Oxford Health Overview

ITEM JHO12

Oxford Health Overview & Scrutiny Sub – Committee

Scrutiny Review of Alcohol Misuse

Review Panel Members: Cllr Paul Sargent Cllr Gail Bones Cllr Gill Sanders Margaret Booth

0696af05bed60995a01f2717efd7362a.doc 1 Contents

Section 1 – Introduction 3 - 8 1.1. The National Context 3 1.2. The development of treatment tiers for alcohol misuse 3 – 4 1.3. Alcohol and young people 4 - 8 1.3.1. Preventative programmes for young people 6 - 8

Section 2 – Scope and Methodology 9 - 10

2.1. Scope of review 9 2.2. Evidence gathering 9 – 10

Section 3 – Findings 11 - 30

3.1. Alcohol related services in Oxford 11 – 12 3.2. Alcohol services and young people 12 - 13 3.3. Local evidence of alcohol misuse in young people 13 3.4. Alcohol treatment / prevention services within Community, Primary Care and Acute Trust settings 14 – 30

3.4.1. Community / local authority based intervention work 14 – 21 3.4.2. Primary care based intervention 21 – 25 3.4.3. Acute Trust Intervention 25 - 30

3.5. Recommendations for coordination of alcohol 31 treatment services

Section 4 – Overall Conclusions 32

Glossary 33

References 34

Appendix 1 – An NTA overview of the economic impact brief intervention programmes could have.

Appendix 2 – Tiers of treatment (based on drug misuse tiers) Appendix 2(a) Tiers of treatment for young persons substance misuse

Appendix 3 – List of interviewees

Appendix 4 – Terms of reference

Appendix 5 – Oxford City Detached Youth Worker project – Key Statistics.

Appendix 6– The PAT alcohol screening tool

Appendix 7 – The AUDIT alcohol screening tool

0696af05bed60995a01f2717efd7362a.doc 2 1. Introduction

1.1. The national context

In March 2004 the Government published the Alcohol Harm Reduction Strategy for England. The strategy aims to address all areas of alcohol related harm in a coordinated manner, the main strands of which are health and crime.

It outlines key ways to tackle alcohol related harm through:

 Improved and better targeted education and communication.  Better identification and treatment of alcohol problems.  Encouraging the industry to continue to promote responsible drinking and taking a role in reducing alcohol related harm.

In terms of implementing the strategy the Government sees Drug and Alcohol Action Teams (DAATs) and Crime and Disorder Reduction Partnerships (CDRP’s) as the key groups for implementing the strategy locally.

The public health white paper ‘Choosing Health’ also states the Governments’ intention to tackle binge drinking and has identified the following key actions needed to reduce harm & encourage sensible drinking. These are as follows;

1. Placing information for the public on alcohol containers and in alcohol retail outlets 2. Raising awareness (campaigns to reduce binge drinking, providing information in healthcare and non healthcare settings) 3. Local authority enforcement - e.g. around selling alcohol to <18s 4. Increased access to and effectiveness of alcohol treatment 5. Screening & brief interventions (piloting interventions in primary care & A&E) 6.Planning local responses (e.g. through Crime & Disorder Reduction Partnerships)

1.2. The development of treatment tiers for alcohol misuse

The Alcohol Needs Assessment Project (ANARP) (2005) report provided the first detailed national picture of the need for treatment and the availability of treatment. The project identified the considerable potential for growth in the screening, identification and referral of individuals with patterns of hazardous, harmful and dependent use of alcohol in both primary and secondary care. (often associated with young people) (see ANARP (2005) Table 1 overleaf)

0696af05bed60995a01f2717efd7362a.doc 3 Table 1 – Profile of alcohol use disorder in England 2004 (findings from Alcohol Needs Assessment Research Project 2005)

In response to these findings the NTA have produced guidance on Alcohol Misuse Interventions targeted towards hazardous and harmful drinkers. The guidance focuses on improving screening and delivery brief interventions Trailblazer projects will run from spring 2006 – summer 2008 to determine the impact of targeted screening and brief interventions in primary care, hospital and criminal justice systems (six monthly updates will be available on this projects) Appendix 1 provides an overview of the economic impact brief intervention work could have from research findings to date, which is considerable and compares favourably with the cost benefits of smoking cessation interventions (NTA 2005)

The NTA are currently consulting on models of care for the treatment of alcohol misuse and these are likely to match the 4 tier treatment levels for drug misuse. (See appendix 2 and 2(a) for details of treatment tiers)

1.3. Alcohol & young people

The Office of National Statistics (ONS) highlights the substantial increases in the numbers of young people drinking above the recommended level and at a younger age between 1988 and 2003. (see glossary for safe drinking levels) The sharper increases are among women, particularly women under 25 years.

0696af05bed60995a01f2717efd7362a.doc 4 Table 2 - Adults exceeding weekly benchmarks of alcohol: by sex and age, 1988/89 and 2002/03, GB

Office of National Statistics Survey 2004

There are also significant rises among <16 year olds in this time period. The average amount drunk by 11 –15 year olds rose from 0.8 units per week in 1990 per to 1.6 units in 1998. Amongst 11-15 year olds who drink the average rose from 5.3 units per week in 1990 to 10.5 units in 2001.

However a more recent survey published by the NHS Health and Social Care Information Centre (2006) shows consumption levels in 11 – 15 year olds reaching a plateau from 2000 onwards. (see table 3 below)

Table 3 – Average alcohol consumption in units among young people (over the last week) (aged 11 – 15 years)

The proportion of under age drinkers (11 – 15 years) is still high at 22% in 2005 and prevalence of drinking increased with age with 46% of 15 year olds having had a drink in the last week.

0696af05bed60995a01f2717efd7362a.doc 5 Marsden et al (2005) in a study involving secondary school pupils (15-16 yrs) and alcohol consumption patterns, found marked increases in consumption after 9 months and 18 month follow-ups. More than 25% of the sample reported drinking 6 units (binge drinking levels) or more on a typical drinking day and only 5% of the sample had never had a drink. School conduct problems featured prominently in the sample and many said they drank to relax or forget about a problem, although social reasons and loss of inhibitions were also important factors. Those who drank more intensely were more likely to report use of cannabis, school conduct problems, more time with friends that drink and more parental encouragement to drink. More parental discouragement to drink led to less frequent drinking by boys and more frequent drinking by girls. The research findings suggest the need for more personal, family and peer and school conduct factors in school-based alcohol education programmes. The researchers also recommend education approaches based on harm minimisation in view of the early age of alcohol initiation.

Research analysed by the Oxford Alcohol Action Group (OAAG) from Youth Justice and Education also highlights a correlation between disengagement from school, low attainment and an increased propensity to anti-social behaviour that is fuelled by alcohol abuse.

1.3.1. Preventative programmes for young people

The National Institute for Health and Clinical Excellence (NICE) (2006) have conducted a review of reviews on ‘Drug use prevention among young people’ this included preventative programmes on alcohol misuse. Some of the key findings from the review are highlighted in table 4 overleaf. In looking at effectiveness this must be taken in its broadest sense in terms of delaying onset and reducing usage. This is particularly applicable when considering alcohol abuse in young people.

