Lundbeck UK Limited and Centre for Public Innovation
Lundbeck UK Limited and Centre for Public Innovation, 2011.
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In the south east of England a bidding exercise spawned a spate of short-term innovative projects to reduce alcohol-related harm, from which five models were assessed as most promising and taken forward for further implementation and assessment the following year – a rapid and intensive test bed from which others can learn as well.
Summary The South East Alcohol Innovation Programme was initiated by the Regional Alcohol Manager at the Government Office for the South East of England. From 2010 to 2011 it funded innovation activities in the public and voluntary sectors designed to reduce alcohol-related harm as measured by the level of alcohol-related hospital admissions, and to influence the adverse impact on population health and criminal justice challenges associated with violence and anti-social behaviour.
Primary care trusts (which fund public health services) and their partners were encouraged to bid for £300,000 to test out innovative approaches to meeting these objectives for between six and eight weeks. Successful bidders were encouraged to report the outcomes using a common framework.
In year one the aim was to fund as many innovative ideas as possible to tackle alcohol-related hospital admissions. In all 26 projects were funded across three thematic grant rounds:
• Seasonal alcohol campaigns;
• High impact grant programmes;
• Joint commissioner-provider pilots.
Using 'innovation funnelling', these projects were then scored against several criteria to agree which would be taken forward. The top five which had the greatest impact were selected as models for the year two bidding round, which resulted in 10 projects running between December 2010 and April 2011. The five models are described below. The projects based on these models in year two may have varied somewhat from these models.
A specialist community-based worker was appointed to work intensively with the 10 patients with the most alcohol-related repeat hospital admissions, to coordinate their care, reduce the impact on other services and ultimately reduce the likelihood of further admissions. Candidate patients were identified through medical assessment unit records and referred to the worker, who proactively contacted them and sought to engage them in a full assessment of their needs, linking with, and coordinating care and treatment from other specialist services. Offering dedicated care management was intended to achieve a more effective and coordinated approach to their treatment, freeing up the resources of those currently working with them in a more sporadic, unplanned way.
The aim was to engage with staff in community pharmacies to enable them to proactively offer brief advice on alcohol to their customers. Information for pharmacy staff covered health awareness, understanding units of alcohol, early identification of possible excess, data capture on awareness and units consumed, and signposting/referral for additional support where required. This aim was to raise awareness of what constitutes safe alcohol consumption amongst low and increasing risk customers unaware of how much they are drinking.
The project funded a clinician to provide clinical support and training for hostel staff to enable them to support previous rough sleepers who are dependent drinkers, with the aim of reducing their drinking and addressing attendant health problems. It extended the opportunities for alcohol-dependent residents to address their substance misuse as well as improve their mental and physical health, a group whose severe dependence and chaotic lives mean they tended not to access existing services. The project targeted drinkers for whom inpatient detoxification does not work, usually ending with a return to the hostel and resumed drinking, aiming to replace this cycle with personalised, gradual detoxification within the hostel environment.
Using the vehicle of alcohol workshops, the project aimed to encourage the formation of a self-help group on drinking problems in a supported housing setting, addressing some of the issues which made residents reluctant to access specialist services while raising awareness of levels of alcohol consumption and how to reduce this to safer levels. The self-help format enabled participants to support one another, drawing on their own skills and experiences. By eliciting and identifying reasons for non-engagement with treatment services, group discussions helped put in place mechanisms to manage these obstacles.
Healthcare support workers in accident and emergency, medical assessment unit and gastroenterology wards were trained in simple techniques to enable them to identify and briefly advise risky drinkers among the patients they came in to contact with. These workers contact all patients admitted and usually have more time than nursing and other medical staff. They were trained how to screen and advise patients while performing basic care tasks, effectively delivering information at a time of crisis for the patient in a way which it was hoped would affect their drinking and reduce repeat admissions for alcohol-related conditions.
Based on experience in year two, identifying high impact projects through incubating, prototyping and funnelling (the year one process of promoting many innovations then selecting the most successful for further implementation) is a successful approach. Objectives to reduce alcohol-related harm and related hospital admissions are apparent across the projects. Alcohol issues acted as an impetus for innovation projects through the process of designing, developing and growing new ideas that work to meet unmet need. Despite their differences, a common message was that reduction in alcohol-related harm will only be achieved through understanding and responding to local needs and circumstances
All the high impact projects in year two have the potential to be replicated elsewhere. Projects registered outcomes relating to reductions in alcohol consumption and dependence, potential amelioration of alcohol-related health and social problems, and general improvements in health and social functioning. They showed that while increasing risk and higher risk drinkers are likely to benefit from being identified and briefly advised by generic workers in almost any setting, dependent and more chaotic drinkers may require more intensive treatment from specialist workers. A robust, flexible and diverse market serving people at risk of alcohol-related harm in all areas of provision (health, housing, social care and community settings) is most likely to generate good outcomes. However, there are some key lessons which should influence future decisions on implementation.
