Ethanol-Based Hand Sanitizing Gel Vapor Causes Positive Alcohol Marker, Ethylglucuronide, and Positive Breathalyzer Gregory E. Skipper, MD, Frieder Wurst, MD, Wolfgang Weinmann, MD, and Michael Liepman, MD Context: Ethylglucuronide (EtG), a minor metabolite of alcohol, is an Ethylglucuronide (EtG) is a nonoxidative metabolite of ethyl alcohol that has recently gained widespread use in monitor-
Models of care for alcohol misusers (mocam)Models of care for alcohol misusers
Models of care for alcohol misusers
DH INFORMATION READER BOX
Partnership Working Best Practice Guidance ROCR Ref:
Models of care for alcohol misusers DH/National Treatment Agency forSubstance Misuse PCT CEs, NHS Trust CEs, SHA CEs, Directorsof PH, Alcohol Treatment Providers, LocalAuthority CEs, GOR RDsPH Best practice guidance on a framework forcommissioning and providing interventionsand treatment for adults affected by alcoholmisuse. It describes a four tier system ofstepped care for alcohol misusers.
Alcohol Misuse interventions: Guidance ondeveloping a local programme ofimprovement (DH 2005)Alcohol Needs Assessment Research project(ANARP) (DH 2005) Alcohol Policy TeamHID-NPD-Substance misuseRoom 628Wellington House 135–155 Waterloo RoadLondon SE1 8UG020 7972 4793 For recipient's use
Crown copyright 2006 First published June 2006 Produced by COI for the Department of Health The text of this document may be reproduced withoutformal permission or charge for personal or in-house use.
Setting the scene
Purpose of Models of care for alcohol misusers The basis for policy on reducing alcohol-related harm and encouraging sensible drinking Types of alcohol misuse and links with interventions required A commissioning framework to deliver alcohol treatment systems
Commissioning alcohol screening and brief interventions and treatment: a PCT responsibility MoCAM provides in-depth guidance to local organisationscommissioning alcohol misuse interventions Commissioning a local system of screening and assessment A stepped care model to assist commissioning Planning for multiple alcohol treatment episodes Commissioning psychosocial and medical prescribing treatment Workforce planning to develop alcohol treatment systems Integrated care pathways for alcohol misuse – ‘alcohol treatment pathways' Criteria for commissioning and provision of local treatment systems
for alcohol misusers
Quality criteria for commissioning alcohol treatment systems Quality criteria for providing an evidence-based alcohol treatment system Models of care for alcohol misusers (MoCAM) Commissioning local systems of alcohol intervention and treatment
A1.4 Joint commissioning for alcohol and drug treatment A1.5 Implementing a commissioning cycle A1.6 Local alcohol treatment needs assessment A1.7 Components of a local system A1.8 Commissioning for a competent workforce Monitoring performance of alcohol treatment systems
A2.4 Monitoring performance A2.5 Service user outcomes A2.6 Minimum data sets Commissioning and providing an alcohol treatment system to meet
a diverse range of local needs
Screening the target population and taking action with individuals
who are hazardous and harmful drinkers
B1.3 Targeted screening Assessing the needs of individuals with identified alcohol problems
B2.4 Local systems of screening and assessment B2.5 Triage assessment B2.6 Comprehensive assessment B2.7 Impact of alcohol misuse on significant others Care planning to meet the assessed needs of individuals with
B3.4 Care planning Providing a range of structured treatment interventions to meet
the needs of alcohol misusers
B4.4 Key factors influencing successful alcohol treatment B4.5 Therapeutic relationship B4.6 Psychosocial therapies B4.7 Pharmacological therapies B4.8 Delivering a range of alcohol treatments in a care-planned approach Helping individuals maintain the gains they have made from
Managing alcohol treatment services
B6.4 Quality standards Links to other commissioning initiatives Standards for organisations commissioning and delivering alcohol services Models of care for alcohol misusers (MoCAM) Wider policy context The Respect Action Plan Every Child Matters Local strategic partnerships (LSPs) Local area agreements (LAAs) Annex C: Associated documents
List of referenced documents National Treatment Agency Department of Health Department for Culture, Media and Sport Office of the Deputy Prime Minister (now Department for Communities and Local Government) Department for Education and Skills Health and Safety Executive UKATT Research Team
I am pleased to be able to introduce this documentto you at this time. With rapid progress towards thedevolution of NHS commissioning to a local level, weneed this document to guide local NHS organisationsas they strive to deliver a planned and integratedlocal treatment system for alcohol misuse. Eventhough we are working hard to improve health andreduce inequalities, we recognise that more progressneeds to be made towards addressing the differentand complex causes of poor health and healthinequalities, including harm caused by alcohol. There is no doubt that alcohol misuse is associated with a wide range of problems,including physical health problems such as cancer and heart disease; offendingbehaviours, not least domestic violence; suicide and deliberate self-harm; childabuse and child neglect; mental health problems which co-exist with alcoholmisuse; and social problems such as homelessness.
We know that much of this harm is preventable and that the introduction anddevelopment of comprehensive, integrated local alcohol treatment systems canhave a beneficial impact on many areas of health and social care. This considerablybenefits hazardous, harmful and dependent drinkers, their families and socialnetworks, and the wider community.
Screening and brief interventions for harmful and hazardous drinkers, as wellas treatment for dependent drinkers, when delivered as part of a planned andintegrated local treatment system, can offer economic benefits in other NHSpriority areas.
Recent studies suggest that alcohol treatment has both short and long-termeconomic benefits. The Review of the effectiveness of treatment for alcoholproblems1 suggests that provision of alcohol treatment to 10 per cent of thedependent drinking population within the UK would reduce public sector resourcecosts by between £109 million and £156 million each year, and analysis from theUnited Kingdom Alcohol Treatment Trial suggests that for every £1 spent onalcohol treatment, the public sector saves £5.
Models of care for alcohol misusers (MoCAM) I recommend this guidance and I know that it will help commissioners to providethe effective and comprehensive local frameworks that will support our citizensand communities to lead healthier, happier and longer lives. Sir Liam Donaldson
Chief Medical Officer
Models of care for alcohol misusers (MoCAM) provides best practice guidance forlocal health organisations and their partners in delivering a planned and integratedlocal treatment system for adult alcohol misusers. It will be relevant to primary caretrusts (PCTs) who will play a leading role, in partnership with other local agencies,to commission appropriate alcohol services. MoCAM is explicitly identified as asignificant milestone towards achieving the second aim of the Alcohol harmreduction strategy for England2 (2004), ‘to better identify and treat alcohol misuse',and is a direct commitment in the Choosing Health3 White Paper (2004).
Alcohol misuse is associated with a wide range of problems, including physicalhealth problems such as cancer and heart disease; offending behaviours, not leastdomestic violence; suicide and deliberate self-harm; child abuse and child neglect;mental health problems which co-exist with alcohol misuse; and social problemssuch as homelessness.
The evidence base indicates that much of this harm is preventable. The introductionand development of comprehensive integrated local alcohol treatment systemsconsiderably benefits hazardous, harmful and dependent drinkers, their familiesand social networks, and the wider community. Recent studies suggest that alcohol treatment has both short and long-termeconomic benefits. The Review of the effectiveness of treatment for alcoholproblems1 suggests that provision of alcohol treatment to 10 per cent of thedependent drinking population within the UK would reduce public sector resourcecosts by between £109 million and £156 million each year. Furthermore, analysisfrom the United Kingdom Alcohol Treatment Trial suggests that for every £1 spenton alcohol treatment, the public sector saves £5.
MoCAM is informed by the document Models of care for the treatment of adultdrug misusers4 (2002), which had drug treatment as its primary focus, but wasacknowledged to be of ‘great relevance' for alcohol service provision. Models of care for alcohol misusers (MoCAM) This document will assist in: improving practice in the commissioning and delivery of alcohol treatmentservices developing integrated local treatment ‘systems', through the tiered frameworkof provision improving the effectiveness of screening and assessment improving care planning in structured treatment developing integrated care pathways (‘alcohol treatment pathways') meeting national quality standards by providing key quality criteria forthe commissioning and provision of services for alcohol misusers identifying appropriate interventions and specific treatment options thatcould be commissioned to meet local need.
The approach described in this document is consistent with, and supported by,the Department of Health guidance Alcohol misuse interventions: guidance ondeveloping a local programme of improvement (2005).5 MoCAM should also beread alongside the linked National Treatment Agency for Substance Misuseguidance documents Review of the effectiveness of treatment for alcoholproblems (2006),1 and Alcohol treatment pathways (2006),6 both of which areaimed at supporting effective interventions at a local level.
1 Setting the scene
Purpose of Models of care for alcohol misusers
Models of care for alcohol misusers (MoCAM) provides best practice guidancefor commissioning and providing interventions and treatment for adults affectedby alcohol misuse. It has been developed by the National Treatment Agency forSubstance Misuse (NTA), with support from the Department of Health (DH).
MoCAM is explicitly identified as a significant milestone towards achieving thesecond aim of the Alcohol harm reduction strategy for England,2 ‘to better identifyand treat alcohol misuse', and is a direct commitment in the Choosing Health3White Paper.
The approach described in this document is consistent with, and supported by,the DH guidance Alcohol misuse interventions: guidance on developing a localprogramme of improvement.5 MoCAM should also be read alongside the linkedNTA guidance documents Review of the effectiveness of treatment for alcoholproblems1 and Alcohol treatment pathways,6 both of which are aimed atsupporting effective interventions at a local level.
MoCAM is informed by the document Models of care for the treatment of adultdrug misusers (2002)4 (MoCDM), which had drug treatment as its primary focus,but was acknowledged to be of ‘great relevance' for alcohol service provision.
MoCAM: builds on all the key foundations laid down in MoCDM develops the notion of integrated local treatment ‘systems', the tieredframework of provision, effective use of screening and assessment, a centralrole of care planning in structured treatment and the development of integratedcare pathways to enhance pathways of care (‘alcohol treatment pathways') describes key quality criteria for the commissioning and provision of servicesfor alcohol misusers describes the interventions and specific treatment options that could becommissioned for people affected by alcohol misuse integrates the evidence base on interventions for hazardous and harmfulconsumption with that for dependent drinking to suggest the use of alcoholbrief interventions and a range of treatment options in a system of care.
Models of care for alcohol misusers (MoCAM) MoCAM provides best practice guidance on commissioning alcohol servicesfor local commissioners and therefore will also be relevant to providers ofalcohol treatment. The DH-commissioned report The Alcohol Needs Assessment Research Project7(ANARP) provides useful information on current needs and provision of alcoholtreatment in England. Existing Public Health Observatory work on alcohol-relatedhealth will be supported by regional information from ANARP.7 This cansupplement other local information and may be used by primary care trusts (PCTs)to help determine local numbers of hazardous, harmful and dependent drinkers,and to identify gaps in local provision, which will be of practical valueto commissioning bodies and partnerships. A web-based tool is available atoviding prevalence data and other information fromthe ANARP7 report.
Between 2006 and 2008, DH will support the delivery of ‘trailblazer' projects toexplore the practical applications of screening and brief interventions in varioussettings. The findings of these projects will serve to inform the furtherdevelopment of local systems.
It is expected that MoCAM will be used by PCTs working in partnership with localcommissioning groups and local service providers. The purpose will be to developand build integrated systems to meet the needs of local people whose alcoholmisuse is harmful and requires intervention or treatment, benefiting them, theirfamilies and communities. This process should be informed by service user input.
The DH guidance document Alcohol misuse interventions: guidance ondeveloping a local programme of improvement 5 is also key to the implementationof MoCAM. The guidance is aimed at senior decision-makers and commissionerswithin local health organisations, local authorities and other stakeholders seekingto work with the NHS to tackle alcohol misuse. It provides guidance on developingand implementing programmes to improve the care of hazardous, harmful anddependent drinkers. It describes both the policy context and the evidence on theharm caused by alcohol misuse to individuals, families and communities, and it setsout practical steps to improve local arrangements for commissioning, monitoringand delivering alcohol interventions.
The harms caused by hazardous, harmful and dependent drinking are associatedwith many other problems to individuals and society, such as inequalities inlife expectancy, cancer, stroke and coronary heart disease, many of which arethemselves areas of high priority to local communities and commissioners of care.
Setting the scene Local organisations may wish to consider the contribution that alcohol treatmentcan make to achieve improvements in these areas, and to any related localtargets. For a more detailed analysis of the wider potential benefits to bederived from effective alcohol interventions and treatment, see Alcohol misuseinterventions: guidance on developing a local programme of improvement,5particularly Annexes A and B.
The basis for policy on reducing alcohol-related harm and
encouraging sensible drinking
Around 90 per cent of adults consume alcohol and the majority do not experienceproblems. The ONS general household survey8 identified that over three-quartersof the adult population in England are either non-drinkers (4.7 million people)or drink less than the Government's previously recommended weekly guidelines(26.3 million people). ANARP7 found that 23 per cent of the population (aged 16–64) drink hazardouslyor harmfully, which equates to approximately 7.1 million people in England.
A further 1.1 million people in England are dependent on alcohol. The Prime Minister's Strategy Unit's Interim analytical report9 identified differenttypes of harm associated with alcohol misuse and estimated the annual costs ofthese harms to be in excess of £15 billion. The Alcohol harm reduction strategy for England2 draws together a range ofgovernment interventions – to prevent, minimise and manage alcohol-relatedharm – into a single strategy. It sets out the Government's four aims for reducingalcohol-related harm: improved and better-targeted education and communication better identification and treatment of alcohol problems better co-ordination and enforcement of existing powers against crimeand disorder encouraging the industry to continue promoting responsible drinking. Building on the Alcohol harm reduction strategy for England,2 the ChoosingHealth White Paper delivery plan outlined the key steps that will support the DHcommitments to reduce alcohol-related harm and encourage sensible drinking setout in Choosing Health: Making healthy choices easier.3 Models of care for alcohol misusers (MoCAM) Types of alcohol misuse and links with interventions required
There is no single concise way of categorising individuals in need of alcoholtreatment. The extent to which individuals would benefit from interventionsdepends on a number of factors. Key factors include: the level of consumption the context in which alcohol is used the seriousness of the alcohol-related problems the severity of the dependence on alcohol.
MoCAM identifies four main categories of alcohol misusers who may benefitfrom some kind of intervention or treatment: hazardous drinkers; harmful drinkers;moderately dependent drinkers and severely dependent drinkers. Thecategorisation should be seen as a conceptual framework to assist commissionersin planning for a full range of services for a local area. Individual drinkers maymove in and out of different categories over the course of a lifetime.
It is important to understand that there can be no precise mapping of categoriesof drinkers to the level and tier of provision required. This is because a numberof other factors are taken into account in determining such decisions for eachindividual. However, the use of these categories enables broad mapping acrosslevels of need and against the range of provision required for any area, and assistsin conceptualising the range of provision that needs to be commissioned.
The majority of the adult population of England are either non-drinkers (12 percent), or are low-risk drinkers who drink within the DH's sensible drinkingguidelines and hence are at low risk of harmful effects (67.1 per cent). Thesepeople are not considered to be alcohol misusers, although a proportion in eachgroup will have previously had alcohol problems and may still need somecontinuing support and intervention.