Research evidence on preventative programmes for young people concentrate on a secondary school age group and there is a paucity of evidence for those 18 years and older.

0696af05bed60995a01f2717efd7362a.doc 6 Table 4

NICE - Evidence of effectiveness key points Age of population Evidence suggests that most effective target audience is 11 – 14 years. (Gottfredson & Wilson 2003) The review does highlight the paucity of evidence focused on the 18+ years. It recognises the need for more research focused on this age group, when there may be dramatic changes to environment and social networks. Programme delivery Interactive approaches, involving the active participation of providers and recipients are the most effective form of delivery e.g. role-plays, active modelling, discussion (Cuijpers (2000) This should incorporate booster sessions or regular revision to reinforce the message, this was seen as important than intensity of programmes Peer led interventions, some evidence in favour of peer led education particularly in secondary school settings. However this superiority diminished if the interventions were co-led by teachers. (Gottfredson & Wilson 2003), (Cuijpers (2000) Design & content There is good evidence to support the effectiveness of programmes based on social influence approaches, particularly when linked to life skills training. Social influence is a model that posits substance misuse stems from direct or indirect social influences such as peer group pressure, media marketing. The model aims to create an awareness of social influence and to teach coping skills to deal with the influences or pressures. Canning et al (2004), (Cuijpers (2000) Family involvement Evidence does support the need for family involvement in prevention programmes. Kumpfer & Alvarado (2003) in particular behavioural parent training, family skills training and family therapy were found to be the most effective family strengthening interventions. Protective family factors were also found to be more important for minority ethnic youth and the female population. Selected prevention There is evidence to suggest that school prevention programmes that target at-risk students are more effective than those that target general student populations (Gottfredson & Wilson 2003) and that cognitive behaviour programmes offer the greater chance of success. Cognitive behaviour programmes basically focus upon the individual and their management of ‘life problems’, recognising that drug / alcohol abuse may stem from low self –esteem, anxiety, anger

0696af05bed60995a01f2717efd7362a.doc 7 Key findings from the studies point to a need for:

 Reinforcement of message and booster sessions  More dynamic / interactive teachers preferably involving peers  Recognition of the wider social influences such peer pressure / the media and coping mechanisms for handling social pressures

The research evidence particularly those deemed ‘at risk’ of early alcohol misuse demonstrated the effectiveness:

 Family support programmes, particularly those which targeted family skills and behaviour management  Targeted intervention providing individuals with life skills training recognising that alcohol misuse problems particularly with vulnerable groups may stem from anger, anxiety, low self esteem.

0696af05bed60995a01f2717efd7362a.doc 8 2. Scope of review and methodology

2.1 Scope of the review The national data demonstrates that Alcohol misuse is on the increase amongst under 25 year olds. Professional opinion also points to evidence that drinking habits tend to have not progressed into a more chronic dependency phase at this age and therefore prevention / treatment services targeted towards this group would have greater long term impacts.

The review group therefore decided to focus its work around hazardous / heavy drinking behaviour, looking at screening and brief interventions models to tackle this. A target age group of 16 - 25 year olds was chosen. (please see appendix 4 for details of the terms of reference for the review group)

The key outcomes for the review group were:

 To develop an understanding of the scale and impact of alcohol misuse on the behaviour & health of young people, within Oxford City. Would local evidence replicate national trends?  To examine local agencies methods for prevention of alcohol misuse & encouraging behavioural change, highlighting any gaps in services and knowledge.  To highlight how effectively & consistently agencies work together  To identify areas of good practice that could be practically implemented at a local level.

2.2. Evidence gathering

The review group gathered local evidence primarily through interviews with a range of professionals and community groups. A key list of witnesses was drawn up at the start of the review and this was revised as the review progressed. Appendix 3 details all the groups / professionals interviewed and how their interview evidence linked to each section of the findings.

The interviews provided some indication of the extent of alcohol misuse in young people, in the absence of extensive quantitative data. They also established factors underlying alcohol misuse, provided examples of what practices worked well, highlighted gaps in local services and the impact of resource constraints.

Evidence from the youth services, public health and counselling services strongly pointed to the importance of looking at a younger age group than 16 years, when considering preventative programmes. Anecdotal evidence from these workers indicated that binge - drinking problems are becoming more prevalent from aged 13 years onwards. In response to this evidence the review group looked at preventative / support programmes targeted towards the secondary school age upwards.

0696af05bed60995a01f2717efd7362a.doc 9 As integrated treatment services for alcohol are still being developed both nationally and locally, the review group sought to gain evidence of best practice. Oxford Brookes – The School of Health and Social Care Department provided evidence from their own evaluation of treatment / prevention programme research on an international scale. The National Treatment Agency, The Dept. of Health, Alcohol Concern and The Alcohol Education Council (AERC) were also good sources of evidence nationally. This combined with primary evidence gained from selected research forms the basis of the case studies illustrated in the report findings.

0696af05bed60995a01f2717efd7362a.doc 10 3. Findings

3.1 Alcohol related services in Oxford

It is recognised that there is a lack of funding towards alcohol treatment services, even with a changing national agenda and the launch of a national alcohol harm reduction strategy.

Locally scarce resources are focused around chronic drinking behaviour rather than the more mainstream targeting of encouraging sensible drinking and reducing harm. However the typology of drinkers produced by the Alcohol Needs Assessment Project (ANARP) (2005) indicates that around 23% of the adult population are hazardous / heavy drinkers, whilst 3.6% fall within the category of alcohol dependent.

The Oxford Alcohol Partnership Group (OAPG) has recently launched an Oxfordshire-wide alcohol harm reduction strategy with minimal dedicated funding for alcohol treatment services.

Presently Oxfordshire DAAT funding is targeted towards drug treatment services and national performance targets are geared towards higher- level treatment needs. There was a possibility that the DAAT’s pooled treatment budget would include dedicated alcohol treatment funding, however this has now looks unlikely for 06/07.

The Choosing Health White Paper led to indicative public health funding for PCT’s. Alcohol screening and brief intervention was part of this targeted funding. It should be noted the Joint Commissioning Board for Oxfordshire PCT’s have decided that the indicative allocation for Choosing Health in 06/07 will not be allocated to its key public health targets. The budget deficit is a contributory factor in this decision.

Outline proposals for the DAAT dedicated alcohol funding included scoping out a model and delivery mechanisms for screening and treatment services within the primary care sector. The original proposals for the ‘Choosing Health’ indicative allocation included funding towards a shared care model for alcohol treatment in primary care in 07/ 08.

Reducing alcohol relating harm also features in ‘Safer and Stronger Communities’ strand of the Local Area Agreement (LAA.) Specifically outcomes relating to alcohol are;

 Reducing the harm caused to young people under 18 from illicit drug and alcohol use  Reducing alcohol related harm

LAA targets will look to;  Increase young people accessing treatment by 50% by 2008/09,  Pilot an adult treatment and support service

0696af05bed60995a01f2717efd7362a.doc 11  Increase participation of adult alcohol treatment and support services in community treatment services

Whilst growth in existing treatment service is a desirable outcome, this work will have to be undertaken using existing agencies scarce treatment funding. Research evidence also highlights the importance of preventative programmes, which delay onset of alcohol misuse in young people as a key component in reducing risk of alcohol harm. Therefore any reducing harm targets need to include broader preventative factors.

