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Published by Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University Castle House North Street Liverpool L3 2AY Tel: +44 (0)151 231 4527 Fax: +44 (0)151 231 4515 e-mail: E.J.McCoy@ljmu.ac.uk web: www.cph.org.uk February 2009 ISBN: 978-1-906591-44-1 (print) ISBN: 978-1-906591-45-8 (web) British Library Cataloguing in Publication Data A Catalogue record for this book is available from the British Library

This publication is the FOURTH annual report of the Cheshire and Merseyside Alcohol Treatment Monitoring System (ATMS). The ATMS was established in 2004 to collect, analyse and present data on clients who are in contact with specialist alcohol treatment services (tier three and four, as defined by MoCAM, Department of Health (DH) and National Treatment Agency (NTA), 2006) in Cheshire and Merseyside. During the 2007/08 reporting period, 20 specialist alcohol services reported attributable data (i.e containing a client s initials, date of birth and sex). This year saw the addition of the ARCH services (Birchwood ARCH, Halton ARCH, Sefton ARCH and Wirral ARCH). A total of 7352 individuals were reported as in contact with structured alcohol treatment. This accounts for 7424 individuals resident in Cheshire and Merseyside when discussed in terms of their PCT of residence (a person may be counted more than once if they were resident in more than one PCT during the reporting year) and a total of 9193 episodes of treatment. This is a 74.0% increase in the number of people reported to the ATMS since the first year of reporting in 2004/05, which includes a 9.3% increase from the reporting year of 2006/07. Of the 7352 individuals in contact with treatment, 65.0% had one treatment episode during 2007/08, whilst 35.0% of individuals accessed more than one treatment service or had multiple treatment episodes within one service. Liverpool PCT reported the highest number of residents accessing treatment (n=1972), followed by Eastern Cheshire PCT with 1208 residents in structured alcohol treatment. Warrington PCT reported the lowest number of residents in treatment with 20 individuals 1. However it must be noted that Warrington did not have an alcohol treatment service reporting to ATMS during 2007/08 which may affect this number. Considering the level of alcohol treatment per head of population, differences were identified when comparing treatment prevalence between PCTs ranging from 3.8 within Eastern Cheshire PCT to 6.2 at Liverpool PCT (per 1000 of population aged 15-64). The majority of alcohol treatment clients in 2007/08 were male (63.0%, n=4635) and of the 93.9% individuals for whom ethnicity was reported, 91.8% (n=6747) defined themselves as White British. The mean age of clients was 43.9 years. The mean age of clients varied between PCTs, with those receiving treatment at Western Cheshire PCT having a mean age of 41.2 years compared to a mean age of 1 Please see methodological section at the end of the report for an explanation 3

46.4 years in Liverpool PCT. The largest proportion of individuals that were aged 65 and over were in contact with treatment in Liverpool PCT (30.6%). The majority of referrals into treatment were made by General Practice (26.7%). Referrals made by hospitals decreased from 23.5% in 2005/06 to 18.9% for the reporting year of 2006/07, although increased again during 2007/08 to 21.8%. This increase may be accounted for by the rise in reported data from the Royal Liverpool & Broadgreen University Hospital (NHS) Trust and University Hospital Aintree. The National Drug Treatment Monitoring System (NDTMS) was established to collect data on all clients in contact with structured drug treatment services (as defined by the Models of Care, DH and NTA, 2002). Data relating to individuals presenting to Cheshire and Merseyside drug services for whom alcohol was their primary substance were included in the 2005/06, 2006/07 and 2007/08 ATMS reports. During 2007/08, 1720 individuals accessed a drug treatment service in Cheshire and Merseyside, with alcohol stated as their primary substance. Residential distribution varied across PCTs, with 5.2% residing within Western Cheshire PCT and 23.3% residing in Liverpool PCT. Warrington PCT had the highest proportional increase (156.6%). This may be explained by a new Warrington based alcohol and drug service (Warrington ADS) reporting to NDTMS in 2007/08. Consistent with previous data reported from the ATMS, the majority of individuals were male (58.5%, n=1007), although the proportion had decreased from 61.7% in 2006/07. All PCTs reported more males than females in treatment, other than Knowsley PCT, reporting more females (56.0%) than males during 2007/08 (this also occurred in 2005/06 and 2006/07). The age profile of alcohol clients reported to the NDTMS in 2007/08 differed considerably to that reported to the ATMS, as it did in 2005/06 and 2006/07. The mean (average) age reported to the NDTMS was 26.5, compared to a mean (average) of 43.8 years from the ATMS. Of those reported to the NDTMS 53.4% (n=1004) were under 25 years of age, indicating a very different client group to specialist alcohol treatment services reporting to the ATMS. According to NDTMS, Eastern Cheshire PCT provided services to the youngest population (mean age 16.1) for the third year running, and the oldest population received treatment from Warrington PCT (mean age 33.8). Western Cheshire PCT had the smallest proportion of women in contact with treatment (34.4%). To provide the most accurate assessment of levels of specialist structured alcohol treatment in Cheshire and Merseyside, the ATMS and NDTMS data are combined and aggregated. In total, 9072 individuals were in contact with tier three or four treatment in 2007/08 (9152 at their last PCT of residence). The overall treatment prevalence across Cheshire and Merseyside rose from 4.9 when only ATMS data were considered to 5.6 when both NDTMS and ATMS were included (aged 15-64 years, per 1000 of population). When both ATMS and NDTMS were considered, alcohol 4

