Health Committee - The Government's Alcohol StrategyWritten evidence from the Royal College of General Practitioners (GAS 66)

About the Royal College of General Practitioners

The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 44,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient–centred generalist clinical care.

The RCGP endorses the points made in the Alcohol Health Alliance UK submission, but has made comments of its own following review by the College’s policy team, led by Honorary Secretary Professor Amanda Howe, and drawing on the expertise of Dr Linda Harris, the College’s Clinical Director for Substance Misuse and Associated Health. RCGP comments are placed in bold in underneath the relevant sections of the AHA text below.1

5. The Role of the Alcohol Industry

5.3 In line with WHO recommendations, while we believe business must play a part and have the opportunity to engage with health issues, health experts must lead on setting policy priorities.2 Although businesses have a role to play in protecting and promoting the health and wellbeing of their employees and the wider community, and implementing and supporting public health initiatives it is not the place or responsibility of business to define public health policy or to be responsible for public health information, as in many cases this is in direct conflict with their interests and responsibilities to their shareholders and employees.

The College supports the statement made in the above paragraph, and would add that there is a need to gather more evidence on what positive role local businesses can play. The College would like to see an interim report on the local implementation of the Responsibility Deal and outcomes achieve so far, with a view to identifying whether it has been successful and what if any pockets of good practice can be identified.

5.4 To address this conflict of interest the AHA recommends that industry contributes to funding for public health initiatives via a truly independent charity or blind trust, constituted as a grant-giving foundation to support bodies operating for the public good with a track record of reducing alcohol harm, without involvement from industry representatives. All programmes and policies should be subject to proactive monitoring and independent evaluation, including those with private investment.

The College supports the above statement, with the addition that Alcohol Concern could be a vehicle for independent public health campaigning, R&D initiatives and targeted specialist campaigning—this would avoid the need to set up a separate charity diluting already very sparse resources for established groups with similar aims and objectives.

6. Greater Investment in Effective Interventions

6.3 The strategy raises a number of health risks such as foetal alcohol spectrum disorders and mental illness, along with highlighting the value of early identification and treatment of alcohol disorders. A comprehensive system of care is required to successfully address the wide spectrum of health harms, however the strategy fails to provide any specific actions or funding in these areas.

The College strongly endorses this point. In the absence of additional or targeted funding, professional and voluntary sector groups working with the consequences of alcohol abuse will find it more difficult to promote their healthy behaviour change messages. Whilst they are less common in general practice than other alcohol-related disorders, foetal spectrum disorders are a concern and investment in prevention is very important.

Early diagnosis and treatment of alcohol use disorders

6.6 The NICE Guidance on alcohol use disorders states that primary prevention of alcohol-related harm at primary care level is both effective and cost effective.3 This should be incentivised through including a measure in the Quality and Outcomes Framework for GPs to record the alcohol intake of their patients and to give brief advice where indicated. For patients who do not respond to simple advice there should be a stepped programme of further intervention.

The College strongly supports the above call for inclusion of a new measure in the Quality Outcomes Framework. In the meantime, there needs to be a focus on promoting the NICE guidance and using the findings of the SIPS project4 as pointers for local commissioners who could strongly influence the development of local service specifications for commissioned alcohol treatment.

6.7 Cost effective treatment interventions for alcohol dependence have been described in NICE guidelines5 but are currently available only to a small proportion of those who could benefit from it. This will require sustained investment in specialist alcohol services to achieve parity for services for drug misusers.

Findings from the National Alcohol Payment by Results Pilots, which concluded in April 2012, will be relevant here. The pilots could potentially provide the basis for a locally-led approach to encouraging providers to benchmark their existing service provision with NICE’s recommendations, and may also encourage service providers to work together to redesign services and promote a more balanced, evidence-based and outcomes-oriented offer. Dissemination and careful consideration of the findings of the pilots is needed. The findings of this pilot should be compared with those of the current (separate) Drugs and Alcohol Recovery Pilot which is not based on NICE based pathways and packages of care. As stated above, the College believes there should be a focus on promoting the NICE guidance.

