The ‘wicked’ problem of alcohol - insights from the data Newcastle upon Tyne North Tyneside Northumberland Lynda Seery Public Health Specialist

Starting point – what do we know? (Nationally) Needs Assessment National Indicator set – NWPHO Hospital admissions for Alcohol-related harm: Understanding the dataset Service Review Models of Care for Alcohol Misusers (MoCAM) Effectiveness review QuADS, DANOS HubCAPP, National Alcohol Treatment Monitoring System The Alcohol Needs Assessment Research Project (ANARP)

Top priority – do we know what is happening locally? a) Local Needs Assessment? b) Multiple strategies across the patch (all at various stages) - Prevention - Early intervention and treatment - Enforcement and control - Partnership c) Local Service Review? How are we measuring progress? - Are we using effective measures? - Short, medium and long term impact – where does the evidence lie? - Alcohol-related hospital admissions

Analysis of hospital admissions complex indicator requested dataset 1/7/08 – 31/3/09 all admissions with any of the 3 codes identified within the spell of care (not necessarily primary diagnosis) –F10 mental & behavioural disorders due to alcohol –K70 alcoholic liver disease –T51 intoxication

Individual patient record postcode level up to 7 identified codes accepted (but some patients have up to 14 attached codes) wholly attributable to alcohol (main focus) 1411 admissions (707) patients between 141 – 202 admissions each qtr Costs = £2.5m 943/1411 readmissions (66.8%) 239/707 patients readmitted (33.8%) 153 males & 86 females 468/707 patients admitted once (66.2%) age breakdown

Newcastle

North Tyneside

Northumberland

Segmentation - understanding the patient layers The ‘patient layers’ fall into the following categories: Patients admitted to hospital for 1 day or less (no overnight stay) Patients admitted only once Patients admitted once for intoxication / patients re- admitted for intoxication Patients with multiple re-admissions for alcohol- related harm (harmful and dependent drinkers) Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas Patients with severe ongoing/end stage illness

Patients admitted once only for 1 day or 8 hours or less

Example of intoxication record Codes listed T40 (primary diagnosis) poisoning by drugs, medicaments and biological substances X620intentional self harm T51intoxication/toxic effects of substances non medicinal as to source S099injuries to head W19fall F101harmful use

‘Frequent users’ or re-admissions to hospital

Example of re-admission record Codes listed K703 (primary diagnosis)Diseases of the liver F102Dependence syndrome I10XHypertensive diseases J459Chronic lower respiratory diseases R18XSymptoms and signs involving the digestive system and abdomen Z720Persons encountering health services in other circumstances Z867Persons with potential health hazards related to family and personal history and certain conditions influencing health status

Phase 1 Initial target groups –patients re-admitted for intoxication - Patients with multiple re-admissions for alcohol-related harm (harmful and dependent drinkers) Significant 20 –Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas North of Tyne 12 MaleFemale Newcastle4449 North Tyneside22 Northumberland1725

Mapping the services and initiatives Tier system –MoCAM (Models of Care for Alcohol Misusers) –Prevention/Early Intervention – implementing IBAs (across primary care & multi agency) –Treatment – Community services & emerging alcohol workforce Virtual team working across primary care, mental health, acute services, social care, voluntary sector, –Enforcement – management of environment & night time economy requires more cohesiveness and connectivity with community services –Rehabilitation – very small numbers –Care Pathway

Improvement methodology Multi agency care plans –(individuals may have a single dominant condition i.e. alcohol but may be known to different agencies) Community Open clinics (walk in, self refer, referred into from any other service) –Professionals available at clinics, clinical & mental health staff, social care, housing, benefits Assertive Outreach STR workers (Support, time and recovery workers) Wider use of IBAs (multi agency) Emerging workforce (i.e. new roles, liaison, co-ordination, systems approach to service delivery) Flexible approach, learning (i.e. PDSA cycles)

Repeated use of the PDSA cycle Changes that result in improvement Hunches Theories Ideas Sequential building of knowledge under a wide range of conditions Very small scale test Follow up tests Wide scale tests of change Implementation of Change Spread A P S D

PDSA stage PDSA cycle 1 –hospital admission analysis –learning has allowed us to ask more questions PDSA cycle 2 –We have filtered through the records and have taken a layer to examine more closely so we are now beginning the process of assessing the actual records of individuals with multiple admissions to determine those patients who may benefit from more joined up multi agency services

Future work – focused/targeted work development of a whole system approach to alcohol related harm - multi stranded work establish a North of Tyne Care Pathway community services established and adapted to meet the need - targeted work (demographics already known) working up from granular level up into communities has the highest potential for positive impact multi agency training – raise awareness, develop skills and competencies systematic, cohesive approach across locality and wider geographic area

How hard can it be? Pace Purpose Passion

Questions?