treatment prevalence at the PCT level varied from 1.9 in Warrington PCT to 7.4 at Liverpool PCT (per 1000 of population aged 15-64 years). The NDTMS has now been expanded to collect data on all individuals accessing specialist tier three and four treatment at both alcohol and drug services. As of April 2008, all specialist tier three and four alcohol services across the North West began submitting data to the NDTMS. Data for the North West of England are collected, compiled and reported by the NDTMS regional team, based within the Centre for Public Health, Liverpool John Moores University. Therefore, alcohol services will be included with NDTMS for future reporting. During 2008/09, the Centre for Public Health will conduct a scoping exercise to identify all tier two services providing alcohol treatment and will continue to provide reporting for these lower threshold services on an annual basis for Cheshire and Merseyside. Developments within the ATMS will see data collection widening to include services providing treatment to young people. During 2008/09 the ATMS will be increasing the collection of attributable data from those individuals receiving brief interventions at tier two level for hazardous and harmful drinking, allowing for recording of clients receiving treatment outside structured treatment services. This widening of data collection will see additional services reporting to the ATMS. 5

With thanks to the management, staff and clients from all the contributing services, without whose co-operation this report could not have been produced. An additional thank you to a number of individuals and organisations for their support: Rod Thomson, Paula Grey, Lynn Owens, Kate Arden, David Taylor-Robinson, Sue Milner and the PCTs of Cheshire and Merseyside. We would also like to thank colleagues at the North West Public Health Observatory and Centre for Public Health for their contribution including Adam Marr, Jess Salmon, Karen Hoare, Sacha Wyke, David Seddon, Michela Morleo, Sian Connolly, Charles Gibbons and Lee Tisdall. With a special thank you to Clare Heraty, Senior Database Assistant at the Centre for Public Health. 6

SECTION 1: Introduction and background 8 SECTION 2: The Alcohol Treatment Monitoring System 18 SECTION 3: Results from year four of the Alcohol Treatment Monitoring System 20 SECTION 4: Alcohol treatment data from the National Drug Treatment 30 Monitoring System SECTION 5: Combined data from the Alcohol Treatment Monitoring System 33 and the National Drug Treatment Monitoring System SECTION 6: Conclusions 35 SECTION 7: References and Methodology 37 7

The year 2007/08 has seen alcohol use and treatment continue to gain attention and importance as a major public health issue. This section will outline some of the key documents published during this period. National Documents Monitoring and reporting http://www.nta.nhs.uk/areas/ndtms/docs/cor e%20data%20set/ndtms_data_set_business_ definition_adult_alcohol_treatment_providers_ v5.3.1_0908.pdf services within the North West. This data collection will support the Governments National Alcohol Strategy. Alcohol treatment providers across the North West were supported in this data collection transition by the regional NDTMS team based at the Centre for Public Health, Liverpool John Moores University. Those structured alcohol services without a NDTMS compliant system were offered the NDTMS Data Entry Tool for data capture and files are submitted on a monthly basis. The regional team provided training to all alcohol providers and have continued to provide support through data collection and monthly submissions. Release documents regarding the new data collection can be found at the NTA website, h t t p : / / w w w. n t a. n h s. u k / a r e a s / ndtms/monitoring_specialist_alcohol_treatmen t.aspx The National Drug Treatment Monitoring system (NDTMS) was introduced in 2001 and was designed to collect data on all clients in contact with structured drug treatment in the North West (tier three and four services as defined by Models of Care (DH and NTA, 2002)). From the 1st of April 2008, the NTA expanded their data collection to include data from all specialist (tier three and four) alcohol 8

their progress towards the National Indicator 39, hospital admissions for alcohol related harm. For more information on LAPE please see: http://www.nwph.net/alcohol/lape Alcohol related harm http://www.nwph.net/nwpho/publications/alc ohol_indications.pdf In 2007, APHO (Association of Public Health Observatories) produced its eighth report in the series of Indications of Public Health in the English Regions highlighting the issue of alcohol. The report is divided into sections to examine indicators directly related to alcohol and those influenced in part by alcohol. This includes mortality, hospital admission, treatment, consumption and others. The report focuses on the nine Government Office Regions in England (Deacon et al., 2007). Whilst the report is discussed in terms of regions, the North West Public Health Observatory (NWPHO) have also developed a web based tool to allow each local authority to observe their specific local alcohol profiles, known as the Local Alcohol Profiles (LAPE) for England. LAPE was launched in 2007 and was updated in 2008 to include information by PCT as well as by local authority (and now comprises of 23 different indicators). It now also provides local areas with information on http://www.cph.org.uk/showpublication.aspx? pubid=326 In order to tackle violence in the night time environment, the World Health Organization Violence Prevention Alliance Working Group on Youth Violence, Alcohol and Nightlife have published a range of four fact sheets. The fourth fact sheet was published in January 2008 (Hungerford et al., 2008) and provides information on preventing sexual violence in nightlife environments. The fact sheet discusses sexual violence and nightlife environments and measures that are being developed to prevent it. 9

http://www.statistics.gov.uk/pdfdir/aldeaths01 08.pdf The latest figures on UK alcohol related deaths were released in January 2008 by the ONS in the Health Statistics Quarterly. Rates continued to increase, rising from 12.9 deaths per 100000 population in 2005 to 13.4 in 2006. Alcohol related deaths have more than doubled from 4144 in 1991 to 8758 in 2006 (6.9 per 100000 population in 1991). Male alcohol related deaths accounted for two thirds of the total amount of alcohol related deaths in 2006, with a rate of 18.3 deaths per 100000 compared to 8.8 for females (ONS, 2008). http://www.cph.org.uk/showpublication.aspx? pubid=413 Excessive alcohol consumption has an impact on the economy and workforce. To investigate the effect of alcohol consumption on the workplace, the Centre for Public Health was commissioned to examine such effects within Liverpool. Key findings showed that, although employers believed alcohol consumption levels to be low, they were aware of occasions when employees were more likely to consume excessive amounts of alcohol, such as after football matches. Of those employees involved in the survey, over half reported that they believed alcohol contributed to employee sickness, with 5% believing that sicknesses related directly to alcohol. Almost a fifth of employees (19%) reported arriving at work with a hangover within the last two weeks prior to the survey, with 15% reported being late for work in the last year due to alcohol and 12% reported that they would like to reduce their alcohol consumption (Harkins et al., 2008). 10

