UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 368-iiHouse of COMMONSMINUTES OF EVIDENCETAKEN BEFOREHEALTH COMMITTEE
ALCOHOL
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This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
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Transcribed by the Official Shorthand Writers to the Houses of Parliament: W B Gurney & Sons LLP, Hope House, Telephone Number: 020 7233 1935 |
Oral Evidence
Taken before the Health Committee
on
Members present
Mr Kevin Barron, in the Chair
Charlotte Atkins
Sandra Gidley
Stephen Hesford
Dr Doug Naysmith
Mr Lee Scott
Dr Howard Stoate
Dr Richard Taylor
________________
Witnesses: Professor Mike Kelly, Director, Centre for Public Health Excellence, National Institute for Health and Clinical Excellence (NICE), Dr Lynn Owens, Nurse Consultant, Liverpool PCT, and Dr Paul Cassidy, GP, Gateshead PCT, gave evidence.
Q108 Chairman: Good morning. Welcome to our second evidence session on our inquiry into alcohol. Could I ask you for the record to introduce yourselves, please.
Dr Cassidy: Dr Paul Cassidy. I am a GP in
Professor Kelly: My name is Professor Mike Kelly and I am the Director for the Centre for Public Health Excellence at NICE.
Dr Owens: I am Dr Lynn Owens. I am a Nurse Consultant and Alcohol Clinical
Lead within Liverpool PCT and an Honorary Research Fellow at the
Q109 Chairman: Welcome. I have a general question to all three of you in relation to alcohol and the National Health Service. Last week we heard a lot of statistics about alcohol related problems. I wonder if I could ask each of you to give us an idea of how alcohol impacts on your little parts of the National Health Service from a personal experience point of view.
Dr Cassidy: It is a routine part of my clinical work. One of the dilemmas is that, often, when GPs think alcohol, they think alcohol dependence. They are the patients who seem to give us the biggest problem, because we have problems getting them into treatment and it is a chronic illness. I see the non dependent drinkers, of whom there are a lot, in everyday practice, and the challenge for me is to pick those people up. The impact is often felt on the more dependent end, but there are the more subtle effects of raising people's blood pressure or leading to small injuries that affect the normal patient who comes through the door. Certainly it is a common and routine part of clinical practice.
Dr Owens: I work in both primary care and the acute hospital trust. As Paul
says, within primary care you have an opportunity very much to help patients
recognise that what they are presenting with to their GP could be a direct
consequence of what they are drinking - minor things like gastritis - and it is
an ideal opportunity to give patients advice, information to help them change
their lifestyle and do some positive things that prevent future ill health. In
the acute trust we tend to see more of the more complex and dependent patients.
We know that within
Professor Kelly: As you know, of course, NICE does not deal with patients in a direct sense, but NICE presently is undertaking a series of reviews in three areas relating to alcohol. One which I am leading on is on the prevention of alcohol misuse. The second is a clinical guideline on the management and treatment of people with alcohol problems. The third is dealing with alcohol dependency and the psychiatric sequilae. There are three big pieces of work underway presently and due for completion in May 2010. My brief on the public health side of things is to determine the extent to which screening, bio-chemical markers, clinical indicators and so on - but particularly screening questionnaires - are effective at picking up these problems early; secondly, whether brief interventions are a cost-effective response; and, thirdly, what are the key barriers to change that arise, both in terms of service configuration and organisation as well as behaviour change as far as patients or members of the public are concerned. We are also going to look at the impact of price and availability and advertising, and the degree to which that, as a sort of very upstream impact, leads to the sorts of problems that my two clinical colleagues were talking about.
Chairman: We will be picking up on one or two of those issues as we go ahead this morning.
Q110 Charlotte Atkins: Professor Kelly, I will start by putting this question to you first, in view of the work that you have been doing. What more could be done by the NHS to prevent the development of alcohol related problems? I do not know what has been demonstrated by your own work, but what is your view on that?
Professor Kelly: Our own work at the moment is midway through. The committees that
are doing the guides are meeting this morning in
Q111 Charlotte Atkins: You talked about picking up problems early. You obviously inferred that the NHS could not do it on its own. Is there any evidence of the effectiveness of multi-agency centres based in schools to try to pick up problems? Related to that, do you find that alcohol tends to go through families and, therefore, is the possibility to pick up the alcohol-related problems of young people based on the experience of their parents?
Professor Kelly: We did produce NICE guidance, in 2007 I think it was, for the school sector on picking up alcohol problems with children, children in secondary schools in particular. In so far as we were able to make sense of the available evidence there, there is good reason to suppose that you can focus on that particular group of the population, youngsters in the school system, as a way of detecting early problems and either referring into appropriate early treatment or dealing in a more universal kind of way - the "stop and think moment" for the person who is drinking too much, so to speak. I am not aware of work on multi-centres, but my colleagues might be - certainly we have not looked at work up until now - as a way of dealing with this. As far as I am aware, and I will double check, I do not remember us coming across that in the evidence base so far. That said, there is all sorts of lateral evidence that would lead one to suppose that that might be a highly effective strategy, because, in general terms, multi-faceted, multi-agency working in public health tends to be a great deal more effective than single-agency working or a single focus. I would not be at all surprised, if such evidence were available, therefore, that it would be supported with that kind of approach. To go on to the question of families, I believe it is the case that patterns of drinking are learned as much as anything. One of the places they are learned is in the family settings, with role models. That is not at all surprising, given other things we know about the way people learn in families. The interesting question you have raised is whether that should be used as a basis for case finding. I am much more familiar with case finding that is done in that way in relation to something like heart disease, where a successful strategy you can use, having identified a family where heart disease exists in a first-degree relative, a brother or parent or something like that, is that is a good reason to go to seek that case out again. It is working laterally rather than directly from the evidence, but the lateral thing that your question presupposes would be a very important hypothesis to take forward, I would say.
Q112 Charlotte Atkins: Would other panellists like to come in on this issue of prevention and what you think works within the NHS?
Dr Owens: I think it is really important to take a whole approach. Clearly you have had evidence about price and promotions. I think we need to re-design our city centres, so that they are mixed economies and they are not just for young people binge drinking, and then we need to provide good, sound, clear advice to individuals about their drinking at the earliest opportunities possible. That should start as early as health in schools, when you visit your GP for routine vaccinations and things like that, and then to help individuals recognise at a very early stage, when they are becoming sick, of the role that alcohol might be playing in that, because I am constantly surprised by reports from patients who have really quite significant co-morbidities, that alcohol and its role in their co-morbidity has never been discussed - from many patients they have been sick for ten years. I think there is this stigma. We have to have a system whereby we do not stigmatise patients, where we do not make them feel that they are to blame, where we treat them very much as individuals and are able to give them individual advice and individual care based on their medical co-morbidity and their particular drinking pattern.
Q113 Charlotte Atkins: Dr Cassidy, do you see your role as helping to prevent alcohol problems developing or do you just see your role as being primarily to treat the effects of alcohol?
Dr Cassidy: This is one of the central paradoxes of this topic, because GPs' thinking is dominated by the dependent end. When we talk to GPs and do qualitative research, there is a cynicism and a pessimism about the topic because people focus on that end. We know the majority of problem drinking, 23% of the population, is hazardous/harmful, and it is a much smaller percentage, 3.6%, who are dependent. We can get the biggest gains early on with the hazardous/harmful. We use the expression "numbers needed to treat": we need to treat eight patients with a brief intervention to get one of them to drink healthily. That is much better than for smoking cessation with the use of patches. The evidence is that it is incredibly effective. Most GPs would acknowledge that there should be something they should do, but they struggle to do it, and there is a cynicism and pessimism because of the focus on dependent drinkers. There is a need to help the system work with dependent drinkers so that we can feed people through quickly. If GPs are going to screen more and more patients, they are going to give up hazardous/harmful drinkers but they are going to pick up a lot more dependent drinkers, and if they pick up the dependent drinkers and nothing gets done with them, they will feel very discouraged. When we talk to GPs, there are many other barriers as well, such as time, materials, perhaps some financial incentives in the system. It has been very heartening to hear that in the new GP contract there is now a new director in the Health Service for new patients, so I think there are some system changes we can make for general practice to make it easier. GPs would want to work with the Government and the PCTs. If they think they are doing everybody else's jobs, they get turned off as well. That is why issues of units, labelling on bottles, licensing laws, taxation issues also affect GPs' thinking, because if in the consultation you are battling against all these social trends, it can be very discouraging.
Q114 Dr Taylor: I found it staggering to learn from our briefing that even a five- to ten-minute focused discussion could be so effective. You have already said it helps one out of eight. What other evidence is there that these brief interventions are effective or cost-effective?
Professor Kelly: This is one of those areas in public health that stands out with the
quality of the evidence and the quality of the direction which the evidence
gives us. I will not say it is exactly unique, but it is remarkable in some
respects. I will give you some examples. Brief interventions are effective in
reducing the following: alcohol consumption; injury; mortality; morbidity; and
the social consequences. There are currently 27 systematic reviews, including
those from the
Q115 Dr Taylor: Whatever do you say in this very previous five minutes? How do you think it is so effective?
Dr Cassidy: The key, the magic of the consultation in primary care, is that we know our patients. We have long-term relationships, so they trust us. If we reflect back to them and challenge their thinking that their drinking does not lead to harm, that has enormous power. Also, if you are able to offer simple steps, simple guidance based on this trusting relationship, it seems to work.
Q116 Dr Taylor: That is why it is effective in primary care.
Dr Cassidy: Yes. We are not quite sure - and our big trailblazer Department of Health research is looking into it - how much extra work and counselling you need to add. Do you get any added value by putting more effort in? In a normal primary care consultation you are really just working for about a minute's worth of time, whereas extended interventions are about 20 minutes/30 minutes, and that is when you may need to refer to a nurse or an alcohol councillor. We are still not 100% sure if it is worth doing that in a cost-effective way.
Q117 Dr Taylor: Is it really scare tactics?
Dr Cassidy: No.
Q118 Dr Taylor: It is not.
Dr Cassidy: No. It is working for patients. It is understanding their agenda. It is an education. It is a more motivational approach to public health.
Q119 Sandra Gidley: I would contest, in the way you are describing it, that you can do that in a minute.
Dr Cassidy: You can if you know your patient.
Q120 Sandra Gidley: Yes, but lots of patients do not go to their GP that frequently, so you do not really know them as well as you might think.
Dr Cassidy: 90% will attend every five years and about 70% every year. It is surprising how much you do get to know your patients.
Q121 Sandra Gidley: Do you know people quite a lot if they only go once every five years?
Dr Cassidy: You know their families, you know their context. There are some who are more passing in and out.
Q122 Dr Taylor: Could this be extended to other sorts of fields, other venues? Could it be done in A&E?
