Alcohol use in the over 50s, Suffolk Needs Assessment

Transcription

1 Alcohol use in the over 50s, Suffolk Needs Assessment Author: Paul Nelson (PHAST) Submission date: 09/02/2016 Revision Date: 09/02/2109 1

2 Contents Alcohol use in the over 50s, Suffolk Needs Assessment... 1 Contents... 2 Executive Summary... 4 Aim Background Definition of problematic alcohol misuse UK Government drinking guidelines Alcohol risk related definitions Alcohol consumption and misuse in England Drinking above recommended limits Frequency of drinking Alcohol consumption by household income The demographic structure of the population of Suffolk aged over Ethnicity Gender Rural urban classification Modelling of alcohol consumption in Suffolk Men Women Persons Drinking behaviour Falls in the elderly Crime figures Homelessness and rough sleepers Street Drinkers Existing services Primary Care Structured Alcohol treatment

3 Activity: Hospital stays for alcohol related harm Hospital stays for alcohol-related harm (original definition) Hospital admissions for alcohol-related conditions, broad definition Hospital admissions for alcohol-related conditions, narrow definition Stakeholder perspective Commissioning landscape Public perspective Frontline Staff Alcohol Attitude Questionnaire Evidence of effectiveness NICE Standards on alcohol dependency NICE Standards of Dual Diagnosis Suffolk alcohol services needs assessment 2013 recommendations as they relate to over 50s Discussion Epidemiology Primary Care Alcohol treatment services Acute NHS services Adult Social Care Service Gaps NORCAS older people s alcohol service Suffolk alcohol-related programmes Conclusions Recommendations Glossary References

4 Executive Summary Background: People over 50 sometimes drink excessively. Although guidance on healthy ageing does not currently identify excessive alcohol consumption as a risk factor for illness and death in older people, the risk that alcohol poses means that it must be considered in assessing their health needs. Aims: The study set out to explore alcohol use and misuse in people over 50 years old in Suffolk, to identify existing services that are available to them, to indicate service gaps and models of good practice and to make recommendations as to how Suffolk County Council can improve services for people over 50 relating to alcohol, with particular areas of interest in socially isolated, deprived and rural contexts. Methods: We identified alcohol data on risk factors, behaviours, need, demand, service provision and outcomes in Suffolk. We then compared Suffolk s services, where possible, with best practice from elsewhere. Finally, we sought stakeholder views via semi-structured interviews with statutory and non-statutory professional and strategic staff, via an online questionnaire for frontline staff and via focus groups for members of the public and alcohol service users in the over 50s age group. Results: The epidemiological needs assessment found that alcohol consumption in Suffolk showed a similar pattern and was marginally lower than in England and Wales and consistent with the research evidence, particularly that alcohol consumption does appear to increase with age, and that consumption is higher among more affluent groups. There has been an overall reduction in the numbers of people drinking on at least five days a week. In the age group, there has been a downward trend in consumption, but no such trend is shown in the over 65s. There was a clear socio-economic downward gradient in excess alcohol consumption: in both sexes, a higher percentage of those in the higher socio-economic categories drank over the recommended limits than the lower socio-economic groups. This finding is in line with national research on drinking in the over 50s (Iparraguirre, 2015). There was some evidence of a gap in services for relatively hazardous drinkers who may wish to cut down to reduce risks to their physical and mental health. However they may not identify as problem drinkers and may be unwilling to engage with substance misuse providers because of social stigma. Services for this group are primarily provided within primary care and not monitored. However, in early 2015, a Nalmefene pathway was introduced where hazardous drinkers can access a Nalmefene prescription and psychosocial interventions via Turning Point as mandated by NICE Technology Appraisal (TA325). There has been limited demand for this service thus far. 4

5 We identified a knowledge and confidence gap regarding addressing alcohol with clients particularly among non-nhs statutory and third sector provider frontline staff. However, we found a willingness and even eagerness to take up identification and brief advice (IBA) training. We found evidence of a vibrant third sector providing support to the over 50 s. Of particular relevance to the rurality of Suffolk were the services provided by The Rural Coffee Caravan. Turning Point services appear to be less well integrated than previous services with respect to the health and social care teams they work alongside. This is likely due in part to relatively recently starting the contract (service started in April 2015 following a retendering exercise). The service model has been reconfigured and the service is working through an ambitious transition period of integrating staff from the previous six different organisations. This appears to have led to a perception in some stakeholders, front-line staff and the public (at least the small subsection of the public we engaged through focus groups) of a less accessible service. We found evidence among stakeholders of some concern about Turning Point s mixed caseload treatment model whereby substance misusers of all types are treated together. This, it was felt by some, led to a potential resistance in, and lack of engagement of, alcohol misusers, particularly in the over 50s age group who would rather not seek help than engage in mixed group therapy because of the stigma which they attach to drug misusers. Joining drug and alcohol services together was heavily explored as part of the consultation pre-tender there were some mixed views on this but it was primarily practitioners rather than service users who were concerned. The specification for the service includes delivering some separate services for different groups including alcohol. There was also a perception from some stakeholders of a loss of morale and retention where expert staff, previously specialising in alcohol or drug misuse, now have mixed drug and alcohol clients. This concern had also been identified by Commissioners in the early phase of the new contract and has been addressed by training to ensure that all staff are competent in managing clients with drug and alcohol treatment needs. There was a perception among some stakeholders that members of the public were not aware of the services that are available and that they did not have a clear idea of how to go about finding out or accessing them. This was corroborated by the views expressed in a small focus group of older members of the rural public. 5

6 Stakeholder consultation suggested a poor rating of the current alcohol misuse service in general and for older people in particular. There was also concern about silo working and lack of integration. Conclusions Alcohol in the over 50s: an important local public health issue: Alcohol in the over 50s directly relates to at least two of the four Suffolk Health & Wellbeing strategy priorities. Research evidence suggests alcohol harm in the over 50s is underestimated and that some people who might consider themselves healthy are in fact putting themselves at risk through excessive alcohol consumption. Yet there is no clear national or local public health message about alcohol for older people. This needs assessment shows there are significant health risks for older risky drinkers in Suffolk. Rural drinkers may be proportionately no more numerous than urban drinkers but they have less access to services. Identification and Brief Advice: In Suffolk there is too little awareness of alcohol in over 50s as a widespread problem. Even with existing initiatives such as Make Every Contact Count and Identification and Brief Advice (IBA) training, many front-line staff, in a wide variety of statutory and non-statutory settings, still do not ask their clients about their drinking. There remains a lack of knowledge and confidence in those staff, yet there is interest and enthusiasm among them to undertake training. Harm Reduction: There is room for an improvement in harm reduction services in Suffolk to provide support beyond brief advice to those requiring a moderate amount of arm s length support to reduce their drinking to healthier levels and to improve harm reduction services in low-level risky drinkers. We estimate that in Suffolk up to 20,000 people (over 50) binge drink and less than 300 people in Suffolk received structured treatment in 2013/14 (this does not include people who have utilised open access provision). However, structured treatment will focus primarily on individuals with some level of dependence. It is likely that the need and potential demand outweighs the provision, however this situation is likely to be no worse in Suffolk than elsewhere in England and Wales. Social stigma remains a barrier to seeking and getting help, particularly among over 50s. There were numerous reports that those who may simply need to cut down a relatively small amount refuse to seek help to avoid identifying as a substance misuse service user. As for other age groups, alcohol harm prevention in over 50s should and could be an issue that falls within the remit of existing structures which deliver prevention, early intervention and health promotion services including Live Well, Adult Social Care, Primary Care, and community mental health services (NSFT). Collaboration with well-placed third sector organisations like Age UK Suffolk and the Rural Coffee Caravan could also support harm prevention. 6

7 The rural third sector: The rural third sector organisation, the Rural Coffee Caravan, is well accepted by older people in rural locations. It has a broad reach and is trusted. There is an increase in the number of community-run pubs in Suffolk. These organisations present an opportunity to reach the over 50s and provide messages and support in an acceptable stigma-free way, particularly to rural communities. It may appear counter intuitive to employ such a vehicle to deliver moderation of drinking behaviour but interviews with local people and rural third sector stakeholders suggested their role could be stabilizing to those tending to drink too much. Alcohol treatment in Suffolk: Some Suffolk residents with severe drinking problems, requiring treatment, refuse to seek help to avoid the stigma of having to identify as a substance misuse service user. This issue is complicated by Turning Point s mixed client model of care (users of different substances are managed together in Turning Point group work). This model may present an extra barrier to entry for many into the alcohol service. Some alcohol misusers are treated by their GPs but close joined working between primary care and specialist treatment services (that was reported to have previously existed), now appears to require improvement. Extreme end spectrum drinkers are treated in the acute hospital setting, sometimes with detoxification. It was reported that their care is not shared by specialist alcohol services and that there are insufficient shared care or joint working arrangements. General practice and the acute medical service appear to be working in parallel rather than in partnership with Turning Point, both offering some alcohol detoxification along with on-going follow-up support. They do not collaborate well with or share care with Turning Point. Up to 50% of all problem drinkers also have a mental health problem, yet dual diagnosis is not practically acknowledged in the form of shared care or joined working, with coordinated input from both Mental Health and alcohol treatment services. It was suggested in the consultation that, in part, difficulties with joined up working are exacerbated because the substance misuse services are no longer collocated with mental health services. However it was also reported that SATS (the previous alcohol services provider) were collocated with Mental Health services (both previously delivered by NSFT) but there were still significant difficulties in working together. This led to joined up working becoming a strong part of the current performance framework in the new contract with Turning Point. There are always organisational risks and opportunities in major tenders and provider changes in delivering services. The recent provider change in alcohol services potentially presents such a risk particularly to over 50s. With the alcohol service in mid transition and community mental health services still in the tender process, the risks associated with multiple organisational changes are present. 7

8 The Turning Point service is not yet fully embedded in the Suffolk health and social care organisational landscape. The policy of giving previously alcohol-specialised staff mixed workloads may be affecting morale and effectiveness and also the reputation of the service to would-be referrers and clients. Recommendations 1) Identify an effective Mechanism to drive implementation of alcohol strategy: We recommend that Suffolk County Council put in place an effective mechanism to drive implementation of alcohol strategy and should particularly consider raising and maintaining the profile of alcohol (and alcohol in over 50s specifically) as a strategically important risk factor for ill health in Suffolk. In relation to the over 50s, we recommend that Suffolk County Council alcohol strategy specifically prioritises the following themes: 2) Identification and dissemination of a clear simple message about alcohol in older people: We recommend that Suffolk County Council support the setting up of an evidence-based social marketing campaign with local customer insight to identify an unambiguous locally tailored message, relating specific levels of drinking with measurable risk of specific illness with which the over 50 s can identify. Allied to the social marketing campaign, we recommend that Suffolk County Council support a mechanism for delivery of a non-alcohol branded harm reduction wellbeing initiative for the over 50s. The initiative should target over 50s, whose drinking has risen to levels that are worrying them, reducing their wellbeing and increasing their health risk. The aim of the initiative would be to provide support to cut down and to de-stigmatise and normalise cutting down as an activity like weight loss, or salt reduction, to reduce long-term health risk. The Turning Point Westminster Resolution Clinic offers a model to inform the delivery structure for such an offer. Potential partners in the initiative include Healthy Lifestyles service provider, Age UK, Turning Point, NORCAS, The Rural Coffee Caravan and Suffolk Mind. 3) Increase delivery of Identification and brief advice services: We recommend that Suffolk County Council supports a mechanism for increasing identification and Brief advice training (additional to the alcohol element offered within Making Every Contact Count training). This would comprise: Requiring providers of relevant services contracted by Suffolk County Council to include the provision of IBA training as part of service agreements 8