Promotion of safer drinking information on unit awareness to show consumers how to use the information on the labelling (DH, 2008b). In May 2008 the Units They All Add Up campaign was launched. The new campaign is aimed at everyone who drinks alcohol to inform individuals how many units are in alcoholic drinks and the risks involved with drinking too much (Home Office, 2008a). For more information on the campaign, please see http://units.nhs.uk/ http://www.dh.gov.uk/en/consultations/liveco nsultations/dh_086412 In May 2007, the Government and the alcohol industry agreed that alcohol unit content should be included on all alcohol bottles (DH, 2008b) and that, by the end of 2008, unit information would be displayed on all alcoholic drink labels. It was proposed that the labelling would include the unit content and the DH recommended guidelines of 3-4 units for a male and 2-3 units for a female as the maximum daily consumption (DH, 2007). According to DH, 86% of people are aware of units and 69% are aware of the recommended daily guidelines. However, only 13% keep a check of the amount of units they consume daily. When asked, 75% of individuals did agree that they supported unit labelling. However, as reported in the Safe. Sensible. Social. Consultation on further action (DH, 2008b), only 57% of products contain alcohol unit information and only 3% contain the entire proposed label (DH, 2008b). The alcohol industry agreed with the Government that they would provide unit information on alcohol bottles if the Government assisted this by providing http://www.cph.org.uk/showpublication.aspx? pubid=368 During 2008, the Centre for Public Health, Liverpool John Moores University produced a series of alcohol fact sheets: 1. Tolerance and perceptions of drinking 2. Alcohol availability to underage drinkers 3. Cheaply available alcohol, irresponsible promotions and deep discounting 4. Restricted drinking in public places 5. Strengthened action on drink driving 6. Licensing hours and density 7. Reducing alcohol content in drinks The first in the series of fact sheets examines tolerance and perceptions of alcohol and alcohol related harm. The fact sheet highlights that, although alcohol causes harm, most 11

people s perceptions of drinking are based on underestimations of their own consumption, lack of knowledge and inflated belief of benefits (Morleo et al., 2008b). The fact sheet discusses the importance of interventions such as national and local marketing campaigns to counteract the glamourised image of alcohol (Morleo et al., 2008b). For more information on the alcohol fact sheets please see http://www.cph.org.uk/publications.aspx campaign 93.9% of those surveyed reported drinking levels that exceeded the daily limit. This decreased to 87.3% following the intervention and individuals reported that they were 1.7 times less likely to binge drink within the last week (Morleo et al., 2008a). Following the campaign, there was a rise in the number of individuals who could correctly estimate the amount of units in a large glass of white wine and a pint of Stella lager (Morleo et al., 2008a). Young People The Updated National Alcohol Strategy (DH, 2007) identified those drinking under the age of 18 as a priority group. http://www.cph.org.uk/showpublication.aspx pubid=430 Sefton PCT ran the It s your choice campaign within the wards of Linacre and Derby during 2007/08 in order to tackle alcohol consumption and alcohol related harm. The campaign aimed to raise awareness of the negative consequences of excessive alcohol consumption through posters, information booklets and a telephone helpline. The Centre for Public Health, Liverpool John Moores University was commissioned to evaluate the impact of the campaign and conducted two surveys on alcohol consumption, behaviour and knowledge before and after the campaign (n=1057 individuals surveyed). Before the The average weekly alcohol consumption in 11-15 year olds has increased from 5 units in 1990 to 11 units in 2006 (Fuller, 2006). In March 2008, the Centre for Public Health, Liverpool John Moores University published Risky drinking in North West school children and its consequences: a study of 15-16 year olds (Hughes et al., 2008). Of the 140 schools surveyed in 19 local authorities in the North West, 84% of pupils consumed alcohol and of those who reported drinking, over half reported consuming more than 10 units in a typical week (Hughes et al., 2008). With the growing concern regarding how much alcohol young people are consuming, the Government made a commitment in the Children s Plan (2007) to look at ways to reduce excessive alcohol consumption for those aged under 18 years (Youth Action Plan, DH, 2008a). 12

Figure 1: Mean alcohol consumption (units) by 11-15 year olds in last week, by gender: 1990-2006 Pupils who drank alcohol in the last week 14 UNITS 12 10 8 6 Boys All pupils Girls 4 2 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 (Fuller, 2006) The Youth Action Plan (2008) documents ways in which to approach this. avoid marketing and promotion of alcohol avoid association with dangerous, illegal or anti-social behaviour ensure staff and companies fully understand and are trained within policies (DH, 2008a). The Youth Action Plan (DH, 2008a) focuses on five main priorities: http://publications.dcsf.gov.uk/eorderingdow nload/cm%207387.pdf Key aims include: promote the sensible drinking message avoid actions that encourage drunkenness, drink driving or drinking in inappropriate circumstances precautions to ensure individuals under the legal purchase age cannot buy alcoholic drinks stepping up enforcement activity to address young people drinking in public places taking action with industry on young people and alcohol developing a national consensus on young people and drinking establishing a new partnership with parents on teenage drinking supporting young people to make sensible decisions about alcohol 13