Dr Owens: Yes. It is done in A&E. I think we have to be very clear about who we are talking about and what level of GP. There has to be really good and accurate assessment as to the patient's level of risk in terms of their drinking. If they are a low-risk drinker, you need much less time than if they are a high risk drinker. You also have to look at the consequences of their drinking that have already occurred. Clearly, if a female is attending an emergency department with a broken ankle because they fell off a bus and they are someone who drinks just above sensible limits, your intervention will be very different for them than for someone who is attending an emergency department with chest pain, for example, who drinks ten units a day. Then you would require a more extended brief intervention. That is where we are still building the evidence base, although there is some good evidence that that can be highly effective in moderating a patient's drinking but, more importantly, helping them to increase their wellbeing and functionality as secondary outcomes to how they manage their drinking behaviour.
Q123 Dr Taylor: Who is going to do this in a chaotic stressed A&E department?
Dr Owens: It is about making the best use of a highly skilled workforce. You can have an individual as a clinical lead, or someone who is there in terms of good leadership, like myself, a nurse consultant, or a consultant within the department, but support others to deliver the more minimal interventions as part of their everyday work. For example, a triage nurse does give brief advice around alcohol consumption, particularly to a young person attending because they feel they might have had their drink spiked. That is something that a nurse would do within her normal role, whether or not they acknowledge for themselves that they are giving brief advice - and perhaps they do not. For the second scenario patient, clearly they would require something quite different, and that is where the role of alcohol specialist nurses within the acute setting may come in.
Q124 Dr Taylor: We are going to come on to that a little bit later. The ordinary A&E staff should be able to give the very brief advice.
Dr Owens: Yes.
Q125 Dr Taylor: And then somebody on call to come in and give the extra.
Dr Owens: Yes.
Dr Taylor: Thank you very much.
Chairman: We are moving on to a few questions around primary care now, Dr Cassidy.
Q126 Mr Scott: Dr Cassidy, as a family GP you must see evidence of the impact alcohol has on families the whole time. Could you tell us a bit about that.
Dr Cassidy: When we look at the attributive fraction that alcohol leads to diseases, it affects the whole disease spectrum in many ways. It is leading to extra high blood pressure and extra strokes, so there is a physical effect on the family. Clearly when we look at the dependent end, that is when we start seeing more problems, more child protection issues, families struggling to cope in our local societies or the communities and using alcohol as a coping strategy which is then, unfortunately, self-defeating.
Q127 Mr Scott: Perhaps the impact on children.
Dr Cassidy: Yes. It would be mainly through the parents. For children who are in families with parents with alcohol dependency, it is a well-known phenomenon that they become carers looking after their parents. It is a regular occurrence; it is not an infrequent occurrence. They are issues that we are involved with. Certainly, once you get to child protection and conferences, I think it is up to about 50%. A lot of child protection cases have alcohol or substance misused involved.
Q128 Mr Scott: What about domestic violence?
Dr Cassidy: The link with alcohol?
Q129 Mr Scott: Yes.
Dr Cassidy: I do not have the figures for the exact number, but it is a common forensic primary care scenario that we see some families where there is a mixture of violence, substance misuse, alcohol, and sometimes mental health issues. It is a difficult triad to try to manage and see your way through the system. Again that is one of the reasons why sometimes there is a pessimism in primary care, because of the complexity of some of these cases which clouds your mind when you think about alcohol. There is a sense that sometimes things do not improve and it is chronic and difficult at this dependent end.
Q130 Stephen Hesford: We have heard evidence that GPs basically see 90% of NHS interventions ---
Dr Cassidy: Over five years. They would see 90% of their population base over five years.
Q131 Stephen Hesford: They are traditionally the gatekeeper for the service. You would imagine that GPs are best placed to do the early intervention for alcohol-related problems, that in fact you would want them to be best placed, but the evidence is that they are not.
Dr Cassidy: No. Quite the reverse, in fact.
Q132 Stephen Hesford: How well, in your experience, talking to your colleagues, do you think GPs are currently doing in that regard?
Dr Cassidy: It will vary from different parts of the country. I think there is a
commitment to do it. There is a belief that something about alcohol should be
in primary care. As I mentioned before, there are a lot of things which
inhibit it happening. I work in
Q133 Stephen Hesford: Do GPs have what I would call an old-fashioned view, that they do not see drink as a problem? They drink. They drink quite a lot. They just do not get it.
Dr Cassidy: When you do qualitative research with the GPs that is an issue. If it is 23% of the population, there will be a certain percentage of the people here drinking too much probably - a little bit. You have to bear that in mind. Again harking back, it is getting away from making people realise that it is not just about dependency. Over the last 20 years we have moved into thinking about hazardous and harmful, I think, once you have sensible conversations and show people the evidence, how it affects hypertension, how it can affect strokes.
Q134 Stephen Hesford: Is training a big issue?
Dr Cassidy: Training is a big issue. That is where primary care organisations have a role to facilitate that. Government can have a role by encouraging PCTs to do that, putting that in performance targets, and having good training materials and changing computer systems so that they work very quickly.
Q135 Stephen Hesford: We had a brief presentation before the evidence session from our colleagues who are assisting us, and one of the statistics we had then was that in 2004 - and I know that is slightly historical - GPs in 70% of the cases where they had a presentation in front of them that is alcohol related, failed to refer on to specialist services for treatment. If that is right, why would that be the case? Is that now historic and are we getting better?
Dr Cassidy: No. Harking back to the fact that we need more specialist services for the dependent drinker, there is a pessimism: you pick somebody up and there is a long waiting list to refer somebody in for more complex treatment, so you get discouraged and you think, "I'm not going to pick it up. I'm not going to do anything." That occurs in other public health arenas - say obesity, and smoking in the past - but once you get extra resources and help to do it, people will start referring in. We also know the figures. Some people say that 98% of hazardous and harmful drinkers are not picked up in the consultation - so if you just go on stereotypes - you know, the guy with the purple nose the obvious alcoholic. To pick people up at the early end, we have to screen them. We have to use some clever screening questionnaires and integrate that into our practice.
Q136 Stephen Hesford: You come on to my next point. We have been helpfully provided with information about the Paddington Alcohol Test for early intervention, and we were told about brief interventions before. Do GPs have access to that? Do they routinely use it? It is a brief questionnaire. We have a copy of it here. Should they use it? Should that be available to them?
Dr Cassidy: GPs have access to lots of screening questionnaires and we are constantly refining and asking the question which one do we use. On the whole, I would guess, GPs would not use that one as much.
Q137 Stephen Hesford: It is for emergency admission.
Dr Cassidy: Yes. There are similar ones.
Q138 Stephen Hesford: You get the idea. There are similar ones.
Dr Cassidy: Yes. There is one called FAST and there is a very intriguing one which has been looked at in the Department of Health project which is called Single Alcohol Screening Questionnaire - one single question which can help decide whether somebody has a problem or not. It is almost like a pre-screening questionnaire. Those sorts of things are very attractive because people can do them quickly, rather than a big ten-item questionnaire. Although that is the gold standard that a lot of them are based on, it does take a bit of time to do, so people are not going to do that in a normal, routine consultation. We are looking at quicker screening questionnaires.
Q139 Stephen
Hesford:
Dr Owens: It is very important to say that the screening is a staged approach. NICE are doing work on what screening tools may be best utilised within different healthcare settings. Within primary care, the audit PC, which takes about a minute to administer, is the current advice; in A&E there are things like the PAT. If you get positive results, then you screen further, so it is very much a staged approach. To reinforce what Paul said, primary care is about a whole team, and there are individuals within that team who would be best placed to give different types of intervention. That goes from the receptionist through to the GP to the nurses, the health visitors, the midwives attached to practice. I think we have to see primary care very much as a team approach if we are going to be successful in responding to all patients' needs, because, although a patient may visit their GP surgery, very often it is the practice nurse whom they see for things like hypertension, screening, diabetes, and so we have to utilise that workforce as well.
Q140 Stephen Hesford: I think we have some questions on that for later. Finally, you have mentioned that there is this pessimism from GPs and that is why they do not involve themselves as much, so that is a barrier. Is that the sort of chief barrier: that down the line they do not see the services are there, even if they refer them on - the waiting list is big or something like that? Is that the issue?
Dr Cassidy: It is one of the key issues, and, again, I would say it is because of this dependency issue. They are all focused on dependency. If we can get that bit right, it will free the system up.
Stephen Hesford: Thank you.
Q141 Sandra Gidley: I am a little bit confused. Earlier on you were saying in response to Dr Taylor that you knew patients well, so you could use these interventions. Just now you said, "Well, we don't spot 98% of the people," which indicates that actually you do not now your patients that well. What is the real picture of how effective GPs are at identifying people? There seem to be two different answers.
Dr Cassidy: It is a paradox and I think it can he held together because of the stigma of alcohol. We do know our patients well, but some of the stigma and some of the fears they have about mentioning alcohol we do not know.
Q142 Sandra Gidley: But you just mentioned to Stephen Hesford in your reply, "We can't spot 98% of the people because they don't conform to the stereotype." I think that is what you said.
Dr Cassidy: Yes, I know I did. That is the overall research, yes, without using screening questionnaires. We know them well but we are not living with them, and because there is a lot of shame and stigma attached to alcohol, it is harder to pick that bit up about patients' lives. But, because they trust us in other areas, once we can bring it out with the screening questionnaire I think we are well able to get into the dialogue around it.
Q143 Sandra Gidley: Let me try to nail down how good GPs are at this. For what percentage of your patients who have some sort of drinking problem do you manage an effective intervention? You have 100 patients with some sort of drink problem. How many of those do you manage adequate intervention for?
Dr Cassidy: I think that what we are seeing across the patch is that we are not doing it well. We are only picking up a small percentage, so maybe it is two or four of those, but maybe when they are picked up, and if they are given a brief intervention, it works reasonably well.
Q144 Sandra Gidley: Even if you do a managed intervention, if you do uncover someone who you think might have more of a problem, is the fact that the specialist treatment is patchy and not always available a barrier?
Dr Cassidy: Yes.
Q145 Sandra Gidley: Why have I never been lobbied by any of my local GPs to say, "We need more training in this," or "We need more specialist services." Why are GPs so uninterested in the subject?
Professor Kelly: I think that is perhaps an unfair way of putting it.
Q146 Sandra Gidley: No, I do not think so.
Professor Kelly: Perhaps I can go back to the point I made at the very beginning. We are where we are, and we are in a situation where it is possible to change things but those changes require a number of different things to happen, one of which relates to properly equipping the frontline services in primary care, both GPs and nurses, with the necessary training, with the necessary ability to get past some of these real difficulties in confronting what is quite an embarrassing and difficult problem, both for some professionals and for the patient, and then using the appropriate techniques and tools which are available and demonstrably effective and using them properly. We are talking here about both a system change and a range of other changes which are perfectly possible, but, in the words I think I used at the beginning, it is getting the National Health Service and, more broadly, society to own the problem. We all have a responsibility to do something here and that is not the way we were thinking about this issue 25 years ago.
Q147 Sandra Gidley: I have never put GPs into the shy and retiring violet category, I have to admit. They are not usually shy about discussing anything in my experience. I just wonder why there is no lobby on this from primary care.
Dr Cassidy: I am saying it and the
Dr Owens: I think there is something of a capsule of despair in primary care. Professor Drummond demonstrated that only 5.6% of patients requiring treatment ever access it, because it is just so scarce, not really available when patients need it, and of all the patients who access specialist treatment 36% self-refer. I think sometimes we are asking GPs to identify patients early on, we are asking GPs to identify more of the problematic, complex patients, but when they do there is very little available in terms of referral on.
