Health and Adult Social Care Overview and Scrutiny Panel 25 November 2013

REDUCING ALCOHOL RELATED HARM WARDS AFFECTED All EXEMPT/CONFIDENTIAL ITEM NO 1. PROPOSED DECISION

1.1. Note the action taken to date to reduce the significant harm caused by alcohol misuse within

the Borough.

1.2. Provide scrutiny in relation to the action plan to reduce the significant harm caused by alcohol misuse within the Borough.

2. JUSTIFICATION FOR THE DECISION

2.1. Despite significant progress, alcohol misuse continues to be a major source of harm in our local communities. That range of harms includes alcohol related violence (including domestic violence), deliberate self-harm, suicide, crime and anti-social behavior, short and long-term damage to physical and mental health, harm to unborn babies, child abuse including neglect and early mortality, as well as increased risk taking in sexual behaviour. Many accidental injuries and road traffic accidents are attributable to substance misuse and it is linked to negative effects on the economy and incalculable misery for individuals and families.

2.2. Currently the cost of treatment for Substance Misuse constitutes 25% of the Public Health

Grant in St Helens. According to the Centre for Social Justice (22: 2013), the UK is now the ‘addicted man of Europe’. The cost of funding demand led treatment services for alcohol and associated illnesses are likely to present an even greater burden on Public Health budgets in the future if robust action is not successful in bringing about wide scale behavior change.

2.3. The multi-faceted, complex nature of alcohol related harm requires a comprehensive

approach which includes prevention, treatment and enforcement. 2.4. In order to obtain results, Partner collaboration and coordination of activity is required. This

enables us to avoid duplication and maximize the use of resources. However, we also require robust leadership at all levels and a collection of minds operating across systems and organisational boundaries to seek new solutions to an age-old problem.

3. FACTS SUPPORTING THE PROPOSED DECISION 3.1. Alcohol (and drug) misuse is a factor in a significant number of children in need and

safeguarding cases. Research suggests that in safeguarding cases, alcohol is a factor in at

least 33% of cases, and in Care Proceedings, drug and alcohol misuse is a factor in up to 70% of cases (Harwin and Forrester, 2003). In the Biannual Analysis of Serious Case Reviews 2005- 2007 (DCSF, 2009), of the 189 cased reviewed 47 (25%) featured parental substance misuse. Many of these families were not known to children’s social care.

3.2. The government recommends that men should not regularly drink more than 3-4 units of alcohol per day and women should not regularly drink more than 2-3 units of alcohol per day (I unit =8g or 10ml of alcohol). Drinking above these limits increases the risk of contracting 13 conditions which are wholly attributable to alcohol consumption for example alcoholic liver disease and chronic pancreatitis (alcohol induced) along with 34 conditions which are partially attributable to alcohol consumption such as some cancers, hypertensive diseases and cardiac arrhythmias

3.3. The scale of the challenge in St Helens cannot be under estimated; In 2012 St Helens was

identified as the 32nd worst affected local authority area (out of 326) in England for alcohol related harm¹ and 12th worst Local Authority Area in England (out of 326) for under 18 alcohol specific hospital admissions. There is still a need to tackle awareness of alcohol related harm and to encourage and support people to take advantage of the services that are on offer.

3.4. St Helens Public Health Team have a positive presence in forums which seek to bring about

change on a national footprint, for example steps to tackle the availability of cheap alcohol and changes to proposed licensing law. Unfortunately progress in these areas has been less positive than desired with the Government recently stating that it will not be proceeding with the introduction of a minimum unit pricing of alcohol at this point in time, or supporting a ban on multi-buy promotions.

3.5. Alcohol-related deaths have doubled since 1991 and liver disease is now one of the ‘Big

Five Killers’ and the only one which is increasing1. There are significantly high rates of alcohol related liver disease in Sefton, Wirral and St Helens and significantly lower rates in Cheshire East and Warrington2.

Key successes to date

3.6. In 2012-13, admissions to hospital for alcohol related harm (includes admissions that are wholly and partially alcohol related) was less than expected at a rate of 2691.93 per 100,000 population. Performance against the target of 2779 was favourable. This positive trajectory continues in 2013/14, to date.

3.7. In relation to admissions that are wholly related to alcohol, data shows that that although St Helens started off with a higher rate of admissions than neighbouring CCGs, the longer term trend has been a continual decrease and the position of the neighbouring CCG’s has increased. This is particularly visible in the 19-64 years age group. See Table 1.

1 Office for National Statistics, Age-standardised alcohol-related death rates, London: ONS, 2013 2 Alcohol Related liver disease in Cheshire and Merseyside -ChaMPs 2012 3 Local unverified HES data

Table 1 3.8. The rate of wholly alcohol related alcohol admissions for ages 0-19 is dropping significantly

both for St Helens and Neighbouring CCGs. This is a positive sign, indicating that the new generation of children to adults are less likely to become an admission than the previous generation. See Table 2.

Table 2

3.9. Although performance in relation to our neighbouring CCGs is again favourable in relation to wholly attributable admissions in the over 65s age group, See Table 3, it is important to note that the rate of admissions for this age group is increasing in line with an increasingly older population. This information assists us in planning for age appropriate campaigns and services in the future.

Table 3

3.10. Prior to the re-commissioning of Alcohol and Drug Treatment Services in April 2012, St

Helens lacked an integrated treatment offer for adults seeking support for alcohol problems and many services were working in isolation.

3.11. The fundamental strategic aim of integrating the treatment offer in St Helens has been achieved. The key service elements along with outputs are shown in Appendix A. This means that not only are the numerous support and treatment services working together to achieve the best results for people but that the treatment offer is seamless for individuals.

3.12. The innovative, Alcohol Nursing Scheme established at Whiston Hospital has now been implemented, opening seven days a week and providing twilight cover on Thursday/Friday and Saturday. The four experienced Alcohol Nurses work closely with the community treatment provider Addaction, to ensure that people who attend hospital for alcohol related harm receive expert care and are linked into longer term support. They have raised the quality of alcohol treatment throughout the hospital and act as Champions for raising awareness and increasing the numbers of staff able to offer support.

3.13. Since the 1st April 2013, the service received 567 referrals and undertook 551(97%)

specialist assessments. Data indicates that 48% of those Assessments took place pre-admission in the Emergency Department, and 52% took place post admission in the Emergency Assessment Unit EAU/Observation Unit, longer stay assessment units or on the wards.

3.14. Females make up 34% of the proportion of individuals assessed by the Alcohol Liaison

Nurses which is slightly less than the proportion accessing community services. Of note is the fact that more females come to the attention of the Alcohol Nurses after they have been admitted into the hospital. Given that many alcohol problems do not become apparent until a patient has been in the hospital for some time, this may indicate reluctance on behalf of

females to disclose an alcohol problem unless it is absolutely necessary. This will be investigated further.

3.15. 72% of people assessed were drinking at levels that indicate alcohol dependence.

3.16. Attendances are significant across the entire 24 hour period but significantly higher between 12 noon and 7pm then 11pm to 7am.

3.17. Activity is spread fairly evenly across the week, with a slight raise on a Tuesday and a

Wednesday.

3.18. The highest numbers of referrals were in the 35-54 age groups.

3.19. 44% of referrals were St Helens registered patients, 22% Knowsley, 17% Halton and 12% Liverpool.

3.20. The table below shows the uptake of the service offer, depending on where patients have

been assessed. Of the high proportion of potentially eligible referrals into community services, less than half consent to referral. Of those who do consent, around 30% go on to access treatment in the Community. This indicates that further work is needed to help build a bridge into community services. On a positive note, this data does not distinguish when one person has been assessed twice and therefore the proportion of people attending may be higher than suggested, but there is still considerable room for improvement. APPENDIX D shows a SWOT analysis of the service.

PRE-ADMISSION POST ADMISSION 208 (77%) of assessed patients were eligible for a referral to community Treatment Services

238 (80%) of assessed patients were eligible for a referral to community Treatment Services

102 (49%) of patients accepted a referral to Community Services

110 (46%) of patients accepted a referral to Community Services

32 (31%) of referrals actually attended or 15% of original eligible cohort

32 (29%) of referrals actually attended or 13% of original eligible cohort

3.21. There has been successful negotiation with Partners and a skilful redesign of the alcohol in-patient detoxification pathway into the Windsor Clinic Alcohol Inpatient Detoxification Unit run by Merseycare NHS Trust. This means that in-patient detoxification is no longer offered as a stand-alone treatment and patients are fully assessed, offered choices and prepared for treatment, as well as receiving support when they leave the In-patient Unit. This allows us to maintain treatment gains and obtain the best use and value out of expensive resources.

3.22. An innovative project is underway to find out what people of all ages in St Helens really think about alcohol harm reduction messages and what role drink plays in their lives. This information will help us to develop a more meaningful dialogue with the Public (assisted by publicity in Alcohol Awareness Week (18-24th Nov 2013) and a ‘Dry January’ Campaign in January 2014, with a view to ensuring that future messages are meaningful and well informed. The research is part funded by a successful bid for 10K from the Department of Communities & Local Government.

3.23. A successful bid application has been made by Addaction Substance Misuse Treatment Service in partnership with Public Health at St Helens Council, to the Department of Health Innovation, Excellence and Strategic Development Fund (IESD), to assist in tackling alcohol and drug related harm in St Helens. In particular, the bid has secured three years funding (total 247K) to facilitate the delivery of Breaking the Cycle (BtC), Addaction’s programme of support for families affected by parental substance misuse. The work will be delivered by

three trained Addaction Breaking the Cycle Substance Misuse Workers in St Helens who will work directly with Social Care Teams focusing on the families who are most in need, including families on a Child Protection Plan and instances wherein pre-court proceedings feature.

