Salford s Alcohol Strategy

Transcription

1 Salford s Alcohol Strategy

2 CONTENTS Page 1 Foreword 3 2 Introduction 4 3 Executive Summary 6 4 Alcohol-related harm 10 5 Policy drivers 14 6 Partnership arrangements 1 7 Strategic Objective 1: Ensure that those who drink alcohol in Salford are able to do so safely and responsibly 21 8 Strategic Objective 2: Reduce the impact of alcohol on ill health and life expectancy 27 Strategic Objective 3: Reduce alcohol-related crime and anti social behaviour Strategic Objective 4: Reduce the harm caused to children and young people by alcohol use Action Plans References 6 APPENDIX 1 Changes suggested in response to the consultation on Salford s Draft Alcohol Strategy 72 APPENDIX 2 Membership of partnership groups 81 APPENDIX 3 Alcohol Clinical Pathway 82 2

3 Salford s Alcohol Strategy Foreword (subject to Lead Member/PCT agreement) We are pleased to introduce Salford s Alcohol strategy which sets out how we plan to tackle alcohol misuse in the City over the next three years. Since the middle of the last century, levels of alcohol consumption have risen. Alcohol has become more affordable, more freely available and has been marketed more attractively. Our relationship with alcohol is a complex one. Alcohol is a widely used and socially acceptable drug, which plays a central role in many social activities. However alcohol is the third biggest contributor to ill health in developed countries and is also a major contributor to crime, disorder and anti-social behaviour. Children and young people are at particular risk of the negative effects of alcohol misuse, either through their own alcohol consumption, or through use of alcohol by those who care for and support them. We want to ensure that Salford residents understand the risks and consequences of alcohol misuse and that they know how to reduce these risks by drinking within the Government s recommended limits. We want to establish a culture of drinking where safe and sensible alcohol consumption is seen as part of a healthy lifestyle, but where people do not drink in order to get drunk. Changing drinking culture will require sustained effort from all partners across the City. This strategy aims to build on the partnership work that has already been undertaken to reduce alcohol-related harm, in order to establish a new culture of responsible drinking in the City. 3

4 2. Introduction Alcohol is a drug which is consumed by the majority of the population in England. Whilst many do so with few negative consequences, for an increasing number of people alcohol consumption results in poor health, social and family problems, and crime and anti-social behaviour. Alcohol misuse is a complex issue. Alcohol use, within the Department of Health s recommended limits, is unlikely to cause harm. However when these limits are exceeded significant problems can be caused, both to the drinker themselves and to those around them. In Salford approximately 60,000 adults drink in excess of the Government s daily recommended limits. In some cases this results in hospital admissions, family problems, committing or being a victim of crime, or even death. The context in which drinking takes place is also complex, and is changing. Over the last 20 years alcohol consumption has increased, with more women and children drinking, and more alcohol being purchased from off-licenses and supermarkets for consumption at home. Public opinion surveys suggest that the acceptability of drunkenness in English drinking culture is increasingly a cause for concern. However national surveys also show a lack of awareness of sensible drinking guidelines and the harm that drinking in excess of these limits can cause. This strategy focuses on carefully managing this complexity to ensure that those who do drink do so without causing harm to themselves or others, and that those who experience negative consequences receive appropriate support. As levels of hazardous and harmful alcohol consumption are higher in the North West region than any other in England (Department of Health 2005), developing and sustaining a concerted local effort to tackle alcohol issues is a priority. Aims and Objectives The aim of this strategy is to reduce the harm caused by alcohol, including harm associated with crime, health, the economy and family and social networks. Its objectives are: 1) To ensure that those who drink alcohol in Salford are able to do so safely and responsibly 2) To reduce the impact of alcohol on ill-health and life expectancy 3) To reduce alcohol-related crime and anti-social behaviour 4) To reduce the harm caused to children and young people by alcohol use 4

5 Notes on how this strategy has been compiled Four key strategic objectives have been identified which must be achieved if we are to achieve our aim of reducing alcohol-related harm. All of these strategic objectives are of an equal level of priority. For each of these objectives a number of sub-objectives, key actions and performance indicators have been identified through which we will monitor progress. Where the term young people has been used in this strategy this refers to those under the age of 18, unless otherwise stated. In order to develop the first draft a range of local agencies and partners were consulted including: Greater Manchester Police, Salford Primary Care Trust, Children s Services, Salford Royal Foundation Trust, Salford Probation, Salford Drug and Alcohol Services, SMART (Young People s Drug and Alcohol Service), Community, Health and Social Care, Environmental Services and Elected Members. During February 2008 the draft strategy was sent to a wide range of partners and members of the public for consultation. Over 250 people received a copy of the strategy, and face to face consultations were undertaken with young people and alcohol service users. The draft strategy was also available on the City Council and DAAT websites. 18 written consultation responses were received. Additional feedback was received through meetings and face to face consultations. A summary of these responses and an explanation of how they have been incorporated into the final version of the Strategy can be found in Appendix 1. 5

6 3. Executive Summary Alcohol is a drug which is consumed by the majority of the population in England. Whilst many do so with few negative consequences, for an increasing number of people alcohol consumption results in poor health, social and family problems, and crime and anti-social behaviour. Alcohol misuse is a complex issue. Alcohol use, within the Department of Health s recommended limits, is unlikely to cause harm. However when these limits are exceeded significant problems can be caused, both to the drinker themselves and to those around them. This strategy focuses on carefully managing this complexity to ensure that those who do drink do so without causing harm to themselves or others, and that those who experience negative consequences receive appropriate support. Alcohol-related harm Alcohol misuse can have a significant impact on communities, including crime, ill health and social and financial costs. In most areas the levels of these harms has increased as alcohol consumption has risen. Between 11 and 2005 the number of alcohol-related deaths in the UK more than doubled from 4,144 to 8,386 (ONS 2006). The rate of alcohol related hospital admissions had also increased by over 50% since the mid 10s. The rate of alcohol-related hospital admissions in Salford is now the 6 th highest in England and Wales. The contribution of alcohol to reduced life expectancy is also above both the national and regional average, contributing to months of life lost for males and 5.5 months of life lost for females. Alcohol misuse is a major contributor to crime, disorder and anti-social behaviour. The contribution of alcohol is particularly significant in incidents of violent crime, with approximately 1/5 of all violent incidents being committed in or around pubs and clubs. In approximately half of all violent incidents, victims believe offenders to be under the influence of alcohol at the time of the offence. This includes incidents of domestic abuse (DH/HO 2007). Alcohol consumption levels can be categorised as follows: Low risk drinking: Drinking within the Government s recommended limits. The Government advises that: Adult women should not regularly drink more than 2-3 units of alcohol a day Adult men should not regularly drink more than 3-4 units of alcohol a day Pregnant women, or women trying to conceive, should avoid drinking alcohol. If they do choose to drink, to protect the baby they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk. 6

