Business Case Template
Project Name: Alcohol Liaison Service
Author: [Name]
Sponsor: [Name]
Version 2
09.10.2013
Amendment History
Issue
Date
Author
Reason
Distribution List
Name
Department / Organisation
Public Health England- Anglia & Essex Centre and South Midlands & Hertfordshire Centre
Liaison Service Business Case
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Alcohol Liaison Service
Contents
1.
Executive Summary .................................................................................................................... 3
2.
Introduction and Overview .......................................................................................................... 5
2.2
The Evidence .......................................................................................................................... 6
3.
Cost / Benefits Assessment ........................................................................................................ 8
4.
Option appraisal .......................................................................................................................... 9
5.
Key assumptions and dependencies ........................................................................................ 10
6.
Risk and Sensitivity analysis ..................................................................................................... 12
7.
Timescales: ............................................................................................................................... 14
8.
Comments / Issues: .................................................................................................................. 15
9.
Conclusions and Recommendations ........................................................................................ 16
10.
References ............................................................................................................................ 17
11.
Appendix 1 ........................................................................................................................... 18
Alcohol Liaison Service Business Case
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1.
Executive Summary
The World Health Organisation (WHO 2011)1, states that excess alcohol consumption is a
growing public health problem, causing around 5.3% of deaths in those aged under 60 years
worldwide. In England, about one in four adults aged 16-65 (about seven million people)
drink at levels that increase risk or high risk. Alcohol accounts for 10% of disability adjusted
life years (DALYs) and costs to the NHS of around £3.5 billion each year, which equates to
£120 for every taxpayer in England2. It is estimated that in England in 2011 there were 6,923
deaths directly related to alcohol consumption. High alcohol consumption is one of the top
modifiable risk factors for premature morbidity and mortality in England.
In England in 2011/12 there were estimated to be 1,220,300 hospital admissions related to
alcohol consumption, where an alcohol related disease, injury or condition was primary
reason for hospital admission or a secondary diagnosis. This is estimated to be a 4% increase
on the 2010/11 figure (1,168,300)3.
The number of alcohol attributed admissions at insert name of Hospital for 2011/12 was …
this equates to a total cost of insert £ 000 per annum.
Evaluation of Alcohol Liaison Services in England suggests that by employing one Alcohol
Liaison Service Nurse /Worker (delete as appropriate), has the potential to reduce alcohol
related attendances, admissions and reduce length of stay, and that savings will be far in
excess of that required to cover salary costs, year on year. For example at the Royal
Liverpool Hospital an average of 86 admissions were saved per Nurse per year. At today’s
prices this would equate a saving of £206,000 per year minus salary costs. In real terms
savings of £000/ £000 (delete as appropriate, e.g. savings if a Nurse or Alcohol worker), per
year could be achieved at Hospital (add name of Hospital) per Nurse /Worker. (delete as
appropriate)
The aim of this proposal is to:
1.
2.
3.
4.
5.
Improve quality and efficiency of care
Reduce admissions and re-admissions for patients with alcohol related problems
Contribute to a potential reduction in alcohol related A&E attendances
Reduce potential alcohol related expenditure
Lower mortality related to the misuse of alcohol
Our principle recommendation is to fund “Alcohol Liaison Services” (ALS’s) within the insert
name of NHS Trust. This service should be led by a Consultant ‘Champion’. The ALS will
collaborate and work in partnership with all wards and clinics within the hospital, Local
Authority Health and Wellbeing Boards, Clinical Commissioning Groups, patient groups and
key stakeholders, to implement locally coordinated alcohol strategy and appropriate
pathways into community based alcohol services.
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The key objectives of the Alcohol Liaison Service workers will be to provide:
1.
Medical management of patients with alcohol problems within the hospital
2.
Liaison with community alcohol and other specialist services
3.
Education and support for other healthcare workers in the hospital
4.
Implementation of case-finding strategy and delivery of brief advice within the
hospital
These four objectives (above) were identified within the Department of Health ‘Signs
for improvement’ (2009), High Impact Change 54, and endorsed and built upon in the
National Institute for Clinical Excellence (NICE) guidance 245, 2011.
