BOARD REPORT AGENDA ITEM NO: WCCCGB/12/05/52 DATE OF BOARD MEETING: Health

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BOARD REPORT DATE OF BOARD MEETING: TITLE OF REPORT: KEY MESSAGES: Clinical Commissioning Priority Update: Alcohol Related Ill Health West Cheshire Clinical Commissioning Group has identified alcohol

1 BOARD REPORT DATE OF BOARD MEETING: TITLE OF REPORT: KEY MESSAGES: Clinical Commissioning Priority Update: Alcohol Related Ill Health West Cheshire Clinical Commissioning Group has identified alcohol related ill-health as one of its six strategic clinical priority areas. Nationally, alcohol misuse costs around 25 billion per year and spans all sectors of the economy such as alcohol-related disorders and disease; crime and anti-social behaviour; loss of productivity in the workplace and problems experienced by those who misuse alcohol and their families. Hospital admissions attributable to alcohol are increasing by about 10% per year, which equates to a cost of approximately 850k per year for West Cheshire Clinical Commissioning Group. The West Cheshire Clinical Commissioning Group Board approved implementation of the recommendations set out in the Alcohol Case For Change in June The Local Enhanced Service for Alcohol Identification and Brief Advice and the Alcohol Counselling services have been decommissioned as set out in the case for change. Work is progressing on the implementation of the remaining service developments described in the case for change. REPORT PREPARED BY: Dr Martin Dennis, Clinical Lead for Alcohol Sarah Murray, Clinical Leadership and Engagement Manager Clinical Commissioning Priority Update: Alcohol Related Ill-Health

2 WEST CHESHIRE CLINICAL COMMISSIONING GROUP BOARD ALCOHOL SERVICES REVIEW INTRODUCTION 1 West Cheshire Clinical Commissioning Group has identified alcohol related illhealth as one of the six clinical priorities that it intends to focus on over the next five years in order to improve health outcomes for its population. 2 This paper sets out the national and local position regarding the impact and costs associated with alcohol related ill-health. It also details the service developments which have been agreed, where they are up to in terms of implementation and the next steps. NATIONAL POSITION 3 Nationally, alcohol misuse costs around 25 billion per year and spans all sectors of the economy such as alcohol-related disorders and disease; crime and anti-social behaviour; loss of productivity in the workplace and problems experienced by those who misuse alcohol and their families. 6 For the NHS alone, the estimated financial burden of alcohol misuse is around 2.7 billion per year in hospital admissions, attendance at A&E and in primary care. More recent analysis now suggests that the cost of alcohol related ill-health to the NHS is 3.3 billion a similar cost to smoking related ill-health. 7 Hospital inpatient and day visits are the greatest expense ( 1,190 million), followed by accident and emergency visits ( 646 million) and ambulance services ( 372 million). 8 The National Institute for Health and Clinical Excellence estimates that alcoholrelated disease accounts for 1 in 26 National Health Service bed days nationally, and up to 40% of all accident and emergency attendances nationally are thought to be alcohol related. Alcohol-related hospital admission rates are strongly associated with deprivation, with higher rates in more deprived areas. 9 The Department of Health recognises the increasing problem of alcohol misuse as it is associated with a wide range of diseases and mental health issues, these include alcohol-specific conditions that are wholly related to alcohol (e.g. alcoholic liver disease or ethanol poisoning) and alcohol-related conditions that are caused by alcohol, in some, but not all, cases (e.g. gastrointestinal, hypertension, stroke, coronary heart disease, several types of cancer and unintentional injury). 10 However, there is considerable evidence that alcohol treatment is effective, for example, studies have shown that after a single treatment episode, approximately 25% of subjects will moderate their consumption throughout the first 12 months, and a further 10% will reduce their drinking to remain free of alcohol-related problems. 1

3 LOCAL POSITION 11 High levels of alcohol related harm has been identified as a key health and wellbeing issue for the population of Cheshire West and Chester, through the Annual Reports of the director of public health, local alcohol profiles for England, joint strategic needs assessment and Rethinking Drinking the local alcohol harm reduction strategy. 12 Across Cheshire West and Chester, issues relating to alcohol are increasing year-on-year. Analysis undertaken for the joint strategic needs assessment indicates that: Around 18,900 people across Cheshire West and Chester are higher risk drinkers; I in 4 people drink alcohol in sufficient quantities to put their health at risk; 20% of people in Western Cheshire binge drink; Locally, one person is admitted to hospital every hour due to alcohol; Alcohol attributable hospital admissions are significantly higher than the national average and are increasing at around 10% per year; There is a three-fold difference in the alcohol specific hospital admission rate between people living in areas of higher deprivation and those living in areas of lower deprivation; Alcohol specific mortality in Cheshire West and Chester is significantly higher than the national average; The alcohol specific hospital admission rate is around a third higher than the rate for England for patients living in Ellesmere Port, Blacon, Lache and Chester City; Around 70% of offenders have a history of alcohol misuse, whilst 52% of offenders have a current need relating to alcohol misuse; There was an alcohol related arrest every four hours during 2011; Last year, domestic violence with an alcohol component, increased by 14.1%; There were 16,334 incidents of anti-social behaviour reported during 2010/11, of these 44.5% were classified as drunken, rowdy or loutish behaviour. COST TO THE LOCAL HEALTH ECONOMY 13 In Western Cheshire the total cost of elective and non-elective admissions during is estimated to be around 10.5 million, This is increasing by approximately 850k per year for our health economy. 14 In alcohol-specific and alcohol-related admissions at the Countess of Chester Hospital NHS Foundation Trust cost NHS Western Cheshire around 7.2 million and is increasing year-on-year. 2

