Health Committee - The Government's Alcohol StrategyWritten evidence from British Society of Gastroenterology (GAS 36)

1. Introduction

1.1 The British Society of Gastroenterology (BSG) is a professional society dedicated to the advancement of standards of care, research, education and training in gastroenterology and hepatology.

1.2 The improvement of clinical services for patients suffering with alcohol-related ill health is a stated priority for the BSG’s Council and broader membership.1

1.3 In response to increasing numbers of patients on gastroenterology and hepatology wards with alcohol related ill health the BSG has produced a range of service design proposals, in conjunction with partner organisations—in particular, the establishment of multi-disciplinary Alcohol Care Teams. The aim of these has been to improve services across hospital trusts and community settings for patients presenting with alcohol-related health problems. These proposals were initially set out in the Joint Position Paper by the BSG, BASL and the AHA which was published in 2010.2 This has since resulted in the publication by NHS Evidence of a co-authored BSG/Royal Bolton Hospital NHS Foundation Trust QIPP Evidence publication. This was most recently updated in February 2012.3 We would like to see the promotion and widespread establishment of Alcohol Care Teams given a higher priority and prominence in the Government’s Alcohol Strategy

1.4 The BSG has for many years supported the introduction of a Minimum Unit Price (MUP) for alcohol and greater regulation of the marketing and availability of alcohol based on the international evidence available. It fully supports the submission of the AHA, in particular its call for the initial level of MUP for alcohol to be set at at least 50p per unit.

2. A Multidisciplinary & Integrated Approach to Alcohol Service Design & Delivery

2.1 As outlined above there is an increasing demand for NHS services for patients presenting with alcohol related ill health. Greater leadership and planning is required to effectively deliver better services for these patients and reduce wider costs associated with acute alcohol-related hospital admissions and readmissions. This demand is felt by A&E departments but is also having a significant impact on gastroenterology and hepatology departments.

2.2 Admissions and readmissions could be reduced if planning was put in place to ensure effective joint working. Each local health area should have a plan to deliver evidence-based care in an appropriate setting, integrated between primary and secondary care. The BSG describes such joint working as “Alcohol Care Teams”. However, the BSG notes that there are unfortunately very few dedicated teams in the NHS.

2.3 The principal recommendation is for a multidisciplinary “Alcohol Care Team” in each District Hospital, led by a Consultant, with designated sessions in their work plans, who will collaborate across hospitals and primary care to develop a coordinated alcohol treatment and prevention programme. This team would organise systematic interventions and alcohol specialist nurses.

2.4 Coordinated policies are essential and the BSG firmly believes that that the NHS and public health (local authority) services need integrated Alcohol Treatment Pathways developed between primary and secondary care, particularly in the light financial penalties for readmissions and for the wider policy agenda of integrating health and social care services. Alcohol Pathways must be led by a clearly defined Alcohol Care Team.

2.5 The BSG believes this approach would have a huge impact on the care of patients with alcohol-related disease, where there are a large number of “frequent attenders”. This serves to highlight the urgent need for commissioners, providers and clinicians to better manage pathways of alcohol care between hospitals and the community. If this is not an active consideration it is patients with alcohol-related ill health that will fall through the gap.

2.6 In addition to this being an opportunity to improve quality of care, both at a population and individual level, there are also are substantial savings to be made. The savings arise from (i) reduced admissions for detoxification (“drying out”) and (ii) reduced readmissions consequent on better management of alcohol addiction and mental health problems, such as, secondary prevention.

2.7 BSG proposals put forward that each multidisciplinary “Alcohol Care Team” should be led by a consultant, with both a clinical and strategic role and five dedicated sessions weekly, who will also collaborate with Public Health structures in Local Authorities, Primary Care Trusts (Clusters and/or CCGs), patient groups and key stakeholders to develop and implement a district alcohol strategy.

2.8 The Team would be a formalised group of individuals, with an overall Lead Clinician. It would include a lead from hepatology, gastroenterology, psychiatry, accident and emergency and acute medicine, other key specialist leads, the Lead alcohol specialist nurse and an executive member of the Trust Board, with a locally appropriate balance of representatives from public health, primary care and patient groups.

2.9 Integration between the Alcohol Care Team and other relevant bodies is vital to a strategy for reducing alcohol-related problems in the district. The BSG strongly advocates that patient groups should be encouraged and supported to develop their own pathways of care, in collaboration with service providers.

2.10 The Lead Clinician would have shared responsibility, with Public Health and primary care, for delivering timely and responsive high quality support services and for achieving targeted quality metrics, including:

reductions in alcohol-related admissions, readmissions and mortality;

improvements in public understanding and awareness of alcohol; and

increased rates of early detection of alcohol misuse.

These metrics align to the NHS and Public Health Outcomes Frameworks.

