Feature / Invest now or pay later

If you want evidence that investing in prevention is worthwhile in a business sense, Arlene Copland (pictured) has plenty. In the four years the alcohol care team has been operational in Sandwell and West Birmingham Hospitals NHS Trust, on top of the better outcomes for patients, it has prevented an estimated 1,990 unnecessary bed days with an estimated saving of nearly £1m.

Average length of stay for alcohol withdrawal admissions has fallen from 3.4 to 2.25 days. And the number of admissions for those in acute alcohol withdrawal has reduced from 1.66% to 0.68% of all acute admissions. In total, says the trust’s alcohol nurse consultant and NHS England’s national lead alcohol nurse, the trust has calculated that there is a £5 return on every £1 spent on the team.

Drinking to excess can destroy lives and families. Deaths from alcohol-specific causes are now at record levels, according to the Office for National Statistics. But there is also a strong financial argument for preventing alcohol-related disease. The NHS long-term plan estimated alcohol-related harm cost the NHS in England £3.5bn every year. And the problem has been growing, not getting better, with a 17% rise in hospital admissions over the decade up to the plan.

Cultural shift

However, Ms Copland says that the success of the Sandwell programme has required both financial backing and a change in culture among the trust’s staff.

‘Addiction is a really complex condition and it’s not rational,’ she says. ‘So, someone could be in hospital with alcohol-related liver disease and they will cope with that diagnosis by going out and drinking – because when alcohol becomes a problem, it becomes your coping mechanism.’

Changes at the trust have included an education programme for nurses and doctors to help them see addiction as a chronic disorder that needs more than an acute intervention.

‘Admitting somebody in alcohol withdrawal from the emergency department for an unplanned detox is actually often not in their best interests, because addiction is largely psychological,’ she adds. ‘There’s only a small component that’s physical, so if you only do the detox and ignore everything else, you’re pretty much setting them up to fail.’

In many cases the best approach is to avoid the admission, and support the patient on an outpatient basis, moving to detox on a planned basis when the timing is right.

 The alcohol care team proactively monitors emergency department attendances, although it also takes referrals wherever they come from – including the community alcohol service, GPs or specialist services. However, as a hospital-based service, the bulk of its work flows from the emergency department.

The team is currently seeing between 250 and 300 people a month, excluding clinic referrals, with cases ranging from primary alcohol-related problems such as liver disease through to conditions where alcohol is a complicating factor.

The team’s response depends on the circumstances. Admission is not the first thought – patients aren’t always admitted for detox, there needs to be a medical concern. But if they are admitted, then the team works with them on a daily basis.

‘Regardless of the reason for them being in hospital, it could be the start of their recovery journey,’ says Ms Copland. ‘Often people know what they should be doing, but when you are in hospital it means something has gone wrong and it is a great time for reflection. So, we make referrals into appropriate services for ongoing support or keep them on our caseload until community services become more appropriate.’

Even if the patient is not ready to stop drinking, the aim is to give them all the resources, so that when they are ready, they know where to go for help. The NHS long-term plan committed to fund the creation of alcohol care teams in hospitals with the highest rates of alcohol dependence-related admissions.

Just under 50 hospital sites received funding, with the funding effectively sufficient to pay for one member of staff per 500 discharges. In some cases, it has been used to start a service from scratch, while in others it has built on existing functions.

However, Sandwell’s team pre-dates this. And one of the keys to its success has been the trust’s financial backing and recognition of the value the service provides.

‘What makes the difference,’ says Ms Copland, ‘is that we’ve been properly resourced from the start. There’s often pressure on hospitals to address alcohol and then they employ one person – and you are never going to get the outcomes you need if that happens.’

Properly resourced initially meant six staff – Ms Copland to set the service up, two band 6 nurses, one band 5 and two band 4 alcohol practitioners, who had been based in the community. Initially these staff ran a five-day-a-week service across the trust’s two hospitals from 8am to 4pm. It wasn’t a huge team, especially given that the trust serves some areas of considerable deprivation, which has a known correlation with alcohol problems. But Ms Copland says the investment was large compared with the resources allocated to alcohol in some trusts.

The team has subsequently expanded further and now provides a full seven-day-a-week service. Ms Copland says there have been benefits for patients – evidenced by patient satisfaction questionnaires – and a real change in culture from staff, with greater recognition of the challenges faced by those with addiction problems.

It can also point to those real reductions in admissions and length of stay. The emergency department no longer admits automatically without an assessment of a person’s motivation or readiness to change.

Setting the example

As national nurse lead for alcohol, Ms Copland is keen to see other trusts follow Sandwell’s example. She says data is key to making the case locally. ‘When I started the team, we basically had one year to prove our worth,’ she says. ‘So I’ve been very data focused and that hasn’t changed. We can clearly demonstrate the impact we continue to make.’

Ms Copland questions why alcohol treatment has to make a case for investment in a way that would happen for say a diabetes nurse. Alcohol is a problem for the whole hospital, impacting on virtually all services from end-of-life to maternity. Everyone knows it is a problem, but either don’t want to get involved or don’t know how to help.

So, a key part of establishing the service was raising its profile across the whole trust. ‘I wanted it to be the case that if the money wasn’t going to be renewed, then the whole hospital would object.’

Raising awareness across different departments is key to establishing services more widely. ‘Don’t assume that people know what you do,’ she says. ‘They can think that we just go up to somebody and tell them to stop drinking, when in reality our patients are so complex. We might have drinkers who have got nowhere to live. They might be pregnant, or there could be safeguarding issues or problems with mental and physical health. Alcohol is often just the symptom of other issues.’

Despite Sandwell’s good resourcing, Ms Copland is keen to do more.’ We’ve just employed a fibroscan nurse, which is exciting,’ she says. The ultrasound device can measure liver inflammation non-invasively and indicate fibrosis or cirrhosis before patients are even symptomatic.

‘The hope is that we can pick up people early and may be able to motivate them to stop drinking,’ she says. ‘What I’d like to do, when we’ve established the service more, is to take it out into the community, because we know there are some really hard-to-reach communities and occupations. We’ve got to start doing things differently.’

The payback for patients is longer, healthier lives, but there are also benefits for society in terms of improved productivity. And it is cost-effective for the NHS too. Research, albeit quite old now, suggests there is a £3.85 return for every £1 invested in the alcohol care team model.

Ms Copland believes the NHS could ease the strain on its bed capacity and avoid the need for far more major interventions downstream. If you want to make a business case for alcohol treatment, the choice is: invest now or pay later, she adds.