underage) decreased from 50% in 2004 to 15% in 2007. Of the 9000 test purchases (2683 premises) attempted by those under 18 years of age during May to July 2007, 14.7% were successful (Home Office, 2007). Also during a February half term clamp down (2008) police seized 20945 litres (44265 pints) of alcohol from underage drinkers across England and Wales (Home Office. 2008b). http://www.alcoholconcern.org.uk/files/20071 108_164726_Cheap%20at%20twice%20the %20price%20Final%20PDF.pdf In November 2007, Alcohol Concern reported that the average pocket money for 12-16 year olds was 9.43, and that it has now become 65% more affordable to purchase alcohol than it was 20 years ago (Alcohol Concern, 2007). The average pocket money is enough to buy 57 units of alcohol a week (16 litres of cider) within the North West (see North West Alcohol Fact sheet two of seven, Phillips-Howard et al., 2008). Although it is illegal for anyone under 18 years of age to buy alcohol, 34.1% of 15-16 year olds who reported consuming alcohol in the North West stated that they bought their own alcohol. These young people were more likely to engage in risky drinking behaviour. They were seven times more likely to drink in public and three times more likely to binge drink than those who drank but didn t purchase their own alcohol (Hughes et al., 2008). The government is tackling the sales of alcohol to underage young people. The UK test purchase failure rates (premises identified by Police and Trading Standards subjected to test purchases by young people under 18 years attempting to purchase alcohol Regional and Local Alcohol Publications Following the publication of the Updated National Alcohol Strategy: Safe. Sensible. Social. (DH et al., 2007), local areas within Cheshire and Merseyside have produced local Alcohol Harm Reduction Strategies. http://www.dh.gov.uk/en/publicationsandstati stics/publications/publicationspolicyandguida nce/dh_075218 These local Harm Reduction Strategies share the national aims of: better education and communication improving health and treatment services combating alcohol related crime and disorder working with the alcohol industry 14

Liverpool launched their second Alcohol Harm Reduction Strategy in November 2007. The strategy aims to achieve the vision of Liverpool as a safe, healthy and enjoyable place to live, work, study and visit (Liverpool PCT, 2007). http://www.seftonpct.nhs.uk/library/board_p apers/april_19th_2007/159%20sahrs%20s ummary%20and%20action%20plan.doc The Sefton Alcohol Harm Reduction Strategy Group was established to develop and deliver a strategy for reducing harm associated with alcohol use. The Sefton Alcohol Harm Reduction Strategy was produced by Sefton PCT in 2007, with an action plan for 2007/08. The strategy shares the same core aims identified in the Updated Alcohol Strategy along with Sefton s aim: To minimise the harm caused to health and the communities of Sefton by alcohol (Sefton PCT, 2007). The Alcohol Strategy Group was established to bring together organisations and community members to produce a strategy to promote safe drinking and reduce alcohol related harm in Liverpool. It addresses local needs to improve the quality of life for people in Liverpool. This multi-agency strategy builds on the previous Liverpool Strategy produced in response to the National Alcohol Harm Reduction Strategy (2004) and utilises the updated strategy: Safe. Sensible. Social. The next steps in the National Alcohol Strategy (DH, 2007). Key priorities and aims: bring about change in drinking culture improve information and communication about safe drinking limits improve screening protect young people from alcohol related harm through education improve the quality of, and access to, alcohol treatment services tackle health inequalities reduce alcohol related crime, disorder and anti-social behaviour http://www.lhps.org.uk/alcohol_files/alcohol_ Strategy.pdf deliver a pro-active approach to licensing keep all stakeholders informed and included 15

http://www.wirraldaat.org/service/alcoholh ARMREDUCTIONSTRATEGYFINAL.pdf Wirral s Alcohol Harm Reduction Strategy 2007-2010 was also launched in 2007 and produced with the aim of addressing the negative effects of alcohol use (Wirral PCT, 2007). The co-ordinated approach working with local agencies, organisations and partnerships aims to: educate young people about the risks of alcohol misuse through preventative campaigns re-design treatment services to meet demand and prioritise those who need it most address alcohol related crime and disorder through criminal justice interventions provide communities with information, advice and guidance on sensible drinking http://www.warrington-pct.nhs.uk/alcohol.htm Warrington and Knowsley have also produced Alcohol Harm Reduction Strategies in recent years. Warrington produced their first Alcohol Harm Reduction Strategy, 2006-2009 (Warrington PCT, 2006). The strategy, developed by members of Warrington Partnership, aims to reduce alcohol related harm and to improve the quality of life for individuals residing, visiting or working in Warrington by addressing local needs through partnership working. Key priorities include tackling health inequalities, establishing effective data collection and protecting young people from alcohol related harm through education and early intervention. Key aims include: building information, education and communication improving treatment and care protecting young people combating alcohol related crime and disorder and working with the alcohol industry 16

http://crime.theknowsleypartnership.org.uk/re sources/156163/alcohol_harm_red_strat.pdf Knowsley published their strategy in 2006 with the main aim being residents of Knowsley will understand the personal and social consequences of alcohol misuse; they will enjoy the benefits of alcohol and limit its negative impacts. Those who suffer as a result of alcohol misuse will be able to access and benefit from appropriate and effective local services and interventions (Knowsley PCT and Social Partnership, 2006). The highlighted outcomes include: an informed and engaged community a healthy community a safe community a responsible alcohol industry safe, healthy and informed young people a safe and productive workforce Halton and St Helens and Cheshire are currently in the process of updating their local alcohol strategies in accordance with national guidance. 17

