1. Alcohol Harm Reduction Strategies in London Frameworks for sustainable delivery? Martyn Penfold Alcohol Strategy Lead NHS Wandsworth PCT Aaron Mills Policy Officer Regional Public Health Group

2. What we know about alcohol harm : A recent history. Report Alcohol Can the NHS Afford it (2001) Royal College of Physicians Alcohol Related Needs Assessment Project (2004) Alcohol Harm Reduction Strategy for England (2004) Strategy Unit Safer Sensible Social (2007 ) Strategy Unit Reducing Alcohol Harm - health services in England for alcohol misuse National Audit Office (2008) Too much of the hard stuff –what alcohol costs the NHS (2010) NHS Confederation and Royal College of Physicians Public Health White Paper (Dec 2010) How to manage alcohol dependence and harmful drinking: National Institute of Clinical Excellence (Feb 2011)

3. Objectives and methodology. Objectives: To review progress against the delivery of alcohol harm reduction strategies in local partnerships across the capital. To identify the extent to which progress reflects a comprehensive and sustainable response. Methodology: A brief (49 point) online questionnaire sent to all 31 London Primary Care Trusts. Follow up telephone contact to: - Validate data - Follow up with supplementary questions

4. Frameworks for strategic delivery Does your partnership have :YESNOMissing A full time strategy lead for alcohol 10 (33%) 20 (67%) 1 A post holder who leads on the alcohol harm reduction strategy as part of a wider brief 18 (90%) 2 (10%) 0 An alcohol harm reduction strategy 26 (87%) 4 (13%) 1 Advisory group that oversees the delivery of your strategy 22 (73%) 7 (23%) 2

5. Reported Progress against Objectives The most common strategic objectives identified were ‘improving access to effective treatment’ (71%) and ‘reducing related crime and disorder’ (71%). 45% of strategies identified ‘preventing alcohol related harm to children and young people’ as an objective. Other objectives included ‘reducing alcohol related admissions’ (19%) and an overarching objective of ‘preventing alcohol related harm’ (19%). The objective most commonly cited as making good progress was ‘improving access to effective treatment’ (59%) The two objectives most commonly cited as making limited progress were ‘preventing alcohol related harm to children and young people’ (85%) and ‘reducing alcohol related admissions’ (61%) Almost half (49%) of those who cited reducing alcohol related crime and disorder as an objective reported making limited or no progress.

6. Average London Spend on Alcohol Misuse Of the 14 PCTs that have (to date) responded to the supplementary audit questions 12 were able to clarify the projected budget for 2010/2011 Identified alcohol funding ranged from £120,000 to £3,000, 000 On average the budget for 2010/2011 is £1,089,000 for each partnership compared to an average of £600,00 reported by the National Audit Office in 2008. This figure compares with an average partnership spend (09/10) of £4.8m on treatment for drug users. (excludes 4 DAAT areas) A number of partnerships were unable to alcohol related funding due to it being integrated with drug treatment services.

7. Dedicated IBA posts in Tier 1 settings YesNoMissingRecurrent funding Non recurrent funding Unsure Primary Care19 (61%) 11 (35%) 113 (68%) 6 (32%) 0 Acute health care incl A&E 19 (61%) 11 (35%) 18 (42%) 4 (21%) 7 (37%) Police custody/courts8 (26%) 22 (71%) 13 (38%) 3 (38%) 2 (24%) Probation5 (16%) 25 (81%) 13 (60%) 1 (20%) 1 (20%) Community Mental heath 5 (16%) 25 (81%) 12 (40%) 1 (20%) 2 (40%)

8. No.(%) Yes No.(%) No No.(%) Missing Do you have an DES for alcohol IBA in general practice23 (74%) 6 (19%)2 (7%) Do you have an LES for Alcohol IBA in general practice10 (32%) 19 (61%) 2 (7%) Screening in Primary Care Out of the 10 PCTs that have an LES, on average 52% of GP practices in each PCT has signed up for Alcohol IBA On average, there is one IBA worker to every twenty GP practices signed up to the LES

9. Community Alcohol Teams Do you have :Yes (%) A dedicated community alcohol team9 (30%) Integrated drug and alcohol team17 (57%) Both3 (10%) Other1 (3%) Who does your CAT treat? Only the most severely dependant drinkers 4 (13%) All severely dependant drinkers 6 (20%) All drinkers, including moderately dependant20 (67%)

10. Assisted alcohol withdrawal in Primary Care YES No. (%) No No.(%) No response Do you have a an alcohol LES for Assisted Alcohol Withdrawal 5 (16%) 22 (71%) 4 (13%) Do you commission any GP led alcohol clinics5 (16%) 19 (61%) 6 (19%) Do you commission alcohol nurse specialists in primary care 11 (35%) 19 (61%) 1 (3%)