Sandra Gidley: Thank you.
Q148 Dr Naysmith: Dr Cassidy, what kind of things do you find are helpful and what kinds of things have hindered you in implementing improvements in your own practice or in general for GPs? For instance, how well does the current GP contract enable you to provide more specialist alcohol services?
Dr Cassidy: My aspects of the new contract have been very positive, I have to say, to the general practice. It has improved morale. A lot of us have bigger teams, better premises. It has been a controversial change because of the big move to a more public health perspective, and that is something that is always debated within primary care: how much do we go on what the patient presents as opposed to public health? There is a clash and there is loads written about it and some people say it has been bad and others say it has been good, but I think it has been positive. I think there is a new direct enhanced service for alcohol for new patients. We are not doing everybody, but for new patients it is a dip in the water. I think that is a move in the right direction. It brings a little bit of money into practice which you can then spend on other attached practitioners or other practice nurse hours.
Q149 Dr Naysmith: In terms of things that hinder you? You have already mentioned that if services are not available then you are reluctant to refer people on because you just put them on the end of a long waiting list.
Dr Cassidy: Yes.
Q150 Dr Naysmith: That sort of thing.
Dr Cassidy: That is very high up, we have to keep beating the drum. We need to expand alcohol services for the more dependent. Technically for GPs there is this training issue, this issue that I think a lot of GPs do not know that a brief intervention is as effective as a smoking intervention. I am sure people do not know that. That is a training issue. There has been an issue of what materials, what literature to give to patients, and knowing exactly how to give it in a brief and effective way.
Q151 Dr Naysmith: Do you think if intervention for hazardous drinkers was to be included in the Quality Framework for GPs that it would provide an incentive?
Dr Cassidy: I know some of the organisations have suggested that. I think the key thing is for alcohol to be in the new contract somewhere. Should it be in the Quality Framework? Should it be an enhanced service? There is debate. The College suggest an enhanced service. I think, personally, that an enhanced service would be better, because you can define the training more and have different levels of intervention for different practices. Some practices would be very keen on alcohol intervention and may do work with dependent drinkers; other practices will not want to touch that but may just want to do a little bit of simple screening and brief intervention. But certainly have it in the new contract.
Q152 Dr Naysmith: I am intrigued by your answer to one of the previous questions and have to ask what is this one question that you can ask people in order to find out whether they have a problem or not? Can you give us a hint as to what it might be?
Dr Cassidy: Yes. It will split people in the Committee, I am sure, but it is: "How often do you have six or more standard units?" to a woman, or "Eight or more?" to a man. If somebody says, "I never do that" then they will not have an alcohol problem. If they answer, "Within the last three months" they may have a problem or may not.
Sandra Gidley: What about people who just drink a little bit every day? That stores up problems. There are those as well. Just the six leads to dangerous complacency from what we have heard from others.
Dr Naysmith: Sandra, I as asking Dr Cassidy.
Q153 Sandra Gidley: Yes, I know. I am just fascinated.
Dr Cassidy: There is lot of interest in whether that one question works.
Dr Naysmith: I can see there could be subtleties in answering that.
Q154 Dr Stoate: The real question, Dr Cassidy, is: "Do you drink more than your doctor?"
Dr Cassidy: I drink sensibly. I enjoy a good glass of wine. That is why it is such a fascinating subject - because alcohol is good, we enjoy alcohol. We are not anti-alcohol, like we are with cigarettes, but it is how much is too much. It is complex.
Q155 Chairman:
Dr Cassidy, I cannot resist asking you this
question. If I go back to my youth, which is a long, long time ago, decades
now, before your time, one of the strongest bottled beers was Newcastle Brown
Ale, and it used to be said that there was a special ward in
Dr Cassidy: Yes, it was before my time. It is still there, though
Q156 Chairman: Was it a myth?
Dr Cassidy: I am sure. It is probably a myth.
Chairman: We are going to move on to some questions about the role of specialist nurses now.
Q157 Sandra Gidley: Dr Owens, we understand that you helped set up a nurse-led alcohol service. It would be helpful if you could tell the Committee how the service operates and how effective it has been.
Dr Owens: The service was set up with some very clear aims. It was in response to recognition that our emergency department in our hospital had a lot of patients who were there as a direct consequence of drinking and we were not really doing anything about it. We were sticking plasters on them and sending them out. We decided that one of the first aims of the service would be to support the medical interventions and optimise the medical management of the patients while they were in hospital. Hopefully that would shorten the length of time the patients needed to be in hospital and mean that we could provide really robust care pathways for patients to enable them to leave hospital early, so we would follow the patients up. Essentially, it is about ensuring that when a patient comes to a hospital they get a timely response to their problem, that they get a treatment pathway that has real choice in it for them, and so they get a choice of treatment setting. They can come back to the hospital - which many patients prefer to do because of the anonymity that that gives them - or they can go to one of the clinics that we have in our GP practices within the primary care clinic. It is about ensuring that, no matter what the level of alcohol-related harm, we are able to individualise our treatment, intervention or management for that individual patient and manage them more effectively.
Q158 Sandra Gidley: Has it worked in practice in the way you hoped it would?
Dr Owens: It has worked extremely well. We have done a full audit of the
effectiveness of the treatment. We have then done a cohort study. We compared
the interventions that have been now in place for about seven years from the
Q159 Sandra Gidley: The bottom line in the NHS is that it always comes down to money.
Dr Owens: Cost.
Q160 Sandra Gidley: Yes, cost. Are you able to demonstrate whether the service has been cost-effective?
Dr Owens: I am a bit reluctant with Christine sitting over there! If you take a very simple analysis and say that an average length of stay in hospital for somebody who has become sick, because they drink and then require management of the withdrawal, is about seven days, and with intervention from an alcohol specialist nurse that goes down to two days, then that is highly cost-effective.
Q161 Sandra Gidley: So you save those bed days.
Dr Owens: Yes.
Q162 Sandra Gidley: Did you encounter any barriers in setting the service up?
Dr Owens: In terms of setting the service up, there were very few barriers in terms of the structures. In terms of attitudes - and I think this is the same for doctors, nurses, dare I say MPs - there is major ambivalence around drinking, so almost everybody acknowledges that drink is harmful, and almost everybody can see why drink is not harmful to them. That was one of the barriers I think you alluded to when you said, "Is that a barrier for GPs because of their drinking?" One of the barriers was this notion of hypocrisy: that I cannot ask patients what they drink based on an audit score because my score is higher. It was about a lot of training in leadership, to say that your responsibility as a healthcare professional is to give the best advice based on that individual's problem and it is almost irrelevant what you drink or what your lifestyle might be at this point. That was the first way we started getting the staff engaged. We never got to the situation where accident and emergency staff did any formal screening, so we asked them to use their professional judgment, and if they felt that an admission or an attendance was alcohol related to do a referral. And they did, and they have been really supportive. Across the hospital it seems like an almost never-ending task, in that we do eight days training every single month, we have been doing it since 1997, and we are nowhere near up to the 20% of the hospital workforce that we hope to train because there is a lot of movement of different staff.
Q163 Sandra Gidley: You have evidence of better outcomes, you have evidence of cost-effectiveness, so how much has this been copied around the country?
Dr Owens: Extensively. I think in the development of the role of an alcohol specialist nurse there is a bit of an issue around nomenclature, whether they are a healthworker, whether they are a nurse. Clearly I advocate for nurses and having a very clear competency framework in which those nurses operate, but there are adaptations of how you respond to alcohol-related attendances in emergency departments and across acute trusts across the country. Currently, there are about 140 individuals with the title of "Alcohol Healthworker" or "Alcohol Specialist Nurse." What we do not know is whether their roles are well defined and exactly what they do and what the aims of their services are and their thinking. If that was more standardised in terms of responses within different clinical settings that would be helpful.
Q164 Stephen Hesford: Coming back to the issue of cost, you told us about the cost-effectiveness but I do not think you are anywhere near the cost of setting it up and running it. Do you have any figures about that?
Dr Owens: We have what it costs to employ a nurse and we have workforce development, in terms of how many nurses you would need in any given setting, how many nurses you would need if you want to ensure that you cross the boundaries of acute care and primary care. All nurses are on Agenda for Change scales. This is where I was saying it is really important to identify what the competencies and skills are, matched to the aims of your service, because that will determine the cost.
Q165 Stephen Hesford: Do you have a budget? When you are the lead nurse, you have your team.
Dr Owens: Yes. Certainly that goes through a procurement process.
Q166 Stephen Hesford: What is your budget? How do you know what you have?
Dr Owens: You know what you have by your business case for how many nurses you need, what hours they can work, and what outcomes you would achieve from that level of intervention. For example, one of the things that our A&E consultants keep asking for is for us to extend the hours of the service, and we have recently done that to include Saturdays, because were a 9.00 to 5.00 service, but it is not easy to persuade commissioners that that is something that we should do. What added benefit you get for each extension of your service into another day, we do not yet know.
Q167 Stephen Hesford: Coming back to rolling out your current programme across the country - and it is comforting to know that it is being picked up - what is the importance of local champions, someone like yourself, someone with knowledge and enthusiasm, as a catalyst for making that happen?
Dr Owens: Absolutely crucial. I think the danger is that when something becomes very high on an agenda you end up with almost too many champions, and I think we need to streamline. I think champions are really, really important, but very often that is done through individual virtuosity, it is just because somebody cares, and it is not structured and planned into the workforce.
Q168 Stephen Hesford: It has to be more rational than that.
Dr Owens: Yes, because if that person leaves, then everything goes with them. I think it has to be something that is planned for the workforce. For example, if an ED consultant is going to be champion for alcohol, then we have to make sure he has two sessions a week to do that and that is backfilled; otherwise, as Paul was saying, it just becomes yet another part of something that you do.
Q169 Stephen Hesford: If you were designing a model classically, who would that champion be?
Dr Owens: Personally, I am going to go for nurses - and shock you all. I think it has to be part of the designed role in terms of leadership. I think leadership is really, really important. I think that that leadership has to be there for the whole workforce. It has to cross professional boundaries as well as setting them. That is why I think there has to be a designated role, as opposed to somebody who is just passionate about the subject, who is very limited in terms of the boundaries they can cross simply because they are time limited, they have lots of other things to do.
Q170 Dr Taylor: Following up on that, I quite accept that you feel that a nurse has to be the leader. In the community, lots of the work is done in the voluntary sector. Alcohol Concern in their written evidence to us call these people Alcohol Health Liaison Workers and they go so far as to say that every hospital ward and A&E department should have access to an Alcohol Health Liaison Worker. Would you accept that those could be perfectly effective if they were not nurses but led by a nurse like yourself?
Dr Owens: It depends what you want them to do. If you want them to reduce length of stay, they have to prescribe for the patients, therefore they have to be quite a senior nurse. Patients may be in alcohol withdrawal, needing a prescription with the primary care, then the nurse needs to prescribe and take on the responsibility for that care.