7 Hazardous drinking: Drinking in excess of the Government s recommended limits, but not yet experiencing harm. Harmful drinking: Drinking in excess of the Government s recommended limits and experiencing harm, or causing harm to others. Women who regularly drink over 6 units a day (or over 35 units a week) and men who regularly drink over 8 units a day (or 50 units a week) are at highest risk of such alcohol-related harm. Dependent drinking: Drinking in excess of the Government s recommended limits and experiencing harm and symptoms of dependence. Binge drinking: Drinking a large amount of alcohol over a short period of time. In surveys, women drinking over 6 units a day and men drinking over 8 units are usually defined as binge drinking. However, in practice, many binge drinkers are drinking substantially more than this level. As levels of hazardous and harmful alcohol consumption, and binge drinking, are higher in the North West region than any other in England, developing and sustaining a concerted local effort to tackle alcohol issues is a priority. Aims and objectives The aim of this strategy is to reduce the harm caused by alcohol, including harm associated with crime, health, the economy and family and social networks. The strategy focuses on four strategic objectives, for which a range of actions and outcome measures have been identified. STRATEGIC OBJECTIVE 1: Ensure that those who drink alcohol in Salford are able to do so safely and responsibly In order to achieve this objective we will develop and deliver a sustained alcohol social marketing campaign for the City, which complements those being delivered across Greater Manchester and through the national Know your limits campaign. Alcohol screening and brief interventions have been shown to be effective in reducing alcohol consumption therefore we aim to ensure that these are provided in a range of agencies including Primary Care and in the Emergency Department. We will work with alcohol retailers to ensure that safe drinking environments are provided, by establishing neighbourhood based licensing fora and continuing to develop a responsible retailers scheme. In addition, we plan to lobby central government to improve regulation of alcohol pricing in off-licenses and supermarkets and address the way that alcohol is promoted and advertised, with particular regards to young people. STRATEGIC OBJECTIVE 2: Reduce the impact of alcohol on ill-health and life expectancy In order to achieve this objective we will expand and improve alcohol treatment provision. This will include developing provision through general 7

8 healthcare services and increasing capacity in specialist services. We will ensure that Service Users and Carers are involved in the development and delivery of these services. Alcohol misuse can have a negative impact on an individuals ability to sustain employment and maintain their housing. We will therefore ensure that appropriate housing, housing-related support and access to employment, education and training are available to those in, or leaving, alcohol treatment. STRATEGIC OBJECTIVE 3: Reduce alcohol-related crime and anti-social behaviour In order to achieve this objective we will further develop the criminal justice alcohol treatment pathway, and increase the capacity and capability of criminal justice agencies to provide alcohol interventions. Ensuring that appropriate intelligence is gathered and shared is also an area of importance. We plan to establish systems in the Emergency Department to collect data on the locations of alcohol related assaults so that this information can be shared with crime and disorder partners. We will also utilise new and existing powers to take action against licensed premises which contribute to crime, disorder and anti-social behaviour. STRATEGIC OBJECTIVE 4: Reduce the harm caused to children and young people by alcohol use In order to achieve this objective we will reduce supply of alcohol to young people by conducting regular test purchasing operations across the City, and taking action against adults who supply alcohol to young people. We will provide alcohol education to young people in schools and community settings and ensure that teachers and parents have the skills and knowledge to provide alcohol information to young people. We aim to provide attractive, affordable alternatives to drinking for young people, however for young people who do drink specialist support will be available. Harm can also be caused to young people as a result of alcohol use by other members of the family/carers. We will therefore ensure that those working with parents are able to recognise and address the impact of parental alcohol use, and that support is provided for families. Performance monitoring From April 2008 there will be 3 national indicators (NI) which specifically focus on alcohol. These are: NI 3 Alcohol-harm related hospital admission rates NI 41 Perceptions of drunk and rowdy behaviour as a problem NI 115 Substance misuse by young people In addition we will monitor progress in achieving our objectives through a range of performance measures including: the prevalence of hazardous, harmful and binge drinking; the proportion of incapacity benefit claims which 8

9 are linked to alcohol dependence; the number of offenders referred for alcohol treatment; and the rate of alcohol-specific hospital admissions for under 18s. Partnership arrangements Salford Drug and Alcohol Action Team is the partnership board responsible for reducing alcohol-related harm in the City. This partnership reports to the Local Strategic Partnership via the Crime and Disorder Reduction Partnership and the Healthy City Executive. A lead officer for alcohol is jointly funded by the PCT and the City Council. An Alcohol Reference Group was established in 2004 to provide a strategic lead on alcohol related issues in Salford. This group currently reports to the Drug and Alcohol Action Team. A review of the Crime and Disorder Reduction Partnership is currently underway, and the Audit Commission are also undertaking a review of Crime and Disorder Reduction Partnerships and alcohol. Proposals for the partnership arrangements to take forward this strategy will therefore be developed following the outcomes of these reviews.

10 4. Alcohol-related harm Alcohol-related harm in England Alcohol misuse can have a significant impact on communities, including crime, ill health and social and financial costs. In most areas the levels of these harms has increased as alcohol consumption has risen. Alcohol consumption Since the 160s there have been large increases in the amount of alcohol consumed in the UK. Whilst the amount of beer consumed has remained relatively stable, there has been a significant increase in wine and spirit consumption (Prime Minister s Strategy Unit 2003). Consumption levels have increased among men and women in all age groups, however the largest increases in consumption have been among year old women, whose alcohol consumption has almost doubled from 7.3 units per week in 12 to 12.1 units in 2002 (Office for National Statistics (ONS) 2004). Whilst the proportion of young people who drink alcohol has declined slightly, those who do drink are consuming more alcohol, more often. Between 10 and 2000 the average weekly consumption of year old drinkers doubled from 5 units to 10 units (Department of Health (DH)/Home Office (HO) 2007). Calculating Units Many people presume that one glass of wine, half a pint of beer or one shot of spirits equals one unit. However drink strengths have increased and the measures that drinks are served in have become bigger, therefore one drink often contains a lot more than one unit of alcohol. The exact number of units of alcohol in a drink can be calculated as follows: Number of units = Volume in millilitres 1000 X % Alcohol By Volume (ABV) This means that: 175ml glass of 13% wine = 2.3 units 250ml glass of 13% wine = 3.3 units 1 pint of 5% lager = 2.8 units 35ml shot of 40% spirits = 1.4 units The Department of Health recommends that men should not drink more than 3-4 units a day, and no more than 21 units per week. Women should not drink more than 2-3 units per day, and no more than 14 units per week. After heavy drinking alcohol should be avoided for 48 hours to give the body tissue time to recover. 10

