Alcohol Policy UK

Nottinghamshire's 'Long Term Condition Team': an example of working with change resistant drinkers

Alcohol Concern have released a report demonstrating a model of working with 'change resistant drinkers', part of the wider 'Blue Light Project'.

The Nottinghamshire Alcohol Related Long Term Condition Team (LTC) assertively case manage people with a combination of alcohol dependence, an alcohol related long term physical health condition and a high risk of readmission to hospital.

Download An evaluation of The Nottinghamshire Alcohol Related Long Term Condition Team: an example of good practice with change resistant drinkers [pdf]

The LTC team consists of four nurses and an administrator who cover the south of  Nottinghamshire. Through assertive case management, the service 'promotes better coordination of care leading to an appropriate use of services', resulting in improved outcomes and cost savings. One patient identified within the case studies was calculated to have cost at least £137,000 in a 12 month period. Outcomes associated with the team's work include reducing issues such as liver disease, pressure on emergency departments (ED), domestic abuse and alcohol fuelled anti-social behaviour, as well as other concerns such as street drinking. 

The report however emphasises the complexity of the client group and its needs. As such, the LTC 'attempts to build its interventions on a comprehensive and holistic assessment reflecting the complexity of the client group. Only by understanding the full range of needs and risks can the team formulate an intervention appropriate to that individual.' Care planning within a multi-agency partnership approach is then integral to the service. Providing end of life/palliative care is also identified as a highly valuable element

The LTC also identifies as working with 'change resistant drinkers' so provides a real life example of the 'Blue Light Project' which aims to challenge the belief that nothing can be done with resistant drinkers who 'do not want to change'. It aims to do so by showing there are a range of positive strategies that can be used to manage risk, reduce harm and promote change.

Serious violence follows binge drinking decline - but could the trend be about to turn?

Serious violence fell again in 2013 according to annual Cardiff University Research, with a 30% drop in people needing treatment in Emergency Departments after violence since 2010.

Falling alcohol consumption appears to have been a significant factor, especially a decline in binge drinking amongst young people as shown in the Opinions and Lifestyle Survey (OPN).

However Professor Jonathan Shepherd, who leads the Violence Research Group at Cardiff, warned that "the issue of alcohol-related violence endures, with violence-related Emergency Department attendance consistently at its highest levels on weekends". Each year over 200,000 people across England and Wales still end up in Emergency Departments with injuries caused by violence, with a recent report indicating binge drinking currently increases daily A&E attendance by 8%.

Shepherd also warned that that a recovering economy alongside public sector cuts could undermine the downward trend:

“We think if funding was taken out of CCTV in public places, together with cost cutting in the police partnerships – taking police analysts out because they are seen as backroom facilities rather than frontline – together with steps in the economy which make alcohol more affordable, would run the risk of violence increasing again.”

Could falling consumption be about to end?

With continued alcohol duty cuts this year and some degree of economic recovery, pressures on falling consumption may be quickly easing. In fact spend on drinking out has increased by 6% compared to last year, according to the Greene King Leisure Spend Tracker. Whilst the increase in drinking out has only been a modest 1% in London and the South East, the jump has been led by the rest of the Britain spending 8% more than last year.

Whilst spend on eating out has also increased (5%), it is the first time drinking out spend has led since the tracker report began. The report also asked drinkers which politician they would most like to have a pint with; 41% favoured none of them, with Nigel Farage beating the rest at 17%. Whichever Government comes in, they may well preside over a term in which a decade of falling consumptions ends.

IAS Alcohol Alert April 2015: calls for new European Union (EU) Alcohol Strategy, product labelling, liver cancer, & more

The latest Institute of Alcohol Studies (IAS) Alcohol Alert: March 2015 is now available (here for PDF version). Read the editorial here and articles below:

• European Parliament Public Health Committee adopts resolution for new Alcohol Strategy

• Alcohol industry players commit to product labelling in principle

• Alcohol and the life-course trajectory

• "Ineffective" and "flawed": Damning reports expose shortcomings of voluntary alcohol pledges

• WCRF: Three alcoholic drinks a day a “convincing cause of liver cancer”

• LGA – Lower the drink drive limit to cut road deaths

• Met chief calls for fewer pubs and licensing reform

• No In:tuition for Drinkaware education scheme among schools

• Industry profits trump public health as alcohol duty cut yet again in Budget

• Alcohol sponsorship and sport: An irresponsible mix

• NICE releases new alcohol ‘quality standard’ for preventing harmful alcohol use

• Binge drinking costing each Brit £77 a day

• Landmark case could open floodgates for councils to be sued over Reducing the Strength Schemes

Findings alcohol bulletins: controlling disorder, minimum pricing 'winners and losers', IBA for students & naltrexone

Recent bulletins from the drug and alcohol bank:

Controlling alcohol-related nuisance and disorder

Within substance use policy there can hardly be a hotter issue than alcohol-related violence and disorder, and how governments can curb it without becoming vulnerable to the accusation of being a nanny-state killjoy.