Q171 Dr Taylor: You as a nurse consultant would be prescribing the drugs to help with alcohol withdrawal.
Dr Owens: Certainly.
Q172 Dr Taylor: And the Antabuse to stop them getting back on.
Dr Owens: We do not prescribe Antabuse, but, yes, that could be the case. It is very much about the aims of the worker. It is the case that within an acute hospital setting people are very sick, so one of the benefits of having nurses is that they can also manage that medical co-morbidity and improve their health and wellbeing. If it is just about alcohol, then healthworkers would be fine. It depends how you design your model and what you want to get out of it.
Q173 Dr Taylor: Would it be theoretically possible to have a nurse trained in your sort of way on each medical ward that takes these sorts of patients throughout the country?
Dr Owens: I think we have to make sure we make the best use of the workforce and certainly with good clinical leadership and education, nurses do, across acute hospital trusts, manage these patients all the time, but they do it with advice and support from a specialist nurse certainly - or that is current the model within our trust.
Q174 Dr Taylor: You would accept that there is a place for these Alcohol Health Liaison Workers in hospitals as well as the nurses?
Dr Owens: So long as their roles and responsibilities are well defined and we are very clear about their competency and what we are asking them to do.
Q175 Mr Scott: A question for Dr Cassidy and Dr Owens. You said earlier that there is a stigmatisation and perhaps discrimination. To what extent do healthcare professionals view that this is self-inflicted harm; how does that affect the treatment given and the staff reaction to people coming in who, as we have said, have self-inflicted themselves with too much alcohol? Or maybe you think it does not make any difference.
Dr Cassidy: I think you have to acknowledge those feelings and bad practice
would be for it to affect you adversely. But when moral issues enter the
clinical encounter you do need help in training to explore those and to think
about the ethics of what you are doing; and then you need champions like
Q176 Mr Scott: And will not necessarily accept that it is not self-inflicted; it is a problem that someone has?
Dr Cassidy: Yes, and that is what they have chosen and it is a moral problem and why should medicine be involved. It is what makes it so interesting as well and why we need everyone involved in the public health approach.
Dr Owens: I think that that certainly is a feature for some people but we have a responsibility to treat all our patients with dignity and that would be the same for someone who is in hospital because they are obese or smoking; so we think it is something that the healthcare professionals are really used to, and it is a training and support issue and it is about within the hearts and minds of the workforce to make them feel valuable because historically it was the cases that nurses and doctors felt that when a patient came in with a complex alcohol problem that that was the end of the road for them, that there was nothing that could be done. Just with quite minimal training, some really good support and leadership we can quite easily convince this workforce that this is an opportunity to start a process of care and treatment that can be highly effective and make the clinicians feel good about the interventions that they can deliver to make a difference to that person's life and if you do that I think you have won the argument, essentially.
Q177 Charlotte Atkins: We are now at the final question and I would like to ask each of you what are the three things you think that the NHS can do, the best interventions to reduce alcohol-related problems. So really what are your prized three areas that you think we should be focusing on to kick this problem out of our society?
Dr Cassidy: More alcohol health workers.
Q178 Charlotte Atkins: At primary care level or secondary?
Dr Cassidy: Across primary and secondary care. More screening intervention in primary care; encouraged through the GP contract and more joined-up government work in the areas of licensing, labelling and taxation.
Professor Kelly: I think my key argument is that we need to see this as a population based problem; that is to say if the NHS focus is only on the far end of the spectrum where the alcohol problems have turned into florid disease, important as that is that is actually missing a significant proportion of where the morbidity has been built up over time. In other words, alcohol use, given it is such commonplace in society, the effort is about reducing overall alcohol consumption in the population as a whole. The National Health Service, and in particular primary care, can play a very important role in that in the ways that we have heard here, but as well as dealing with the extreme end of the spectrum dealing with ordinary patients coming in and testing the "stop and think moment" with them - even if it is with that one question that lets you know one way or the other. I think that should be encouraged. But on its own that is insufficient; we need a national strategy, which is about bringing down the overall levels of alcohol consumption in the population as a whole, especially, I might say, among people who consider themselves to be sensible drinkers because that is where the problems begin to build.
Dr Owens: I think price promotions and city centres are really, really crucial because they impact on the whole healthcare system; and I will go for every acute trust needs a clinical leader that is able to bridge those primary, secondary gaps and help patients navigate this system because one of the things that stops patients getting well and doing well in treatment is often that the services are not set up in response to their need - they are set up historically. So I think a clinical lead who can help patients navigate systems in and out as and when they need it would be crucial.
Q179 Sandra Gidley: And more nurse specialists as well?
Dr Owens: Yes!
Chairman: Could I thank all three of you very much indeed for coming along and helping us with this inquiry this morning.
Witnesses: Professor Robin Touquet, Accident and Emergency Consultant, St. Mary's Hospital London, Ms Carole Binns, Commissioner, Southampton PCT, Mr Brian Hayes, Alcohol Bus Service, London Ambulance Service and Dr Duncan Raistrick, Alcohol Treatment Specialist, Leeds Addiction Unit, gave evidence.
Q180 Chairman: Good morning and welcome to our second evidence session in our inquiry into alcohol. Could I ask you for the record if you could give us your name and the current position that you hold. Can I start with you, Professor Touquet?
Professor Touquet: Robin Touquet; I have been a consultant in emergency medicine at St Mary's Hospital Paddington for 23 years and that is where the Paddington Alcohol Test was born in 1996.
Dr Raistrick: I am Duncan Raistrick; I am a consultant addiction psychiatrist at Leeds Addiction Unit, which is a clinical and a national training centre.
Ms Binns: I am Carole Binns; I am Commissioning Service Manager for Mental Health and Substance Misuse with Southampton City Council in Southampton PCT and my background is that I am a qualified social worker.
Mr Hayes: Brian Hayes, paramedic team leader. We started the Booze Bus in
Q181 Chairman: Thank you and welcome. I have a question to all of you to start with and then we will have specific questions around your particular expertise. My first question is what in your experience does the National Health Service do well and badly in managing alcohol-related problems?
Mr Hayes: I think we highlight the problems quite well but the position that we are in, because we get people at the point that the phone call has been made and then we release that patient once we at hospital, for us doing anything else - we do not get patients long term. We will get regular callers and we will be able to highlight patients that could have a problem but because we get patients for about half an hour at the most what we do quite well, I think, is highlight the problems that we are beginning to face as a service.
Ms Binns: I think we are very good at dealing with people with chronic and long term problems around alcohol misuse, so we provide very good services when people reach a critical stage, particularly around A&E emergencies and around liver disease - it is not because our liver consultant is in the room! I think what we are not very good at is actually seeing alcohol issues as everybody's problem in the NHS and in social care services, so responsibility for alcohol provision and treatment and for commissioning alcohol services tends to be placed with specialists, with commissioners like myself or with specialist treatment personnel or teams and we do not look at the impact across key disease groups like cardiovascular, cancers, mental health issues, so the approach is not very integrated yet the impact is across a whole wide proportion of the population.
Dr Raistrick: I think we are very good at dealing with people who have developed disease or come into A&E departments but that is somewhat divorced then from dealing with the substance misuse problems, particularly alcohol in this case. I think where there are specialist alcohol services then they are generally quite sophisticated and quite effective, so I think we are good in so far as we do deal with the alcohol problems in the specialist areas.
Professor Touquet: I will not agree with that entirely. The medical profession loves pathology; they find that very interesting. They are less interested in picking up self destructive behaviour early on and helping patients to develop insight. Unfortunately the NHS is quite structured with substance misuse, including alcohol being part of substance misuse services within psychiatry, and psychiatric services are in separate trusts from acute hospitals; so doctors tend to feel that alcohol and drug abuse is part of psychiatry. Even worse, they will feel that early intervention - and Sir Graeme Catto of the GMC has said - that all healthcare workers had a duty of care to reduce unscheduled re-attendance. But there is a tendency - and it is a fault of medical education - that that is seen as public health, which is separate from day to day jobbing work in primary care or A&E and clearly we are at the sharp end and we have the opportunity of picking up self destructive behaviour early on, and we are bad at that.
Chairman: We have some personal questions for individuals now.
Q182 Dr Naysmith: Dr Raistrick, I have a few questions for you. To what extent have alcohol-related problems changed over the past 30 years?
Dr Raistrick: It is difficult to say that they have changed in character; I think they have probably changed in quantity and there are probably plenty of statistics you have already had to show that. If we look over recent years it is easy to look at health problems - there are plenty of statistics - and we can see that the admissions for all kinds of alcohol-related problems have steadily increased, so we are looking in the last ten years at something like a tripling of admissions for cirrhosis and a doubling of admissions for mental and behavioural problems. So I think that had been the trend and just an increase in quantity rather than type.
Q183 Dr Naysmith: Interestingly there have been these increases, increases that have not occurred in some other European countries; why do you think they have occurred here?
Dr Raistrick: I think there has been a change of culture as well in recent times, so there has been a shift - as also, with the previous panel - there was a culture of drinking to get drunk and that has always been seen as something of a northern European sort of culture. I think that has exaggerated in the last few years, perhaps partly because it has been policy to make alcohol more available in this country. So there has been a shift of drinking to get drunk but on limited occasions. It is difficult to get statistics on that; it is difficult to really get much of a handle on that. I am not really aware of any data that is currently available that really gives much of an idea of the extent to which intoxication causes crime, causes accidents, the usual things that we associate with intoxication.
Q184 Dr Naysmith: The sections of the population where the increases have been greatest are in young people and in people over 65, in the last four or five years particularly. Is that your experience too and why do you think that is?
Dr Raistrick: It is and I think that has
been the shift. Interestingly I was coming back from
Q185 Dr Naysmith: Do you think this is going to continue into the next few years? In the next ten years do you see these trends continuing?
Dr Raistrick: I do not think so because I
think probably people like yourselves are going to take some action. It is
difficult to escape that if we as a country drink more we are going to have
more problems and I think that something has to be done at that population
level. There have already been suggestions - the obvious things to look at
price but also the availability of drink in terms of the number of outlets,
opening hours and so on, as well as possibly specific measures. For example, I
am always surprised when I go to the airport that
Q186 Dr Naysmith: Finally, how about the alcohol rate of admissions that have increased in the over 65s in the last few years? Is that just because of increased affluence among some sections of the pensioner population?
Dr Raistrick: I do not know why it is but I would speculate that that is the case. Often people are retiring somewhat younger and anticipating and enjoying their retirement and they have the financial means to do that and I guess that that includes drinking. But of course there are particular problems for older people as well, which may well lead them into drinking - various losses and so on.
Q187 Dr Stoate: I want to look at government strategy over the last few years, particularly the 2004 National Alcohol Strategy and the follow-up Safe, Sensible and Social. I want to look at how effective they have been in helping with reducing alcohol-related problems. Do you have any views on that? I will start with Professor Touquet and then move on to you, Dr Raistrick.