9 Support should be targeted to relevant third sector organisations to take up IBA training and support their staff to attend (e.g. Age UK Suffolk, Suffolk Mind and Rural Coffee Caravan). Support available for statutory and NHS staff to refresh IBA training as part of their Continued Professional Development (CPD) Turning Point target IBA training at those groups identified in stakeholder consultation as being under-confident in discussing drinking behaviour 4) Improve joint working arrangements between Treatment services (Turning Point), primary care and other relevant organisations: We recommend that Suffolk County Council supports Turning Point to engage further with, and establish clear documented referral arrangements with, primary care (through CCGs), Social Care (and their Tier 1 provider Age UK Suffolk), Community Mental Health (NSFT), NORCAS over 65 s service and the acute liver teams at West Suffolk and Ipswich Hospitals. We recommend that Suffolk County Council explore how to best ensure operational joined working and/or shared care arrangements between Turning Point and the organisations above, including criteria for when joined working or shared care is appropriate. Shared care/joint working should require regular case conferences, either in person or else by conference call. Particularly, we recommend that Suffolk County Council and Suffolk Clinical Commissioning Groups explore how best to establish robust joined working or shared care arrangements for anyone undergoing detoxification in Suffolk or anyone with dual diagnosis of mental illness as well as alcohol related harm, to ensure no one falls through the gaps. 5) Improve the offer to Alcohol users provided by Turning Point: We recommend that Suffolk County Council work with Turning Point to ensure that they fully deliver the specification, including a separate alcohol pathway to reduce stigma and encourage access. 6) Raise awareness about services available for people who are concerned about their alcohol use: We recommend that information is provided for members of the public by Public Health Suffolk and Turning Point to promote the services that are available and how to access them. 7) Improve arrangements for joint working where clients have a dual diagnosis: When published in Autumn 2016, review NICE Dual Diagnosis guidelines across the system and consider how they can be implemented in Suffolk. 9

10 8) Improve ability to meet need of over 65 s: We recommend that Suffolk County Council ensure that services for the over 65s are reviewed to ensure they increase the ability of Suffolk to meet the needs of this population and that data collection and evaluation of the services for this specific group takes place. 10

11 Aim To determine the health related effects of alcohol in the 50+ population of Suffolk. The scope of the needs assessment includes a broad focus on the effect of alcohol on the lives of older people (over 50s) living in Suffolk. We consider the wider impact of alcohol on the workplace, on health and wellbeing, particularly mental health services, on crime, and on families and relationships. Background Alcohol has potential to do great harm, not only associated by causing serious ill health but also through domestic violence, neglect, crime and disorder. However, it also plays a significant cultural and economic role in society and in the local socioeconomic life of Suffolk. The UK is home to several large alcohol producers. In 2012/13, HMRC received 2% of total tax receipts (approximately 10 billion) from alcohol duties whilst approximately 600,000 people are thought to work in the alcohol industry and a further 1.1 million work in the related, wider economy. The alcohol business sector is particularly important in Suffolk, a significant employer but also an important part of Suffolk s tourism industry. Hazardous drinking is a pattern of alcohol consumption that carries risk of physical and psychological harm to the individual. Harmful drinking denotes the most hazardous use of alcohol, at which damage to health is likely. One possible outcome of harmful drinking is alcohol dependence, a cluster of behavioural, cognitive, and physiological phenomena that typically includes a strong desire to consume alcohol, and difficulties in controlling drinking. Compared to non-drinkers, harmful drinkers are 3-5 times more likely to get cancer of the mouth, neck and throat, 3-10 times more likely to develop liver cirrhosis. Men have four times the risk of having high blood pressure and women are at least twice as likely to develop it. There is twice the risk of arrhythmias and women are approximately 1.5 times as likely to get breast cancer (NHS Choices, 2015). The risks are dose related so lower consumption of alcohol still confers raised risks of these disorders. Excessive intake of alcohol poses a significant risk to the health and wellbeing of individuals, families and communities. Alcohol is the third most important contributor to the global burden of disease as measured in disability-adjusted life years (DALYs) contributing 5% (World Health Organization, 2009). Yet there is no consistent clear national or local public health message about alcohol, particularly, for older people. Measures of alcohol consumption and definitions of alcohol harm (such as hazardous drinking, harmful drinking and risky 11

12 drinking) are not clearly defined and do not clearly relate to specific measurable risks of actual specific health consequences. It is impossible for an older person to know if I drink this much, I am at that much risk of X. Without such a clear message, the health messages will continue to have limited impact. UK government recommendations can be found on the Live Well site. There, recommendations state: No one can say that drinking alcohol is absolutely safe, but by keeping within these guidelines, there s only a low risk of causing harm in most circumstances. There is also a caveat, although no one can say alcohol is absolutely safe, before specific recommendations about high risk drinking that men should not regularly drink more than 8 units a day or 50 units a week, and that women should not regularly drink more than 6 units a day or 35 units a week. The 2013 Suffolk Alcohol Treatment Services Needs Assessment did not focus specifically on older people. While the report was informative of the health concerns, new evidence shows emerging health needs particularly in terms of older adults relationships with alcohol. Excessive drinking in older age groups is rising. Alcohol-related deaths in the UK in 2012 for those aged 75 and over are 18% for men and 12% for women (Suffolk County Council, 2014). Alcohol-related hospital admissions, illnesses and mental health disorders are also rising, with a third of older people with drinking problems developing them for the first time in later life. Bereavement, physical ill-health, difficulty getting around, becoming a carer, social isolation and loneliness can lead to boredom and depression, and alcohol can make these difficulties more bearable in the short term. There is less pressure to give up drinking than with younger people, especially when there is no need to go to work, fewer family responsibilities, changes in routine or other circumstances. Alcohol can present specific health risks to older people as tolerance to alcohol reduces with age. Older people often have a reduced ratio of body water to fat, and so there is less water to dilute alcohol consumed. Moreover, if a person has a decreased hepatic blood flow, then onset of disease occurs earlier (Wadd & Galvani, 2014). Iparraguire et al, (Iparraguirre, 2015) examined the socioeconomic determinants of risk of harmful alcohol drinking and of the transitions between risk categories over time among people age 50 or over responding to the English Longitudinal Survey of Ageing (ELSA). Findings fell into three categories: 12

13 Risks to men: There was a non-linear association between age and risk for men (falling with age), peaking in their mid-60s. Single, separated or divorced men show a greater risk of harmful drinking. Not eating healthily, being younger and having a higher income increase the probability of becoming a higher risk alcohol drinker. Risks to women: Retirement and income were found to be positively associated with a higher risk for women but not for men. Women with caring responsibilities were at lower risk of their drinking increasing. In women, being younger and having a higher income at baseline was associated with increased probability of becoming a higher risk alcohol drinker over time. Risks to both men and women: Higher levels of education and smoking were found to be positively associated with increased risk drinking for both sexes. Significantly higher risk drinking falls with age for both sexes. The Iparraguire et al study counter-intuitively found no association between risk drinking and loneliness or depression. Furthermore, the presence of children living in the household, being lonely, being older and having a lower income was associated with ceasing to be a higher risk alcohol drinker over time. This last finding is not easy to reconcile with research on occupation, which shows alcohol-related disease deaths were 3.5 times higher in men with jobs classed as routine compared with managerial or professional jobs (Institute of Alcohol Studies, 2014). These two pieces of apparently conflicting research demonstrate the complexity of research about the health impact of alcohol. The authors suggested that the socioeconomic factors that were found to be associated with high-risk alcohol consumption among older people were exhibited by those who would still fall under a classification of ageing successfully, i.e. affluent, functioning people according to nationally recognised definitions. The authors recommended that policies that deal with definitions of successful ageing, active ageing, or productive ageing should allude to specific recommended quantities of alcohol consumption in their range of components (Bristow & Clare, 1992; Depp & Jeste, 2009), since they may overlook the risks associated with alcohol consumption in this group as currently defined. This study has been taken by some as suggesting that that successful ageing is correlated with risky level of drinking. However, the current classifications are too 13

14 broad and therefore give a false sense of security to those who fit the current components, without considering alcohol intake. There is growing evidence to suggest that safe drinking levels for older people could be less than the current recommended daily limits, because older people break down alcohol more slowly than younger people (Psychiatrists, 2011). Approximately onethird of all prescribed drugs are prescribed to the over 65s and alcohol can interact with some medicines and increase the likelihood of confusion and falls. Depression is the most common mental health condition in older people; 13-16% have sufficiently severe depression to need treatment. Men are more likely than women to commit suicide at all ages. This is also true for older men over 75, who have higher rates of death by suicide. This may reflect the impact of depression, social isolation, bereavement or physical illness. Alcohol dependency is also common among older adults who attempt suicide. Definition of problematic alcohol misuse UK Government drinking guidelines Department of Health (1995) made recommendations in relation to levels of alcohol use that are unlikely to accrue any significant health risks. These were dailyrecommended levels of not more than 2-3 units of alcohol per day in a woman and 3-4 units per day in a man. In January 2016, the Department of Health have issued proposed new guidelines which are currently out for consultation until April They recommend a reduction in overall weekly limits of consumption to 14 units for both men and women (weekly limit for men was previously 21 units). Alcohol risk related definitions (NHS Choices, 2015) Lower-risk drinking Lower-risk drinking is drinking at a level associated with a low risk of future harm to your health. For men, lower-risk is drinking no more than 3-4 units of alcohol a day on a regular basis. For women, it s lower risk if they drink no more than 2-3 units of alcohol a day on a regular basis. Sensible' or 'responsible' drinking are sometimes used to mean lower-risk drinking. Increasing-risk drinking Increasing-risk drinking is drinking associated with an increased risk of future harm to your health, with the risk increasing the more you drink. 14

15 For men, this riskier level of drinking is drinking more than 3-4 units of alcohol a day on a regular basis. For women, it's drinking more than 2-3 units a day on a regular basis. Higher-risk drinking Higher-risk drinking is drinking at such a high level that you re at particularly high risk of harming your health. For men, higher-risk drinking is regularly drinking over 50 units a week (eight units of alcohol a day). For women, it s regularly drinking over 35 units a week (more than six units of alcohol a day). Binge drinking The term 'binge drinking' usually refers to an episode of heavy drinking over a short period of time, such as over the course of an evening or over an hour or two. It also refers to an episode of drinking to intoxication or to drunkenness. Binge drinking can affect your health in a number of ways. For example, it can increase your immediate risk of being in an accident, becoming involved in an argument or fight, or taking part in illegal or risky behaviour, such as drink-driving or unsafe sex. Different people are affected differently by how much they drink. Alcohol can also affect a person differently at different times. Some people will be at risk of the immediate harms to their health even if they don t think they re getting drunk. Hazardous drinking Hazardous drinking usually refers to drinking above the recommended lower-risk levels but without, yet, showing evidence of harm to health. Harmful drinking Harmful drinking refers to those already experiencing or showing evidence of health harms (but not if just showing evidence of alcohol dependence). Dependent drinking Dependent drinking refers to having developed alcohol dependence, which is a specific health harm where the person affected has started to have an excessive desire to drink, or is showing some loss of control over their drinking. This has usually started to affect the person s quality of life and relationships, but they may not always find it easy to see this or to accept it. 15

16 For someone with severe alcohol dependence who experiences physical alcohol withdrawals when they cut down or stop drinking, suddenly cutting down or stopping can be dangerous without seeking medical advice. Physical withdrawal symptoms include: hand tremors ('the shakes') sweating nausea visual hallucinations (seeing things that aren t real) seizures (fits) in the most serious cases Psychological withdrawal symptoms include: depression anxiety irritability restlessness insomnia (difficulty sleeping) Severely dependent drinkers usually experience severe withdrawal symptoms. They often fall into a pattern of 'relief drinking', where they drink to avoid withdrawal symptoms. Severely dependent drinkers are often able to tolerate very high levels of alcohol, amounts that would incapacitate or even kill some people. 16