ANARP7 found 32 per cent of men and 15 per cent of women (age 16–64) drinkat hazardous or harmful levels (23 per cent overall), equating to approximately7.1 million people in England.
Six per cent of men and two per cent of women (approximately 1.1 million peoplein England) are dependent drinkers. Twenty-one per cent of men and nine per cent of women are binge drinkers. Setting the scene The World Health Organization (WHO) defines hazardous use of a psychoactivesubstance, such as alcohol, as ‘a pattern of substance use that increases the riskof harmful consequences for the user… In contrast to harmful use, hazardous userefers to patterns of use that are of public health significance despite the absenceof any current disorder in the individual user.'10 Hazardous drinkers are drinking at levels over the sensible drinking limits, either interms of regular excessive consumption or less frequent sessions of heavy drinking.
However, they have so far avoided significant alcohol-related problems. Despitethis, hazardous drinkers, if identified, may benefit from brief advice about theiralcohol use. The WHO International Classification of Diseases (ICD-10)11 defines harmful useof a psychoactive substance, such as alcohol, as ‘a pattern of use which is alreadycausing damage to health. The damage may be physical or mental.' This definitiondoes not include those with alcohol dependence. Harmful drinkers are usually drinking at levels above those recommended forsensible drinking, typically at higher levels than most hazardous drinkers. Unlikehazardous drinkers, harmful drinkers show clear evidence of some alcohol-relatedharm. Many harmful drinkers may not have understood the link between theirdrinking and the range of problems they may be experiencing.
Identification of and intervention for hazardous and harmful drinkers
Simple and reliable instruments, such as the alcohol use disorders identificationtest (AUDIT) and derivatives such as the fast alcohol screening test (FAST) tool(see Review of the effectiveness of alcohol treatment1), can be used to identifyhazardous and harmful drinkers and provide an indication of the likely extent andseverity of their alcohol-related problems. As these drinkers do not have significantevidence of alcohol dependence, advice and brief interventions are often suitableto meet the needs of both these groups.
Dependent drinkers and drinkers with complex problems
Dependence is essentially characterised by behaviours previously described as‘psychological dependence', with an increased drive to use alcohol and difficultycontrolling its use, despite negative consequences. More severe dependence isusually associated with physical withdrawal upon cessation, but this is not essentialto the diagnosis of less severe cases. Models of care for alcohol misusers (MoCAM) The main groups of alcohol users who clearly may benefit from specialistalcohol treatment are those who are moderately and severely dependent. Thiscategorisation into those with moderate and those with severe dependence issupported in the NTA Review of the effectiveness of treatment for alcoholproblems1 as a pragmatic classification. The review suggests that, for treatmentplanning purposes, the most useful categorisation is into ‘moderate dependence'and into ‘severe dependence/dependence with complex needs'. This is becausethe latter ‘severe and complex' group is likely to require a higher level ofintervention at the outset than those with moderate dependence. The actuallevel of intervention to be provided initially, or subsequently, in individual casescan only be determined following comprehensive assessment, but broadly this issuggested as a valuable pragmatic categorisation.
Moderately dependent drinkers
Moderately dependent drinkers may recognise that they have a problem withdrinking, even if this recognition has only come about reluctantly throughpressure, for example from family members or employers. The level of dependence of drinkers in this category is not severe. For example,they may not have reached the stage of ‘relief drinking' – which is drinking torelieve or avoid physical discomfort from withdrawal symptoms. This is a verybroad category and includes a wide range of severities and types of problem.
Nevertheless, in older terminology, drinkers in this category would probably nothave been described as ‘chronic alcoholics'. Moderately dependent drinkers'treatment can often be managed effectively in community settings, includingmedically assisted alcohol withdrawal in the community. The choice of settingin each individual circumstance will depend on the range of accompanyingphysical, psychological or social problems, including risks posed to the drinkerand risks to others from the drinker's behaviour. Some in this category willbe identified as needing interventions more typically provided to severe orcomplex dependent drinkers.
Severely dependent drinkers
People in this category may have serious and long-standing problems. Thiscategory includes individuals described in older terminology as ‘chronic alcoholics'. Typically, they have experienced significant alcohol withdrawal and may haveformed the habit of drinking to stop withdrawal symptoms. They may haveprogressed to habitual significant daily alcohol use or heavy use over prolongedperiods or bouts of drinking.
Setting the scene Given adequate risk assessment and a comprehensive and intensive care plan,medically assisted alcohol withdrawal can safely be provided to many severelydependent drinkers in the home or in community settings. However, more drinkersin this category may be in need of inpatient assisted alcohol withdrawal andresidential rehabilitation. Some may have special needs, such as treatment for co-existing psychiatric problems, polydrug dependence or complicated assistedalcohol withdrawal; others may need rehabilitation and strategies to address thelevel of their dependence, or to address other issues, such as homelessness orsocial dislocation. Some may have had multiple previous episodes of treatment.
Some will respond to community interventions more typically successful whenprovided to moderately dependent drinkers.
Drinkers with complex problems
Those with additional and co-existing problems, including people with mentalhealth problems, people with learning disabilities, some older people, and somewith social and housing problems, may be particularly vulnerable. They may havecomplex needs that require more intensive or prolonged interventions, even atlower levels of alcohol use and dependence. Complex problems may also includedifficulties that have significant impact on others, such as domestic abuse, whetheras victim or perpetrator.
Personal characteristics and patient choice
The personal characteristics of alcohol misusers, their social circumstances andindividual preferences influence decisions about the nature, timing and placeof treatment.
Patient choice is a key theme in the DH's Standards for better health12 and it isimportant that individuals' preferences, guided by the professionals, are taken intoaccount when developing their care plans. This is not merely because it is theirentitlement; it is also because a treatment approach has a greater chance of asuccessful outcome if it has been selected and committed to by the individual.
When commissioning alcohol treatment systems, it is important to recognise thediverse requirements of a local population. Black and minority ethnic populationgroups may require approaches that are sensitive to cultural or religious attitudesto alcohol, or that can be provided in a range of settings including the home.
Alcohol-misusing parents may be simultaneously concerned at the impact ofalcohol on their children and worried they may get into trouble for being ‘poorparents' – even if their parenting is adequate. Those living in rural areas maybenefit from domiciliary appointments or help with transport. Alcohol-misusing Models of care for alcohol misusers (MoCAM) offenders may benefit from a variety of assessments, referrals or treatments incustodial or community settings, where appropriate. Whatever an individual'scircumstances, a local system of alcohol intervention and treatment should seekto maximise engagement with those in need and ensure that provision is asappropriate as possible, to meet a range of diverse needs. Alcohol treatmentinterventions should always be designed to meet needs and reduce risk, both tothe individual drinker and to others affected by their drinking, including partners,children, family and the wider community. 1.3.10 Co-existing health conditions or drug misuse problems
If an individual has other physical or mental health conditions or drug problems, inaddition to requiring alcohol intervention or treatment, these issues can be crucialin deciding on appropriate alcohol treatment and treatment goals. For example: A quarter to one-third of drug misusers also misuse alcohol. The NationalTreatment Outcome Research Study13 (NTORS) found that drug treatmentservices were having little or no impact on drug service users' drinkingbehaviour, despite half having identified alcohol problems. These individualsshould be offered treatment for both drug and alcohol misuse. Drug users intreatment should have their alcohol use and treatment needs routinely andcontinually assessed, and it is good practice for drug users in treatment to havetheir alcohol problems treated in the same setting where possible. Referrals tospecialist alcohol treatment, and guidance from specialist alcohol workers,should be a routine feature in the treatment and care of drug misusers. Wheredrug misusers are already attending a combined drug and alcohol treatmentservice, where external referral may not be needed, it is vital that themanagement of alcohol misuse is clearly identified for action as part of theservice user's formal care plan. In addition, just over 40 per cent of drugmisusers in drug treatment in 2004 were hepatitis C virus infection positive.
Alcohol use and misuse is the single biggest contributory factor to those withhepatitis C virus infection developing fatal liver disease. These individuals andothers suffering from liver disease, or other medical conditions exacerbated byalcohol, should all receive alcohol interventions or treatment.
Pregnant women and those who are trying to become pregnant should beinformed of the current advice on alcohol and its effects on conception andduring pregnancy. This includes advice that if they do drink, they should notget drunk and should not consume more than one or two units once or twiceper week during pregnancy. Women who are dependent on alcohol and arepregnant, or currently trying to become pregnant, should receive immediatetreatment for their alcohol problems.
Setting the scene Some alcohol misusers may also have co-existing mental health needs. The DHdocument Dual diagnosis good practice guide14 provides guidance on effectiveapproaches to the commissioning and provision of treatment for those withsubstance misuse and severe mental illness. The importance of all aspects of physical health for people with severe mentalillness is recognised in Choosing Health.3 This states that people with poor mentalhealth tend to experience worse physical health, but that a healthier lifestyle willhelp improve mental health, mood and well-being. As such, local treatmentsystems should work together to avoid alcohol misuse being addressed in isolationfrom other physical and mental health issues.
2 A commissioning
framework to deliver
alcohol treatment systems
Commissioning alcohol screening and brief interventions
and treatment: a PCT responsibility
As part of NHS provision, commissioning alcohol interventions and treatment isthe responsibility of local Primary Care Trusts (PCTs). The following section focuseson the principles of commissioning a local system for alcohol treatment and itscomponent parts, including a four-tiered framework of provision (see 2.2 onpage 19) and local systems of screening and assessment. This section outlinesthe processes that should ideally be followed to meet best practice in thecommissioning of alcohol treatment systems. In line with the more devolved planning and performance system for healthand social care set out in National standards, local action: Health and social carestandards and planning framework 2005/06–2007/08,15 PCTs can set local targetsin response to local needs and priorities without prescriptive guidance from theDepartment of Health (DH) or strategic health authorities (SHAs). The system doesset out a framework of principles for developing local plans and target-setting,asking PCTs to ensure that their plans: are in line with population needs address local service gaps are evidence-based are developed in partnership with other NHS bodies, local authoritiesand other partners offer value for money.
Alcohol misuse interventions: guidance on developing a local programme ofimprovement 5 suggests practical steps that PCTs can take, using the aboveframework to improve the identification and treatment of individuals whosedrinking is potentially hazardous, is causing harm to themselves or others, orhas led to dependence on alcohol. A commissioning framework to deliver alcohol treatment systems MoCAM provides in-depth guidance to local organisations
commissioning alcohol misuse interventions
Models of care for the treatment of adult drug misusers (MoCDM)4 outlinedthe four-tiered framework of provision for commissioning drugs (and alcohol)treatment, providing a conceptual framework to aid rational and evidence-basedcommissioning in England. That framework has been maintained but developedin this document and made specific for the provision of alcohol interventions. The MoCDM (2002)4 framework enabled a better description of provisionof treatment. However, the tiers were a conceptual framework and were notintended to be a rigid blueprint for provision. They have been interpreted ratherrigidly at times, with some unintended consequences which need to be rectified.
It is important to note that the tiers refer to the level of the interventions providedand do not refer to the provider organisations (for example referring to a ‘Tier 3agency' is not correct, as such an agency will often need to provide Tier 2interventions alongside Tier 3 interventions).
In line with MoCDM update 2006,16 Tier 1 interventions are not the genericservices themselves (for example housing, social services). Rather, Tier 1 consists ofa range of interventions that can be provided by generic providers, depending ontheir competence and partnership arrangements with specialised alcohol services.
Given this change in emphasis, interventions that were previously described inMoCDM (2002)4 as Tier 4b (for example care provided by inpatient hepatologyunits) are redesignated to Tier 1.
Commissioners need to ensure that all tiers of interventions are commissionedto form a local alcohol treatment system to meet local population needs. Localsystems should allow for some flexibility in how interventions are provided, withthe crucial factors being the pattern of local need and whether a service provideris competent to provide a particular treatment intervention.
Models of care for alcohol misusers (MoCAM) The four tiers of interventions
The following tables suggest what should be commissioned in local alcoholtreatment systems.
Tier 1 interventions: alcohol-related information and advice; screening; simple brief
interventions; and referral
Tier 1 interventions include provision of: identification of hazardous, harmfuland dependent drinkers; information on sensible drinking; simple briefinterventions to reduce alcohol-related harm; and referral of those withalcohol dependence or harm for more intensive interventions.
Commissioners need to ensure that a range of generic services provide asa minimum the following Tier 1 alcohol interventions:• alcohol advice and information• targeted screening and assessment for those drinking in excess of DH guidelines on sensible drinking and for those who may needalcohol treatment • provision of simple brief interventions for hazardous and harmful drinkers• referral of those requiring more than simple brief interventions for specialised alcohol treatment • partnership or ‘shared care' with specialised alcohol treatment services, e.g. to provide specific alcohol treatment interventions within the contextof their generic services.
Tier 1 interventions can be delivered by a very wide range of agencies andin a range of settings, the main focus of which is not alcohol treatment. Forexample: primary healthcare services; acute hospitals, e.g. A&E departments;psychiatric services; social services departments; homelessness services;antenatal clinics; general hospital wards; police settings, e.g. custody cells;probation services; the prison service; education and vocational services;and occupational health services.
Such interventions can also be provided in highly specialist non-alcohol-specific residential or inpatient services, which have service users with highlevels of alcohol-related morbidity who may require care plans and support tofacilitate their access to alcohol-specific provision. Examples include: specialistliver disease units, specialist psychiatric wards, forensic units, residentialprovision for the homeless, and domestic abuse services.
This is provision that depends on at least minimal skills in alcohol misuseidentification, assessment and interventions. Those delivering Tier 1 provisionmay require the following competences from the Drugs and Alcohol NationalOccupational Standards (DANOS):17• AA1 Recognise indications of substance misuse and refer individuals • AF1 Carry out screening and referral assessment• AH10 Carry out brief interventions with alcohol users• AB2 Support individuals who are substance misusers• AB5 Assess and act upon immediate risk of danger to substance misusers.
A commissioning framework to deliver alcohol treatment systems Tier 2 interventions: open access, non-care-planned, alcohol-specific interventions
Tier 2 interventions include provision of open access facilities and outreachthat provide: alcohol-specific advice, information and support; extendedbrief interventions to help alcohol misusers reduce alcohol-related harm;and assessment and referral of those with more serious alcohol-relatedproblems for care-planned treatment.
Tier 2 interventions include open access facilities and outreach targetingalcohol misusers, which provide:• alcohol-specific information, advice and support • extended brief interventions and brief treatment to reduce alcohol-related • alcohol-specific assessment and referral of those requiring more structured alcohol treatment • partnership or ‘shared care' with staff from Tier 3 and Tier 4 provision, or joint care of individuals attending other services providing Tier 1interventions • mutual aid groups, e.g. Alcoholics Anonymous • triage assessment, which may be provided as part of locally agreed Settings
Tier 2 provision may be delivered by the following agencies, if they havethe necessary competence, and in the following settings: specialist alcoholservices; primary healthcare services; acute hospitals, e.g. A&E and liver units;psychiatric services; social services; domestic abuse agencies; homelessnessservices; antenatal clinics; probation services; the prison service; andoccupational health services.
