Alcohol: the big and local pictures

Andrew MacDonald Salford DAAT

Alcohol CoordinatorMarch 2009

Background

• Alcohol Needs Assessment Research Project (ANARP) 2004

• National Alcohol Strategy 2004

• Models of Care for Alcohol Misuse (MOCAM) 2006

• Safe, Sensible, Social: next steps national alcohol strategy 2007

• Salford’s Drug and Alcohol Strategy 2008 – 2011

Where we are now?

• Alcohol issues cross-cut health, economy, crime & disorder, education, children and families, employment, social and cultural norms et al

• Health inequalities: predictions of cost / harm

• Ongoing price & availability debate – 50p a unit?

Consumption UK (per person age 15+) relative to price: 1960 - 2002

% Adults Binge

Drinkers

(6 units + per night)

Synthetic estimate Health Survey England

2000-2002

Salford Alcohol Profile

North West Public Health Observatorynwpho.net

Salford

National Indicator 39: Alcohol

related hospital admissions

• Salford 6th highest rate in England:

- 2,349 admissions per 100,000 (England average = 1,400)

- 5,545 admissions per year

- 10% increase 2005/6 to 2006/7 (England average = 8%)

ICD code ICD name

Alcohol specific treatment interventionsT51.0 Ethanol poisoningT51.1 Methanol poisoningK70, K74 Liver cirrhosisI85 Oesophageal varicesC00-C14 Malignant neoplasm of lip, oral cavity and pharynxK22.6 Gastro-oesophageal laceration-haemorrhage syndrome

C32 Malignant neoplasm of larynxC15 Malignant neoplasm of oesophagusX31 Accidental excessive coldC50 Malignant neoplasm of breast

Managing alcohol related LTCsI42.6 Alcoholic cardiomyopathyK29.2 Alcoholic gastritisG72.1 Alcoholic myopathyG62.1 Alcoholic polyneuropathyE24.4 Alcohol-induced pseudo-Cushing's syndromeG31.2 Degeneration of nervous system due to alcoholK86.0 Chronic pancreatitis (alcohol induced)G40-G41 Epilepsy and Status epilepticusI10-I15 Hypertensive diseasesI47-I48 Cardiac arrhythmiasL40 excluding L405 PsoriasisK85, K86.1 Acute and chronic pancreatitisI60-I62, I69.0-I69.2 Haemorrhagic stroke

Alcohol related accidental injury§§ Pedestrian traffic accidentsX00-X09 Fire injuriesW65-W74 Drowning§ Road traffic accidents (driver/rider)W00-W19 Fall injuriesV90-V94 Water transport accidents

Single use over consumptionO03 Spontaneous abortionX45 Accidental poisoning by and exposure to alcoholT51.9 Toxic effect of alcohol, unspecified W78-W79 Inhalation of gastric contents/Inhalation and ingestion of food causing

obstruction of the respiratory tract Alcohol related crime & disorder

X85-Y09 AssaultW32-W34 Firearm injuries

Alcohol realted mental ill healthF10 Mental and behavioural disorders due to use of alcohol

X60-X84, Y10-Y33 Intentional self-harm/Event of undetermined intent

• DoH estimates rate alcohol-related hospital admissions will rise to 2010/11.

• Salford PCT target is to curb rise by 1% year-on-year

• So… admissions continue to rise but actions mean rise less than predicted

Projected rate alcohol related admission and 1%

targetRate of Alcohol Related Hospital Admission in Salford per 100,000

0

500

1000

1500

2000

2500

3000

3500

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

1% Target Projected

100 people were responsible for 13.1% of the sum A&E total (as opposed to total episodes), this equates to 7.4% of the overall sum total for all alcohol-related admissions.

• Potential Impact of Reducing Repeat A & E Admissions on VSC26 / NI39: many ‘repeaters’ are admitted across a range of diagnoses, the complexity of which do not lend themselves to analysis that is meaningfully presentable.

• Instead we look at individuals repeatedly admitted under a single diagnosis and calculate what the impact would be if it had been possible to intervene at second admission and prevent subsequent readmissions.

Note: This downplays the full contribution that interventions could makeamong those individuals with repeat admissions across diagnoses (andpotentially via other admission routes) but is informative nonetheless andthe potential gains identified are conservative.

Repeat A & E Hospital Admissions (2005-2008)

% of Total Attributable Factor of All 15,272 Individuals (2005-08) A&E Only

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2500 5000 7500 10000 12500 15000

Number of Individuals

% o

f T

ota

l Att

rib

uta

ble

Fac

tors

10,000 people = 92.3%

1000 people = 38.5%

100 people = 13.1%

A very large number of interventions wouldbe required to reduce repeat admissionsamong hypertension patients - the relativeContribution of each intervention would beless.