Professor Touquet: I am a jobbing A&E consultant and I do not have the overall perspective that my colleague in public health has. I certainly think that the Department of Health has done a lot of very good work, working up to PSA25 and that they are very much aware and are trying to help the process of all healthcare workers understanding the difference between brief advice, which is one to two minutes - the duty of all of us - and brief intervention, which is a specific skill which I do not have but which Lynn Owens of PhD nurse background does have and has demonstrated that leadership to you. I think that the downside - and I have responded to the Safe, Sensible and Social - the three Ss - document and much that is good in it. But there does need to be a culture change within medical education and I understand that £100,000 has been set aside to improve the amount of medical education in undergraduate education that is furthered on one hand by the Medical Council on Alcohol, the MCA, and on the other hand by Professor Hamid Ghodse with his group at St. George's Hospital, who I think are going to be the beneficiaries of that money and to make sure that it is spent articulately. So the answer is in summary to your question, successful in part but the medical profession is perhaps the most reluctant to change its attitudes.
Q188 Dr Stoate: Dr Raistrick, what do you think about this?
Dr Raistrick: I would agree with that. We conducted a survey of staff in secondary care NHS facilities who were particularly likely to come into contact with substance users and it is interesting that there was an inverse relationship between the seniority of staff and their commitment, their enthusiasm for dealing with substance misuse problems; so in other words the junior healthcare assistants saw themselves as both willing and effective at working with people who had alcohol problems, whereas the medical staff were," Not my business" and very resistant to dealing with it and nursing staff were somewhat intermittent. So I think there is a need for some training and, I think as several people have said, a wholesale change of thinking in the NHS so that everybody sees drinking and other substance misuse - smoking, drugs - as everybody's business because it is at the early stages where brief interventions are going to be effective, and I think it is entirely possible to train the entire workforce to be competent at some form of brief intervention or, at the very least, identification.
Q189 Dr Stoate: I appreciate all that and there is nothing wrong with that answer. What I am trying to get at is how helpful has the government been in terms of strategies and initiatives to try and help this process along and what does the government now need to do to improve the situation?
Dr Raistrick: I do not think that the government strategy has been terribly helpful really. I think it was helpful to have a national alcohol strategy; it is a pity that it was called Harm Reduction Strategy because I think that rather reduced the impact, and I think publications since have actually not been very helpful.
Q190 Dr Stoate: Carole, do you have any view about that? Do you think that the government strategy has been helpful in any way?
Ms Binns: I think the national strategies have been helpful; they have provided a framework, particularly for commissioners. There has been a great deal of helpful information about evidence-based interventions, which has helped certainly to raise the profile around prevention and early intervention where I think in the past we have actually been focused on treating people at the higher end, and I think it has started to shift the debate as to whether we should focus on those earlier stages. I think unfortunately again the strategies have been seen as being owned by specialist commissioners, like myself, and specialist providers and I do not think the information in the various documents has been widely disseminated across other parts of the NHS.
Q191 Dr Taylor: To Professor Touquet really. I regret I have only just seen your PAT revision paper which makes it absolutely clear at the top of page 3 about the brief advice that any ED doctor should be able to give, so that is extremely helpful. My questions are about alcohol-related harm and to give us some sort of idea of what sorts of alcohol-related problems you commonly encounter in the A&E department.
Professor Touquet: Thank you. Let me say that when I started at St. Mary's in 1986 I had no particular interest in alcohol misuse and if it is helpful to the Committee I would like to give a historical perspective. When I arrived the only service for alcohol misusing patients was an appointment with a consultant psychiatrist, Dr Bernard Marjoe (?) at St Benedict's Hospital, which is the far side of Ealing, which is 12 and a half miles from Mary's and the waiting time for an appointment was six weeks, and a very senior colleague, when I was trying to drum up support to make the case to get resource in to help patients who were sick and who would come in, collapse into A&E, etcetera, he said to me, "Robin, be a man, it is just part of your work." I said, "Yes, it is part of my work - drunks are sick; and I am a man because I am ex-Royal Marines and I do not like being patronised." Since that time we have published about 15 peer review papers because nothing is worse to an NHS manager, who is under awful pressures and can lose their job if they do not conform, than an emotional consultant saying, "We have to have this resource or patients will die!" You have to give objective, cold, hard clinical evidence. So in answer to your question, the Paddington Alcohol Test, which was evolved from the frontline highlights that the top ten presentations - and we published on that - will come to no surprise to you - collapse, head injury, assault, accident are the top five, and doctors are the worst at asking patients who have been assaulted because they feel sorry for them. And if I could just come back to that. Then the next five being unwell. A&E quite legitimately is a place of safety; patients come when they are distressed and I would far prefer a distressed patient coming into A&E before they have done something to themselves than to be brought in as a multiple injury having jumped under a tube and you have to say that again and again and again to staff: "We are a place of safety", and you have to be very careful of triaging patients who may not be able to articulate their problems well. Gastrointestinal, cardiac, psychiatric and repeat attending. But with a patient who has been assaulted, if they are seen quickly - and I have spoken out publicly saying that the 98% target through in four hours is a very good thing. After all, if you are going home and you are in an A&E department and something awful has happened and you have fallen over and broken your wrists you want sympathy, you want humanity, you want to be given pain relief, you want to be seen by somebody who knows what they are at; then, hopefully, if that happens you will feel grateful and then the healthcare professional, be it nurse or doctor can introduce their own agenda when the patient is saying thank you, which one hope one does. In the NHS you do not get paid for how many patients you see but it is very nice being thanked, and I have been in medicine 44 years. Then you can introduce your own agenda by saying - and we routinely ask all patients, going back to your point about assault - who have been assaulted, "Do you drink alcohol?" and if you approach that rear-ended, having generated gratitude then I think the NHS has a huge amount to offer, be it the A&E department; Jonathan Shepherd has done wonderful work for facial maxillary surgery on assault patients; fracture clinics; sexually transmitted disease patients; and may I just introduce at the bottom of the pack about the resuscitation room, which shows that 15% of patients over one year had a raised blood alcohol concentration and the top five conditions associated with a raised blood alcohol concentration in the resuscitation room - collapse, self-harm, trauma, gastrointestinal bleeding and non-cardiac chest pain. I have to say with all due humility that two doctors at St. Mary's have rung the chemical pathology lab to say, "What is the normal range for a blood alcohol concentration?" I would like to reassure the Committee that the normal range is zero!
Q192 Dr
Taylor: Thank you very much, it is a great
relief to hear that things have improved in 20 years in accessibility of
health. Recently we have been on a visit to
Q193 Dr Taylor: So it is 30% to 70%. Do you see many people who have been harmed by people who were drunk? They are not drunk themselves; any percentages for that?
Professor Touquet: Yes, I have a slide of somebody who tried to break up a fight at the Dorchester Hotel. He was entirely sober but when people have been drinking their inhibitions are suppressed - if they feel like crying they cry, if they feel like punching they punch and he was entirely sober but he came in with his white shirt with blood down it and a split lip and he was very, very affronted.
Q194 Dr Taylor: Is this a relatively common occurrence that perfectly normal people who are not drunk have been damaged by drunk people?
Professor Touquet: Yes, in every sort of situation. For instance, in the inner city it is often the drunk pedestrian who is hit by the sober driver and the sober driver may be more upset than the drunk pedestrian. Also, if you are in your A&E department, hopefully not waiting too long, you do not want to sit next to an over familiar person who is obviously inebriated and A&E departments are a place of safety and we have security in the A&E department at night all the time now at Mary's because patients have to feel secure and unthreatened within that environment.
Q195 Dr Taylor: And it really is possible in this pretty chaotic environment to give this one to two minute brief advice?
Professor Touquet: We have shown in the largest randomised control trial, which his
pragmatic, where the brief advice has been given by routine staff that for
every two patients who accept an appointment with the alcohol nurse specialist
for definitive brief intervention there is one less re-attendance over a
12-month period and you do not get papers published in The Lancet without very heavy peer review. Albeit I am extremely
grateful for
Q196 Chairman: If anybody goes into A&E who is a victim of a car accident there is a payment made to the National Health Service, is there not? Does it still happen? It used to be on an individual basis but do insurance companies do it now?
Professor Touquet: I believe it does, but as a jobbing clinician who has held no managerial responsibility now for seven years I am not best qualified to answer that.
Q197 Chairman: I think that is the case but it is all hidden now through insurance companies. I want to take you down a path that you may be reluctant to go down, but I want to pursue this anyway. I am not talking about people who have chronic problems with alcohol, but this is about behaviour, particularly on the Friday and Saturday nights that you have graphically described, that people will go out drinking and drink to irresponsible levels and become in need of your services in your hospital, in A&E. Because of this personal responsibility do you think, given the amount of time and money they consume from us as taxpayers, for being irresponsible, that any charge - not dissimilar to one for a car accident - should be made by the NHS for treating these people? I am not saying do not treat them - obviously your instinct would be to do exactly that, but should they be charged? Do you think that if there was a possibility that there may be a charge for using A&E facilities particularly because they have been a bit stupid that it may change their order in terms of priorities when they go out at night and they may not drink as much? I know there is a lot in that but I just wanted your view on it.
Professor Touquet: I understand your question exactly. I have had the privilege of being in medicine for 44 years and I have always worked within the NHS and I think one of the many very good things within the National Health Service is that the threshold for seeking help should be very low and not related to the person's ability to pay. The simple answer to your question is no because there will then be a reluctance of people to seek help early on and the thrust - and I hope the message, which when I was sitting as an observer, has been to you - that if you can intervene early on with young people to get them to contemplate change before they become dependent, that is very much better than trying to treat all the interesting pathology that the dependent drinker will have. The risk of charging is that the NHS will become less effective at picking people up earlier. Our friends in the Ambulance Service do have the most awful job of trying to decide whether to take patients to A&E, whether to manage them on the spot and I think they do a wonderful job under very difficult circumstances. But charging patients would be self-defeating and certainly people like myself would, I think, find it very difficult within the way we have been brought up within the NHS.
Q198 Chairman: Presumably you would argue that one of the ways to reduce consumption of alcohol is to put up the price of it?
Professor Touquet: I say very humbly that I am a jobbing A&E consultant and even though I enjoy drinking alcohol myself - it is an enjoyable social lubricant - there is no doubt that A&E is a place of safety, sees the consequence of the fact that alcohol has, pro rata, got cheaper; and that the availability, especially in supermarkets, goes round the clock and the perniciousness is that young people feel, "No government would give 24-hour availability at cheap prices if alcohol was dangerous; after all, they would not do that for heroin or cocaine. They do it for alcohol; alcohol must be safe." We all know that alcohol is enjoyable and art of our culture and part of Church of England and Roman Catholic rituals - not Muslim rituals - but it sends a wrong message to the young that alcohol must be safe; and alcohol is not safe. That is why I say to the young people, "Why make yourself vulnerable?"
Q199 Chairman: I accept that entirely; it is the issue about how do you change lifestyles? Brian, obviously your members have this problem most nights, not just Friday and Saturday nights?
Mr Hayes: Every night of the week, yes.
Q200 Chairman: Do you think there is anything that can be done at the front door that would not stop people being looked after?