T his is the fourth annual report of the Cheshire and Merseyside Alcohol Treatment Monitoring System (ATMS) for tier three and four specialist alcohol services. The ATMS was established in 2004 to develop a robust mechanism of collecting, collating, analysing and reporting data relating to patients and clients attending specialist alcohol treatment services in Cheshire and Merseyside. These services are classed as providers of tier three or four interventions and are defined as community-based or residential alcohol treatment that are care co-ordinated and care planned (DH and NTA, 2006). Section 3 discusses the results from the fourth year of the Alcohol Treatment Monitoring System. All contributing agencies complied with a recognised dataset of pseudoanonymised client information (initials, date of birth, sex and part postcode of residence) that contributed to a central monitoring system within the Centre for Public Health, Liverpool John Moores University. In addition to providing reports of service activity and engagement, together with the identification of client characteristics, the system enabled the removal of double counting of individuals across agencies and Primary Care Trust/Drug (and Alcohol) Action Team areas. A full description of the aims and methodology of the ATMS can be found at the end of this report and in the previous ATMS annual reports (Brown et al., 2005; McVeigh et al., 2006; McCoy et al., 2007). Section 4 of this report utilises alcohol related data from the National Drug Treatment Monitoring System (NDTMS) to provide additional intelligence relating to the extent of alcohol treatment service provision across Cheshire and Merseyside. The NDTMS collects data on all clients in contact with structured drug treatment services, i.e. high threshold tier three and four services as defined by the Models of Care (DH and NTA, 2002; Hurst et al., 2008). Records of clients attending drug services within Cheshire and Merseyside who present with alcohol as their stated primary substance have been analysed for inclusion within this report. In Section 5 of this report, data from primary alcohol users reported via the NDTMS have been amalgamated and aggregated with the ATMS dataset to provide the number of problematic alcohol users engaged in treatment within Cheshire and Merseyside. 18

Developments in the Alcohol Treatment Monitoring System There have been continued improvements and developments in the flow of data from alcohol treatment service providers across Cheshire and Merseyside to the ATMS based at the Centre for Public Health. Data were obtained from the services on a monthly basis, resulting in a high level of data accuracy. During the 2007/08 reporting period, 20 specialist alcohol services reported attributable data (i.e containing a client s initials, date of birth and sex). This year saw the addition of the ARCH services (Birchwood ARCH, Halton ARCH, Sefton ARCH and Wirral ARCH). increasing the collection of attributable data from those individuals receiving brief interventions at tier two level for hazardous and harmful drinking, allowing for recording of clients receiving treatment outside structured treatment services. This widening of data collection will see additional sites reporting to the ATMS and provide a more comprehensive view of alcohol related interventions across Cheshire and Merseyside. From April 2008, all specialist tier three and four alcohol services across the North West began submitting data to the National Drug Treatment Monitoring System (NDTMS). The NDTMS was established in 2001 to collect data on all clients in contact with structured drug treatment services. Data for the North West of England are collected, compiled and reported by the NDTMS regional team, based within the Centre for Public Health, Liverpool John Moores University. The NDTMS has now been expanded to collect data on all individuals accessing specialist tier three and four treatment at both alcohol and drug services. Therefore alcohol services will be included in the NDTMS annual report in future years. The Centre for Public Health are in the process of conducting a scoping exercise to identify all of the tier two services providing alcohol treatment and will provide reporting for these lower threshold services on an annual basis for Cheshire and Merseyside. The ATMS will be 19

T his section examines the number of individuals in contact with specialist alcohol treatment services, identifying specific characteristics of the treatment population, such as age, sex and ethnicity. Findings are reported for individuals across the whole of Cheshire and Merseyside, by D(A)AT of residence and by PCT of residence where appropriate. The numbers of individuals in treatment, together with in-treatment prevalence (for those aged 15 to 64 years) are illustrated by postcode district. Further analyses are reported relating to PCT of treatment and specific specialist alcohol treatment service. The ATMS currently reports only on those individuals in contact with structured alcohol treatment services, for whom the common, pseudo-anonymised dataset (i.e. containing each persons initials, date of birth, sex) has been reported (n=7352). Unless otherwise identified, episodes are defined as people who were in face-to-face contact with specialist alcohol treatment services in Cheshire and Merseyside within the reporting period 1st April 2007 to 31st March 2008. Individuals in contact with Specialist Alcohol Treatment Services During the year 2007/08, 7352 2 individuals accessed treatment within Cheshire and Merseyside, this accounts for 7424 individuals by their PCT of residence (in specified analyses, a person may be counted more than once if they were resident in more than one PCT during the reporting year) and a total of 9193 episodes of treatment. This compares to 4227 individuals reported in the first year of the ATMS, 6393 for the second year and 6729 for the third year of reporting, and equates to an increase of 74.0% from 2004/05, including a 9.3% increase from 2006/07. This increase is attributed to the inclusion of data from an increasing number of services over the four years of the ATMS, together with the reporting of increased levels of activity at the majority of services who have contributed consistently across the time period. 20 2 Please see methodological section at the end of the report for an explanation