Winners and losers from alcohol minimum unit pricing in England

Minimum unit pricing for alcohol has in England faced the barrier of being seen as punishing the majority drinking public for the minority of irresponsible and ‘binge’ drinkers. This report reassuringly assessed the impacts on moderate drinkers as minor – but less reassuringly, so too the impacts on young male ‘bingers’ and the crimes they commit.

Support for brief intervention for heavy-drinking students

Synthesis of randomised trials of one of the most widely implemented approaches to heavy-drinking among college students finds it does reduce drinking and related problems, but compared to what is unclear, and none of the individual trials was convincing.

Psychosocial therapies do not augment naltrexone for alcohol dependence

If an alcohol-dependent patient is being prescribed the relapse-prevention medication naltrexone, does it help to supplement medical care with cognitive-behavioural therapies? On average, no, was the conclusion of this synthesis of studies. However, these therapies have elevated outcomes among patients not prescribed an active medication.

Main party manifestos quiet on alcohol policy and minimum pricing

Back in 2010, the Conservative's manifesto set out the so called 'below cost ban', as well as pledges to 'overhaul' the licensing regime. The Liberal Democrats 2010 manifesto also set out support for a below-cost ban, as well as in principle support for minimum unit pricing. Labour didn't rule out minimum pricing, but their 2010 manifesto focused on support for pubs and treatment for offenders. 

Five years later and alcohol policy seems much less of a feature for the two main parties. However health groups may see this as good news; with minimum pricing hardly a vote winner, early in the parliamentary term is when less popular policies may be more likely to be implemented. Scotland's long running MUP battle is however still being dragged through the European courts, so any other Government is unlikely to attempt it before the verdict. Least of all the Tories one would assume, given their infamous minimum pricing u-turn.

Still, alcohol and related policy does get some mention in the main 2015 manifestos.

The Conservatives 

One the one hand the Tories could be claiming they've followed through on their 2010 commitments - in alcohol policy terms. However little is mentioned in the 2015 version, other than a commitment to "make sobriety orders available to all courts in England and Wales, enforced through new alcohol monitoring tags". Perhaps a popular 'tough on crime' message, but evaluation of the pilot schemes has not concluded.  Not much else in the manifesto itself, though it commits to addressing alcohol dependency as one of the the 'root causes of poverty'.

However the Morning Advertiser (MA) have reported that the Tories have pledged licensing fees for the majority of pubs would be frozen and reviewing business rates to support small firms. Trade reaction expectedly supportive, but wanting more clarity on the fees promise.

Labour

The party manifesto itself gives just one specific alcohol policy mention - to "take targeted action on those high strength, low cost alcohol products that fuel problem drinking". Sounds rather like an excerpt from the 2012 alcohol strategy, but without the detail of how. Would it be a tweaking of the near meaningless below cost ban, re-instating alcohol duty escalators, or joining up with the SNP in the minimum pricing fight?

Again outside of manifesto pledges, the MA highlights Labour's £8 minimum wage promise would of course be highly relevant to many working in the alcohol trade.

Other parties

The Liberal Democrats however have committed to "introduce Minimum Unit Pricing for alcohol, subject to the outcome of the legal challenge in Scotland", as well as further powers for local authorities and more work promoting healthier lifestyles. The MA also highlights laws to help prevent pubs being converted for other uses.

The Green Party has also spoken in support of minimum pricing, as well as an 'unhealthy food tax', and Plaid Cymru also support a 50 pence MUP. UKIP opposes minimum pricing, but has called for the introduction of pub smoking rooms.

Last year an All Party Parliamentary Group on Alcohol Misuse (APPG) manifesto was released, urging political parties to adopt ten key alcohol policies ahead of the 2015 election.

Comprehensive approach to improving schools-based alcohol and drug education needed, says Mentor

In this guest post Jamila Boughelaf, Project Manager at Mentor, looks at the current position of drug and alcohol education in schools and what Mentor are doing to improve standards.