Tier 2 interventions require competent alcohol workers who should havebasic competences in line with DANOS,17 including those required for Tier 1.
Competency can also depend on what cluster of services is provided.
Front-line staff would normally have competence in motivational approachesand brief interventions. Those providing interventions at Tier 2 may require the followingcompetences from DANOS:17• AB2 Support individuals who are substance users• AB5 Assess and act upon immediate risk of danger to substance users• AF2 Carry out assessment to identify and prioritise needs• AG1 Plan and agree service responses which meet individuals' identified needs • AH10 Carry out brief interventions with alcohol users.
Models of care for alcohol misusers (MoCAM) Tier 3 interventions: community-based, structured, care-planned alcohol treatment
Tier 3 interventions include provision of community-based specialised alcoholmisuse assessment, and alcohol treatment that is care co-ordinated andcare-planned. Tier 3 interventions include:• comprehensive substance misuse assessment• care planning and review for all those in structured treatment, often with regular keyworking sessions as standard practice • community care assessment and case management of alcohol misusers• a range of evidence-based prescribing interventions, in the context of a package of care, including community-based medically assisted alcohol withdrawal(detoxification) and prescribing interventions to reduce risk of relapse • a range of structured evidence-based psychosocial therapies and support within a care plan to address alcohol misuse and to address co-existingconditions, such as depression and anxiety, when appropriate • structured day programmes and care-planned day care (e.g. interventions targeting specific groups) • liaison services, e.g. for acute medical and psychiatric health services (such as pregnancy, mental health or hepatitis services) and social careservices (such as child care and housing services and other generic servicesas appropriate).
Tier 3 interventions are normally delivered in specialised alcohol treatmentservices with their own premises in the community (or sometimes on hospitalsites). Other delivery may be by outreach (peripatetic work in generic servicesor other agencies, or domiciliary or home visits). Tier 3 interventions may bedelivered alongside Tier 2 interventions.
Some of the Tier 3 work is based in primary care settings (shared careschemes and GP-led prescribing services), but alcohol specialist-led servicesare required within the local systems for the provision of care for severe orcomplex needs and to support primary care.
The work in community settings can be delivered by statutory, voluntary orindependent services providing care-planned, structured alcohol treatment.
Tier 3 services require competent drug and alcohol specialised practitionerswho should have competences in line with DANOS.17 The range ofcompetences required will depend on job specifications and remits. Those delivering Tier 3 interventions may require a wide range ofcompetences from Key Area A in DANOS17 and many of the competencesfrom Area AH, depending on the type of alcohol treatment provided.
Medical staff (usually addiction psychiatrists and GPs) will require differentlevels of competence, depending on their role in alcohol treatment systemsand the needs of the service user, with each local system requiring a range ofdoctor competences (from specialist to generalist) in line with joint guidancefrom the Royal Colleges of General Practitioners and Psychiatrists, Roles andresponsibilities of doctors in the provision of treatment for drug and alcoholmisusers,18 summarised in the National Treatment Agency for SubstanceMisuse briefing document Roles and responsibilities of doctors in theprovision of treatment for drug and alcohol misusers.19 A commissioning framework to deliver alcohol treatment systems Tier 4 interventions: alcohol specialist inpatient treatment and residential rehabilitation
Tier 4 interventions include provision of residential, specialised alcoholtreatments which are care-planned and co-ordinated to ensure continuity ofcare and aftercare.
Tier 4 interventions include:• comprehensive substance misuse assessment, including complex cases • care planning and review for all inpatient and residential structured • a range of evidence-based prescribing interventions, in the context of a package of care, including medically assisted alcohol withdrawal(detoxification) in inpatient or residential care and prescribing interventionsto reduce risk of relapse • a range of structured evidence-based psychosocial therapies and support to address alcohol misuse • provision of information, advice and training and ‘shared care' to others delivering Tier 1 and Tier 2 and support for Tier 3 services as appropriate.
Specialised statutory, independent or voluntary sector inpatient facilitiesfor medically assisted alcohol withdrawal (detoxification), stabilisation andassessment of complex cases.
Residential rehabilitation units for alcohol misuse.
Dedicated specialised inpatient alcohol units are ideal for inpatient alcoholassessment, medically assisted alcohol withdrawal (detoxification) andstabilisation. Inpatient provision in the context of general psychiatric wardsmay only be ideal for some patients with co-morbid severe mental illness, butmany such patients might benefit from a dedicated addiction specialistinpatient unit.
Those with complex alcohol and other needs requiring inpatient interventionsmay require hospitalisation for their other needs (e.g. pregnancy, liverproblems) and this may be best provided for in the context of those hospitalservices (with specialised alcohol liaison support).
Inpatient and residential interventions providing medically assisted alcoholwithdrawal (detoxification) and specialist assessment and stabilisation wouldnormally require medical staff with specialist competence in substance misuse(rather than generalist GPs). The level of specialised medical staff competencerequired will depend on the types of service provided and the severity of theservice users' problems. Addiction specialist competences will be needed for inpatient units for severeand complex problems. Suitably competent GPs can provide support to someunits for patients with less complex needs. Staff in residential rehabilitationunits that are registered care homes will need to meet relevant social carenational occupational standards. Hospital-based services will also be requiredto meet practitioner standards for independent or NHS hospitals.
Those delivering Tier 4 interventions may require a wide range of competencesfrom Key Area A in DANOS,17 and in particular many of the competences fromArea AH ‘Deliver healthcare services, depending on the alcohol treatmentprovided'. All staff working in all residential settings are advised to demonstratecompetence against DANOS17 at both manager and practitioner levels.
Models of care for alcohol misusers (MoCAM) Commissioning a local system of screening and assessment
Local commissioners should work with local providers to develop local systems ofscreening and assessment. Assessment is a process by which to establish the nature and extent of alcohol(and any drug) misuse, what level of need an individual may have and whatinterventions are required. Assessment varies in its depth and level of detail,depending on the purpose and anticipated outcome of the assessment process.
MoCDM (2002)4 identified three levels of assessment: screening, triage andcomprehensive assessment. These are reiterated here and described as theyapply to assessment for alcohol problems.
Screening assessment is a brief process that aims to establish: whether anindividual has an alcohol problem (hazardous, harmful or dependent use); thepresence of related or co-existent problems (including any drug misuse); andwhether there is any immediate risk for the service user. Screening assessment mayincorporate or be followed by a brief intervention. The assessment should identifythose who require referral to alcohol treatment services and the urgency of thereferral. Screening is likely to be carried out in generic settings.
Triage assessment usually takes place when an individual first contacts specialistalcohol treatment services. The aim of this assessment is to determine theseriousness and urgency of a service user's problems and the most appropriatetype of intervention. It involves a fuller assessment of the individual's alcoholproblems than is conducted at screening, as well as assessment of a serviceuser's motivation to engage in treatment, current risk factors and the urgencyof need to access treatment. Following triage assessment, a service user mightbe offered services within the assessing agency or onward referral to anotherservice. A further outcome of triage assessment is that, where appropriate, workis undertaken to further engage and prepare the service user for treatment.
Initial care plan
Following triage-level assessment, it may be good practice in some cases toproduce an initial care plan for service users, particularly for clients who areidentified as being at high risk, who may have complex alcohol-related problemsor who are likely to be hard to engage.
A commissioning framework to deliver alcohol treatment systems The initial care plan could be used to facilitate a focus on a service user'sengagement in the treatment system, to ensure their immediate needs are met,particularly if relating to a high risk, to build a therapeutic alliance and to ensureappropriate interim support if they are waiting to undergo comprehensiveassessment. Such an initial care plan, if used in such cases, would be set at Tier 2 interventions level.
Comprehensive assessment is targeted at problem alcohol users with morecomplex needs and those who may require structured alcohol treatmentinterventions. The assessment aims to determine the exact nature of the serviceuser's alcohol and other substance misuse problems, and co-existing problems,including with health (mental and physical), social functioning, offending and legalproblems. A full risk assessment will also be conducted. Comprehensive assessmentmay be conducted by one or more members of a multidisciplinary team, becausedifferent competences may be necessary to assess different areas of service userneed (for example a doctor or an independent nurse prescriber for particularprescribing interventions or a psychologist to conduct specialist assessment).
Comprehensive assessment can be seen as an ongoing process rather than a singleevent. Comprehensive assessment will be carried out with a service user who may: require structured and/or intensive intervention have significant psychiatric and/or physical co-morbidity have a significant level of risk of harm to self or others be in contact with multiple service providers have a history of disengagement from alcohol treatment services be pregnant or have children ‘at risk'.
Comprehensive assessment provides information that will contribute to thedevelopment of a care plan for a service user.
The levels of assessment reflect different levels of complexity and expertiserequired to carry out screening and assessment at each stage. Validated alcoholmisuse screening and assessment tools are available, which may already be usedby local services and can usefully be integrated into locally agreed assessmentprocedures across agencies, as appropriate. Agreement on common ‘standards'of screening, assessment and recording, based on the three ‘Models of care'levels, is important in developing an integrated system of care in any area.
Models of care for alcohol misusers (MoCAM) It is important to recognise that differences may be appropriate in the use ofspecific tools and recording forms in particular services and settings and fordifferent levels of specialism, while sustaining the advantages of commonlyagreed standards of monitoring.
Assessing risk is an integral element in screening, triage assessment andcomprehensive assessment. It provides information that will inform the careplanning process. Risk assessment should include alcohol problems, as well asreflecting broader risks to the individual, to others and to the wider society.
Risk assessment aims to identify whether the individual has, or has had at somepoint in the past, certain experiences or displayed certain behaviours that mightlead to harm themselves or others. The main areas of risk requiring assessmentinclude: risks associated with alcohol use or other substance use (such as physicaldamage, alcohol poisoning) risk of self-harm or suicide risk of harm to others (including risks of harm to children and other domesticviolence, harm to treatment staff and risks of driving while intoxicated) risk of harm from others (including being a victim of domestic abuse) risk of self-neglect.
When risks are identified, risk management plans need to be developed andimplemented to mitigate immediate risk. As with comprehensive assessment, riskassessment is a continuing process and requires integration into care planning.
Issues of risk highlight the need for appropriate information-sharing protocolsbetween services and the need for cross-agency policies and plans, and for claritywith service users about the limits of confidentiality. If a service has concerns aboutthe needs and safety of children of alcohol misusers, local protocols should befollowed. For example if there are concerns about risk of significant harms,social services would normally be involved in further assessment of risk.
Local commissioners can usefully require local providers to: use clear and standardised screening procedures across all relevant agencies use clear assessment processes and standardised procedures to ensureadequate recording of triage or comprehensive assessment information A commissioning framework to deliver alcohol treatment systems use agreed assessment tools or recording forms, but only as appropriate forthe particular setting or degree of specialism involved ensure adequate sharing of appropriate information between services in analcohol treatment system, to minimise multiple assessment without action develop clear criteria for referral and eligibility for entry into each point of thealcohol treatment system develop protocols for joint and collaborative working between alcoholspecialist treatment services and other agencies, where regular shared careand concurrent work is anticipated and required contribute to a locally commissioned directory of alcohol interventions andtreatment, which is regularly updated and disseminated widely provide adequate training to staff carrying out screening and assessment. A stepped care model to assist commissioning
Some service users may want to achieve a reduction in alcohol consumption towithin sensible limits; some may want to abstain from drinking; others may notwant to change their drinking patterns. It is important that local alcohol treatmentsystems are commissioned to meet a range of goals and that alcohol misusers arenot excluded from all types of support, interventions or treatment if they decline tochange their drinking or choose to pursue a goal of continued, moderated drinking. Local treatment systems should provide alcohol interventions and treatments thatmeet a range of treatment goals. Brief intervention and the range of treatmentsfor alcohol misuse should seek to achieve a reduction in alcohol-related harm andimprovements in health and social functioning. This would normally include areduction in alcohol consumption or changes in patterns of alcohol consumptionthat contribute to harm, or a significant risk of harm, to the service user or riskto others, particularly partners and family members. Abstinence will be thepreferred goal for many problem drinkers with moderate to severe levels of alcoholdependence, particularly for individuals whose organs have already been severelydamaged through alcohol use, and perhaps for those who have previouslyattempted to moderate their drinking without success. Moderation, or controlleddrinking, is often a more acceptable goal for problem drinkers with low to moderatelevels of alcohol dependence. Moderation can also be used as a goal with problemdrinkers for whom abstinence would usually be advisable, but for whom this goal isnot currently acceptable. A reduction in alcohol consumption will be likely to conferbenefits and may offer a stepping-stone to abstinence in the future. Models of care for alcohol misusers (MoCAM) Housing and hostel provision for homeless alcohol misusers may need to beconsidered in tandem with developing local systems for alcohol treatment andbrief interventions. This provision is not normally within the direct remit ofhealthcare commissioners, although there is scope for them to influence housingproviders through participation in local strategic partnerships. Best practiceexamples involve joint commissioning mechanisms, to ensure local systemsmeet alcohol misusers' healthcare and housing needs. MoCAM advocates a stepped model of care. In practice there are two maincomponents to the stepped care model for alcohol misusers which are, broadly: provision of brief interventions for those drinking excessively but not requiringtreatment for alcohol dependence provision of treatment interventions for those with moderate or severedependence and related problems.
Hazardous and harmful drinkers without complex needs are offered simple,structured advice to encourage reduced consumption of alcohol to sensible or lessrisky levels. If simple or minimal intervention does not succeed, they may be offeredan extended brief intervention by a suitably competent practitioner. A small numbermay also be reassessed as actually needing treatment for alcohol dependence(where it was not initially identified) and would enter the part of the stepped caremodel below for those needing treatment for dependence and related problems.
In other circumstances, particular needs may be identified in relation to alcoholuse, for example domestic abuse, where more complex, co-ordinated interventionsare indicated. Therefore, care is stepped up only as required.
Moderately and severely dependent drinkers will require more specialisedtreatment for their alcohol dependence. A proportion of this group will also needtreatment for physical dependence. The stepped care model suggests that newentrants for such treatment should be assessed, and initially receive the leastintensive or least prolonged intervention considered suitable for the level of needand complexity identified. If response to such a limited initial intervention isinadequate, a more intensive or prolonged package of care may be needed.
It is important to recognise that the stepped care model is not rigid, so thoseservice users identified at the outset as being unlikely to respond to a less intensiveintervention, including for example some moderately dependent drinkers who haveadditional problems or who are already known to services and have previously beentreated and relapsed, may require the more intensive or prolonged interventionfrom the outset.
A commissioning framework to deliver alcohol treatment systems For commissioning purposes, flexibility in applying the stepped care concept isimportant in ensuring a range of suitable alcohol misuse provision for the serviceuser and effective and cost-effective use of resources.
Commissioners are therefore advised that, when planning local treatment systems: an estimate is made of the numbers of people by type of alcohol misuser, andlikely demand is calculated (the Alcohol Needs Assessment Research Project(ANARP)7 ocess) alcohol interventions and treatment services are commissioned on the principlethat certain types of interventions or treatments are the most successful andmost cost-effective with different types of alcohol misusers there is flexibility in application of this model, as there is no intervention thatshould always be applied for a particular type of alcohol misuse. Decisions onindividuals will take into account a wider assessment of need, including theneeds of others affected and the availability of appropriate provision.
