Treatment Policy in England A NICE perspective

1. Treatment Policy in EnglandA NICE perspective Professor Eileen Kaner

2. Translational agenda – getting evidence into practice to reduce alcohol-related risk and harm

3. So much evidence • Freemantle 1993 - 6 trials in primary care • 24% drop in consumption (95% CI 18 to 31%) • Moyer 2002 – 56 trials, 34 relevant to PHC • Consistent +ve effect, NNT 8-12 (smoking is 20) • Cost savings found at 4 years in the USA • Kaner 2007 – 29 trials in PHC & A&E • Consistent positive effects ~7 drinks less/week • Evidence strongest for men, less work on women • No significant benefit of longer versus shorter BI

4. So little practice • Majority of GPS may be missing up to 98% of excessive drinkers in PHC (Kaner et al. 1999) • NAO 2008 report on recent activity • 58% PCTs have an alcohol strategy • 69% provided data on expenditure • Spend is ~£600,000 on alcohol • About 0.1% of PCT annual expenditure of £460M

5. General policies – not enough • Alcohol harm reduction strategy 2004 • Choosing Health White paper 2004 • Prison Service Alcohol strategy, 2004 • DH Local Implementation guidance 2005 • Models of Care for Alcohol misuse 2006 • National Probation Service / NOMS 2006 • Safe, Sensible, Social – next steps 2007 • BMA tackling the alcohol epidemic 2008 • Safe, Sensible, Social: further action, 2008 • Healthcare Commission on choosing health, 2008

6. Practitioners want prioritisation: their ‘to do’ list

7. National Institute for Health and Clinical Excellence (NICE) • NICE produces guidance in three areas • health technologies – Drugs and interventions • clinical practice – Appropriate delivery of care • public health – Prevention goes beyond NHS

8. The alcohol agenda – it’s like buses! • Three referrals on alcohol to NICE • Prevention • Physical treatment • Mental Health Management • They came to separate parts of NICE • Complex agenda • Is carving it up the best way to deal with it?

9. Prevention guidelines due March 2010 • Scope: The prevention of alcohol-use disorders in people 10 years and older, covering: • interventions affecting the price, advertising and availability of alcohol; • how best to detect alcohol misuse both in and outside primary care; • brief interventions to manage alcohol misuse in these settings.

10. Clinical Management guidelinesdue May 2010 • Scope: Assessment and clinical management in adults and young people 10+, covering: • acute alcohol withdrawal including delirium tremens; • liver damage including hepatitis and cirrhosis; acute and chronic pancreatitis; • management of Wernicke’s encephalopathy

11. Dependence guidelinesdue January 2011 • Scope: Diagnosis & management of dependence & harmful use in people 10+, covering: • Identification and assessment • pharmacological and psychological/psychosocial interventions, • prevention and management of neuropsychiatric complications of alcohol dependence or harmful alcohol use

13. Levels of prevention • Primary prevention – strategies that aim to deter people from drinking heavily (whole population approaches, media campaigns, labelling) • Secondary prevention – early identification of clinical risk or harm and intervention to modify it • Tertiary prevention – intervention in early stage disease that aims to slow or stop its progression to more advanced or irreparable disease

14. Upstream

15. Down stream

16. Primary prevention questions • Price: What type of price controls are (cost)effective at reducing alcohol consumption and/or harm • Availability: Which interventions are (cost)effective at managing alcohol availability • Promotion: Which strategies are (cost)effective at reducing the promotion of alcohol use

17. Primary prevention outcomes • Expected outcomes: achange in the levels of alcohol consumption across the population • alcohol sales, availability, marketing activity • From these we can assume a subsequent impact on alcohol-related health or social problems across the population

18. Caveats • How robust is the evidence? • Difficult work methodologically • How specific is the evidence? • To adults &/or young people • How relevant is the evidence to England? • Can we make inferences from other countries

19. Secondary prevention questions • Context: What key factors increase the risk of hazardous and harmful drinking? • Identification: Are screening questionnaires, biochemical markers or clinical indicators a (cost)effective way of identifying risk or harm? • Brief Intervention: Are brief interventions (cost)effective at managing hazardous and harmful drinking? • Implementation: What arethe key barriers influencing practitioners’ ability to help people manage their drinking?

20. Secondary prevention outcomes • list of the key factors (contexts) associated with an increase in alcohol–related risk or harm - who may be at risk. • an efficient way of identifying adults and young people who are at risk due to their drinking. • a reductionin hazardous and/or harmful drinking in adults and young people. • System requirements to enable SBI to occur • Training/support • Materials • Time • Referral routes

21. Caveats • Imperfect evidence • Methodological flaws • Realistic evaluation of complex problems • How relevant is SBI evidence to England specifically • Volume of evidence • Summary of published reviews for BI – blunt approach • But are young people, BME groups adequately covered? • Making reasonable extrapolations • How far can you extend beyond published studies?

22. Challenges • NICE made up of different organisational cultures • 3 groups with ownership over the 3 scopes • Overlaps & gaps • prevention and early treatment • can we separate • physical and mental health management? • planned & unplanned detoxification? • Can this formal (rigid) process capture complexity • The continuum of risk/harm/dependence • Remitting nature of alcohol related problems

23. Consultation – interesting challenges • Some people shout louder than others • Where science and the ‘real world’ collide

24. Bringing it all together • Different timescale for the 3 sets of guidance • Integrated care pathways will be challenging • What impact will the consultation & field work testing processes have on the science • Will the ‘plain English’ editing strengthen/dilute the content • Making policy-level recommendations • If a general election is called, NICE goes into ‘purdah’