3.2. Alcohol Services and young people

Oxfordshire DAAT funds or part funds substance misuse workers and projects to work with children and young people up to 19 years of age on education, prevention, early interventions and harm minimisation.

The Oxfordshire DAAT Action Plan for Young People’s Substance misuse 05/06 highlights the fact that no new funding is attached to the problem and that using drugs treatment money for alcohol is not permitted. However as detailed earlier this is set to change with a minimal amount of funding to be targeted to alcohol misuse for 06 / 07. The plan also identifies that a recurrent theme from consultation with substance misuse practitioners was the need for increased substance misuse counselling capacity.

Significantly the National Treatment Agency for Substance Misuse (NTA) targets relate to higher tier intervention services, which conflicts with research evidence of where the main problem is in relation to alcohol e.g. hazardous / harmful drinkers who would benefit from tier 1 and 2 services.

The Oxfordshire DAAT are planning to introduce a dedicated treatment service for young people aged 10 – 18 years from March 06 and will look at treatment needs in a more holistic way, including counselling, motivational therapy and harm reduction therapy. The service is in response to the fact that the only treatment available to young people with problematic drug or alcohol use has been counselling

The service will offer tier 3 level treatment services and will be targeted towards young people who require: complex / multiple substance misuse intervention, access to community detox, substitute prescribing. The service will have a consultant psychiatrist (0.3 FTE), an addiction nurse and 3 drug workers.

The Oxfordshire-wide alcohol harm reduction strategy includes a chapter on young people. Young person specific objectives include;

 Increasing the reporting of underage alcohol sales  Increasing the availability and awareness of substance misuse information for young, their parent and carers.  Commencing alcohol education at primary school stage

0696af05bed60995a01f2717efd7362a.doc 12  Making the links between substance misuse and risky sexual behaviour more of a focus at secondary school stage  Developing substance misuse (including alcohol) support and treatment services available to young people.

A Young Persons Alcohol Strategy Group (comprising of representatives from education, public health, youth work, trading standards, youth offending) coordinated this chapter.

3.3. Local evidence of alcohol misuse in young people

Although OAPG state that a local picture of alcohol misuse is not presently available, indicators can be gained from agencies working with young people.

The Oxfordshire DAAT have analysed figures from agencies working with vulnerable young people, who have identified alcohol misuse problems and these are highlighted below;

Countywide ‘Face to Face’ counselling service 20 clients, 19 who have identified alcohol problems (work with clients aged 13 –19 yrs)

City detached youth worker (Oct 04 – Nov 05) 51 clients, 43 who have identified alcohol misuse problems (work with clients 13 – 25 yrs)

The Bridge / The Gap (Dec 04 – Jan 05) 48 clients, 42 who have identified alcohol misuse problems (work with clients 16 – 25 yrs)

The Oxford City Detached Youth Project in its 04 /05 report analyses the types of substance misuse young people report. Although contact figures are small it does provide a picture of patterns of drug / alcohol misuse (see appendix 5) and one which corresponds to evidence from other youth workers / counsellors.

This evidence is also concurs with referral evidence from the former Drugs Worker attached to the City. This post was attached to the Youth Service and funded by the ‘Safer Communities Partnership.’ (The funding was not renewed when the post holder left the post) The post was created to provide a support service for young people at risk of misusing drugs and being excluded from school. An analysis of referrals from Dec 02 - August 05 indicate that most related to cannabis misuse and those relating to alcohol misuse were the second highest. The referrals cover an age range 12 – 25 yrs with 13 – 15 years predominating and with the majority of referrals coming from Education Social Workers and individual schools. Further to individual referrals the post holder was also offering support and drop-in services to a variety of secondary schools and making links with local GP’s and sexual health services.

0696af05bed60995a01f2717efd7362a.doc 13 3.4. Alcohol Treatment / Prevention within Community, Primary Care settings

3.4.1 Community / local authority based intervention work

In the more deprived estates such Barton, Rosehill, Blackbird Leys cannabis and alcohol in under 18 years are more common forms of substance misuse and correlate with the agency findings detailed above.

Counselling services such as ‘Face to Face’ suggest abuse is linked to the masking of emotional / family difficulties, lack of opportunity and boredom. Binge drinking is noted as being more prevalent in young girls, with boys more likely to favour cannabis. Counsellors are also reporting increased incidents of ‘risky’ sexual behaviour in girls and increased incidents of sexual abuse / rape where young women are under the influence of alcohol.

Professionals reported a paucity of residential care placements for young people in Oxfordshire. Professionals thought there was an increased likelihood that those at risk with substance abusing parents or those with significant substance misuse problems will remain in an environment that will not break the cycle of misuse problems. Significantly workers identified the need for a rehabilitation centre for young people. This is seen as a key mechanism for breaking the cycle of misuse.

Counselling services run for both parents and young people and these programmes both encounter substance misuse issues in the context of much wider family / social problems.

‘Face to Face’ is a voluntary counselling services for young people aged 13 – 19 years and part of Oxfordshire County Council Youth Services. The service has faced cuts, in a climate of increased referrals. Referrals come from various sources;  Young people / parents  GP’s  Psychiatrists  Social workers

1.5 FTE counsellors working with substance misuse problems cover the whole of the County (these posts are funded from Oxfordshire DAAT).

The average age for onset of drug / alcohol problems is getting lower, 12 –13 years is not uncommon. The counsellor thought that binge drinking for 13 – 16 year olds, particularly girls is part of the social culture. Part of the counsellors work was highlighting the emotional / health / personal safety risks. They felt that the drug / alcohol education in schools should encompass these issues. The counsellor highlighted links to self - esteem and self-confidence and inability to withstand peer pressure.

0696af05bed60995a01f2717efd7362a.doc 14 ‘Parent Talk’ part of Oxfordshire County Council Lifelong Learning team provide group and individual support and skills for parents of 10 – 17 old children. Referral routes are Social & Healthcare, Education Services. Most parents attend voluntarily, though some are on Parenting Orders. The programme believes that Behavioural and Social Learning techniques have the greatest impact on changing the behaviour of young people. The 17 workers come from backgrounds in youth work, community development and working within family centres. A programme report for 03 / 04 noted that;

 Age of referral is dropping from 14 four years ago to 12 years (Increasingly more parent of boys are being referred)  Referral numbers had increased by 70% (Referrals predominately come from 0X4 area in the City)  Health (via health visitors) referred the most parents. (parents felt less judged by these workers)

‘Many parents find themselves with emotionally charged situations, often combined with social deprivations, many parents have been taking anti- depressants and suffer from low self esteem.’