Financial Summary
The potential return on investment over a three year period for the Alcohol Liaison Service
is detailed below.
Investment Value (£) –
Staffing
Return on Investment
(ROI)
Reduction in alcohol
related admissions
Reduction in alcohol
related bed days
% Reduction in all
admissions
Year 1
Year 2
Year 3
£insert
£ insert
£ insert
Total Direct
Investment
£insert
£ insert
£ insert
£ insert
£ insert
insert
insert
insert
insert
insert
insert
insert
insert
insert %
insert %
insert %
Alcohol Liaison Service Business Case
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2.
Introduction and Overview
The number of alcohol related hospital admissions is calculated using information from the
Hospital Episode Statistics (HES) database6. In addition to estimates gathered from Alcohol
Attributable Fractions (AAFs) devised by North West Public Health Observatory (NWPHO)7
which calculates that there are 47 conditions where a link to alcohol consumption has been
established. The NWPHO has identified 13 conditions which are wholly attributed to alcohol
and 34 conditions where there is an association (fraction) with alcohol consumption.
In 2011/12 (in England) there were 1,220,300 hospital admissions where there was either a
direct correlation between alcohol consumption and the presenting reason for admission
(e.g. liver cirrhosis, malignant neoplasm of the esophagus) or where there was a partial
association (fraction) with alcohol consumption. This is an increase of 4% on the 2010/11
number of attributable alcohol hospital admissions, and more than double the number of
alcohol attributable admissions in 2003/04 (510,700). Approximately 304,200 of the total
admissions were wholly attributed to alcohol consumption, with 49,500 of these being for
alcohol liver disease (ICD-10 code K70)8. For England these figures equate to 2,298 alcohol
related hospital admissions per 100,000 population. By using the Alcohol Related deaths in
the UK 20119 it is calculated that there were 8,748 alcohol related deaths in 2011 in
England, with 6,923 deaths directly related to alcohol, which is a 3.8% increase on the 2010
figure of 6,669 deaths. Of this number, 64% (4,441) were directly as a result of alcoholic liver
disease. The number of male deaths continues to be higher than female deaths as a direct
result of alcohol. By including the Alcohol Attributable Fractions (AAFs 34 partially identified
conditions) it is estimated that in 2009 there were 15,401 deaths attributed to alcohol
consumption.
It is estimated that the associated alcohol related harm costs to the NHS in England in 2013
was £3.5 billion, which equates to £120 for every tax payer2. This is an increase on the
estimate identified in 2008 (£2.7 billion) of £0.8 billion in the DH report ‘The cost of alcohol
harm to the NHS in England. Department of Health 2008)10.
The average length of stay for all admissions including alcohol related attributable
admissions (wholly and partially attributable) in England 2011 was 5.2 days11 with an
average cost of an admission costing £1,758, this assumes the national tariff cost (2013/14)
divided by the total number of admissions for alcohol attributed admissions (304,200).
Therefore the average cost for an alcohol related bed day is £338.
The average cost of employing an Alcohol Liaison Nurse /Worker (delete as appropriate) is
£43,000 / £36,000 (delete as appropriate). Therefore, an Alcohol Liaison Nurse /Worker
(delete as appropriate) salary costs could be recouped by reducing just 24 / 20 (delete as
appropriate) alcohol attributable admissions per year.
It is believed that the presence of an effective ALS will have a beneficial impact on A& E
attendance levels and the consequential costs (average cost £110 per band 4 attendance).
However, the degree to which such attendance and cost reductions can be evidenced is
currently not sufficiently robust to be included in this model. There is no doubt that the
Alcohol Liaison Service Business Case
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Alcohol Liaison Service
most substantial savings will arise from a reduction in in-patient admissions, hence the focus
on that in relation to cost saving opportunity in this business case.
The number of alcohol attributable admissions at insert name of Hospital for 2011/12 was …
this equates to a total cost of insert £ 000 per annum.
2.2
The Evidence
There is a growing body of evidence that by providing Alcohol Liaison Services in acute NHS
hospital trusts, a significant reduction in alcohol associated morbidity can be achieved, in
addition to reductions in associated costs and hospital attendances and admission, and
efficiency gains for the trust by reducing length of stay. It has been demonstrated that by
preventing as few as 24 / 20 (delete as appropriate) inpatient admissions each year the
salary costs of one Nurse /Worker (delete as appropriate) would be saved.