Thus, commissioners are advised to ensure provision of: targeted and opportunistic screening systems and simple brief interventions
for hazardous and harmful drinkers. These will, by definition, be routinely
provided in non-alcohol-specialist settings. While most such cases will only
require information, simple advice and follow-up (i.e. more minimal brief
interventions), some may need more extended brief interventions to assist
them in making reductions in their excessive, but non-dependent drinking.
This more extensive brief intervention and follow-up may be offered in
non-alcohol-specialist settings, where the staff have the requisite levels of
competence. Such staff could be employed within the agency to undertake
these specific duties or may be employed by specialist alcohol treatment
agencies in a liaison role
assessment and appropriately co-ordinated care-planned treatment for
moderately dependent drinkers and for severely dependent drinkers or
those with complex problems associated with their alcohol use. This may
be provided within specialist substance misuse services or within non-alcohol-
specialist settings by practitioners with the necessary expertise and resources
for treating alcohol misusers to meet locally identified needs. Most moderately
dependent drinkers will require less intensive interventions, and higher levels
of co-ordination of multidisciplinary or specialist care will be required for those
with more severe or complex needs.
Models of care for alcohol misusers (MoCAM) Planning for multiple alcohol treatment episodes
While many hazardous drinkers are able to modify their drinking behaviour inresponse to brief interventions, alcohol dependence is recognised particularly tobe a commonly recurring condition. Individuals may require a number of episodesof treatment before they reach their goals, which in relation to their drinkingbehaviour are likely to be either lower-risk drinking or abstinence. Some more‘entrenched' or recurrent alcohol misusers with severe dependence, and whomay have other problems, may not reach their drinking goals or other goals ina particular episode of care. Treatment interventions may, in some cases, need tobe carried out over extended periods, or individuals may benefit from multipletreatment episodes. Research indicates that there is a positive cumulative effectof a series of alcohol treatment episodes, even if this is not immediately apparent.
The Review of the effectiveness of treatment for alcohol problems1 indicates thatcareful assessment and strategies to optimise the success of medically assistedwithdrawal treatment should routinely be adopted. Commissioners should ensure local treatment systems are able to respond tosevere and recurrent cases, ensuring that drinkers can, when appropriate, accessalcohol treatment on multiple occasions, together with appropriate concurrentinterventions from other services. This would include support from groups such asAlcoholics Anonymous (AA) or other available mutual support services (which mayneed to be commissioned to complement existing models such as AA). Commissioning psychosocial and medical prescribing treatment
Structured alcohol treatment interventions, comprising a single intervention or acombination of interventions or therapies delivered in the appropriate sequence,can be effective in helping individuals with alcohol problems either abstain fromdrinking or achieve a return to controlled, less risky drinking and maintain thispattern of behaviour over an extended period of time. For detailed discussion ofthe evidence for psychosocial and prescribing treatment, please refer to theReview of the effectiveness of treatment for alcohol problems,1 which isparticularly relevant for commissioners and service providers. Most treatment for alcohol dependence and alcohol-related problems includes someform of therapy to support the individual's psychological and social development.
The Review of the effectiveness of treatment for alcohol problems1 identifies awide range of treatments shown to be effective in research studies, includingcognitive-behavioural therapy, motivational enhancement therapy, 12-step A commissioning framework to deliver alcohol treatment systems facilitation therapy, coping and social skills training, community reinforcementapproach, social behaviour and network therapy, behavioural self-control training,and cognitive-behavioural marital therapy.
In practice, the delivery of psychosocial therapies is not necessarily discrete.
Different therapies often share common components and, indeed, they are alldesigned to help alcohol misusers change their behaviour in some way. They alsooften help alcohol misusers develop new skills, allowing them to handle high-riskdrinking situations without relapsing in the future.
Commissioners need to ensure the availability of a range of psychosocial therapiesto meet the needs of the local population, including targeted interventions fordiscrete groups, and services competent to respond to specific cultural and genderissues and issues of sexuality.
Brief interventions are effective in a variety of settings, including medical settings,such as primary care and A&E, and in generic non-specialist services. Evidencedemonstrates that properly implemented brief interventions can help hazardousand harmful drinkers and some moderately dependent drinkers. Simple brief interventions are specific brief advisory interviews, often deliveredafter opportunistic screening identifies alcohol as a potential problem.
Simple brief interventions are sometimes referred to as ‘minimal interventions'and are usually provided by a competent practitioner in about five minutes,immediately following a screening assessment or at another ‘teachable moment'.
Simple advice may include: information about the nature and effects of alcohol and its potential for harm personalised feedback on risk and harm emphasis on the individual's personal responsibility for change attempts to increase the patient's confidence in being able to reduce theiralcohol consumption (‘self-efficacy') goal-setting, for example start dates and daily or weekly targets for drinking written self-help material for the individual to take away, containing moredetailed information on consequences of excessive drinking and tips forcutting down (this can be in a variety of media, including electronic, suchas the internet) Models of care for alcohol misusers (MoCAM) signposting individuals to having a wider general health check, where indicated arrangements for follow-up monitoring.
Extended brief interventions comprise a series of structured interviews (betweenthree and twelve) in general or non-alcohol specialist settings. Where appropriatelycompetent and trained staff are not available, such extended brief interventionscould be delivered as part of shared care or partnership working with specialisttreatment providers. The evidence shows that brief interventions are only effectiveif delivered in accordance with the current description of best practice for thatintervention and delivered by a competent practitioner. Brief interventions should be followed up to ensure that service users havebenefited from them and to identify those for whom further, perhaps moreintensive or extended, interventions are required. Elements of training, supervision and follow-up should form an integral part ofcommissioning these brief interventions, as part of a stepped care local alcoholtreatment system.
Motivational enhancement therapy
Motivational enhancement therapy is identified as the best evidenced, mosteffective extended brief intervention and should be regarded as an essentialelement in the local treatment system. Other brief forms of treatment should alsobe considered and commissioned, as appropriate to local need.
Psychosocial treatments for alcohol dependence
A range of more intensive, structured psychosocial treatment interventions will berequired for people with moderate and severe alcohol dependence, for those withrecurrent alcohol problems, for those with complex needs and for those who maybe particularly vulnerable. Commissioners should identify the range of treatmentsto be made available and ensure that arrangements are developed to deliver care-planned structured treatment to meet service users' needs. This will include thedevelopment of integrated care pathways for alcohol problems (‘alcohol treatmentpathways') linked with local protocols for prescribing, when required. A commissioning framework to deliver alcohol treatment systems 2.6.2 Prescribed
Pharmacological therapies are most effective when used as enhancements topsychosocial therapies as part of an integrated programme of care. The Reviewof the effectiveness of treatment for alcohol problems1 identifies three classes ofpharmacotherapy that are effective in the treatment of alcohol misusers: medications for treating patients with withdrawal symptoms during medicallyassisted alcohol withdrawal medications to promote abstinence or prevent relapse, includingsensitising agents nutritional supplements, including vitamin supplements, as a harm reductionmeasure for heavy drinkers and high-dose parenteral thiamin for theprevention and treatment of individuals with Wernicke's encephalopathy.
The availability of appropriate medications will be an essential element inany comprehensive local treatment system. Prescribed medications are not a stand-alone treatment option and are only recommended as part ofcare-planned treatment. Medication for assisted withdrawal from alcohol
In appropriate circumstances, where withdrawal from alcohol is not expected toproduce complications and with the availability of appropriately trained andexperienced staff, some people can safely undergo withdrawal without use ofprescribed medication. Medically assisted withdrawal from alcohol using prescribed medication can oftenbe safely carried out in the home or other community settings, such as daycentres. Only a minority of people will be so vulnerable as to require inpatienthospital treatment. Local assessment and prescribing protocols should be adoptedand commissioners should ensure dissemination to all medical practitioners in allsettings. There is significant research evidence and consensus on the mostappropriate medications to use in managing the side effects of withdrawal fromalcohol and these conventions should be followed.
Typically, the medications of choice will be benzodiazepines, such aschlordiazepoxide or diazepam. In circumstances where service users have ahistory of seizures, alternative medication may be indicated. In every circumstance,medically assisted withdrawal from alcohol should form part of a treatment planthat includes follow-up and strategies to maintain the benefits of the treatment.
Models of care for alcohol misusers (MoCAM) There is some evidence that multiple episodes of assisted withdrawal can beassociated with increased harmful outcomes – therefore it is important that thistreatment is not used as a stand-alone treatment.
Medication to support relapse prevention
Sensitising medication such as Antabuse® (disulfiram), which causes an unpleasantreaction when alcohol is used, can support abstinence, but only when serviceusers have continuing support from professionals, and from their families orsocial networks.
Medications have been developed which are claimed to reduce the craving foralcohol. The evidence is that such medications should only be prescribed alongsidecontinuing psychosocial treatment and are not appropriate as stand-aloneinterventions. In general, sustained heavy drinking may result in vitamin deficiency, and prescribedvitamin supplements can be considered. When a service user is at high risk of, orhas a suspected or confirmed diagnosis of, Wernicke's encephalopathy – a conditionassociated with severe vitamin deficiency – thiamin by injection is indicated. Workforce planning to develop alcohol treatment systems
Workforce strategies to maximise and expand the expertise in alcoholinterventions and treatment should complement the development of tieredframeworks of provision in local areas. Workforce strategies will focus on ensuringthere are sufficient competent staff to deliver the evidence-based treatment andinterventions that comprise the commissioned local alcohol treatment system.
These should be developed in partnership with those responsible for developinglocal workforces, including: workforce confederations and strategic health authorities responsible fordeveloping NHS services local voluntary sector employers criminal justice workforce planners responsible for developing community-based and local prison workforce competence local training and education providers local Learning and Skills Councils local or regional representatives of Sector Skills Councils.
A commissioning framework to deliver alcohol treatment systems Alcohol training and liaison posts would be helpful in promoting alcoholinterventions and treatment in primary care, acute hospital, criminal justice,domestic abuse, housing, social services and other mainstream settings. Integrated care pathways for alcohol misuse – ‘alcohol
Alcohol treatment pathways: guidance for developing local integrated carepathways for alcohol6 is a companion publication to MoCAM. It details theconcept and purpose of developing local pathways for alcohol treatment, whichis a specific commitment in the national Alcohol Harm Reduction Strategy forEngland. As well as pathways for access to alcohol interventions and treatment,the guidance addresses the issue of developing detailed pathways for vulnerableservice users with complex needs, including alcohol problems, for example peoplewith mental heath problems, people affected by domestic violence, homelesspeople or drug users.
Each alcohol treatment pathway (ATP) describes the local route for a particularalcohol treatment. Commissioners will want to ensure that the service user'sexperience of treatment (described as the ‘alcohol treatment journey') is so clearthat everyone involved in the process has an agreed understanding of their roleand responsibilities at every stage. An individual's journey through alcoholtreatment will usually comprise more than one ATP.
An integrated care pathway (ICP) describes the nature and anticipated course oftreatment for a particular client and a predetermined plan of treatment. A systemof care should be dynamic and able to respond to changing individual needsover time. It should also be able to provide access to a range of services andinterventions that meet an individual's needs in a comprehensive way. Previousconsultation has shown that the majority of respondents found that the ICPs fordrug users set out in MoCDM (2002)4 had been useful to them in their work.
ICPs should be developed for drug and alcohol misusers because: alcohol misusers can have multiple problems that require effectiveco-ordination of treatment several specialist and generic service providers may be involved in the careof an alcohol misuser simultaneously or consecutively an alcohol misuser may have continuing and evolving care needs requiringreferral to services providing different tiers of intervention over time Models of care for alcohol misusers (MoCAM) ICPs ensure consistency and parity of approach nationally ICPs ensure that access to care is not based solely on individual clinicaldecisions or historical arrangements.
Elements of ICPs
Commissioners should ensure that each alcohol treatment intervention has an ICP,which should be agreed with and between local providers, and built into servicespecifications and service level agreements. Integrated care pathways shouldcontain the following elements: a definition of the treatment interventions provided aims and objectives of the treatment interventions a definition of the client group served eligibility criteria (including priority groups) exclusions criteria or contraindications a referral pathway screening and assessment processes development of agreed treatment goals a description of the treatment process or phases co-ordination of care departure planning, aftercare and support onward referral pathways the range of services with which the interventions interface.
These elements are designed to provide clarity as to the type of client the alcoholtreatment intervention caters for, what the client can expect treatment services toprovide, and the roles and responsibilities of the service within the integrated caresystem and towards the individual client.
A commissioning framework to deliver alcohol treatment systems ICPs and the treatment journey
An ICP will not necessarily be the whole description of a person's treatment journey.
An individual ICP will be focused on one treatment intervention in a client's careplan, within which a client may receive a further range of interventions. Therefore,it is important that the development of local ICPs takes into account the clienttreatment journey through care-planned treatment and represents it in a way thatclients can understand and see their experience reflected.
Local ICPs should describe the structure and content of alcohol treatmentinterventions, but these should be adapted to local needs and alcohol treatmentproviders as appropriate. As well as ICPs for specific treatment types, local ICPswill also need to be developed for specific client groups, particularly excludedgroups of service users who may have difficulty in gaining access to treatmentbecause they have complex needs and because they are vulnerable.
3 Criteria for commissioning and
provision of local treatment
systems for alcohol misusers
Department of Health's Standards for better health
Standards for better health12 was published in July 2004. Its purpose is to provide: a common set of requirements applying across all healthcare organisations,to ensure that health services are provided which are both safe and of anacceptable quality a framework for continuous improvement in the overall quality of care thatpeople receive. The framework ensures that the extra resources being directedto the NHS are used to help raise the level of measurable performance yearon year.
There are two sets of standards: Core standards must be universal and describe an acceptable level of service.
Meeting the core standards is mandatory. Healthcare organisations must comply
with them from the date of publication.
Developmental standards are designed for a world in which patient expectations
are increasing. The current levels of investment in the NHS make achievements
against these standards realistic. Progress is expected to be made against the
developmental standards across much of the NHS as a result of The NHS
Improvement Plan: Putting people at the heart of public services20 and extra
investment in the period to 2008. The Healthcare Commission will, through its
criteria for review, assess progress by healthcare organisations towards achieving
the developmental standards.
Both the core and developmental standards cover seven domains: safety, clinicaland cost-effectiveness, governance, patient focus, accessible and responsive care,care environment and amenities, and public health.
MoCAM supports local healthcare organisations to meet core and developmentalstandards, including the following domains: Criteria for commissioning and provision of local treatment systems for alcohol misusers Second domain: Clinical and cost-effectiveness
Outcome: Patients achieve healthcare benefits that meet their individual needsthrough healthcare decisions and services based on what assessed researchevidence has shown provides effective clinical outcomes.
C5 Healthcare organisations ensure that: a) they conform to National Institute of Health and Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationallyagreed guidance when planning and delivering treatment and care b) clinical care and treatment are carried out under supervision and leadership c) clinicians continuously update skills and techniques relevant to their d) clinicians participate in regular clinical audit and reviews of clinical services.