4 15 The cost of alcohol related attendances at accident and emergency at the Countess of Chester Hospital NHS Foundation Trust increased by 7% between 2007/08 to 2009/10, however, in 2010/11, just over 2,000 attendances were recorded by local clinicians for Cheshire West and Chester residents as alcoholrelated. This represents between 4-5% of total attendances and is much lower than expected from national reports (30-40%). Between 2008/09 and 2010/11 the number of attendances fell by around 8%. The number of alcohol-related attendances due to assault has fallen considerably by 129 attendances (38%) over the same period. 16 The joint strategic needs assessment states that there are concerns regarding how complete a picture this data is showing given the suggested pattern from national reports and the high rates of alcohol specific hospital admissions locally. COMMUNITY ENGAGEMENT 17 According to the results of the Western Cheshire Big Drink Debate, completed in 2010, the drunken behaviour of others is a concern for around 62% of people in Cheshire West and Chester who were surveyed. Locally, over 600 people responded to the questionnaire and gave their opinion. In addition, the survey found that: 47% of respondents agreed with the introduction of a minimum price per unit to reduce alcohol related harm, whilst only 29% disagreed; 68% were concerned about children drinking on the streets and in parks; 60% of people drink alcohol to relieve stress and to unwind; 58% of people indicated that they regularly buy alcohol from supermarkets; 47% see alcohol-related crime as a concern locally; 79% think low prices and discounts increase people s alcohol consumption. 18 The local alcohol harm reduction strategy, Rethinking Drinking, highlighted a number of gaps in alcohol intervention and treatment services and a lack of an integrated care pathway. Historically, the focus has been on providing Tier Three specialist treatment services for dependent drinkers. 19 Our Life, an organisation specialising in community engagement, was commissioned to work with local people to investigate what they felt should be done locally to tackle the negative impact of alcohol in Ellesmere Port. Another important aim of the inquiry was to empower and enable communities to articulate an informed view of the actions that individuals, community, organisations and decision-makers should support and adopt to reduce alcohol related harm. The recommendations from the inquiry are provided in Appendix 1. CLINICAL ENGAGEMENT 20 Local clinical engagement has highlighted a number of key issues as well as concurring with the evidence base and research findings. Issues raised by clinicians include: 3

5 Lack of a coherent pathway across primary and secondary care; Patients undergoing detox in secondary care who could have been treated in community services; Issues with re-admissions and frequent attenders; Lack of a tier 2 alcohol service within the community and the need for further training and resources to support Identification and Brief Advice. UNMET NEED AND SERVICE GAPS 21 The alcohol case for change paper, which was presented to the West Cheshire Clinical Commissioning Group Board in June 2011, reported that: There was no integrated alcohol care pathway across Primary and Secondly Care; Tier 1 services, Identification and Brief Advice, were provided by community services and in some departments at the Countess of Chester Hospital NHS Foundation Trust, for example accident and emergency and sexual health. The GP local enhanced service was under-utilised; There was no tier 2 service in place, representing a significant gap in the care pathway; Tier 3 services needed to be redesigned to link in with secondary care and become part of a coherent alcohol pathway; NHS Western Cheshire has not fully implemented high impact changes recommended by the Department of Health; The Countess of Chester Hospital NHS Foundation Trust had only one alcohol liaison nurse covering office hours Monday to Friday, leaving a large proportion of the week uncovered; There was no assertive outreach service for high risk and dependant drinkers based in the Countess of Chester Hospital NHS Foundation Trust. 22 The Board approved the implementation of the recommendations set out in the alcohol case for change paper, which aims to develop a local stepped care approach, building on existing services to meet the needs of local people and patients who fall into various risk groups e.g. increasing risk, high risk and dependent drinkers. The service developments agreed were: Development of a local integrated care pathway: This would cut across all provider levels and organisations, ensuring patients are seen appropriately. Increase the provision of identification and brief advice training and support material available to NHS and non-nhs staff by the use of contractual levers and partnership working. Development of a community based tier 2 service. This service will deal with people identified as being at increasing risk and accept both self-referrals and referrals from tier 1, providing early intervention, which in-turn, reduces pressure on the tier 3 service. 4