17 Alcohol consumption and misuse in England Hazardous drinking is a pattern of alcohol consumption carrying risks of physical and psychological harm to the individual. Harmful drinking denotes the most hazardous use of alcohol, at which damage to health is likely. One possible outcome of harmful drinking is alcohol dependence, a cluster of behavioural, cognitive, and physiological phenomena that typically include a strong desire to consume alcohol, and difficulties in controlling drinking. Hazardous and harmful drinking can be measured using the AUDIT (Alcohol Use Disorders Identification Test). Alcohol dependence is assessed using the SADQC (Severity of Alcohol Dependence Questionnaire, community version) (Barbor et al., 2002). Results of a household survey (National Center for Social Research, University of Leicester, 2007) presents prevalence estimates of hazardous (AUDIT score greater than 8) and harmful drinking, and of alcohol dependence, in the adult general population in England. The survey reported that the prevalence of hazardous drinking was 24.2% (33.2% of men, 15.7% of women). This included 3.8% of adults (5.8% of men, 1.9% of women) whose drinking could be categorised as harmful. In men, the highest prevalence of both hazardous and harmful drinking was in year olds, in women in 16 to 24 year olds. The prevalence of alcohol dependence was 5.9 % (8.7% of men, 3.3 % of women). For men, the highest levels of dependence were identified in those between the ages of 25 and 34 (16.8%), for women in those between the ages of 16 and 24 (9.8%). Most recorded dependence was categorised as mild (5.4%), with relatively few adults reporting symptoms of moderate or severe dependence (0.4% and 0.1% respectively). The prevalence of alcohol dependence was lower for men in 2007 than in 2000, whereas it remained at a similar level in women. Alcohol dependence was more common in white men and women than in those from minority ethnic groups. There were no significant variations in the prevalence of dependence by region or income. However, the likelihood of being a hazardous drinker did vary between regions. 14% of alcohol dependent adults were currently receiving treatment for a mental or emotional problem. Dependent women (26%) were more likely than dependent men (9%) to be in receipt of such treatment. In the absence of available detailed local data on alcohol consumption, we examined the General Lifestyle Survey (GLS) 2012 analysis at the England level. The GLS age breakdown includes those aged years, rather than over 50s specifically. 17

18 Drinking above recommended limits Figure 1 shows trends in percentages of men who drank above the recommended limit (4 units) on at least one day in the week before the survey. There was an apparent fall in the number of people aged 45 to 64 drinking excessively between 2005 and 2011 from 42% to 38%. Rates, in the 65+ age group, have remained relatively stable at approximately 20%. Figure 1: Percentage of men in drinking > 4 units per day, England, 2005/ % Year Total Source: GLS

19 Figure 2 shows trends in percentages of men who drank at least double the recommended limit (8 units) on at least one day in the week before the survey. Figure 2: Percentage of men drinking > 8 units per day, England, % Total Year 65 + Source: GLS

20 Figure 3 shows trends in percentages of women who drank above the recommended limit (three units) on at least one day in the week before the survey. Rates in the year age group have dropped between 4% and 5% while levels in the over 65 age range have remained fairly constant. Figure 3: Percentage of women drinking > 3 units per day, England, % Total Year Source: GLS

21 Figure 4 shows trends in percentages of women who drank above the recommended limit (6 units) on at least one day in the week before the survey. Figure 4: Percentage of women drinking > 6 units per day, England, % Total Year 65 + Source: GLS 2012 While there has been a reduction in the overall percentage of people drinking above recommended limits, this reduction has been in the younger age groups. There may be a slight downward trend in the age group, but there was none in the over 65s. 21

22 Frequency of drinking The GLS 2012 presented data on the percentages of men and women who drank on at least five days in the week before the survey (see figure 5 below). Figure 5: Percentage of men drinking on at least five days a week, England, % Total Year Source: GLS

23 Figure 6: Percentage of women drinking on at least five days a week, England, % Total Year Source: GLS 2012 There has been an overall reduction in both sexes of people drinking at least five days a week. In the age group there has been a general downward trend, but no such trend is shown in the over 65s. 23

24 Drinking above recommended limits by socio-economic classification The GLS 2012 presented data on the percentages of men and women who drank over the recommended limits by socio-economic classification (SEC). Table 1 shows percentages of men and women over age 16 who drank more than the recommended limits (4/3 units per day) on at least one day in the previous week by SEC. Table 1: Percentages of men and women over age 16 who drank more than the recommended limits (4/3 units per day) on at least one day in the previous week by SEC, England, 2011 Socio-economic classification of household reference person Men Women All persons Managerial and professional Large employer and higher managerial Higher professional Lower managerial and professional Intermediate Intermediate Small employers/own account workers Routine and manual Lower supervisory and technical Semi-routine Routine Total Source: GLS 2012 Table 2 shows percentages of men and women over age 16 who drank at least double the recommended limits (8/6 units per day) by SEC. Table 2: Percentages of men and women over age 16 who drank at least double the recommended limits (8/6 units per day) by SEC, England, 2011 Socio-economic classification of household reference person Men Women All persons Managerial and professional Large employer and higher

25 managerial Higher professional Lower managerial and professional Intermediate Intermediate Small employers/own account workers Routine and manual Lower supervisory and technical Semi-routine Routine Total Source: GLS 2012 In both sexes, more people in the higher socio-economic categories drank over the recommended limits than in the lower socio-economic groups. This finding is in line with national research on drinking in the over 50s (Iparraguirre, 2015). 25

26 Drinking above recommended limits by rural urban classification The GLS 2012 presented data on the percentages of men and women who drank over the recommended limits by urban/rural classification (RUC) of area of residence by age-band and sex. Table 3 shows percentages of men and women by amount of alcohol consumed (maximum amount on any one day), by RUC, for year olds and over 65s. Table 3: Percentages of men and women by amount of alcohol consumed GLS England, 2011 Source: GLS 2012 Urban Rural Urban Rural Men Drank nothing last week Drank within rec. limit Drank over the rec. limit Drank > double the limit Women Drank nothing last week Drink within rec. Limit Drank over the rec. limit Drank > double the limit All persons Drank nothing last week Drink within rec. limits Drank over the rec. limits Drank > double the limit There are clear differences in alcohol consumption patterns between urban and rural areas. Those living in urban areas are more likely not to drink at all. Those who live 26

27 in rural areas are more likely to drink within the recommended limits and to drink over the recommended limits. The position is unclear for those who drank more than double the recommended limit. Alcohol consumption by household income The GLS 2012 presented data alcohol consumption by sex by equivalised household income. Equivalised household income has been adjusted for household size and composition. Table 4 show patterns of alcohol consumption in the week before the GLS by sex and by equivalised household income divided by quintiles, as percentages of those over 16. Table 4: Patterns of alcohol consumption in the week before the GLS by sex and by equivalised household income divided by quintiles, as percentages of those over 16, England, 2011 Drank last week Equivalised gross weekly household income quintiles Lowest Second Third Fourth Highest Men Women All persons Drank on 5 or more days Men Women All persons Drank more than rec. limits Men Women

28 All persons Drank more than double rec. limits Men Women All persons Source: GLS 2012 [*Equivalisation is a technique in economics in which members of a household receive different weightings. Total household income is then divided by the sum of the weightings to yield a representative income] Figure 7: Percentage who drank in the last week, by household income, GLS England, Men All persons Women % Lowest Second Third Fourth Highest Household income fifths Source: GLS

29 Figure 8: Percentage who drank on at least 5 days in the last week, by household income, England, % 10 Men All persons Women 5 0 Lowest Second Third Fourth Highest Household income fifths Source: GLS 2012 Figure 9: Percentage who drank more than the recommended limit, by household income, England, Men All persons Women 35 % Lowest Second Third Fourth Highest Household income fifths Source: GLS

30 Figure 10: Percentage who drank more than double the recommended limit*, by household income, England, 2011 % Men All persons Women Lowest Second Third Fourth Highest Household income fifths Source: GLS 2012 *(Maximum drunk on any one day in the last week) Figure 7, Figure 8, Figure 9 and Figure 10 show that household income has a clear influence on the proportion of people who consume alcohol, the amounts they drink and the frequency with which they drink it: the higher the household income the more likely people are to drink at all, to drink frequently, and to drink above recommended limits. The exception is that the percentages of women in the second lowest group (between the first and second quintiles) are lower than those in the lowest income group. 30

31 Alcohol consumption by region and nation The GLS 2012 presented data alcohol consumption by sex by Government Office Region and nation within Great Britain. Suffolk forms part of the East of England Region. Table 5 shows data on alcohol consumption for the East of England, England, and Great Britain, by sex, as percentages of those aged over 16 years. Table 5: Data on alcohol consumption, by sex, as percentages of those aged over 16 years, East of England, England, and Great Britain, 2012 Drank last week Drank on 5 or more days last week Drank more than rec. limit on at least one day Drank more than double rec. Limit on at least one day Men East of England England Great Britain Women East of England England Great Britain All persons East of England England Great Britain Source: GLS

32 Age-band Alcohol consumption patterns in the East of England are similar to the national patterns for overall drinking and frequent drinking. For both men and women, the East of England has lower percentages drinking above the recommended limits and drinking more than double the recommended limits. The demographic structure of the population of Suffolk aged over 50 The following population pyramid shows the age and sex structure of the population of Suffolk compared with that of England, as recorded in the 2011 Census. Figure 11: Population pyramid, Suffolk and England, 2011 Census England Suffok Suffok England Males Females Source: Census 2011 (Bars represent Suffolk, Lines represent England) Suffolk's proportions of its male population aged and over 85 are higher than England's. Suffolk's proportions of its female population aged over 55 are higher than England's. 32

33 Table 6 shows the absolute numbers in each age-band in thousands, rounded to the nearest hundred. Approximately 41% of women and 38% of men in Suffolk are over 50 years of age. Table 6: Numbers of people in each age-band in thousands in Suffolk rounded to the nearest hundred, 2011 Source: Census 2011 Age band Female (000s) Male (000s) Age 50 to Age 55 to Age 60 to Age 65 to Age 70 to Age 75 to Age 80 to Age 85 to Age 90 and over All Ages Over over Ethnicity According to the Suffolk Demographic Profile 2013 (Suffolk County Council), 95% of the population identify as White, and 5% from all Black and Minority Ethnic group (BME) combined, compared with 86% and 14% respectively England and Wales. Muslims, who culturally are unlikely to consume alcohol, made up less than 1% of the population of Suffolk according to the 2011 Census (compared with 5% nationally). It seems unlikely that ethnicity and religion are major contributors to understanding the impact of alcohol on Suffolk's over 50 year olds. The ethnic position in the Ipswich district is different from the rest of Suffolk. In Ipswich 11% are from BME groups. Ipswich is also a dispersal centre for Asylum seekers and refugees and some remain once they acquire the right to stay in the UK. Ipswich is host to University Campus Suffolk, and this may account for some of the difference. Also, Ipswich is the most urbanised part of Suffolk and is more multicultural. For the most part, university students are of ages outside the scope of this study, and Ipswich has relatively few people over the age of 50 years. 33

34 Gender The following maps show the distribution of over 50 year olds in Suffolk for women, men, and persons, at Middle Super Output Area level, with district local authority boundaries. Women Figure 12: Distribution of over 50 year olds for women by Middle Super Output Area (MSOA) with LAD boundaries Suffolk, 2013 Source: Calculated from data from 2011 census 34

35 Men Figure 13: Distribution of over 50 year olds for men by Middle Super Output Area (MSOA) with LAD boundaries Suffolk, 2013 Source: Calculated from data from 2011 census Persons Figure 14: Distribution of over 50 year olds in Suffolk for persons by Middle Super Output Area (MSOA) with LAD boundaries Suffolk, 2013 Source: Calculated from data from 2011 census 35

36 There is no clear pattern to the distribution of over 50 year olds in Suffolk. With the exception of Ipswich, every District in the County has areas with high numbers of over 50 year olds. Rural urban classification The following map shows MSOAs in Suffolk by rural or urban classification. Figure 15: Distribution of over 50 year olds for persons by urban rural classification with LAD boundaries Suffolk, 2013 Source: Calculated from data from 2011 census and 2013 Department for Environment, Food & Rural Affairs (Defra) Rural Urban Classification (RUC) for 2011 Census areas ( Each of the local authority districts of Suffolk has some element of urban centres and considerable rurality. Rurality is not concentrated in one particular part of the County and so issues related to rurality affect all part of Suffolk. 36