The County’s Parents / Carers Drug Education Co-ordinator was providing the group with a session drug / alcohol awareness. The Co-ordinator stated drugs / alcohol do feature predominately in the parents / young people lives and are used as coping mechanisms

The Young Peoples Alcohol Strategy group in Oxfordshire believe ‘that to promote a healthy attitude towards alcohol in young people, education is needed for their parents and carers. It recommends in the new Oxfordshire Alcohol Strategy that the Parents / Carers Educator (currently employed part- time by the Oxfordshire County Youth Service and previously by DAAT) focus on alcohol as well as drugs. It also advises the possibility of extending capacity in this field. However this post has been cut from the services 06/07 budget.

The co-ordinator in her 2005 report ‘Beneath the radar’ highlights add hoc services targeted towards parents / carers with substance misusing children. Key findings from the report are;

 Lack of designated support for parents/carers of young substance misusers  Lack of co-ordination and gaps in provision  Crisis driven funding targeted towards class A substance misuse

0696af05bed60995a01f2717efd7362a.doc 15 Drayton school project

A pilot project to tackle alcohol problems amongst young people in North Oxfordshire, based in Drayton School Banbury and Bicester Community College has recently come to an end with a full evaluation report due in April 06. The catalyst for the project was concerns raised around problematic drinking incidents amongst teenagers, especially young girls. The project was funded by the Police through a Cherwell Community Safety Partnership grant of £3,710.

The project trained 31 front-line multi-agency workers who had a high degree of contact with young people in brief intervention work, using CAN a local drugs and alcohol organisation.

An audit process has been set up to assess the number of brief interventions carried out following training.

Initial findings from the project;

 Significant funding would need to be identified to pay for the implementation of multi-agency staff. In addition the need for a project co- ordinator was identified to allow for the more robust evaluation of project outcomes.  Further training and support needs were identified by workers with no previous experience of counselling / intervention work.  Young people need to feel a high degree of trust e.g. Street Wardens were perceived as the eyes and ears of the police and therefore intervention work was less successful with this group.

The review group were concerned that the project would not be considering measures around the impact on young people themselves, but recognised the significant funding constraints the project was under.

Full findings of the project will be available from April 06.

CAD Projects

The Communities Against Drugs (CAD) initiative was launched by the Government to help communities mobilise against drugs. Two projects were launched in Barton and Blackbird Leys using this funding via the Crime and Disorder Reduction Partnership (CDRP). Both projects have sought to look at alcohol and drug issues, recognising that alcohol misuse is a significant issue on the estates too.

CAD funding has now come to end. The Barton project now has a project officer funded from a ‘Building safer Communities Fund’ (BSCF) via the Oxfordshire Basic Command Unit. The Blackbird Leys project now has charitable status, in recognition of the wider community development remit of

0696af05bed60995a01f2717efd7362a.doc 16 the project. The Blackbird Leys project has received minimal funding for next year via the BSCF, but needs to secure further external funding to survive. It should be noted that the City Council did not support grant funding of £10,000 for this project in 06/07 due to an inadequate funding case being made. It recommends funding towards England Church Housing Association and Libra. These projects whilst being worthwhile target a small and narrow client base and these services are not based on estates where alcohol is a problem e.g. Barton, Blackbird Leys and Rosehill.

Barton has sought to disseminate more widely, information on how to access support and treatments in settings such as the neighbourhood and family centres. This was in response to community concerns around a lack of knowledge of where to turn to for help and at what stage drinking consumption becomes a treatment issue. In workshops run by the County Parent / Carer Drug Educator, significant numbers of attendees requested further information about alcohol.

Blackbird Leys CAD project have sought to engage the community through a broader health focus and are offering healthy living sessions, which include drug and alcohol awareness. The project also offers a drop – in session two days a week for advice and information on drugs and alcohol.

Barton and Blackbird Leys CAD have both used funding to enable project workers to attend drug (& alcohol) awareness training courses. As yet due to funding limitations this has not been further advanced to include the training of workers in brief intervention work. However both CAD project workers saw this as a cost – effective mechanism to bridge the current lack of provision in this area.

The CAD projects work with minimal support from Oxfordshire DAAT. Significantly DAAT substance information leaflets that have been targeted for wider community dissemination were seen as confusing or needing high literacy levels.

Project workers attached to CAD projects have highlighted a need for;

 More prevention / education work targeted to secondary schools, but outside of classroom, teacher-led sessions. Energy and Vision were cited as a good example of alcohol / drug awareness education by using the ‘life stories’ of ex-addicts.  More diversionary activities targeted towards a broader range of young people, encompassing substance misuse awareness sessions  Community based consultation where anecdotal evidence shows there are significant alcohol issues. Involvement of the community such as CAD workers in conducting the consultation.  A standard training package for ‘frontline’ staff such as Youth Workers, CAD project leaders, School Nurses in brief intervention, ‘signposting’ and counselling.  Oxfordshire DAAT to become more proactive and offer subsidised training courses in the above areas.

0696af05bed60995a01f2717efd7362a.doc 17  Oxfordshire DAAT to become the hub for disseminating good practice, information on support and treatment services available. (The Oxfordshire DAAT web site was cited as an ideal mechanism for this and workers felt presently this site was severely under-developed)  The Oxfordshire Alcohol Harm Reduction Strategy to be used as a platform for the development of community level action plans.

It was thought that the LAA should encourage funding from district, county, and the Crime and Disorder Reduction Partnership for Alcohol Misuse, particularly in light of constrained PCT & DAAT resources. It is felt that a pooled budgeting rather aligned budgeting would encourage joint initiatives.

Oxfordshire DAAT is developing an arrest referral scheme at the present time, whereby anyone arrested by the Thames Valley Police (TVP) for an alcohol related incident, or one in which alcohol was a factor, could be referred for further assistance. It was felt that it would be very beneficial to refer this idea to the Public Service Board so that this body could take it forwards and disseminate it to all its partners. The DAAT should also ensure prevention / treatment services are in place to meet anticipated referral demand.

International and national evidence on community based prevention / treatment programmes for young people.

The review group have looked into community projects that have been highlighted as examples of good practice.

A team at the School of Health & Social Care (Oxford Brookes University) have appraised published / unpublished research mainly on the preventative side of alcohol misuse & young people but have looked at treatment areas too.

A preventative programme that has been identified by the team as having significant impact is the ‘Strengthening families’ initiative that has been led by Iowa State University.

‘Strengthening families’ programme

The programme aims to work in community / school settings and works with parents / young people together over a period 7 – 8 weeks. The programme seeks to delay the age at which young people start to drink. This is linked to evidence that the later young people start to drink, the less chance they will have of developing alcohol dependency / drinking problems later on in life.

The target age group for this programme is 10-14yrs and has been tested working with families in the most economically disadvantaged areas. The programme aims to reduce adolescent substance abuse and other behaviour problems by increasing parenting skills, strengthening family bonds, building life skills and providing young people with the skills to resist peer pressure.

0696af05bed60995a01f2717efd7362a.doc 18 The School of Health & Social Care Dept. (Oxford Brookes University) are helping to lead the pilot studies, with part-funding from the Home Office. The research findings (Alvarado and Kumpfer 2000) have demonstrated positive results for both parents and youth. Comparisons between the intervention and control groups showed significantly improved parenting behaviours. An analysis of young persons substance use and use-related problems have demonstrated positive outcomes at follow-up assessments. Compared with young people in the control group those in the intervention group showed delayed initiation of alcohol, tobacco and cannabis use. Significantly these positive results increased over 6 years of the follow-up assessment.