11 Health Alcohol is linked to more than 60 types of disease, disability and injury, and is the third leading contributor to the disease burden in developed countries (Scottish Health Action on Alcohol Problems (SHAAP) 2007). Increases in consumption over the past half a century have resulted in corresponding increases in the health harms related to alcohol misuse. Between 15/6 and 2005/6 the number of hospital admissions of over 16 year olds, with a primary diagnosis related to alcohol, increased by just over 50%. For under 16 year olds admissions increased by 2% over the same period (ONS 2007). Alcohol-related illness and injury now accounts for approximately 180,000 admissions per year. In Emergency Departments approximately 70% of admissions at peak times (Friday and Saturday evenings) are related to alcohol (DH/HO 2007). Between 11 and 2005 the number of alcohol-related deaths in the UK more than doubled from 4,144 to 8,386 (ONS 2006). The largest increase was among year old males. Trends in liver cirrhosis mortality demonstrate the significant increase in alcohol-related deaths since 10. (Leon, D.A. and McCambridge, J. 2006) The annual number of deaths as a result of chronic conditions linked to alcohol is greater than the combined number of people who die from breast cancer, cervical cancer and MRSA each year (Alcohol Concern 2006). Crime, disorder and anti-social behaviour Alcohol misuse is a major contributor to crime, disorder and anti-social behaviour. The contribution of alcohol is particularly significant in incidents of violent crime, with approximately 1/5 of all violent incidents being committed in or around pubs and clubs. In approximately half of all violent incidents, victims believe offenders to be under the influence of alcohol at the time of the offence. This includes incidents of domestic abuse (DH/HO 2007). National surveys indicate that alcohol-related anti-social behaviour is of concern to the public with 25% believing that people being drunk or rowdy in public places is a significant problem (DH/HO 2007). 11

12 The economy Alcohol makes a significant positive contribution to the UK economy with over 1 million people being employed in hotels, pubs, bars, nightclubs and restaurants. In some areas the growth of the night-time economy has supported the redevelopment of town and city centres. However there are also significant costs to the economy, for example, loss of work productivity caused by alcohol-related harm costs approximately 20 billion per year in England and Wales. In addition costs arising from unemployment as a result of harmful and dependent drinking are estimated to be in the region of 1. billion per year (DH/HO 2007). Families The impact of alcohol use spreads far beyond the impact on the individual, and can make a significant contribution to family problems including violence, divorce and family break-up. Parental alcohol misuse affects up to 1.3 million children living in England and can impact on family functioning and stability, parent/child relationships, child development, health, safety, educational achievement, reception into care and the likelihood of involvement in substance use and offending (Prime Minister s Strategy Unit 2003). Alcohol-related harm in Salford Measures of alcohol-related harms for each Local Authority in England were first published in 2006, to assist local areas in understanding how alcohol is affecting residents and services, which can be compared between authorities and examined for trends from year to year. These measures have been updated in 2007 (NWPHO 2007). The measures show that levels of alcoholrelated harm are higher in the North West than in other regions in England, and that Salford has one of the highest levels of alcohol-related harm in the North West. The measures indicate that alcohol has a particularly large impact in the following areas: Hospital admissions for males and females Incapacity Benefit or Severe Disablement Allowance claims where the main medical reason is alcohol dependence Prevalence of harmful drinking and binge drinking Alcohol use by adults In 2007 Salford PCT conducted a lifestyles survey with a sample of local residents, which included questions about alcohol consumption. This survey showed that 25% of respondents had drunk over 21 units in the week prior to undertaking the survey. Alcohol use by young people In 2005 and 2007 Trading Standards commissioned a survey of year olds to investigate their alcohol consumption and purchasing patterns. This survey showed that between 2005 and 2007 the proportion of young people claiming to drink once a week or more reduced from 60% to 34% and the number of young people saying that they buy their own alcohol also reduced, from 41% to 21%. However, whilst the survey showed very significant 12

13 reductions in these two measures in Salford, responses also indicated that young people in Salford are more likely to drink in public places than others in the North West (51% in Salford compared to North West average 37%) and are more likely to drink in large groups (2% drinking in groups of more than 20, compared to North West average 18%). Levels of regular binge drinking in Salford are also among the highest in the North West (37% drinking 5 or more drinks on one occasion at least once a week). The 2007 survey had a smaller sample size for Salford, with 250 young people participating in 2007 and 550 in 2005, therefore this may have affected the results outlined above. Alcohol-related crime Data from the local alcohol profiles for England show that levels of alcoholrelated crime in Salford are higher than the national average, with the rate of alcohol-related recorded crime being the 26 th highest nationally. The Greater Manchester Police crime recording system enables crimes and incidents to be recorded as being alcohol-related. However, the alcohol marker is not always used consistently as a result of the person recording the incident/offence not mentioning alcohol as a factor in the crime, or there being no witnesses to the offence. For the period April December 2007 there were 55 crimes recorded in Salford, and 5,422 incidents, which had the alcohol-influence marker attached. Conclusions As levels of alcohol consumption increased over the past half a century there has been a corresponding increase in levels of alcohol-related harm. In Salford levels of alcohol consumption are higher than the national average and this also results in levels of alcohol-related harm being particularly high in the City. The harms experienced have a significant impact on quality of life in the City and contribute to performance against key targets such as life expectancy, violent crime, anti-social behaviour and children s health and wellbeing. Concerted local action to reduce alcohol-related harm is therefore needed. 13