6 Develop the alcohol liaison nurse service, based within the Countess of Chester Hospital NHS Foundation Trust, increasing capacity so that the service functions twelve hours per day, seven days per week. This will provide specialist support and advice and a link with the community alcohol services, ensuring treatment is carried out in the most appropriate place. The alcohol liaison service would also link-in with other services such as psychiatric liaison and community matrons. The provision of a safe, effective and non-discriminatory assertive outreach alcohol service delivered in a timely manner. This would be made-up of suitably trained staff who provide/facilitate pro-active aftercare via the community alcohol service, community matrons, GP practices, social services, housing trusts, benefits offices and voluntary groups. The aim of this service would be to help reduce the number of alcohol related repeat admissions. MEASURABLE BENEFITS 23 The following benefits have been identified: Patient focused interventions will lead to a reduction in the number of alcohol attributable hospital admissions/readmissions ( frequent attenders ). This will be monitored using the national indicator attached to the commissioning and contracting datasets. The introduction of a stepped service people and patients identified as being at risk can be referred to the appropriate service in a timely manner. This will help reduce hospital admissions, attendances at accident and emergency, and in the medium term, mitigate demand on tier 3 alcohol services. This will be monitored through commissioning and contracting datasets, analysis of patient flow through the stepped service and activity within the alcohol liaison nurse/outreach service within secondary care. Implementation of these services will improve patient experience and patient reported outcomes, these will be monitored through key performance indicators which will be a contractual requirement for all service providers. FINANCIAL IMPACT 24 Initial findings from the alcohol system dynamic model, based on work undertaken at Salford, Blackpool and Warrington, forecasts that the introduction of a new alcohol care pathway and interventions would result in sufficient savings to be cost neutral within two years, off-setting the implementation costs and generating potential savings in subsequent years e.g. 70,939 in year three, increasing to 344,859 in year five. However, if the assumptions in the model do not hold true, the model potentially could produce an under or over estimate of any potential changes overtime. This will be monitored using the National Indicator attached to the commissioning and contracting datasets. 5

7 25 Evidence shows that every 1 spent on alcohol harm reduction saves between 3 and 5. identification and brief advice in primary care and accident and emergency saves between 3.81 and 10 for every 1 spent, and stepped care has been shown to provide a cost-saving of around 9,000 per patient, compared to people receiving minimal intervention. Whereas, the alcohol case for change in secondary care produced by Dolton et al (2010) concluded that service intervention can result in a 5% reduction in alcohol attributable admissions. The case is based on the commissioner and provider agreeing to share the cost benefits of bed reduction and tariff avoidance; these cost benefits amount to a potential 1.6m locally. Estimated change in expenditure over time, based on the reduction in Alcohol Attributable Hospital Admissions and Accident & Emergency activity, forecast using the Alcohol System Dynamic Mode ( baseline) 300, , , , , , , , ,000 Year Source Alcohol System Dynamic Model seeded with NHS Western Cheshire Data STRATEGIC AIMS AND OUTCOMES 26 We have set out in our strategic plan for that we want to: increase the delivery of brief interventions by front-line services; develop community-based alcohol services; further develop alcohol liaison and outreach from our main hospital provider; offer evidence-based psychological intervention to adults who misuse alcohol. slow the projected growth rate of hospital admissions for alcohol-related harm between and by 1.8%. This links to the NHS outcomes framework measure: to reduce emergency admissions for acute conditions that should not usually require hospital admission. 6

8 27 In 2012/13, we will move towards achieving our vision for alcohol services by commissioning: A community-based alcohol service to cover West Cheshire; A brief intervention training post for NHS and non-nhs Staff. 28 These are two vital steps in the delivery of our alcohol strategy and have already been approved as part of a major change programme for alcohol services agreed in 2011/ In addition we will pursue improvements in issues highlighted by our member practices. These included examining the availability of detoxification facilities in the community. In response to a Home Office initiative, we will also increase the dataset that is collected in A&E departments to record attendances associated with crime and assault - and linked to alcohol. 30 Alcohol attributable hospital admissions and mortality from chronic liver disease have been proposed as indicators in the new public health outcome framework. Locally, both indicators have increased over time, and the rates locally, are significantly above those for England as a whole as highlighted earlier in this report. PERFORMANCE MEASURES Commissioning for Quality and Innovation 31 In 2011/12 a commissioning for quality and innovation (CQUIN) was agreed with the Countess of Chester Hospital NHS Foundation Trust and Community Care Western Cheshire to develop the workforce to be able to deliver identification and brief interventions. To date, 1000 staff have been trained. 32 In 2012/13 a commissioning for quality and innovation (CQUIN) has been agreed with the Countess of Chester Hospital NHS Foundation Trust to identify patients at risk from an alcohol related problem and then direct patients to the appropriate pathway. Quality, Innovation, Productivity and Prevention 33 Quality, Innovation, Productivity and Prevention, or QIPP, is the current process of improving quality whilst delivering efficiencies and across the NHS. The introduction of a new Alcohol Care Pathway and interventions will result in sufficient savings to be cost neutral within two years, off-setting the implementation costs and generating potential savings in subsequent years e.g. 70,939 in year three, increasing to 344,859 in year five. IMPLEMENTATION PLAN 34 The Local Enhanced Service for Alcohol Identification and Brief Advice and the Alcohol Counselling service have been decommissioned as set out in the case for change. 7

