Islington Alcohol Harm Reduction Strategy

Transcription

1 Islington Alcohol Harm Reduction Strategy Introduction 2 2. Getting the measure of alcohol in Islington 4 3. Vision and strategy Promoting safe, sensible drinking Early identification: screening & brief interventions Treatment services Working with the licensed trade Alcohol related crime and disorder The partnership 43 APPENDICES 1. Definitions and advice Trends in consumption and groups at particular risk of harm Action plan 49 1

2 1. Introduction While alcohol can bring both social and economic benefits, its misuse in Islington is a serious social, economic and health problem. This strategy therefore sets out steps to turn around the increase in ill-health, crime and anti-social behaviour, worklessness and loss of productivity that alcohol has fuelled over recent years. The need for a joined up approach Alcohol is not a stand alone issue: it cuts across and impacts on a wide range of public service priorities: health, well-being, children & young people, crime & disorder, the local economy. A partnership approach is therefore essential. This is illustrated in the chart below, which correlates Public Sector Agreement [PSA] targets with alcohol related national performance indicators. Alcohol related PSA and National Indicators PSA areas Related PSA targets Alcohol Related National indicator Fairness and opportunity for all A better quality of life Stronger communities Secure and environmental opportunity PSA Delivery Agreement 10: Raise the educational achievement of all children and young people PSA Delivery Agreement 11: Narrow the gap in educational achievement between children from low income and disadvantaged backgrounds and their peers PSA Delivery Agreement 12: Improve the health and well-being of children and young people PSA Delivery Agreement 13: Improve children and young people s safety PSA Delivery Agreement 14: Increase the number of children and young people on the path to success PSA Delivery Agreement 17: Tackle poverty and promote greater independence and wellbeing in later life PSA Delivery Agreement 21: Build more cohesive, empowered and active communities PSA Delivery Agreement 23: Make communities safer PSA Delivery Agreement 24: Deliver a more effective, transparent and responsive Criminal Justice System for victims and the public PSA Delivery Agreement 25: Reduce the harm caused by alcohol and drugs NI 15: Serious violent crime rate NI 17: Perceptions of anti-social behaviour NI 20: Assault with injury crime rate NI 21: Dealing with local concerns about anti-social behaviour and crime issues by the local council and police NI 27: Understanding of local concerns about anti-social behaviour and crime issues by the local council and police NI 32: Repeat incidents of domestic violence NI 39: Rate of Hospital Admissions per 100,000 for Alcohol Related Harm NI 41: Perceptions of drunk or rowdy behaviour as a problem NI 43: Young people within the Youth Justice System receiving a conviction in court who are sentenced to custody NI 49: Number of primary fires and related fatalities and non-fatal casualties (excluding precautionary checks and first aid cases NI 58: Emotional and behavioural health of looked after children NI 70: Reduce emergency hospital admissions caused by unintentional and deliberate injuries to children and young people NI 106: Young people from low income backgrounds progressing to higher education NI 110: Young people's participation in positive activities NI 111: First time entrants to the criminal justice system aged NI 114: Rate of permanent exclusions from school NI 115: Substance misuse by young people NI 137: Healthy life expectancy (HLE) at age 65 NI 173: Flows on to incapacity benefits from employment 2

3 Policy context In recent years, alcohol policy has been driven by the National Alcohol Strategy, which was published in 2004, and a subsequent update in The Alcohol Harm Reduction Strategy [2004] had four national objectives: Better education & communication to achieve long-term changes in attitudes. Improving health & treatment services, including early identification Combating alcohol related crime and disorder, including exclusion orders and tackling underage sales. Working with the alcohol industry at both national and local level Safe. Sensible. Social. The next steps in the National Alcohol Strategy [2007] built on the strategy and placed a focus on: Wide and effective use of laws and licensing powers The minority who cause most harm. Work with all agencies, statutory and voluntary, the industry, the wider business community and the media to shape an environment that promotes sensible drinking. The next steps it set out were: Sharpened criminal justice for drunken behaviour A review of NHS alcohol spending More help for people who want to drink less Toughened enforcement of underage sales Trusted guidance for parents and young people Public information campaigns to promote anew sensible drinking culture Public consultation on alcohol pricing and promotion Local alcohol strategies This strategy supports the delivery of these national objectives, shaped to the needs of Islington. 3

4 2. Getting the measure of alcohol in Islington Alcohol is a serious public health and social problem in Islington. Consumption has climbed steeply in recent years and more people are suffering from, or are at risk of, alcohol related harm. Alongside this, the burden of harm is shifting to younger age groups and towards more socially deprived groups. 1 A tension lies at the heart of the problem. This is because alcohol is strongly embedded in our culture and economy and, on one hand, brings both social and economic benefits, while on the other hand it causes significant levels of illhealth, crime and disorder, as well as social and economic harms. The challenge is to balance these benefits and harms better. Social benefits Economic benefits Health harms Crime & disorder Social harms Economic harms 2.1 Social and health benefits National estimates indicate that 90% of adults drink alcohol and it plays an important and positive role in our society: it is a part of many people s family and social life, enhancing meal times, special occasions and time with friends. Moderate consumption is not usually harmful to health. Indeed, consumption at or below moderate levels in older men and women is associated with a lower risk of coronary heart disease, ischaemic stroke and diabetes mellitus. Nationally, the protective effect of moderate alcohol consumption is estimated to save 15,000-22,000 lives every year, which is roughly equivalent to the number of alcohol related premature deaths. [It should be noted, however, that alcohol related deaths in Islington are higher than England as a whole and the highest in London among men.] 2.2 Economic benefits Islington has a reputation as an entertainment area and alcohol is therefore an important part of the local economy. Food and drink retail businesses account for about 4% of businesses in Islington and nearly all have an off licence for alcohol. Alongside this, restaurants, bars and hotels - nearly all of which have on licences - account for a further 13% of Islington s total businesses. 4