14 5. Policy drivers National National Alcohol Strategy The Government published its first national alcohol harm reduction strategy in This strategy included 4 key aims: To improve the information available to individuals to start the process of change in the culture of drinking to get drunk To better identify and treat alcohol misuse To prevent and tackle alcohol-related crime and disorder and deliver improved services to victims and witnesses To work with the industry in tackling the harms caused by alcohol The national strategy was updated in June 2007, with the publication of Safe. Sensible. Social: the next steps in the National Alcohol Strategy. This updated strategy identifies 3 key groups who cause or experience the most alcohol-related harm: young people under 18 who drink alcohol; year old binge drinkers; and harmful drinkers. Safe. Sensible. Social also identifies the following next steps to tackle alcohol misuse in England: Sharpened criminal justice for drunken behaviour A review of NHS alcohol spending More help for people who want to drink less Toughened enforcement of underage sales Trusted guidance for parents and young people Public information campaigns to promote a new sensible drinking culture Public consultation on alcohol pricing and promotion Local alcohol strategies Performance monitoring From April 2008 there will be 3 national indicators (NI) which specifically focus on alcohol, through which the Government will measure local progress in reducing alcohol-related harm. These are: NI 3 Alcohol-harm related hospital admission rates NI 41 Perceptions of drunk and rowdy behaviour as a problem NI 115 Substance misuse by young people In addition reducing alcohol-related harm can make an important contribution to other national indicators, for example those relating to life expectancy and violent crime. Policy and guidance Since November 2005 the Department of Health and the National Treatment Agency for Substance Misuse have published a number of key documents to guide the commissioning of alcohol treatment services: Alcohol Needs Assessment Research Project (ANARP) : measured the gap between the demand for and provision of specialist alcohol treatment services 14

15 at a national and regional level. This identified that for every 12 people requiring alcohol treatment in the North West of England only 1 person is able to access it. This is regarded as a low level of access. Alcohol Misuse Interventions: Guidance on developing a local programme of improvement : provides guidance on developing and implementing local programmes to improve the care of hazardous, harmful and dependent drinkers and identified 15million of Government investment to improve the commissioning and delivery of alcohol treatment services. Models of Care for Alcohol Misusers (MoCAM) : provides a framework for commissioning alcohol treatment services, and advises that a local treatment system should comprise 4 tiers of intervention: Tier 1: Alcohol-related information and advice, screening, simple brief interventions and referral, provided by a range of generic services Tier 2: Open access, non-care planned, alcohol-specific interventions Tier 3: Community-based, structured, care-planned alcohol treatment Tier 4: Alcohol specialist inpatient treatment and residential rehabilitation Review of the effectiveness of treatment for alcohol problems : provides a critical appraisal of the evidence base for the treatments available for people with alcohol problems, which identified that every 1 spent on alcohol treatment saves the public sector 5. The Public Health White Paper Choosing Health outlined plans to pilot alcohol screening and brief interventions in primary care, A&E and the Criminal Justice System. Working with the alcohol industry to develop an information campaign to reduce binge drinking and a voluntary social responsibility scheme for alcohol producers and retailers was also proposed. Every Child Matters: Change for Children is the Government s vision for ensuring that agencies work together to protect and promote the well-being of children and young people. The Government s aim is for every child, whatever their background or circumstances, to have the support they need to: Be healthy Stay Safe Enjoy and achieve Make a positive contribution Achieve economic well-being Alcohol use by young people, or their parents and carers, can have an impact on all of these five areas. The National Supporting People Strategy Independence and Opportunity was launched in June This strategy acknowledges that having the right housing and support available at the right time is an essential part of ensuring that every citizen has the opportunity to live a fulfilled, active and independent life. Importantly, the national strategy clearly acknowledges that problems and uncertainties can affect anyone, but they are most likely to affect the more disadvantaged and vulnerable members of our society, and that assistance at the right time can often prevent a full-scale, long-term crisis. 15

16 The National Drugs Strategy Drugs: protecting families and communities, was published in February The Strategy sets out how the Government aims to restrict the supply of illegal drugs and reduce the demand for them over the next ten years, with a focus on protecting families and strengthening communities. However alcohol use by young people is also included within the remit of the Strategy. Legislation The Licensing Act 2003 came into force on 24 th November The Act includes four licensing objectives which all licensed premises are now required to meet: Prevention of crime and disorder Promotion of public safety Prevention of public nuisance Protection of children from harm The Act devolved licensing responsibilities to Local Authorities, made provision for flexible opening hours and set up a system of personal and premises licenses under the scrutiny of 7 Responsible Authorities including Police, Trading Standards, Fire and Rescue Service and Local Safeguarding Children Boards. The Violent Crime Reduction Act 2006 provides additional powers to tackle alcohol-related violence in the Night-time Economy, including Drinking Banning Orders, under which restrictions can be imposed on individuals who commit alcohol-related offences, and Alcohol Disorder Zones, so that, in areas affected by significant alcohol-related crime and disorder, licensed premises can be required to contribute to the costs of managing the night time economy. Local Needs assessment An alcohol health needs assessment was completed in June 2007, examining the needs of the adult population in Salford. The needs assessment identified that whilst the burden of alcohol related disease and mortality has increased across the country, these increases have been particularly pronounced in Salford. The City experiences higher levels of alcohol related harms to health, the rates of which appear to be increasing more rapidly than the rest of England. Rates of alcohol related deaths have increased particularly sharply among year old males. This reflects the increase in weekly alcohol consumption from the mid 150s onwards. As there have been further increases in alcohol consumption among year old women, and continued heavy drinking among year old males, it is likely that this will be reflected in higher rates of liver cirrhosis in the future unless alcohol consumption can be reduced. This needs assessment also identified that further investment is required at all tiers ( Models of care for alcohol misusers DH 2006) if the rise in alcohol consumption and alcohol-related harm is to be halted. 16

17 Local Area Agreement Salford s Local Area Agreement includes a number of alcoholrelated indicators: The number of hospitalised admissions due to all conditions attributed to alcohol The number of young people receiving an alcohol intervention from young people s substance misuse service The number of young people referred to a specialist service as a result of admission to A&E for drugs or alcohol misuse Increase the number of offenders referred for alcohol treatment There are a number of other local indicators to which alcohol makes a significant contribution, particularly violent crime, anti-social behaviour and domestic violence; health inequalities and life expectancy; educational attainment and employment activity; child protection and family support. Tackling alcohol-related harm in Salford can play an important role in achieving performance targets in these areas. Salford s LAA will be revised during 2008, with 35 improvement targets (in addition to 18 statutory education and early years targets) being selected for the City. As the rate of alcohol related hospital admissions in Salford, is the 6 th highest nationally, it is very likely that reducing alcohol-related hospital admissions will be one of the 35 improvement targets in the Local Area Agreement. Alcohol Commission In 2006, an Alcohol Scrutiny Commission was established to investigate The nature and extent of alcohol-related problems in the city and the measures in place to deter and prevent anti-social behaviour resulting from them with regards to young people (under 18 years). The Commission s recommendations included: Improved collaboration between partners when considering and implementing initiatives, with the DAAT having a strategic overview of all work undertaken Implementation of a proof of age scheme for all 16 year olds to be issued when leaving secondary school education Greater emphasis on alcohol education in primary and secondary schools Implementation of a city-wide by-law for a street drinking ban Regional and sub-regional coordination At regional level there is a North West Alcohol Strategy Group. Work commissioned by this group has included the Regional Alcohol Indicators and the North West Trading Standards survey which examined alcohol use and purchasing by young people. This has recently been complemented by the establishment of a Greater Manchester Alcohol Strategic Group, which will lead on initiatives which are best carried out at this sub-regional level, for example social marketing. This group will also provide a link between Local Authority/PCT areas and the Regional Alcohol Strategy Group. The Greater 17