Projects to help people frequently admitted to hospital due to drink-related problems ('frequent flyers') have been successful. There were clear benefits in terms of client outcomes and financial savings, and the potential for replicating and scaling up and diffusion to other services. All projects which had been completed could identify a reduction in hospital-related admissions and significant financial savings could be expected based on certain assumptions. A dedicated, intensive approach was shown to yield the best results in terms of effectively engaging patients and motivating them to remain in treatment and make positive health and lifestyle changes. However, particular attention needs to be given to the setting up of these projects to ensure clear terms of reference, referral guidelines, and commitment from all the agencies involved.
At the other end of the spectrum, the project involving screening and brief advice at pharmacies showed that such interventions are effective when directed at patients drinking at increasing or higher risk levels who are typically not complaining about or seeking help for an alcohol problem. Although the project had issues in showing outcomes in the three months, it has moved forward and gained momentum locally.
Supported housing self-help group projects faced the biggest challenges, particularly in engaging and training appropriate workers and clients. Other projects had more success, in particular the hostel clinical nurse project, which helped problem drinking residents reduce drinking, significantly reduced hospital admissions, and improved access to primary health care including dentistry. Hostel staff attitudes were challenged and changed as a result of participating in the pilot. Enhanced staff skills and knowledge meant they saw the potential for positive change by working differently with residents they previously saw as unwilling to change.
A testimony to the innovation projects has been that four generated through the NHS have been adopted by the QIPP (Quality, Innovation, Productivity and Prevention) initiative, while others have been given extended funding and future planned funding on the basis of the initial outcomes.
Recommendations based on the outcomes of the projects, the barriers they faced, and the lessons learnt, include:
• Commissioners of alcohol projects should consider using 'innovation funnelling' to identify promising local initiatives;
• As a basis for deciding which initiatives to invest in, they should also have a good understanding of the drink demography of the community for whom they are commissioning, including approximate numbers of lower risk, increasing risk, and high risk drinkers;
• Providers and commissioners should ensure significant buy-in across statutory and voluntary organisations to ensure key aims of projects are explicit in service specifications and supported to reduce and avoid duplication of service delivery;
• Providers should ensure that there are clear terms of reference for the initiative, effective project planning, and identification of resources;
• Commissioners should hold service providers to account for delivery. There should be a commitment by senior management and commissioners, particularly in the statutory sector, on staff resources for the duration of a project to avoid projects failing when staff are given alternative tasks;
• Commissioners should consider third-sector providers to deliver services to certain communities;
• Confidentiality and data protection issues should be addressed prior to commencing projects so that data to monitor progress can be accessed;
• Changes to the political landscape and funding in the statutory sector should be taken into account when first implementing projects;
• Clarity on the potential financial efficiencies expected from the interventions, how these will be defined, and how performance will be measured, should be agreed at the start;
• Consideration needs to be given to the most appropriate staff to deliver interventions and supporting delivery with ringfenced, allocated time;
• Twenty-four hour services, if judged cost effective, should be provided to enhance impact;
• Providers and commissioners need to recognise this is a difficult client group (who may have a dual diagnosis), so alcohol innovations should not be seen as an answer in isolation from other projects;
• It should be understand that alcohol intervention can have impact even when abstinence is not the end goal; a moderation goal should be considered;
• Projects receiving ongoing funded should be subject to regular review to ensure continued effective performance.
commentary Generally it was assumed that the projects would have the desired end-results on the basis of their activities and the degree of engagement of and by clients, rather than these impacts being shown to have happened, the short duration and nature of the evaluations being such that concrete outcomes could normally not be determined. Even when they could, there was no comparison group offered no intervention or an alternative against which to benchmark the focal intervention, and projects self-assessed their performances. This means that the initiatives can only be considered promising (in some cases, very promising) in terms of achieving their aims.
From the details in a report appendix, it seems that the only model to register concrete, quantified end results was hostel clinical nurse support, one implementation of which saw dramatically reduced emergency call-outs and hospital admissions among clients who engaged with the project, resulting in substantial cost savings. There seems no reason to believe that these reductions would have happened anyway even without the nurse being there. The project was also thought to have resulted in fewer evictions, less chaotic behaviour in the hostels, and less street drinking and antisocial behaviour.
Thanks for their comments on this entry in draft to Mark Napier of the Centre for Public Innovation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 20 August 2012
STUDY 2016 Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial