In 2014 Alcohol Concern released the Blue Light Manual as part of a project to develop alternative approaches and care pathways for treatment resistant drinkers who place a burden on public services. Since then, a number of local areas have developed initiatives focusing on 'high impact' drinkers and new research on an assertive outreach trial has been released.
Last year a progress report on the Blue Light project's story so [pdf] far identified seven local areas who had commissioned pilot projects, including Sandwell, Devon, Lincolnshire and Nottingham's Alcohol Related Long Term Condition Team (LTC) as previously reported. As such the development of 'blue light' projects may be considered an emerging component of local alcohol strategies addressing the more complex end of problem drinking groups.
Surrey County Council 'High Impact Complex Drinkers' pilot
Surrey County Council (SCC) recently released findings from a High Impact Complex Drinkers Pilot 2016' [pdf] and a 'Key messages and Future Directions' [pdf] summary report. The full report states 'High Impact Complex Drinkers' (HICD) are frequently socially excluded and can become isolated from services, which may then classify them as ‘treatment resistant’, ‘intentionally homeless’ or ‘hard to engage’. As such SCC first undertook a needs assessment for an assertive outreach model (taking services to clients) to improve pathways and outcomes for HICDs and reduce the impact on public services. Within the three identified catchment areas, 46 patients were found to have either attended A&E or been admitted to one of the hospitals on four or more occasions within the year with alcohol as a significant factor.
SCC then piloted two community workers employed by the hospital trust to provide assertive outreach and care coordination with key HICDs, adopting a Motivational Interviewing approach rather than a focus on clinical work. Outcomes from the project reported significant reductions in drinking days (46% of clients reporting daily drinking down from 96% at baseline) and improvements in health measures for the 14 key clients. Based on a cost analysis, an expected 1:4 (£) return on investment was calculated assuming a rolling caseload of 36 clients across a 12 month period. According to the report, further HICD investments of £75,000 in Surrey is expected to reduce health costs from £612,125 to £303,151.
Assertive community treatment (ACT): RCT raises questions?
However a recent Randomised Control Trial (RCT) testing an Assertive Community Treatment (ACT) model found more mixed results. Whilst ACT clients also receiving treatment as usual (TAS) were found to have more abstinent days at 12 months than TAS only clients, the ACT group also reported more alcohol-related problems and poorer quality of life. However the study suggest these apparent negative outcomes may be linked to 'a beneficial reduction in unplanned care' as ACT clients had more facilitated healthcare access and better treatment engagement. The authors also noted that the study was largely designed as a feasibility pilot, and that a 'definitive trial is now warranted'.
SCC's key messages and future directions report though sets a comprehensive description of the complexity of such cases and the wide ranging impact they can have across many services. Small numbers of 'high impact' service users can cost the public purse many millions of pounds, so the potential for savings and other benefits - such as reduced police call outs as reported in Lincolnshire - certainly make sense. The report urges that significant system wide changes are required, including multi-agency and integrated commissioning responses across a range of issues including mental health, housing and safeguarding.
Many variables evidently exist between such projects, including the service models and definition of 'high impact' service users. As such, it may still be considered early days in the research and development of 'blue light' projects when comparing to the commissioning of other alcohol interventions and services. However debates over evidence and rationales still occur across the range of alcohol activities spanning drinking problems and agencies. At a time though when public health budgets are facing ongoing pressures and the removal of ring-fencing, demonstrating cost-effectiveness is likely to be ever more important.
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