Related developmental standard: D2 Patients receive effective treatment and care which: a) conforms to nationally agreed best practice, particularly as defined in the National Service Frameworks, NICE guidance, national plans and agreednational guidance on service delivery b) takes into account their individual requirements and meets their physical, cultural, spiritual and psychological needs and preferences c) is well co-ordinated to provide a seamless service across all organisations that need to be involved, especially social care organisations d) is delivered by healthcare professionals who make clinical decisions based on evidence-based practice.
Fifth domain: Accessible and responsive care
Outcome: Patients receive services as promptly as possible, have choices inaccess to services and treatments, and do not experience unnecessary delayat any stage of service delivery or of the care pathway.
C17 The views of patients, their carers and others are sought and taken intoaccount in designing, planning, delivering and improving healthcare services.
C18 Healthcare organisations enable all members of the population to accessservices equally and offer choice in access to services and treatment equitably.
Models of care for alcohol misusers (MoCAM) Related developmental standard: D11 Healthcare organisations plan and deliver healthcare that: a) reflects the views and health needs of the population served and which is based on nationally agreed evidence or best practice b) maximises patient choice c) ensures access (including equality of access) to services through a range of providers and routes of access d) uses locally agreed guidance, guidelines or protocols for admission, referral and discharge that accord with the latest national expectations on accessto services.
Seventh domain: Public health
Outcome: Programmes and services are designed and delivered in collaborationwith all relevant organisations and communities to promote, protect andimprove the health of the population served and reduce health inequalitiesbetween different population groups and areas.
C22 Healthcare organisations promote, protect and demonstrably improve thehealth of the community served, and narrow health inequalities by: a) co-operating with each other and with local authorities and other b) ensuring that the local director of public health's annual report informs their policies and practices c) making an appropriate and effective contribution to local partnership arrangements including local strategic partnerships and crime and disorderreduction partnerships.
C23 Healthcare organisations have systematic and managed disease preventionand health promotion programmes which meet the requirements of the NationalService Frameworks and national plans with particular regard to reducing obesitythrough action of nutrition and exercise, smoking, substance misuse and sexuallytransmitted infections.
Criteria for commissioning and provision of local treatment systems for alcohol misusers Related developmental standard: D13 Healthcare organisations: a) identify and act upon significant public health problems and health inequality issues, with primary care trusts (PCTs) taking the lead role b) implement effective programmes to improve health and reduce health inequalities c) protect their populations from identified current and new hazards to health d) take fully into account current and emerging policies and knowledge on public health issues in the development of their public health programmes,health promotion and prevention services for the public, and thecommissioning and provision of services.
National standards for professionals working in alcohol services
A number of recently developed standards for individuals providing interventionsand treatment for alcohol misuse are of importance in ensuring that thosecommissioning and providing services are clear about the required knowledgeand skills of staff. The main frameworks are: NHS Knowledge and skills framework
The NHS Knowledge and skills framework (NHS KSF) defines and describesthe knowledge and skills which NHS staff need to apply in their work in orderto deliver quality services. It provides a single, consistent, comprehensive andexplicit framework on which to base review and development for all staff.
The NHS KSF and its associated development review process lie at the heart ofthe career and pay progression strand of Agenda for change. They are designedto apply across the whole of the NHS for all staff groups who come under theAgenda for change agreement.
Specific professional registration criteria and qualifications or accreditationprogrammes exist for groups such as nurses, general practitioners and addictionpsychiatrists involved in substance misuse treatment.
Models of care for alcohol misusers (MoCAM) Drugs and Alcohol National Occupational Standards
The Drugs and Alcohol National Occupational Standards (DANOS)17 describecompetent performance of the functions carried out in tackling alcohol anddrug misuse. They give clear descriptions of the standards required and of theknowledge and understanding necessary to perform to those standards.
DANOS, together with other National Occupational Standards – such as thosefor mental health and learning and development – provide every worker with theblueprint they require to perform competently in their role. A new qualificationframework for DANOS is being developed which will identify a range ofqualifications and awards appropriate for those who are new to the field with norelevant qualifications and for those with generic professional qualifications who arenew to substance misuse work. Training providers increasingly offer programmesthat are linked to National Occupational Standards which will enable employers toensure new workers can be quickly inducted and existing workers can be providedwith the knowledge and skills needed to perform their roles competently.
Social care standards for those working in registered care homes
The national minimum care standards for social care are of particular relevance tothose providing residential rehabilitation in registered care homes. In order to meetregistration criteria, staff and managers are required to have relevant qualificationsor demonstrate that they are working towards them. The quality criteria
This chapter sets out the criteria for key quality requirements which representnationally agreed best practice for the treatment of alcohol misusers. The criteriaare divided into: A – criteria for commissioners; and B – criteria for providers.
Quality criteria for commissioning alcohol treatment systems
Commissioning alcohol treatment systems Monitoring the performance of alcohol treatment systems Commissioning and providing an alcohol treatment system to meet adiverse range of local population needs Criteria for commissioning and provision of local treatment systems for alcohol misusers Quality criteria for providing an evidence-based alcohol
Screening the target population and taking action with individuals who arehazardous and harmful drinkers Assessing the needs of individuals with identified alcohol problems andothers who may be affected Care planning to meet the assessed needs of those with alcohol problems Providing a range of structured treatment interventions to meet the needsof alcohol misusers Helping individuals maintain the gains they have made fromalcohol treatment Managing alcohol treatment services The criteria are based on existing agreed sector-specific criteria and qualityframeworks previously commissioned by the Department of Health, specifically: Quality in Alcohol and Drug Services (QuADS) – Organisational Standards forAlcohol and Drug Treatment Services21 and Commissioning Standards – Drugand Alcohol Treatment and Care22 DANOS for individuals providing drug and alcohol information, screening, briefinterventions and treatment, and commissioning substance misuse systems.
These quality criteria have also been aligned with the White Paper The New NHS23and other standards for health, social care and criminal justice provision.
The Choosing Health Planning and Performance Toolkit for PCTs and theirPartners24 commits the Department of Health to continue to work closely withthe independent inspectorates to ensure that inspection systems are consistentwith each other, are aligned with national priorities to improve population health,and continue reducing the burden of bureaucracy on front-line organisations.
The Department of Health is looking at how National Treatment Agency andHealthcare Commission work on drug treatment can be used as a model foralcohol interventions. A1 Commissioning local
systems of alcohol
intervention and treatment
To ensure that a local system of alcohol misuse screening and brief intervention,assessment and treatment is commissioned to meet the needs of the localpopulation.
Criterion 1: Commissioning local systems of alcohol intervention and treatment
Every PCT identifies an alcohol treatment commissioner, responsible for identifyingand quantifying the needs of the local population; identifying local resources;planning the development of a local system in consultation with key stakeholders;prioritising needs within resources; commissioning required services; andmonitoring effectiveness in meeting local needs.
The needs of those with alcohol misuse problems call for a range of interventionsand providers of care which requires the development of a treatment system basedon assessment of need.
Development standard D11 states that healthcare organisations plan and deliverhealthcare which: a) reflects the views and health needs of the population served and is based on nationally agreed evidence or best practice b) maximises patient choice c) ensures access (including equality of access) to services through a range of providers and routes d) uses locally agreed guidance, guidelines or protocols for admission, referral and discharge which accord with the latest national expectations on accessto services.
Commissioning local systems of alcohol intervention and treatment Joint commissioning for alcohol and drug treatment
There may be economies of scale to be derived from commissioning, and possiblyfrom delivering, alcohol and drug treatment services in tandem. However, theprofile of most alcohol misusers may differ significantly from drug misusers andthis should be reflected in the way services are designed, configured and delivered. Implementing a commissioning cycle
Local commissioners in commissioning partnerships or groups are advisedto develop a rolling process of annual local needs assessment, planning,commissioning, monitoring and review, as described in Figure 1. This wouldinvolve partnership working with service providers, service users and otherstakeholders including local strategic planning bodies. Figure 1: The commissioning cycle
Local alcohol treatment needs assessment
Assessing the needs of the local population in respect of alcohol interventions andtreatment will involve: defining the geographic area estimating the size and composition of the population requiring treatment(with reference to the ANARP web-based tool) assessing current provision and spend Models of care for alcohol misusers (MoCAM) describing the desired system of services estimating the demand for each type of service comparing the estimated demand with current capacity for each serviceand devising a means of changing the pattern of services towards therequired provision developing alcohol integrated care pathways (‘alcohol treatment pathways').
Refer to guidance accompanying MoCAM – Alcohol treatment pathways6 identifying key indicators and monitoring systems to monitor provision orreview progress.
Components of a local system
Local PCT commissioners should commission local alcohol treatment systems inaccordance with the four tiers of interventions in MoCAM. Commissioners should require the development of local systems of screening,triage and comprehensive assessment for alcohol misusers. Local alcohol treatmentsystems should develop alcohol assessment protocols, which may include adoptingor integrating recognised valid alcohol dependence assessment tools, and shoulddevelop local protocols for sharing information and for joint collaborative working.
The development of alcohol treatment pathways will facilitate this process.
Local areas should develop alcohol screening and brief intervention protocols,either by adopting or integrating validated screening tools, standard materialsand manuals for brief intervention which exist for Tier 1 and 2 interventionsinto existing screening, triage or relevant associated intervention documents.
The development of alcohol treatment pathways will facilitate this process.
A range of evidence-based alcohol treatment interventions, covering motivationalenhancement and a range of other psychosocial therapies and pharmacologicaltreatment, for example medically assisted withdrawal from alcohol – detoxification– will be required as part of the available Tier 3 and 4 interventions. These aredescribed in more detail in the following sections. The development of local pathways for integrated care (‘alcohol treatmentpathways') should also be required, to describe treatment pathways for typesof alcohol treatment and for groups with specific needs, such as people with co-existing mental health problems, people affected by domestic abuse andpregnant alcohol-dependent women. Commissioning local systems of alcohol intervention and treatment The process of developing a local alcohol treatment system should be seenas developmental and will require local consultation and negotiation. Afterconsultation, when agreement has been reached, commissioners may needto develop or amend service level agreements to reflect this. Commissioning for a competent workforce
Local commissioners are advised to develop – with local providers, employersand other strategic partners – a local workforce strategy to ensure local specialistalcohol services, general health professionals and other professionals areappropriately competent. This may require the development of skills andknowledge. DANOS will provide useful benchmarks for most staff. The RoyalCollege of General Practitioners and the Royal College of Psychiatrists haverecently produced useful benchmarks for medical practitioners in substancemisuse on roles and responsibilities in delivery of care linked to training andcompetency requirements.
A2 Monitoring the performance
of alcohol treatment systems
To ensure that commissioners implement local monitoring and review protocols foralcohol treatment systems, so that resources are expended to maximise cost-effectiveness and have a positive impact on individuals with alcohol problems.
Criterion 2: Monitoring and review of alcohol treatment services
Local commissioners agree the local monitoring of services, including service userdata and key indicators. Monitoring data is used to inform regular service reviews,including annual contract reviews. Monitoring alcohol treatment activity against planned activity and reviewing theinitial impact of treatment provided is essential in order to: ensure that alcohol treatment services are meeting service level agreementson volume and quality indicators assist in understanding which provisions are most effective with which targetgroups and therefore be in a position to make incremental improvements totreatment and the targeting of treatment assist in understanding the relationships between the resources and treatmentoutcomes, to inform decisions regarding the future allocation of resources anddevelopment of the treatment system.
The World Health Organization defines monitoring as ‘the following up ofactivities to ensure that they are proceeding according to plan'. Monitoring shouldbe carried out against an agreed plan, complete with objectives, schedule andbudget, and cover: Inputs – what resources (funding, workforce numbers and levels of competence,
buildings, equipment, medication and other consumables) have been used in the
treatment and are these within budget? This information is needed when
calculating unit costs of different types of treatment.
Monitoring the performance of alcohol treatment systems Outputs – what activities have been carried out as part of the treatment
programme and are these according to the schedule?
Outcomes – what were the results, or measurable changes, that can be attributed
directly or indirectly to the treatment programme and are these in line with the
programme's objectives and individual treatment goals? Monitoring of outcomes
allows commissioners to evaluate the impact of the programme.
Service user outcomes
The overall outcome sought from alcohol treatment is reduction in alcohol-relatedharm (to the individual, to others directly affected by their behaviour and to thewider community) and an improvement in the health and social functioning ofthe alcohol misuser. However, these goals are usually measured through progresstowards measurable outcomes in the following domains: reduction of alcohol consumption – this may be an abstinence goal or a
reduction in alcohol dependence
amelioration of alcohol-related health problems – such as liver disease,
malnutrition or psychological problems
amelioration of alcohol-related social problems – such as family and
interpersonal relationships, ability to perform effectively at work, avoidance
of criminal activity
general improvement in health and social functioning.
Measurable goals can be agreed and progress towards those goals monitored andthe benefits to the individual evaluated. The benefits to the health system fromthe individual's reduced usage of healthcare services can also be evaluated and thecost savings calculated.
Because alcohol dependence is a highly relapsing condition, it may be beneficialto maintain routine monitoring of the completion of initial treatment through acontinuing care programme, with checks on the maintenance of initial gains atthree, six and twelve months. Follow-up monitoring work should be commissionedas an integral element of routine treatment. For service users whose drinkingproblems have resumed, follow-up contact could offer an early return tointervention and treatment, thus minimising harm.
Models of care for alcohol misusers (MoCAM) Minimum data sets
There are time and financial costs involved in data recording, analysis andreporting. These can be kept to a minimum by ensuring that the data collected isessential, to ensure resources are used cost-effectively and to inform decisionsregarding resource allocation and possible improvements in treatment. Localminimum data sets should incorporate any national minimum data set forreporting requirements.
A3 Commissioning and providing
an alcohol treatment
system to meet a diverse
range of local needs
To ensure all individuals with alcohol-related problems have equal access torelevant alcohol interventions.
Criterion 3: Equal access to relevant alcohol assessment and treatment
Individuals with alcohol problems are able to access suitable assessment andtreatment services locally, regardless of their geographical location, occupation,disability, family status, gender, sexuality, ethnicity, language, ability, age orlegal status.
Core standard C18 in the Department of Health's Standards for better health12requires that ‘healthcare organisations enable all members of the populationto access services equally and offer choice in access to services and treatmentequitably'. This standard relates directly to NHS core standard C18 and othernational frameworks concerning race equality (Race Relations (Amendment)Act 2000), gender identity, disability, etc.
Assessment, interventions and treatment for alcohol problems should be availableto all those who need them. Commissioners and providers should consider wholepopulation needs when establishing local alcohol treatment systems, includinggroups traditionally marginalised from mainstream health and other services.
Specific, targeted interventions may be required for locally under-represented orhard-to-reach groups. Similarly, provider service level agreements should specifyhow a diverse range of needs are to be met in providing services that are relevantand appropriate for local needs, for example alcohol competence in relation tolocal population groups.