The Government’s Alcohol Strategy 201212 supports the use of Identification and Brief
Advice (IBA) in A&E, as an intervention that has been “proven to reduce drinking, leading to
improved health and reduced calls on hospital services”, for those people who are not
necessarily seeking help for alcohol problems. In addition the Government’s Alcohol
Strategy recommends that all hospitals to employ Alcohol Liaison Nurses (workers) to
provide secondary prevention support to those with severe alcohol related conditions.
Evaluation of several Alcohol Liaison Services in England suggests that by employing one
Alcohol Liaison Service Nurse /Worker, (delete as appropriate) reductions in alcohol related
admissions in excess of that required to cover salary costs could be achieved, year on year.
At the Royal Liverpool Hospital the Alcohol Liaison Nurse provided intensive care
management and discharge planning interventions. During an 18 month period the service
demonstrated the prevention of 258 admissions or re-admissions, with cost savings
estimated to be £175,000. This is in addition to demonstrating significant reductions in
alcohol consumption by hazardous drinkers and over reliance on healthcare use by heavy
and dependent drinkers13. Averages of 86 admissions were saved per Nurse per year. At
today’s prices this would equate a saving of £206,000 per year minus salary costs. In real
terms savings of £163,000 / £170,000 (delete as appropriate), per year could be achieved at
Hospital (add name of Hospital) per Nurse /Worker. (delete as appropriate)
In 2010 the Safer Portsmouth Partnership provided an initial £200,000 to set up a nurse-led
alcohol treatment team within the local Portsmouth NHS Hospital. This team has since
received additional resources to provide enhanced services targeted at ‘frequent flyers’. 74
admissions were avoided as a result of the services interventions in 2011, with a reduction
of 830 bed days, which saved £343,900 within a nine month period in Portsmouth. For the
whole of Hampshire an average 152 bed days were saved each month, which equates to a
saving of £756,960 per annum (using 2010/11 reference costs) or 1,824 bed days.
At the Bristol Royal Infirmary, two Alcohol Liaison Nurses are employed. One Nurse works
specifically in A&E, whilst the other Nurse works with inpatient wards. The Nurse working
with inpatients receives approximately 700 referrals each year, with a 60% take up of
Alcohol Liaison Service Business Case
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support from patients.
This service reports an abstinence rate in cirrhosis cases of 47% at six months after
interventions. A local document ‘Calling time on alcohol-related harm: Evaluation of an
Alcohol Nurse Specialist within United Bristol Healthcare Trust’ reports reductions I length
of stay, reductions in finished consultant episodes within the trust in the ‘frequent flyer’
cohort and reductions in A&E attendances. Research by the Psychiatry team showed a
reduction in alcohol related violence and aggression.
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3.
Cost / Benefits Assessment
The required investment and potential return on investment over a three year period for
the Alcohol Liaison Service is detailed below.
Investment Value (£) –
Staffing
Return on Investment
(ROI)
Reduction in alcohol
related admissions
Reduction in alcohol
related bed days
% Reduction in all
admissions
Year 1
Year 2
Year 3
£insert
£x insert
£ insert
Total Direct
Investment
£insert
£ insert
£ insert
£ insert
£ insert
insert
insert
insert
insert
insert
insert
insert
insert
insert %
insert %
insert %
Alcohol Liaison Service Business Case
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4.
Option appraisal
Option 1. (Recommended)
Hospital wide coordinated Alcohol Liaison Services which link into appropriate community
alcohol services can achieve significant reductions in the number of people requiring
hospital admission, re-admission and A&E attendances attributed wholly or partly to alcohol
consumption.
It is estimated for an annual investment of £000, to employ number of WTE Alcohol Liaison
Service Nurse/ workers (delete as appropriate) there will be demonstrable benefits:
1.
2.
3.
A reduction in admissions either wholly or partly attributable to alcohol by Number
A reduction in bed days either wholly or partly attributable to alcohol by Number
and a subsequent reduction in A&E attendances either wholly or partly attributable
to alcohol consumption
A full description of the Alcohol Liaison Service roles and responsibilities can be found in
Appendix 1
1.