Alcohol and drug education is currently a statutory part of the national science curriculum, which mainly covers physical and biological aspects of drugs and related effects on the body. But is this enough to provide children and young people with a comprehensive knowledge about alcohol and drugs?

Alcohol and drug use is only one of many risks that young people may encounter as they grow up, and it is often related to other social, personal and cultural risk factors. Addressing risks in isolation - such as addressing specific substances within the science curriculum without reflecting on related life experiences, or interlinked risk and protective factors - does not give young people the opportunity to explore the interconnections between these issues.

Research suggests that effective alcohol and drug education should be part of a holistic approach encompassing the different environments children and young people are surrounded by. It should be underpinned by a whole school approach to health and wellbeing and enhanced by family-based education and prevention programmes.[1]

For this reason, the Department for Education suggests that alcohol and drug education is included and further developed as a consistent and fundamental part of Personal, Social, Health and Economic (PSHE) education. PSHE has been defined as “the curriculum that prepares young people for life” through the provision of relevant information, knowledge and skills required to face the challenges and opportunities of future life. PSHE helps young people to develop values and skills and to reflect on their place in society.

When informing pupils about risks associated with alcohol and drugs we cannot forget about the social skills, values and assertiveness needed to make informed choices. Alcohol and drug education cannot exist outside the wider context of PSHE education.

However, the current non-statutory status of PSHE education, and the subsequent inconsistency of teaching quality, means alcohol and drug education in schools is often neglected. In fact, the latest Ofsted report ‘Not yet good enough’ showed that PSHE provision was inadequate or needed improvement in over 40% of schools inspected.

Findings from a national survey delivered by the PSHE Association on behalf of Mentor also show that, as a result of poor quality PSHE, alcohol and drug education provision remains inconsistent and ‘patchy’ across educational establishments in England.

The survey outlined three key obstacles to providing effective alcohol and drug education:

1. Lack of curriculum time: The varying level of importance placed on PSHE education and subsequently on alcohol and drug education within schools often impacts on the number of hours teachers are able to give to alcohol and drug education provision. This often results in a fragmented topic-style teaching approach, which consequently leads to a lack of continuous learning for pupils.
2. Lack of financial capacity to secure good external support or resources.
3. Non-specialist teaching: alcohol and drug education, and PSHE education more generally, are often delivered by non-specialist teachers (with no initial teacher training on the subject), resulting in varying levels of confidence among teachers and preventing continuous learning for pupils.

On the basis of these findings, the Alcohol and Drug Education and Prevention Information Service (ADEPIS) was established with the aim to address existing gaps, promote evidence-based practice, provide support to schools and practitioners involved in alcohol and drug education, and to enable both schools and practitioners to improve their provision of alcohol and drug education and prevention. 

Within this context, alongside numerous briefing papers for schools and practitioners, ADEPIS produced the “Quality standards for effective alcohol and drug education”

The Mentor-ADEPIS quality standards have been produced to be used within the context of a well-planned PSHE programme. The standards, used in conjunction with Ofsted and PSHE Association frameworks, enable assessment of a whole school approach to alcohol and drug education and PSHE. The standards encourage schools to build on existing skills to develop an ethos promoting health, well-being and positive social norms.

The quality standards have been developed to make sure schools apply principles for effectiveness, ensuring that:

• The alcohol and drug education curriculum is thoroughly planned to be relevant and responsive to pupils’ developmental stages and needs, and taught in the context of other personal, social and health issues relevant to children and young people’s lives.
• The curriculum builds on previous learning, is consistently re-visited and adapted to meet ever-changing needs and knowledge of students, also reflecting cultural or religious differences.
• The selected material and activities are delivered through interactive teaching styles, exploring pupils’ attitudes, and allowing opportunities to develop social skills.
• The programme of alcohol and drug education promotes positive social norms, whilst challenging myths and misconceptions around the use of alcohol and drugs among peers, by using reliable and up-to-date information.

In the coming year Mentor-ADEPIS will look at exploring innovative ways to further support schools and other educational institutions in assessing the quality of their alcohol and drug education provision. To find out more, please visit mentor-adepis.org or email adepis@mentoruk.org

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[1] The Drug Education Forum, The principles of good drug education

Evaluation of a 'Rapid Access to Alcohol Detox Acute Referral' (RADAR) service shows savings

An evaluation report of a novel rapid access alcohol detox service identifies significant cost savings as a result of reductions in drinking and subsequent use of health services.