18 Manchester group can also devolve work to the Greater Manchester Alcohol Leads group which comprises alcohol strategy coordinators and lead commissioners from the 10 Greater Manchester districts. Conclusions Alcohol is an issue which cross cuts a number of policy areas. This means that tackling alcohol related harm can contribute to the achievement of targets in a number of areas, but also that coordinated partnership working is needed. Since the publications of Safe. Sensible. Social in 2007 alcohol issues have assumed an increasingly prominent position on national and regional policy agenda. It is, therefore, important that local effort to reduce alcohol related harm keeps pace with these changes, particularly as Salford experiences relatively high levels of alcohol related harm. 18

19 6. Partnership arrangements Salford Drug and Alcohol Action Team is the partnership board responsible for reducing alcohol-related harm in the City. This partnership reports to the Local Strategic Partnership via the Crime and Disorder Reduction Partnership and the Healthy City Executive. A lead officer for alcohol is jointly funded by the PCT and the City Council. An Alcohol Reference Group was established in 2004 to provide a strategic lead on alcohol related issues in Salford. This group currently reports to the Drug and Alcohol Action Team. A review of the Crime and Disorder Reduction Partnership is currently underway, and the Audit Commission are also undertaking a review of Crime and Disorder Reduction Partnerships and alcohol. Proposals for the partnership arrangements to take forward this strategy will therefore be developed following the outcome of these reviews. During the implementation of Salford s Drug and Alcohol Strategy a number of sub groups of the DAAT have been established to take forward work on alcohol. To deliver this new strategy it is proposed that these sub groups are reorganised in order to fit with the key areas of work in the new strategy. The existing Responsible Authorities meeting will continue to take forward the aspects of the strategy which relate to alcohol retailing. The existing Young People s Substance Misuse Commissioning Group will continue to commission drug and alcohol services for young people and take forward the aspects of the strategy which relate to children and young people. The Criminal Justice Alcohol Steering Group will merge with the Drug Interventions Programme Steering Group to form a Drug and Alcohol Criminal Justice Group which will take forward the crime and disorder elements of the strategy. The Hospital Alcohol Steering Group will be expanded to be an Alcohol Health and Treatment Group to take forward the aspects of the strategy which relate specifically to healthcare and alcohol treatment. A list of the organisations which are represented in each of these proposed groups can be found in Appendix 2. 1

20 Related local strategies and action plans Alcohol is a cross cutting issue and this strategy therefore has close links with a number of other key strategies and action plans in the City including: Community Safety Strategy Road Safety Strategy Children and Young People s Plan Joint Strategic Needs Assessment Young People s Substance Misuse Treatment Plan Salford DAAT Service Users and Carers Strategy Reducing Re-offending Action Plan Homelessness Strategy Supporting People Strategy & associated plans Supported Employment Strategy Corporate Employment and Skill Action Plan Community Plans Health Improvement Action Plans Annual Teenage Pregnancy Action Plan Sexual Health Strategy Healthy weight Strategy Health Inequalities Strategy Safeguarding Children s Plan The Local Alcohol Strategy is designed to support the work of these linked strategies and plans and ensure that national and local targets are achieved. 20

21 7. STRATEGIC OBJECTIVE 1: Ensure that those who drink alcohol in Salford are able to do so safely and responsibly National Context Levels of alcohol consumption Most of the data that is available on alcohol consumption in the UK comes from national surveys where people self-report their consumption level. In 2005 the average number of units consumed by adults per week was 10.8, with 35% of men, and 20% women drinking over daily benchmarks on at least one day. However customs and excise data on the amount of alcohol purchased in the UK suggests that people are actually consuming alcohol at twice the level reported in surveys (DH/HO 2007). Alcohol consumption levels can be categorised as follows: Low risk drinking: Drinking within the Government s recommended limits. The Government advises that: Adult women should not regularly drink more than 2-3 units of alcohol a day Adult men should not regularly drink more than 3-4 units of alcohol a day Pregnant women, or women trying to conceive, should avoid drinking alcohol. If they do choose to drink, to protect the baby they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk. Hazardous drinking: Drinking in excess of the Government s recommended limits, but not yet experiencing harm. Harmful drinking: Drinking in excess of the Government s recommended limits and experiencing harm, or causing harm to others. Women who regularly drink over 6 units a day (or over 35 units a week) and men who regularly drink over 8 units a day (or 50 units a week) are at highest risk of such alcohol-related harm. Dependent drinking: Drinking in excess of the Government s recommended limits and experiencing harm and symptoms of dependence. Binge drinking: Drinking a large amount of alcohol over a short period of time. In surveys, women drinking over 6 units a day and men drinking over 8 units are usually defined as binge drinking. However, in practice, many binge drinkers are drinking substantially more than this level. Knowledge of units and risks of alcohol-related harm Although most drinkers have heard of measuring alcohol consumption in units (86%) and most people are aware of the daily benchmarks (6%), only 13% keep a check on the number of units they drink. In October 2006 the Government launched a national campaign targeting year old binge drinkers. The campaign aimed to increase knowledge and understanding of sensible drinking guidelines, and raise awareness of the 21

22 consequences of binge drinking. The Government has made a commitment to continue this campaign and it will be further developed to target other groups of drinkers, for example those drinking at hazardous and harmful levels at home. National campaigns will also aim to raise the public s knowledge of units of alcohol and ensure that people have the information to accurately estimate how much they drink. The Government has also launched Screening and brief interventions trailblazers, in NHS and criminal justice settings, to investigate how harmful drinkers can be identified and supported to reduce their drinking to sensible levels. The results of these trials are due to be reported in May 200 Alcohol retailing The real price of alcohol has decreased steadily over the past 50 years. Over the same period alcohol consumption has increased. Consumption of alcohol in the UK (per person aged 15+) relative to its price: SHAAP (2007) As part of the new National Alcohol Strategy the Government has announced its intention to commission an independent national review of evidence on the relationship between alcohol price, promotion and harm. The 2004 Alcohol Harm Reduction Strategy for England set clear objectives for the industry to demonstrate its willingness to reduce alcohol-related harm and establish a code of good practice. The industry has since set up and funded the Drinkaware Trust to raise awareness, challenge attitudes and change behaviour in relation to alcohol misuse and alcohol-related harm. In November 2005 the alcohol industry launched the Social Responsibility Standards for the Production and Sale of Alcoholic Drinks in the UK. 22