Tier 1 interventions: alcohol-related information and advice; screening; simple
brief interventions; and referral.
2.
Tier 2 interventions: open access, non-care-planned, alcohol-specific interventions.
Models of care for alcohol misusers (MoCAM) Best Practice Guidance, National Treatment
Agency for Substance Misuse, Department of Health, (2006)14.
Option 2. – Do Nothing
It is estimated that if there is no investment in Alcohol Liaison Services the number of:
hospital admissions; readmissions; and A&E attendances will inevitable continue to increase
with resultant increases in alcohol related illness and related deaths and increasing the cost
burden to the NHS. Assuming that the number of alcohol related admissions continues to
increase at the same rate (4% increase between 2010/11 and 2011/12) for (insert name of
Hospital Trust) the additional cost to the hospital would be (add £000,000).
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5.
Key assumptions and dependencies
The key assumptions that underpin the financial projections are set out in the table below:
1
2.
3.
4.
5.
6.
7.
8.
9.
Average length of stay for alcohol attributed admission (based on HES data for
national total number of admissions)
Cost of Alcohol wholly and partially attributed admission (based on 2011/12
activity, costed at 2013/14 national tariff)
Bed day cost of alcohol attributed admission based on 2) and 1) above
A&E cost for alcohol attributed attendance (average cost – band 4 attendance
national tariff 2011/12)
Nurse - band 7 mid-point
Alcohol worker - equivalent band 5 mid-point
Estimated number of interventions delivered by each nurse or alcohol worker
per year (based on Liverpool model and verified against local schemes)
Alcohol related admissions (wholly and partially attributable) as a % of total
admissions (based on data from Institute of Alcohol Studies and HES)
Estimated ratio of admissions saved (for every 3 interventions 1 admission will
be saved)
5.2 days
£1,758
£338
£110
£43,000
£36,000
258
8.2%
3:1
Assumptions (within the hospital)
It is assumed that the following operational and service related issues that are seen to
contribute to the effectiveness of Alcohol Liaison Services have been addressed (author to
amend/add as required to meet local circumstances):
1.
Procedures and protocols within the A & E Department to ensure effective
identification, delivery of identification brief advice (IBA) and referral (where
appropriate) are developed and implemented.
2.
In patient treatment pathways (to include referral to community services) for alcohol
related diagnosis are developed and implemented – reflecting the need for more
flexible treatment practices in the management of patients with alcohol related
problems.
3.
The competence, experience, qualifications and individual approaches of the Alcohol
Liaison workers are appropriate for the specific hospital setting and in line with the
Drug and Alcohol National Occupational Standards (DANOS)15.
4.
The appropriate level of awareness, engagement and co-ordination of hospital staff/
wards/departments regarding identification and referral of patients with alcohol
related diagnosis.
5.
Where nurse prescribers are employed that their role and responsibilities are clear
and well communicated to all relevant staff groups: to ensure that the benefit from
this resource is maximized and to avoid duplication. Where nurse prescribers are not
employed, the doctors involved in the clinical management of these patients are
effectively trained/ briefed.
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6.
The audit or assessment tool to be used to trigger the involvement of the Alcohol
Liaison Service is developed and implemented
7.
The Alcohol Liaison Service will work within the local hospital procedures and
protocols, be seen to be a key element of the hospital service and have appropriate
access to relevant information systems) for the treatment of alcohol related
conditions and will contribute to its periodic review.
8.
A nominated consultant level clinician is appointed to act as an ‘Alcohol Champion’
who will serve to ensure that the impact of the misuse of alcohol and the range of
measures to ameliorate it are visible and considered by the key decision makers of
the organization, staff and external partners.
Dependences (external to the hospital)
1.
A multi-agency Alcohol Strategy has been developed and accepted by partners
across the health and social care system.
2.
The Health and Wellbeing Board acts as the multi-agency governance arena to
ensure that the Alcohol Strategy is implemented, monitored and periodically
reviewed.
And probably the most significant factor is that;
3.
The access routes to and the capacity and capability of community based statutory
and voluntary sector services to support clients with alcohol problems are
appropriate, effective and visible.