Mr Hayes: There is no way that we would refuse anybody help. Where we have a
problem, I think there is a massive void between us picking these patients up,
them going to A&E to be treated and then the following up of the patients
from there. I think we are in a really good position where we get to these
patients - it could be the first time they have got into this stage. I was
listening to the one before and they were saying, "Have you drunk six units
before?" We are lucky if we can get anybody that can answer that question, let
alone know their name. The problem that we are getting is the assaults on
staff, the assaults that happen because people have been drinking alcohol. The
question I ask myself with a lot of them is, "Right, if this person had not got
drunk tonight would they have been beaten up, or would they have tripped over
on their high heels?" The answer is not that it would not have happened; so it
is not just the people that we are going to who are comatose through alcohol,
it is the injuries that happen. You are talking about split lips and so on; we
are talking about people that because of alcohol have jumped up on a wall
because they think it is a bravado thing to do with their mates, not realising
that the drop the other side is 60 feet and they have gone down it. Their one
massive night out has ended up with a family with someone who is deceased; and
that is not an occurrence that happens every so often - this is every weekend
that this is happening, whether they die or not. We have had to get our
helicopter out on six occasions in the last three years to people where the
call has come in as unconscious and where the person has been asked on the
phone have they been drinking - yes, they were drunk, but when we have got
there the injuries we have been faced with have been so horrific, due to a bus
driver who had kicked somebody off his bus and his head had been used as a
football by about five or six blokes who were all drunk, and he ended up in
intensive care. This is happening week in, week out; it does not have to be a
Friday or a Saturday. But what we are finding is that most of the males we are
going to will initially be for the injuries they have received - minor head injuries
and things like that, assaults. But when we go to the younger females and
females in general it is purely the alcohol we are going for, to the point
where they are not waking up where they are in A&E four or five hours
later. We went to one young female who was found staggering down a road in
south-east
Q201 Charlotte Atkins: Professor Touquet, you mentioned in your previous intervention about the importance of early intervention. What sort of early intervention would you see as being practical and effective?
Professor Touquet: Thank you. I am glad you used the term "early intervention" because
I do try and encourage people not to use the "s" word, which is screening,
because that excites a very negative reaction amongst the medical profession -
less so with the nursing profession. But I do believe that people who work in
the acute sector - and obviously I am a prisoner of my own work environment,
that all of our junior doctors who change with us every six months, albeit it
nationally, in a majority now of A&E departments, sadly the junior doctors
change every four months. You need to change their attitudes; you need them to
understand that alcohol is a drug. They need to understand that something can
be done. We are extremely grateful to Westminster PCT because we now have two
alcohol nurse specialists and they are the stress relievers for the staff in A&E
and you need the junior doctors especially to understand that there is
something that they can do, and by back-ended, when you have hopefully
generated the gratitude factor of saying to a patient, "We routinely ask
everyone who has fallen, 'Do you drink alcohol?'" then that is an unthreatening
way of putting the question and you then have question 4 on the PAT, "Do you
feel your attendance at A&E is related to alcohol?" If they say, "No, doc,"
and you get the full force of a bottle of
Q202 Charlotte Atkins: You have. What do you think primary care should be doing? You see them at a stage not too late but at a stage where they are already hooked on alcohol to a very bad extent, but what should primary care be doing alongside acute hospitals along the line of prevention?
Professor Touquet: Could I answer that in two parts? First of all, we in A&E will see a lot of young people who do not necessarily make use of their GP and we will see often the first manifestations of alcohol misuse of fall, collapse, head injury, assault. In primary care I would agree with what has been said before. You have heard about the shortened audit questionnaire and I think it is on two levels. First of all, when patients register with the GP; then it is very appropriate that the word "screening" is used as a basic index, bearing in mind you have to get empathy with the patient so that they are not worried that the nurse will be judgmental if they give an all too honest answer. Secondly, when patients can see their GP with conditions such as lack of sleep, palpitations, alteration in bowel habit, unable to cope with life, that is a potential opportunity for opportunistic intervention with a teachable moment, and certainly alcohol can be one of the underlying causes which any GP should be alive to.
Dr Raistrick: Can I just comment on psychosocial interventions a bit more
generally because I think it is really important to understand that we are
talking about interventions that are fundamentally different to, for example,
having a course of Tamiflu. The difference is that we are talking about a
process of change and it is the way that the treatment is delivered and when it
is delivered that matters as much as the particular treatment. I think we have
a very good grasp of what are the effective ingredients of interventions for
addiction problems. For example, what you are trying to do with a psychosocial
intervention is either start that process of change going or, if it has already
started, to move it along. So you are asking if there was one question what
would you ask? It might be something like, "What do you mind most about your
drinking?" because a question like that might resonate with where the person
was already at; and you would get very different answers. For example, two
rather extreme cases I can think of, a musician in response to that question
said he fell off the stage when he was drunk and that is what he minded most
and that was the driver for him to change his behaviour. Another example I
remember particularly was a mother who forgot to pick her child up from school
because she was so drunk and that is what she minded most. More commonly it is
things like relationships breaking down and so on. But the idea of the
psychosocial intervention is to tune in to the concerns that the individual
already has. To demonstrate how that happens, it is pretty typical if you look
at people coming to specialist services that somewhere around about 20% will
already have stopped drinking by the time they come to the service. That is not
to say that they are better, but it is to say that they have already started
that process of change themselves; so you are picking them up part way along
the journey. The key to success is making lifestyle changes which is quite
difficult to do and quite a long process. I think we should be making much more
use of community resources to help people do that; we should be using self-help
agencies much more; and the family has already been mentioned. A treatment you
might be familiar with that we looked at in the
Ms Binns: I just wanted to add something very briefly to what we can do around prevention and it was the fact that I think any prevention needs to start from the point that alcohol affects all sectors of the community, the whole population, and whereas acute hospitals and GPs are very important contact points lots of people are not coming into contact with those people regularly. Young people, for example, do not see their GPs very often and do not come into contact with any healthcare workers. So prevention needs to actually target a range of primary contact points and that would include schools, youth services, criminal justice, occupational health, major employers, and we need to widen the base to where we push out prevention messages and where we give out preventive services, rather than look at a small number of very targeted, very specialist areas.
Q203 Dr Naysmith: Dr Raistrick, you had really started on the sort of area that I want to explore, so we can it from some of the things you have already been saying. The question is how effective is the treatment for alcohol misuse in your experience - that means the Leeds Addiction Unit, I presume? Is it effective? Then I want you to compare it with what happens with drug treatment for other substance misuse. How does alcohol compare? Is it effective and how does it compare with the way that treatment is administered and is available for other substance misuse?
Dr Raistrick: The difficulty is that it depends what you mean by "effective".
Q204 Dr Naysmith: Does it work?
Dr Raistrick: Putting that aside for the moment, as a unit we have been rather fortunate, I guess, in that we have generally been involved in research projects to improve our practice and the UK Alcohol Treatment Trial was a good example of that; so within the UK Alcohol Treatment Trial we were delivering something like 40% of people were becoming abstinent and others were improving. That would be fairly typical for our patient group as a whole. If we look at heroin users and alcohol users we get something like 50% will show significant improvement and that would be a statistically significant improvement. If you apply more stringent tests and look at what is clinically significant improvement then that drops down to something a bit more like 30%, but that is a pretty harsh test and there is a range of improvement which you might not consider good enough improvement, so it depends a bit on what you mean by improvement; and it also depends on what areas you are looking at improvement.
Q205 Dr Naysmith: Presumably you cannot do control trials and leave people untreated can you, or can you look at a population of untreated people that have never been offered it and see what proportion of them improve just automatically?
Dr Raistrick: I do not think you can any more actually. This was one of the ethical considerations we had when we looked at the UK Alcohol Treatment Trial and we came to the conclusion that you could not actually have the no treatment control group; although methodologically it is always a bit unsatisfactory to have a group where you are not doing anything and in UKATT we had two interventions that everybody was very enthusiastic about - there was a brief motivational therapy and a slightly more intensive social networking therapy. So we took the view that the ethical approach was to say that there is a gold standard treatment here, namely the motivational treatment and we will judge things against the motivational treatment as the gold standard.
Q206 Dr Naysmith: One of the points I am really trying to explore is the belief for which there is a fair bit of evidence that there is more effective treatment for drug misuse than there is for alcohol misuse; is that fair?
Dr Raistrick: I would not say that was fair at all, no.
Q207 Dr Naysmith: Only 5.6% of dependent drinkers were receiving treatment in 2004; and last year there were 55,000 people receiving treatment for alcohol disorders, compared to 193,000 for drug disorders. So there were more people on drug treatment than there were on alcohol treatment, yet probably there are more dependent drinkers than there are drug addicts.
Dr Raistrick: I am sorry, I think I must have misheard you. Certainly there are more resources going into drug treatment.
Q208 Dr Naysmith: That is the point, is it not?
Dr Raistrick: Sorry, I misheard your question.
Q209 Dr Naysmith: Is that right?
Dr Raistrick: That is certainly the case.
Q210 Dr Naysmith: Should that be the case, given the bigger problem that alcohol must be compared with drug abuse?
Dr Raistrick: I think the difference is huge, is it not? The National Audit Office produced figures saying that it is something like £1700 per head spent on drugs and £200 on alcohol, so clearly that is a huge discrepancy. I think there are other problems with that as well, that the drugs strategy is driven by a separate bureaucracy which is also hugely expensive, whereas the alcohol services are not - they are driven through the usual Department of Health systems. Certainly in the early days the driving of the drugs policy, to my mind, lacked any sort of therapeutic optimism and I think there was a satisfaction to have essentially a methadone programme that was on the harm reduction ticket but a methadone programme that really did not deliver very much in terms of other health and social gains. So it seems to me that while a lot of money is being spent on the drugs field the money is not being very well spent.
Q211 Dr Naysmith: What are the inadequacies then in the treatment of alcohol-related problems - people who are drinking too much and people who have got to the stage of problems with their drinking? What are the inadequacies in the treatment that you see?
Dr Raistrick: Other people have said that there needs to be a range of services. Clearly
primary care is an important starting point; there is good evidence for brief
or briefer interventions in primary care, but it has proved very difficult to
role out what we know to be effective treatment into the primary care setting -
very, very difficult to do that. The alternative is to say let us have some
specialist workers going into primary care settings if the primary care teams
are not willing or able for some reason to deliver the services. So that would
be important for the longer term reduction and prevention of problems, but of
course if you do intervene more actively in those settings and in all the other
generic settings - social services, probation and so on - that will uncover a
lot of people with more dependent drinking, so there needs to be an increase in
specialist services. There need to be services such as
Q212 Sandra Gidley: The Government claim that there has been more money put into alcohol services but it just goes into the PCT pot. Do you think that all of the money that is in theory designated for the alcohol services is actually spent on alcohol services?
Dr Raistrick: I would think that it was not; there generally is not any evidence for that! I can really only speak for where I work, which is Leeds and as far as I am aware none of that money has yet been allocated - none of the money at all has been allocated.
Q213 Sandra Gidley: So does there need to be a dedicated funding stream?
Dr Raistrick: It always helps or some clear guidance from the Department of Health. I know that the Department of Health see that they cannot be directed but I think some very strong guidance saying "You should have this; you should have that" usually results in the money being spent, although times might now be difficult.