In the UK, Barnsley, Chester & Cardiff are piloting the project. Pending the results of the pilot studies (evaluations from the pilot projects will report in Sept 07) the Home Office are planning to undertake a much larger national study. The Welsh Assembly have started to roll the programme out throughout Wales based on early successes of the programme.

Conclusion

 Anecdotal evidence suggests that alcohol and cannabis are the main forms of substance misuse in young people.

 There is a lack of treatment / prevention services targeted towards a significant and growing group of hazardous young drinkers, who are at risk of dependency, alcohol related illnesses in later life. A small amount of short-term funding, grants etc have led to short-term and uncoordinated projects.

 There has been a steady erosion of youth service posts particularly in connection with tier 1 and tier 2 prevention / intervention and substance misuse, with an increase in referrals. This is of concern in light of the Joint Ofsted and Commission for Social Care Inspection Report on Education and Children’s Social Care 2005 which stated that tackling binge drinking and drug taking was a key area for improvement.

 This has led to DAAT partially funding posts such as ‘Face to Face’ Counsellors (DAAT funds 1.5 posts) and the Detached Youth Worker in the City. However the Youth Service Drugs Worker has not been replaced. This post was building vital links with secondary schools and providing support for young people with substance misuse problems who risked exclusion from school.

 Project workers have identified a need for a variety of ‘frontline’ workers to receive training in ‘signposting’, brief intervention, counselling work with young people, such as youth workers, school health nurses where the relationship is one of high trust / confidence. The ODPM paper ‘Transitions : Young Adults with Complex Needs’ (2006) which looks at an age range of 16 – 25 year olds has highlighted the importance a ‘trusted

0696af05bed60995a01f2717efd7362a.doc 19 mentor or guide’ who can ensure continuity of support and act as a broker to a range of specialist services.

 A generic counselling service for young people is seen as one that is more able to deal with a complex range of issues, of which substance misuse may be the catalyst or a coping mechanism. This has been endorsed by a recent ODPM paper ‘Transitions : Young Adults with Complex Needs (2006)

 The Young Peoples Alcohol Strategy Group in Oxfordshire has stated ‘that a vital long-term strategy to promote healthy attitudes towards alcohol in young people is to educate their parents and carers.’ It further adds a need to explore the possibility of extending capacity in this field. Pending early findings from the UK research, the ‘strengthening families’ programme offers significant potential to deliver this.

Arguably the ‘Face to Face’ and ‘Parent Talk could with more resources potentially offer the joint expertise to pilot a ‘strengthening families’ project within the city.

 Concern is noted regarding the erosion of the parent / drug co-ordinator post. The Young Peoples Alcohol Strategy group in Oxfordshire recommended an extension to the role seeing parent / carers playing a vital role in influencing the attitudes of young people in relation to substance misuse. National evidence also points to the importance of parental support in delaying and reducing alcohol consumption in young people.

 Oxfordshire DAAT have set up a new substance misuse service for Young People working a Tier 3 Treatment levels and above. Findings indicate that a co-ordination of services at Tiers 1 and 2 also needs to take place.

 To target young people project workers thought a broader range of diversionary activities would need to be offered, which included drug / alcohol awareness sessions. Surrey DAAT, Eastleigh Borough Council and PCT have taken this approach offering a range of diversionary courses such as professional DJ coaching which included sessions on life skills. These activities have been targeted to those at risk of or already substance misusing Initiatives have been developed in consultation with young people and evaluated to ensure there is an impact on drugs or alcohol and crime in the area. The results of the consultation exercise carried out in October 05 by Energy and Vision, with pupils at Cherwell and Peers schools noted that alcohol was already part of the social scene for 13 – 16 year olds and the fact that they had no alcohol education. However they stated that they would choose football or music sessions in preference to drinking.

0696af05bed60995a01f2717efd7362a.doc 20 Recommendations

R1 A broader range of diversionary leisure activities to be partnership funded and targeted towards areas where there are problems of substance misuse. It was thought that the City Council should be the lead partner in taking this forward. (The Local Area Agreement is seen as the key mechanism for delivering this and should be included as a significant factor in achieving the LAA target of ‘Reducing the harm caused to young people under 18 from illicit drug and alcohol use’.)

R2 The Children’s and Young Person’s service at Oxfordshire County Council to review;

Current funding of generic counselling support services for young people and parent / carers

Substance misuse support / brief intervention work within the school setting (in consultation with Oxfordshire DAAT)

R3 Pending the results of the ‘ Strengthening Families’ programme in the UK, Oxfordshire DAAT should investigate the possibility of a pilot programme operating in Oxford (shire) utilising the expertise of Oxford Brookes University, ‘Face to Face’ and ‘Parent-Talk’ Services.

R4 Oxfordshire DAAT should be the hub for disseminating good practice, information on support and treatment services available (e.g. a more developed web site and ‘Crystal Mark’ approved help / support literature)

R5 Oxfordshire DAAT to develop a standard training package for ‘frontline’ staff such as: ‘Signposting’ for Community substance misuse workers; Brief Intervention work for Youth Workers, School Nurses and offer subsidised training courses in the above areas.

3.3. Primary care based intervention

The National Alcohol Harm Reduction Strategy (2004) has identified the need to identify ‘capture points’ at which to identify and intervene with risky / hazardous drinkers. It points to Primary Care as the single most important capture point, with 98% of the population registered with a GP.

0696af05bed60995a01f2717efd7362a.doc 21 Shared Care Model contracts for alcohol misuse work

From 2007 GP’s may be able to enter into a shared care model contracts that include alcohol misuse. The aim of the Alcohol National Enhanced Service (NES) section of the contract is to create a small number of more specialist GP’s who undertake basic screening and more specialist interventions. Presently there is shared care scheme that links specialist addiction nurses from the Mental Health Care Trust with around 40 GP surgeries, but this is targeted towards drug misuse. There is no routine monitoring by GP’s of patient attendances that are linked to alcohol problems. The intervention work would also apply to all age groups.

Alcohol Concern (2004) has identified two fundamental omissions in the Alcohol National Enhanced Service (NES) contracts, which will need to be addressed at a local level:

 The specification of essential services contains no mention of alcohol, ’so the contract does nothing to encourage the appropriate clinical management of alcohol across the vast majority of GP’s and thus the vast majority of patients.’ Although Alcohol Concern does recognise that quality of care will increase if NES GPs are strategically spread across PCT areas.  The contract lacks a clear definition of ‘alcohol misuse’. Alcohol Concern perceive a risk that this wording will be assumed to apply only to dependent drinkers and not the much larger group of hazardous / risky drinkers.

The contract is also unclear whether the payment is based on numbers of patients who screened positively or those with whom an intervention is made. Proposing a register for those that ‘admit they are alcohol misusers’ also suggest a reactive approach. Alcohol Concern state that many of the target population do not know they are misusing alcohol. The WHO research highlighted below also suggests ‘opportunistic’ screening and intervention is more effective.