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6.
Risk and Sensitivity analysis
Risk assessment
(Author to review and amend as required in order to address local approach to risk
management)
Description of risk
1
2
3
4
5
6
7
8
9
10
Likelihood
of risk
occurring
(L)
Score 1-5
Impact of
risk
occurring
(I)
Score 1-5
Risk score
(L*I)
Mitigating action (s)
Level of funding insufficient
to cover proposed costs
Continuity of funding not
secured
Loss of key personnel
Failure to collect data to
monitor impact
Failure to promote the
service within the hospital to
maximise benefit
Failure of key partners to
commission and support
community based services
for clients with alcohol
problems
Impact of changes to
commissioning arrangements
for alcohol support services
Failure to appoint
appropriately skilled and
experienced staff
Discontinuation of funding
resulting in increased burden
of alcohol related
attendances/admissions and
higher levels of alcohol
related health harm and
morbidity
Failure to implement NICE
guidance concerning the
provision of training,
resources and time to
implement alcohol screening
and brief interventions
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POET analysis
Political
Operational
 Supports national imperatives associated with
A&E 4 hour targets
 Reduces the operational burden on staff in A&E
 Helps to reduce burden on acute hospital care
settings - A&E departments and inpatient
wards by reducing volumes and placing more
care in the community
 Improves the medical management on the wards of
patients with alcohol related conditions
 Will support delivery of the Government’s
Alcohol Strategy 201212
 Has an impact on problematic drinking in
communities and support for families
struggling with problematic consumption of
alcohol
 Supports the Public Health Outcomes
Framework16:
Outcome 1 – Increased healthy life expectancy
Outcome 2 – Reduced differences in the life
expectancy and health life expectancy between
communities
 Improves overall experience of patients with alcohol
problems within hospital settings and into the
community- improved ratings in family and friends
test
 Better recognition of alcohol related symptoms by
general nursing and medical staff resulting in more
appropriate treatment regimes for patients
 A reduction in alcohol related violence on the wards
as a result of better management of alcohol
withdrawal - benefitting all patients when such
incidents are averted
 Provides key decision makers with an assurance of
effective service delivery for this group of patients
 Reduces the resource required to handle impact of
intoxication of patients in A&E
 Improves the opportunities to effectively and
flexibly manage bed stock by reducing the number
of bed days required for patients with alcohol
related problems
Economic/financial
Technical
 Offers financial benefits associated with a
reduction in bed days for patients with alcohol
related problems
 The presence of the Alcohol Liaison Service
increases the potential for spotting and gaining any
benefit as a result of technological or medication
advances in the identification and or treatment of
alcohol related conditions
 Offers capacity utilisation benefits for the
hospital in A&E and on the wards associated
with reduced alcohol related attendances as
well as reduced inpatient bed days
 Opportunities to use technology to improve data
capture and sharing across agency boundaries
 Is a viable ‘invest to save’ proposition
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7.
Timescales:
(Author to fill in local timescales and/ or amend to meet local circumstances)
Key milestones and dates
Proposed Proposed Notes
start
end
November
2013
Business case submitted
Refinements/amendments to business case
Operational amendments
(procedures/protocols etc.)
Confirmation of service, review service
specifications and issue of contractual
documents
Confirm governance arrangements
Confirm procurement arrangements and
required documentation
Recruitment of any additional nurses or
alcohol workers
Commencement of commissioned or recommissioned service
April 2017
Service review
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8.
Comments / Issues:
Author to add local issues, or delete section if not required
This section to be used if needed to draw attention to additional local points or issues, which
should be taken into account when considering the business case.
<Write any comments here.>
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9.
Conclusions and Recommendations
The resources deployed to address the consequences of alcohol consumption for the NHS
are considerable, costing £3.5 billion (in England) in 2011/12, with hospital admissions
increasing by 4% from in 1,168,300 in 2010/11 to 1,220,300 in 2011/123.
Alcohol Liaison Services have been demonstrated to significantly reduce hospital
admissions, readmissions, bed days and A&E attendance and associated costs. It has been
estimated that by preventing 24/20 (delete as appropriate) admissions (attributable to
alcohol) the salary costs of one Alcohol Liaison Service Nurse /Worker (delete as
appropriate) can be recouped.
