ALCOHOL & NICE a rapid overview Trevor McCarthy January 2014
Trevor McCarthy January 2014
New Commissioning Arrangements
Public Health England & Health and Well Being Boards
Aspiration to align NHS + Public Health + Social Care outcomes
Public Health have not been involved in drug commissioning (untainted)
Alcohol is a Top 3 priority for Public Health (after smoking & obesity)
Trevor McCarthy January 2014
NICE NICE NICEso good they named it 3 times (so far)
• New Labour 1st policy white paper: The New NHS: Modern, Dependable 1997
• 1999: National Institute for Clinical Excellence
• 1 April 2005 + Health Development Agency → National Institute for Health & Clinical Excellence
• Health and Social Care Act 2012 → 1 April 2013: National Institute for Health and Care Excellence (new responsibilities for social care)
Trevor McCarthy January 2014
Understanding the evidence base
… science isn’t hard – academics around the world explain hugely
complicated ideas to ignorant eighteen-year-olds every September –
it just requires motivation.
BEN GOLDACRE Bad Science 2009
Trevor McCarthy January 2014
What are guidelines? Clinical guidelines are systematically
developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.
Guidelines provide recommendations for effective practice in the management of clinical conditions where variations in practice are known to occur and where effective care may not be delivered uniformly.
Trevor McCarthy January 2014
NICE guidance• NICE has produced guidance in three areas:
Public health – guidance on promoting health and preventing illness
Health technologies – use on medicines, treatments and procedures
Clinical practice – guidance on appropriate treatment and care of people with specific diseases and conditions in the NHS.
Forthcoming: social care
Trevor McCarthy January 2014
Hierarchy of Evidence 1
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
Trevor McCarthy January 2014
Hierarchy of Evidence 2
2++ High quality systematic reviews of case control or cohort or studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies - low risk of confounding or bias and a moderate probability that the relationship is causal
Trevor McCarthy January 2014
Hierarchy of Evidence 3
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
(in the absence of evidence – then expertise is OK)
Trevor McCarthy January 2014
So – What is NICE for?
Fairness: vs ‘postcode lottery’ Effectiveness – scientific validation Cost effectiveness (no longer able to make
recommendations re: cost of medications) Hierarchy of evidence Not set in stone – evidence updates (e.g. PH24) Countering: advertising; anecdotes; special
interest groups; experts; prejudice; inequity
Trevor McCarthy January 2014
The way I see it, it is my civic duty to live fast, die
skint and leave a dirty big fat bastard of a corpse
Rab C Nesbitt. BBC. Series 10 Episode 2 - 12 October 2011
Trevor McCarthy January 2014
AHRSE 2004 - 4 key strands
1. Improved, better-targeted, education and communication
2. Better co-ordination and enforcement of existing powers against crime and disorder
3. Encourage industry to promote responsible use & take a role in reducing alcohol-related harm
4. Better identification & treatment of alcohol problems
Trevor McCarthy January 2014
MoCAM: framework describing what should be commissioned in each local area
Evidence based guidance & consensus based – professionals & service users
Mainstream alcohol interventions to develop integrated local alcohol treatment systems
Tier I: all frontline staff able to identify drinkers, provide info, brief interventions
Tier II: all staff deliver extended brief interventions, referrals and joint working
Trevor McCarthy January 2014
Safe, Sensible Social
Aimed to: Build on progress made in implementing
2004 strategy & To minimise health harms, violence &
antisocial behaviour associated with alcohol, while ensuring that people are able to enjoy alcohol safely and responsibly.
Trevor McCarthy January 2014
March 20121.1 Over the last decade we
have seen a culture grow where it has become
acceptable to be excessively drunk in public and cause
nuisance and harmto ourselves and others.
Trevor McCarthy January 2014
No-one. Not researchers; not commissioners; not practitioners; not drinkers. No-one else suggests that our alcohol problem arose in the 10 years preceding this (when the current Prime Minister’s party were mainly in opposition). Policy is always political: this is the least substantial, most politicised alcohol strategy yet.
Trevor McCarthy January 2014
Uniquely Insulting Tone PM foreword: more powers for hospitals not just
to tackle the drunks turning up in A&E 3.12 we will work with the police to tackle the issue
of serving alcohol to drunks 3.16 staff can refuse to treat drunks who are
abusive in A&E Drunks. Not People with alcohol related health
problems. Not People who need help. Not People who have a right to treatment and respect.
