1. Alcohol: a Case for Change Chief Executives’ Forum

2. NHS North West Chief Executives’ Challenge : Consultation: Establishment of review groups including: chief executives, consultants, specialist nurses, commissioners, Department of Health Alcohol Team. National Activity (Activity Analysis): Review NI39 information to establish: the basis for the target reduction (5%); regional profile. Acute Activity (Activity Impact Assessment: Establish the data collection requirements for alchol related activity to HRG level. Review local implications of a 5% reduction. Modelling: Review and application of modelling options; assessment of economic evaluation. Approach To reduce by 5% alcohol related admissions to hospital by 2011 (NI39 target)

3. Scale of the Challenge – this isn’t going to be easy + 11% over 7 years + 8% over 3 years

4. Impact of the 5% Objective 3 Options have been tested:- ▫ 5% reduction in the NHSNW projections. ▫ Zero line reduction i.e. maintenance of the 2009/10 levels. ▫ 5% reduction in the baseline (2009/10). % impact required each year 5% 7% 12% Hospital admissions are 3 times the NI39 figures quoted

5. All NW PCTs are in the national ‘worst half’ Hospital Admissions for Alcohol Related Harm (NI39). Data Source: (Centre for Public Health NW Public Health Observatory, derived from the Hospital Episode Statistics (HES)

6. What is an Attributable Fraction? Ethanol poisoning 2 XHypertension10 X Breast cancer25 X 5% reduction required on NI39s not hospital admissions 37 Alcohol Related Hospital Admissions = 6 NI39s 2NI39s + +

7. Typical Hospital 70,000 Hospital Admissions 20,000 Alcohol Related Admissions 30% admissions are alcohol related 6,500 NI39 1/3 of alcohol related admissions equate to NI39 = 325 NI39s 5% reduction in NI39 1000

8. Hospital Activity Profile Half of patients stay 1 day or less But 2/3 of bed days are occupied by patients staying 10+ days

9. Dynamic Modelling Brief Intervention Increased Alcohol Liaison Nursing Service or Tier 3 and 4 aftercare and rehab services Identification and Brief Advice Enforcement Activity Pricing Social Marketing Extended Brief Intervention

10. Understanding Case Mix and Solutions Cohort 1 Patients staying zero to 1 day (low ‘fraction’ patients) e.g. 1:6 hypertensions have an alcohol misuse problem. Solution Need to screen / triage and provide ‘brief intervention’ Cohort 2 Patients staying 10+ days (high ‘fraction’ patients) e.g. Alcoholic Liver Disease 1:1 have alcohol misuse problem Solution Needing greater intervention and assertive outreach

11. Assertive Outreach 30+30 High Fraction / Frequent Admissions Hospital Alcohol Nursing Service 6 Wte 7 day Service Leadership Modelling Solutions £270k £390k 400 admissions 133 NI39s = -1% 475 admissions 475 NI39s = - 4% Investment Benefits Realisation

12. Service Cost £ Bed Liberation Tariff Liberation £ Hospital Alcohol Nurse Team £270k2 beds£698k Assertive Outreach £390k8 beds£895k £660k£275k£1,593k

13. Executive Summary 69% increase over the last 7 years. 7% increase in activity in the last year. Nationally the NW is the second highest after the North East. NW has the most actual alcohol related admissions. 15/24 of the NW PCTs in the bottom quartile nationally. Strategic Context - alcohol related admissions *5% reduction off projected activity = 9,000 (annual) *Zero growth = 11,400 reduction (annual) *5% off growth = 20,410 reduction (annual) Objective Impact (NI39 Reduction) *NW – 500,000 admissions, 3 million bed days *55% of beds are utilised for alcohol related activity. Approx 12% of activity is a wholly attributable. *Approx 60% admissions are emergency related. *Over 34% activity= zero LOS. (60%= Hypertension, 48% in the over 70’s) *16% activity = 1 day LOS. Hospital Context – alcohol related activity Modelling provides a basis for assessing a range of interventions, effectiveness is subject to current services and the profile of patients i.e. classification of drinker (harmful, hazardous etc) The most effective solutions include:- Alcohol Liaison Nursing Brief Advice Extended Brief Advice High Intensity interventions. Dynamic Modell ing Health Economy Implications Assertive Outreach Alternative Commissioning Solutions Economic Modelling Commissioning – health economy level reviews required to develop unified structures to the conduct of commissioning arrangements. Pathways – health needs assessment required to inform commissioning plans. Alcohol Liaison Service – review to manage service development (training, staffing etc.) Observed Findings ( Recomme ndations ) Reduce admissions by 5% Service Context Case for Change

14. In a Nutshell Do you want to crack the problem? Personal involvement as Chief Executive will be crucial. The Business Case stacks up – but needs local adaption You need to agree a risk share arrangement - close beds, share liberated costs and tariff Every £1 frees up £3 and you reduce admissions by 5% Over to you…… are you up for it?