23 Local Context Alcohol consumption in Salford Levels of alcohol consumption in Salford, like many urban areas in the North West, are significantly higher than the national average. Among the adult population in Salford there are approximately: 40,400 hazardous drinkers (23%) 13,200 harmful drinkers (7.5%) 4,200 dependent drinkers (4%) These figures also include approximately 44,000 (26.5%) binge drinkers (NWPHO 2007). Levels of alcohol consumption within the different neighbourhoods and communities of Salford is not yet fully understood and requires further investigation. Raising awareness of the risks of alcohol-related harm Since the publication of the last local alcohol strategy (2005) a series of relatively small alcohol campaigns have been delivered in Salford, aiming to raise awareness of local support services and to encourage people to consider the negative consequences of drinking over recommended limits. These campaigns have primarily targeted people drinking outside the home. A Greater Manchester wide marketing campaign is now being coordinated by the Association of Greater Manchester PCTs and will be rolled out in Salford during 2008/. In order to reduce the number of people drinking over recommended limits training has been developed to enable staff from a variety of services and backgrounds to deliver alcohol screening and brief advice to those they work with. This training has been delivered to supported housing providers and Health Trainers. Screening has also now been established in the Emergency Department at Salford Royal Hospital. Working with alcohol-retailers Some on licensed premises in Salford engage in local pubwatch meetings and work is underway to increase engagement in such forums, particularly in areas which seem to experience high levels of alcohol-related crime. In addition a city-wide Licensees Forum was established in early 2007, however this has attracted little interest from local on and off license holders, therefore a new approach to working with the licensed trade needs to be found. Following consultation with licensees two training sessions were organised, covering responsible alcohol retailing and conflict management. Both sessions were accredited by the British Institute of Innkeeping Awarding body and were well received by licensees who attended. In order to promote good practice, off licensed premises are now being asked to make a commitment to comply with a list of conditions, in additional to those already included on their license, for example having electronic till prompts to safeguard against under age sales, and having CCTV pictures 23

24 available to the police. It is intended that this voluntary conditions scheme will be expanded to cover on licensed premises and will form the basis of a code of good practice for alcohol retailers in the City. Evidence & Gap Analysis Alcohol consumption and price The relationship between alcohol price, consumption levels and associated harm has been the subject of much research attention. The vast majority of these studies have found that an increase in the price of alcohol generally leads to a decrease in consumption, and visa versa. A review undertaken in Scotland in 2007 estimated that a 10% rise in alcohol price would save the lives of 47 Scottish men and 265 women every year (SHAAP 2007). Current legislation does not permit the regulation of prices at a local level. Consequently if prices are to be reduced there is a need to lobby Government for changes in national pricing policies or legislation to ensure that price can be used as a mechanism to reduce consumption. Responsible retailer schemes The Home Office have highlighted a range of good practice schemes which encourage partnership working with alcohol retailers in order to reduce alcohol misuse. A range of code of practice and award schemes are in place across the country in a variety of settings including city centres, small towns and rural areas. Salford s responsible retailing scheme is in the very early stages of development, however by further developing the scheme and encouraging licensees to meet the standards set we can ensure that licensed premises are managed responsibly. Developing a balanced night time economy Research by the Civic Trust found that: More people would use centres at night if they were safe, more accessible and offered more choice A good mix of clientele can lessen intimidation and improve perceptions A wider range of attractions and consumers leads to longer-term economic viability. The Civic Trust therefore recommends that local partnerships should have a vision for their night time economy and should plan for a positive, balanced mixture of businesses and activities that will attract all sections of the community to the area at night (The Civic Trust 2006). Salford s Urban Regeneration Company have already commenced work with the Civic Trust to support redevelopment work being undertaken in Central Salford, and it is intended that this relationship with the Civic Trust will be continued to ensure that this, and other new developments are in line with Civic Trust recommendations. 24

25 Social marketing The Public Health White Paper Choosing Health advocated the use of social marketing techniques to raise public awareness and change behaviour. Social marketing involves the use of marketing, alongside other concepts and techniques, in order to achieve behavioural change. Systematic reviews have shown that social marketing techniques have successfully been applied to alcohol (Stead et al 2006). By using social marketing techniques in Salford we can change drinking behaviour among those groups most at risk of experiencing alcohol-related harm. Screening and brief advice There is a large body of international research evidence to demonstrate the effectiveness of screening, using alcohol screening tools (such as the Alcohol Use Disorders Identification Test (AUDIT) and Fast Alcohol Screening Tool (FAST)) and simple, brief advice, in reducing people s drinking to more sensible levels. The evidence indicates that for every eight people who receive advice, one will reduce their drinking to within low-risk levels. This compares favourably with smoking where only 1 in 20 will act on the advice given (Raistrick et al 2006). Screening and brief advice are not routinely provided in Salford. There is considerable opportunity to screen the public and provide advice through front-line services working with the public. If training is provided so that frontline services can provide alcohol screening and brief interventions, this has great potential to reduce the prevalence of hazardous, harmful and binge drinking in Salford, and reduce the harm associated with alcohol misuse. Recommendations Considering the evidence above and the gaps identified, over the next three years our work to reduce the number of people drinking over recommended limits should focus on the following areas: Delivering a sustained alcohol social marketing campaign to encourage those drinking at hazardous and harmful levels to reduce their alcohol consumption and the risk of harm. Providing alcohol screening and brief advice through a wide range of front line services so that levels of alcohol consumption are assessed, and appropriate prevention and harm reduction advice can be provided to reduce levels of alcohol consumption and associated harm. Lobbying central government to ensure that pricing and promotions are controlled in order to reduce levels of alcohol consumption across the population. Creating safe drinking environments by working with alcohol retailers to ensure that on and off licensed premises are managed responsibly. 25