Models of care for alcohol misusers (MoCAM) In commissioning an alcohol treatment system, particular consideration should begiven to locally identified groups, such as individuals from black or minority ethnicgroups; individuals with physical disabilities; homeless people and rough sleepers;offenders; older people; gay, lesbian, bisexual or transgender individuals; women;people affected by domestic abuse; individuals in rural communities; individualswith children; and individuals with work commitments. The development of localalcohol treatment pathways should facilitate this process. Commissioners and providers should ensure that uptake of intervention andtreatment services is routinely monitored, to ensure that no group suffers under-representation or poorer treatment outcomes due to services not being relevant orappropriate. If under-representation or poorer outcomes do occur, corrective actionshould be taken.
B1 Screening the target population
and taking action with
individuals who are
hazardous and harmful drinkers
To provide targeted screening and brief interventions for hazardous and harmfuldrinkers to encourage them to reduce consumption, reduce alcohol-related harmand refer dependent drinkers for structured treatment, as appropriate.
Criterion 4: Targeted screening
Hazardous and harmful drinkers are identified through targeted screening.
Criterion 5: Brief advice and support
Identified hazardous and harmful drinkers are offered information and brief adviceand intervention.
Criterion 6: Referral to specialist alcohol services
Dependent drinkers are referred for comprehensive assessment and care-plannedalcohol treatment.
Screening for individuals who drink in excess of the recommended guidelines,combined with brief interventions for hazardous drinkers and harmful drinkers, canbe cost-effective in reducing alcohol-related harm to the individuals and othersthey are in contact with. It can also be effective in limiting the demand for moreintensive interventions in the future.
Screening also identifies those who have definite alcohol-related problems andmoderate to severe alcohol dependence, so that they can be referred for specialistalcohol treatment as appropriate.
Models of care for alcohol misusers (MoCAM) The Alcohol harm reduction strategy for England2 recommends targeted screeningrather than universal screening. With targeted screening, only those who presentwith symptoms and conditions that may be linked to problematic drinking arescreened or those joining a new primary care practice. A number of psychologicaland physical symptoms and signs may suggest excessive drinking.
Screening may be carried out with the support of a simple assessment tool.
Such tools include: the alcohol use disorders identification test (AUDIT) the FAST screening tool (validated in both primary healthcare and A&Esettings) the Paddington alcohol test (effective in identifying hazardous and harmfuldrinkers in busy A&E departments) the T-ACE and TWEAK screening instruments (effective in detecting alcoholmisuse among pregnant women). These tools are described in detail in the Review of the effectiveness of treatmentfor alcohol problems.1 Simple brief interventions (sometimes referred to as ‘minimal intervention') are
usually provided by a competent practitioner in about five minutes, immediately
following a screening assessment or in another ‘teachable moment'. Simple advice
information about the nature and effects of alcohol and its potential for harm personalised feedback on risk and harm emphasis on the individual's personal responsibility for change attempts to increase the patient's confidence in being able to reduce theiralcohol consumption (‘self-efficacy') goal-setting (for example, start dates and daily or weekly targets for drinking) written self-help material for the individual to take away, containingmore detailed information on consequences of excessive drinking and tipsfor cutting down (this can be in a variety of media, including electronic, suchas the internet) signposting individuals to having a wider general health check, where indicated arrangements for follow-up monitoring.
Screening the target population and taking action with individuals who are hazardous and harmful drinkers Extended brief interventions typically take 20–30 minutes to deliver and can
involve a small number of repeat sessions (between 3 and 12).
Where moderately or severely dependent drinkers and those with identifiedalcohol-related problems in need of more intensive care-planned treatment areidentified, this group should be referred directly to specialist alcohol provision. Commissioners and PCTs should ensure the following are in place to develop localtargeted screening and brief intervention and support networks: simple, practical screening tools materials providing information and advice about the sensible use of alcohol arrangements for referring moderately and severely dependent drinkersto specialists training in the provision of screening and brief interventions withalcohol misusers.
B2 Assessing the needs of
individuals with identified
To ensure treatment decisions for individuals with alcohol-related problems arebased on reliable and cost-effective assessments of their needs, within locallyagreed protocols for screening and assessment.
Criterion 7: System of Assessment for alcohol misusers at appropriate levels
Local areas establish a system of three levels of assessment comprising screening,triage assessment and comprehensive assessment. Criterion 8: Comprehensive assessment for alcohol misusers to inform care
Individuals with identified alcohol problems are comprehensively assessed insufficient detail to identify the most appropriate treatment and inform anindividualised care plan to meet their needs. MoCDM (2002)4 outlined a three-tier system of screening and assessment forimplementation in each local area, depending on local configuration of services.
Initial consultation with alcohol treatment stakeholders has found widespreadsupport for this model (2004).
The three levels of assessment recommended are: Level 1: screening (with brief interventions) and referral Level 2: alcohol misuse triage assessment Level 3: comprehensive alcohol or substance misuse assessment.
Level 1 screening is covered in Section B1 (see page 53). In MoCAM it coverstargeted screening and brief interventions for hazardous and harmful drinkers,as well as onward referral. Section B2 focuses on: the need for a local systems approach to screening, assessment and referral Level 2 triage and Level 3 comprehensive assessment.
Assessing the needs of individuals with identified alcohol problems Local systems of screening and assessment
In each area, commissioners and providers are recommended to develop localsystems, which cover the three levels of screening and assessment. The levels ofassessment reflect the different levels of complexity and expertise required to carryout the assessment at each stage. In this system, a broad base of personnel –who can carry out less complex screening and screening for alcohol – is required,allowing more opportunities for preventative brief interventions, more points ofaccess to the specialist alcohol treatment system and less delay in treatment entry. Assessment is an intervention in its own right, which can help to change theindividual's perception of their problem, their expectations of help and theircommitment to treatment, and can prompt a reduction in alcohol consumption.
There is evidence to suggest that excessive drinkers will reduce their drinking tosensible or less risky levels following a short assessment of their alcoholconsumption and related problems.
The levels of screening and assessment should map onto the four tiers (see Section 2.2.1 on page 20) in that: Level 1 screening and referral (and simple brief intervention) is essentiallya Tier 1 provision, although it may also be a Tier 2 provision if the briefintervention is extended Level 2 triage assessment is essentially a Tier 2 provision and is, in essence,a filtering process to establish what type of alcohol treatment is likely to berequired, to assess the level of risk and to refer to the most appropriatespecialist alcohol treatment provider Level 3 comprehensive assessment is essentially a Tier 3 and Tier 4 provision,though may be undertaken by some practitioners providing mainly Tier 2interventions if they are trained and competent in comprehensive alcoholassessments. This level of assessment covers various domains, may need to bemultidisciplinary and should inform the development of the care plan. There isa basic alcohol-specialist level of knowledge and skills needed to complete aLevel 3 comprehensive assessment. More specialised practitioners will, inaddition, carry out further and more specialised alcohol assessment (forexample psychometric or psychiatric assessments) as part of theircomprehensive assessment of such service users when appropriate.
Models of care for alcohol misusers (MoCAM) However, the effectiveness of such a system depends on standardisation ofapproach. Specifically, commissioners should ensure the following elementsare present in each locality: clear and standardised screening and assessment procedures and processesused across all agencies clear criteria for referral and eligibility for entry to each part of the alcoholtreatment system clear local alcohol treatment pathways a local directory of services for alcohol misusers clear criteria for priority treatment entry and accelerated access adequate training of personnel carrying out screening and assessment ateach level protocols for sharing appropriate information between agencies in the alcoholtreatment system monitoring, auditing and reviewing of the screening and assessment system.
Different levels of assessment require different levels of competence in assessors.
Commissioners and providers should ensure that local training in screening, triageand comprehensive assessment is available, following the development of locallyagreed processes, criteria, information-sharing protocols and monitoring. The system should minimise the potential burden of multiple assessments of anindividual service user. Sharing relevant information between agencies followingassessment should be encouraged, to avoid repeated assessment of service userswithout action and to manage risk to the service user and others. Commissionersshould encourage locally agreed policies across different agencies on informationsharing, including informed service user consent. Information-sharing protocolsshould be sensitive to service user confidentiality, while facilitating referral totreatment options required by the service user. Assessment and care planning needs to be an inclusive process, in whichservice users and assessors work in partnership to identify needs and plan careappropriately. The assessment should achieve sufficient agreement betweenservice user and assessor on the needs to be addressed by treatment and themost appropriate course of action. Without a sufficient level of consensus, futurereferral and effective engagement in treatment may be compromised, or at worstmay fail. Similarly, issues of diversity and the development of services sensitive to Assessing the needs of individuals with identified alcohol problems a range of service user needs are crucial – these are essential ingredients ofeffective treatment systems. Evidence from other areas of healthcare – in particularmental health – shows a need for assessment procedures and tools that take intoaccount the cultural diversity of local populations.
Triage assessment should identify the seriousness of alcohol-related problems, theurgency with which they require treatment, any immediate risk of harm to serviceusers or key people with whom they are in contact, and should refer the individualto the most appropriate local alcohol treatment provider. Triage assessment usually covers: alcohol consumption alcohol dependence alcohol-related problems co-existing health conditions, including co-existing drug and/or mentalhealth problems risk of harm to self and others urgency for treatment motivation and readiness to change For further information on screening and assessment tools, refer to the Review ofthe effectiveness of treatment for alcohol problems.1 The purpose of comprehensive substance misuse assessment is to determine theprecise nature of the alcohol problems, including co-existing health conditions orsocial problems, to enable an individualised care plan to be prepared. This processmay also begin the building of a helping alliance between the therapist or serviceand the individual service user.
Models of care for alcohol misusers (MoCAM) The comprehensive substance misuse assessment provides full data to inform thedevelopment of an individualised care plan. It will normally involve assessment ofa range of domains, including: alcohol consumption, dependence and alcohol-related problems co-existing health conditions, including co-existing drug and mentalhealth problems cognitive functioning risk of harm to self and others urgency for treatment motivation and readiness to change socio-demographic data family relationships and social network functioning.
There are many validated assessment tools for alcohol dependence andassessments. It may be helpful for local area providers to use the same assessmenttool or, as a minimum, to agree common elements of local assessment tools.
It is important to recognise the roles and competence of different professionalsin multidisciplinary assessments. Particular aspects of assessment may be thespecific remits of certain groups, for example: doctors and independent nurseprescribers, in the prescribing of medication; detailed psychometric assessments bypsychologists; psychiatric assessment by addiction psychiatrists; and occupationaltherapy assessments.
Impact of alcohol misuse on significant others
Alcohol misuse and withdrawal can have a wide range of negative impacts on thoseclose to the problem drinker. These include a greater propensity for involvement indomestic abuse (as perpetrator or victim), domestic and road traffic accidents,negative impact on partners and on parenting capacity, lack of funds to pay foressentials such as food, housing, heating and clothing, and damage to unbornchildren of pregnant drinkers. In extreme cases, it may lead to hospitalisation,imprisonment or death of the problem drinker and potentially to serious harm tothose associated with them. Assessment processes should be sensitive enough tocover key areas of risk and impact on others, particularly children.
Assessing the needs of individuals with identified alcohol problems A large proportion of alcohol misusers have responsibility for the care of children.
Alcohol (or other substance) misuse does not necessarily lead to problems or poorparenting, neglect or abuse of children. However, it is important to consider theimpact of parental alcohol misuse on the welfare of children in their care. If aprofessional has concerns about the welfare or safety of the children of alcoholmisusers, from assessment or indeed at any point during treatment, they shouldfollow local joint working arrangements as agreed by the local safeguardingchildren boards (formerly area child protection committees). This would normallymean involving social services. Some local areas have now developed specificpolicies for working with drug and alcohol misusers, agreed by the boards. Partners, carers and others affected by someone else's drinking behaviour shouldreceive the protection and support of the police, social services and a wide rangeof voluntary agencies and mutual support groups. Alcohol treatment services alsohave a role to play in the provision of services to those affected by someone else'sdrinking, both in identification of risk and problems and initiating appropriateaction and referral, and in providing services, whether directly or in partnership.
B3 Care planning to meet the
assessed needs of individuals
with alcohol problems
Following comprehensive assessment, structured alcohol treatment is deliveredin the context of a care plan with clear and agreed goals and review processes.
The accepted core principles and key elements of practice in care planning forsubstance misuse treatment are described in the Care planning practice guidance.25 Criterion 9: Individualised care planning
Following assessment, individuals with alcohol dependence have an individualisedcare plan, which is agreed with the service user. The care plan states the treatment goals, the treatment interventions and servicesto be provided, and the responsibilities of professionals, the individuals, their carersand others in the co-ordination and delivery of treatment in the care plan. The care plan is effectively co-ordinated and reviewed on a regular basis withthe service user and other relevant professionals by the keyworker who is thededicated and named practitioner responsible for ensuring the client's care planis delivered and reviewed.
‘Keyworking' is a process undertaken by the keyworker to ensure the delivery andongoing review of the care plan. This would normally involve regular meetingsbetween the keyworker and the client where progress against the care plan wouldbe discussed and goals revised, as appropriate. The keyworker should have atherapeutic relationship with the client and would normally be a member of themultidisciplinary team responsible for delivering most of the client's care andusually, but not necessarily, the main therapist.
Those with alcohol problems may have a number of needs and treatmentgoals involving more than one individual or agency to assist achievement of thesegoals. They may have multiple needs in a variety of domains, including alcoholdependence, co-existing physical health needs, co-existing mental health needs,drug misuse, issues relating to social functioning, housing, education, training andemployment, and risk of harm to self and others.
Care planning to meet the assessed needs of individuals with alcohol problems Identifying such needs and goals in dependent drinkers requires a comprehensivealcohol misuse assessment and the development of an individualised care plan.
This should be agreed with the service user and should have clear treatment goals.
It may also need to identify different professionals who may need to be involvedto meet multiple needs, and to be shared with a range of services to meet theindividual's needs in a coherent way.
Commissioners should ensure that structured alcohol treatment employs a care-planned approach. The assessment of the alcohol misuser should result in awritten care plan. A care plan is a structured, often multidisciplinary, task-orientedindividual treatment plan, which details the essential steps in the care of analcohol misuser and describes the alcohol misuser's expected treatment and carecourse. The care plan involves the translation of the needs, strengths and risksidentified by the assessment into a service response. A care plan is a tool tomonitor any changes in the situation of the alcohol and drug misuser and tokeep other relevant professionals aware of these changes. It is ideally a paperdocument that is available to the client and service providers. A care plan shouldbe brief and readily understood by all parties involved and should be a sharedexercise between the client and service. It should document and enable routinereview of client needs, subsequent goals and progress across the key domains ofcomprehensive assessment.
The care plan should: set the goals of treatment and milestones to be achieved (taking into accountthe views and treatment goals of the alcohol and drug misuser and developedwith their active participation) indicate the interventions planned and the agencies and professionalsresponsible for carrying out the interventions make explicit reference to risk management and identify the risk managementplan and contingency plans identify information sharing (what information will be given to otherprofessionals and agencies and under what circumstances) identify the engagement plan to be adopted with alcohol misusers who aredifficult to engage in the treatment system identify the review date (the date of the next review meeting is set andrecorded at each meeting) Models of care for alcohol misusers (MoCAM) reflect the cultural and ethnic background of the drug and alcohol misuser, aswell as their gender, sexuality and preferences in terms of service delivery make clear who is the named keyworker who has agreed to be responsiblefor drawing up the care plan with the service user, involving any others asappropriate, and who will monitor the care plan and ensure its review.
