Examination of Witnesses (Question Numbers
200-219)
PROFESSOR ROBIN
TOUQUET, MS
CAROLE BINNS,
MR BRIAN
HAYES AND
DR DUNCAN
RAISTRICK
7 MAY 2009
Q200 Chairman: Do you think there
is anything that can be done at the front door that would not
stop people being looked after?
Mr Hayes: There is no way that
we would refuse anybody help. Where we have a problem, I think
there is a massive void between us picking these patients up,
them going to A&E to be treated and then the following up
of the patients from there. I think we are in a really good position
where we get to these patients—it could be the first time
they have got into this stage. I was listening to the one before
and they were saying, "Have you drunk six units before?"
We are lucky if we can get anybody that can answer that question,
let alone know their name. The problem that we are getting is
the assaults on staff, the assaults that happen because people
have been drinking alcohol. The question I ask myself with a lot
of them is, "Right, if this person had not got drunk tonight
would they have been beaten up, or would they have tripped over
on their high heels?" The answer is not that it would not
have happened; so it is not just the people that we are going
to who are comatose through alcohol, it is the injuries that happen.
You are talking about split lips and so on; we are talking about
people that because of alcohol have jumped up on a wall because
they think it is a bravado thing to do with their mates, not realising
that the drop the other side is 60 feet and they have gone down
it. Their one massive night out has ended up with a family with
someone who is deceased; and that is not an occurrence that happens
every so often—this is every weekend that this is happening,
whether they die or not. We have had to get our helicopter out
on six occasions in the last three years to people where the call
has come in as unconscious and where the person has been asked
on the phone have they been drinking—yes, they were drunk,
but when we have got there the injuries we have been faced with
have been so horrific, due to a bus driver who had kicked somebody
off his bus and his head had been used as a football by about
five or six blokes who were all drunk, and he ended up in intensive
care. This is happening week in, week out; it does not have to
be a Friday or a Saturday. But what we are finding is that most
of the males we are going to will initially be for the injuries
they have received—minor head injuries and things like that,
assaults. But when we go to the younger females and females in
general it is purely the alcohol we are going for, to the point
where they are not waking up where they are in A&E four or
five hours later. We went to one young female who was found staggering
down a road in south-east London, completely out of it on alcohol.
When we got her into the ambulance we went to remove her jacket
to take her blood pressure and she had nothing on underneath,
and did not have a clue what had happened to her. When she got
tested at St. Thomas' that night there was no evidence of any
date rape drugs or anything like that, it was purely alcohol.
So it is a massive spectrum we are dealing with and the stuff
that goes on in and around the alcohol as well. What we would
like to do is to have somewhere in the West End of London where
we would deal with these people, in addition either with consultants
or alcohol help groups like Drink Aware and groups like that,
where we can do the intervention—not a brief, two or three
minute questionnaire where we have to hurry up and we have to
get people in because of four-hour targets—where they can
be handed over to people and the process can be taken from there
and they can be given help before they end up being long-term
stay in hospital through cirrhosis or other medical problems.
Q201 Charlotte Atkins: Professor
Touquet, you mentioned in your previous intervention about the
importance of early intervention. What sort of early intervention
would you see as being practical and effective?
Professor Touquet: Thank you.
I am glad you used the term "early intervention" because
I do try and encourage people not to use the "s" word,
which is screening, because that excites a very negative reaction
amongst the medical profession—less so with the nursing
profession. But I do believe that people who work in the acute
sector—and obviously I am a prisoner of my own work environment,
that all of our junior doctors who change with us every six months,
albeit it nationally, in a majority now of A&E departments,
sadly the junior doctors change every four months. You need to
change their attitudes; you need them to understand that alcohol
is a drug. They need to understand that something can be done.