Q214 Sandra Gidley: Would you like to put a figure on how much more money needs to be made available to tackle the problems? Or even in your area, to give us a rough idea of the shortfall?
Dr Raistrick: I think it is unlikely really that a lot more money would be available and I think the money could be better spent; I think we could reduce the drugs bureaucracy and move some of that money into alcohol. We could reduce the bureaucracy generally - I know everybody always says that and it is difficult to do, but we could try and do that. We could use resources that already exist in primary care and in secondary care. It is very difficult to put a figure on it.
Q215 Sandra Gidley: Would you say that it is fairer to say it is more of an overall lack of attention to the problem than necessarily needing a dedicated funding stream?
Dr Raistrick: I think both things need to happen. There is an overall lack of attention to the problem and I think if you look around the country the range of services available in any town or city varies hugely and undoubtedly there is a need for additional services, but I am not in a position to put a figure on it.
Ms Binns: Could I comment on that from the commissioning perspective because you are asking about the investment levels in the PCT? The DoH has come out with the formula that for every pound we spend on alcohol treatment we save £5 in the rest of the NHS. I do not think that is something that anyone would argue with; there is ample evidence around that. So in some respects investing in alcohol services is a spend to save approach. However, shifting money within the NHS is much more complex than that, so whereas if we are saying that if we spend money today we may save money in some of the higher end treatments in five, ten, 15 years' time but we cannot actually take the money out of those services today.
Q216 Sandra Gidley: So you need transition funding?
Dr Raistrick: We need transition funding, yes. Also, the additional item is that many people who we know have an alcohol problem or are developing an alcohol problem are not in contact with treatment services at the moment; they have not yet been identified and they have not identified their end problem. So this is a new group for whom we are not currently providing services. Again, we know that the evidence is that if we identify those people and give them early treatment then they will not cost us a great deal of money further down the line.
Q217 Dr Naysmith: We have seen some figures that suggest that the voluntary sector spends a lot more than the NHS on delivering alcohol treatment. Is that your experience, Dr Raistrick?
Dr Raistrick: I think there has been a changing pattern and there has been a shift of services into the voluntary sector. I understand from commissioners that the main purpose of that is to create a market place. I do not know if that is true but I can understand why that would be the case. So money has gone from the Health Service into the voluntary sector.
Q218 Dr Naysmith: Are we coming to rely on the voluntary sector in this area then and are they capable of delivering a service, given the way they have to raise money and so on?
Dr Raistrick: I think the voluntary sector has been a part of alcohol services for as long as I have been in the field, which is quite a long time, so I do not think it is really about relying on one sector or the other - the sectors have generally always contributed a particular part to the whole. I think that probably has changed, as I say, recently for the purposes of creating the market.
Q219 Dr Naysmith: Can they cope with the demands that are being placed on them now?
Dr Raistrick: I think there possibly is an over enthusiasm by some non-statutory sector services to go for contracts that possibly they are not likely to be competent to deliver; indeed, that has happened recently somewhere I know, where a non-statutory agency got a contract to deliver an arrest referral scheme and then phoned a specialist service saying, "Our staff do not know how to deal with alcohol problems; how do we refer to you?" So there is, I think, a bit of a problem. Having said that, the staff in the NHS are not always competent to deal with these problems either.
Q220 Dr Naysmith: It has been suggested that the caseload sometimes might be too complex and too complicated for some of these organisations to deal with.
Dr Raistrick: I think that is certainly the case.
Q221 Dr
Naysmith: Yet my experience in
Dr Raistrick: No, I do not think they are, and particularly with alcohol there has been a very big focus on delivering brief interventions, presumably because brief also means inexpensive, without recognising the knock-on effects of doing that. A lot of brief intervention would no doubt be a very good thing but the knock-on effects of that are more people being identified and coming to specialist services, as is the case with more workers in the hospital settings and now of course the focus on the PSA25, so a lot of people are looking at how do we reduce hospital admissions. I think there is a general agreement that the only way you are likely to do that in the short term is by developing more specialist services to pick up the load.
Q222 Dr Taylor: We have already heard about the importance of early intervention and I was not quite sure, Carole, this spending a pound to save £5; is that specifically from early intervention or is that across the whole field?
Ms Binns: My understanding of that is across the whole field and it reflects the fact that the range of problems people present with, from hazardous difficulties, harmful difficulties right up to dependent drinkers, the cost of treating those people increases the longer those problems are entrenched. So the earlier you treat people and the quicker you get people accepted into treatment the more savings you will make in the longer term. So it really reflects the argument that high volume low intensity interventions are in the long run much cheaper and have better outcomes than high-end interventions for people that have had difficulties that have been entrenched for many years.
Dr Raistrick: That figure came from the UK Alcohol Treatment Trial.
Q223 Dr Taylor: As a commissioner are you able to shift money into prevention rather than treatment?
Ms Binns: It is difficult and it is complex and it comes back to the point I was making earlier really. I think people accept that early intervention is the way to go; it is the long term answer to this problem. But if I just use the Southampton experience, we calculated that we spend around £4 million on treating the effects of alcohol misuse, but the majority of that is spent in the acute sector - over £3 million is spent in the acute sector at hospital-based provision. But actually taking that amount of money out of a general hospital is actually difficult to achieve; it is the old argument, you cannot take money out of a hospital by closing one bed - you need to close a whole ward. So whereas I think they are long term savings it does require some short term funding and transition funding in order to commission services at such a volume as to make the shift.
Q224 Dr Taylor: We have also heard that GPs feel a shortage of secondary care services. Do you get GPs in your area pushing you to improve secondary care services or have you already been able to do that?
Ms Binns: No, we certainly have the same problem. Our view of this is that to tackle the volume of problems we have around alcohol misuse now requires a whole system approach. So it is not just a question of increasing services at one level - primary care level, secondary care level - what we need is to increase services across a variety of levels, and that would start with health promotion of campaigns and information to the wider public; then go on to look at screening and brief interventions to try and stop people developing entrenched difficulties and then obviously you would need to develop a volume of service that could cope with the people that were newly identified as having difficulty and needing treatment, and then at the more specialist end where people have very serious problems and need inpatient detox and residential rehabilitation services. So it is a question of looking at investment at all those levels. What we believe, though, is that we should be shifting the investment towards the early levels.
Q225 Chairman: We have heard this morning about that brief interventions work in about one in eight; what happens to the other seven?
Ms Binns: The evidence and the information that we have is that obviously alcohol misuse is by its very nature a relapsing condition. One of the things that we personally have not found any evidence around is what the long term impact of a brief intervention is. We have very good evidence that the short term intervention - I believe that is up to around four years - is very good and that is where the one in eight figure comes from. We do not know if there is an impact later, so whether of those seven people that people still retain that information and may change the behaviour later. The other thing that we do know is that people change their behaviour spontaneously anyway as a result of other information that comes their way or it might be impact from family and friends. So although one in eight people, it is a very good success rate compared to some other interventions and it is possible that the overall result is better than that but we just do not have the evidence. It does compare favourable with smoking cessation though.
Dr Raistrick: To come back to the point about understanding that we were dealing with a process of change so that the brief intervention should not perhaps be judged solely on the single intervention but looked at in a more cumulative perspective, which is the point that if everybody in the Health Service every time they saw somebody with a drink problem did something motivational, even if it was just the one question, the cumulative effect would add to the impact of these interventions. I am slightly worried that we get a bit too focused on the intervention rather than the process.
Chairman: We are coming on to commissioning and planning now.
Q226 Sandra
Gidley: I think I understand the theory of
commissioning; in practice it seems more like a black art I am afraid. How do
you currently commission services for alcohol prevention and treatment in
Ms Binns: We are changing the way we are commissioning alcohol services in
Q227 Sandra
Gidley:
Ms Binns: We are an outlier in some areas, yes.
Q228 Sandra Gidley: I went along to see the local liver specialist a couple of years ago and he told me that there is a very effective intervention, a day a week nurse saved something like - I cannot remember off the top of my head and I might be exaggerating when I say £95,000; but it was either 75 or 95. Yet that service has not been commissioned. Why not? Who is responsible for that?
Ms Binns: It has been re-commissioned. I do not know the absolute detailed history of that because I was not involved in those discussions, but, yes, I agree, I do know that there was evidence around a service that was provided by the acute hospital; it was nurse follow up from the liver unit. It had good results and good outcomes. Funding had ceased I think due to general cost pressures in the local NHS, but the arguments were made and that service has now been re-commissioned.
Q229 Sandra Gidley: When was it re-commissioned?
Ms Binns: September/October last year.
Q230 Sandra
Gidley: The Chief Executive of the hospital
did not seem to think it had when I spoke to him, so there is obviously a
breakdown in communication there. So how much has
Ms Binns: What we commission - and I am a joint commissioning manager and I work across the city council and the PCT, so this would be across health and safety care - one of our difficulties is that the way we have presented it in the strategy work that we have done is that a lot of our investment in alcohol services is unplanned spend, so it is not spend on designated alcohol services. It is just short of £1 million; it has not changed apart from being inflated for a number of years, so that has been a consistent figure. What we actually spend in terms of treating the impact of alcohol misuse is about £4 million. What we are looking at trying to do is to shift the unplanned spend towards planned spend, so actually move investment towards treating prevention and early intervention, rather than continuing to have investment in treating the impact of long term use.
Q231 Sandra Gidley: So why were the local detox facilities closed down? Was that a commissioning problem or was that a separate problem?
Ms Binns: There was a local detox unit that was provided by a voluntary sector provider. The outcomes were not good and the service has been re-commissioned from another provider, so there was not any reduction in funding around alcohol - the full amount was re-commissioned.
Q232 Sandra Gidley: You have highlighted some of the barriers, particularly around shifting resources. Are there any others that you have not had a chance to mention?
Ms Binns: One of the difficulties is making the argument to trust boards, to elected members around moving investment to strategies that have a long term outcome. Most planning cycles and most targets you are expected to deliver changes within two, three, perhaps five years. Some of the changes that lots of people have been arguing about today would not show impact for much longer than that, so you are talking about impacts over ten, 15 years. Very good but long term health gains, so difficult to fit into planning and funding cycles that only last two or there years. Also, I think probably the answer to investment is to get a number of agencies to act together - criminal justice agencies and agencies like police, probation, health and social care. It is a complex area where lots of people are spending in an unproductive way and it is a question of getting all of those agencies to join together in a joint investment plan to all spend their money together in a more productive way.
Q233 Chairman: Did you have a comment to make, Professor Touquet?
Professor Touquet: Yes. Many of us find it very difficult to clarify in our own minds countrywide about commissioning for services and in preparation for today. Could I just highlight to the Committee the Department of Health National Audit Office Report which was published in October 2008 because I thought I might be asked about the PSA25? Could I read two sentences from the page on PSA? It is not my field but reading these two sentences it does seem that regional directors of public health have quite a responsibility. The last two sentences read: "The Department of Health has committed 2.7 million per year for three years from 2008/2009 for regional alcohol offices with dedicated regional alcohol managers to support commissioners in delivering the PSA. Regional directors of public health will assess whether planned activity is both realistic and reflects local need and will check performance by PCTs against local targets annually." Reading this yesterday I just felt it pertinent to highlight those two sentences.
