Supplementary memorandum by the Department
of Health (AL 01D)
I am writing further in response to the matter
you raised with me about the care of patients who are intoxicated
when they present for treatment at hospital A&E departments.
You raised the question of payment for this in the context of
the recovery of NHS costs following road traffic accidents (RTAs).
A&E departments see acute health harms resulting
from a wide range of human activities, lifestyle choices and misadventure.
Acute instances of health harms resulting from alcohol misuse
present at A&E alongside the other accidents, poisonings,
para-suicides, falls, sporting injuries etc. Nevertheless, the
NHS has never sought to single out any avoidable injury, illness
or health harm, nor to charge the patient for any treatment required.
Following RTAs, the recovery of NHS treatment
costs made under the Injury Cost Recovery scheme arises only where
there is a successful claim for personal injury compensation.
Our proactive approach is to invest resources
in prevention, to save on NHS costs in the future. This means
tackling issues like smoking, obesity, lack of exercise and misuse
of alcohol to prevent the associated health harms from occurring.
For alcohol misuse, preventive action to reduce consumption, early
interventions and effective treatment for alcohol dependence reduce
both short-term health harms, like accidents and poisonings, and
longer-term consequences, like cancers and cirrhosis.
It is now widely recognised that every £1 invested
in interventions and treatment to address alcohol misuse saves
the economy £5. Of this, £3 is a direct saving
to the NHS. Improving the way the NHS tackles alcohol misuse,
which we are seeking to do through the Alcohol Improvement Programme,
is thus very much in the economic interest of the NHS, as well
as in the interests of the population.
I am attaching some further information for
the Committee, on the care that hospitals may provide for intoxicated
patients and on the payments that may be made to NHS trusts following
RTAS.
I hope this is helpful. Please let me know if
you would like any further information.
V. NHS CARE FOR
INTOXICATED PATIENTS
NHS hospitals provide a range of facilities
and approaches to meet the needs of patients presenting at A&E
following injuries, accidents, poisonings etc.
If patients are also drunk on arrival, clinicians
are presented with an additional hurdle in assessing the extent
of other injuries or illness that these patients may have, and
which their intoxication may conceal.
The NHS has a duty of care to patients who are
intoxicated who may be a danger to themselves or to others and
who may also have other medical or mental health issues that need
to be assessed and treated.
The governing principle is that a place of safety
is required and therefore such patients need to be admitted and
observed. The emergency care facilities most likely to be available
to intoxicated patients presenting at a District General Hospital
(DGH) A&E are a Clinical Decision Unit (CDU) or an Emergency
Assessment Unit ( EAU).
Clinical Decision Unit (CDU)
CDUs deal with A&E patients with a specific
set of presentations where rapid diagnosis and monitoring is required.
This might include, a head injury, chest pain, possible deep vein
thrombosis or pulmonary embolism. CDUs are not in-patient wards
and tend not to be open 24 hours a day. CDUs are not present
in all hospital Trusts and tend to be confined to the larger Trusts.
CDUs may be used to place intoxicated patients
who require monitoring and observation for more than the four
hours that they might be expected to stay in A&E. Some intoxicated
patients may also be placed there as they require psychiatric
referral, which can take several hours to arrange, not least as
psychiatrists may find it difficult to assess a patient until
he or she is sober.
St Mary's Paddington and St Thomas' both have
a Clinical Decision Unit as an extension of the A&E department.
The CDU functions by rapid turnover and is designed to have 250%
occupancy in 24 hours. The CDU provides a quieter environment
for patients to receive time-critical investigation and/or time
limited treatment for their illnesses. Some patients may stay
a short time, eg awaiting a blood test result, others may remain
on the unit up to 24 hours.
Patients go to the CDU if they are not fit to
go home—but should be able to do so within 24 hours
and do not warrant the involvement of specialist teams.
Emergency Assessment Unit (EAU)
EAUs are in place in most hospital Trusts. These
units take either medical patients only, or medical and surgical
patients and they cater for a much wider group of patients than
CDUs. EAUs tend to be open 24 hours a day and will take referrals
from GP's, or from A&E, and sometimes from outpatient clinics.
Intoxicated patients requiring observation may be placed in EAUs
where appropriate.
The purpose of the EAU is to allow a complete
assessment of the patient, to determine whether they need to be
admitted and, if so, to which type of ward (cardiac, gastro etc.)
A typical patient might be an older person who has had a fall
at home and their GP is concerned that there may be an undiagnosed
medical cause. EAUs also deal with the CDU range patients, where
no CDU is in place
Role of A&E, CDUs and EAUs in tackling alcohol
misuse
When people who are severely intoxicated are
admitted to CDUs and EAUs this presents an opportunity for interventions
to tackle alcohol misuse. For example, the consultant at St Mary's
advises that their CDU is fertile ground for referrals to their
Alcohol Health Worker for brief advice and interventions.
In addition to providing brief advice, Alcohol
Health Workers and specialist alcohol nurses in hospitals can
identify dependent drinkers and refer them into appropriate treatment
services. This has been shown to cover the cost of employing such
a specialist nurse in as little as three months.
Extending the evidence base on interventions for
alcohol misuse
DH is seeking to extend the current evidence
on interventions for alcohol misuse in different settings. Since
November 2007, it has been running the £4 million Screening
and Intervention Programme for Sensible Drinkers (SIPS).
SIPS is testing intervention approaches for
people drinking at increasing-risk or higher-risk-levels in three
settings (A&E, GP practices, probation). Initial findings
on best practice for each setting are expected in 2010.
VI. RECOVERY
OF NHS TREATMENT
COSTS FOLLOWING
ROAD TRAFFIC
ACCIDENTS
The Department of Health recovers NHS treatment
costs relating to road traffic accident personal injury cases,
but only where an injured person makes, and is successful with,
a claim for personal injury compensation.
Hospitals have been able to recover the cost
of treating victims of road traffic accidents for more than 70 years.
The current scheme, the NHS Injury Costs Recovery (ICR) Scheme
has been in force since 2007, when it subsumed the provisions
of the Road Traffic (NHS Charges) Act 1999.
Operation of the scheme is carried out on behalf
of the Secretary of State (for England and Wales) and the Scottish
Government (for Scotland) by the Compensation Recovery Unit (CRU),
part of the Department for Work and Pensions. CRU calculates how
much will be payable in NHS charges, if the compensation claim
is successful.
CRU uses a tariff system and the tariffs are
uprated annually. Currently, these are £695 per day
for in-patient treatment and a one-off charge of £566 for
out-patient treatment. There is an overall cap on the amount that
can be recovered in NHS charges for any one injury, currently
standing at £41,545 (the equivalent of 60 days'
in-patient treatment).
CRU issues a certificate to the person or body
liable to pay the compensation confirming the amount due and collects
the payment. CRU forwards the funds recovered to the relevant
NHS trust(s) that treated the injured person. All monies recovered
go direct to the NHS trust(s), not to central Government.
Gillian Merron
Minister of State for Public Health
11 December 2009
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