Trevor McCarthy January 2014
The prevention paradox
The majority of alcohol related harms are associated with people whose drinking is hazardous & harmful
Dependent drinkers are likely to experience and be linked with greater degrees of harm
But there is so much drinking that the hazardous & harmful drinkers harm outweighs that of dependent drinkers
Trevor McCarthy January 2014
Motivational Government
All the alcohol strategies have taken whole population Public Health approaches
Bear down on overall consumption to reduce levels of problems
Strategies decorated with headline criminal justice initiatives
Good luck persuading ‘pre-contemplative’ drinkers to moderate by calling them ‘Drunks’
Trevor McCarthy January 2014
No top down re-organisation of the NHS?
“The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK,”
Mark Pearson: OECDCoalition health bill will undermine NHS, says OECD thinktank
Guardian 23 November 2011
Trevor McCarthy January 2014
NICE: Alcohol Prevention Guidance
NICE Public Health Guidance 24Published June 201012 recommendations
Trevor McCarthy January 2014
Policy Recommendations (1-3)
1 Price: Consider minimum price per unit.
2 Availability: Consider licensing legislation; protecting public’s health as an objective; availability and alcohol-related harm & immediate sanctions on premises in breach
Consider reducing personal import allowances
3 Marketing: Minimise young’s exposure to alcohol advertising - consider complete ban
Trevor McCarthy January 2014
Practice Recommendations (4-8)
4 Licensing
5 Resources - screening & brief interventions
6 Supporting children & young people 10 - 15
7 Screening people aged 16 & 17 years
8 Extended brief interventions - 16 & 17
Trevor McCarthy January 2014
Practice Recommendations (9-12)
9 Screening adults
10 Brief advice for adults
11 Extended brief interventions for adults
12 Referral
Trevor McCarthy January 2014
Recommendation 5 (highlight)
Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.
Trevor McCarthy January 2014
NICE: Alcohol Use Disorders:Physical Complications
NICE Clinical Guideline 100Published June 2010
38 clinical recommendations7 research recommendations
Trevor McCarthy January 2014
NICE: Alcohol Use Disorders:Diagnosis, assessment and management of
harmful drinking and alcohol dependence
NICE Clinical Guideline 115Published February 2011
Comprehensive treatment recommendations6 research recommendations
Trevor McCarthy January 2014
CG 115: PRINCIPLES OF CARE Building a trusting relationship and providing
information Working with and supporting families and carers All interventions for people who misuse alcohol
should: Be delivered by appropriately trained &
competent staff Be the subject of routine outcome monitoring
… to inform decisions about continuing psychological & pharmacological treatments.
Trevor McCarthy January 2014
CG 115: Identification & Assessment Risk assessment to inform care plan inc. risk to self
(inc. unplanned withdrawal, suicidality and neglect) & risk to others.
NHS funded services – staff who care for people who potentially misuse alcohol should be competent to ID harmful drinking & dependence & to assess need for intervention … if not competent(?) refer to service that can assess.
Assessment in specialist alcohol services:do not refuse treatment to service users who do not agree to a goal of abstinence.
Trevor McCarthy January 2014
CG 115: Interventions for alcohol misuse• For all people … motivational intervention as
part of initial assessment. • Care coordination & case management• For harmful drinking & mild dependence
offer psychological intervention (CBT, behavioural therapies (MI / MET) or social network & environment-based therapies SBNT) focus on alcohol-related cognitions, behaviour, problems & social networks.
• Assessment & interventions for assisted alcohol withdrawal & Drug regimens
• Interventions after successful withdrawal
Trevor McCarthy January 2014
NICE PH24 – the immediate response from Andrew Lansley Health Minister*
“Regarding NICE's recommendations on minimum pricing for units of alcohol, it is not clear that the research examines specifically the regressive effect on low income families, or proves conclusively that it is the best way to impact price in order to impact demand.”
Published 2 June 2010
• http://www.dh.gov.uk/en/MediaCentre/Statements/DH_116534
*The Prime Minister disagreed. CAMRA disagreed. NICE disagreed.
Trevor McCarthy January 2014
Merchants of Doubt
“Doubt is our product,” ran the infamous memo written by one
tobacco industry executive in 1969, “since it is the best means of competing with the ‘body of fact’ that exists in the
minds of the general public.”
Merchants of DoubtNaomi Oreskes & Erik M Conway 2010
Trevor McCarthy January 2014
Prejudice Based Policy
You cannot reason people out of positions
they didn’t reason themselves into.
Bad Science BEN GOLDACRE
Trevor McCarthy January 2014
The presence of those seeking the
truth is infinitely to be preferred to those
who think they’ve found it.
TERRY PRATCHETTMonstrous Regiment
Trevor McCarthy January 2014
If you can’t make decisions in life, you’re a bloody menace. You'd be better becoming an MP!
Trevor McCarthy January 2014
Commissioning Alcohol Services & Pavlov’s Cash Register
• Performance related pay • Payment by Results
• Performance related pay• Payment by Results
• Focus on what works and what is most important• N.B. It’s not the pay ………………………..