37 Table 7 shows the population aged over 50 in Suffolk by sex and Rural Urban classification (RUC). 37

38 Table 7: The population aged over 50 by sex and RUC Suffolk, 2011 Sources: Census 2011, Defra over 65 Over 50 Men Rural Urban Total Women Rural Urban Total All Rural Urban Total In all, 42% of Suffolk's population aged over 50 live in rural areas, and 58% in urban areas. This is consistent by sex and by sub age band. Modelling of alcohol consumption in Suffolk In the absence of local figures on rates of drinking in older people, we modelled them for binge drinking rates (those who drank at least double the maximum recommended amount on at least one day in the week prior to being surveyed), at the Middle Super Output Area (MSOA) level. The Alcohol Consumption report on the GLS 2011 included a range of aggregate analyses of amounts and frequency of drinking: by amount, by sex, by age-band (45-64, >65), by rural/urban classification of area and by Government Office Region. By combining these and applying the result to the population at local area level, we can arrive at a modelled estimate for local areas. These data are available for men, women, and persons. We are concerned with over 50 year olds, so must assume that the rates for are applicable to the age group (i.e. we must ignore the year olds, which might potentially bias a model). The Rural Urban Classification has several sub-categories but can be simplified into just rural or urban. All this data is available for men, women, and persons. Use of this data results in estimated numbers at the England rates. Consumption data by Government Office Region includes percentages for each region and for England. Suffolk forms part of the East of England Region, so modelled estimates for Suffolk at England rates can be adjusted by the ratio of the East of England overall rate to that of England. 38

39 The following tables show the percentages of over-16s drinking more than twice the maximum recommended limits, for year olds and over 65s by sex, in total and by rural/urban classification, and the proportions for the East of England and England overall, as recorded in the GLS Table 8: Maximum drunk on any one day in the last week, by sex, age and urban/rural classification, England, 2011 All Urban Rural Urban Rural Men times limit More than 3 times limit Total binge drinkers Women 2-3 times limit More than 3 times limit Total binge drinkers Source: GLS 2011 Table 9: Percentage of binge drinkers on one day in the last week by sex, England, 2011 Source: GLS 2011 % binge drinkers Men East of England 14 England 18 Women East of England 10 England 12 Applying these percentages to the 2011 Census population as MSOA level and aggregating at District level arrives at modelled estimates of binge drinking by LA district in Suffolk (see Table 10). 39

40 Table 10: Modelled estimates of binge drinkers aged 50 years+ by LA district in Suffolk, 2011 Women Total 50+ Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney Men Total 50+ Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney Persons Total 50+ Babergh Forest Heath Ipswich Mid Suffolk St Edmundsbury Suffolk Coastal Waveney Source: GLS 2011 and 2011 Census The following maps show the distribution of the modelled estimates at MSOA level, for men, women, and persons. 40

41 Men Figure 16: Distribution of the modelled estimates of binge drinker at MSOA level, for men, Suffolk, 2011 Source: GLS 2011 and 2011 Census 41

42 Women Figure 17: The distribution of the modelled estimates of binge drinker at MSOA level, for women Suffolk, 2011 Source: GLS 2011 and 2011 Census 42

43 Persons Figure 18: The distribution of the modelled estimates of binge drinker at MSOA level, for persons, Suffolk, 2011 Source: GLS 2011 and 2011 Census Figure 16, Figure 17 and Figure 18 show modelled estimates correlate directly with population density, with the highest estimated levels of binge drinking in urban areas including Ipswich, Bury St Edmunds, Lowestoft and Newmarket. 43

44 Drinking behaviour Data on local drinking prevalence data for people over 50 is theoretically available from the Health Check programme (see NHS Health Check section) but was not available for this report. We therefore used the online alcohol-related information resources from the national charity, Drinkaware. Drinkaware agreed to support this study by supplying web analytics data from November 2014 to November 2015 concerning their website resource pages accessed by residents in Suffolk. The number of page visits from browsers based in Suffolk cities and towns was ascertained using the Google Analytics service. This is an experimental proprietary service with a disclaimer suggesting that the experimental nature of the tool has inherent undefined inaccuracies. Drinkaware also provided figures of downloads of their mobile phone app, which supports people to monitor and cut down their alcohol consumption. The number of people who visit the Drinkaware website from Suffolk was 65,775 from an adult population of approximately 600,000 i.e. approximately 11% of the adult population. Ipswich is the 33 rd most popular for referrals in the Drinkaware website whilst being the 42 nd largest city by population. The percentage of those visiting for the first time was 82%. Of the 65,775 visits to the Drinkaware website, Table 11 shows the breakdown by specific page, of how approximately 53,000 page were attributed to IP addresses associated with the five towns in Suffolk. Table 11: Drinkaware web statistics for Suffolk towns (November 2014 to November Source: Drinkaware GoogleAnalytics) Web Page Ipswich Lowestoft Bury St Edmunds Newmarket Stowmarket Population (2001 census) Unit Calculator 13, Day Calculator 4, Drink Driving 3, Homepage 2, The Law on Alcohol & Under 18s 1, Alcohol & Your Liver 1,

45 Is it safe to drive the morning after drinking alcohol 1, Self-Assessment Tool 1, Unit & Calories in Wine 1, Health Effects of Alcohol 1, Dealing with a hangover Alcohol & Mental Health: Make a change What is an alcohol unit How to stop drinking alcohol Concerned about someone's drinking Alcohol & Your Liver Calories in Alcohol Underage drinking Alcohol Poisoning Alcohol and Sleep Is it safe to drive the morning after drinking alcohol Is alcohol harming your stomach How to talk about alcohol Check the facts Drink Driving and the legal alcohol limits Alcohol and food equivalents total 33,394 2,770 5,353 3,097 8,355 Hits per head of population

46 The unit calendar was the most popular page view indicating that those visiting the site were interested in knowing their alcohol consumption in a way that can be compared with recommended limits. Also the IPs of people living in rural communities in Suffolk are likely to be attributed to internet routing hubs in towns and cities, so these figures most likely represent, not only users in the towns themselves but also in the surrounding rural areas. This might explain why Stowmarket with a population of only 15,000 has relatively high number of hits attributed to it and why Felixstowe and Haverhill are absent from the list. The dataset from towns other than Ipswich was too small to analyse by age and gender. However, for Ipswich 56% of web hits were estimated by Google from women and 43% from men, also approximately 20% of hits came from people in the 55+ age range. These data provide an insight into the interest of a large proportion of the population searching for information relating to alcohol dangers, moderating and monitoring their alcohol consumption in Suffolk. Drinkaware App Drinkaware have created a downloadable app for smartphones. Nationwide there have been 209,000 downloads. The number of people who have downloaded the app from Suffolk is 1,765, which suggests that this number of people who are actively concerned about their alcohol intake have chosen this route to examine their intake. Suffolk has approximately 0.5% of the population of England and Wales and about 0.85% of app downloads, i.e. app downloads Suffolk use of the Drinkaware App represents approximately 1.5 x average for England and Wales. This might indicate that the public are not only relying on local services to provide support for moderation of their drinking but proactively finding tools such as the Drinkaware App and website to support their efforts to self-moderate. However, there are too many confounding factors to make this more than one explanation among many. Falls in the elderly Falls in the relatively young elderly that lead to hospital admission are a surrogate measure of the consequences of alcohol misuse in the over 50s. We explored the availability of data from national and local sources in order to examining these data. However none were routinely available from sources such as Public Health England (PHE) and the Health and Social Care Information Centre (HSCIC). 46

47 Crime figures We contacted the Suffolk constabulary in an attempt to gain data about alcohol related crime perpetrated by the over 50s. We were informed that this was not available without a freedom of information request, which was not possible within the timescale of this project. Homelessness and rough sleepers Alcohol misuse is one of the most important causes and effects of homelessness. The prevalence of alcohol use disorders in homeless people and rough sleepers is between 38 and 50% in the UK. Homeless people are particularly vulnerable to health-related harm associated with alcohol including damage to liver, heart and stomach, high blood pressure, double incontinence, fits, mental health problems, depression, blackouts and memory loss (Goodall, 2011). Data from Turning Point, the provider of drug and alcohol services in Suffolk, showed that only one person registered as no fixed abode was in contact with the alcohol service as of 16/12/2015. Street Drinkers Street drinkers are very often marginalised by society and are largely hidden from view, mostly unemployed, often (but not always) homeless and are often parted from their families and support networks. Street drinkers are likely to have complex needs such as severe alcohol dependency and a history of serious physical or mental health problems. A further problem is that many street drinkers are resistant to the notion of treatment, even though they are aware of local services. Ipswich has a street-drinking scheme in place designed to ban drinking in public spaces in the town centre that have experienced alcohol-related disorder or nuisance. Although this approach has reduced the visibility of street drinking and anti-social behaviour, it may also have had unintended consequences. For example, it can make it more difficult for outreach workers to support street drinkers, which could inadvertently worsen their health. There is a perception that this scheme is pushing the visibility of drinking rather than reducing its prevalence. Some street drinkers have been displaced from the town centre into adjoining residential areas. It is essential that carefully co-ordinated support packages accompany any enforcement interventions with this vulnerable group of people. Anglia Care Trust have completed their fourth year of an Alcohol Recovery Project employing two outreach officers to work with identified street drinkers to support them into and through the recovery and rehabilitation process. As of end of 2014, ACT had supported 34 people into recovery, ranging from medical help, engagement and attending detox and residential rehab clinics. In their 2014 annual report they 47

48 stated that Most importantly, support to Service Users to sustain their accommodation has contributed towards other positive outcomes through the year. The reduced number of referrals and number of new service-users returning to the service can be attributed to the reduction of the core group of street drinkers in Ipswich achieved by the multi-agency working carried out by Start Afresh. It is important to note that there are no figures available on the number of street drinkers who are over 50. Suffolk also offers a Marginalised Vulnerable Adult (MVA) service which provides health services to people who do not already have a GP or, if they do, might need more assistance like: homeless people, refugees and asylum seekers, migrant workers, ex-offenders, gypsies and travelers, black and minority ethnic people. The MVA service also provides a first response to immediate need like wound care, health checks, sexual advice, drug and alcohol services, needle exchange and prescribing. It also takes up the safeguarding role and the team is available to provide training and expert advice. 48

49 Existing services Primary Care Primary care is important in supporting older people s healthy relationship with alcohol. The GP practice is the gateway to other health services and a link between acute and community health service and social care. Primary care (General practice, pharmacies, optometrists and dentists) is where most interactions between the public and the NHS take place. Primary care roles begin with identification and brief advice in general practice this includes management of alcohol-related illnesssometimes including pharmaceutical prevention, also potentially harm reduction as well as referral into specialised services. NHS Health Check is a primary care cardiovascular screening programme offered to year olds. It includes the AUDIT Questionnaire assessing drinking with a score (1-20) with clinical pathway (see figure 31, p.75, Heath Check). Audit scores of 20+ lead to referral and scores of lead to brief advice (Barbor et al., 2002). Data on NHS Health Check AUDIT questionnaire scores in Suffolk were not available to this study. Four GPs responded to the frontline staff questionnaire, indicating they were comfortable and optimistic about working with alcohol issues. They also indicated they felt identification and brief advice training was unnecessary for them. Evidence from public focus groups, professional stakeholders and from questionnaire responses suggest that primary care is poorly integrated with alcohol treatment services and that some GPs are not interested in supporting patients who come to them worried about their alcohol intake. Stakeholder interviews suggested that the joint working arrangements between GPs and specialist treatment had been better under the previous system (pre-april 2015). General practice has a potentially pivotal role in identifying and managing dependent drinking (Barbor et al., 2002). However, shared care/joint working is minimal and users reports of GP support and interest in alcohol were mixed. The Suffolk service needs assessment 2013 reported GP prescribing of disulfiram (Antabuse) consistent with GP-initiated community-based medically assisted alcohol withdrawal (estimated 2,000 episodes) independent of specialist services. Among medically assisted alcohol withdrawal (in the community) in Suffolk in 2012, only 55 (3%) of episodes benefited from specialist provider input and 5% of eligible patients received relapse prevention prescribing. One possible reason for the low rates of specialist input in prescribing was the lack of a medical lead for SATS (the largest alcohol specialist provider in Suffolk at the time). However, Turning Point now has a medical specialist consultant in post. It would be informative to measure the 49