We are extremely grateful to Westminster PCT because we now have
two alcohol nurse specialists and they are the stress relievers
for the staff in A&E and you need the junior doctors especially
to understand that there is something that they can do, and by
back-ended, when you have hopefully generated the gratitude factor
of saying to a patient, "We routinely ask everyone who has
fallen, `Do you drink alcohol?'" then that is an unthreatening
way of putting the question and you then have question 4 on the
PAT, "Do you feel your attendance at A&E is related to
alcohol?" If they say, "No, doc," and you get the
full force of a bottle of Bell's you say, "Look, if you had
not been drinking would you be in A&E?" A more neglected
area is the resuscitation room, if I could highlight that again,
but I obviously believe that every acute trust—and there
were about 194 at the last count, depending on how you define
A&E departments, and many have amalgamated and Dr Taylor will
be able to tell you more about that than myself—every hospital
should have a clinical lead. It can be a nurse—and you have
seen that within Dr Owens. Within my job plan—I do not get
paid anything extra for being the alcohol lead at Mary's—the
hospital recognises my role by giving me a four-hour allocation
of time for making alcohol misuse high profile within the hospital
and highlighting a role of alcohol nurse specialist so that early
intervention can be given; also, that blood alcohol concentrations
are sent from patients in the resuscitation room. You can imagine
that if you are brought in by blue light ambulance to the resuscitation
room even if you have a normal Glasgow coma score—and a
large percentage will not—you will not want to be asked
questions about alcohol within the resuscitation room because
it is airway breathing, circulation and stabilising the patient's
vital signs. But it is very revealing what blood alcohol concentrations
are and it was one of our Lithuanian patients who had a blood
alcohol concentration of 690 mgs per 100 ml. The majority of people
in this room would probably stop breathing at about a level of
450, remembering that the current legal limit for driving in this
country is 80 and the Alcohol Health Alliance has made the case
that really we should be like the rest of Europe and it should
be 50. Again, it is culture because the blood alcohol concentration
results coming back bring home to the medical staff especially
that alcohol is a drug. Like you ask for a salicylate level, paracetamol
level, you have a blood alcohol concentration level. So every
hospital should have a consultant lead; every hospital should
have at least one alcohol nurse specialist and every hospital
should have the facility for doing blood alcohol concentrations
within the hour. Sadly, only half of our acute trusts have any
facility for doing blood alcohol concentrations and there was
St. Mary's, the great London Teaching Hospital, when I started
we had to send bloods off to Guy's poison centre to get a blood
alcohol concentration. So I hope I have answered your question.
Q202 Charlotte Atkins: You have.
What do you think primary care should be doing? You see them at
a stage not too late but at a stage where they are already hooked
on alcohol to a very bad extent, but what should primary care
be doing alongside acute hospitals along the line of prevention?
Professor Touquet: Could I answer
that in two parts? First of all, we in A&E will see a lot
of young people who do not necessarily make use of their GP and
we will see often the first manifestations of alcohol misuse of
fall, collapse, head injury, assault. In primary care I would
agree with what has been said before. You have heard about the
shortened audit questionnaire and I think it is on two levels.
First of all, when patients register with the GP; then it is very
appropriate that the word "screening" is used as a basic
index, bearing in mind you have to get empathy with the patient
so that they are not worried that the nurse will be judgmental
if they give an all too honest answer. Secondly, when patients
can see their GP with conditions such as lack of sleep, palpitations,
alteration in bowel habit, unable to cope with life, that is a
potential opportunity for opportunistic intervention with a teachable
moment, and certainly alcohol can be one of the underlying causes
which any GP should be alive to.
Dr Raistrick: Can I just comment
on psychosocial interventions a bit more generally because I think
it is really important to understand that we are talking about
interventions that are fundamentally different to, for example,
having a course of Tamiflu. The difference is that we are talking
about a process of change and it is the way that the treatment
is delivered and when it is delivered that matters as much as
the particular treatment. We have a very good grasp of what are
the effective ingredients of interventions for addiction problems.
For example, what you are trying to do with a psychosocial intervention
is either start that process of change going or, if it has already
started, to move it along. So you are asking if there was one
question what would you ask? It might be something like, "What
do you mind most about your drinking?" because a question
like that might resonate with where the person was already at.
You would get very different answers. For example, two rather
extreme cases I can think of, a musician in response to that question
said he fell off the stage when he was drunk and that is what
he minded most and that was the driver for him to change his behaviour.
Another example I remember particularly was a mother who forgot
to pick her child up from school because she was so drunk and
that is what she minded most. More commonly it is things like
relationships breaking down and so on. But the idea of the psychosocial
intervention is to tune in to the concerns that the individual
already has. To illustrate how the process happens, I can say
it is pretty typical if you look at people coming to specialist
services that somewhere around 20% will already have stopped drinking
by the time they come to the service. That is not to say that
they are better, but it is to say that they have already started
that process of change themselves; so you are picking them up
part way along the journey. The key to success is making lifestyle
changes which is quite difficult to do and quite a long process.
I think we should be making much more use of community resources
to help people do that; we should be using self-help agencies
much more; family support has already been mentioned. A treatment
you might be familiar with that we looked at in the UK Alcohol
Treatment Trial—the Social Behaviour and Network Therapy,
which aimed to draw on the person's social network to support
change. We talked about people who are dependent which is another
dimension really, so that the more dependent people are the more
their life is entwined in drinking or use of other substances
and the more difficult it is to make those lifestyle changes—that
is really all that dependence adds to the equation.
