An opportunity to make a difference INITIAL BRIEF ADVICE National Alcohol CQUIN

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1 An opportunity to make a difference INITIAL BRIEF ADVICE National Alcohol CQUIN Adrian Brown Alcohol Nurse Specialist Northwick Park Hospital ade.brown@nhs.net

2 About me Worked on Paddington Alcohol Test at St Mary s 1998 to 2010 employed by local addictions services Developed alcohol care team at St George s Local CQUIN for alcohol screening and referral 2010 to 2014 employed by acute hospital trust Now at Northwick Park Hospital Involved in dual diagnosis working group developing SUFARI for mental health services. Adopted for CQUIN 2014 to? Employed by liaison psychiatry

3 Abstract The Alcohol CQUIN is part of Preventing ill health caused by risky behaviours alongside smoking. The CQUIN applies to in-patient health services (community and mental health, general hospitals next year). Evidence for alcohol brief interventions and advice for hazardous and increasing risk drinkers. Brief interventions for alcohol users in the context of national CQUIN and the principle of Making Every Contact Count. MECC applies to all health and social care settings. A simple structure for the screening as part of nursing and medical assessment or other roles. Screening can become part of identifying all alcohol risks, including withdrawals.

4 Commissioning for Quality and Innovation (CQUIN) Payments that encourage continuous improvement in care, and sharing of good practice. There are two indicators for alcohol Alcohol screening for all admissions Alcohol brief advice & referral This CQUIN will aim to deliver objectives set out in the Five Year Forward View (5YFV), particularly the radical upgrade in prevention and incentivising and supporting healthier behaviour.

5 Preventing ill health caused by risky behaviours - alcohol and tobacco

6 Preventing ill health caused by risky behaviours CQUIN MILESTONES Training for appropriate (all?) staff in Q1 2 day physical health training implemented How will IBA be recorded and monitored? SHINE is our trust s physical health assessment SUFARI is our new alcohol and drugs tool Baseline findings Providers will be expected to audit alcohol screening, and interventions delivered, for newly admitted patients All electronic records (or a proportion of manual notes) and submit quarterly data to CCGs.

7 Smoking cessation Indicator name Description of indicator Indicator name Description of indicator Indicator name Description of indicator Indicator 9a Tobacco screening Percentage of unique adult patients who are screened for smoking status AND whose results are recorded. Indicator 9b Tobacco brief advice Percentage of unique patients who smoke AND are given very brief advice Indicator 9c Tobacco referral and medication offer Percentage of unique patients who are smokers AND are offered referral to stop smoking services AND offered stop smoking medication.

8 Alcohol (Brief) Interventions Indicator name Description of indicator Indicator name Description of indicator Indicator 9d Alcohol screening Percentage of unique adult patients who are screened for drinking risk levels AND whose results are recorded in local data systems Indicator 9e Alcohol brief advice or referral Percentage of unique patients who drink alcohol above lower-risk levels AND are given brief advice OR offered a specialist referral.

9 Making Every Contact Count MECC is about having the initial conversation and creating a positive experience. It is about you helping other people to know how they can improve their own health and well-being. Knowing key health facts about alcohol consumption, smoking cessation, physical exercise, healthy eating and mental health & wellbeing. Signposting people to the local resources and specialist services.

10 Screening in CNWL SUFARI = Substance Use Frequency, Amount & Risk Identification This is required on admission to any mental health service. (CQUIN does not require repeat screening, but best practice will be to review at key times.) Complies with AUDIT-C recommended by PHE & NICE for alcohol screening. Links with SHINE project for physical health of mental health service users. Includes up to date list of drugs of misuse, helps to prompt conversation by non-specialists.

11 Advice & Referral ADVICE Training needed on IBA model & alcohol awareness including local services. Included in one day MECC. E-learning (Alcohol Learning Centre & SMMGP). How to implement ongoing supervision? REFERRAL Information kept up to date about local services. Liaison workers / champions support service users. Simple way to record these interventions on electronic systems.