50 impact of this post on coordination of alcohol-related harm management in the community. Structured Alcohol treatment The number of adults in structured alcohol treatment in Suffolk for was 826 with a national figure of 114,877. The number and proportion of adults starting structured alcohol treatment in was 589 with 80,888 nationally. The number and proportion of adults in structured drug treatment in who cite additional problematic alcohol use was 270 (42,755 nationally). Age-specific national data for structured alcohol treatment are published by the National Treatment Agency (Table 12). Table 12: Age and gender of clients in (structured alcohol) treatment, England and Wales, 2013/14 Age Female Male Total n % n % n % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % Total Source: National Treatment agency alcohol annual report It can be seen that 30% of female clients, 28% of male clients and 28% of all clients were over 50. The national figures in Table 13 were used to estimate expected numbers of adults in Suffolk in treatment, starting treatment or with combined drug and alcohol problems. 50

51 Table 13: Numbers of all adults and estimated over 50s in Structured Alcohol treatment in Suffolk, 2013/14 All adults Estimated number over 50 Adults in treatment Adults starting treatment Adults in drug treatment with additional alcohol problems Source: NDTMS (All Adults) 51

52 Table 13 shows actual number of adults in treatment, starting treatment and those with a drug and alcohol problems in Suffolk, along with estimated numbers for over 50s based on national figures for the over 50s applied to local totals. It can see that the estimate for numbers in treatment is a very accurate estimate of the actual number (see Table 14). It is therefore plausible to assume that the estimates for adults over 50 starting treatment with both a drug and alcohol problem are also reasonable. These figures indicate the extent of met need for alcohol misuse services in Suffolk. Table 14: Numbers in treatment for alcohol misuse by age group and year Suffolk 09/10 13/14 Age Group 09/10 10/11 11/12 12/13 13/ Total over 50s Total Proportion over 50 22% 24% 26% 27% 28% Source: NDTMS ViewIt tool accessed 16/12/2015 Note in 13/14 methodology for data collection changed so that anyone who had opiates recorded as primary, secondary or tertiary drug were removed from the primary alcohol figures. (See Caution should be exercised in drawing comparisons between this data over time as methodologies have changed (e.g. see above) and the robustness of recording practices (for example in recording structured treatment/open access provision) have changed. Outcomes of alcohol services for people over 40 This section presents information on alcohol consumption of people aged 40 years and over who completed treatment in the period 2013 to Data was not separately available for those over 50 years old. The number of people who completed treatment rose from 402 in 2013/14 to 479 in 2014/15, an increase of 52

53 19%. On exit from treatment, 54.6% of Suffolk's clients were abstinent in 2013/14, and 42.7% in 2014/15. In 2013/14, the average client in Suffolk drank on 19.9 days per month (28 days), and in 2014/ days. On exit from treatment, the figures were 13.1 days (34% reduction) and 12.7 days (39% reduction) respectively. These were about a day a month less than the England averages of 20.8 and 21.2 days at the start, and 13.5 in 2013/14 and 13.6 days on exit in 2014/15. Figure 19 shows the quarterly breakdown. Figure 19: Average drinking days per 4 weeks, Suffolk, 2013/14 to 2014/ Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14 Q1 14/15 Q2 14/15 Q3 14/15 Q4 14/15 start Suffolk exit Suffolk start England exit England Source: NDTMS TOPS reports 2013/15 Note: TOPS only reports outcomes for clients within first 6 months of treatment and when they leave the service The following chart shows the average days reduction (per 4 weeks), quarterly. 53

54 Figure 20: Average days reduction (per 4 weeks), quarterly, Suffolk 2013/14 to 2014/ Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14 Q1 14/15 Q2 14/15 Q3 14/15 Q4 14/15 l Suffok England Source: NDTMS TOPS reports 2013/15 Note: TOPS only reports outcomes for clients within first 6 months of treatment and when they leave the service While simple linear regression would suggest that Suffolk's reduction in days is increasing faster than England's, the variability from quarter to quarter suggests that this conclusion cannot be safely drawn. At the start of treatment, the average number of units consumed on a drinking day was 19.9 in 2013/14 and 18.4 in 2014/15. On exit from treatment, the figures were 12.9 units in 2013/14 (a 35% reduction) and 8.7 in 2014/15 (a 53% reduction). The equivalent reductions for England were 35% and 51% respectively. Figure 21 and Figure 22 show the quarterly absolute and percentage reductions in numbers of units consumed between start of and exit from treatment for Suffolk and England over the period. 54

55 Figure 21: Average reduction in units of alcohol drunk on a drinking day, Suffolk, 2013/14 to 2014/ Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14 Q1 14/15 Q2 14/15 Q3 14/15 Q4 14/15 l Suffok England Source: NDTMS TOPS reports 2013/15 Note: TOPS only reports outcomes for clients within first 6 months of treatment and when they leave the service Figure 22: Average percentage reduction in units of alcohol drunk on a drinking day, Suffolk, 2013/14 to 2014/15 Source: NDTMS TOPS reports 2013/15 Note: TOPS only reports outcomes for clients within first 6 months of treatment and when they leave the service 55

56 There was a steady improvement in the reduction of units of alcohol consumed achieved by treatment in Suffolk from Q2 2013/14 to Q4 2014/15. In terms of the percentage reduction, there appears to have been a step-change between 2013/14 and 2014/15, as both Suffolk and England improved from a 35% reduction to over a 50% reduction. This may represent artefact due to definition change or another systematic data issue. Overall, Suffolk's results are similar to those of England. 56

57 The reach of alcohol treatment in Suffolk In the context of the figures from our modelled estimates of binge drinking in Suffolk (see Table 10) and also data from the Drinkaware website and App (see section: Drinking behaviour), we estimate that there were 23,000 binge drinkers over the age of 50 years in Suffolk in 2012/13, and that the total number of people looking up alcohol-related information from Drinkaware among over 50s was 13, The estimated number of Drinkaware App downloads from Suffolk in the over 55s was approximately 350. We do not have any reason to believe that the figures in Suffolk differ from the rest of England and Wales; these figures show that those in treatment represent only a very small minority of those who may benefit from harm reduction services. However, structured treatment is generally for those who have some level of dependence and may not be appropriate for people who are binge-drinking or just require more information about reducing harms from alcohol. Figure 23: Comparison of numbers of people over 50: estimated to be binge drinkers or who have sought alcohol related information on Drinkaware website or who are in structured alcohol treatment services. Suffolk, 2013/14 Number of people, over 50, who looked up informa on on the Drinkaware website in Suffok 2013/14 (13,000) 36% Es mated binge drinkers, over 50, in Suffolk 2013/14 (23,000) l 63% Number of people, over 50, in alcohol treatment services in l Suffok 2013/14 (232) 1% Source: Drinkaware web analytics, binge drinking estimates from this report and structured treatment numbers NDTMS 2013/14 1 Estimated by applying the Drinkaware data relating to the proportion of hits from people over 55, i.e. 2% in Ipswich (where data were available to the total number of hits on the Drinkaware website i.e. 66,

58 Activity: Hospital stays for alcohol related harm In view of number of historic changes to the definitions of alcohol-related harm in hospital episode statistics, time-trend statistics for alcohol-related harm may not be reliable, and data relating to different periods may not be comparable. The definition in force at the time must be borne in mind by the reader. Hospital stays for alcohol-related harm (original definition) Hospital episode data were not available by age band; we therefore present data for Suffolk for all ages. The following table and chart show hospital stays for alcoholrelated harm from 2008/9 to 2012/13 for Districts in Suffolk, Suffolk and England. (Source: Public Health England, accessed 2 July 2015), using the older definition. Table 15: Hospital stays for alcohol related harm (SAR 2008/9 2012/13) for districts in Suffolk 95% Confidence Interval SAR Lower Limit Upper Limit Suffolk Coastal Mid Suffolk Babergh Suffolk Forest Heath Ipswich St Edmundsbury Waveney England 100 Source: PHE local health website, accessed July 2015 Suffolk as a whole, and Suffolk Coastal, Mid Suffolk, Babergh, Forest Health, Ipswich, and St Edmundsbury had lower rates than England. The differences are statistically significant at the usual 5% level. Waveney had significantly higher rates that England. Because the method of calculation of SARs does not allow for differences between local area populations, each SAR can be validly compared with England, but the local area figures cannot be valid compared with each other. So for example, the magnitude of figures for Waveney and for Suffolk cannot be validly compared. Hospital stays for alcohol-related harm (revised 2014 definitions) As well as revising the broad definition and introducing a new narrower definition of alcohol-related harm, the Health and Social Care Information Centre (HSCIC) has 58

59 revised the forms in which alcohol related hospital stays are presented and the basis of calculation. Data are now issued as directly standardised rates (DSR) per 100,000 population, rounded to the nearest 10. The reference population is the population of England (not, as with all previous HSCIC DSRs the European Standard Population). Although the standardisation methodology allows for the calculation of confidence intervals, the HSCIC has not issued these, and without detailed age-sex fractionation the end user cannot calculate them. It is therefore not possible to determine the level of statistical significance of differences in these figures. Hospital admissions for alcohol-related conditions, broad definition The following table and charts show DSRs per 100,000 population for hospital admissions related to alcohol (including subsidiary diagnoses) in and , for persons, men and women. Table 16: DSRs per 100,000 population for hospital admissions related to alcohol (including subsidiary diagnoses) in persons, men, and women, Suffolk, 2012/13 and 2013/14 Admissions per 100,000 Persons Men Women 2012/ / / / / /14 England ,480 2,580 1,310 1,370 East of England ,130 2,240 1,150 1,240 Suffolk ,090 2,090 1,160 1,170 Babergh ,950 1,890 1,060 1,060 Forest Heath ,180 2,340 1,420 1,350 Ipswich ,290 2,460 1,270 1,290 Mid Suffolk ,710 1, ,030 St.Edmundsbury ,300 2,290 1,270 1,310 Suffolk Coastal ,670 1, ,030 Waveney ,570 2,170 1,320 1,230 Source: PHE Local Alcohol Profiles for England, issued June

60 DSR / 100,000 Figure 24: Admissions for alcohol related conditions (broad), districts, comparators, DSR, Persons, Suffolk, to England Ipswich Forest Heath St. Edmundsbury East of England Waveney Suffolk Babergh Mid Suffolk Suffolk Coastal / /14 Year Source: PHE Local Alcohol Profiles for England, issued June

61 DSR / 100,000 Figure 25: Admissions for alcohol related conditions (broad), districts, comparators, DSR, Men, Suffolk, to England Ipswich Forest Heath St. Edmundsbury East of England Suffolk Mid Suffolk Waveney Suffolk Coastal 550 Babergh / /14 Year Source: PHE Local Alcohol Profiles for England, issued June

62 DSR / 100,000 Figure 26: Admissions for alcohol related conditions (broad), districts, comparators, DSR, Women, Suffolk, to St. Edmundsbury Ipswich Forest Heath England Suffolk Babergh East of England Mid Suffolk Suffolk Coastal Waveney / /14 Year Source: PHE Local Alcohol Profiles for England, issued June 2015 (For women, East of England and Mid Suffolk had the same values, so only one line can be seen on the chart). Overall, there was an increase between the two years at national level, which was not observed in Suffolk. For men and for both genders together, all parts of Suffolk had admission rates below those of England. For women, Suffolk as a whole had lower rates than England, but St Edmundsbury, Ipswich, and Forest Heath had higher rates than England. Waveney had substantial reductions of admission rates for both men and women. Admission rates were considerably higher for men than for women. 62