Ms Binns: I just wanted to add
something very briefly to what we can do around prevention and
it was the fact that I think any prevention needs to start from
the point that alcohol affects all sectors of the community, the
whole population, and whereas acute hospitals and GPs are very
important contact points lots of people are not coming into contact
with those people regularly. Young people, for example, do not
see their GPs very often and do not come into contact with any
healthcare workers. So prevention needs to actually target a range
of primary contact points and that would include schools, youth
services, criminal justice, occupational health, major employers,
and we need to widen the base to where we push out prevention
messages and where we give out preventive services, rather than
look at a small number of very targeted, very specialist areas.
Q203 Dr Naysmith: Dr Raistrick, you
had really started on the sort of area that I want to explore,
so we can it from some of the things you have already been saying.
The question is how effective is the treatment for alcohol misuse
in your experience—that means the Leeds Addiction Unit,
I presume? Is it effective? Then I want you to compare it with
what happens with drug treatment for other substance misuse. How
does alcohol compare? Is it effective and how does it compare
with the way that treatment is administered and is available for
other substance misuse?
Dr Raistrick: The difficulty is
that it depends what you mean by "effective".
Q204 Dr Naysmith: Does it work?
Dr Raistrick: Putting that aside
for the moment, as a unit we have been rather fortunate, I guess,
in that we have generally been involved in research projects to
improve our practice and the UK Alcohol Treatment Trial was a
good example of that; so within the UK Alcohol Treatment Trial
we were delivering something like 40% of people were becoming
abstinent and others showing reductions in drinking. That would
be fairly typical for our patient group as a whole. If we look
at both heroin users and alcohol users we get something like 50%
will show significant improvement and that would be a statistically
significant improvement. If you apply more stringent tests and
look at what is clinically significant improvement then that drops
down to something a bit more like 30%, but that is a pretty harsh
test and there is a range of improvement which you might consider
good enough improvement, so it depends a bit on what you mean
by improvement; and it also depends on what areas you are looking
at improvement.[1]
Q205 Dr Naysmith: Presumably you
cannot do control trials and leave people untreated can you, or
can you look at a population of untreated people that have never
been offered it and see what proportion of them improve just automatically?
Dr Raistrick: I do not think you
can any more actually. This was one of the ethical considerations
we had when we looked at the UK Alcohol Treatment Trial and we
came to the conclusion that you could not have the no treatment
control group; although methodologically it is always a bit unsatisfactory
to have a group where you are not doing anything and in UKATT
we had two interventions that everybody was very enthusiastic
about—there was a brief motivational therapy and a slightly
more intensive social networking therapy. So we took the view
that the ethical approach was to say that there is a gold standard
treatment here, namely the motivational treatment and we will
judge things against the motivational treatment as the gold standard.
Q206 Dr Naysmith: One of the points
I am really trying to explore is the belief for which there is
a fair bit of evidence that there is more effective treatment
for drug misuse than there is for alcohol misuse; is that fair?
Dr Raistrick: I would not say
that was fair at all, no.
Q207 Dr Naysmith: Only 5.6% of dependent
drinkers were receiving treatment in 2004; and last year there
were 55,000 people receiving treatment for alcohol disorders,
compared to 193,000 for drug disorders. So there were more people
on drug treatment than there were on alcohol treatment, yet probably
there are more dependent drinkers than there are drug addicts.
Dr Raistrick: I am sorry, I think
I must have misheard you. Certainly there are more resources going
into drug treatment.
Q208 Dr Naysmith: That is the point,
is it not?
Dr Raistrick: Sorry, I misheard
your question.
Q209 Dr Naysmith: Is that right?
Dr Raistrick: That is certainly
the case.
Q210 Dr Naysmith: Should that be
the case, given the bigger problem that alcohol must be compared
with drug abuse?
Dr Raistrick: I think the difference
is huge, is it not? The National Audit Office produced figures
saying that it is something like £1700 per head spent on
drugs and £200 on alcohol treatment episodes, so clearly
that is a huge discrepancy. I think there are other problems with
that as well, that the drugs strategy is driven by a separate
bureaucracy which is also hugely expensive, whereas the alcohol
services are not—they are driven through the usual Department
of Health systems. Certainly in the early days the driving of
the drugs policy, to my mind, lacked any sort of therapeutic optimism
and I think there was a satisfaction to have essentially a methadone
programme that was on the harm reduction ticket but a methadone
programme that really did not deliver very much in terms of other
health and social gains. So it seems to me that while a lot of
money is being spent on the drugs field the money is not being
very well spent.
Q211 Dr Naysmith: What are the inadequacies
then in the treatment of alcohol-related problems—people
who are drinking too much and people who have got to the stage
of problems with their drinking? What are the inadequacies in
the treatment that you see?
