1. Alcohol: the big and local pictures Andrew MacDonald Salford DAAT Alcohol Coordinator March 2009

2. 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

3. 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?

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

5. % Adults Binge Drinkers (6 units + per night) Synthetic estimate Health Survey England 2000-2002

6. Salford Alcohol Profile North West Public Health Observatory nwpho.net

8. National Indicator 39: Alcohol related hospital admissions Salford 6 th 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 codeICD name Alcohol specific treatment interventions T51.0Ethanol poisoning T51.1Methanol poisoning K70, K74Liver cirrhosis I85Oesophageal varices C00-C14Malignant neoplasm of lip, oral cavity and pharynx K22.6Gastro-oesophageal laceration-haemorrhage syndrome C32Malignant neoplasm of larynx C15Malignant neoplasm of oesophagus X31Accidental excessive cold C50Malignant neoplasm of breast Managing alcohol related LTCs I42.6Alcoholic cardiomyopathy K29.2Alcoholic gastritis G72.1Alcoholic myopathy G62.1Alcoholic polyneuropathy E24.4Alcohol-induced pseudo-Cushing's syndrome G31.2Degeneration of nervous system due to alcohol K86.0Chronic pancreatitis (alcohol induced) G40-G41Epilepsy and Status epilepticus I10-I15Hypertensive diseases I47-I48Cardiac arrhythmias L40 excluding L405Psoriasis K85, K86.1Acute and chronic pancreatitis I60-I62, I69.0-I69.2Haemorrhagic stroke Alcohol related accidental injury §§Pedestrian traffic accidents X00-X09Fire injuries W65-W74Drowning §Road traffic accidents (driver/rider) W00-W19Fall injuries V90-V94Water transport accidents Single use over consumption O03Spontaneous abortion X45Accidental poisoning by and exposure to alcohol T51.9Toxic effect of alcohol, unspecified W78-W79Inhalation of gastric contents/Inhalation and ingestion of food causing obstruction of the respiratory tract Alcohol related crime & disorder X85-Y09Assault W32-W34Firearm injuries Alcohol realted mental ill health F10Mental and behavioural disorders due to use of alcohol X60-X84, Y10-Y33Intentional self-harm/Event of undetermined intent

9. 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

10. Projected rate alcohol related admission and 1% target

11.  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 make among those individuals with repeat admissions across diagnoses (and potentially via other admission routes) but is informative nonetheless and the potential gains identified are conservative.

12. Repeat A & E Hospital Admissions (2005-2008)

13. A very large number of interventions would be required to reduce repeat admissions among hypertension patients - the relative Contribution of each intervention would be less. The potential sum impact per individual Intervention increases through from epilepsy, to self-harm and on to mental and behavioural disorders where the greatest sum gains could potentially be made.

14. 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).

15. 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%.

16. 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’

17. Strategy Aim is to:..reduce the harm caused by alcohol, including harm associated with crime, health, the economy and family and social networks

18. 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

19. 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)

20. 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

21. Objective 2: Reduce the impact of alcohol on ill-health and life expectancy Background 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

22. Objective 2: Reduce the impact of alcohol on ill-health and life expectancy Action 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

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

24. 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

25. Objective 4: Reduce the harm caused to children and young people by alcohol misuse Background 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

26. 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

27. 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.

28. 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)

29. Tier 1 Tier 2 Tier 3 Tier 4 A&EGeneral 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

30. 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, 3 rd sector Tier 2 Triage /Semi Structured Non care planned Brief Interventions Follow up in Primary Care Annual Review Refer on to Tier 3

31. 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

32. 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

33. 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: discharges post 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

34. 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

35. Thank you for listening: any questions? Andrew MacDonald Salford DAAT Alcohol Coordinator 0161 603 4170 andrew.macdonald@salford.nhs.uk andrew.x.macdonald@salford.gov.uk