Secondary care services

6.8 Healthcare modelling methodology suggests that if each district general hospital established a seven day Alcohol Specialist Nurse Service to care for patients admitted for less than one day and an Assertive Outreach Alcohol Service to care for frequent hospital attendees and long-stay patients, it could result in a 5% reduction in alcohol-related hospital admissions, with potential cost savings to its locality of £1.6 million per annum. This would equate to savings of £393 million per annum if rolled out nationally.6

6.9 The AHA recommends that there should be a multidisciplinary ‘Alcohol Care Team’, a seven day Alcohol Specialist Nurse Service and an ‘Assertive Outreach Alcohol Service’ in every District Hospital. Transitions between teams and services should be quick and seamless in order to increase the efficiency and cost effectiveness of the service.

GPs and Primary Care teams play a crucial role in liaison with acute and community services and we would stress that these teams should be involved in step up/step down interventions and packages of care as part of integrated care pathways. They could also involve already funded out of hours providers as part of a local collaborative.

7. The Changing Public Health System

7.1 The AHA believes there is potential to work more closely with local authorities to drive change and innovation, and deliver services targeted to the needs of local communities. However, with the changes to the public health system come risks that must be mitigated. These include: unjustifiable variation, piecemeal and fragmented service provision, an absence of quality evaluation metrics, and a lack of information sharing and best practice. The AHA are keen to work with central and local government to identify mechanisms that deliver on the localism agenda, whilst protecting the need for coordinated, integrated and evidence-based policy-making and service delivery.

The College would agree that the need to embrace localism is key. Health and Wellbeing Boards have a vital role through Joint Strategic Needs Assessments in influencing the commissioning decisions made by CCGs. The Boards will need to effectively campaigns to ensure alcohol treatment and service provision is balanced and adequately resourced at a local level.

7.2 A national service framework on alcohol, which could be adapted to local needs, would be an effective way of keeping costs down, sharing best practice and getting the best value for money. A framework could be led by a dedicated alcohol team within Public Health England, with established experts leading the research work at the highest level, setting out principles for action, rather than prescriptive plans. This allows for local areas to develop plans to meet local needs with the backing of expertise and knowledge provided by PHE.

In the College’s view national service frameworks (NSFs) have the potential to be very effective when introduced and implemented rigorously through a nationally applied performance management structure. However, alongside the Alcohol Health Alliance’s call for an NSF, the College argues that there is a need to focus on the development and use of the current NICE guidance and the associated commissioning guidance which would then be adopted by Health and Wellbeing Board. We would also reiterate (as stated in 6.7 above) that there is a need to carefully analyse the forthcoming findings of the national alcohol payment by results pilot, which is based on NICE packages of care.

9. Coordination of Alcohol Policy

9.1 Policies relating to alcohol fall under a broad range of governmental departments, including the Home Office, the Department of Health, the Treasury, the departments of Culture, Media and Sport and Transport and Communities and Local Government and the Ministry of Justice. There is therefore a particularly strong case for a cross-departmental unit on alcohol, and the AHA suggests that such a unit could be led by the Chief Medical Officer—reporting to the Home Affairs (Public Health) Cabinet Sub-committee. A cross governmental alcohol unit could maximise the impact of the different strands of the government’s strategy and ensure there is rigorous evaluation applied to all aspects of the strategy.

9.2 A cross governmental alcohol unit would also be well placed to coordinate policy with the devolved administrations. Greater consistency around policies relating to the price, availability and promotion of alcohol will be important in ensuring success across the UK. In particular, efforts to introduce a minimum unit price on alcohol are already well underway in Scotland and under discussion in Northern Ireland—therefore it is important that the timeframes for introducing a minimum unit price in England and Wales aligns as closely as possible with the devolved administrations.

The College strongly endorses the call for a cross-governmental alcohol unit. The current Department of Health alcohol policy unit is small and has little or no budget of its own. The inter-ministerial group on drugs is an example of a cross-departmental group that is driving forward key changes in policy.

May 2012

1 For full text of Alcohol Health Alliance UK submission see HC 132 Ev ???

2 World Health Organization. The World Health Report 2002: reducing risks, promoting healthy life. Geneva: WHO, 2002.

3 National Institute for Health and Clinical Excellence. Alcohol-use Disorders: Preventing the Development of Hazardous and Harmful Drinking: PH24. London: NICE, 2010.

4 The Alcohol Screening and Brief Intervention Pilots:

5 National Institute for Health and Clinical Excellence. Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. Clinical Guideline 115. London: NICE, 2011.

6 The British Society of Gastroenterology and the Royal Bolton Hospital NHS Foundation Trust . Alcohol Care Teams: to reduce acute hospital admissions and improve quality of care. London:NHS Evidence, 2011.

Prepared 21st July 2012