Alcohol Health Workers

Transcription

1 Alcohol Health Workers Description and review of the Alcohol Health Worker posts Prepared for the Department of Health July 2010

2 Alcohol Concern Alcohol Concern is the national agency on alcohol misuse campaigning for effective alcohol policy and improved services for people whose lives are affected by alcohol-related problems. Alcohol Concern Training and Consultancy We work to develop the knowledge and skills of practitioners supporting people with alcoholrelated problems and operate a specialist consultancy service for commissioners: Providing customised training on alcohol issues for all mainstream workers through a network of alcohol professionals and experts. Offering a range of solutions to local areas delivering action on alcohol needs assessment and harm-reduction targets, including commissioners, service providers and planners. This project was written and researched by Mike Ward and Julie Aulton for the Alcohol Concern Consultancy and Training Unit and was funded by the Department for Health. Published by Alcohol Concern, 64 Leman Street, London E1 8EU Consultancy and Training Unit (CTU) Saneal Randeria CTU Manager Tel: , Fax: , consultancy@alcoholconcern.org.uk, Website: Copyright: Alcohol Concern July 2010 All rights reserved. No part of this publication may be produced, stored in a retrieval system, or transmitted by any means without the permission of the publishers and the copyright holders. Alcohol Concern is a registered charity no and a company limited by guarantee registered in London no

3 Contents Page Introduction 5 Describing the eight projects: 6 Doncaster 7 Westminster 9 Hertfordshire 11 Bolton 13 Liverpool 15 Bristol 18 Middlesbrough 21 Nottingham 24 A thematic review of the projects 26 Commentary 37 Appendix 40 1: Materials received 41 2: Questionnaires 43 3

4 Introduction Introduction 4

5 Introduction Since their report in 2001, the Royal College of Physicians has advocated the appointment of a dedicated Alcohol Health Worker or an Alcohol Liaison Nurse in each major acute hospital, to work with a named Consultant/Senior Nurse Alcohol Lead, to provide a focus for: Medical management of patients with alcohol problems within the hospital Liaison with community alcohol and other specialist services Education and support for other healthcare workers in the hospital Implementation of a case-finding strategy and delivery of brief advice within the hospital. The aim of this work is to: Produce a descriptive text on the variety of Alcohol Health Worker models being used across the country. The objectives are: To produce a report describing eight different alcohol health worker / liaison nurse teams to initiate a discussion about this type of work. To compile service specifications, service protocols, structures, job descriptions, data collection systems and other related information which can then be hosted on the Alcohol Learning Centre Website. Methodology Alcohol Concern agreed with the Department of Health eight different services which would be included to provide a range of models in the report: Doncaster, Westminster, Hertfordshire, Bolton, Liverpool, Bristol, Middlesbrough and Nottingham. A number of these have already been recognised as models of good practice in arenas such as the HubCAPP website or national reports; others were included because they were known to offer different approaches. Alcohol Concern interviewed the Alcohol Health Workers / Liaison Nurses and other relevant staff using a semi-structured interview format agreed with the Department of Health. Information from HubCAPP was also used. In addition Alcohol Concern sought and reviewed documents surrounding the project e.g. service specifications, service protocols, structure diagrams, job descriptions, data collection systems, data reports, annual reports or publicity material. These are listed in Appendix 1. The questionnaires used are included at Appendix 2. Acknowledgements The authors, Mike Ward and Julie Aulton, would like to thank Don Lavoie at the Department of Health, all of the interviewees and the Regional Alcohol Managers for their assistance in this project. 5

6 Describing the eight projects 6

7 Description of the eight projects This section provides a brief, standardised description of each of the eight projects. Doncaster Location: Doncaster Royal Infirmary Length of operation: Started November 2008 Number and type of staff One prescribing nurse based in an office in the hospital. Ownership of the service Employed by the Doncaster and Bassetlaw NHS Foundation Trust, who manage Doncaster Infirmary and have a similar and longer standing, post in Bassetlaw (North Notts). Role A drug and alcohol liaison nurse working equally with drug users and problem drinkers. The aim of the work is to: Make sure that existing polices and procedures about the management of substance misusers are adhered to across the site. Improve the quality of the patient journey. Provide support to patients and staff: in particular on prescribing to substance misusers and by acting as a link to specialist services. The long-term aim is to reduce hospital admissions. Training The nurse is involved in staff training. The nurse gives new staff an overview of alcohol and drug services and runs a two-day training course on alcohol and drug management in the hospital setting. Activity 600 referrals per year. 50% of the nurse s work is alcohol related. Source of referrals Medical assessment wards are the major referrer, but all the wards have a risk assessment procedure which includes FAST (Fast Alcohol Screening Test) and can refer clients. People who are moderately and severely dependent will be referred; however, the worker is not really providing a service to increasing risk and high risk drinkers, but will talk to them if the staff ask for it. Notifications may be received from A&E that a client is coming in to the wards and they may be seen in A&E but the post doesn t cover A&E. Links to external organisations The worker can refer to the two local services DAS (Doncaster Alcohol Service) or the CAT (Community Alcohol Team ). But both services have a waiting list. DAS prefer self-referral but will accept written referrals from the nurse. The wait for a CAT assessment is 8 to 12 weeks. CAT referrals will have to have another assessment, but clients could go straight from the ward to the CAT antabuse programme. They are looking at whether they can begin prescribing in hospital and then link the clients in to an out-patient clinic 7