26 Implementation In order to reduce the number of people drinking over recommended limits we will focus on the following objectives: Delivering a sustained alcohol social marketing campaign a) Understand the target audience for responsible drinking campaigns and how to reach them b) Develop local campaigns to complement those being delivered across Greater Manchester and through the national alcohol harm reduction campaign programme, in line with market analysis c) Increase the availability of unit and responsible drinking information across the City d) Encourage local employers to provide responsible drinking information e) Work with the University of Salford to reduce the risk of alcohol-related harm to students Provision of screening and brief advice f) Provide alcohol screening, using World Health Organisation recognised screening tools, and brief advice in all GP practices in the City (clinical pathway described in Appendix 3) g) Ensure that alcohol screening and brief advice is available in the Emergency Department h) Ensure that front-line staff in a variety of agencies have the knowledge and skills to provide alcohol screening and brief advice Lobbying on price, promotions and advertising i) Lobby Central Government to: - Improve regulation of alcohol pricing in off-licenses and supermarkets - Address the way that alcohol is promoted and advertised, with particular regards to young people Creating safe drinking environments j) Establish neighbourhood based fora for the licensed trade to improve communication between enforcement agencies and the trade, and promote best practice k) Continue to develop voluntary conditions/responsible retailing scheme so that on and off licensed premises in all areas of the City are involved l) Provide and promote training for bar staff and licensees m) Ensure that the vision for the regeneration of the City encompasses the Civic Trust standards for a balanced night-time economy A more detailed action plan can be found at the end of this document. Performance Measures: We will measure our progress through the following outcome measures: Prevalence of hazardous drinking Prevalence of harmful drinking Prevalence of binge drinking 26

27 8. STRATEGIC OBJECTIVE 2: Reduce the impact of alcohol on illhealth and life expectancy National Context Impact on physical health Alcohol contributes to a wide range of health conditions and accounts for almost 10% of the burden of disease in the UK, being surpassed only by tobacco and high blood pressure (SHAAP 2007). For conditions such as lip cancer, chronic pancreatitis, chronic hepatitis and cirrhosis of the liver, over half of cases are thought to be attributable to alcohol (Morleo et al 2006). In addition, regular heavy drinking significantly increases the risks of developing conditions such as hypertension, stroke and coronary heart disease. Such conditions make a significant contribution to life expectancy. Increased risk of ill-health to harmful drinkers: Department of Health/Home Office (2007) The health problems caused by alcohol place a significant burden on the National Health Service, resulting in approximately 180,000 hospital admissions per year, and up to 70% of emergency admissions at peak times. Impact on mental health As well as physical health alcohol also has a close link with mental health problems, including depression, anxiety and suicide. Mental health problems can be a cause of heavy drinking, and heavy drinking can be a cause of mental health problems. 42% of men and 16% of women suffering from depression drink over recommended limits. 65% of suicides are alcoholrelated (Alcohol Concern 2006). Impact on sexual health Alcohol use can lower inhibitions and increase risk taking, this can include having unwanted or unprotected sex. Thus alcohol can contribute to unwanted pregnancies and the spread of sexually transmitted diseases. Sexual health services are therefore an important route through which to deliver alcohol advice and information. 27

28 Health inequalities Alcohol-related harms to health disproportionately affect the most deprived areas of the country, thus making a significant contribution to health inequalities. For women living in the most deprived areas alcohol-related death rates are three times higher than for those living in the least deprived areas. For men living in the most deprived areas alcohol-related death rates are over five times higher than for those living in the least deprived areas (DH/HO 2007). Drinking during pregnancy Guidance on drinking during pregnancy has recently been updated to recommend that women who are pregnant or trying to conceive should not drink alcohol. 54% of mothers currently report drinking during pregnancy, with 8% drinking more than 2 units per week on average (DH/HO 2007). Alcohol can damage the baby s developing organs and nervous system, resulting in later mental and physical problems, and can cause miscarriage. There were 128 cases of Foetal Alcohol Syndrome in England in , however there is no reliable data available on the incidence of other Foetal Alcohol Spectrum Disorders. It has been estimated that per every 1000 live births in Western Countries involve children affected by Foetal Alcohol Spectrum Disorder (British Medical Association 2007: 3). This would equate to 27 children born with a Foetal Alcohol Spectrum Disorder in Salford each year. Employment Alcohol misuse and its associated health problems can have a negative impact on maintaining employment. Approximately 17 million working days are lost each year due to alcohol misuse. Alcohol is also involved in 20% of industrial accidents. Whilst many who access alcohol treatment will be in employment, re-engaging those who are not in education, employment or training is an important goal of alcohol treatment and can help to achieve successful treatment outcomes. Housing Alcohol misuse can have a negative effect on individual s ability to maintain their housing, either through not being able to meet rent/mortgage payments, or neglect of living conditions. Indeed, house fires are frequently associated with alcohol use, with 1 in 3 fire related deaths happening when people have been drinking. Homelessness is also thought to be a cause of, and can exacerbate, alcohol problems, for example Shelter have estimated that 50% of rough sleepers are alcohol dependent. Ensuring that people with alcohol problems find sustainable and secure housing is an important element of alcohol treatment, as relapse is more likely when housing is not suitable or stable. The Supporting People Programme aims to ensure that the most vulnerable and disadvantaged people in our communities, such as those with alcohol problems, are offered a choice and range of good quality supported accommodation services to enable and empower them to develop the skills and confidence to live, and remain living, independently. 28

29 Alcohol Treatment The Government s framework for alcohol treatment services recommends that alcohol treatment systems should comprise four tiers (see page 8). Whilst Tiers 1 and 2 can be provided by a range of non-specialist alcohol services, for example in primary care and probation, Tiers 3 and 4 require specialist alcohol workers and services. The Department of Health has calculated Prevalence Service Utilisation Ratios for each region of England to assess the availability of alcohol treatment, relative to need. This varied from 1 in 12 alcohol dependent people accessing treatment in the North West, to 1 in 102 in the North East (DH 2005). In North America an access level of 1 in 10 is regarded as a low level of access, 1 in 7.5 medium and 1 in 5 high. These findings highlight the lack of capacity in alcohol treatment services across the Country. Consequently, Safe. Sensible. Social. identified the need for further provision of alcohol treatment for harmful and dependent drinkers and outlined plans for the development of a framework to support commissioners in planning local investment. However, this has not yet been published. As part of the new national alcohol strategy the Government will also be expanding the range of support available to those who wish to reduce their drinking, this may include helplines, internet-based guidance and questionnaires, and self-help and mutual aid groups. Drug use and alcohol The National Treatment Outcome Research Study (NTORS) found that 33% of drug misusers entering treatment were drinking above safe weekly limits (NTA (2004) Promoting Safer Drinking: A Briefing Paper for Drugs Workers). Models of Care for Alcohol Misusers (NTA 2006) therefore recommends that drug users in treatment have their alcohol use and treatment needs routinely and continually assessed, and it is good practice for drug users in treatment to have their alcohol problems treated in the same setting. Local Context Life expectancy and health inequalities Increasing life expectancy and reducing health inequalities are key targets for the City. In Salford, alcohol results in months of life lost for males and 5.5 months of life lost for females. The contribution of alcohol to reduced life expectancy in Salford is above both the national and regional average (NWPHO 2007). Hospital admissions From April 2008, the number of hospital admissions attributable to alcohol is a national indicator, and Salford will therefore set targets to reduce the incidence of such admissions. Ensuring that alcohol treatment services are fit for purpose and have sufficient capacity to meet demand is essential if this target is to be achieved. Alcohol treatment provision in Salford 2