5 Islington has about 1,060 premises licensed to sell alcohol. 2 This represents the 4th highest rate per 10,000 population in London and 1.5 times the rates for London & England. 3 Number of premises with: On-licences 267 Off-licences 344 Both on and off licences 453 [There are also 92 Night Cafés, which are licensed to serve food after 11pm with a separate alcohol licence.] In July 2007, 2,100 were employed in Islington bars, accounting for 1% of all employees. 4 The majority of licences are distributed along the A1 and towards the south in the Clerkenwell and Bunhill wards. 5

6 2.3 Health harms Alcohol causes a range of serious preventable illnesses, for example 5 It has been shown to be causally related to over 60 different acute and chronic medical conditions, including cancer, cardiovascular disease and obesity. It is a significant cause of morbidity and premature death. The frequency of heavy drinking by pregnant women is associated with the occurrence of a range of completely preventable mental and physical birth defects, collectively known as Foetal Alcohol Spectrum Disorders. Heavy alcohol consumption is also clearly implicated in areas of mental illhealth, including depression, anxiety and suicide. Alcohol is strongly linked to unintentional injuries and trauma due to violence. Based on national research, Islington is likely to have in excess of 32,000 residents who are drinking at hazardous or harmful levels and more than 5,000 dependent drinkers 6. Locally, alcohol related hospital admissions and deaths are significantly worse than national and regional averages: HOSPITAL ADMISSIONS In 2007/08, 1,567 Islington men and 815 women were admitted to hospital with alcohol related conditions. Of these, 589 men and 245 women were admitted for alcohol-specific conditions [where alcohol is causally implicated]. The admission rate was significantly higher than for both London and England as a whole. 86 young people aged under 18 were admitted to hospital with an alcohol-attributable condition. The most common alcohol related admissions were for chronic conditions [54%] and mental and behavioural disorders due to alcohol [28%] The rate of alcohol related admissions rose 89% over the period 2002/ /09 from 1,034 per 100,000 population to 1,951 per100,000 population. DEATHS There were 55 deaths attributable to alcohol in Islington during [44 were men and 11 women.] Islington s mortality rates for men remained constant between 2006 and 2007, but rose for females. AMBULANCE CALLS 6

7 Islington has the 4th highest rate of alcohol related ambulance calls in London and the estimated cost is 165 per call. Historically the rate of calls has largely stayed the same over the last two years. As shown in the two charts below, Islington compares poorly in terms of alcohol related harm when compared to England and, more specifically, London as a whole 7 Profile of Alcohol Related Harm [Aug 10] The chart shows Islington's measure for each indicator, as well as the regional and England averages and range of all local authority values for comparison purposes. Alcohol-specific - Conditions that are wholly related to alcohol (e.g. alcoholic liver disease or alcohol overdose). Alcohol- attributable - Alcohol-specific conditions plus conditions that are caused by alcohol in some, but not all, cases (e.g. stomach cancer and unintentional injury). NI39 data (alcohol related admissions) are classified into 4 subcategories: Mental and behavioural conditions associated with alcohol; acute conditions; chronic conditions; conditions with a low attributable fraction. 7

8 ISLINGTON S RANKING AMONG LONDON S 33 BOROUGHS This chart shows Islington s ranking among London s 33 Boroughs for a series of measures. The list is ordered with those indicators where Islington performs worst at the top. MEASURE RANK Months of lives lost [males] 1 Alcohol-specific hospital admission [under 18s] 1 Alcohol-specific hospital admission [males] 3 Harmful drinking [synthetic estimate] 4 Binge Drinking [synthetic estimate] 4 Alcohol-specific hospital admission [females] 6 Hazardous drinking [synthetic estimate] 7 Alcohol specific mortality [males] 10 Months of lives lost [females] 12 Mortality chronic liver disease [males] 15 Hospital admissions for alcohol-related harm [NI 39] 20 Alcohol specific mortality [females] 20 Alcohol-attributable hospital admission [males] 21 Alcohol-attributable hospital admission [females] 21 Mortality chronic liver disease [females] 24 Mortality land transport accidents Crime and disorder Islington is ranked 12th in the UK - and 6th in London - among the top 50 areas which have the highest levels of alcohol-related crime, disorder and public concern about drunk and rowdy behaviour 8. 3,009 crimes attributable to alcohol were recorded in Islington in 2008/09. Alcohol related violent crime including sexual violence was significantly higher in 2008/09 when compared with both London and England as a whole. In 2007/08, 80% of suspects were male. The majority were aged and 61% lived in Islington 8