63 DSR / 100,000 Hospital admissions for alcohol-related conditions, narrow definition The following table and charts show DSRs per 100,000 population for hospital admissions related to alcohol (using primary diagnoses and alcohol-related external causes) in and , for all persons, men, and women. Table 17: Show DSRs per 100,000 population for hospital admissions related to alcohol (using primary diagnoses and alcohol-related external causes) in and , for all persons, men, and women Admissions per Persons Men Women 100, / / / / / /14 England East of England Suffolk Babergh Forest Heath Ipswich Mid Suffolk St. Edmundsbury Suffolk Coastal Waveney Source: PHE Local Alcohol Profiles for England, issued June 2015 Figure 27: Admissions for alcohol related conditions (narrow), districts, comparators, DSR, Persons, Suffolk, to England St. Edmundsbury Ipswich Forest Heath Suffolk East of England Mid Suffolk Suffolk Coastal Waveney Babergh / /14 Year Source: PHE Local Alcohol Profiles for England, issued June

64 DSR / 100,000 DSR / 100,000 Figure 28: Admissions for alcohol related conditions (narrow), districts, comparators, DSR, Men, Suffolk, to England Ipswich Forest Heath St. Edmundsbury East of England Suffolk Mid Suffolk Waveney Suffolk Coastal 550 Babergh / /14 Year Source: PHE Local Alcohol Profiles for England, issued June 2015 Figure 29: Admissions for alcohol related conditions (narrow), districts, comparators, DSR, Women, Suffolk, to St. Edmundsbury Ipswich Forest Heath England Suffolk Babergh East of England Mid Suffolk Suffolk Coastal Waveney / /14 Year 64

65 Source: PHE Local Alcohol Profiles for England, issued June 2015 There was a small increase in admissions for alcohol-related conditions between the two years at national level in both men and women. Suffolk did not experience an increase in admissions of men. For men and all persons all parts of Suffolk had admission rates in below those of England. For women, Suffolk as a whole had lower rates than England, but St Edmundsbury, Ipswich, and Forest Heath had higher rates than England. Waveney had substantial reductions of admission rates for both men and women. Admission rates were considerably higher for men than women. Overall, admissions for alcohol-related conditions were consistently lower than for England across districts of Suffolk. Waveney had reported higher rates in 2012/13 but they fell considerably back towards the Suffolk average in 2013/14. This single year spike most likely indicates either random variation or a coding issue for the year 2013/14. 65

66 Stakeholder perspective Commissioning landscape From April 2013, as a result of the Health and Social Care Act 2012, the pooled Treatment Budget (which was ring-fenced for drug treatment and administered by DAAT s in Local Authority) went into the Public Health ring-fenced grant and could be used for drug or alcohol treatment. The Public Health Directorate at Suffolk County Council assumed lead responsibility for the commissioning of specialist alcohol services as part of its public health role, with the Health and Wellbeing Board (HWB) playing a strategic coordinating role. In Suffolk there are three clinical commissioning groups (CCGs) the Ipswich and East CCG, West Suffolk CCG, and Health East (Great Yarmouth and Waveney CCG), which also includes part of Norfolk. These are the NHS commissioning bodies for Suffolk, with responsibility for the design of local health services including acute hospital services, mental health services, ambulance services, continuing care and arranging emergency and urgent care services. The CCGs do not hold budgets for commissioning local specialist alcohol services, although GPs and other organisations will often have a role in alcohol misuse interventions. CCGs are responsible for overlapping issues principally acute hospital care and mental health and may assume some wider responsibilities for alcohol misuse commissioning as their roles develop. Prison health services (including alcohol treatment) are the responsibility of the offender health team at NHS England. Alcohol Treatment Services in Suffolk Needs Assessment (2013) proposed the formation of an alcohol healthcare partnership comprising the local authority, CCGs, and healthcare provider partners, the police and crime commissioner and Suffolk Constabulary. The group was set up to be responsible for sharing information between partner organisations, exploration of ways of joint commissioning and further integration of the various services currently provided in Suffolk. During this project we were unable to meet with the Local Alcohol Partnership Board because it was not meeting until another chair could be appointed. Table 18, derived from the NHS England guidance Commissioning fact sheet for clinical commissioning groups (July 2012), shows the respective organisations and their commissioning responsibilities with respect to the care for alcohol misuse disorders. 66

67 Table 18: Alcohol treatment commissioning responsibilities for various organisations Public Health Directorate Alcohol misuse services Prevention and treatment Clinical commissioning groups in Suffolk Alcohol health workers in a variety of healthcare settings Acute hospital admissions East Anglia Area Team, NHS England Brief interventions in primary care Source: NHS England commissioning fact sheet July 2012, extracted from (2013) In April 2015 a social enterprise, Turning Point, won a tender to lead delivery of drug and alcohol treatment services in Suffolk. There is also one small service delivered by NORCAS (Phoenix Futures), funded via a three-year National Lottery grant, aimed specifically at supporting over 65s. Other organisations also have roles in the delivery of related services, including two hospital-based Alcohol Liaison nurses, Adult Social Care, a Marginalised Vulnerable Adults project (MVA), Anglia Care Trust (Street Drinkers Service), Focus12 and East Cost Recovery (Residential provision for drug and alcohol treatment) as well as ICENI (who focus on family interventions). Further organisations who work with many of the same clients include Parents under Pressure (NSPCC), The Chapman Centre (IHAG), The Bridge Project and Dual Diagnosis Service (Access Community Trust). Organisations in the statutory health and social care and third sector having a role in delivering services relating to alcohol in Suffolk comprise: GPs and other primary care providers: Brief Interventions, AUDIT Screen Front-line staff: (adult social care, housing, community nurses) Brief interventions Public Health: Social Marketing Adult social care The Adult social care (ASC) commissioning model in Suffolk, was described by a ASC stakeholder as taking a customers needs and customer groups based approach. This was explained to mean that there is no specific dedicated lead for clients with a particular need. For example there is no specific dedicated lead for older people s services. This feature is a key element of the delivery model within the portfolio of work commissioned from Suffolk Family Carers and Age UK. The model is delivered via the ASC programme called Supporting Lives, Connecting 67

68 Communities (SLCC). The SLCC programme provides a three-tiered approach for older people s services across Suffolk. The approach is as follows: Tier 1: information, advice and advocacy, support to live independently at home for longer Tier 2: links into the community to support people to regain their independence offering immediate, or short-term assistance Tier 3: on-going support for older people in need of maintenance, such as homecare, residential, care homes Adult Social Care teams or primary care refer older people to Age UK, which provides the only Tier 1 support specifically for older people. In principle, if alcohol is identified as being problematic, services are theoretically engaged to wrap around (i.e. meet all of) the needs of that older person. The county council commissions Age UK to identify vulnerable older people and works collectively (Suffolk County Council & Age UK) to pool resources. This Age UK advice service is the main social care service commissioned specifically for older people s services in Suffolk. However, stakeholder interviews revealed no evidence that those clients with alcohol-related needs have been identified via the Tier 1 Age UK service. Age UK Suffolk advisors took part in a front-line staff attitude questionnaire as part of this study. However, front-line staff of the carer arm of Age UK Suffolk were not permitted to take part by Age UK management. Most advisors reported that that they had suspected alcohol misuse to be a contributory factor for one or more clients but less than half had talked to the client about it. None of the advisors had had identification and brief advice (IBA) training but all said they would take it up if offered. The advisors were generally ambivalent about working with drinkers, but when asked how the partnership could improve services in Suffolk they were strongly in favour of IBA training and being given a clear message to give out about the dangers of alcohol. They wanted to see better joined-up working across organisations and they perceived the need for more visible social marketing. The previous adult care service model focused on specialisms (e.g. such as dementia falls and trips). The new services appear to be reconfigured in a more generic way to respond and provide a gateway service to specific providers addressing the needs of users across Suffolk. For this to work effectively for older people with alcohol-related needs, two criteria must be fulfilled. Firstly, the Tier 1 service frontline staff must ask about alcohol, identify and refer. Secondly, there must be acceptable alcohol services to refer to, with capacity, skills and treatment 68

69 pathways appropriate to older people. Neither of these two criteria appears to be appropriately fulfilled in Suffolk. Alcohol treatment services (Turning Point) Turning Point is a large nationwide provider of substance misuse, mental health and primary care services with over 4000 staff across the country. In April 2015, many of the staff of six Suffolk substance misuse treatment delivery organisations transferred to the new service managed by Turning Point. These organisations services comprised services for adults and young people, including criminal justice focused services, and including both drugs and alcohol. Turning Point sub-contracts with ICENI, Suffolk Family Carers and AIR Sports. The Turning Point stakeholder interviewee described the service as still bedding down with an expectation that this settling in period will take a total of between 12 and 18 months in all. Referrals to Turning Point occur both through self-referral and from health and social care professionals. Turning Point offers the generic referral national pathway using Tier 1, 2 and 3 services (Figure 30). There are local differences: for example, there is no community detox nurse in Suffolk. It employs a mixed caseload model whereby professionals do not formally specialise in one particular kind of addiction but service users with different substance misuse problems are placed together in the same therapeutic groups. This is a change from part of the previous system where there was specialisation in staff and separation of alcohol and other substance misuse therapeutic groups (except in Waveney). However, counsellors and keyworkers tend informally to specialise by taking on caseloads related to their interest and expertise. The Turning Point senior team are watching the development of this mode of working and considering whether this should be formalised to improve the quality of service. Turning Point has premises in Lowestoft, Ipswich and Bury and also offers satellite services and an online presence via Breaking Free Online a self-help programme. There is also a community detoxification service, though few people appeared to be aware of this. Turning Point offers open access support for a limited number of hazardous/harmful drinkers compared with the number who may potentially benefit from support. Currently it offers limited options for Tier 3 clients who do not wish to attend joint group therapy that may include non-alcohol substance users. The Turning Point model focuses primarily on group work as a means of building recovery capital and peer support although individual support is available. There is no formal referral pathway to the NORCAS over 65s service. However, it was reported that here have been discussions about instituting them. 69

70 Turning Point services were reported as being less well integrated than previous alcohol services with the rest of health and social care. This is likely due in part to recently winning the contract, changing the model and taking over staff from other organisations. It was also reported that Alcohol pathways are still in development including the community detox pathways/work with GPs/access to inpatient provision. Outreach does exist in the form of the Young People elements (which are mostly undertaken via outreach). There is no outreach service specifically focused on people over 50. The engagement team within Turning Point is trying to get people to come into treatment services where they can benefit more from a range of provision. Other Turning Point services (in London) have developed an easy access service for people who may not access traditional substance misuse services, perhaps because they cannot attend during work hours or because of stigma. The clinic offers advice for people who may wish to cut down on their drinking or stop altogether and is known as the Resolution Clinic. Use of a similar service model is planned for Suffolk and could increase the ability of Suffolk to meet the needs of people who do not identify as alcoholic or problem drinkers to access support in a non-stigmatised environment to cut down their alcohol consumption. 70

71 AFTERCARE DETOX PROCESS ASSESSMENTS & PREPARATION REFERRAL Figure 30: Turning Point Pathways Diagram Alcohol Overall Pathway with reference to other related alcohol guidance pathways External Referral from GP or other service Drop In/Self-Referral or sent by other service Offer appt Phone call to invite to drop in or to offer appt. Send letter if no answer. Open EPR / CIM Drop in assessment 1. Goals/motivation and prioritisation 2. Risks 3. Brief interventions and signpost 4. Document on EPR / CIM Assessment appt Triage AUDIT & SADQ included in Triage and Assessment Exit if treatment declined (offer drop-in) Low scores (AUDIT < 20) or high scores but declines detox H ighscores (AUDIT 20)a d desires to detox See TP Alcohol Pathway - Tier 2 Level of intervention relates to AUDIT score (AUDIT categories < 8, 8-15, 16-20) See TP Alcohol Pathway to services Tiers 2 & 3 See TP Alcohol Pathway - Tier 3 Comprehensive assessment, care plan, risk mgt plan etc MOPSI groups, 1 to 1 work, drink diary, prep for detox assess readiness to change If wants detox and ready, refer to Community Detox Nurse (see Guidance for keyworkers about clients with alcohol problems ) Medical assessment by GP, detox centre or TP doctor Community alcohol detox (see The community alcohol detox process - guida ceforprescriber s ) Residential detox (see TP alcohol pathway Tier 4 pathway ) Community rehab post detox (see TP alcohol pathway aftercare ) Residential rehab post detox via CCA panel Close if DNA Referral to community based services e.g. Mutual aid groups (SMART, AA, NA), employment, exercise, other activities Source: Turning Point Suffolk The details of the Tier 2 and 3 pathways are shown in Appendix 3. Commissioners identified that Turning Point also administers the Tier 4 referral process for Suffolk, which facilitates inpatient detoxification and residential rehabilitation of eligible people with severe alcohol misuse each year into specialised units located throughout the country. 71