Alcohol Concern would also like to see a clearer definition for ‘brief intervention’ in the contract and one that is linked to standardised protocols and screening processes. They have made the following recommendations;

 An analysis of current practices and training requirements in relation to screening, prevention and treatment for alcohol misuse. (Alcohol Concern recommends training on screening and brief interventions to the competences described in ‘Drug and Alcohol Occupational Standards unit – AH10 – Carry out brief interventions with alcohol users.’

 The introduction of minimum standards for screening & brief intervention work.

0696af05bed60995a01f2717efd7362a.doc 22 WHO implementation project in Newcastle Upon Tyne

Northumbria University are leading research into disseminating evidence about brief alcohol intervention in primary care and on promoting its use in routine practice. Two large trials with GP’s and primary care nurses have been run as part of a WHO collaborative study.

The research has found strong evidence that screening and brief intervention delivered opportunistically in primary health care settings to ‘at risk’ drinkers is effective in leading to reductions in drinking. However the research team also found evidence that health-care professionals are slow to incorporate brief interventions routinely in their work.

The study has looked to customise brief intervention methods (A toolkit will be available from March / April 06) and has looked at strategies to maximise their use. Findings from the study suggest that more direct approaches such as personal visits / telemarketing were more successful at encouraging GP’s to take brief intervention materials. For implementation the team also found that one - hour practice based training and further telephone- based support was the most effective method.

Further research has been conducted with primary health care professionals, alcohol –service workers gaining expert opinion on approaches to implementing routine screening and brief intervention. Two clear conclusions have emerged from the study

 That routine screening should be confined to new patient registrations, general health checks and special types of consultation.  The employment of a specialist alcohol worker as a member of the primary- health care team, working with GP practices. The role of this worker was seen as carrying the main load of work created by delivery of brief interventions and the link for referrals to more specialist addictions agencies.

Danish research into ‘risky’ drinking behaviour & impacts of normative feedback.’

Oxford Brookes School of Health & Social Care research into effective prevention / intervention programmes has highlighted a Danish research study on reducing alcohol consumption amongst young ‘risky drinkers’

The study looked at how the behaviour of ‘risky’ drinkers compared to average drinkers and examined what the consequences of risky (heavy) drinking were likely to be.

Those identified as having high alcohol consumption levels via a questionnaire, were sent a brief letter giving feedback on the consequences of

0696af05bed60995a01f2717efd7362a.doc 23 their heavy drinking behaviour (normative feedback) from a medical practitioner. This was found to have an impact on drinking levels when the sample base was questioned a year later and significantly was just as effective as more costly best practice models such as cognitive feedback (involving counselling feedback)

The School of Health & Social Care is looking to replicate this study, with a sample base of 1000 students.

At enrolment time students will be asked to complete a screening questionnaire. For those scoring above the risky drinking threshold, a normative feedback letter will be sent. Similar to the Denmark model a follow- up questionnaire on risky drinking will be conducted a year later, to assess changes in drinking patterns.

If the pilot study findings indicate that this intervention lowers alcohol consumption involvement of a wider student base should be considered. Research could link directly into primary care settings, as OU students are registered with GP practices in Beaumont St, Jericho & North Oxford and Brookes students with St Bartholomews surgery.

Conclusion

 Oxfordshire PCT’s will need to develop a clear definition of what alcohol misuse is and audit current screening and intervention work practices amongst GP’s.

 PCT’s will also need to consider customised screening tools and brief intervention models. (The WHO toolkit would offer a good starting point)

Dr Andy Chivers (Lead GP for Substance Misuse in Oxford City area) agreed with conclusions from the Who study that routine screening should be part of new patient registrations and health checks. He felt that GP’s should be thinking of alcohol as a factor in most consultations and recording their findings. ‘Realistically there has to be an acceptance GP’s will not be 100% effective at identifying all problem drinkers. However ‘GP’s should ensure that key identifiers: accidental injury, insomnia, work problems trigger appropriate responses from GP’s and that they have the right templates to record it and offer the right interventions.’

 The Oxford Brookes research into the impacts normative feedback into ‘risky drinking’ offers the potential of cost effective intervention in the primary care setting. There has been positive feedback from St Bartholomews Surgery and Dr Chivers from the Brookes University research and discussions are underway to conduct a pilot study of Brookes students registered at St Bartholomews.

0696af05bed60995a01f2717efd7362a.doc 24 Recommendations

It is understood that the dedicated alcohol budget for Oxfordshire DAAT in 06 / 07 is uncertain. However the review group support the proposal that any future funding will be targeted towards the scoping of primary care and shared care treatment. The review group recommends that this scope should include:

R6 An analysis of current practices and training requirements in relation to screening, prevention and treatment for alcohol misuse.

R7 The introduction of minimum standards for screening & brief intervention work e.g. QUADs (Quality in Alcohol & Drug Standards) or Models of Care.

R8 Introduction of common questioning / screening tools e.g. AUDIT model (see appendix 7) The WHO brief intervention ‘toolkit’ once launched would enable this.

‘Shared Care’ contracts

The review group recommend that a Shared Care contract for alcohol include:

R9 A broad but clear definition of alcohol misuse, that includes hazardous / risky drinkers

R10 A payment system which encourages as many practices as possible to participate e.g. initial set-up costs, one off payments on evidence of implementation of the locally agreed screening protocol.

Pending the results of pilot study findings from Brookes University (on reducing ‘risky drinking patterns) Oxfordshire PCT’s should consider allocating any future ‘Choosing Health’ funding towards:

R11 Wider research initially linked with GP surgeries with a high student or 18 – 25 year patient base. (Oxford University could be approached to help finance this)

3.4. Acute Trust intervention

Alcohol related incidents at Oxford Radcliffe Hospital Trust

It can be seen from the tables overleaf that the highest rates of alcohol related attendances at A & E are in the 20 – 29 year age group for both males and females and that the Oxford City PCT has the highest rate of alcohol related attendances. (see charts 1-3 overleaf) However the figures in Oxford are low

0696af05bed60995a01f2717efd7362a.doc 25 compared to those in other cities with similar demographics. Presently this alcohol related attendance data is not routinely collected and cases are assumed to be non – alcohol related in the absence of any other data. Based on comparative data (A & E Depts with similar patient demographics) this could mean under reporting by a margin of over 20%.

Anecdotal evidence also suggests that significant cases of alcohol related injuries present from Thurs – Saturday evening to the John Radcliffe A & E Department. Accident and Emergency data also confirms that a high number of injuries are caused by violence or accidents that involve alcohol, whether for the injured person or a perpetrator of violence. These are mostly male on male, although the last 4/5 years have seen increasing number of young women involved in alcohol related assaults. Presently the A & E department at the John Radcliffe Hospital is seeking funding from GOSE to improve its data collection systems and is looking towards the Cardiff model highlighted in the next section. More accurate recording systems to identify the scale of the problem is seen as a necessary precursor to the development of any alcohol intervention or treatment models.

Improvements therefore need to be made to the data recording systems with for example a dedicated person collecting relevant data.

The A & E department are also looking into the viability of using screening techniques such as the PAT / AUDIT (see appendices 6 & 7 ) tests and whether they could be used within existing resources.