30 Greater Manchester West Mental Health NHS Foundation Trust provide Tier 2 and Tier 3 alcohol services in Salford. This service operates in all areas of the city, with the majority of referrals coming to the service via GP practices. In addition the service has link workers with mental health services, the criminal justice system (see objective 3), and the hospital (see below). In 2006/7 almost 1,500 adults engaged in treatment with Salford Alcohol Service. This represents approximately 11.5% of harmful and dependent drinkers in the City (see page 18). From April 2008 Salford Alcohol Service will be integrated with Salford Drug Service, providing an integrated substance misuse service from three sites across the city. This development aims to ensure that the service is equipped to meet the changing needs of the Salford population and ensure that the service is accessible to residents of all parts of the City. Greater Manchester West Mental Health NHS Foundation Trust and Salford Royal NHS Foundation Trust jointly provide a Tier 2 and 3 alcohol service at Salford Royal Hospital for harmful and dependent drinkers attending hospital. This service helps to reduce length of stay for patients with alcohol-related conditions and prevent readmission to hospital. Since 2007 Salford Drug and Alcohol Services have employed an alcohol worker to work with drug users who are drinking at harmful and dependent levels. Of approximately 1,200 clients in contact with Salford Drug Service an estimated 30% are drinking at dependent levels. This new post is also responsible for providing training to drugs services staff in providing alcohol screening and brief interventions. Alcoholics Anonymous also provide a Tier 2 service, providing 6 groups across the City. In light of increases in alcohol consumption and rising levels of alcohol-related harm an expansion of alcohol treatment services is needed to keep pace with demand. There is potential to expand the range of agencies providing Tier 2 alcohol services so that the specialist alcohol service can focus on providing more specialist Tier 3 services. This would increase the availability of treatment for dependent and harmful drinkers and thus would assist in reducing waiting times. Tier 4 residential alcohol detoxification and rehabilitation services are commissioned by Salford PCT and Council, from a range of providers, primarily based in Greater Manchester. Ensuring that this provision is sufficient to meet the increasing demand created by an increase in alcohol consumption and associated problems is a challenge. Employment Employability is a key theme in Salford s Local Area Agreement and tackling alcohol-related harm has an important part to play in increasing employability. Salford has the 4 th highest proportion of its population claiming incapacity benefit or severe disablement allowance as a result of alcohol dependence (NWPHO 2007). Work is already underway in the city to reduce the impact of alcohol on local businesses and increase the number of people entering 30

31 employment following alcohol treatment. Salford Drug and Alcohol Action Team have developed a Drug & Alcohol in the Workplace Policy which has been adopted by the City Council and is being promoted as an exemplar policy to other local employers. Guidance has also been developed for employers to assist them in supporting employees with alcohol problems. Through services, such as Aspire and Progress 2 Work, alcohol users who are accessing alcohol treatment are being supported to enter training and employment. Housing A strategic review of supported housing for substance misusers and offenders was undertaken in early The purpose of the review was to identify and map current provision for adult drug and alcohol users, offenders and those at risk of offending. Workers within Salford Alcohol Service were asked to record the housing status of all the service users seen over a one month period: 10% were not in secure accommodation. The Supporting People Programme in Salford acknowledges that vulnerable people often have multiple complex needs and therefore the support offered across individuals within these groups, for example those with drug and alcohol problems, those at risk of offending, and those with a dual diagnosis often overlap, therefore service provision is built around attaining to support an individual to address needs on a sequential and multidimensional level. The Salford Supporting People Programme commission accommodation based services which offer support and accommodation on a 24 hour basis, floating support services which offer housing related support in a persons own home and resettlement support which offer services that support move on from supported / temporary accommodation to accommodation that is deemed independent i.e. own tenancy The programme in Salford currently commission: 8 units of floating support and 16 units of accommodation based support for people who s primary issues are alcohol related. 50 units of floating support for people who s primary issues are drug related with secondary issues relating to alcohol. In addition there are several short term accommodation based and hostel services which support people with complex needs who may have a primary issue around homelessness, however have secondary and tertiary issues around drug and alcohol misuse and or a dual diagnosis and or offending Evidence & Gap Analysis Effective alcohol treatment In 2007 the Department of Health and the National Treatment Agency for substance misuse published a review of the effectiveness of treatment for alcohol problems (Raistrick et al 2006). This review identified a range of interventions which are effective for harmful and dependent drinkers. Brief 31

32 interventions can successfully be delivered in settings such as primary care, but provision of support and training for practitioners is important in ensuring effective implementation. Such less intensive treatments are likely to be attractive for people with a moderate severity of problem. For those who are dependent drinkers, or who find it difficult to cut down following brief interventions, a range of psychological interventions are effective. These include cognitive behavioural therapy, motivational enhancement therapy and mutual aid groups. In addition pharmacological interventions can be effective in supporting detoxification and relapse prevention. The review also identified that planned and structured aftercare is effective in improving outcomes among service users with more severe alcohol problems. Safe. Sensible. Social. identified the significant savings to the NHS, at national and local level, which could be made by investing in alcohol treatment (DH/HO 2007): Therefore by investing in expanding and improving in alcohol treatment in Salford there is the potential for Salford PCT and local GP clusters to make substantial savings. Local alcohol service provision includes the provision of brief interventions, psycho-social interventions and pharmacological interventions to support detoxification and relapse prevention. Brief interventions can be provided by any suitably trained individual, therefore by providing training to primary care services we can expand alcohol treatment provision considerably. Such an expansion is necessary if there is to be sufficient provision for the rising 32