Evaluation of Alcohol Liaison Services in England suggests that by employing one Alcohol
Liaison Service Nurse /Worker, (delete as appropriate) reductions in alcohol related
admissions in excess of that required to cover salary costs could be achieved, year on year.
For example at the Royal Liverpool Hospital an average of 86 admissions were saved per
Nurse per year. At today’s prices this would equate a saving of £206,000 per year minus
salary costs. In real terms savings of £163,000 per year is being achieved.
The number of alcohol attributable admissions at insert name of Hospital for 2011/12 was
…this equates to a total cost of insert £ 000 per annum.
It is recommended that in order to reduce the number of alcohol attributable hospital
admissions at insert name of Hospital Trust that insert number of Nurse /Worker (delete as
appropriate) at a cost of insert £000 per annum be invested in order to achieve the
objectives of:
1.
Improve quality and efficiency of care
2.
Reduce admissions and re-admissions for patients with alcohol related problems
3.
Contribute to a reduction in alcohol related A&E attendances
4.
Reduce potential alcohol related expenditure
5.
Lower mortality related to alcohol consumption
Alcohol Liaison Service Business Case
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10.
References
1.
Global Status Report on Alcohol and Health. WHO Global Health Observatory 2011
2.
Public Health Responsibility Deal, Department of Health 2013
3.
Statistics on Alcohol: England, 2013. Health and Social Care Information Centre. 2013
4.
Department of Health ‘Signs for improvement’ High Impact Change 5 (2009)
5.
Alcohol-Use Disorders: Diagnosis, assessment and management of harmful drinking
and alcohol dependence. NICE Guidance 24. National Institute for Clinical Excellence,
2011.
6.
Hospital Episode Statistics (HES). Health and Social Care Information Centre, 2013
7.
Alcohol-attributed fractions for alcohol attributed mortality and hospital admissions
produced North West Public Health Observatory.
8.
International Statistical Classification of Disease and Related Health Problems, 10th
Revision. WHO. 1990
9.
Defining alcohol-related deaths summary of responses to ONS proposals, Office for
National Statistics 2006
10.
The cost of alcohol harm to the NHS in England. Department of Health 2008
11.
The Nuffield Trust. 2013
12.
The Government’s Alcohol Strategy. HM Government 2012
13.
Safe, Sensible, Social: The next steps in the National Alcohol Strategy. Department of
Health 2007
14.
Models of care for alcohol misusers (MoCAM) Best Practice Guidance, National
Treatment Agency for Substance Misuse, Department of Health, 2006
15.
DANOS - Drugs and Alcohol National Occupational Standards 2012 produced by the
Federation of Drug and Alcohol professionals in consultation with the Competence
Group and Skills for Health 2012
16.
Public Health Outcome Framework: Improving Outcomes and Supporting
Transparency 2013-2016. Department of Health 2012
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11.
Appendix 1
Models of care for alcohol misusers (MoCAM) Best Practice Guidance, National Treatment
Agency for Substance Misuse, Department of Health, (2006)
Tier 1 interventions: alcohol-related information and advice; screening; simple brief
interventions; and referral
Definition Tier 1 interventions include provision of: identification of hazardous, harmful
and dependent drinkers; information on sensible drinking; simple brief interventions to
reduce alcohol-related harm; and referral of those with alcohol dependence or harm for
more intensive interventions.
Interventions Commissioners need to ensure that a range of generic services provide as
a minimum the following Tier 1 alcohol interventions:
• alcohol advice and information
• targeted screening and assessment for those drinking in excess of DH guidelines on
sensible drinking and for those who may need alcohol treatment
• provision of simple brief interventions for hazardous and harmful drinkers
• referral of those requiring more than simple brief interventions for specialised alcohol
treatment
• partnership or ‘shared care’ with specialised alcohol treatment services, e.g. to provide
specific alcohol treatment interventions within the context of their generic services.
Settings Tier 1 interventions can be delivered by a very wide range of agencies and in a
range of settings, the main focus of which is not alcohol treatment. For example: primary
healthcare services; acute hospitals, e.g. A&E departments; psychiatric services; social
services departments; homelessness services; antenatal clinics; general hospital wards;
police settings, e.g. custody cells; probation services; the prison service; education and
vocational services; and occupational health services.
Such interventions can also be provided in highly specialist non-alcohol specific residential
or inpatient services, which have service users with high levels of alcohol-related morbidity
who may require care plans and support to facilitate their access to alcohol-specific
provision. Examples include: specialist liver disease units, specialist psychiatric wards,
forensic units, residential provision for the homeless, and domestic abuse services.
Competency This is provision that depends on at least minimal skills in alcohol misuse
identification, assessment and interventions. Those delivering Tier 1 provision may require
the following competences from the Drugs and Alcohol National Occupational Standards
(DANOS):17
• AA1 Recognise indications of substance misuse and refer individuals to specialists
• AF1 Carry out screening and referral assessment
• AH10 Carry out brief interventions with alcohol users
• AB2 Support individuals who are substance misusers
• AB5 Assess and act upon immediate risk of danger to substance misusers.
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Tier 2 interventions: open access, non-care-planned, alcohol-specific interventions
Definition Tier 2 interventions include provision of open access facilities and outreach
that provide: alcohol-specific advice, information and support; extended brief interventions
to help alcohol misusers reduce alcohol-related harm; and assessment and referral of those
with more serious alcohol-related problems for care-planned treatment.
Interventions Tier 2 interventions include open access facilities and outreach targeting
alcohol misusers, which provide:
• alcohol-specific information, advice and support
• extended brief interventions and brief treatment to reduce alcohol-related harm
• alcohol-specific assessment and referral of those requiring more structured alcohol
treatment
• partnership or ‘shared care’ with staff from Tier 3 and Tier 4 provision, or joint care of
individuals attending other services providing Tier 1 interventions
• mutual aid groups, e.g. Alcoholics Anonymous
• triage assessment, which may be provided as part of locally agreed arrangements.
Settings Tier 2 provision may be delivered by the following agencies, if they have the
necessary competence, and in the following settings: specialist alcohol services; primary
healthcare services; acute hospitals, e.g. A&E and liver units; psychiatric services; social
services; domestic abuse agencies; homelessness services; antenatal clinics; probation
services; the prison service; and occupational health services.
Competency Tier 2 interventions require competent alcohol workers who should have
basic competences in line with DANOS,17 including those required for Tier 1.
Competency can also depend on what cluster of services is provided.
Front-line staff would normally have competence in motivational approaches and brief
interventions.
Those providing interventions at Tier 2 may require the following competences from
DANOS:17
• AB2 Support individuals who are substance users
• AB5 Assess and act upon immediate risk of danger to substance users
• AF2 Carry out assessment to identify and prioritise needs
• AG1 Plan and agree service responses which meet individuals’ identified needs
• AH10 Carry out brief interventions with alcohol users.
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Tier 3 interventions: community-based, structured, care-planned alcohol treatment
Definition Tier 3 interventions include provision of community-based specialised alcohol
misuse assessment, and alcohol treatment that is care co-ordinated and care-planned.
Interventions Tier 3 interventions include:
• comprehensive substance misuse assessment
• care planning and review for all those in structured treatment, often with regular key
working sessions as standard practice
• community care assessment and case management of alcohol misusers
• a range of evidence-based prescribing interventions, in the context of a package
of care, including community-based medically assisted alcohol withdrawal (detoxification)
and prescribing interventions to reduce risk of relapse
• a range of structured evidence-based psychosocial therapies and support within a care
plan to address alcohol misuse and to address co-existing conditions, such as depression
and anxiety, when appropriate
• structured day programmes and care-planned day care (e.g. interventions targeting
specific groups)
• liaison services, e.g. for acute medical and psychiatric health services (such as pregnancy,
mental health or hepatitis services) and social care services (such as child care and housing
services and other generic services as appropriate).
Settings Tier 3 interventions are normally delivered in specialised alcohol treatment
services with their own premises in the community (or sometimes on hospital sites). Other
delivery may be by outreach (peripatetic work in generic services or other agencies, or
domiciliary or home visits). Tier 3 interventions may be delivered alongside Tier 2
interventions.
Some of the Tier 3 work is based in primary care settings (shared care schemes and GP-led
prescribing services), but alcohol specialist-led services are required within the local systems
for the provision of care for severe or complex needs and to support primary care.
The work in community settings can be delivered by statutory, voluntary or independent
services providing care-planned, structured alcohol treatment.
Competency Tier 3 services require competent drug and alcohol specialised practitioners
who should have competences in line with DANOS.17 The range of competences required
will depend on job specifications and remits.
Those delivering Tier 3 interventions may require a wide range of competences from Key
Area A in DANOS17 and many of the competences from Area AH, depending on the type of
alcohol treatment provided.
Medical staff (usually addiction psychiatrists and GPs) will require different levels of
competence, depending on their role in alcohol treatment systems and the needs of the
service user, with each local system requiring a range of doctor competences (from
specialist to generalist) in line with joint guidance from the Royal Colleges of General
Practitioners and Psychiatrists, Roles and responsibilities of doctors in the provision of
treatment for drug and alcohol misusers,18 summarised in the National Treatment Agency
for Substance Misuse briefing document Roles and responsibilities of doctors in the provision
of treatment for drug and alcohol misusers.
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Alcohol Liaison Service
Tier 4 interventions: alcohol specialist inpatient treatment and residential rehabilitation
Definition Tier 4 interventions include provision of residential, specialised alcohol
treatments which are care-planned and co-ordinated to ensure continuity of care and
aftercare.
Interventions Tier 4 interventions include:
• comprehensive substance misuse assessment, including complex cases when appropriate
• care planning and review for all inpatient and residential structured treatment
• a range of evidence-based prescribing interventions, in the context of a package of care,
including medically assisted alcohol withdrawal (detoxification) in inpatient or residential
care and prescribing interventions to reduce risk of relapse
• a range of structured evidence-based psychosocial therapies and support to address
alcohol misuse
• provision of information, advice and training and ‘shared care’ to others delivering Tier 1
and Tier 2 and support for Tier 3 services as appropriate.
Settings Specialised statutory, independent or voluntary sector inpatient facilities for
medically assisted alcohol withdrawal (detoxification), stabilisation and assessment of
complex cases.
Residential rehabilitation units for alcohol misuse.
Dedicated specialised inpatient alcohol units are ideal for inpatient alcohol assessment,
medically assisted alcohol withdrawal (detoxification) and stabilisation. Inpatient provision
in the context of general psychiatric wards may only be ideal for some patients with comorbid severe mental illness, but many such patients might benefit from a dedicated
addiction specialist inpatient unit.
Those with complex alcohol and other needs requiring inpatient interventions may
require hospitalisation for their other needs (e.g. pregnancy, liver problems) and this may
be best provided for in the context of those hospital services (with specialised alcohol
liaison support).
Competency Inpatient and residential interventions providing medically assisted alcohol
withdrawal (detoxification) and specialist assessment and stabilisation would normally
require medical staff with specialist competence in substance misuse (rather than generalist
GPs). The level of specialised medical staff competence required will depend on the types of
service provided and the severity of the service users’ problems.
Addiction specialist competences will be needed for inpatient units for severe and complex
problems. Suitably competent GPs can provide support to some units for patients with less
complex needs. Staff in residential rehabilitation units that are registered care homes will
need to meet relevant social care national occupational standards. Hospital-based services
will also be required to meet practitioner standards for independent or NHS hospitals.
Those delivering Tier 4 interventions may require a wide range of competences from Key
Area A in DANOS,17 and in particular many of the competences from Area AH ‘Deliver
healthcare services, depending on the alcohol treatment provided’. All staff working in all
residential settings are advised to demonstrate competence against DANOS17 at both
manager and practitioner levels.
Alcohol Liaison Service Business Case
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Alcohol Liaison Service
Grey
Laughton
Associates
Unlocking the potential to reduce offending by improving health, wellbeing and independence…
Susan Grey: 07779 235399 greysusangrey@alo.com , Hilary Laughton: 07985 492954 hilary.laughton205@btinternet.com
Alcohol Liaison Service Business Case
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08 February 2016