The potential sum impact per individualIntervention increases through fromepilepsy, to self-harm and on to mental andbehavioural disorders where the greatestsum gains could potentially be made.

Overview of local A & E data (2005-2008)Admissions via A & E (and dental casualty) = 59.7% sum total all alcohol-related hospital admissions (2005-2008). Overall number A & E admissions has risen year-on-year (breakdown by diagnosis below).

Sum of Top 10 Attributable Episodes by Category (all)

0

100

200

300

400

500

600

700

800

900

Men

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Hyp

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Car

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Inte

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self-

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Ass

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Ped

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Chr

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panc

reat

itis

(alc

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indu

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2005/06

2006/07

2007/08

e.g. Mental / Behavioural disorder due to the use of Alcohol

• 2007/08 515 individuals admitted via A & E - 98 admitted more than once, 50 admitted on 3+ occasions.

• If could intervene with all 98 at second admission via A&E and prevent 50 being readmitted sum total alcohol-related admissions would reduce by 1.95%.

Salford Alcohol Strategy 2008-2011

• Local developments across Tiers 1-4• New ways to draw patients into

treatment• New ideas as to how to ‘market’

treatment• Wider access to services• Fewer ‘gaps’

Strategy Aim is to:

• ..reduce the harm caused by alcohol, including harm associated with crime, health, the economy and family and social networks

Strategic Objectives

• Ensure that those who drink alcohol in Salford are able to do so safely and responsibly

• Reduce the impact of alcohol on ill health and life expectancy

• Reduce alcohol related crime and anti-social behaviour

• Reduce the harm caused to children and young people by alcohol use

Objective 1: Ensure that those who drink alcohol in Salford are able to do so safely and responsibly

• Background• In England 35% of men and 20% women drink over daily

recommended limits at least once a week• Most people do not measure how much they drink• In Salford approximately 58,000 people drink over

recommended limits– 40,400 hazardous drinkers– 13,200 harmful drinkers– 4,200 dependent drinkers– These figures also include 44,000 binge drinkers (26.4% of

adult population)

Objective 1: Ensure that those who drink alcohol in Salford are able to do so safely and responsibly• Action plan• Social marketing• Provide alcohol screening and advice• Lobby Government to address the

issues of alcohol pricing and promotion• Work with licensees to create safe

drinking environments

Objective 2: Reduce the impact of alcohol on ill-health and life expectancyBackground• Alcohol accounts for almost 10% of the disease burden in

the UK. Only tobacco and high blood pressure greater• 54% of women report drinking during pregnancy, 8%

drink more than 2 units a week• Salford has 3rd highest rate of incapacity benefit claims

as a result of alcohol dependence in England• Only 1 in 12 people with an alcohol dependence are able

to access treatment in the North West • For every 8 people who received advice, 1 will reduce

their drinking to within recommended limits

Objective 2: Reduce the impact of alcohol on ill-health and life expectancyAction plan• Expand and improve alcohol treatment

provision• Provide brief interventions to harmful drinkers• Increase capacity in specialist alcohol

treatment services• Improve alcohol treatment monitoring• Extend provision of housing support for

dependent drinkers• Increase access to supported employment and

training for alcohol service users

Objective 3: Reduce alcohol related crime and anti-social behaviourBackground• Alcohol contributes to 50% of violent incidents• Some areas introduced data sharing A&E and

Crime and Disorder Reduction Partnerships (CDRP Cardiff = 40% reduction violent assaults)

• Criminal Justice based alcohol interventions are well established in Salford

Objective 3: Reduce alcohol related crime and anti-social behaviour

Action plan• Evaluate the effectiveness of criminal justice

alcohol interventions • Establish data collection systems in A&E to

provide information about alcohol related assaults to the CDRP

• Work with licensees to reduce crime and anti-social behaviour

Objective 4: Reduce the harm caused to children and young people by alcohol misuseBackground• Average weekly consumption of 15 year olds doubled

between 1990 and 2000• 1 in 14 young people aged15 – 16 say they have had

unprotected sex after drinking• Regional surveys highlight street drinking and regular

binge drinking as areas of particular concern for Salford• Support is in place to develop alcohol education in

schools• Large reduction in the percentage of premises who fail

alcohol test purchases• The majority of referrals to SMART (YP substance use

service) are alcohol-related• Approximately 4,000 young people in Salford live with a

parent who is a dependent drinker

Objective 4: Reduce harm caused to children and young people by alcohol misuse

Action plan

• High quality alcohol education schools and community settings

• Provide alcohol education to parents

• Provide attractive alternatives to drinking for young people

• Provide accessible specialist support for young drinkers

• Intensive intelligence-based test purchasing operations

• Specialist programmes for families affected by alcohol misuse

Alcohol consumption categories:

• Low risk drinking: Drinking within the Government’s recommended limits.