72 Over 65s service (NORCAS) This Big Lottery Funded niche service, NORCAS (Phoenix Futures), launched in March 2015, (although the alcohol treatment service for all clients, including the over 65 s sits within the integrated contract provided by Turning Point). The NORCAS service provides specialist support including brief intervention, one to one work, advice and information, and alcohol harm reduction to isolated and vulnerable hazardous and harmful older drinkers. The service offers to meet people in a public location or their home if they are unable to get out. It aims to work alongside relevant organisations to raise the awareness of alcohol and drug misuse in this age group and to help front-line workers identify the indicators. NORCAS over 65+ service is not widely known about by potential sources of referral and co-providers in Suffolk. Since April 2015, there have only been small numbers of clients in the service and few referrals from Turning Point, The NORCAS 65+ service works with clients from 65 to 70+ but has not had many clients in their 80 s. There have been some referrals from housing, older people s accommodation worker, Turning Point, Social Services and alcohol liaison nurses from Ipswich Hospital. The service is keen to work more closely with Turning Point in the future. The NORCAS service currently has six active clients. The NORCAS 65+ service signposts its clients to resources from elsewhere Drinkaware (e.g the use of alcohol cups) as well as deploying other resources from alcohol concern, getselfhelp.com, psychologytools.com, NHS choices, MoodJuice.com, and bemindfulness.com. The service also participates in Golden Age Fairs and collaborates with the Rural Coffee Caravan. Acute hospital services In Suffolk, there are two consultants of Hepatogastroenterology and two liver specialist nurses who deliver acute and follow up services for people with alcoholrelated liver disease, most of whom are under the age of 50. They provide treatment for acute liver disease including the consequences of alcohol poisoning and long term extreme drinking. Alcohol detoxification is undertaken when required as part of acute treatment. Patients are discharged with clinic follow-up, including up to six weeks of support from a specialist liver nurse. The group of patients were reported not wishing to be referred to Turning Point service because they did not wish to identify as substance misusers and experienced the idea of mixed substance support groups as stigmatising. In contrast to the past, stakeholders report that there is no meaningful, smooth referral system between acute care and alcohol misuse services in Suffolk. 72

73 Norfolk and Suffolk Foundation Trust Community based Mental Health Services Norfolk and Suffolk NHS Foundation Trust (NSFT) provide mental health and learning disability services across Suffolk. They aim to support and enable people with mental health problems, or who need to improve their wellbeing, to live a fulfilling life and make their personal recovery journey. NSFT s integrated delivery team provides assessment and a care programme for clients, including a wellbeing service, early intervention for psychosis and improving access to psychological therapies (IAPT). In the past, alcohol misuse services and mental health services were co-located and (according to some stakeholders) highly integrated, permitting diagnosis and management of dual diagnosis (mental ill-health and substance misuse). Currently the services are located apart and it was reported do not confer to the same extent over cases. Effective diagnosis and co-management of dual diagnosis in Suffolk was reported to have ceased by some stakeholders. This may be particularly relevant to the over 50s who are more likely to have comorbidity (Schulte & Holland, 2008). Commissioners are seeking tenders to provide community mental health services in Suffolk at the time of writing of this report. Relevant health and social care programmes in Suffolk There are a number of programmes in Suffolk, which are relevant to alcohol misuse because they support health and wellbeing. We examine to what degree they may formally acknowledge their role in identification, brief advice, support and referral of clients who may have alcohol misuse needs. We consider the scope for leveraging existing infrastructure and brand to improve the access, experience and outcomes of over 50s alcohol misusers. Supporting Lives Connecting Communities (Spencer, 2014) Supporting Lives Connecting Communities (SLCC) is the approach to adult care currently employed in Suffolk. Making Every Contact Count Making Every Contact Count (MECC) is an approach to improving health and reducing health inequalities developed by the NHS and local government. Every contact with a customer should be seen as an opportunity to encourage healthier lifestyle choices. MECC is a system for making the best of every appropriate opportunity to: raise the issue of healthy lifestyle 73

74 systematically promote the benefits of healthy living ask individuals about their lifestyle and changes they may wish to make respond appropriately to lifestyle issues once raised take the appropriate action to either give information, signpost or refer service users to the support they need From 2012, alcohol screening was included as part of the MECC initiative. MECC was piloted within Suffolk region to encourage and help individuals make healthier lifestyle choices to achieve positive long-term behaviour. Both Ipswich Hospital and West Suffolk Hospital were signed up to a Commissioning for Quality and Innovation (CQUIN) payment for alcohol with the PCT and used this as a commissioning lever to embed practice. Live Well Suffolk, the current Healthy Lifestyles service provider delivers MECC training. Table 19 shows number of referrals to Live Well, the Suffolk wellbeing service (see below) and also how people who referred themselves heard about Live Well. From the table below, the data from July 2014 to October 2015) is most accurate as 2012/13 had CQUINs in place for trusts for smoking cessation and MECC training. Table 19: Number of MECC referrals and staff trained 01/04/14 26/11/2015, Suffolk 2012/ / / Referrals Staff Referrals Staff Referrals Staff Staff Referrals July-Mar Health Staff 377* Others 169* Selfreferrals (How heard about Live Well Suffolk LWS) Selfreferrals (How

75 heard about LWS via health profession al) Ipswich Hospital Trust) SCH/SER CO etc.* Inc midwifery 1008 (Incl WSH) NSFT Primary Care West 537 Inc Suffolk 1356 midwifery Hospital 0 See IHT 0 Other HCPs Total Source: Suffolk CC MEEC team It can be seen that there are 542 trained staff in 2012/13, 375 in 2013/14, and 235 in 2014/15. Figures on referrals are not informative as there may be many referrals due to MECC which cannot be identified because the way in which the client arrived at the service is not asked as a matter of course in many NHS, social care and third sector services. Live Well does not offer specific alcohol services, although, in theory, alcohol needs would be flagged within the service and either IBA or referral offered. Live Well Suffolk (Suffolk County Council, 2015) Live Well is Suffolk s healthy lifestyle service. It provides information and practical support to help local people become healthier. It provides support for smoking cessation, weight loss, increased activity and improving diet. Its main office and drop-in centre is based in Ipswich and it provides outreach via local Community Health Coaches based in Bury St Edmunds, Felixstowe, Haverhill, and Sudbury. Live Well is potentially well placed to provide low-key advice and support service around alcohol consumption reduction. This would fit in well with existing services and would particularly support older drinkers who would consider themselves, and would have been considered, from a health professional perspective to be in a category of ageing successfully (Bristow & Clare, 1992). 75

76 NHS Health Check NHS Health Check is a screening programme of cardiovascular health offered to all those aged in primary care. It includes the AUDIT Questionnaire, which assesses and determines levels of drinking leading to a score of 1-20 with a clear pathway describing actions Practices must take at different levels of risk (see p74 Heath Check). Audit scores of 20+ lead to referral and scores of lead only to brief advice (Barbor et al., 2002). Data on Health Check AUDIT questionnaire scores was not available for our report. In 2013/14, 42,575 NHS Health Checks were offered to Suffolk s year olds with 22,857 NHS Health Checks received, an uptake of 53.7% (Table 20 below). Table 20: NHS Health Checks in Suffolk 2013/14 Source: Suffolk Health Check team Offered Delivered Uptake (%) Quarter Quarter Quarter Quarter Total Target Difference The alcohol risk assessment, using the AUDIT questionnaire, is now part of the Health Check. Local authorities are mandated to ensure that everyone having an NHS Health Check has their alcohol consumption assessed. Potentially, health checks will provide a very clear local picture of the size of the problem in the over 50s. Unfortunately the report for Health Check in Suffolk for only looked at data from the claim forms that Practices complete on a monthly basis to be paid. This was very limited and included no data on alcohol. The next report will look at all aspects of the health check including alcohol. Outreach providers have been asked for their results on alcohol, however these were not returned in time for inclusion in this evaluation. 76

77 Figure 31: NHS Health check alcohol care pathway Source: Suffolk Health Check Team The Reducing the Strength scheme This is a partnership with local businesses set up by the Suffolk Constabulary in and around Ipswich where store owners agree not to stock high strength beers, ciders and other alcoholic drinks. The initiative has been heralded as highly successful with 100/140 retailers signing up and a 43% reduction in street crime committed by street drinkers in a year (Everitt, 2014). Participants in the service users focus group were less positive about the scheme suggesting that heavy drinkers know where to buy the strong alcohol and that many outlets are ignoring the scheme. Mutual aid Mutual aid is an important resource among over 50s for those who identify as alcoholics. Alcohol mutual aid programmes are a feature of both commissioned services and also are a key feature of Alcoholics Anonymous which is active in Suffolk. Alcoholics Anonymous is an international mutual aid fellowship founded in AA s stated "primary purpose" is to help alcoholics "stay sober and help other alcoholics achieve sobriety based on AA's Twelve Step programme of spiritual and character development. AA's initial Twelve Traditions were introduced in 1946 to help the fellowship be stable and unified while disengaged from "outside issues" and influences. Alcoholics Anonymous operates in Suffolk and is an important resource offering community and mutual help for those who identify as alcoholic. This group, however, represents a small proportion of harmful drinkers, who most frequently do not identify 77

78 as alcoholic even when they wish to cut down. Twelve step programmes are also used within the context of statutory and non-statutory services. Rural Coffee Caravan The Rural Coffee Caravan grew out of a farmers crisis helpline to provide a social hub in rural communities. It consists of two vehicles, which set up on village greens providing coffee, leaflets, low-key advice and a friendly face. There are currently two staff and 25 volunteers visiting 125 villages, each village having a further volunteer. 60% of attendees are over 60 years of age. The coordinator was interviewed about alcohol in the over 50s. He felt that this group has never been better informed about alcohol. The caravan carries Drinkaware material such as units calculators and also material about the NORCAS service for older people and information about Alcoholics Anonymous. The coordinator reported that a lot of people pick up the unit calculator wheels and from time to time someone will enquire further, for example, on behalf of a neighbour about whom they are worried. RCC expressed an interest in providing volunteers to train to offer an identification and brief advice service. Suffolk Mind Suffolk Mind is the local affiliate of the national mental health charity, Mind. It s organisational mission is to improve mental health for everyone. Suffolk Mind does not have a policy about alcohol in the over 50s nor specific services for them. There is no formal framework for dealing with alcohol misuse at Suffolk Mind and Suffolk Mind does not work closely with treatment services. Age UK Suffolk Age UK Suffolk is the local affiliate of the National Charity, Age UK, serving the needs of, and providing advocacy for, older people in UK. In Suffolk, Age UK receives County Council funding to deliver information and advice services to older people as part of the Adult Social Care s core offer with a focus on diversion and preventing crises. There is nothing specific being commissioned by the County Council through Age UK that is focused on alcohol and older people, although Age UK has a current campaign targeting loneliness in older people in Suffolk. We sought Age UK Suffolk s perspective on Suffolk s over 50s alcohol misuse landscape. They saw a number of key issues for Suffolk: Advisors have experience of alcohol related harm in older more affluent drinkers and they believed that drinking problems exist across all 78