9 VICTIMS OF CRIME Data suggests that drinking may increase vulnerability to crime, especially among younger people. Of the offences where at least one victim was noted as having consumed alcohol 56% of victims were males, 43% females. The greatest proportion were aged between and 61% cited Islington as their home. Unsurprisingly, there is a strong correlation between alcohol related offences and the night time economy, when there are many visitors to the borough. Alcohol related crime is focused predominantly around the borough s main entertainment areas and frequently identifying licensed premises. The rate of alcohol related recorded crimes and alcohol related sexual offences fell between 2004 and 2007, but this fall levelled off in 2008/09. The rate of alcohol related violent crimes also fell between 2004 and 2007, but increased in 2008/09. 9 THE IMPACT OF ANTI-SOCIAL BEHAVIOUR ON LOCAL COMMUNITIES Two different surveys [the PAS and Place surveys] ask similar questions about drunk or rowdy behaviour. Although the results differ - with 33% and 43% viewing it as a problem in the last surveys - historically both surveys have shown little fluctuation in overall levels. The Citizen s Panel survey, conducted in March 2009, indicated that 86% of residents thought that drunk or rowdy behaviour was an important issue for Islington s Safer Islington Partnership to tackle and 32% were dissatisfied with the way it was currently being managed. 9

10 2.5 Social harms and hidden harm FAMILIES, CHILDREN AND YOUNG PEOPLE Children affected by parental alcohol misuse will not necessarily be in need, or at risk, but are known to be at increased risk of vulnerability and isolation. They may find it hard to access support due to family secrecy, shame, embarrassment or fear and anxiety about consequences of talking about family life. The Bottling It Up report estimated that 1.3 million children in the UK [1 in 11] are affected 10, 11 by parental alcohol misuse. Alcohol misuse can impact on a child s environment in many social, psychological and economic ways. It can also result in substantial mental health problems for family members. High levels of need can also be passed on through generations, so intervening offers a chance to create greater family resilience, as well as individual resilience for the children. Alcohol misuse is also correlated with child abuse and is a significant contributory factor in domestic violence incidents. Child protection registrations in Islington Parental substance misuse combined with mental ill health and or domestic violence were a contributory factor in over 80% of all children protection registrations in Drug and alcohol issues were present in 41% of these registrations. A snap shot of child protection registrations for the three month period June to August 2008 showed that alcohol was a contributory factor in 14.5% of cases. 12 Alcohol abuse and domestic violence The British Crime Survey indicated that 37% of domestic violence cases involved alcohol. 13 A range of adverse outcomes are associated with alcohol use among children and young people themselves, including increased risk of unsafe sex, teenage pregnancy, unintentional injuries, committing crimes and being a victim of crime. As highlighted above, Islington has the highest rate in London for alcohol related admissions to hospital among people under 18. Whilst nationally the number of children aged who report they had drank alcohol in the previous week has fallen slightly since its peak in 1996, mean consumption has more than doubled since 1990, with the increase for girls being slightly higher than for boys 10

11 101 test purchases were attempted in Islington by young under age volunteers and 34 sales (33%) were made. Seven shops sold twice, despite being given warnings and advice. OLDER PEOPLE 14 Generally, alcohol consumption declines with age. There is evidence, however, that today s population of older people may be relatively heavy drinkers. Surveys suggest that since 1984, the proportions of both men and women aged 45 and over exceeding the sensible limits have been rising steadily. One study found 5 12% of men in their 60 s to have alcohol problems, although other studies have shown lower figures. A recent government health survey found that 1 to 5 per cent of elderly people who drank more than occasionally were problem drinkers, reporting significant psychological and/or physical dependence on alcohol. Disruption of lifestyle [such as retirement and decreased social activity], isolation and loneliness are thought to be some of the main contributory factors among older people who develop a drink problem. Coming to terms with illness and pain which might accompany old age can mean that people use or start to use alcohol as an anaesthetic and this may also be seen as a way of justifying drinking. Tolerance to alcohol is significantly lowered in older people so it can have a more detrimental effect. It depresses brain function to a greater extent, impairing co-ordination and memory, which can lead to falls and general confusion. It can also heighten emotions leading to moodiness, irritability or even violence. Alcohol in excess affects digestion, making it more difficult to absorb vitamins and minerals and alcohol in conjunction with prescribed medication can cause adverse side effects. Alcohol misuse may lead to an increased likelihood of falls, incontinence, cognitive impairment, hypothermia, alcohol related dementia and self-neglect. It can also be obscured by non-specific health problems such as gastrointestinal problems and insomnia, or misdiagnosed as dementia or depression. Health professionals may recognise and diagnose the secondary medical problem, but fail to combat the possible primary cause. FIRE SAFETY 3,029 incidents were investigated by The London Fire Brigade s Fire Investigation Officers between April 07 and March 09. Across London alcohol consumption was recorded at 314 these incidents [10%], involving 27 deaths and 202 injuries 11