3.24. Such is the rate of growth in recovery for alcohol and drugs in St Helens that the Recovery Centre is no longer big enough to meet demand. St Helens Council has sourced Lincoln House, a new venue for Drug and Alcohol treatment and recovery which is ideally located in the Town Centre and which can meet the requirements of a modern, integrated Recovery Service. Satellite clinics run in GP’s surgeries and Children Centre clinics will be maintained to maximise service user choice.

3.25. Addaction are keen to ensure that women in the Borough are encouraged to access the services that are on offer and have established a weekly Women’s Recovery Group and a Pregnancy Clinic. Strong links have been developed with MARAC and outreach into the Women’s Refuge is planned. Data shows that the numbers of women accessing the service is increasing on a monthly basis but that the number of females as a proportion of the treatment cohort remains relatively stable at around 37%. In June 2013, 65 of the 177 active alcohol service users were female.

Areas for Development

3.26. Addaction have experienced considerable success locally in assisting people with drug addiction to turn their lives around. They are tasked with achieving similar success is in relation to alcohol. This includes ensuring that the pathways that are in place to tackle housing issues, mental health concerns or other factors which are important to recovery are proving to be effective. Unfortunately, the information systems nationally and regionally which support the collection of data around alcohol outcomes are not as robust or as reliable as in the case of drugs. Public Health England is currently undertaking work in this area and a locally developed performance systems have been developed to assist us in gathering more information about the effectiveness of the actions we have undertaken.

3.27. Strategically the focus for the remainder of 2013/14 will be on embedding the alcohol treatment offer for individuals and families and opening up a dialogue with the public. This will inform future prevention activity in 2014/15.

3.28. Addaction is making recovery visible through supporting 14 local Recovery Champions and

21volunteers in Year1 and encouraging the growth of mutual aid groups (AA and NA) in the area. This will raise ambition and show people what can be achieved, as well as providing longer term support to prevent relapse. Further work is needed across the partnership to reduce stigma, streamline care pathways and to take action to prevent alcohol misuse disorders in the first instance.

3.29. The two Case Studies in Appendix C are presented in the words of the Service Users

themselves (identities changed) and show how, even in the most difficult circumstances, people can turn their lives around. What is apparent is that progress is not always linear but with the right support, freedom from addiction is achievable.

4. RISKS 4.1 Risks Associated with the Proposed Decision

Whilst everyone will be familiar with the harmful effects of alcohol misuse, there are still only relatively few visible examples of what success or recovery looks like. Visible recovery will act as a mechanism to attract people into and through their treatment journey. However, becoming drug or alcohol free is only part of the journey; the process of becoming active and

productive citizens who are able to contribute to family and community has interdependencies with housing, employment, education and many other organisations. St Helens Cabinet has an opportunity to help develop an infrastructure that supports not only freedom from addiction but a meaningful growth in recovery.

4.2 Should this Risk be added to the Corporate Risk Register? No

5. OTHER IMPLICATIONS 5.1. Legal – None

5.2. Financial – Existing budget, no implications. 5.3. Human Resources – None 5.4. Land and Property (assets) – None 5.5. Anti-Poverty – Supports the policies to reduce social exclusion – Yes. 5.6. Effects on existing Council Policy – None 5.7. Effects on other Council Activities – None.

5.8. Human Rights – None.

5.9. Equalities – Equality impact assessments are undertaken on individual initiatives where

appropriate.

5.10. Asset Management – None.

5.11. Health – Alcohol is a key strategic priority of the St Helens Health and Wellbeing Strategy.

6. PREVIOUS APPROVAL / CONSULTATION

Approval at the St Helens Health and Wellbeing Board on 26th September 2013.

Consultation at St Helens CCG on 4th October 2013. Approval at St Helens Cabinet on 23rd October 2013

7. ALTERNATIVE OPTIONS AND IMPLICATIONS THERE OF

None

8. APPENDICES

Appendix A: Key Alcohol Service Elements/Outputs Appendix B: Alcohol Action Plan

Appendix C: Case Studies Appendix D: Swot Analysis of Alcohol Service

LEAD OFFICER FOR THIS REPORT Liz Gaulton Director of Public Health St Helens Council CONTACT OFFICER Collette Walsh Head of Public Health Commissioning St Helens Council ColletteWalsh@sthelens.gov.uk 01744 671046 Supported by Kimberley Woodward Contracts & Commissioning Support Manager Data Analysis supported by Jason Taylor Performance & Planning Data Facilitator St Helens CCG.