Q234 Sandra Gidley: Carole, have you had much support from the regional director of public health? I am sure I know who it is.
Ms Binns: I have had a lot of support from our local director of public health but not necessarily from the regional director. I think the leadership and drive has come from our local director of public health, who is very interested in this area and very active nationally.
Q235 Sandra Gidley: Would it be fair to say that there is a lack of interest at strategic health authority level?
Ms Binns: I would not want to go as far as to say there is a lack of interest. I think it reflects the level of interest that alcohol has in national and regional levels - it is seen as a very specialist area and it has not really attracted the leadership in the past.
Q236 Sandra Gidley: Do you know how any of this money has been spent that has been highlighted by Professor Touquet?
Ms Binns: Locally we have had a small increase investment from Choosing Health as a result of the intervention of our public health director.
Q237 Sandra Gidley: That is Choosing Health; that is not part of this pot?
Ms Binns: Not part of this pot, no.
Q238 Charlotte Atkins: There is a gulf between the money spent on commissioning drug services and the money spent on commissioning alcohol services. How do we overcome that problem of that gulf?
Ms Binns: The difference between the drug services and alcohol services, drug services came with a ring fenced allocation, which is one of the reasons why there has been a considerable increase in services for drug mis-users over the past few years. There has been a reasonable level of investment, I would have to say, new investment. I am not going to sit here as the commissioning person on the panel and argue for more resources because I would feel it a little bit of a cliché really. But I do think that there is an issue about help in terms of ring fenced funding for alcohol services and also in terms of transition funding because I think we all accept that we are spending money at the wrong end of the spectrum and that we can make savings by spending differently and more effectively; it is just very difficult to make that transition without some pump priming money at the start of that process. We had that for drugs and we have made lots of changes and we have not yet had that for alcohol.
Q239 Charlotte Atkins: One of the problems is that we have drug advice centres which also supposedly cover alcohol - I have one in Leek although the sessions have been reduced massively. But there seems to be a hierarchy of self-harmers and the alcoholics or people abusing alcohol seem to think that the drug addicts are right at the bottom of that hierarchy and they are at the top; therefore they do not like going to the same advice centres. Is that a problem that you have come across?
Ms Binns: I certainly think that there is a problem in people with alcohol problems accessing the substance misuse service that deal with a range of people with both drug and alcohol problems because I think you are right, there are some people with the dual problem; but most people with an alcohol difficulty do not see themselves in the same category as drug mis-users. One of the obvious reasons around that is because drugs are illegal and alcohol is legal. I also think in terms of accessing any service that there is huge stigma around alcohol difficulties. It is often reflected back to us that if people say to you, "I am trying to give up smoking" you actually get quite a lot of support and people wear patches very openly, but if you actually say to somebody, "I am trying to give up drinking" all sorts of other responses come forward. So I think that access to any alcohol service needs to be quite sensitively managed. There used to be a myth that people with alcohol problems were sitting in the park and drinking out of bottles in brown paper bags. No, lots of people are at universities and college and lots of people are in good jobs and sitting at home drinking at night. So it has to be services that are sensitive to a very wide group of people. That is why I am saying that in terms of prevention and early intervention we need to make access across a lot of points and we also need to make those points place us where people routinely come into contact with people.
Q240 Charlotte Atkins: You spoke earlier about a new group, young people who do not generally go to their GPs and who do not come across health services. So as a commissioner how much multi-agency support do you commission which is delivered at school level?
Ms Binns: As a result of the strategy work that we have been doing recently we have been talking to not just schools but to a wide group of agencies that work with young people.
Q241 Charlotte Atkins: Like?
Ms Binns: Youth agencies, youth counselling agencies, young offenders' teams - really anybody that comes into contact with young people for any reason. I think it is important not say, "This is the young person's agency that deals with alcohol problems" because I think, particularly with young people, some of the interventions, to be most successful, need to be opportunistic. People need information about alcohol to be able to give to a young person that has come to them with another problem or routinely, to talk to a teacher, but as a result of that discussion something else emerges, and if we do not have a person at that point that can respond to that issue then we have lost a big opportunity.
Q242 Charlotte Atkins: Given that youngsters are supposed to go to school - put it that way - what sort of services are you intending to commission at the early intervention level to get those young people that do not normally access health services?
Ms Binns: We are looking to commission on the same basis as we are targeting adults but from a youth-friendly perspective, so we are looking at good information and advice but information and advice that young people respond to. For example, we have done some consultation and focus group work with students in Southampton to see what sort of messages might appeal to them and they are tending not to be long term arguments about health, they are tending to be other arguments about image and the possibility of having a criminal record and not getting a good job, and things like that. So it is advice and information but particularly targeted at young people and being youth-friendly. It is also again basic screening and brief interventions information but delivered by people who are used to working with young people and can talk at their level, so youth workers and teachers. In the same we are talking about nurses should have those skills in hospital, teachers should have those skills in school and that is what we are looking at.
Q243 Charlotte Atkins: Teachers but presumably working with other agencies and not necessarily expecting teachers to be able to deliver what is sometimes quite a difficult message.
Ms Binns: Perhaps to be able to deliver that first message and to have information and contacts to then be able to refer a person who needs more intensive help to the correct agency, but what you always have to bear in mind with a young person is that you need that immediate response so that you do not lose the opportunity and also you need to be able to accompany that young person to the next stage if that is necessary. Most young people will not respond to giving them a card or an appointment in three weeks - you might have to broker that arrangement and provide support to get the person to the right contact point.
Q244 Charlotte Atkins: So why do they not come into the schools and do it that way?
Ms Binns: We are looking at going into the schools and working jointly with the schools but that would also be around training the teachers as well to make that first level response.
Q245 Charlotte Atkins: If you have a multi-agency centre within a school then obviously young people could just drop in and have a cup of coffee or whatever.
Ms Binns: Also there are key people within schools. Sometimes there are teachers dedicated to look at health and social needs of the pupils; sometimes there are school counsellors. So it is also about responding to what you actually have in your local area and building on that and making the best use of the contacts that we already have. There may be a school nurse, for example.
Q246 Charlotte Atkins: Lastly, do you think that duty on alcohol should be increased and that duty should be used to fund alcohol treatment services?
Ms Binns: I think it is a complex issue. I think the answer to this is across a range of interventions. My expertise is around care and treatment and commissioning those services. What is helpful to us is that if there is - and certainly at government level as well - a cross departmental approach to this, so looking at pricing policy, licensing issues and looking at all those issues, then we will have maximum impact.
Q247 Chairman: Brian, we are moving on to you now; thank you for your patience. Not those in the back of the ambulance, but your patience!
Mr Hayes: Can I just add one thing about the school stuff? Two weeks ago - I do
not know if you have heard of Junior Citizens, where Transport for
Q248 Charlotte Atkins: It is all levels.
Mr Hayes: And just pointing out not only the damage that it does to your body but the fact that you can get into serious trouble. Some of the photos we showed them were quite graphic and what was really surprising was the fact that the teachers were going away having no idea that these kids have put their hands up that they had had alcohol and some of them had been drunk. Yes, I can take on board that some of it would have been bravado and one or two of them might have seen their mates put their hands up and they have put their hands up. But out of that it is quite worrying how many of them have actually been drunk before.
Q249 Charlotte Atkins: If it is going to happen to ten-year-olds it is going to be happening a lot more to 13 and 14-year-olds, is it not?
Mr Hayes: On the ambulances we have been to ten-year-old kids, absolutely wasted. There is something that a young kid said to me, that there is something they call "mine sweeping", where they will be at family parties and they will sweep all the dregs. It actually has a street term name to it - "Yes, I was at a party and I was mine sweeping", and these are ten, 11, 12-year-old kids doing it.
Q250 Sandra Gidley: To move on to the Booze Bus, which I think is a London innovation, I do not know if it was your idea, but can you tell us how it works and the thinking behind it?
Mr Hayes: It was reluctantly my idea. Five years ago we were coming up to the
Christmas period, which is always busy, especially in the West End and certain
parts of
Q251 Sandra Gidley: These are purely people that are drunk and you are driving them around and basically to help them to sober up ---
Mr Hayes: No, that is just a by-product of what has happened, where we go from job to job. The way we run it now is that we have two paramedics on it; we have a PTS driver and two paramedics and in that way when we get out to go and pick up someone who is drunk the people on the vehicle are still left with a paramedic and the other paramedic and the PTS person.
Q252 Sandra Gidley: So do they all get taken to the same hospital eventually?
Mr Hayes: No. Because of the area we operate in they are split between
Q253 Sandra Gidley: I think Professor Touquet wanted to come in.
Professor Touquet: Certainly with the changes in licensing hours and regulations we have seen the peak of what is colloquially known as chucking-out time pushed to the early morning and we hear a cacophony of stories which echo what Brian Hayes has said. What one does wonder is how on earth these people are going to go to work in the morning or do anything meaningful. You asked me, Mr Chairman, right at the beginning, should we charge these patients? There is one aspect I did not say, which is that the drinks companies spend billions advertising and you can view that the young people are responsive to that and that they are therefore victims of society and the LAS is picking up the bill. The drinks companies will say that fewer people in this country drink. Correct; that is because of immigration and the number of people who abstain is higher. They will say that one to two drinks is sensible drinking, but it is a J-shaped curve. That is now disputed because the non-drinkers included previous dependent drinkers who are now abstinent, who clearly have an increased mortality. Is it surprising when you have a group of people in the drinks industry spending billions on publicity that you hear the stories that you do, which is why our time is so worthwhile being able to give evidence to politicians.
Q254 Sandra Gidley: Obviously this service helps up paramedics' time to do other things and go on to the urgent calls. You described earlier some of the more graphic cases that you had had to deal with, but what is an average night like? How much of a paramedic's time is actually spent dealing with alcohol-related problems?
Mr Hayes: Over a year it is 6% overall, the whole of
Q255 Sandra Gidley: Coming back to an earlier point, somebody on the receiving end of an assault, would that be flagged up as alcohol-related?
Mr Hayes: Not that I know of.
Q256 Sandra Gidley: So the figure is probably higher?
Mr Hayes: Yes, it probably is. I would say that through alcohol you could at least double that 61,000 - that is alcohol-related incidents. What happens on our patient report forms is that we will get an incident box which will give you a list of accident, self-harm or RTC and so on, and then you will have a code for what the problem is, and that will be taken from that only. So if we go to somebody and they have an open fracture to the femur due to a fall because they were drunk, the alcohol probably would not get filled in because obviously that femur is the overriding problem. So it is probably not a true capture of the information.
Q257 Sandra Gidley: I gather that you are running the bus every weekend; is that because Londoners are getting drunker?
Mr Hayes: It would seem so. We have had an 11% increase; so, yes, definitely. I
think it is where you get the mass bars and things like that where the real
problems are. Our two highest ones are
Chairman: I think that is the end of the session. Could I thank all four of you very much indeed for coming along and helping us with this inquiry. If you have any further thoughts on what is being said or asked this morning we will be more than happy to receive them in email form or written form. Thank you.