12 2.6 The costs of alcohol misuse Weighed against the economic benefits to the borough that have been highlighted above, the cost of alcohol misuse is substantial, relating to Direct costs, such as emergency services, hospital services, alcohol treatment services and criminal justice services Indirect costs, including the loss of productivity and the impact on family and communities. There is currently limited Islington specific data on the costs of alcohol harm, but in 2003 national estimates suggested that alcohol-related harm cost: Health services up to 1.7 billion a year The criminal justice system 7.3 billion a year Workplaces 6.4 billion a year 15 Based on the national estimates, the costs of alcohol harm in Islington in 2007/8 was estimated at 230 million. 16 More recently, the NHS Confederation and Royal College of Physicians, found that treating alcohol conditions cost the NHS approximately 2.7 billion in 2006/7, almost double the 2001 cost

13 3. Vision and strategy 3.1 Vision: where we want to get to SENSIBLE A wide public understanding of the harms that alcohol can cause, so people make informed choices about their drinking SUPPORTIVE Effective early interventions to help people reduce their drinking. Effective treatment services for harmful and dependent drinkers SAFE A community that - Protects young people from the harms of alcohol - Doesn t tolerate alcohol related violence & anti-social behaviour SOCIABLE A vibrant, viable, night time economy 3.2 Strategy There is good evidence, which is discussed in subsequent sections, about what influences alcohol consumption and alcohol related harm, as well as the interventions that have a positive impact: Education and health promotion can raise awareness, increase knowledge and modify attitudes about drinking, although this needs to be supplemented by other policies and actions in order to significantly change behaviours. A whole school approach is recommended to prevent and reduce alcohol use among children and young people. Screening and brief interventions can significantly reduce chronic ill health and hospital admissions. Good access to evidenced based, effective treatment offers real opportunities to help dependent drinkers and reduce alcohol-related hospital admissions. The design of licensed premises, the training of bar staff, robust management of premises and good liaison with the police have a significant impact on reducing alcohol-related crime and disorder. Excessively cheap promotions in licensed premises [incl., off licences, supermarkets and local convenience stores] are particularly likely to fuel 13

14 heavy drinking and alcohol-related crime and disorder. Community based approaches such as those being developed in Clerkenwell, and which are discussed later - are a mechanism for reducing problem behaviour: voluntary codes of practice for licensed premises have only been shown to be effective when combined with community pressure from the police and public. Active enforcement of licensing laws that regulate licensing hours and prohibit the sale of alcohol to individuals who are drunk or those who are underage have been shown to be effective. This is because the ease with which people can access alcohol is an important determinant of its use. Licensing interventions that regulate where, when and to whom alcohol can be sold are one of the most influential methods for controlling consumption and misuse. On the basis of this and related evidence, the partnership needs to take joined up action on six fronts. 1. PROMOTE SAFE, SENSIBLE DRINKING. Objective: Raise awareness of the impact of alcohol misuse on health, crime and well-being and promote a culture of safe, sensible drinking. Next steps Develop a joint strategic approach that Draws on the national alcohol social marketing programme 18 Optimises impact by supporting and connecting effectively with other elements of this strategy. Ensures effective educational arrangements are in place in schools and in other settings where local agencies work with children and young people. 2. INTERVENE EARLIER: IMPROVE SCREENING & BRIEF INTERVENTIONS Objective: Improve the way we identify individuals at risk of alcohol harm and intervene earlier by developing a more systematic, coordinated and effective approach to alcohol screening, brief interventions and advice in a range of settings. Next steps - Focus initially on improving arrangements in Primary Care and the development of health services within new polysystem arrangements, A&E, selected criminal justice settings, and Tier 1 & Tier 2 Treatment Services [including Primary Care Alcohol Workers]. 14

15 - This will include work to continue to strengthen arrangements for identifying and addressing hidden harm among children and young people, which is co-ordinated through the Hidden Harm Steering Group Subsequently develop screening, brief interventions and advice in a wider range of settings: for example, through hospital liaison, other criminal justice settings, the police, fire services & services working with young people. Encourage more people to seek assistance through improving information about services and through raising the profile of early intervention, linking this to the work described above. This will include reviewing access to information, the use of web sites, peer support groups and staff training. 3. STRENGTHEN TREATMENT SERVICES Objective: Increase the effectiveness of the local treatment system through increasing access to services and improving care pathways. Next steps: Increase referrals, improving access to services and improving care pathways & retention rates in treatment services for children and young people Use the recent Alcohol Needs Assessment to determine how best to increase the effectiveness of adult treatment services Improve our understanding of the local factors for high use of alcohol-related ambulance calls and A&E use and investigate steps to address the pattern of high use 4. WORK CONSTRUCTIVELY WITH THE LICENSED TRADE Objective: Engage actively with licensees to ensure a consistent standard of responsible retailing that promotes a culture of safe, sensible drinking. Next steps Ensure a rigorous approach to enforcement, in particular - Tackle sales to under-age drinkers and the sale of counterfeit alcohol - Work closely with licensed traders to address crime, disorder and antisocial behaviour in and around licensed premises - Continued active use of licence review process to ensure consistent standards 15

