALNs are employed need to be defined• 7. Work force Planning• 8. Clinical governance • 9. Data capture and evaluation – assess the effectiveness• 10. “tracking” patients

Documents

Alcohol Improvement Programme Heart of Birmingham PCT, NHS South Birmingham, Birmingham DAAT Max Vaughan Alcohol Commissioning Manager Birmingham DAAT