9 35 Work is progressing on the implementation of the remaining service developments described in the case for change. Discussions are underway with the Countess of Chester Foundation Trust and Cheshire and Wirral Partnership Trust regarding the potential for integration of a Rapid Assessment, Interface and Discharge (RAID) model. The outcome of these discussions will influence the delivery timescales for the remaining service developments agreed in the case for change. SUMMARY 36 As a key clinical priority area for the clinical commissioning group, changing the delivery of alcohol services, through the various services highlighted in this report, offers an opportunity to address key areas for improvement highlighted within the joint strategic needs assessment. RECOMMENDATIONS 37 The Board is asked to note the scope of current work around alcohol services. 38 The Board is also asked to support the details contained in the implementation plan and note the timescales involved. Dr Martin Dennis, Clinical Lead for Alcohol Sarah Murray, Clinical Leadership and Engagement Manager May

10 APPENDIX 1 - The Ellesmere Port Alcohol Inquiry Report, March 2012 Recommendations The recommendations that were voted upon are as follows, the ranking for each of the votes received for each recommendation are displayed also. Rank 1st 2nd 3rd 4th 4th 5th 6th 6th 6th 7th 7th 8th 8th 8th 9th 9th Recommendation More informal education in youth centres Minimum price charge alcohol price by unit. (effectively making it harder for people with problems to obtain cheap booze) Community pub run by community with a designated smoking area (outside) Structured education about alcohol (including binge drinking), its effects (good and bad), how to enjoy responsibly etc (with speaker/s who have experienced alcohol problems and/or specialist workers). This should be a gradual introduction from the end of primary school onwards Supermarkets should not be allowed to place alcohol so it s right in your face when you walk in and only have dedicated alcohol aisles. Bring DISC (Drug Intervention Service Cheshire) back All health workers (including GP s) need more training on the aspects of alcohol Stop signs in small shops advertising cheap booze When people have dried out the local GP refers people to an informal support group run by ex-addicts (e.g. members of the group) Police should crack down on the sale of illegal alcohol Local MP s to stop alcohol ads at certain times a watershed so TV advertising of alcohol should be only allowed at certain times. (e.g. Jeremy Kyle Tesco booze ad at 10am) Drink driving sentences increased Teaching health benefits of not drinking through sports, activities, free gym admission Make a drinking license for younger people where a national database would only allow them so many units in a 24 hour period (photo ID card) Drink drive rehab programme post-sentence, including education, effects on families/community etc Stop using tasty flavours e.g. alcopops/wicked (WKD)/Vodka cherry to encourage young people to drink 9

11 Does this report / its recommendations have implications and impact with regard to the following: A. Clinical Commissioning Group Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient experience) please outline impact The developments outlined in the report will significantly improve the quality of patient care and patient experience. 2. Commissioning Of Hospital And Community Services please outline impact The developments outlined in the report will impact on hospital and community services ie the development of the alcohol liaison service and the development of an integrated care pathway for alcohol. 3. Commissioning and Performance Management of GP Prescribing please outline impact Yes Yes No 4. Delivering Financial Balance please outline impact Not initially 5. Development Of The Clinical Commissioning Group as a Commissioning Organisation please outline impact No B. Governance please outline impact No 1. Does this report: provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) have any legal implications promote effective governance practice 2. Additional resource implications (either financial or staffing resources) No 3. Health Inequalities No 4. Human Rights, Equality and Diversity Requirements No 5. Clinical Engagement Yes Has this report been developed with clinical input and do local clinicians support the report s recommendations? If yes, please outline the clinical engagement Alcohol has been identified as a priority by practices and clinical Leads 6. Patient and Public Engagement Yes Our Life, The Big Drink Debate completed in March

GOVERNING BODY REPORT

GOVERNING BODY REPORT DATE OF MEETING: 20th September 2012 TITLE OF REPORT: KEY MESSAGES: NHS West Cheshire Clinical Commissioning Group has identified heart disease as one of its six strategic clinical