Table 3.1: Number and prevalence of people in contact with specialist alcohol treatment services in relation to area of residence, 2007/08 D(A)AT of Residence PCT of Residence D(A)AT Individuals reported to ATMS# PCT There were variations in the numbers of residents in contact with services in 2007/08, ranging from 20 individuals in Warrington PCT to 1972 in Liverpool PCT (table 3.1). Across Cheshire and Merseyside, specialist alcohol treatment prevalence was 4.9 (per 1000 of population aged 15-64) compared to 4.07 in 2006/07 and 3.06 in 2005/06. Differences were identified when comparing treatment prevalence between PCTs ranging from 3.8 within Eastern Cheshire PCT to 6.2 within Liverpool PCT of residence (per 1000 of population aged 15-64). There were 9193 episodes of treatment accessed during 2007/08, this did not include 110 that were reported as having no fixed abode for the accommodation status and 28 episodes that were made by residents from outside Cheshire and Merseyside 3. Individuals reported to ATMS # No. % In-Treatment Prevalence [per 1000 aged 15-64 years] Cheshire 2012 Cheshire (Eastern) 1208 16.3 3.8 Cheshire (Western) 804 10.8 5.1 Halton 163 Halton and 947 12.8 4.6 St Helens Knowsley 486 Knowsley 486 6.5 4.7 Liverpool 1972 Liverpool 1972 26.6 6.2 Sefton 872 Sefton 872 11.7 4.7 St Helens 784 Halton and St Helens 947 12.8 4.6 Warrington 20 Warrington 20 0.3 0.2 Wirral 1115 Wirral 1115 15.0 5.3 # Cheshire and Merseyside Alcohol Treatment Monitoring System, 2007/08 Population estimate for mid 2005, released 2007. The Information Centre for health and social care www.nchod.nhs.uk/ 3 Please see methodological section at the end of the report for an explanation When comparing the number of residents in contact with alcohol services, all areas other than Eastern and Western Cheshire PCT and Warrington PCT have increased. The decrease within Warrington PCT may be explained due to no services from Warrington reporting to ATMS. The largest increase in numbers in contact with specialist alcohol service providers occurred in Liverpool PCT, with an increase of 592 individuals (42.9%). The largest proportional rise occurred in Halton and St Helens PCT, a 104.5% increase (from 463 clients in 2006/07 to 947 in 2007/08). Liverpool PCT accounted for the largest population of residents in contact with structured alcohol treatment services (26.6% of all individuals in contact with treatment in Merseyside and Cheshire). 21

Figure 3.1: Distribution of individuals in contact with specialist alcohol treatment services by postcode district (with PCT boundaries overlaid), 2007/08 Number of individuals in contact with structured alcohol services by postcode (with PCT boundaries overlaid) 1-24 25-40 41-60 61-80 81-100 101-120 121-150 151-199 200+ PCT boundary Figure 3.2: Distribution of individuals in contact with specialist alcohol treatment services per 1000 of the population (aged 15-64) by postcode district (with PCT boundaries overlaid), 2007/08 Postcode prevalence of individuals in contact with alcohol treatment (per 1000 population aged 15-64) 0.1-1.5 1.6-2.5 2.6-3.5 3.6-4.5 4.6-5.5 5.6-6.5 6.6-7.5 7.6-8.9 9-10.9 11-12.9 13+ PCT boundary 22

Demographics This section describes the basic demographic characteristics of each individual in contact with specialist alcohol treatment services, as Age and Sex reported to the ATMS in 2007/08. Each person is counted once (n=7352), unless otherwise stated (PCT residence n=7424). Figure 3.3: Number of individuals in contact with specialist alcohol treatment by sex, 2007/08 Female Male 1400 NUMBER OF INDIVIDUALS 1200 1000 800 600 400 200 0 Eastern Cheshire Halton and St Helens Knowsley Liverpool Sefton PCT OF RESIDENCE Warrington Western Cheshire Wirral Individuals reported to ATMS, by PCT of residence: n=7424 Of those in contact with specialist alcohol treatment services in 2007/08, 63.2% were male (62.7% in 2006/07). Considering female clients across PCT of residence, (figure 3.3) Wirral reported the lowest proportion, 32.6% (n=363), with Eastern Cheshire reporting the highest 43.3% (n=523). 23

Figure 3.4: Age and sex of individuals in contact with specialist alcohol treatment, 2007/08 Female Male 1400 NUMBER OF INDIVIDUALS 1200 1000 800 600 400 200 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Individuals reported to ATMS n=7352 AGE GROUP The mean age of all people in contact with alcohol treatment services during 2007/08 was 43.9 years, compared to 43.4 years in 2006/07. The age range for 2007/08 was 15 to 91, similar to the previous year (14 to 90). There was little difference between the mean age of females (43.8) and males (43.9). Of those aged under 25 (n=374), 63.1% (n= 236) were male, and the highest proportion of this age group were resident in Halton and St Helens PCT (20.3%). Of those in contact with structured alcohol treatment, 5.6% (n=418) were aged 65 years or older and, within this age group, 68.9% (n=290) were male. Liverpool PCT had the highest proportion of individuals who were aged 65 and older (29.4%), compared to 5.7% aged 65 and older resident in Knowlsey PCT. 24

Figure 3.5: Proportion of individuals in contact with specialist alcohol treatment services by PCT of treatment, showing breakdown of age, 2007/08 4 100% 65+ 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 under 15 AGE GROUP (%) 80% 60% 40% 20% 0% Eastern Cheshire Halton and St Helens Knowsley Liverpool Sefton Western Cheshire AGE BY PCT OF TREATMENT Wirral Windsor Clinic Individuals by PCT of treatment; n=7716 5 The mean age of clients varied between PCTs, with those receiving treatment at Western Cheshire PCT having a mean age of 41.2 (also the youngest in 2006/07) compared to a mean age of 46.4 in Liverpool PCT. The Windsor Clinic is not discussed in terms of PCT of treatment as it is funded by a number of PCTs. The age distribution across PCTs of treatment was influenced by the older cohorts of clients receiving treatment at services provided by University Hospital Aintree (mean age 46.4) and the Royal Liverpool & Broadgreen University Hospitals (NHS) Trust (mean age 48.8). The service with the youngest mean age of clients was Halton ARCH at 39.1 years. Halton and St Helens PCT provided treatment to the largest proportion of individuals under the age of 25 years (20.8%, n=80) compared to Knowsley PCT who provided treatment to 1.0% of this age group (422 individuals, 5.5% aged under 25 accessed treatment during 2007/08). Considering treatment providers, Wirral Alcohol Service provided treatment to more young people under 25 (12.7%, n=49) compared to other providers. Liverpool PCT provided treatment to 30.6% (n=129) of 4 Please see methodological section at the end of the report for an explanation 5 Please see methodological section at the end of the report for an explanation 25

