Alcohol Care in NHS Hospitals:Needs better integration with the

wider care system

Professor Colin DrummondNational Addiction Centre

Institute of Psychiatry, Psychology and NeuroscienceKing’s College London

Danish National Conference on Alcohol, Jan 2020

Alcohol related hospital admissions England 2003-2017

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200.000

400.000

600.000

800.000

1.000.000

1.200.000

2003

/04

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2015

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WhollyPartly

Drivers:-Baby boomers-Increasinginequalities

• 26 wholly alcohol attributable conditions• 124 studies; 1.7m patients• Harmful alcohol use = 20%• Alcohol dependence = 10%• 10x higher than general population• 20-30x higher than NHS (HES) estimate

Proportion of smokers and excessive drinkers offered SBI by PHC last year

(Alcohol Toolkit Survey – Brown et al., 2016, BJGP)(n=15,252)

• 20% smokers (n=3,043)

• 62% visited GP last yr• 52% of smokers

received BI for smoking• (30% of all smokers)• Older, female, less

education, disability,higher dependence,more quit attempts

• 12.4% excessive drinkers(n=1,894)

• 59% visited GP last yr• 6.8% of XSD received BI

for alcohol• (4% of all XSD)• Older, smokers, higher

dependence, male

5

26 25

50

80 80

2,66

30

15

50

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60

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130

Problem gambling Alcohol dependence Drug dependence Psychosis Psychosis withdependence

Prevalence and treatment for dependence and comorbidity

Prevalence % x 100 Treatment for MH % Treatment for SM %

1.2%(600K)

0.8%(380K)

0.5%(240K)

0.15%(72K)

0.7%(340K)

(Drummond et al, APMS 2014)

6

http://www.clahrc-southlondon.nihr.ac.uk/files/Alcohol%20care%20in%20NHS%20hospitals%20–%20Full%20report.pdf

Alcohol CQUIN –Identification and brief advice

≥ 80% brief

advice

Adult inpatient

≥ 50% Screened

Dependent

Low-risk or non-drinker

≥ 80% Referral

offerReferred

Does not accept referral

IDENTIFY ADVISE ACT

Increasing or high-

risk

Alcohol CQUIN – expected impact

~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.

Smoking

Even if only half of patients get screened.

~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.

The NHS could save >£20M per year from reductions in ill-health caused by drinking.

Alcohol

ALCOHOL RELATED FREQUENT HOSPITAL ATTENDERS

www.slam.nhs.uk

What problem did we address?

• Alcohol-related frequent hospital attenders (ARFA):– 3+ alcohol-related admissions per year– Multiple unmet physical, mental and social care

needs– Rarely access community addiction services– Feel stigmatized and socially excluded– Represent 9% of people with alcohol dependence

but 59% of alcohol admissions– 1.4 million bed days per year = £848 million– Identified 324 ARFA patients in Lambeth and

Southwark, with £5m annual cost15

68

22,9

45,4 40,7

9,1

54,6 59,3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Prevalence Spells OBDs

%

Distribution of alcohol admissions in people with alcohol dependence

3+ admissions

1-2 admissions

No admissions

54,369

136,015

404,616 303,313

365,359 1,402,600

962,718

£848 Million

£704 Million

Total = £1.6 BillionTotal = 2.4 Million

16

Total = 600,000

Alcohol Frequent attenders per 100,000 and Index of Multiple Deprivation x10 South London

60

110

160

210

260

310

360

0 50 100 150

ARFA rateARFA rateLineær (ARFA rate)

IMD

ARFA

LEWGRE

SOULAM

CROWAN

BEXSUTBRO

KINRIC

MER

r = 0.74

Health inequalities and the alcohol harm paradox

Alcohol Assertive Outreach Team Colin Drummond, Emily Finch, Barney Hyndman

18

www.slam.nhs.uk

What is Alcohol Assertive Outreach Treatment?

• Minimum weekly contact for 12 months• Small keyworker caseloads ≤15• Persistent, assertive engagement• Home-based or community setting• Working across traditional professional boundaries• Patient-led agenda• Engagement with families, carers and professionals• Supporting patients to attend addiction and health

services• Volunteers provided practical help and support

19

www.slam.nhs.uk

What we did

• Worked with patients and clinicians to adapt anAssertive Outreach Treatment model used in severemental illness training manual

• AAOT much more intensive and prolonged thanstandard alcohol care

• AAOT clinical team for Lambeth and Southwark• Created partnerships with hospital and community

teams• Identified ARFA patients through hospital e-records• Recruited 174 ARFA patients into a trial of AAOT versus

Care as Usual, 87 per treatment group

20

Value in reduced healthcare costsMean inpatient nights pre-post intervention

0,27 0,21

26,8

10,5

0,07 0,191,15

5,2

0,27 0,21

26,8

10,5

0,05 0,18

22,5

14,6

0

5

10

15

20

25

30

SIPS PHC AESOPS ACTAD AAOT

Intervention Baseline Intervention 6 months Control baseline Control 6 months 21

www.slam.nhs.uk

Change in alcohol admissions via Emergency Department in King’s College Hospital

-25

-20

-15

-10

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2014/15 2015/16 2016/17 2017/18

F10 admissions % change

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Introduction of AAOT

BMJ Mental Health Team of the Year 2019

Extrapolation from AAOT trial to national ARFA data

• England 54,369 ARFAs• OBDs 1,402,600• Cost £848M• Saving AOT compared to CAU = £13,819/case = £751M• AOT treatment cost = £2,979/case = £161M• Net saving = £10,840/case = £590M• For every £1 spent, net cost saved = £3.66• So potential cost saving overall = £590M in England

Alcohol CQUIN – expected impact

25

~1.6M smokers should receive very brief advice due to PIHCQUIN; of whom ~486K can be expected to take up a referral; and we could expect 110K may quit.

Smoking

Even if only half of patients get screened.

~896K of patients drinking above the low-risk guidelines will get IBA & ~64K will be referred to treatment in the community.

The NHS could save >£20M per year from reductions in ill-health caused by drinking.

Alcohol

Cost of implementation: BA £10 per case (SIPS ED) = £10 x 900,000 = £9MNet saving = £11M

900

5411

590

0100200300400500600700800900

1000

IBA AOT

Numbers of patients and cost savings for IBA and AOT

Number of patients (1000s) Net cost saving (£M)

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£12 per patient

£11,000 per patient

Value for healthcare costs

Figure 2. Differential changes in liver morbidity risk related to changes in alcohol consumption in dependent and hazardous/harmful drinkers following intervention

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Dependence (ACTAD)Reduction 238 units/dayRisk reduction 4188.2x= -410

Hazardous/Harmful (Cochrane)Reduction 4.44 units/dayRisk reduction 2.92.6x= -0.3

-15 U/day

-410x risk

Conclusions• Alcohol care in acute hospitals is enjoying growth• But focus is on SBI rather than complex needs• Community addiction services shrinking and cater for more

motivated, less complex people• Hazardous/harmful drinkers more numerous but morbidity

and costs relatively small and natural remission high compared to dependence

• Although intervention costs 150 times more for AOT than SBI, risk reductions and cost savings exponentially greater

• Focus needs to shift to High Need High Cost patients with multimorbidity and complex needs

• Need for Integrated Care Pathways between hospital and community