Service users with multiple needs may receive care from a range of providers ofcare. This will require the keyworker to co-ordinate elements of the care plan toensure that the service user receives appropriate interventions and that providerswork together effectively.
A care plan should be reviewed and evaluated at regular intervals and at therequest of a member of the care team, the service user or their carer. The dateof the next review meeting is set and recorded at each meeting. In reviewing thecare plan, the following is assessed: the relevance of the care plan the effectiveness of care plans and outcomes the service user's satisfaction with the care.
Over time, the care planning process should also reflect the expected service usertreatment journey. It should have a clear beginning to treatment, which maximisesinitial retention and service user motivation. The subsequent stage of treatmentis where the bulk of the therapeutic work is undertaken and, when appropriate,there should be a clear exit strategy from treatment which may include thedevelopment of post-treatment support mechanisms, open access, therapeuticsupport, housing and education or employment opportunities. A small numberof service users may require ongoing care. Many problem drinkers will relapse and require more than one cycle ofinterventions before they achieve their goal (abstinence, harm-free drinking andassociated improvements in health and well-being). However, each relapse offersthe problem drinker a potential learning experience that may improve the chanceof a successful outcome in future. Successful treatment interventions may noteliminate all future risk and harm, but may ameliorate them to a level acceptableto the service user and others affected by their behaviour.
Responsibility for co-ordination of the individual's care plan should clearly rest withone person, the keyworker, who would normally be the person responsible for the Care planning to meet the assessed needs of individuals with alcohol problems delivery of the bulk of the alcohol treatment – the service user's main therapist. Inthis instance, care planning and effective co-ordination of care will involve liaisonwith professionals involved with the service user, to check that interventionsand treatments are delivered in accordance with the care plan. This will usuallyinvolve having review meetings of progress with the service user, and others asappropriate, towards the goals in the care plan, and making amendments to thecare plan where necessary. This role also may involve keeping relevant partiesinformed of change or progress in the care plan and of any changes in rolesand responsibilities, in accordance with agreed information-sharing protocols.
Care planning in groups with externally co-ordinated care Some groups of individuals require particular co-ordination of care with otheragencies. For individuals with severe mental health problems, the lead organisationin co-ordinating their care will be the relevant mental health services (see Dualdiagnosis good practice guide14). Care will be co-ordinated under the careprogramme approach (CPA) by a named mental healthcare co-ordinator. Serviceusers receiving community care funding, for example to pay for residentialrehabilitation treatment, will typically have a community care manager responsiblefor their treatment. In these, and other similar instances, the structured alcoholtreatment providers will liaise and work collaboratively with the other agenciesinvolved. The development of detailed local alcohol treatment pathways willfacilitate this process. B4 Providing a range of
interventions to meet the
needs of alcohol misusers
Provide a range of structured community-based and inpatient alcohol treatmentinterventions, to meet a range of needs of individuals with alcohol problems. Criterion 10: Care-planned treatment for alcohol misusers
Local alcohol treatment systems should provide a range of community-based andinpatient structured alcohol treatment interventions, to meet a range of local needs. Structured alcohol treatment interventions, comprising a single intervention or acombination of interventions or therapies delivered in the appropriate sequence,can be effective in helping individuals with alcohol problems either abstain fromdrinking or achieve a return to controlled, less risky drinking and maintain thispattern of behaviour over an extended period.
Section 2 outlined the range of structured alcohol treatment interventions thatshould be commissioned and provided for residents of each local area. Theseshould be provided by those with competence in provision of specialist alcoholtreatment and commissioned at Tier 3 and Tier 4. Key factors influencing successful alcohol treatment
Many alcohol therapies have been shown to be effective in treating dependentdrinkers. Among effective therapies, no single therapy stands out as being moreeffective in all circumstances than others. Key components in effective treatment appear to be: a supportive and empathetic therapeutic relationship (helping alliance) the expertise of the therapist the level of motivation (readiness for change) of the alcohol misuser Providing a range of structured treatment interventions to meet the needs of alcohol misusers the cognitive ability of the alcohol misuser the presence of a social network that is supportive of the chosen drinking goal.
However, any effective care plan for an alcohol misuser is likely to contain anumber of the components described below.
The quality of the relationship between the alcohol misuser and the professionalworking with them is one of the most powerful determinants of successfuloutcomes of alcohol treatment, accounting for up to 40 per cent of the outcomevariances in randomised controlled trials. The most effective therapists arecharacterised as: helping and understanding encouraging service user autonomy effective at helping service users access external resources.
A confrontational approach has been found to be far less effective than asupportive one. Ensuring competence of staff in alcohol treatment provision is key to providing effective alcohol treatment.
Most treatment for alcohol dependence and alcohol-related problems includessome form of therapy to support the individual's psychological and socialdevelopment.
As well as brief support for behaviour change discussed in Section 2, the Reviewof the effectiveness of treatment for alcohol problems1) identifies a wide rangeof treatments shown to be effective in research studies, including cognitive-behavioural therapy, motivational enhancement therapy, 12-step facilitationtherapy, coping and social skills training, a community reinforcement approach,social behaviour and network therapy, behavioural self-control training, andcognitive-behavioural marital therapy.
Models of care for alcohol misusers (MoCAM) In practice, the delivery of psychosocial therapies is not necessarily discrete.
Different therapies often share common components and, indeed, they are alldesigned to help alcohol misusers change their behaviour in some way. They alsooften help alcohol misusers develop new skills, allowing them to handle high-riskdrinking situations without relapsing in the future.
Commissioners need to ensure the availability of a range of psychosocial therapiesto meet the needs of the local population, including targeted interventions fordiscrete groups, and services competent to respond to specific cultural and genderissues and issues of sexuality.
Pharmacological therapies are most effective when used as enhancements topsychosocial therapies as part of an integrated programme of care. The Reviewof the effectiveness of treatment for alcohol problems1 identifies three classes ofpharmacotherapy that are effective in the treatment of alcohol misusers: medications for treating patients with withdrawal symptoms during medicallyassisted alcohol withdrawal medications to promote abstinence or prevent relapse, including sensitisingagents nutritional supplements, including vitamin supplements as a harm reductionmeasure for heavy drinkers and high-dose parenteral thiamin for the treatmentof individuals with Wernicke's encephalopathy and its prevention.
Psychosocial approaches may be delivered through individual counselling, groupwork or within the context of structured residential or outpatient programmes.
Psychosocial and pharmacological therapies should be delivered in the context ofstructured care-planned treatment, and commissioners will determine the range ofappropriate settings to meet local needs in consultation with service providers. Staff competence is a key factor in the successful delivery of alcohol treatment,together with continuing supervision and professional development.
Whatever delivery mechanism and settings are chosen to meet local needs,local commissioners and providers should ensure evidence-based practice isunderpinned by good clinical governance and audit mechanisms (or equivalent).
Providing a range of structured treatment interventions to meet the needs of alcohol misusers Delivering a range of alcohol treatments in a care-planned approach
Each alcohol misuser with an individualised care plan will have a uniquecombination and schedule of treatments and services to meet their particularneeds. However, the overall model of care will be largely similar.
In line with a ‘stepped care' model of intervention for alcohol misusers, introducedin the Review of the effectiveness of treatment for alcohol problems,1 moderatelyor severely dependent drinkers will usually be offered the least intensive treatmentsappropriate for their assessed needs. If this fails to deliver a positive outcome, theyshould be offered more intensive or prolonged treatment until their treatmentgoals have been achieved. Because alcohol dependence is a relapsing condition,individuals' progress must continue to be monitored after the formal end of care-planned treatment and should at least be followed up after all structuredintervention has ended.
Care-planned alcohol treatment can be delivered in a variety of settings, includingthe home, workplace, general and psychiatric hospitals, primary care, hostels andcommunity-based treatment agencies. The selection of setting will depend on anumber of factors, including individual choice, safety, opportunism, accessibility,availability of treatment and cost.
Community settings are preferred for the treatment of the majority of alcoholmisusers, both because individuals need to learn how to change their drinkingbehaviour in their normal social environment and because it is cost-effective.
Those individuals who are unable to leave the home or who would have difficultiesattending a specialist agency – for example older people, disabled people andparents with childcare responsibilities – may need specialist alcohol treatment intheir own homes or other community settings. However, some individuals willrequire treatment in hospital or in supported residential accommodation.
Dependent drinkers who have difficulty in achieving abstinence through treatmentin community settings may require inpatient treatment. Criteria for inpatientadmission may include: severe dependence a history of withdrawal complicated by seizures or Delerium Tremens (DTs) poor physical or psychological health a risk of suicide other drug misuse. Models of care for alcohol misusers (MoCAM) Homeless people, those who lack social support or those who have had previousunsuccessful attempts at withdrawal in the community may also require inpatienttreatment. Inpatient prescribing will be available to those who require stabilisationin a controlled environment.
Inpatient assisted withdrawal should lead seamlessly into structured care-plannedtreatment and support, whether delivered in the community or in residentialrehabilitation services. For further guidance relating to the use of specialistinpatient substance misuse provision, see Scan consensus project 1: InpatientTreatment of Drug and Alcohol Misusers.26 Inpatient and residential rehabilitation services may have capacity to offer servicesin more than one area. Commissioners can explore opportunities for collaborativecommissioning arrangements with other areas to optimise the efficient use ofresources dedicated to these components of their local treatment systems. B5 Helping individuals maintain
the gains they have made
from alcohol treatment
To prevent individuals relapsing after participating in alcohol treatment.
Criterion 11: Maintaining gains from alcohol treatment
Individuals who have participated in alcohol treatment receive information, adviceand continuing support to help them maintain improvements in their health andsocial well-being and reductions in their alcohol consumption.
Alcohol dependence is, for some people, a relapsing condition. Individuals canquickly return to their previous drinking habits and their health and well-beinggains can rapidly be eroded if they are not provided with information, advice andcontinuing support to address the social, environmental and financial factorsassociated with their substance misuse. While they are undergoing alcohol treatment and afterwards, individuals may needhelp to: maintain their personal commitment to their drinking goals avoid the company of heavy drinkers access training and education to develop employment and life skills manage their personal finances achieve lasting changes in their lifestyle.
The relevance and importance of these factors need to be identified as part of thecomprehensive substance misuse assessment (see Section 2) and the strategy foraddressing these issues developed as part of the individualised care plan.
Models of care for alcohol misusers (MoCAM) Relapse prevention is best viewed not as a separate activity, but as integral to thecare plan. It may involve: psychosocial therapies, as identified in Section 2, especially those that help
individuals avoid or cope with high-risk drinking situations
social support to make lifestyle changes, such as housing, employment,
family and social relationships
pharmacological therapies as an adjunct to psychosocial interventions –
not as stand-alone treatments
a structured programme of activities, at set intervals following the initial
achievement of the individual's drinking goals, designed to monitor the
individual's progress, build on their successes, identify problems and ways
of overcoming these, reinforce skills and behaviour changes and prevent a
lapse turning into a full relapse.
Psychosocial factors that may lead to relapse are identified as part of thecomprehensive substance misuse assessment. Action to address these is includedin the individualised care plan, which will also identify the nature of rehabilitationand continuing care required. A range of other services to prevent relapse (suchas support with housing, employment, family and social relationships) may beprovided in parallel with the core treatment interventions for alcohol problems. Once the individual's drinking goal has been achieved, they may need a period ofsupported rehabilitation to maintain their treatment gains. For some this may takethe form of structured interventions (such as forms of structured counselling orstructured day services) to help individuals restructure their lives; for others a moresupportive and closely monitored approach in a residential facility may be required.
Local needs assessment will inform commissioners about the level of demand forcommunity and residential rehabilitation required.
Because of the relapsing nature of alcohol dependence, all alcohol misusers whohave been treated should be monitored and followed up in a structured way.
Continuing care, with appointments on an individual or group basis at regularintervals after the completion of treatment, can: enable the early detection of a relapse and attempt to limit its negativeconsequences help prevent a minor lapse from turning into a full relapse Helping individuals maintain the gains they have made from alcohol treatment provide an opportunity to evaluate the usefulness of new skills and behavioursthat individuals have been trying to put into effect, including lifestyle changes,and discuss any problems that may have arisen provide specific booster sessions for skills and behavioural changes thatneed strengthening provide the means of monitoring and recording progress and of reinforcingindividuals' success.
Rehabilitation and continuing care form a continuum of a range of activities,initially provided in a more structured way based on the individual's assessedneeds, but later delivered in response to the individual's ongoing requirements.
Mutual aid and self-help groups are often a useful local resource, particularly foraftercare. Alcoholics Anonymous (AA) offers a model of support and continuingcare for alcohol misusers, using the 12-step approach, and has the benefit of beingavailable nationally. Other complementary mutual aid services may need to bespecifically commissioned in each area to offer choice and an appropriate rangeof provision.
B6 Managing alcohol
To ensure organisations providing alcohol treatment deliver quality services thatmeet the needs of service users and the requirements of service level agreements.
Criterion 12: Managing alcohol treatment services
Organisations providing alcohol treatment services are managed to meet therequirements of service level agreements, ensure staff competence, deliverevidence-based practice, undertake regular reviews of performance based onservice user monitoring data, and have good relationships with commissionersand other providers.
Like all organisations, alcohol services can only be fully effective if they areproperly managed. This means: being clear about the strategic aims and objectives of the organisation, how itfits into the wider alcohol treatment system, the services it offers and those itdoes not offer proactively involving service users in the planning, design, delivery, monitoringand evaluation of services agreeing with commissioners the type and level of services to be provided towhich groups of users and the quality, time and cost parameters around these developing and adhering to an operational policy and planning the deliveryof services providing an environment that is safe and conducive to the effective deliveryof services recruiting, supervising, developing and retaining a workforce with the requiredmix of competences for delivering services maintaining complete, accurate and accessible records and keeping thesesecure within agreed confidentiality protocols Managing alcohol treatment services establishing and maintaining effective processes for communication and jointworking between workers within the organisation and with other organisations using data from routine service user monitoring to review practice regularly undertaking regular service audits or clinical guidance reviews assuring the quality of services and promoting continuous improvement intreatments, processes and outcomes monitoring performance and reporting to commissioners and statutorybodies as required.
It is the responsibility of service managers to ensure that services are accessible andprovided equitably to all users in their defined target groups.