• Hazardous drinking: Drinking in excess of the Government’s recommended limits, but not yet experiencing harm.

• Harmful drinking: Drinking in excess of the Government’s recommended limits and experiencing harm, or causing harm to others. Women who regularly drink over 6 units a day (or over 35 units a week) and men who regularly drink over 8 units a day (or 50 units a week) are at highest risk of such alcohol-related harm.

• Dependent drinking: Drinking in excess of the Government’s recommended limits and experiencing harm and symptoms of dependence.

• Binge drinking: Drinking a large amount of alcohol over a short period of time. In surveys, women drinking over 6 units a day and men drinking over 8 units are usually defined as binge drinking. However, in practice, many binge drinkers are drinking substantially more than this level.

Salford DAAT Pathways- See detailed Pathways and Systems handout /

diagrams- Access and Identification- Tiers 1-4 intervention deriving from screening /

triage / assessment / care planning - Fast Alcohol Screening Test (FAST) - Alcohol Use Disorders Identification Test

(AUDIT)

Tier 1

Tier 2

Tier 3

Tier 4

A&E General Hospital

Criminal Justice

Primary Care

Other Generic Services

Hospital-based alcohol service

Criminal Justice alcohol service

Salford Drug & Alcohol Services

Alcohol LES

Inpatient detoxification

Residential Rehabilitation

Alcohol Treatment System Overview

Tier 1

• Low Threshold • Screen, advise,

engage, motivate, refer Tiers 2-3

• Non specialist • Primary Care• A+E, Wards• Police, Court,

Probation, HMP Primary Care (not Healthcare)

• Housing, 3rd sector

Tier 2

• Triage /Semi Structured

• Non care planned• Brief Interventions• Follow up in Primary

Care• Annual Review• Refer on to Tier 3

Tier 3• Structured• National Guidance

What Works• Care Plans• 3 monthly Reviews• Discharge • Follow up Primary

Care

Tier 4• Highly Structured• Residential Treatment• Detoxification• National Guidance

What Works• Complex Care• Care Plans• 3 monthly Reviews• Follow up Tier 2/3

Tier 1 Primary Care Pathway

• FAST 2 NFA• FAST 3+ AUDIT Qs• AUDIT 3-15 Brief Advice• Structured, personal style

and content, harm and risk, advice, strategy, empathic, motivating

• AUDIT 16-19 refer Tier 2• AUDIT 20+ refer Tier 3

Tier 2 Primary Care Pathway

• Triage in Primary Care• 30 minute Brief

Intervention• Diaries, risk management

plan, my rules, alternatives, lifestyle

• Co-morbidity drugs, Mental Illness refer Tier 3

• 2-3 month follow up, annual review or refer Tier 3

Hospital Pathway: admissions post screening A+E / Ward

• See detailed handout• Hazardous admissions Brief

Advice A+E / Ward staff• Harmful / Dependent

admissions Alcohol Specialist Nurse

• Harmful admissions Brief Interventions Alcohol Specialist Nurse with outpatient & Tier 2/3 follow up on discharge

• Dependent admissions Ward Detoxification or refer Tier 3 on discharge

Hospital Pathway: dischargespost screening A+E / Ward

• See detailed handout• Hazardous discharges Brief

Advice A+E / Ward staff• Harmful / Dependent

discharges Brief Advice Alcohol Specialist Nurse

• Harmful / Dependent discharges further assessed for Brief Interventions with Alcohol Specialist Nurse

• Dependent discharges referred to Tier 3

Criminal Justice Pathway• Alcohol defined Police /

Court, screened FAST / AUDIT by Probation

• Bail / Conditional Caution / Alcohol Treatment Requirement

• Assess Brief Intervention or ATR Criminal Justice Alcohol Worker

• Define Harmful / Hazardous / Dependent

• Refer Tier 3 as required

Generic Pathway

• FAST / AUDIT Screening• Hazardous / Dependent• Brief Advice to Hazardous

drinker in Generic Service• Harmful refer to Tier 2• Dependent refer to Tier 3

Thank you for listening: any questions?

Andrew MacDonald Salford DAAT Alcohol Coordinator

0161 603 4170andrew.macdonald@salford.nhs.ukandrew.x.macdonald@salford.gov.u

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