Dr Raistrick: Other people have
said that there needs to be a range of services. Clearly primary
care is an important starting point; there is good evidence for
brief or briefer interventions in primary care, but it has proved
very difficult to role out what we know to be effective treatment
into the primary care setting—very, very difficult to do
that. The alternative is to say let us have some specialist workers
going into primary care settings if the primary care teams are
not willing or able for some reason to deliver the services. So
that would be important for the longer term reduction and prevention
of problems, but of course if you do intervene more actively in
those settings and in all the other generic settings—social
services, probation and so on—that will uncover a lot of
people with more dependent drinking, so there needs to be an increase
in specialist services. There need to be services such as Lynn
has described in the general hospitals, and as Robin was saying
the whole of the alcohol delivery services need to be more linked
together. At the moment they are seen as pretty much separate
from the rest of the NHS.
Q212 Sandra Gidley: The Government
claim that there has been more money put into alcohol services
but it just goes into the PCT pot. Do you think that all of the
money that is in theory designated for the alcohol services is
actually spent on alcohol services?
Dr Raistrick: I would think that
it was not; there generally is not any evidence for that! I can
really only speak for where I work, which is Leeds and as far
as I am aware none of that money has yet been allocated—none
of the money at all has been allocated.
Q213 Sandra Gidley: So does there
need to be a dedicated funding stream?
Dr Raistrick: It always helps
to have some clear guidance from the Department of Health. I know
that the Department of Health see that they cannot be directive
but I think some very strong guidance saying "You should
have this; you should have that" usually results in the money
being spent, although times might now be difficult.
Q214 Sandra Gidley: Would you like
to put a figure on how much more money needs to be made available
to tackle the problems? Or even in your area, to give us a rough
idea of the shortfall?
Dr Raistrick: I think it is unlikely
that a lot more new money will be available and I think the existing
money could be better spent; we could reduce the drugs bureaucracy
and move some of that money into alcohol. We could reduce the
bureaucracy generally—I know everybody always says that
and it is difficult to do, but we could try and do that. We could
use resources that already exist in primary care and in secondary
care. It is very difficult to put a figure on it.
Q215 Sandra Gidley: Would you say
that it is fairer to say it is more of an overall lack of attention
to the problem than necessarily needing a dedicated funding stream?
Dr Raistrick: I think both things
need to happen. There is an overall lack of attention to the problem
and I think if you look around the country the range of services
available in any town or city varies hugely and undoubtedly there
is a need for additional services, but I am not in a position
to put a figure on it.
Ms Binns: Could I comment on that
from the commissioning perspective because you are asking about
the investment levels in the PCT? The DoH has come out with the
formula that for every pound we spend on alcohol treatment we
save £5 in the rest of the NHS. I do not think that is something
that anyone would argue with; there is ample evidence around that.
So in some respects investing in alcohol services is a spend to
save approach. However, shifting money within the NHS is much
more complex than that, so whereas if we are saying that if we
spend money today we may save money in some of the higher end
treatments in five, 10, 15 years' time but we cannot actually
take the money out of those services today.
Q216 Sandra Gidley: So you need transition
funding?
Dr Raistrick: We need transition
funding, yes. Also, the additional item is that many people who
we know have an alcohol problem or are developing an alcohol problem
are not in contact with treatment services at the moment; they
have not yet been identified and they have not identified their
end problem. So this is a new group for whom we are not currently
providing services. Again, we know that the evidence is that if
we identify those people and give them early treatment then they
will not cost us a great deal of money further down the line.
Q217 Dr Naysmith: We have seen some
figures that suggest that the voluntary sector spends a lot more
than the NHS on delivering alcohol treatment. Is that your experience,
Dr Raistrick?
Dr Raistrick: I think there has
been a changing pattern and there has been a shift of services
into the voluntary sector. I understand from commissioners that
the main purpose of that is to create a market place. I do not
know if that is true but I can understand why that would be the
case. So money has gone from the Health Service into the voluntary
sector.
Q218 Dr Naysmith: Are we coming to
rely on the voluntary sector in this area then and are they capable
of delivering a service, given the way they have to raise money
and so on?
Dr Raistrick: The voluntary sector
has been a part of alcohol services for as long as I have been
in the field, which is quite a long time, so I do not think it
is really about relying on one sector or the other—the sectors
have generally always contributed a particular part to the whole.
I think that probably has changed, as I say, recently for the
purposes of creating the market.
Q219 Dr Naysmith: Can they cope with
the demands that are being placed on them now?
Dr Raistrick: There is an over
enthusiasm by some non-statutory sector services to go for contracts
that possibly they are not likely to be competent to deliver;
indeed, that has happened recently somewhere I know, where a non-statutory
agency got a contract to deliver an arrest referral scheme and
then phoned a specialist service saying, "Our staff do not
know how to deal with alcohol problems; how do we refer to you?"
So there is, I think, a bit of a problem. Having said that, the
staff in the NHS are not always competent to deal with these problems
either.
1 Note by witness: Usually domains of substance misuse,
dependence, psychological and social well being. Back
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