2.11 The Lead Clinician would usually be a hepatologist, gastroenterologist or liaison psychiatrist. However, the lead could also be an acute medicine physician, accident and emergency consultant or nurse consultant. The lead clinician would identify individuals responsible for alcohol policy in key clinical areas. The lead clinician requires the skills and knowledge to be able to develop, implement, monitor and evaluate effective treatment pathways across disciplines and services, and the ability to provide clinical supervision and support to a range of care providers of different professional groups and specialties. The lead would also provide clinical expertise to policy makers at local, regional and national level (for example at local authority level, within Public Health England or the NHS Commissioning Board).

2.12 The BSG estimates that these proposals could generate £1.6 million savings for a District General Hospital serving a 250, 000 population. This equates to £640,000 per 100,000 population (based on national indicators and length of stay costs).

3. A Leading Role for Alcohol Specialist Nurses

3.1 The dramatic impact of Alcohol Specialist Nurses (ASNs) during a five-day working week highlights the need for them to work routinely on a seven-day basis in hospitals, especially since such a large proportion of alcohol-related problems present out-of-hours, particularly at weekends. Alcohol specialist nurses pay for themselves many times over, in terms of improved detection of alcohol misuse, accessibility, waiting times, DNA rates, reduced inpatient detoxifications and length of stay, thus achieving four-hour trolley waits, relieving bed pressures and reducing A&E attendances, admissions and readmissions.

3.2 A hospital requires a minimum of four Alcohol Specialist Nurses to provide a seven-day rota. Their primary role is to assess and treat all patients admitted to the Acute Medical Units, A&E admissions and to supervise the care of all inpatients with an alcohol-related problem. This improves clinical outcomes, including patient engagement with treatment, inpatient length of stay and mortality.

3.3 The nurses would require a skill mix of mental health, liver and accident and emergency experience, and the competencies to recognise liver disease and psychiatric disorders, especially depression, at an early stage. Where appropriate, two hospitals might provide a combined rota, or a combined hospital and community nurse service could be developed, as in Liverpool.

3.4 Implementation of an ASN service in Nottingham improved the health outcomes and quality of care of patients admitted to hospital for detoxification, and also of those admitted for the complications of alcohol-related cirrhosis (S.D.Ryder et al, 2010). Hospital admissions were reduced by two thirds, resulting in a saving of 36.4 bed days per month in patients admitted for detoxification. Clinical incidents were reduced by 75%. Liver enzyme abnormalities were halved and there was also a reduction in bed days used in the cirrhotic group from 6.3 to 3.2 days per month. Nurse- led follow-up attendance was high in both groups (see Figures 1 & 2).

Figure 1: Impact of Nurse-led Alcohol Care Team compared with “conventional” care on (a) self-reported alcohol intake and (b) the liver enzyme gamma GT, showing halving of alcohol intake and liver damage. Ryder et al, 2010

Figure 2: Impact of Nurse-led Alcohol Care Team on admissions to hospital for alcohol withdrawal. The service was introduced in Q2. (Q1 etc refer to three-month periods from 2002). Ryder et al, 2010

4. Alcohol Outreach Services to Reduce Admissions and Readmissions

4.1 The BSG recommends that each DGH should establish a hospital-led, multi-agency Assertive Outreach Alcohol Service (AOAS), including an emergency physician, acute physician, psychiatric crisis team member, alcohol specialist nurse, Drug and Alcohol Action Team member, hospital/community manager and Primary Care Trust Alcohol Commissioner, with links to local authority, social services, third sector agencies and charities. This will provide integrated medical, psychiatric and social care, especially housing, for the most frequent attenders, some of whom attend Emergency departments, often in different hospitals, on more than 100 occasions per year.

4.2 Salford Royal NHS Foundation Trust has established a hospital-led AOAS. The team works with a cohort of the top 30 patients (frequent attenders), with the highest levels of alcohol-related admissions over a six month period. Each six months, this cohort is refreshed. The team also works proactively with any patient, who has had two alcohol-related admissions within a short period of time, the so-called “fast risers”. Work with the first top 30 cohort resulted in a 66% reduction in Emergency Department attendances in the three month period post-intervention, when compared to the three month period prior to intervention (average monthly attendances were reduced from 83 to 28). There was also a 63% reduction in hospital admissions (35 to 13). This reduction in admissions is being maintained, even though the team is now working with the next top 30 cohort.

4.3. If each DGH establishes a seven-day Alcohol Specialist Nurse Service to care for patients admitted for 0–1 day, together with an AOAS to care for frequent hospital attenders and long-stay patients, for example those with alcohol-related liver disease, healthcare modelling methodology suggests that this could result in a 5% reduction in alcohol-related hospital admissions, with potential cost-savings to its locality of £1.6 million annually. Since the UK population in 2008 was £61.4 million, this would equate to an annual saving for the overall UK economy of £393 million.