(Please note that it is not possible to determine from the data whether the involvement of alcohol relates to the attendee, or the person/persons responsible for the attendance.) Chart 1: Percentage of Alcohol-related attendances at Oxfordshire A&E departments - 2003/04 compared to 2004/05 by PCT

5.0 4 .5 4 .5

s 4.0 e 3 .6 c 3 .5 3 .5 3 . 3 n 3 . 2 3 .3 a

d 3 . 0 2 .9 3 .0 n 2 .8 e 3.0 t t 2003/04 a

2004/05 e 2.0 g a t n e c r

e 1.0 P

0.0 Cherw ell Vale North East Oxford City South East South West All Oxon PCTs Prim ary Care Trust

Source: Oxfordshire Injury Surveillance Oxford City PCT had the highest percentage of alcohol-related attendances in both 2003/04 and 2004/05 (4.5% both years)

0696af05bed60995a01f2717efd7362a.doc 26 Chart 2: Number of alcohol-related attendances by males at Oxfordshire A&E departments – 2003/04 compared to 2004/05 by age group

800 7 5 9 s

e 700 6 5 3 c n

a 600 2003/04 d n

e 500 4 4 6 4 4 8 2004/05 t t a

f 400 3 5 1 3 5 8

o 3 1 2 3 1 4

r 300 e

b 1 9 2 1 8 8

m 200 u

N 100 6 6 5 7 2 7 4 7 4 6 4 0 6 5 5 2 1 8 1 4 1 7 2 2 1 4 2 4 8 9 0 0-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-64 65-69 70-74 75-79 80-84 85+ Age group

Source: Oxfordshire Injury Surveillance

There were small increases in the number of alcohol-related attendances of males in some age groups between 2003/04 and 2004/05, with the largest increase being in the 20-29 age group.

Chart3: Number of alcohol-related attendances by females at Oxfordshire A&E departments – 2003/04 compared to 2004/05 by age group

450 3 9 2 400 3 7 1 s

e 350 c 2003/04 n

a 300 d 2 4 5 2 5 7 2004/05 n

e 250 t 2 1 3 t 2 0 0 a 1 9 6

f 200 1 7 3 o

b 1 1 5 1 0 9

m 100 u N 3 5 2 9 50 2 3 2 5 1 4 2 0 1 4 4 3 1 5 1 5 1 3 1 0 1 3 1 0 1 5 1 5 0 0-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-64 65-69 70-74 75-79 80-84 85+ Age group

Source: Oxfordshire Injury Surveillance

There was no overall trend or any dramatic change in the number of alcohol-related attendances in females.

0696af05bed60995a01f2717efd7362a.doc 27 Best practice models on brief intervention within the acute setting

An overview of the research evidence, indicates that alcohol misuse is probably accountable for at least 10% of unplanned attendances to Accident and Emergency Departments and a higher percentage of attendances of those with head / facial injuries and trauma requiring admission to orthopaedic wards.

A summary of findings nationally suggest that there is a strong case for incorporating screening into routine health care provided in the general hospital setting and that nurses have been shown to be better and more cost effective than doctors at screening for alcohol misuse.

Intervention work in this setting has also had a marked effect on reducing alcohol intake. Evidence from the Royal College of Physicians (2001) suggests an average reduction of alcohol intake of around 20% following an intervention.

St Mary’s Hospital – Paddington (The Accident and Emergency Department)

The Accident and Emergency Department has been identifying and treating patients with alcohol misuse problems for over 15 years. The Hospital has developed a four item - screening questionnaire (PAT) (see appendix 6) that establishes whether a person is drinking over the limits or if they feel the attendance could be related to alcohol. Doctors working in the Accident and Emergency department are trained in the use of PAT and are encouraged to screen all patients who present with problems such as; falls, collapse, head injury, assaults and other medical problems linked with alcohol misuse.

Those found misusing alcohol are then offered an appointment with an alcohol health worker. This worker provides a patient - centred assessment of alcohol problems, discusses the impact of alcohol use and provides further information or referral.

The hospital has looked at the impacts of intervention in reducing alcohol consumption in patients. Using a sample of 599 patients, St Mary’s looked at the impacts of receiving an information leaflet or receiving a leaflet and an appointment with an alcohol health worker on reducing alcohol consumption. Patients were followed up at six months and twelve months. At six months brief intervention was associated with a much more dramatic drop in alcohol consumption than with provision of a health information leaflet. (59.7 units per week compared with 83.1 units per week) However the difference was less marked at 12 months due to further falls in alcohol consumption of those who had had the information leaflet (57.2 units compared to 70.8 units)

The study also noted a mean reduction of 0.5 fewer visits to the emergency department for persons in the brief intervention groups. This is made more significant given that 22% of all patients screened were found to be misusing

0696af05bed60995a01f2717efd7362a.doc 28 alcohol. The evidence suggests that direct cost savings can be delivered via reduced attendances and St Mary’s are currently conducting a cost – effectiveness analysis of intervention.

Royal Liverpool Hospital

The hospital has set up a lifestyles team out of recognition that 12% of A & E attendances and 33% of Intensive Treatment admissions were alcohol related.

One alcohol specialist nurse is employed within the hospital trust to respond to alcohol – related referrals from A & E, clinics and ward areas throughout the hospital. A study was conducted over an 18 month period to assess the effects of her interventions on staff and patients. In this period she received 1654 referrals, 437 of whom were suitable for brief intervention. An AUDIT (see appendix 7) screening tool was used (similar to the Paddington test, it is a quick method of identifying daily & hazardous drinking patterns) 90 patients were followed up. At 6 months mean alcohol consumption had dropped from 20.5 per week to 8.5 units per week. The nurse also estimated that in total her interventions prevented 258 admissions.

Reducing alcohol consumption in young men with alcohol - related facial injuries – University of Wales College of Medicine

Maxillo – facial surgeons see a regular stream of young male casualties with alcohol – related facial injuries. Casualties attend an A & E department, receive treatment and are given an appointment for a follow-up clinic within the next 10 days. Dr Jonathon Shepherd (maxillo-facial surgeon at University of Wales College of Medicine) thought the clinic would provide an ideal opportunity to influence the drinking patterns of these patients. A randomised controlled trial involving 150 young men was conducted to test out the impact of brief intervention. A 20 minute brief dialogue between patient and nurse resulted in significant changes in alcohol consumption over the year. Prior to admission 60% of men in the group were consistently exceeding the recommended limits, one year later this had reduced to 27%. In the control group (with no intervention) 54% were found to be exceeding recommended limits and this had dropped to 50% over the year, showing that some small changes had occurred without intervention.

The University of Wales College of Medicine have progressed intervention further by developing a data recording system that records not only alcohol related incidents, but where it occurred. This A & E data is then compared weekly with Police data and has led to more targeted policing of licensed premises. The inner city area has seen a 25% reduction in alcohol related violence.

David Shehan (GOSE) and Dr Jo Nurse (Public Health Group South East) are presently investigating the potential for more widespread data capture e.g. antenatal, STD clinics, fracture clinics and the mechanisms for referring on for brief intervention.

