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 Page 1 of 22 08 February 2016 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 Page 2 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 3 of 22 08 February 2016 Alcohol Liaison Service 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 Page 4 of 22 08 February 2016 Alcohol Liaison Service 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 Page 5 of 22 08 February 2016 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 Page 6 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 7 of 22 08 February 2016 Alcohol Liaison Service 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 Page 8 of 22 08 February 2016 Alcohol Liaison Service 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). Alcohol Liaison Service Business Case Page 9 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 10 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 11 of 22 08 February 2016 Alcohol Liaison Service 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 Alcohol Liaison Service Business Case Page 12 of 22 08 February 2016 Alcohol Liaison Service 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 Alcohol Liaison Service Business Case Page 13 of 22 08 February 2016 Alcohol Liaison Service 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 Alcohol Liaison Service Business Case Page 14 of 22 08 February 2016 Alcohol Liaison Service 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.> Alcohol Liaison Service Business Case Page 15 of 22 08 February 2016 Alcohol Liaison Service 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 Page 16 of 22 08 February 2016 Alcohol Liaison Service 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 Alcohol Liaison Service Business Case Page 17 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 18 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 19 of 22 08 February 2016 Alcohol Liaison Service 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. Alcohol Liaison Service Business Case Page 20 of 22 08 February 2016 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 Page 21 of 22 08 February 2016 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 Page 22 of 22 08 February 2016