Sober realisation: specialist support for the NHS's alcohol problems15 May 2012
Alcohol-related admissions to hospitals in England have topped the one-million mark for the first time. The solutions some hospitals are putting in place to tackle the problem are timely, as Sir Ian Gilmore, Royal Liverpool Hospital, and Eric Appleby, Alcohol Concern, tell Nic Paton.
Debate and discussion around how healthcare systems should handle the issue of alcohol is anything but new. In 2001, the UK's Royal College of Physicians of London published a ground-breaking report, 'Alcohol - can the NHS afford it?', which made a series of important recommendations for the development of a "coherent" alcohol strategy for British hospitals.
The report argued that with over one in three men and one in five women regularly consuming more than the recommended limits, alcohol use was placing a significant burden on the workload of the NHS, and acting as a major cause of attendance and admission to hospitals, especially in A&E and nonemergency settings.
Among a raft of recommendations, it called for hospitals to develop better defined strategies for tackling alcohol misuse, more use of specialists, better assessment and intervention and, crucially, more leadership and direction at all levels to manage the effects of alcohol misuse on the health service.
There has been progress since the publication of that report, not least with the launch in 2007 by the Department of Health and the Home Office of a joint Government alcohol strategy that set out clear goals and actions to promote sensible drinking and reduce the harm that alcohol can cause.
But the unveiling of figures in 2011 by the NHS Information Centre (NHSIC), which suggested that alcohol-related admissions to hospital in England had topped the one-million mark in 2009/10 for the first time, shows just what a difficult and potentially intractable issue this is, for governments and health professionals.
Moreover, it is not just a UK problem - in Ireland, figures published last year calculated that hospitals spent more than €800m treating alcohol-related illnesses during 2000-04. Within the US, the health effects of alcohol use and misuse also remain a key area of concern for physicians and hospital administrators.
Alcohol specialist nurses
What is clear, argues Sir Ian Gilmore, professor of haepatology at Royal Liverpool University Hospital and past-president of the Royal College of Physicians of London, is that there are no quick fixes or easy answers to what is a complex problem that encompasses not just the resourcing of health services, but also much wider societal and cultural questions.
<div class="leftpullquote">"The use of specialist alcohol nurses by an increasing number of UK hospitals has proved successful."</div>
Yet Gilmore, who is one of the drivers behind the formation of the Alcohol Health Alliance UK in 2007, also argues that some of the solutions being put in place by hospitals can be effective without being overly expensive or complicated. In particular, the appointment and use of specialist alcohol nurses by an increasing number of UK hospitals has proved successful.
"I was involved with the first alcohol specialist nurses when they first emerged around a decade ago at Royal Liverpool Hospital," he says. "They have been incredibly cost-effective. We are seeing more alcohol specialist nurses, but it has been a very slow process over the past 10-15 years to get such positions implemented more widely."
Eric Appleby, chief executive of the charity Alcohol Concern, agrees that alcohol liaison nurses have a huge role to play in reducing the problems associated with alcohol. "The experience we have with them - and they are relatively new and the evidence is still emerging - is that they can make a significant difference," Appleby explains. "They can have a really solid effect on readmissions, and play an important part in picking up on cases, as well as informing training and best practice."
The 'Alcohol - can the NHS afford it?' report was essentially a blueprint designed to get administrators, politicians and clinicians to recognise the value that specialist input could have across a wide range of departments and specialities, according to Gilmore.
"It was very much about alcohol specialists needing to be the champions in the hospital setting," he explains. "Often you can find people with alcohol-related conditions simply ending up in A&E or being referred to gastroenterology because they deal with liver issues.
"What you need is a dedicated individual, perhaps a nurse or a mental health nurse, someone dedicated to working with alcohol-related problems. They will need to be able to work with staff within A&E, as well as with primary services and the community, to be able to get patients with alcohol problems referred to the most appropriate service, rather than necessarily coming to the hospital. It is about working across the primary and secondary care divide."
For example, the alcohol specialist nurse at Royal Liverpool has moved out into the community and holds clinics in a general practice setting. According to Gilmore, it is not just about seeing patients but changing attitudes.
"Often what happens is patients simply end up again and again within A&E, and A&E really cannot do anything except patch them up," he says. But with specialist support, there are some hugely cost-effective treatments out there. It is also about trying to make senior managers aware of the impact of alcohol on hospital services. It is a huge problem, much bigger than many people realise, but it is not a problem without solutions."
Appleby agrees it is not always about easing the burden on A&E, although that is an important part. "A lot of heart disease, cancer and strokes are alcohol-related, and some of those are not necessarily going to be going to A&E," he says. "For many chronic conditions, dealing with alcohol can be an important factor in helping to mitigate them; it is not just about people coming into A&E.
It should be noted that the rising figures suggested by the NHSIC may not all be bad news. Part of the increase can be put down to more screening in health services and better referral of alcohol-related problems - the effect of positive initiatives highlighting the extent of the problem more accurately.
Nevertheless, both Gilmore and Appleby say that a government-led focus on cuts, efficiencies and austerity across the West, in the UK specifically, and the distraction of significant NHS reforms, is not helping. Alcohol Concern has argued that, without more proactive government action, alcohol-related hospital admissions will have risen to 1.5 million by 2015, while the annual health cost will have increased to £3.7bn.
"The key, as ever, within hospitals is that it needs to be something being led from the top - from the senior management level - and that has been one of the problems in the past," says Appleby. "In any institution where there has not been a buy-in from the top, then it is going to be hard to feed it out across the organisation. But with something like this, it is possible to see benefits spread across the hospital. There can be more liaison, more collaboration, more openness and more learning.
"Alcohol is one of those areas that everyone knows plays a role, but it can be hard to pin down. Even when you are in a medical situation, it can be a topic that is difficult to broach. People can find talking about someone's drinking embarrassing and hard to address."
Talking about alcohol problems
One of the key roles of an alcohol liaison nurse is to get people talking about their alcohol problems, ensuring they get support and training and, according to Appleby, if the alcohol problem is addressed at the hospital, it could save millions.
"It is about achieving joined-up services across primary and secondary care, and making effective use of alcohol specialists," says Gilmore. "We have to keep on top of things, even in the context of the wider upheaval that is going on within the NHS at the moment."