8 Clinical governance Supervision comes from the Alcohol Health Worker (AHW) at Bassetlaw. The consultant at the drug and alcohol team and the consultant gastroenterologist have been helpful. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes. The aim of this post is to make sure that existing polices and procedures about the management of substance misusers are adhered to across the site. Investment 1 x nurse prescriber post. Evidence on effectiveness The post is relatively new but they are using assessment and risk assessment and structuring care based on the outcome of these assessments. Data gathering They are using a self-developed Excel framework to gather data. 8

9 Westminster Location: St Mary s Hospital Paddington Length of operation: The service has been in operation since January Number and type of staff Equivalent of two whole time equivalent (WTE) band seven nursing staff based in an office on the hospital site. Ownership of the service The post is owned by CNWL (Central and North West NHS Foundation Trust) who run substance misuse services locally. Role The work falls into three areas: Identifying hazardous, harmful and to some extent dependent drinkers and offering them IBA (Identification and Brief Advice). Education work. Supporting detoxification of dependent drinkers. The latter group constitute the majority of the referrals and are more likely to attend sessions than other clients. Training In the hospital they are still in the junior doctor rotation. Training for nurses is harder because of time pressure and because nurses don t have a structured education. But the Alcohol Health Workers occasionally do minutes on the wards focussing on nursing tasks and alcohol e.g. going to handovers for nurses to do brief education. Nurses involved in the care of individuals will be given feedback as an ad hoc form of teaching. Activity Two workers are covering Monday to Friday 8am to 5pm: a Saturday pilot has not been continued. The majority of work is assessment in terms of simple numbers but in terms of time the majority is withdrawal work although this has not been quantified specifically in terms of time. There have been 800 referrals for the year all will have had a brief intervention from the workers or the doctor, 100 will have been seen before. There are nearly 300 additional contacts i.e. outpatient appointments for controlled drinkers and other follow-ups or reviews. 9

10 Source of referrals The workers try to cover all parts of the hospital; however, the response varies. The medical admissions ward and the liver ward are the best. The orthopaedic work has never taken off and they are trying to link to the Falls Prevention agenda. Older adults are lower on their agenda. However, older people would have a huge impact on numbers if staff routinely asked everybody about drinking. The Trust has a maternity drug and alcohol worker and as a result they only receive a couple of referrals. They are a very aware group of staff and have been provided with teaching sessions. The psychiatric liaison team deal with alcohol as part of their assessments, but it will not be their priority and they would probably not have the time to do it. Links exist and the liaison team have just done a self-harm audit which highlights alcohol s role. The community drug and alcohol service can be encouraged to send people if they are concerned about medical issues and GPs have, on a couple of occasions, sent a patient to speak to them. Links to external organisations Good links exist with alcohol treatment systems: they are part of the same Trust. The question is how far out of borough to go to make contact with all the areas covering patients admitted to St Mary s. Clinical governance In the hospital the line of contact is the consultant in A&E but all the consultants and registrars are approachable for problems. Line management is received from the substance misuse services and a third branch is nursing supervision within CNWL. A monthly report goes to the commissioners and is copied to A&E consultants and managers and discussed with the lead consultant for A&E where any issues arise (such as current reduced numbers of referrals). Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes. It was developed five years ago. Practice was variable before that: people were going into withdrawals or being over-treated. The policy is due for review this year: it has been reviewed once already. They hope to review it in line with the NICE (National Institute for Clinical Excellence) guidance. Investment Two nursing posts. Evidence on effectiveness The impact of the Paddington Alcohol Test has been widely researched and has been shown to be effective. However, it is harder to prove the impact of the AHW role. Patients are not followed up. The workers feel they are having an impact on bed nights but cannot prove it as yet. Data gathering The actual dataset has been largely devised by the AHW and now includes an AUDIT score. Data can also be drawn from the hospital Symphony system which has an alcohol screen and from the Paddington Alcohol Test form used in A&E. 10

