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

2. ScopeQuestions to be answered Whether all patients need to attend A&E for alcohol related incidents and could an alternative model be developed 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 could they be managed elsewhere for example, a commissioned service provided on or near an available NHS site)? What would be the treatment pathways to and from an alternative site? Would these pathways be clinically safe? Are there any physical or environmental concerns relating to an alternative model of provision? Can ambulance services categorise alcohol related incidents and potentially divert patients to designated drop-off points accordingly? How will ambulance staff diagnose an alcohol-related disorder? Whether alcohol interventions could be better placed within a dedicated unit? Where will this dedicated unit be located and what will be the pathways to admission? Are there any alternative models of care?What will these look like and how will they interface with existing service provision? Are these models financially viable?What is the “break-even” point whereby the cost of a new model of care pays for itself through reduced admissions

3. 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

4. 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

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

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

7. The number of admissions by individuals by Birmingham residents, 2007/2008 Number of times a patient was admitted Number of patientsTotal number of admissions 1846 2390780 3168504 4-5121273 6-1074544 >1020306

8. 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

9. Options for Alcohol Improvement Programme Investment ! Brief interventions External diversion Internal diversion

10. Option 1 BRIEF 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

11. 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

12. Alcohol Liaison Nurse Screening at A&E and on key wards Links to community based provision Clinical services

13. Option 2 External diversion AdvantagesDisadvantages  Belief 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 attendance  Patient 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

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

15. OPTION APPRAISAL Appropriateness Feasibility Desirability Sustainability

16. The Task ! Complete the tables in groups

17. Options evaluation and appraisal- qualitative analysis of key success factors FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Appropriateness Do the objectives fit in with the wider goals 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 concern over bottlenecks that may reduce patient flow – may impact on 4-hour targets

18. Options evaluation and appraisal- qualitative analysis of 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 FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Appropriateness

19. Options evaluation and appraisal- qualitative analysis of key success factors Does the option link in with the wider cultural elements of the NHS? Yes - although perceptions suggest BI best undertaken by nurses than other sectors Cultural impact of ambulance crews explored in that concerns that teams will be resistant to changing existing working patterns Broadly - although this may be stretched if AMAU is seen as impacting on 4 hour targets FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Appropriateness

20. Options evaluation and appraisal- qualitative analysis of key success factors FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Feasibility What 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

21. Options evaluation and appraisal- qualitative analysis of key success factors FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Feasibility What are the timing issues? Will an impact be seen in the short term or longer term? Impact can be seen in the short term as recruiting an ALN should be Straightforward Long-term impact. Building new physical structures plus possibility of planning permission for a new use will prevent short-to medium term gains Medium term as disruption will be affected through building new AMAU. Possible knock-on effects on existing MAU in terms of reduced patient flows etc

22. Options evaluation and appraisal- qualitative analysis of key success factors FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Desirability What are the perceived clinical risks?Few as based in acute wards will mitigate any clinical risk Potentially huge if crash team required. Unclear what happens if a patients requires referral back to an acute setting for other Interventions Low as based within acute setting so most emergency requirements will be to hand

23. Options evaluation and appraisal- qualitative analysis of key success factors FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU Desirability What are the health and safety issues for staff in terms of security? Low as sits within existing arrangements High as intoxicated clients are located together. Concern over the perception of the clinic in the public's mind may foster illusion of a "drunk tank" Moderate/high as intoxocated patients are placed together as with external option. May be mitigated by being within A&E environment

24. Options evaluation and appraisal- qualitative analysis of key success factors Sustainability Is this option sustainable in the longer-term and can it run after Alcohol-improvement investment has been completed? Easily sustained in the longer term Dependent on the initial success at diverting patients away from an I/P admission Medium term once AMAU has been accepted as an alternative option FactorsAlcohol Liaison Nurse delivering BI External diversion to a non-acute site Internal diversion to an AMAU

25. The Scores! Alcohol Liaison Nurses 127 External diversion73 Internal diversion103

27. YearNumber of BIsReduced A&E attendanceReduced I/P attendance Annual totalDH EstimateCautious est.% Year 1792396238(30%)25 Year 2792396317(40%)35 Year 3792396 (50%)45 TOTAL2,3761,188951-105 Estimate of the impact of one ALN over three years at one site (based on City Hospital)

28. 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