Health Committee - The Government's Alcohol StrategyWritten evidence from the NHS Confederation (GAS 64)

Executive Summary

The NHS Confederation represents all organisations that commission and provide NHS services. It is the only membership body to bring together and speak on behalf of the whole of the NHS. While we recognise the range of actions proposed across government in the alcohol strategy, our submission focuses on the area where we have expertise, the health service.

Alcohol abuse is putting a growing strain on our health services. Alcohol related admissions to hospitals more than doubled between 2002–03 and 2009–10. The burden on the NHS will be unsustainable if demand continues to grow.

Improvements to public health and NHS services must be made in conjunction with cross government action if we are to effectively tackle the impact on our health of the way in which we consume alcohol. We therefore welcome the Government’s efforts in the alcohol strategy to provide additional powers to health trusts and local authorities to work together to reduce alcohol harm.

Our submission outlines examples of successful NHS led initiatives, on both a local and regional level. However, the fact that only one in 18 people who are dependent on alcohol receives treatment shows there is scope for further improvement. This will require further action from central and local government as well as the NHS. The NHS Confederation makes the following recommendations to help address this issue:

GPs, community providers, mental health services and ambulance trusts can all play a greater role in tackling alcohol abuse.

Mechanisms for offering financial incentives to NHS providers for their prevention and health promotion activities should be considered. The current tariff system of paying for many services effectively penalises rather than rewards preventative, demand-reducing work. Furthermore, the pressure to meet rapidly increasing demand from drinkers who urgently need services in a crisis makes it difficult for preventative work to keep pace.

The NHS needs to maximise the opportunities healthcare professionals have with individuals and communities to improve their health and well-being (the so-called “every contact counts” approach). We recommend that:

National bodies’ contracts should be reviewed to ensure they support the delivery of the every contact counts approach.

Commissioners should similarly consider how their service specifications in providers’ contracts support this approach.

The NHS should also develop services which help individuals with an alcohol related disease to understand the root causes of their condition in order to tackle it more effectively.

Local authorities must have enough money to commission and deliver public health services, including alcohol services.

Health and wellbeing boards should coordinate work to tackle alcohol abuse at a local level, to make the most of the resources and expertise across the whole range of organisations, funding, commissioning and delivering this. In doing so, they should engage with Police and Crime Commissioners and academy schools, as neither are represented on health and wellbeing boards.

Local coordination and clear accountabilities for both commissioning services and achieving outcomes are important in preventing fragmentation of support for young people and children, given arrangements for commissioning their services will be even more complex in the new system.

Public Health England and the NHS Commissioning Board should lead on providing the support and advice that local areas will need to develop cost effective and best practice based plans for tackling alcohol abuse.

To assist health and wellbeing boards in their role coordinating joint work on alcohol harm reduction, we would like the Government to articulate how taken together outcome framework indicators could be used to encourage more preventative work.

1. The impact of alcohol abuse on the NHS

1.1 The increase in alcohol abuse in the UK has resulted in an increased demand for NHS services. It was already costing the NHS £2.7 billion a year in 2006/07 (the most recent year for which figures are available)1 and demand has increased significantly since then. For example, alcohol related admissions to hospital more than doubled between 2002–03 and 2009–10, from 510,200 to 1,057,000.2 Difficulties in recording alcohol-related harm mean that the impact is likely to be even higher. The burden on the NHS will be unsustainable if demand continues to grow.

1.2 With the pressure to react to a growing number of urgent needs, preventative and specialist services have struggled to keep pace with alcohol driven demand and hospitals have been bearing the brunt of the burden. In 2008 over 70% of the cost of alcohol to the NHS was spent on hospital treatment.3 Inpatient costs were almost 45% of the total NHS expenditure in alcohol related services that year compared to around 12% in 2001.4

1.3 Other NHS services are also experiencing rising demand as a result of alcohol abuse. For example, a third of mental health service users have alcohol problems.5 Furthermore, over six% of calls to London ambulance services are alcohol related incidents. This is approximately 68,792 calls a year.6 Since the ambulance crews only record the illness and not the cause of the illness, the actual figure is likely to be much higher. This adds to growing pressures; the overall number of calls handled by the ambulance service nearly doubled between 2000–1 to 2010–11, from 4.41 million to 8.05 million.7

2. How the NHS is tackling alcohol abuse

2.1 Our report Too much of the hard stuff: what alcohol costs the NHS8 sets out a number of initiatives our members have implemented to tackle alcohol abuse and decrease the impact this problem has on NHS services. This includes the Royal Bolton Hospital which established a specific alcohol team overseeing both inpatient and outpatient care, with patients being seen in a specialist clinic. The team saved the trust over 1,000 bed days a year by ensuring that patients who previously would have received inpatient treatment were given rapid outpatient appointments with the community alcohol team. This meant a saving to the trust of approximately £250, 0009 over one year.

2.2 NHS North West has established a large scale project to target alcohol abuse and reduce alcohol related hospital admissions. The project has resulted in greater partnership working between agencies and more consistency in the way the problem is dealt with across the region. A range of practical measures have been implemented including better training for staff and placing alcohol specialist nurses in acute services. This is a long term project, which hopes to save £36 million over the next two years and there are already signs of progress. For example, Blackpool Acute Trust reported a 7% decrease in hospital admissions, a net saving of £130,000, in 2010, the first year of implementing the project. This was in comparison to a 14% increase in admissions during 2009.