16 Determine the scope for a cumulative impact policy in the Clerkenwell area and assess other situations where cumulative impact policies may impact on crime, disorder and anti-social behaviour Promote best practice in the local licensed trade through award schemes, training, workshops and seminars Collaborate closely with bars, pubs, clubs and the police to improve the way we prevent and tackle alcohol related sexual violence and harassment 5. TACKLE ALCOHOL RELATED CRIME AND DISORDER Objective: Reduce alcohol related crime and disorder through the effective application of licensing and policing powers and robust multi agency work. Next steps Build on current multi agency work, including work with the licensed trade as outlined above Continued enforcement of the controlled drinking zone around the Emirates Stadium and consult over the introduction of a controlled drinking zone in Clerkenwell Make full and effective use of licensing and policing powers, including - where appropriate - the use of Cumulative Impact Policies, Controlled Drinking Zones, Dispersal Orders and Designated Public Place Orders. Strengthen crowd control arrangements Improve information sharing to better identify and focus action on crime and disorder hotspots Link enforcement measures to brief interventions and treatment Strengthen joint working to tackle alcohol related domestic violence 6. BUILD THE PARTNERSHIP Because alcohol related harm cuts across a wide range of public service priorities, developing the partnership approach to ensure a strong, shared response is essential. To progress this, the following are being considered: Identifying a named alcohol co-ordinator to co-ordinate the partnership and identifying and supporting champions in key settings Review and developing data sharing protocols Providing more opportunities for staff to network [incl. front line staff] for example through facilitated events and more joint training 16

17 As a part of the launch of this strategy, providing information to staff across the system about different services to encourage closer joint working Examining the scope for and benefits of joint work with neighbouring boroughs, where value can be added. Exploring ways to engaging more with local communities Carrying out work locally to deepen understanding of specific areas and developing intelligence on the costs of alcohol misuse in the borough, so that ways of further refocusing the system and resources towards prevention and earlier intervention can be identified. THE SIX STRANDS OF THE STRATEGY General population inc. prevention with young people Hazardous drinkers 1. Promote safe, sensible drinking 2. Intervene early before problem escalate Harmful drinkers 3. Strengthen treatment services to address problems Dependent drinkers 4. Work constructively with the trade 5. Tackle alcohol related crime & disorder 6. Building the partnership 17

18 4. Promoting safe, sensible drinking OBJECTIVE To raise awareness of the impact of alcohol misuse on health, crime and well-being and to promote a culture of sensible drinking. 4.1 Where we are now BACKGROUND The Government s update to the national Alcohol Harm Reduction Strategy 19 highlighted that despite broad public awareness of the harms caused by alcohol, a detailed understanding of the extent and seriousness of these harms is generally lacking. Local evidence about the extent of alcohol related harm supports this. National surveys of public opinion suggest that most people think the root of the problem lies in the English drinking culture and that many people are too willing to tolerate drunkenness and antisocial behaviour as an accepted part of life. 20 This accepted culture of heavy drinking - to which many younger people have already been introduced - is taking an increasing toll on community health and well-being. Because it is deeply engrained, a sustained educational programme - targeting a wide range of age groups and diverse communities - represents an important part of any strategy to increase understanding and thus change behaviours. To this end the Government has invested in a national alcohol social marketing strategy 1. Evidence supporting social marketing exists in areas such as smoking, sexual behaviour and nutrition, although direct evidence concerning alcohol is still emerging. 21 Importantly however, the British Medical Association has highlighted that while alcohol educational programmes can be justified in terms of raising awareness, increasing knowledge and modifying attitudes, the extent to which they change drinking behaviour is limited. Programmes therefore need to be supplemented by other policies and actions that are more effective at altering behaviour Social marketing is the systematic application of marketing, along with other concepts and techniques, to achieve specific behavioural goals for a social good 18

19 A whole school approach is recommended by the National Institute for Health and Clinical Excellence to prevent and reduce alcohol use among children and young people 23. CURRENT EDUCATIONAL PROGRAMMES The Government has introduced a range of initiatives to raise awareness about the harms of alcohol misuse, including the Know Your Limits campaign, the THINK! drink-driving campaign and guidance about safe drinking that is related to units of alcohol. There are national plans to develop such campaigns further. Locally a number of initiatives have sought to build on national work: The Council has promoted safer drinking messages every year [in particular over the holiday periods, such as Christmas], which are targeted mostly at hazardous and harmful drinkers. However, the impact of these has not been evaluated as yet. Islington Healthy Schools programme delivers substance misuse education as part of the PSHE curriculum, and as discussed in Section 6 is supported by a range of early intervention and treatment programmes. Research has recently been carried out to consider attitudes towards alcohol among people aged in the borough and this will help to inform further work 24 Overall however, work to date has been limited and fragmented across the partnership. 4.2 The challenges The challenges of raising awareness and promoting a sensible drinking culture are immense and this can be illustrated by considering three dimensions: 1. TARGETING THE RIGHT GROUPS, IN THE RIGHT WAY The table below provides a summary analysis of groups who appear to be at particular risk of alcohol related harm, based on recent trends in drinking patterns. [Further information is included in Appendix 2] Trends in alcohol consumption and groups at risk The proportion of young people aged years who have never drunk alcohol has risen in recent years Young people aged are most likely to binge drink and are at particular risk of developing alcohol dependence 19