5. The Alcohol Strategy

5.1 The BSG welcomes the Government’s recently published Alcohol Strategy and has been actively engaged with both the Department of Health and other parts of Government in the lead up to its publication.

5.2 The focus on price within the Alcohol Strategy is to be welcomed, given that this is the principal drivers of alcohol-related health problems in the UK. While it is understandable that binge drinking, and the associated impacts on the criminal justice system, draw the attention of the headlines, it is important to address the long term effects of population level alcohol consumption on the health of the general population.

The BSG is disappointed that the strategy does not contain specific proposals to reduce the exposure of children and young people to alcohol marketing. Increases in alcohol marketing, together with the development of alcopops in the 1990s were a key factor in the development of our current problems with young people and alcohol. The first ever independent analysis (commissioned by the EU Alcohol Forum) recently showed that children in the UK have a higher exposure to alcohol marketing than adults; the forum science committee previously concluded that “alcohol marketing increases the likelihood that adolescents will start to use alcohol, and to drink more if they are already using alcohol.” A simple solution to this problem was proposed by a member of the Health Committee, Dr Sarah Wollaston, in a 10 Minute Rule Bill introduced last year—a proposal supported by the BSG.

5.3 While the Alcohol Strategy is clearly a cross-Government document drawing in a range of social policy drivers, it is vital that the health challenges and potential health benefits remain at the forefront of the Government’s efforts. The BSG recognises that these issues are interlinked, but hopes that the Department of Health and the emerging structures that follow the Health and Social Care Act 2012 will be given a leading role in implementation. It is equally important that these bodies work effectively across an issue, which spans the various strata of health and social care delivery. The remits of Clinical Commissioning Groups, Local Authorities, the NHS Commissioning Board and Public Health England need to work effectively together, to truly address the problems of alcohol-related harm.

5.4 As outlined in previous sections, it is vital that services are properly designed, planned and integrated to ensure the outcomes for alcohol-related ill health are achieved. While there is some recognition of the need to invest in services (for example alcohol specialist nurses), the Strategy is disappointingly vague on the need for service reform.

5.5 The BSG notes the very distinct possibility that the commissioning of alcohol services, such as those described above, will be pushed between commissioning bodies as “someone else’s responsibility”.

5.6 The levels of consumption of alcohol are still a serious issue for the UK, given that high rates of consumption correlate with alcohol-related harms. Any evidence of a recent fall in alcohol consumption does not constitute a return to the historically much lower levels of consumption. Attempts by the previous Government to liberalise licensing laws has most probably not reduced the amount of alcohol being consumed in the UK and could well have increased the levels.

5.7 The BSG notes that messages about alcohol consumption are often confused and unhelpful. The most important point for policymakers should be the amount of alcohol being consumed, rather than where the alcohol is consumed, who it is consumed with, or the type of alcohol being consumed. As referenced previously, the focus on binge drinking can obscure or deflect from the serious health problems that long term consumption of alcohol can cause.

5.8 The BSG also notes that it is vital that hospital trusts drastically improve the granularity of coding in hospital admissions, in order for the true extent of alcohol-related health service delivery to be reflected and measured. For admissions where alcohol is a secondary factor in hospitalisation, this must also be reflected in statistics, rather than just when it is part of the primary diagnosis.

5.9 A range of studies and modelling have shown the relationship between increasing alcohol unit prices and a reduction in alcohol consumption. The BSG also notes that minimum unit prices affect those who drink at the most harmful level, as they tend to buy the cheapest alcohol in larger quantities. In Canada, where minimum pricing has been implemented, it has been shown to have an effect on levels of consumption.

5.10 The BSG believes that minimum unit pricing is the fairest and most targeted way of addressing harm because it will impact on the heaviest drinkers and on underage drinkers. The BSG also notes that the impact on the most serious drinkers will be seen within a relatively short time frame (three to four years).

5.11 The BSG supports the introduction of a minimum unit price at 50p as this will have the most significant impact on consumption and mortality.

5.12 Alcohol- related mortality is very strongly linked to income and deprivation. According to the ONS, there is a five-fold excess mortality in the most deprived 20th of the male population, compared with the least deprived. The solution to this problem is to take extremely cheap alcohol completely out of the system. The welfare of most deprived sectors of the population should be improved by reducing inequalities in society, not by the provision of cheap alcohol, with its manifold effects on the health of consumers, their families and children. The spurious arguments of the drinks industry, which reaps 75% of its profitability from hazardous and harmful drinkers, should be rejected. The industry is no more interested in the welfare of the poorer sections of society than it is of the children, for whom alcopops was developed.

May 2012

1 The BSG is also a member of The Alcohol Health Alliance (AHA) and has close working relationships with a range of patient and advocacy groups that share an interest in improving patient care for people with alcohol-related disease or ill-health

2 Moriarty et al:

3 NHS Evidence:

Prepared 21st July 2012