individuals aged 65 and older, compared to Knowsley PCT which provided treatment to 1.7% (n=7) of those aged 65 and older. The Royal Liverpool & Broadgreen University Hospitals (NHS) Trust accounted for the provision of treatment to 23.0% (n=97) of those aged 65 and older. Ethnicity For the 7352 Cheshire and Merseyside residents accessing treatment in 2007/08, ethnicity was recorded for 93.9% of individuals (an increase from 89.5% in 2006/07). For those individuals where this information was recorded, 91.8% were recorded as White British. Referral Sources To provide the fullest possible understanding of the ways in which clients were referred into service, results of all presentations have been used here 6. The majority of referrals were made by either General Practice (n= 2411, 26.7%) or self (n=2317, 25.7%). Referrals made by hospitals decreased from 23.5% in 2005/06 to 18.9% for the reporting year of 2006/07, although increased again in 2007/08 to 21.8%. This change in referral profile may have reflected the reduced reporting from the Royal Liverpool & Broadgreen University Hospital (NHS) Trust and University Hospital Aintree in 2006/07. Due to a transitional phase in the recording systems at these sites, the ATMS was unable to report all individuals in contact with these services during 2006/07. Therefore, numbers reported under represented the level of activity within these agencies. This has now been resolved and 2007/08 has seen an increase of 128.6% for the Royal Liverpool & Broadgreen University Hospital (NHS) Trust and 42.9% for University Hospital Aintree 7. Figure 3.6: Referral sources of those in contact with alcohol treatment (all treatment episodes), 2007/08 Drug Service Statutory 2% 3% 3% 13% 2% 4% 27% Other Alcohol Service GP Self Hospital/A&E Criminal Justice Service 22% 26% Mental Health Services Social Services Other Treatment episodes reported to ATMS; n=9193, referral source data missing; n=167 * Percent greater than 100 due to rounding 26 6 Please see methodological section at the end of the report for an explanation 7 Please see methodological section at the end of the report for an explanation

Alcohol Treatment Providers in Cheshire and Merseyside Data were collected from 20 specialist alcohol treatment providers across Cheshire and Merseyside. Table 3.2: Numbers and characteristics of clients in contact with specialist alcohol treatment by service provider, 2004/05, 2005/06, 2006/07 and 2007/08 (n = 9193) 8 Treatment provider No. In contact 2004/05 No. In contact 2005/06 No. In contact 2006/07 No. In contact 2007/08 % Change from 2006/07 % Male % Under 25 % Over 65 Birchwood ARCH - - - 105-58.1 1.9 2.9 Central Cheshire 617 725 903 637-29.5 53.1 3.9 4.9 Alcohol Service Chester AS 369 413 377 384 1.9 64.3 8.3 2.6 Chester Turning Point 108 105 137 141 2.9 63.8 2.1 0 Dovecot CIC 72 112 130 155 19.2 46.5 1.3 3.2 Ellesmere Port AS 331 431 483 486 0.6 68.3 8.4 3.7 Halton ARCH - - - 123-56.9 9.8 0 Halton CIC 22 34 26 32 23.1 43.8 15.6 0 Knowsley Community AS Liverpool CIC Addiction Service Macclesfield and Congleton Priory Royal Liverpool & Broadgreen University Hospitals (NHS) Trust Sefton Alcohol Services - - 208 137-34.1 51.8 2.9 5.1 296 138 403 395-2.0 62.0 7.6 1.5 341 591 794 849 6.9 60.8 5.1 8.8-1119 420 960 128.6 72.9 2.6 10.6 236 283 274 219-20.1 50.2 3.7 5.5 Sefton ARCH - - - 21-52.4 19.0 4.8 St Helens CIC 122 236 197 296 50.3 61.1 9.1 5.4 Community Link St Helens Lifestyles - - 502 731 45.6 66.3 6.8 5.3 University Hospital 252 575 303 433 42.9 67.0 3.0 7.2 Aintree Windsor Clinic 993 1046 925 1857 100.8 62.7 2.0 2.7 Wirral AS 751 1043 1063 1022-3.9 69.2 5.3 6.6 Wirral ARCH - - - 210-60.0 7.6 0.5 - New service 8 Please see methodological section at the end of the report for an explanation 27

The Windsor Clinic provided treatment to the highest number of individuals during the 2007/08 reporting period (n =1857 individuals). The majority of clients at all services were male, with the exception of Dovecot Community AS and Halton CIC (see table 3.2). Of the 20 services that provided data to ATMS for 2007/08, 11 reported an increase in the number of individuals receiving treatment. The Royal Liverpool & Broadgreen University Hospital (NHS) Trust and the Windsor Clinic had the greatest proportional increase with a rise of 128.6% and 100.8% respectively. Figure 3.7: Referral source into treatment, all treatment providers (all treatment episodes), 2007/08 100% 90% Other Social Services Mental Health Services Criminal Justice Service Hospital/A&E Self GP Other Alcohol Service Drug Service Statutory REFERRAL SOURCE (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% Birchwood Arch Central Cheshire Alcohol Services Chester AS Chester Turning Point Dovecot CIC Ellesmere Port AS Halton Arch Halton CIC Knowsley Community AS Liverpool CIC Addictions Service Macclesfield and Congleton Priory Royal Liverpool & Broadgreen Hospitals (NHS) Trust Sefton Alcohol Services Sefton Arch TREATMENT PROVIDER St Helens CIC St Helens Lifestyles University Hospital Aintree Windsor Clinic Wirral Alcohol Services Wirral Arch Treatment episodes reported to ATMS; n=9193, referral source data missing; n=167 28