The standard of performance required of individual managers within alcoholservices is described in Key Area B ‘Management of Services' of the Drugs andAlcohol National Occupational Standards (DANOS).17 Quality in Alcohol and Drug Services (QuADS) Organisational Standards forAlcohol and Drug Treatment Services21 remains a relevant, nationally agreedquality framework for alcohol treatment and represents good practice. Annex A
Links to other commissioning initiatives
Models of care for alcohol misusers has not been developed in isolation. It hasbeen developed with reference to Models of care for the treatment of adult drugmisusers4 and complements the forthcoming Models of care for the treatment ofadult drug misusers: Update 2006. Alcohol brief interventions and treatment are integral to NHS and social carecommissioning and should be provided in line with the Department of Health'sNational standards, local action: Health and social care standards and planningframework 2005/06–2007/0815 and Alcohol misuse interventions: Guidance ondeveloping a local programme of improvement.5 Standards for organisations commissioning and delivering alcohol services
Other commissioning guidance that can contribute to understanding thecommissioning process includes: Commissioning standards for drug and alcohol treatment and care
Commissioning standards for drug and alcohol treatment and care22 weredeveloped by the Substance Misuse Advisory Service in 1999 as a tool forcommissioners of treatment and care. The standards were designed to develop firm mechanisms for health and localauthority treatment commissioning and to ensure that all treatment programmesaccord with a nationally accepted standard. The standards provide guidance on thecommissioning of comprehensive and evidence-based alcohol and drug treatmentand care systems. Quality in Alcohol and Drug Services (QuADS)
QuADS21 was developed jointly by Alcohol Concern and DrugScope and is stillwidely used by alcohol and drug treatment services throughout England, as the setof quality standards for organisations in the sector. Organisations use the standardsfor self-assessment and also for peer review.
QuADS is particularly relevant when considering the management and qualityassurance of alcohol treatment services. It is therefore referenced in Section B6Managing alcohol treatment services in Chapter 3 Criteria for commissioning andprovision of local treatment systems for alcohol misusers.
National minimum standards for care homes for younger adults
National minimum standards for care homes for younger adults are issued by theSecretary of State for Health under section 23(1) of the Care Standards Act 2000.
They came into effect on 1 April 2002.
It is the responsibility of the Commission for Social Care Inspection (CSCI) to applythem to the circumstances of individual establishments, agencies and institutionsthrough regulation.
The standards apply to homes for which registration as care homes is required,including currently registered residential care and nursing homes, small homes,new facilities, local authority homes and establishments that were exempt underthe Registered Homes Act 1984 (for example charter homes). The standardsspecifically apply to care homes for people with alcohol or substance misuseproblems. The standards cover: choice of home; individual needs and choices;lifestyle; personal and healthcare support; concerns, complaints and protection;environment; staffing; and conduct and management of the home.
Other quality frameworks and standards
Other quality improvement frameworks, standards or accreditation systems mayalso be relevant to alcohol intervention and treatment systems. These may includeclinical governance mechanisms in NHS providers, Investors in People, criminaljustice accredited programmes and standards and registration for independenthospital provision. Commissioners and providers should be clear about the requirement aroundindividual quality initiatives and how they contribute to demonstrating the qualityof local provision. Commissioners should minimise duplication of effort forproviders in monitoring and reporting requirements where possible. Annex B
Wider policy context
Creating a patient-led NHS
The NHS now has the capacity and the capability to move on from being anorganisation that simply delivers services to people to being one that is totallypatient led – responding to their needs and wishes.
Every aspect of the new system is designed to create a service that is patientled, where: people have a far greater range of choices, and information and help tomake choices there are stronger standards and safeguards for patients NHS organisations are better at understanding patients and their needs, usenew and different methodologies to do so and have better and more regularsources of information about preferences and satisfaction.
In order to be patient led, the NHS will develop new service models which buildon current experience and innovation to: give patients more choice and control wherever possible offer integrated networks for emergency, urgent and specialist care to ensurethat everyone throughout the country has access to safe, high-quality care make sure that all services and all parts of the NHS contribute to healthpromotion, protection and improvement.
The NHS will also develop the way it secures services for its patients: It will promote more choice in acute care: Primary care trusts (PCTs) will be responsible for making sure that from2006 they offer choices to patients PCTs will not need to direct patients to particular providers but will offer achoice of four or five local NHS providers, together with all NHS foundationtrusts and nationally procured independent sector treatment centres All other independent sector providers may apply to be on the list ofchoices for patients, if they are able to operate to NHS standards andat the NHS tariff Primary and community services will be encouraged to develop newservices and new practices Existing networks for emergency, urgent and specialist services will bestrengthened, with PCTs and strategic health authorities (SHAs) havingexplicit responsibility to review and develop them Current practice in shared commissioning will be developed with the aimof creating a far simpler contract management and administration system,which can be professionally managed and provide better analysis whileleaving practices and PCTs in control of decision making There will be greater focus on health improvement and developinglocal patient pathways and services.
The NHS needs a change of culture as well as systems to become truly patientled, where: everything is measured by its impact on patients the NHS is as concerned with health promotion and prevention – lookingafter the whole person – as with sickness and injury the staff directly looking after patients have more authority and autonomy,supporting the patient better. This will require: action to tackle the barriers that create rigidity and inflexibility inthe system shared values and codes of conduct, enshrining the desired changesin culture greater support of front-line staff and clinical leadership continuous learning, supported by the new NHS Institute forInnovation and Improvement a new model for managing change suitable for the new environment clearer leadership at all levels, integrated nationally through the newNational Leadership Network for Health and Social Care.
Models of care for alcohol misusers (MoCAM) A patient-led NHS needs effective organisations and incentives, with: a new development programme to help NHS trusts become NHSfoundation trusts a similar structured programme to support PCTs in their development further development of Payment by Results to provide appropriatefinancial incentives for all services greater integration of all the financial and quality incentives full utilisation of the new human resources and IT programmes.
Change on this scale involves uncertainty, and all organisations need toplan to manage the risks with some national support to: strengthen the role of the NHS Bank improve the way the NHS handles service and organisational failures improve the way that service change and reconfiguration is managed.
Alcohol harm reduction strategy
The Alcohol harm reduction strategy for England2 has four themes: improved education and communication better identification and treatment alcohol-related crime and disorder supply and industry responsibilities.
Choosing Health White Paper
Choosing Health: Making healthy choices easier3 highlights action on reducingalcohol-related harm and encouraging sensible drinking as one of its six priorities,and places alcohol firmly in the realm of public health practice. Choosing Health emphasises and builds on the recommendations in the Alcoholharm reduction strategy for England.2 It proposes: a national information campaign to tackle the problems of binge drinking a social responsibility scheme training for professionals piloting screening and brief interventions in primary and secondary healthsettings, including accident and emergency similar pilots in criminal justice settings a programme of improvements for treatment services additional funding will be available from April 2007. Crime and Disorder Act 1998
PCTs in England became ‘responsible authorities' under the Crime and DisorderAct 1998 (as amended by the Police Reform Act 2002) on 30 April 2004. Thismeans that PCTs now have a statutory responsibility to work in partnership withother responsible authorities, namely the police, fire services, local authorities andco-operating bodies to tackle crime, disorder and the misuse of drugs.
Over a three-year cycle, the Act places a duty on PCTs to: participate in an audit of crime and disorder, anti-social behaviour and drugmisuse for the crime and disorder reduction partnership (CDRP) area or areasin which they fall contribute to the development of local strategies that effectively deal with theissues which are identified.
The first audit in which PCTs participated was completed by the end of September2004 and, after consultation with local communities, the local CDRP was requiredto publish their strategy by April 2005. The strategy will last for three years.
The extent to which the PCT is involved in the delivery of the strategy is notspecified. In practice, this will be determined through local negotiation and it islikely to be greatest in areas where the delivery of action on drugs, alcohol andcrime and disorder makes a significant contribution to the PCT's own national orlocal priorities.
Action in support of local crime and disorder strategies may impact positively on a range of national NHS priorities, including: reducing health inequalities positive patient satisfaction surveys positive staff satisfaction surveys improvement in the life chances of children Models of care for alcohol misusers (MoCAM) increasing the participation of problem drug users in treatment implementation of the National Service Framework for mental health reductions in waiting times.
The Tackling Violent Crime Programme (TVCP), launched by the Home Office inNovember 2004, is one of the programmes funded and delivered through crimeand drugs partnerships. TVCP targets the highest violent crime areas only andfocuses on domestic violence and alcohol-related violence. (The British CrimeSurvey shows that 47 per cent of victims described their assailant as being underthe influence of alcohol.) Local crime and drugs partnerships work to deliver the young people's substancemisuse prevention agenda, and local authorities hold the young people'spartnership grant on behalf of the partnership. There is a particular emphasison targeting young people in high-focus areas (HFAs).
The Licensing Act 2003 is intended to provide: a clear focus on the prevention of crime and disorder a clear focus on public safety the prevention of public nuisance the protection of children from harm.
PCTs are not responsible authorities under this Act and local licensing committeesare not required to consult with PCTs when granting licences. Licensingcommittees are required to consult with crime and drugs partnerships, andPCTs can make their views and recommendations known through their crimeand drugs partnership.
The Respect Action Plan
The Government's proposals to deliver on the ‘respect' drive were set out in theRespect Action Plan. The aim of the respect drive is to ensure that all local areastackle unacceptable behaviour and its causes to improve quality of life for residents– particularly those in the most disadvantaged communities. Commissioners can ensure that alcohol treatment services inform and contributeto the provision of services to address the needs of those whose alcohol-relatedbehaviour causes harm to the wider community. Every Child Matters
This White Paper focuses on supporting all children, particularly those in vulnerablegroups, to have better outcomes as adults. Substance misuse, including alcohol, isan important element of this. Local strategic partnerships (LSPs)
In the interests of strong multi-agency working, a PCT will commonly agree itsshared objectives with local authorities and other partners through LSPs. Local area agreements (LAAs)
LAAs are an important new planning process that brings health inequalitiesand health outcomes to the forefront of local community planning. LAAs arenegotiated and agreed by regional Government Offices (GOs) on behalf of theGovernment, with SHAs responsible for agreeing PCT contributions to the LAAand informing GOs that they are acceptable. Regional directors of public healthwill support SHAs and represent the Department of Health in this process. Outcomes are negotiated between local authorities (and their partners) and GOson behalf of central departments. LAAs reflect both local and national priorities.
PCTs are responsible for leading the development and delivery of the healthelements of LAAs, with the support and encouragement of SHAs. The health and social care input in phase two LAAs (from April 2006) isfocused on public health and on services to adults at the interface betweenhealth and social care agencies For phase two LAAs, there is a need to ensure that LAAs' proposals areconsistent and aligned with already agreed local delivery plans (LDPs), throughlocal targets or agreed contributions to national priorities There should be scope for the LAA to build on the LDP, for example byidentifying joint action to tackle the wider determinants of health such asthe reducing alcohol harm priority identified in Choosing Health.3 Spearhead PCTs have been set particularly challenging targets to reduce healthinequalities in their area. Through the LAA process, PCTs can engage the localauthority and other local partners in the co-delivery role described inChoosing Health.3 Annex C
List of referenced documents
Review of the effectiveness of treatment for alcohol problems (NationalTreatment Agency for Substance Misuse, 2006) Alcohol harm reduction strategy for England (Prime Minister's Strategy Unit, 2004) Choosing Health: Making healthy choices easier (Department of Health, 2004) Models of care for the treatment of adult drug misusers (MoCDM) (NationalTreatment Agency for Substance Misuse, 2002) Alcohol misuse interventions: guidance on developing a local programme ofimprovement (Department of Health, 2005) Alcohol treatment pathways: guidance for developing local integrated carepathways for alcohol (National Treatment Agency for Substance Misuse, 2006) The Alcohol Needs Assessment Research Project (ANARP) (Department ofHealth, 2005) Office for National Statistics general household survey (Office for NationalStatistics, 2001) Interim analytical report (Prime Minister's Strategy Unit, 2003) World Health Organization lexicon of alcohol and drug terms (World HealthOrganization, 1994) WHO International Classification of Diseases: The ICD-10 Classification ofMental and Behavioural Disorders (World Health Organization, 1992) (ICD-10)(World Health Organization, 1994) Standards for better health (Department of Health, 2004) National Treatment Outcome Research Study (NTORS, 2001) Dual diagnosis good practice guide (Department of Health, 2002) National standards, local action: Health and social care standards and planningframework 2005/06–2007/08 (Department of Health, 2004) Models of care for the treatment of adult drug misusers: update 2006 (NationalTreatment Agency for Substance Misuse, 2006) Drugs and Alcohol National Occupational Standards (DANOS) (Skills for Health,2002) Roles and responsibilities of doctors in the provision of treatment for drug andalcohol misusers (Royal College of General Practitioners and Royal College ofPsychiatrists, 2005) Roles and responsibilities of doctors in the provision of treatment for drug andalcohol misusers, NTA briefing document (National Treatment Agency forSubstance Misuse, 2005) The NHS Improvement Plan: Putting people at the heart of public service(Department of Health, 2004) Quality in Alcohol and Drug Services (QuADS) – Organisational Standards forAlcohol and Drug Treatment Services (Alcohol Concern/DrugScope, 1999) Commissioning Standards – Drug and Alcohol Treatment and Care (SubstanceMisuse Advisory Service, 1999) The New NHS White Paper (Department of Health, 1997) Choosing Health Planning and Performance Toolkit for PCTs and their Partners(Department of Health, 2005) Care planning practice guidance (National Treatment Agency for SubstanceMisuse, 2006) Scan Consensus Project 1: Inpatient Treatment of Drug and Alcohol Misusers(Specialist Clinical Addiction Network, 2006) National Treatment Agency
Promoting safer drinking: A briefing paper for drug workers (2004) Department of Health
NTORS after five years (National Treatment Outcome Research Study):Changes in substance use, health and criminal behaviour in the five yearsafter intake (2001) Tackling health inequalities: A programme for action The NHS cancer plan: A plan for investment, a plan for reform National Service Framework for coronary heart disease Guidance for partnerships and primary care trusts (PCTs): Commencement ofPCTs as responsible authorities from 30 April 2004 Models of care for alcohol misusers (MoCAM) Home Office
Crime and Disorder Act 1998 and Police Reform Act 2002 The respect agenda Crime and disorder reduction partnerships Violent crime (including domestic violence) Violent Crime Reduction Bill Department for Culture, Media and Sport
Licensing Act 2003 Office of the Deputy Prime Minister (now Department for
Communities and Local Government)
‘How to' guide on engagement for integrated partnerships in respect of crime,alcohol and drugs Local strategic partnerships Local area agreements guidance Department for Education and Skills
Every Child Matters Health and Safety Executive
Guides to alcohol and employment Local alcohol strategy toolkit UKATT Research Team
UKATT Research Team (2005) Effectiveness of treatment for alcohol problems:findings of the randomised UK alcohol treatment trial (UKATT). British MedicalJournal: 2005 331 (download fr UKATT Research Team (2005) Cost-effectiveness of treatment for alcoholproblems: findings of the randomised UK alcohol treatment trial (UKATT).
British Medical Journal: 2005 331 (download fr Crown copyright 2006275925 1p 3k Jun 06 (ESP)Produced by COI for the Department of Health If you require further copies of this title quote 275925/Models of care for alcohol misusers (MoCAM) and contact: DH Publications OrderlinePO Box 777, London SE1 6XH Tel: 08701 555 455Fax: 01623 724 524Textphone: 08700 102 870 (8am to 6pm Monday to Friday) 275925/Models of care for alcohol misusers (MoCAM) can also be made available on request in Braille, in audio, on disk and in large print.
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