The RADAR (Rapid Access to Alcohol Detox Acute Referral) service was established in Greater Manchester as a direct pathway from A&E departments into specialist detox facilities. RADAR accepts referrals from eleven different acute hospitals in the area, combining a range of psychosocial interventions with physical health management and aftercare planning. Stays typically take between 5 and 7 days before discharge and referral to community alcohol services.

Evaluation outcomes

The Centre for Public Health conducted an evaluation of RADAR to explore experiences of stakeholders and cost-effectiveness. The RADAR service has four main aims: reducing the burden on acute trusts, improving clinical outcomes for service users, providing improved experience for service users in a therapeutic setting and demonstrating cost-effectiveness.

The report outlines overwhelming positive perceptions of the service, particularly from patients. Six months after discharge, just over half of those who could be contacted reported either being abstinent or being controlled drinkers. This resulted in fewer contacts with Acute Hospitals, with reductions in both the number of A&E attendances and nights in hospital being reported. The cost-effectiveness analysis of RADAR suggests a projected saving of £1,320,921 over a 12 month period.

Although the evaluation identifies that patient outcomes rely on self-reported data, it found the average visits to A&E before entering RADAR were around three visits per patient, while visits after were found to be around one visit per patient. A statistically significant reduction in overnight hospital stays resulting from hospital visit was also found, reducing from an average of two to less than one post-RADAR. A reduction in GP visits was also found, although not statistically significant.

Over half of the patients did not attend and alcohol service before RADAR (53%), in comparison to 69% attending after RADAR. However use of self-help groups did not increase following engagement in the service.

Read the report here or see a summary presentation of the award-winning service.

A new model for Hospital pathways?

Over recent years the presence of alcohol liaison roles or teams in hospitals has been rising, in line with NICE and PHE guidance. However RADAR may be considered novel despite a wide range of models existing. Last year PHE released a report reviewing the provision of alcohol services in England's hospitals which identified integration with community services as a key issue.

PHE also recently released guidance to improve support for young people in A&E with alcohol related problems.

Responsibility Deal 'unlikely' to reduce alcohol harm say researchers

Research into the likely effectiveness of the Responsibility Deal alcohol pledges has suggested there will be little impact on harmful alcohol consumption. Findings from the two reports produced by the London School of Hygiene and Tropical Medicine (LSHTM) say the Deal's pledges are mainly ineffective, or were already taking place.

The research includes two reports; one analysed all publicly available data about organisations’ plans and progress towards achieving key alcohol pledges - see here. The second was a systematic review of international evidence about the different types of interventions proposed by the organisations involved - see here.

LSHTM say 75% of the pledges aimed to provide consumer information and choice, which they say have limited effectiveness. The other 25% included measures such as reducing alcohol content in products, but there are complexities around the likely impacts of unit reduction approaches, as separate research by the Sheffield Alcohol Research Group recently highlighted.

The press release said that pledge progress reports from industry organisations were most often found to be poor quality, incomplete or unavailable, whilst only 11% of alcohol pledge-related activities were found to be a direct result of the Responsibility Deal. Lead author Dr Cécile Knai, from the Policy Innovation Research Unit at the LSHTM, said:

“We know that effective voluntary agreements are based on clearly-defined, evidence-based and quantifiable targets, which require partners to go beyond ‘business as usual’, and penalties for not delivering the pledges. However the alcohol pledges of the Public Health Responsibility Deal haven’t met these criteria."

Dr Knai also said interventions "which change the market environment to make alcohol less available and more expensive" were more effective, reflecting most of the public health field's desire for minimum unit pricing.

Celebrating success?

However the research goes against the grain of messages from both Government and of course sections of the alcohol industry. At an event that took place last month, Minister for Public Health Jane Ellison gave a talk to around 60 Responsibility Deal partners, 'celebrating the achievements of the Deal across the four networks'. See the presentation here [pdf].

Those such as the Portman Group, the responsibility body for drinks producers in the UK, have also vocally championed the Responsibility Deal and voluntary action alongside other sections of the alcohol industry.

Writing in Off-License news, drinks journalist Phil Mellows responded to the recent LSHTM and Sheffield critiques suggesting neither 'properly understands the drinks industry', which he argues does have a legitimate role in reducing alcohol harm. Mellows also says there are examples of pledges that "go beyond business as usual", such as the recent pledge to cease production of cans of high-strength beers and ciders containing more than four units. Either way, the fate of Responsibility Deal certainly hangs in wait of the forthcoming general election results.