Table 3.3 illustrates the relationship between PCT of residence (shown as rows) and PCT of treatment (shown as columns) 9. Table 3.3 looks at individuals at the last PCT of treatment they attended. The majority of treatment within Cheshire and Merseyside was provided to the PCTs own residents. The exception to this is where specialist alcohol treatment provision is jointly commissioned by a number of PCTs, as in the case of the Windsor Clinic. Another exception was Warrington as during 2007/08 no Warrington based services provided data to ATMS. Therefore, the majority of individuals with a Warrington PCT of residence received treatment from Halton and St Helens PCT. Table 3.3: Number of individuals in contact with specialist alcohol treatment providers by PCT of residence and PCT of treatment, 2007/08 Eastern Cheshire Halton and St Helens PCT OF TREATMENT Knowsley Liverpool Sefton Western Cheshire Windsor Clinic Wirral Eastern Cheshire 1184 0 0-0 50 0 0 PCT OF RESIDENCE Halton and St Helens - 827 6 6 0 0 179 0 Knowsley 0 57 114 117 6 0 222 0 Liverpool - 22 11 1124 17-751 - Sefton 0-0 171 343 0 442 0 Warrington 0 15 - - 0 0-0 Western Cheshire 27-0 5 0 740 0 12 Wirral 0-0 10 0 33-1065 Total 1215 926 132 1436 366 824 1599 1081 Individuals by PCT of treatment; n=7716 Numbers below 5 have been suppressed 9 Please see methodological section at the end of the report for an explanation 29

T he National Drug Treatment Monitoring System (NDTMS) was established to collect data on all clients in contact with structured drug treatment services (as defined by the Models of Care, DH and NTA, 2002). Data relating to the 1720 individuals (1854 episodes) presenting to Cheshire and Merseyside drug services (1728 by their PCT of residence) for whom alcohol was their primary substance are reported in this section. A total of 82 different services within Cheshire and Merseyside reported primary alcohol users to the NDTMS, with 26 of these services being specific young person s services. A total of 1854 treatment episodes occurred during 2007/08 and 52.3% (n=970) occurred within a young persons service (80% in 2006/07). Table 4.1 illustrates the residential distribution of alcohol clients reported to NDTMS. High proportions were reported as residing in Liverpool, (23.3%, n=402). Western Cheshire reported the lowest amount of individuals reporting to the NDTMS with alcohol as their primary substance (5.2%). Warrington PCT had the highest proportional increase with 156.6%. During 2007/08 no services from Warrington reported data to ATMS and therefore this increase reported to NDTMS may be explained by residents attending structured drug and alcohol treatment services within Warrington with alcohol as their primary substance. Table 4.1: Number of individuals in contact with structured treatment with alcohol as primary problematic substance reported to NDTMS, 2007/08 PCT of Residence Primary alcohol users 2006/07 Primary alcohol users 2007/08 Eastern Cheshire 137 177 Halton and St Helens 236 323 Knowsley 67 141 Liverpool 300 402 Sefton 59 98 Warrington 99 254 Western Cheshire 38 90 Wirral 293 243 Total 1229 1728 Primary alcohol users reported to NDTMS; n=1728 30

Figure 4.1: Number of individuals stating alcohol as their primary substance reported to NDTMS by gender, 2007/08 Female Male 300 NUMBER OF INDIVIDUALS 250 200 150 100 50 0 Eastern Cheshire Halton and St Helens Knowsley Liverpool Sefton PCT OF RESIDENCE Warrington Western Cheshire Wirral Primary alcohol users reported to NDTMS: n =1728 Figure 4.1 illustrates the distribution of primary alcohol users by PCT of residence and gender. Similar to data from the ATMS, the majority of individuals were male (58.5%), although this proportion has decreased in comparison to the previous year (61.7% in 2006/07). As in 2005/06 and 2006/07, Knowsley PCT was the exception to this, reporting more females (56.0%) than males in the reporting period of 2007/08. Western Cheshire PCT had the lowest proportion of women (n=90, 34.4%). The age profile of alcohol clients reported to NDTMS in 2007/08 differs considerably to that reported to ATMS, as it did in 2005/06 and 2006/07. The mean average age reported to NDTMS was 26.5 years, compared to a mean average of 43.8 years from ATMS. Of those reported to NDTMS, 53.4% were aged under 25 years, indicating a very different client group to specialist alcohol treatment services reporting to ATMS. 31

Figure 4.2: Number of primary alcohol users reported to NDTMS by PCT of treatment, showing breakdown of age, 2007/08 100% 65+ 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 under 15 AGE GROUP (%) 80% 60% 40% 20% 0% Eastern Cheshire Halton and St Helens Knowsley Liverpool Sefton Warrington Western Cheshire Wirral PCT OF TREATMENT Individuals by PCT of treatment: n=1753 Eastern Cheshire PCT of treatment provided services to the youngest population (mean age 16.1) for the third year running, and the oldest population received treatment from Warrington PCT (mean age 33.9). 32 32

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