0696af05bed60995a01f2717efd7362a.doc 29 Conclusion

 Research evidence points to effectiveness of intervention work and that raising awareness at a critical time (admission to hospital) may effect behavioural changes. Implications from the above evidence, also suggest the need for an alcohol health worker to be available to work with referrals from a variety of hospital settings.

 Alcohol Health Workers delivering an intervention service would offer a more joined approach up to screening and treatment in the hospital settings. Providing counseling and referral to more specialist detox services would also allow for more co -coordinated working with primary and mental health care services.

 One of the aspiration objectives from the Alcohol Strategy is;

‘To decrease the number of patients admitted to Oxfordshire’s Accident & emergency departments with alcohol related presentations by 10% by March 2009.’

Based on best practice evidence this will only realistically be achieved with linked screening and intervention work in a hospital setting. (An improved data collection system will also naturally lead to sharp rises in recorded cases and therefore this indicator will be meaningless until data collection figures establish an accurate baseline figure.)

Recommendations

R12 Oxford Radcliffe Hospital Trust pilot the use of alcohol screening questionnaires within Accident & Emergency departments.

R13 Pending results of more accurate data recording for alcohol related incidents at A & E, Oxfordshire PCT’s (in consultation with DAAT) should consider the appointment of alcohol health worker(s) within hospital setting(s), to provide brief intervention treatment or appropriate referral to a more specialist counselling / detox services

0696af05bed60995a01f2717efd7362a.doc 30 3.5. Recommendations for coordination of alcohol treatment services

R14 All agencies connected with alcohol treatment / prevention should co-operate in sharing information around current work to ensure the best use of limited resources.

R15 Resources should only be used for projects where there is evidence of effectiveness or if research funds can be obtained, on well structured projects testing the effectiveness of different approaches.

R16 Intervention / treatment pathways should be modelled in accordance with ‘Models of Care’ (see appendix 2 & 2(a)) with interventions tiered to match patient need and clinical pathways.

R17 Resourcing of treatment services need to be reconfigured towards need and prevention. Increasing brief intervention work with a large and growing population of hazardous / heavy drinkers is regarded as the most effective use of scarce resources.

Monitoring recommendations

R18 Oxford Health Overview and Scrutiny Sub – Committee to review progress against key objectives outlined in the Alcohol Strategy for Oxfordshire 2006 – 09.

0696af05bed60995a01f2717efd7362a.doc 31 4. Overall Conclusions

The review group findings have highlighted the following:

1. There is little ‘hard’ local evidence on alcohol misuse particularly in relation to hazardous / heavy drinking. However anecdotal evidence and individual agency data suggests that alcohol misuse amongst young people is not only increasing but onset of alcohol consumption is also occurring at a younger age

2. Social / family consequences of alcohol misuse are already noted by agencies working with the most vulnerable groups of young people.

3. Best practice evidence points to the effectiveness of intervention work at ‘critical times’ e.g. after an alcohol related injury

4. Future expenditure is likely to be minimal compared to the scale of the problem. ‘Choosing Health’ indicative funding was the only significant future funding that had the potential to be directed towards prevention and early intervention. This funding is a national indicative allowance and with precarious Oxfordshire NHS finances will be diverted for 06 / 07.

5. Due to scarce treatment resources, substance misuse prevention and intervention work with younger school aged groups is paramount

6. Research evidence points to the importance of family involvement, peer – led and interactive education programmes. Locally, there has been an erosion of a parent / carer drug coordinator and drug worker (attached to City schools) posts in the last year.

0696af05bed60995a01f2717efd7362a.doc 32 Glossary

Units – a unit of drink contains 8g of alcohol. This is approximately the amount of alcohol contained in half a pint of medium strength beer or a small (100ml) glass of wine or single pub measure (25ml) of spirits.

Sensible Drinking – A man who drinks 21 units or less per week, or woman who drinks 14 or less units per week.

Very heavy drinker – a man who drinks 50 or more units per week or a woman who drinks 35 or more units per week.

Binge drinker – A man who regularly drinks 10 or more units in a single session or a woman who regularly drinks 7 or more units in a session.

Hazardous (or at risk drinker) Very heavy drinkers and binge drinkers that have drinking patterns that pose a considerable risk to their own and others health.

Harmful drinker – Where there is clear evidence that alcohol use is responsible for (or contributes to) physical or psychological harm.

Drinking types (for assessment and treatment)

Type 1 : Binge drinking, hazardous drinking

Type 2 : Early signs of physical, psychological or social harm

Type 3 : Withdrawal symptoms, dependant drinking

Brief Intervention – Usually consists of an assessment of alcohol intake; Information on hazardous / harmful drinking and clear advice for the individual, often with booklets and details of local services. It may also involve motivational counselling. All the techniques involve catching those with alcohol problems at a ‘teachable moment’ e.g. someone who has been involved in alcohol related violence and attends hospital to have their stitches out. Interventions are usually carried out by generalist workers in specialist settings and are brief and user-friendly.

0696af05bed60995a01f2717efd7362a.doc 33 References

Alcohol Concern (2004) ‘Primary Concern. Supporting alcohol work in primary care. The brief intervention debate.’

Alvarado, R., Kumpfer, K. (2000) ‘Strengthening America’s Families’ Juvenile Justice Journal, Vol VII, No 3.

Cottle, R, et al (2005) Annual report 2004 – 2005 Oxford City Detached Youth Project.

Crawford, M.J, et al (2004) ‘ screening and referral for brief interventionof alcohol – misusing patients in an emergency department : a pragmatic randomised controlled trial.

Dept of Health (2005) Alcohol Misuse Interventions - Guidance on developing a local programme of improvement

Heather, N. , et al (2004) ‘Implementing routine screening and brief alcohol intervention in primary health care: A Delphi survey of expert opinion.’ Journal of Substance use April 2004: 9 (2) 68 - 85

Kingsland – Townley, K., (2005) Youth Service – Drug Worker (Oxford City) Project Report – Dec 2002 – August 2005.

McGrath, Y. , et al (2006) ‘Drug use prevention among young people: a review of reviews. National Institute for Health and Clinical Excellence

Marsden, J. et al (2005) ‘Personal and social correlates among mid – adolescents.’ British Journal of Developmental psychology, Vol 23, pp 427 – 450

Office of the Deputy Prime Minister (2006) ‘Transitions : Young Adults with Complex Needs. A Social Exclusion Unit Final Report.

Oxfordshire Alcohol Partnership Group - Oxfordshire Alcohol Harm Reduction Strategy 2006 –2009

Royal College of Physicians of London (2001) ‘Alcohol – can the NHS afford it? Recommendations for a coherent strategy for hospitals.’ – A report of a working party of the Royal College of Physicians.

Sheehan, D., Nurse, J. , (2006) ‘Alcohol and Violence’ Presentation and workshop – South East Public Health Conference.

Strategy Unit (2004) ‘Alcohol Harm Reduction Strategy for England.’ Cabinet Office.

Tunnicliffe, A., (2005) ‘Beneath the radar – substance misuse services for parents / carers / families in Oxfordshire.’ Oxfordshire County Council

0696af05bed60995a01f2717efd7362a.doc 34