Reducing the strength: LGA guidance on setting up schemes

Last year we reported on a growing number of off-licenses agreeing to adopt 'reducing the strength' style initiatives, whereby shops agree not to sell beer or cider of 6.5% ABV or above.

The Local Government Association (LGA) has subsequently released guidance for councils considering setting up such as scheme - pdf briefing here.

The schemes typically aim to reduce street drinking and associated problems, with a number of areas showing significant impacts on crime and disorder. However the LGA briefing urges areas considering the introduction of such schemes to adopt a careful process of assessing and engaging key stakeholders, and evaluating the impact of the schemes.

The briefing also addresses other areas such as potential legal considerations - some trade sections had warned over possible breaches of competition law. The LGA however says councils 'in this context, are unlikely to be caught by Competition Law specifically',  as long as they 'ensure that retailers are aware they must make individual and independent decisions about whether to participate in such schemes'.

The LGA also advise consideration of other voluntary local approaches including Community Alcohol Partnerships (CAPs), or responsible retailer schemes. However critics of such industry-involved local level initiatives may highlight the limited evaluation or evidence of effectiveness. Questions over the sustainability of voluntary initiatives may also be valid, as well highlighting that street drinking or alcohol consumption in public are not offences in themselves, even within 'controlled drinking zones'.

See a briefing on Street drinking: enforcement Vs Support? or all street drinking tagged reports.

Report puts cost of UK's binge drinking at £4.9 billion per year

A report by researchers at the University of Bath have estimated the costs of binge drinking to the UK economy, and explored the potential impact of key policy options. It suggests while pricing policies in particular may be able to mitigate the costs to society, economic policies should not be used in isolation.  

Download the full report, The cost of bringe drinking in the UK [pdf], see the summary here or the Independent's take.

The research looks at the effects of 'binge drinking' on A&E admissions, road accidents, arrests and the number of police officers on duty and estimates that binge drinking increases:

• The average number of daily injury-related A&E admissions by 8% (equivalent to 2,504 additional daily admissions nationally).
• The daily average of road accidents by 17% (equivalent to 82 additional accidents per day nationally).
• The average number of alcohol-related arrests by 45% (equivalent to 786 additional arrests per day nationally).
• The number of police officers on duty by around 30% (equivalent to an additional 3.2 police officers on duty at the weekend for every 10,000 people in the country).

Minimum pricing and other policy responses?

The research calculates the cost of binge drinking to roughly £4.86 billion per year, which equates to £77 per year per capita - of course this figure is less than the £21 billion a year estimated cost for all types of alcohol misuse in England.

It explores what impact minimum unit pricing (MUP), alcohol excise taxes and a higher minimum legal drinking age (MLDA) could have. For MUP, it suggests that a 52 pence MUP would 'offset' the economic costs; 10 pence higher than the current average retail price of 42p per unit for 2013/14.

Tax increases could also be used to offset the costs, although this would require an overall 23% increase which would equate to an extra 23p per pint of beer and 99p per bottle of wine.

Increasing the minimum level drinking age would have some impact on binge drinking costs. Increasing the drinking purchase age to 21 would potentially reduce the number of road accidents by 15%, leading to a £100 million saving. However this saving represents only 2.1% of the total £4.86 billion and the report emphasises that pricing responses should not be adopted in isolation of other alcohol policy.

Binge drinking - back to the fore? 

The report highlights that it is the first to look at more detail into the economic impacts of binge drinking, as opposed to more frequent or generalised patterns of alcohol use. However the concept of 'binge drinking' has been attacked from multiple perspectives.

Firstly, frequency of drinking, binge or otherwise, is important, so looking at single occasion drinking may not accurately reflect an overall level of risk. Secondly, 'binge drinking' as a definition is highly subjective and applied widely either to describe amounts or styles of drinking. Finally, there are undoubtedly multiple and complex factors that surround binge drinking, which public health messages have often overlooked. 

The report defines binge drinking 'as the consumption of 12+ units of alcohol in any one period of drinking and typically taking place on Friday and Saturday nights among individuals aged between 18 and 30'. However Government statistics define binge drinking as consuming twice the daily recommended guidelines in one session.

A 2011 Demos report argued that binge drinking should be recognised as 'young adults that drink to extreme excess, often in an intentionally reckless and very public way, putting themselves and others at risk of harm'. More recently, Drinkaware have centred much of its work around research into 'drunken nights out', a package of behaviours in which drinkers make calculated choices relating to the risks and benefits of deliberate intoxication.