20 The proportion of women drinking excessively has been increasing over the years, but men typically remain the heaviest drinkers Alcohol use amongst older people is more widespread and harmful than is commonly realised, and it is a largely hidden and unacknowledged problem. While people from several black and minority ethnic groups are more likely to be non-drinkers and less likely to drink above sensible levels, they have a similar prevalence of alcohol dependence to the white population. The Irish community are, however, more likely to drink above sensible levels. Social class is a risk factor for alcohol related mortality, although the relationship is complex and alcohol misuse reinforces health inequalities Other groups of people who are vulnerable to the harms of alcohol include exprisoners, homeless people, those who suffered abuse as a child and those from a family where alcohol was misused. This highlights the scale and scope of the problem and serves to demonstrate the complexities involved in determining which groups to target, the messages which should be communicated to different groups, and the best ways of doing so. 2. EMPLOYING A SUFFICIENTLY SOPHISTICATED APPROACH Marketing by the alcohol industry has had a significant impact on consumption levels over recent years and the need to employ a high level of sophistication in communicating messages about sensible drinking is clearly demonstrated by analysing the alcohol industry s approach to marketing. The marketing of alcohol The alcohol industry spends around 800 million on alcohol advertising. As shown in the diagram below, the marketing of alcohol involves a number of layers, including mass media marketing; other marketing communications; consumer marketing; stakeholder marketing, which includes partnership working and industry funded health education that can be used by the alcohol industry to influence policy makers and regulators. These layers then combine to impact not just on individual consumers, but on our social norms about alcohol

21 Without a carefully designed and skilfully executed approach, local health promotion efforts will simply be dwarfed by the alcohol industry s efforts. The marketing of alcohol 3. GETTING THE MESSAGE ACROSS AND CHANGING BEHAVIOURS The impact of delivering alcohol related messages is limited not only by overt marketing by the alcohol industry, but also by people s perceptions about their own drinking. Perceptions of alcohol and harm 26 People s perceptions of their own drinking are typically based on underestimates of their own intake, lack of knowledge of harms and inflated belief of the benefits 21

22 People s understanding of problems relating to alcohol are based on the extreme behaviours of others, for example anti-social behaviour at night in town centres, rather than informed knowledge. The public often defines moderate drinking as not getting overtly drunk, but this equates to a higher maximum consumption than that advised by Government guidelines The complexity of communicating messages in a way that changes people s behaviour is further illustrated by analysis of the public s reactions to national guidance about safe drinking levels. National research indicates that although most drinkers have heard of measuring alcohol consumption in units [86%] and most people are aware of the daily benchmarks [69%], only 13% keep a check on the number of units they drink. Many people are confused about what a unit means and about the relationship between units and glass sizes and drink strengths. 27 This has been underlined in local research which showed people tend to rely on past experience and an intuitive sense to quantify how drunk they are getting, despite the fact that intuition can be both inaccurate and dangerous if relied on in isolation Next steps DEVELOPING A JOINT STRATEGIC APPROACH Given these challenges, the partnership needs to carefully design a shared approach to health promotion. In doing so it should Draw on the evidence, strategic framework and tools from the national alcohol social marketing programme 29 Consider the scope to work with neighbouring boroughs Ensure the strategy supports, and connects with, other actions in this document in order to optimise impact FACTORS TO CONSIDER The priority groups the partnership wishes to target, the messages it wishes to communicate to them and the approaches to be employed The evidence relating to what works for different groups Ways in which any educational programme and communications will 22

23 supplement and support other policies and actions proposed in this strategy. [This will include, for example, the way people are signposted and nudged to other forms of support, including brief interventions and self help] How to optimise impact through meshing any local programmes with national campaigns, campaigns by other groups and initiatives across London and by other boroughs The resources that partners are able and willing to allocate and the extent to which these resources should be pooled Ways of engaging other agencies, including licensees, schools, health, housing, social care, local employers, the fire service and police. Delivery arrangements, including the arrangements for monitoring and reviewing progress and impacts 23

24 5. Early identification: screening & brief interventions OBJECTIVE To identify individuals at risk of alcohol harm and to intervene earlier through developing a more systematic, co-ordinated and effective approach to alcohol screening and brief interventions. 5.1 Where we are now BACKGROUND There is strong international evidence that significant reductions in chronic ill health and hospital admissions can be achieved through the earlier identification of people whose drinking is causing, or could cause harm, and by providing brief interventions. 30 BRIEF INTERVENTIONS These can range from 5-10 minutes of information and advice to 2-3 sessions of motivational interviewing or counselling. Brief interventions are targeted at people who are drinking excessively, but not yet experiencing major problems from their consumption. They are not designed for dependent drinkers 31. CURRENT ARRANGEMENTS Currently local arrangements for alcohol screening and brief interventions are fragmented and need to become a more systematic part of routine health care. Screening and brief interventions are highly cost-effective and there is significant scope to develop the offer. CURRENT ARRANGEMENTS FOR SCREENING & BRIEF INTERVENTIONS 32 Brief interventions are not consistent across all GP practices. Currently, just under two-thirds of all Islington GP practices [25 practices, 65%] provide brief interventions in line with Department of Health Direct Enhanced Service [DES] national guidance The DES only covers screening and brief interventions for newly registered patients, and does not cover screening of existing patients with indications 24

25 associated with hazardous or harmful drinking. - The DES monitoring data set provides only very brief, annual activity reports on screening and brief intervention, giving little insight into population trends. 29 [out of 38] practices provide alcohol satellite services, where an alcohol specialist offers advice and treatment. Of these 29, 13 include offer of support for brief interventions. NHSI and the Whittington have worked together to develop screening and brief interventions in A&E. However, there is significant potential to develop this further. Key success factors for effectiveness of screening and follow-up in A&E include senior level clinical leadership and systematic monitoring and review of screening to ensure it is carried out consistently and sustainably as part of routine assessment and care 5.2 Next steps DEVELOPING A MORE SYSTEMATIC APPROACH TO SCREENING & BRIEF INTERVENTIONS The partnership needs to develop a more systematic and co-ordinated approach to screening and brief interventions across the whole system of services. - The initial focus will be to ensure that arrangements are working effectively within Primary Care, A&E, Acute Healthcare settings, Tier 1 Treatment Services, which are discussed in the next section. - This will include work to continue to strengthen arrangements for identifying and addressing hidden harm among children and young people, which is co-ordinated through the Hidden Harm Steering Group Subsequently the focus should open out to encompass screening, brief interventions and advice in a wider range of settings. INITIAL PRIORITIES Implementing a standardised alcohol screening process [using a validated tool, such as FAST or AUDIT] Prioritising screening and brief interventions in primary care settings, including polysystem development, ensuring systematic delivery and evaluation, and in accident and emergency settings Continuing to build on the work the Hidden Harm Steering Group to develop arrangements for screening intervention and co-ordination across agencies 25

26 EXPANDING SCREENING, BRIEF INTERVENTIONS AND BRIEF ADVICE [initial scoping of priority groups and possible settings] Excluded and vulnerable young people through youth settings: schools, pupil referral units, youth offending services, detached youth work. Team by team approach CIN/LAC, Connexions Opportunistic screening and brief interventions for women. Other health settings, over time, for example maxillofacial clinics, fracture clinics, sexual health clinics Older people through training in the third sector, and also staff in health and social care. Offenders and criminal justice settings through introducing arrangements in custody suite Workplace early interventions, for example WorkFit ENCOURAGING MORE PEOPLE TO SEEK ASSISTANCE To support this more systematic approach to screening and early intervention, the partnership wishes to improve information about services and raise the profile of early intervention. This is so More people with drink problems are encouraged to seek assistance Partners and other family members can access information and advice Frontline staff - including, for example, housing and social care staff are better informed about services and feel more confident about recognising problems and signposting people to sources of support As a part of the work to develop a joint strategic approach to promoting safe, sensible drinking discussed in the previous section the partnership will therefore review current arrangements including Access to information Use of web sites [including web based self help programmes] Peer support groups Training and awareness raising for staff 26

27 6. Treatment services OBJECTIVE To increase the effectiveness of the local treatment system through increasing access to services and improving care pathways. Dependent drinkers represent a very high risk group for alcohol related hospital admissions. Providing evidenced based, effective treatment as well as increasing treatment opportunities may offer the most immediate opportunity to reduce such admissions. The Review of the Effectiveness of Treatment for Alcohol Problems provides the evidence base for effective treatment. 34 Islington s plans for its treatment services are set out in detail within its Substance Misuse Treatment Plans 35. This section summarises key priorities 6.1 Treatment services for young people Where we are now There is a range of specialist alcohol treatment services available in Islington, which are based on the Models of Care for Alcohol Misusers [MoCAM] guidance 36. This includes services provided by the Islington Young People Drug and Alcohol Service [IYPDAS]. IYPDAS provides an integrated service across four tiers with a multi-disciplinary team across children s services and Children and Adolescent Mental Health Service (CAMHs) working with young people under 19 years. This aims to provide a series of specialist substance misuse services within mainstream service provision so that young people and their families can access a complete package, or select the most appropriate combination of services for their needs. The majority of service users have dual addictions: alcohol is mostly secondary to cannabis. 70% of service users are male and 30% female. ALCOHOL AND SUBSTANCE MISUSE SERVICES FOR YOUNG PEOPLE: Tier 1 interventions [alcohol-related information and advice; screening; simple brief interventions and referral to other services]. Islington s Healthy Schools programme is delivered jointly by Islington Cambridge Education and Islington Primary Care Trust, and works closely with IYPDAS in delivering substance misuse education as part of the PSHE curriculum. Tier 2 Interventions [open access, non-care-planned, alcohol-specific interventions]. Services assigned to Pupil Referral Units, referral pathway with 27

28 Children s Services in order to meet the needs of young people, predominantly young women at risk of sexual exploitation. Tier 3 Interventions [community-based, structured, care-planned alcohol treatment]. IYPDAS provides a comprehensive assessment and treatment service for young people who are using drugs and /or alcohol at levels that impact on their ability to function emotionally, socially and in an age appropriate manner. Tier 4 interventions: [alcohol specialist in-patient treatment and residential rehabilitation]. IYPDAS provides case management with the support of the CAMHS clinical part of the service, including nurse and psychiatrist input. These arrangements include supervised consumption and paying for placements in specialist residential drug and alcohol treatment facilities. There was one in-patient alcohol admission in Other services for young people affected by substance misuse provided by IYPDAS and other partners include: The Y Team Truck project. Islington s mobile detached youth engagement project with two trucks and a team of youth workers providing outreach on estates and within drug hotspot areas. Hidden Harm. Service to address the needs of families affected by problematic parental drug and alcohol use Islington Fab Group pilot New services for children, using group work as a means of supporting children and young people affected by parental substance misuse. The Family Drug and Alcohol Court [FDAC]. Operational at the Inner London Family Proceedings Court at Wells Street since January 2008 and will run for three years dealing with cases brought by Camden, Islington and Westminster. Multi Agency Adolescent Support Service. Works jointly with case holding and fostering social workers to improve outcomes for young people aged who are deemed to be at significant risk of social exclusion, on the edge of care and those at risk of in-house foster placement disruption. Think family Islington. A One Door Service that allows parents or guardians with mental health issues and, in some cases, additional substance misuse problems, to access to a multitude of agencies that will be able to assist their needs across Adult and Children's services. The service works with all members of the family to meet their individual needs as well as those of the family as a whole. 28

29 A recent needs assessment 37 highlighted the need to increase people s awareness of services [given the relatively small number of referrals], to improve treatment retention rates and to strengthen pathways between services. Next steps INCREASING REFERRALS, IMPROVING ACCESS TO SERVICES AND IMPROVING CARE PATHWAYS & RETENTION RATES PRIORITIES To improve the referral pathways from universal and targeted services to increase the numbers of young people in specialist substance misuse treatment To carry out a full service review to plan for the expected reduction in funding from April 2011, ensuring that young people s substance misuse treatment is highlighted with the Islington Children s Services strategy To ensure that all young people across Child and Adolescent Mental Health Services are screened for substance misuse and referred where appropriate. To continue to increase access to specialist treatment and support for children and young people affected by parental substance misuse To develop transitional arrangements from young people s services to adult treatment services. To improve the retention of young people in treatment [in particular young offenders] and improve after care services To develop links with, and services to, black and minority ethnic communities and lesbian, gay, bisexual and transgender/transsexual communities 6.2 Adult treatment services Where we are now As with services for children and young people, Models of Care For Alcohol Misusers [MoCAM] 38 recommends services should be organised in 4 tiers. These range from alcohol related advice through open access services to structured treatment and rehabilitation. 29

30 NHS Islington commissions a range of local drug and alcohol services across these tiers, including GP Primary Care Drug and Alcohol Services (GP - PCDAS) Satellites 39. Alcohol Services Map. 40 G P /P C A D S S a te llite s T ie r 2 /3 A lco ho l S pe cific T ie r 4 A lcoho l S p e cific C row n cop yright. A ll rights res erved. L on do n B oro ug h of Islington LA , C o pyrig ht C ollins B artholom ew Ltd., Improvement priorities 41 that have been identified to date include: The need to address the late identification of service users [for example when people are already heavily dependent and/or have had an alcohol related life event such as losing their job, family problems or acquiring physical symptoms]. - This will build on recent work to improve pathways through primary care and PCADS, and through the realignment of services in the nonstatutory sector. Further work will link with early intervention work discussed in the previous section 30

31 The need to better identify the number of younger adults who are hazardous or harmful drinkers and to make services more acceptable to them The need to reduce the number of discharged clients who re-present to services at a later date The need to maintain the current focus on improving out of hours support, access to residential services and after care. The need to address the needs of groups who may be at higher risk of harm because of barriers to accessing services, including some women and members of ethnic minority communities Next steps REVIEWING THE EFFECTIVENESS OF ALCOHOL TREATMENT SERVICES An Alcohol Needs Assessment 42 has recently been completed and this is being reviewed to determine next steps As greater emphasis is placed on screening and early intervention [as discussed in the previous section], it is possible that demand for treatment services will increase. Work is therefore required to model likely demand against future capacity. 6.3 Ambulance calls Where we are now As discussed previously Islington has the 4th highest rate of alcohol related ambulance calls in London and the estimated cost is 165 per call out. Historical data indicates that the rate of calls has generally stayed the same over the last two years. As with crime, alcohol related ambulance calls are heavily associated with the night time economy. Next steps DETERMINING THE SCOPE TO REDUCE AMBULANCE CALL OUTS This is to better understand why the call out rates are high and to determine if alternative and more cost effective arrangements can be put in place. The work discussed in Section 8 to apply the Cardiff Model will help to inform this [The Cardiff model uses A&E data to track the place of incidents and to analyse patterns over time]. 31