2.3 Our Mental Health Network’s report Seeing double: meeting the challenge of dual diagnosis10 argued that NHS organisations need to improve training, promote greater awareness in staff and encourage greater partnership working between agencies if the NHS is to effectively tackle alcohol abuse. The report looked specifically at the challenges posed by people who have concurrent mental health and substance abuse or alcohol problems, so called “dual diagnosis”. It highlighted that the complex interrelation between alcohol and mental health problems in these cases means that the stakeholders involved in effective interventions are numerous. An integrated and coordinated service with cross agency working is therefore key. The report found excellent examples of good practice but argued that national level provision is patchy and remains an area of concern.

2.4 While a number of our members have implemented successful alcohol initiatives, overall the increase in demand for NHS services as a result of alcohol abuse has not been matched with an increase in the availability of appropriate alcohol services. Only one in 18 people who are dependent on alcohol receive treatment and the availability of specialist services differs widely across England.11 The pressure to meet rapidly increasing demand from drinkers who urgently need services in a crisis makes it difficult for preventative work to keep pace. Furthermore, current financial pressures could make it harder still to fund preventative work.

2.5 There is clearly scope for further improvement to NHS services to tackle alcohol abuse. However, this will require further action from central and local government as well as the NHS.

2.6 The current system of paying for the amount of work done in many services (tariff) means efforts to reduce demand through preventative work not only lack positive incentives, but also could effectively be penalised rather than rewarded. We recommend that mechanisms for offering financial reward to providers for their prevention and health promotion activities should be considered by the Department for Health. For example, the Commissioning for Quality and Innovation payment framework could include public health incentives.

2.7 Hospitals cannot tackle this problem alone. Effective interventions for patients need to be mirrored in the community and in primary care. As we argued in Too much of the hard stuff: what alcohol costs the NHS, out-of-hospital services can provide high quality and cost effective solutions and ease the pressure on hospital services. GPs, for example, are well placed to identify and address alcohol related harm given their close community links. A series of controlled trials demonstrated that brief advice from a GP or community nurse leads to one in eight people reducing their drinking to within sensible limits.12 The study found the figure was one in 20 for smoking cessation services.13 Mental health services and ambulance trusts can also play an increased role.

3. Making every contact count

3.1 The NHS must maximise the opportunities healthcare professionals have to improve the health and well-being of individuals, families and communities (the so-called “every contact counts” approach). There are many instances where individuals who are unaware that their regular overconsumption of alcohol is harming their health come into contact with the NHS. The NHS needs to work with others, including the police and local authorities, to ensure all age groups, particularly young people, are aware of these risks.

3.2 While we welcome the Government and the Future Forum’s support for making every contact count, we believe that the NHS needs to make a cultural shift in thinking and behaviour to ensure this policy becomes the norm throughout the health service. Financial incentives must be looked at (see paragraph 2.6). The following steps would also help achieve this:

National bodies’ contracts should be reviewed to ensure they support the delivery of the every contact counts approach. If the Department of Health, for example, plans to redesign community pharmacy to support this objective then the national pharmacy contract will need to be revisited.

Commissioners should similarly consider how their service specifications in providers’ contracts support this approach.

3.3 In addition to making every contact count, the NHS should build on what individuals identify as supporting their own well-being, rather than focusing on the separate lifestyle behaviours identified by the health service, such as alcohol consumption. In practice, this would mean services which help individuals with an alcohol related disease to understand the root causes of this condition in order to tackle it more effectively. Such an approach would also help change the existing power dynamic between patients and the NHS; turning patients from passive recipients of services to potential partners, who actively take responsibility for their own health.

4. Integration and making the funding work

4.1 In the new system, NHS funding for alcohol services will be transferred to local authorities as part of the public health ring-fenced budget. Additional funding for alcohol services will come from a number of other sources. The Police and Crime Commissioners (PCCs) will have funding to tackle alcohol related harm within their areas. Schools will have funding for personal, health, social and economic education (although they will not have a statutory place on health and well-being boards). Local authorities are also in receipt of funds for the troubled families programme.

4.2 We are concerned that this arrangement risks fragmenting efforts to tackle alcohol abuse. To address this we recommend:

Health and wellbeing boards play a leadership role, coordinating joint work on tackling alcohol abuse at a local level. The boards should ensure various commissioning bodies work together to make the most of resources and expertise across the system.

It will be essential that the boards engage with PCCs and academy schools, as neither are represented on health and wellbeing boards.

Public Health England and the NHS Commissioning Board should lead on providing the support and advice that local areas will need to develop cost effective and best practice based plans for tackling alcohol abuse.

There are a number of indicators in the different outcomes frameworks which are relevant to alcohol. To assist health and wellbeing boards in their role coordinating joint work on alcohol harm reduction, we would like the Government to articulate how taken together the indicators could be used to encourage more preventative work.

4.3 The risk of fragmentation in alcohol services is even greater in relation to children and young people. In addition to the situation described above, there are eight levels in the new system at which health and wellbeing commissioning for children and young people will take place. To address this we recommend:

The Government is explicit about where accountability lies for alcohol services for children and young people and how shared outcomes between the NHS and public health outcomes frameworks will be monitored, measured and incentivised across organisational boundaries.

The outcomes strategy for children incorporates all health-related (NHS, social care, public health) and non-health (education, youth justice, policy, children’s services) services to make it clear how different sectors contribute to reducing alcohol related harm and improving health and wellbeing outcomes.

4.4 Our members are concerned that local authorities may not have enough money to commission and deliver all the public health services that they will be responsible for, including alcohol services. While the public health budget will be ring fenced, we emphasise that it is not easy to define “public health” and therefore to identify public health activity and spend accordingly. This could mean the budget set by the Government for public health funding will not adequately meet local needs.

May 2012