Alcohol - Health Committee Contents


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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