79 demographics and are not tied to deprivation. They believe there is a significant problem in the ubiquity of positive marketing images in the streets and in the media and that front-line staff are not asking difficult questions about the alcohol consumption of their clients. There is often a common theme in Suffolk in older people, recently retired, suffering loss of status or of a partner, bored and socially isolated who are at particular risk of increasing alcohol consumption to levels that are damaging. They noted that currently there is no way of knowing if falls referred to the fall service are related to alcohol. Age UK Suffolk reported examples of older men asking their home care team to bring them whisky as part of their shopping list and that this remains a thorny ethical issue. They believe that people don t know the facts and need more information and that the correct clear messages across Suffolk have not yet been found and that one of the key issues that needs tackling is social isolation. The one stop shop model does not work, people with alcohol problems do not see themselves as having the same problems as drug users. They believe that stigma is a key factor in users being grouped together and that there are Huge gaps for older people trying to access the relevant services they need (they won t attend drug services) - clients don t see their needs as being the same. Clients are falling through the gap whilst the new integrated drug & alcohol in Suffolk services beds in. Ipswich Night Shelter (IWNS) The vision for IWNS is to provide an overnight shelter for residents of the Ipswich locality, during the three coldest months of the year, hosted each night by one of seven town centre churches (one for each night of the week), which will take in twelve people who would otherwise have to sleep rough. The Shelter works alongside agencies already working in the town to encourage the guests to receive help and advice to restore their lives, find long-term accommodation, regain self-esteem and dignity, and return to society as an equal. The Shelter is not an on call hostel but part of a programme of restoration to bring structure back into chaotic lives, assisted by the Night Shelter Befriending Project. IWNS is not specifically aimed at the over 50s but potentially provides support to over 50s with severe alcohol misuse problems in the area of Ipswich. 79

80 Suffolk Family Carers (SFC) Suffolk Family Carers is a registered charity providing services and advocacy to 14,239 family carers in association with health and social care providers. The organisation aims to minimise the hardships, difficulties and other challenges family carers face, to raise awareness of family carers and ensure their voices are heard throughout Suffolk. In response to increased demand, SFC has developed new preventative services in partnership with Suffolk County Council, the NHS and the Big Lottery. SFC is also working strategically with the Triangle of Care in Suffolk, which joined Norfolk and Suffolk Foundation Trust and The Carers Trust to provide collaborative and relevant support and respite for Family Carers. They have also begun to deliver monthly drop-in sessions for family carers of hospital inpatients. SFC offer an alcohol service, subcontracted from Turning Point, which supports families and carers affected by drugs and alcohol. However, this is not specifically targeted at people over 50. The service forms part of the Suffolk Recovery Network (Turning Point). Fourteen of SFC s front-line staff participated in the Frontline Staff Alcohol Attitude Questionnaire (FSAAQ) designed for this needs assessment. The SFC stakeholder interviewees identified that there has been very little research to describe the impact of alcohol misuse in the relationship between a sick person and their carer. They also noted that there is currently no formal assessment of alcohol misuse in carers themselves (of any age). Ten of the fourteen staff who participated in the FSAAQ indicated they had suspected alcohol misuse among their clients, none had received or been offered intervention and brief advice training, but 13 out of the 14 said they would take it up if offered. Staff members were not confident about asking about alcohol and were in favour of more IBA training for front-line staff as well as support groups for people wanting to reduce consumption. Drinkaware Drinkaware is a national charity that is funded by the drinks industry. It provides resources to raise awareness about the risks associated with alcohol consumption. Drinkaware is limited in its constitution to the provision of information and does not act in the realm of policy or advocacy. Drinkaware resources are thought to be helpful and are being used in Suffolk, along with many others (including alcohol concern, getselfhelp.com, psychologytools.com, NHS choices, MoodJuice.com, bemindfulness.com) among the various alcohol services in Suffolk in both statutory and non-statutory settings. 80

81 Drinkaware has collaborated with the authors of this study to provide Suffolk data on the use of some of its online tools and its app. This information has been reported in the epidemiological section of this needs assessment (Drinkaware App). Focus 12 Focus 12 is an independent charity based in Suffolk. It was established in It provides residential and day-care drug and alcohol rehabilitation offering a range of services from individual therapy through to an intensive treatment programme of up to 12 weeks that includes detoxification from alcohol, opiates, benzodiazepines, cannabis and all other drugs. Focus 12 have clients from 18 to 83 years, approximately one third of clients are funded by Local Authorities (across the whole of the UK). Focus 12 perspective Older people tend to experience more problems than younger clients, for example: high blood pressure, malnourishment, and significantly more social isolation. Once in therapy, older clients tend to self-separate, however with good group facilitation this can be minimised. Focus 12 see group work as at the heart of recovery; you can hide in a 1:1 session and described the nature of problem drinking has having a societal, health and social dimension. Considering a pragmatic definition of when drinking becomes problematic, the Focus 12 respondent identified if the person is no longer feeling ok, if they feel their drinking is affecting them and if they have symptoms such as indigestion, if they have sleep disturbance when they drink, if alcohol is affecting their enjoyment of life and added, Most people know if there is something up The respondent s view on treatment in Suffolk was that for the extreme end of the alcohol harm spectrum there is a treatment service available but it is narrow in its scope. They felt that many who drink too much simply want to (and need to) recalibrate and noted that there is currently no harm reduction service available to this group in Suffolk. Although Suffolk does have harm reduction services in the form of Identification and brief advice and a drop in service from Turning Point among others, it is clear that there is no coherent, scaled service in harm reduction accessible to those who wish to cut down but who do not identify as alcoholics. Public perspective We undertook two small focus groups, one of rural Suffolk residents and one of treatment service clients. The first was attended by over 50s recruited with the help from the Rural Coffee Caravan, in the village of South Elmham. Turning Point service users aged over 50 years attended the second focus group. It took place at Turning Point premises. It is important to note that these focus groups were small 81

82 and therefore not necessarily representative of the social groups from which they came and their opinion must therefore not be relied upon to a great degree, nevertheless their views can equally not be discounted. Focus Group: Rural coffee caravan: older people from a rural setting With the help of the Rural Coffee Caravan we held a focus group in the village hall in South Elmham. There were four participants, all over 50. There was a mixed response from the respondents regarding the question of whether alcohol is a problem for older people in Suffolk. Participants identified alcohol is a problem for some older people, but felt that a lot of older people cannot afford to consume large amounts of alcohol. They felt, rather in contradiction to the issue of expense, that there may be a problem for older people in high unemployment areas such as Lowestoft. Participants thought there may be secret hidden drinkers. They also thought the problem affects big towns in Suffolk with many pubs rather than smaller village communities. Participants were confident that there were no secret drinkers in South Elmham village since it such a close-knit community; if someone drank they would all know. Participants explained that limited transport links in rural areas limits amount people drink because of the need to drive to a pub. None of the participants had personal experience of hidden alcohol harm in their social networks. In summary, participants appeared to come from a relatively affluent demographic and were confident that there is no particular problem in their community. This may be the case or may underline the assertion of the Iparraguirre study (Iparraguirre, 2015) that there is complacency about alcohol in affluent communities who are unaware that their drinking levels are associated with health risk. The fact that participants felt that they were familiar with the health promotion messages around alcohol and that no one in the village drank too much alcohol, in the context of the modelled estimates which suggest that irrespective of social class 20% of the Suffolk Population binge drinks (see Figure 18: The distribution of the modelled estimates of binge drinker at MSOA level, for persons, Suffolk, 2011) may suggest that the message is not being correctly understood and that a new clear message is required for the over 50s. Focus group: Turning Point clients We undertook a focus group of service users over 50, at Turning Point premises. Service Users were offered a 20 Boots token as an incentive to participate. Four service users took part. We asked several questions relating to alcohol in the over 50s in Suffolk. 82

83 Participants felt that alcohol is big problem for people in Suffolk. Participants reported that alcohol is cheap and readily available, 24 hours a day people can get cheap alcohol in Suffolk and that misuse often occurs with unemployment in older people who believe they have no hope of getting new work. Participants perceived treatment to be ineffective. I have been in alcohol treatment since 2006, rehab has not worked. They suggested this was because treatment did not address the unemployment, hopelessness, boredom and mental illness which they suggested were the underlying causes. Participants felt that rural people drank less because of the inaccessibility of pubs. They also felt they had less access to services. Participants indicated that drug users who are unable to get their drug of choice often fall back on alcohol as a substitute and there was considerable cross addiction. There was lack of faith in the effectiveness of alcohol service rehab. There was also disillusionment with the Street Drinking Campaign Reducing the strength championed by Ipswich, which was felt to be ineffective. Participants also offered insight into the reasons why they lacked confidence in the effectiveness of services. Participants indicated that boredom and social isolation lead to drinking and that alcohol is a way of life. If someone takes alcohol away, I have nothing to substitute it with. Participants said, regarding the Reducing the strength scheme that Everyone knows where to buy strong drink and that off-licences did not adhere to licensing regulation around street drinking. They also believed that shops in Ipswich town centre still sell high-strength lager and cider although the ban is in place, openly flouting the scheme. Participants felt that the focus of alcohol services was on drugs and that some GPs do not take clients seriously and some do not know where to refer alcohol misusers. Frontline Staff Alcohol Attitude Questionnaire We sought the support of the senior management teams of the key Suffolk organisations both in the public and private sector to disseminate an online questionnaire to front-line staff examining their experience of and attitudes and behaviours towards clients and possible alcohol misuse. The questionnaire was designed to establish front-line staff s attitudes and behaviours relating to working with clients over 50, who may have problems relating to alcohol use. We built upon a validated Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ) employed in the Alcohol Screening and Brief Intervention Trailblazer A & E study (professional attitudes and behaviour) (Lock et al., 2009). We tailored this questionnaire for application to a wider audience and added questions relating specifically to Suffolk. 83

84 With the support of Suffolk County Council, we approached statutory, non-statutory and independent sector organisations to participate. Ninety-two front-line staff from eight organisations including Norfolk and Suffolk Foundation Trust, Suffolk Wellbeing, Suffolk Mind, Primary Care, Age UK Suffolk and Adult Community Services participated. There were 21 respondent from NHS, 44 from social care/council and 27 from third sector organisations. The majority of front-line staff were female (86% female v 14% male) and the vast majority identified ethnically as white. Sixty-seven % of respondents had worked in their service between two and 10 years and 89% of respondents spent between 50% and 100% of their time with clients. 66% of respondents interacted with more than 10 clients per week, suggesting that these respondents are well placed to represent the views of frontline staff. Over 90% of respondents had, in the past, suspected alcohol to be a contributory factor to a client s problem, 18% said this happened often, 60% sometimes and 13% rarely. NHS staff suspected alcohol to be a contributory factor often more frequently (38%) than social care/council staff (12%) and third sector staff (4%). This may reflect a greater prevalence of alcohol problems contribution to health-related interactions in the NHS or less confidence among social care/council staff and third sector respondents. Approximately 17% of front-line staff had never talked to a client about their alcohol use. Deeper interrogation of the data shows that most of the staff who had not talked to a client about alcohol were employed in the third sector and none were in the NHS. 22% of staff had been offered training and taken it up. All found the training informative but NHS respondents were more likely to use the training many times. This could be because problem drinking may be more likely to occur in those consulting the NHS or it may be that the culture of the NHS is more open to considering and asking about alcohol intake. 82% of social care/council staff and 89% of third sector staff had never been offered training, whilst in both groups under 5% of those who had been offered it had declined to take it up. 91% of untrained respondents said they would take up IBA training if offered. Although 80% NHS of staff said they would take up training, many said they had already had training or felt that the skills that they had were transferable. 84

85 Staff were asked a validated set of questions (Lock et al., 2009) regarding their knowledge, attitudes and behaviour. NHS staff expressed more confidence in their knowledge, they were more positive about working with alcohol issues and were more confident of having a positive impact. While social care/council staff, were less positive than NHS Staff about working with alcohol and were less confident that they would have a positive impact (see Figure 32). Figure 32: Distribution of responses (strongly agree far left to strongly disagree far right) Source: FSAAQ questionnaire responses as part of this study We asked respondents how the County Council and its public sector partners working across health and adult social care could engage more effectively with people over 50 to promote better awareness regarding alcohol related harm. They were offered a number of options across the spectrum of public health activities of health prevention and protection. The most popular responses mirror the findings of the other parts of this needs assessment. Respondents most frequently selected support groups for people wanting to cut down, better training for frontline staff to 85