11. Comprehensiveness in response Structured interventionsYesNoMissingAverage no per annum Structured Counselling25 (81%)0550 Structured Day Care22 (71%)2 (6%)645 Inpatient detoxification25 (81%)0535 Residential rehabilitation24 (81%)0525 Targeted interventionsYes Parental alcohol misuse15 (48%) Alcohol related offenders13 (42%) Alcohol related repeat A&E attenders20 (65%) Rough sleepers11 (35%) Treatment resistant drinkers11 (35%)

12. Sustainability 14 (52 %) of PCT’s reported that additional investment had been made available to increase alcohol prevention and treatment activity. Evidence suggests that a significant percentage this may come from Choosing Health budgets. 10 (32%) of PCT’s reported that some level of commissioned activities were non recurrently funded with a further 11 (35%) unable to confirm whether posts were recurrently funded 8 or 26% of PCT’s reported choosing health as a source of funding for IBA or treatment activity. A further 6 or 22% reported using under spends against drug treatment or other commissioning budgets The most common mechanisms for increasing alcohol related activity were service redesign 19 (61%), integration 15 (48%) and procurement 15 (48%) with many using a combination of all three

13. Preliminary observations: : There has been good progress in developing alcohol harm reduction frameworks in the majority of local partnerships, but data submitted suggests that further work is required to measure whether this progress is sustainable. A range of strategies have been used to reduce waiting times for treatment. These have shown a downward trend since 2007 to an average of three weeks in 2010. Evidence suggests that capacity in other structured interventions remains limited which could impact on the effectiveness of services. Despite evidence of some growth in investment it is likely that capacity across all modalities falls short of estimated need. The level of activity commissioned using non recurrent funding suggests that some progress may be at risk, particularly that relating to IBA. Further work is required to identify what exit or continuation strategies are in place for activity at risk due to non - recurrent funding.

14. Preliminary observations continued Whilst progress against improving access to effective treatment is generally reported as good, there is less success in delivering to objectives linked to crime and disorder, children and young people. Despite the majority of PCT’s investing in specialist alcohol nurses in the acute health care setting, progress in reducing alcohol related admissions (NI39) is reported as limited or poor. This may in part be attributable to ineffective treatment pathways between hospital and community services. Investment in primary care based interventions for prevention and treatment of alcohol misuse is limited. This can increase pressure on specialist services and fails to ‘capture’ a significant amount of treatment capacity.

15. Preliminary observations continued Despite evidence of a higher risk incidence of alcohol use disorders amongst offender and adult mental health populations there appears to be limited focus on developing IBA strategies targeted at these groups. Substance misuse commissioners have employed a range of mechanisms to increase access to alcohol misuse interventions most notably redesign, integration and procurement. These offer a part solution, but will only deliver sustained benefits if alcohol outputs are protected from any acceleration on drug treatment outputs.

16. Options for improvement Further work is needed to understand funding structures for alcohol treatment within partnerships to ensure that the use of under spends or non recurrent funding does not put progress at risk. Information should be provided to GP commissioning consortia and other commissioning bodies highlighting the health gain and cost benefits associated with direct investment in alcohol interventions as well as the evidence highlighting the effectiveness of these treatments. There is a strong ‘invest to save’ case for investment in alcohol services across all health care sectors and commissioning streams.

17. Options for improvement Flexibility in the use of drug related funding to support the development of alcohol services. Further work is needed to establish robust frameworks for identifying and effectively treating alcohol use disorders in general practice.This will allow specialist teams to act as an expert resource, focusing on those with more complex needs. Future commissioning frameworks should give consideration to integrating alcohol screening into ‘mainstream’ assessments in areas such as CMHT’s, NHS health checks and IAPT.

18. Options for improvement Where integration and procurement are employed as mechanisms to increase treatment capacity for alcohol misuse, commissioners should consider protect ing alcohol activity to avoid it being compromised by any acceleration of drug treatment outputs. Increased efforts should be made to develop more effective, targeted screening and intervention strategies of offender and mental health populations who are not only high risk groups for alcohol misuse but present with multiple risks including co-morbidity and drug misuse. The DOH funded alcohol hubs have offered frameworks for shared leaning across partnerships and there needs to be a commitment at both government and partnership level to put in place structures to retain the benefits delivered by the hubs.

19. Next steps Brief audit of Liaison nurses to identify barriers for effective interventions Brief audit of probation alcohol workers to identify current treatment pathways for offender populations. Review early lessons from integration and redesign strategies Detailed analysis of audit data Review conclusions/recommendations with alcohol leads Publish full report January 2011

20. Thank you