12 The St Mary s Model: The Paddington Alcohol Test & A Teachable Moment PAT is a shorter adaptation of AUDIT Consultant champion leadership: focused identification + all ED staff give simple (1-2 mins) Brief Advice. Alcohol Nurse Specialist stress reducer by providing clinical support. As well as extended (20-30 mins) Brief Intervention for patients possibly developing dependency; + follow up of BACs >80mgs% (Resusc.) based within the ED for ease of access for every two people referred to an ANS, one less ED visit at 1yr (Crawford M, Patton R, et al. Lancet 2004:364:1334-9)

13 The Paddington Alcohol Test & A Teachable Moment Findings In a busy Emergency Department, with the right leadership and good resources for extended interventions and referral / liaison with community services, staff become empowered to: Ask about alcohol Give structured brief advice Rate of attendance for IBA decreased steadily as the delay in appointment increased from 0 days (i.e. same day) to 5 days. This decrease visibly demonstrates a half-life -like effect. As the attendance rate dropped from 65% (same day) to 28% (day 2) So the half-life of the teachable moment is 2 days; hence same-day or next-day appointments are vital. Similar findings for referrals longer wait means less likely attendance. KEY MESSAGE Early identification AND brief advice, rather than referral to specialist

14 SIPS: Screening & Intervention Programme for Sensible Drinking The largest alcohol treatment research project conducted in the UK. Aimed to find the best method of helping people whose lives and health are affected by alcohol. Carried out by Kings College, with Universities of Newcastle, York, Imperial College and Alcohol Concern, we aim to be able to recommend to the government the most cost effective method of helping people who are drinking in a harmful way, in health and criminal justice settings." (Professor Colin Drummond. Oct 2006) Three trials in EDs, Primary Care and Criminal Justice. Screening with SASQ, FAST or modified PAT, then either: Feedback [screening result] + Patient Information Leaflet (PIL) Feedback + 5mins structured advice using SIPS brief advice tool + PIL Feedback + 20 minutes of Brief Lifestyle Counselling (BLC) + PIL

15 SIPS: Screening & Intervention Programme for Sensible Drinking In Primary care settings, FAST proved best at identifying risky drinkers. When it came to how to respond to these risky drinkers, anticipated extra benefits from the longer and more sophisticated theory-based interventions were not shown, even for heavier drinkers. Often interpreted as just a leaflet because outcomes were similar, but this is not proven. And unlikely. Probable variations in implementation, even when closely following feedback rules. findings.org.uk/php/dl.php?file=kaner_e_10.txt

16 Scotland experience with Alcohol Brief Interventions National Standard: NHS Scotland Boards to sustain and embed alcohol brief interventions in 3 priority settings (primary care, A&E, antenatal) and broaden delivery in wider settings. Current National Performance: In the year ending March 2017, NHS Scotland Boards carried out 86,560 interventions, exceeding the Standard of 61,081.

17 How to implement? Training for alcohol awareness Training and practice of interventions Target all people (all admissions, all clients) ie Universal screening AKA Early Identification Standard recording protocol (audit forms!) (optional) Ongoing review of levels of drinking to monitor outcomes.

18 MECC Plan for the Day Session Underpinning knowledge of MECC BREAK Session 2 Introduction to skills to help people change (Motivational Interviewing and brief interventions) LUNCH 1.15 Session 3 Lifestyle topics and signposting (Alcohol, Tobacco, Diet, Exercise, Well-being) 2.45 Break 3.00 Continue lifestyle topics and signposting 4.30 FINISH 18

19 Initial Brief Advice (IBA) aka Alcohol Brief Intervention

20 Range of alcohol treatment & interventions Severely Dependent Moderately Dependent HARMFUL HAZARDOUS

21 New SUFARI tool

22 New SUFARI tool HOW OFTEN? HOW MUCH?

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24 Summary of IBA Use of AUDIT-C (modified to extend scope for dependent drinking) Provide structured brief advice (requires training and supervision/follow up sessions) Refer if dependent or higher risk (local service info must be up to date) Record actions (on SUFARI) for electronic audit

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