11 Hertfordshire Location Based in four hospitals across Hertfordshire: Watford General, QE2 Welwyn Garden City, Lister Stevenage and Hemel Hempstead Urgent Care Centre (may also soon incorporate St Albans urgent care). Urgent care services have lower levels of demands. Length of operation Started in late 2008, but there was a pilot in Watford General in Number and type of staff One WTE alcohol worker in each of four locations although the Hemel post which is less active is also working across to Watford. The workers have bases in each hospital site where they can access computers and see clients. However, they do not have a formal office base. They come into the Turning Point office for supervision. Ownership of the service Turning Point under contract to the DAAT Joint Commissioning Team. Role This service s focus is on the provision of IBA to people who present at A&E and in the rest of the hospital with alcohol related problems. It does not undertake detoxification or detoxification support work. However, clients could be referred into their Tier 3 service for a comprehensive assessment and thereby to the local CDAT (Community Drug and Alcohol Team). Staff, e.g. A&E nurses, have a screening form to complete and then refer to the AHWs. The workers arrange to see the client before they are discharged from hospital. They deliver a brief intervention and give them a binge pack with alcohol information. They use FRAMES to structure the intervention. If more serious problems are identified they work to engage them in structured services. The AHWs do see people who come through A&E and are not admitted. They are also doing shifts to 3am on Friday and Saturday to cover the peak A&E period. This is working well and they are picking people up. If people are too drunk, the AHWs will leave details for the client to make contact. Training The AHWs have undertaken training with: Discharge Coordinators Nurses band 4 Sisters band 7 Junior Doctors FY1 Junior Doctors FY2 Registrars Ambulance personnel The AHWs don t teach how to deliver brief intervention: the sisters have said it is too time consuming, although originally this was the aim. They take slots in team meetings and handovers. 11

12 Activity Each worker sees patients per week, plus they do follow-up for those that need onward referral. Alcohol-related crime data is also being collected and passed on to the police. This logs where the incident took place, whether a weapon was used and where the person was drinking. (This is anonymous data and is essentially from the victim not the perpetrator). Source of referrals Primarily referrals come from A&E (80-90%). Acute admissions unit and gastroenterology are the other main source. They have worked with maternity on awareness raising but they have had no referrals. Links to external organisations Turning Point is a Tier 3 service in Hertfordshire and, therefore, provide a link into local substance misuse services. They have very few clients from out of area activity (less than 1%). Clinical governance They are covered by the Turning Point clinical governance framework. All roles are mapped to a profile and a job description and managed accordingly e.g. training and induction. They have six-weekly one-to-one management support and supervision. File audits are undertaken. They have monthly hospital liaison workers team meeting and the workers support each other. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? They are not aware of this as it is not part of their role. Investment 140,000 per annum via the Joint Commissioning Team. Evidence on effectiveness Targets are in place from the commissioner; these cover turnover and the number of binge packs given out, the number of people referred into Tier 3 and the number of re-presentations. Three months after every brief intervention they do a telephone follow up and complete a questionnaire with the client as well as re-doing the AUDIT. Feedback has been very positive. Data gathering The AHWs use an alcohol brief screening form and the Hertfordshire triage form. Both are completed with the patient as well as a risk assessment. They record the AUDIT score, attendances, follow-up evaluation feedback, alcohol-related crime data, the number of binge packs, the number of onward referrals and number of readmissions following the brief intervention. All the data goes on to the Turning Point client management system and it can run reports per hospital, client features and what activity was undertaken. 12

13 Bolton Location: Royal Bolton Hospital Length of operation Post has existed 12 years; current post-holder has been in place for 6 years. Number and type of staff One WTE nurse based in an office on the Gastroenterology ward on the hospital site. About three years ago they established a liver nurse post who works alongside the AHW on alcohol detoxifications on the gastroenterology ward. Ownership of the service The main post is owned by the Greater Manchester West Mental Health Trust who run the local substance misuse services. The liver nurse post is owned by Royal Bolton Hospital NHS Foundation Trust who run the hospital. Role The main focus of the post is working with dependent drinkers. The aim is to identify clients as early as possible to see if they need admission or can detoxify at home and to undertake and support detoxification. Brief Interventions constitute only 15-20% of the work. Tasks include: Visits to the medical assessment unit on Monday to Friday mornings to pick up referrals. Running a clinic on A&E two mornings per week. The A&E can book anyone who has been in A&E and is being sent away. The aim was to do Brief Interventions but it has tended to more dependent clients. Brief Intervention is about 15-20% of the work. They try to have a link nurse on each ward that is responsible for maintaining ward information and acting as a link. This system does work well. Training Training is a big part of the role. The worker has staff and students who spend a day shadowing. They recently ran a full day training package covering IBA and long term physical health and detoxification. They were running a rolling four-week training programme covering information, detoxification and effects of alcohol. This ran continually for six months. This was run at a time when staff were able to attend i.e. at shift handovers. However, this dropped off towards the end and they stopped it but may start it again soon. Staff turnover is high so the worker had to run the training again. They try and run link nurse updates on a quarterly basis. Activity 296 referrals and 190 assessments in 2008/9. 13

14 Source of referrals The main sources of referrals are the Gastroenterology ward and the Medical Assessment wards. Referrals from Surgical, Orthopaedic and Cardiology wards are fewer. They receive an occasional referral of an older person from complex care. Maternity are not referring. Medical Assessment has become better at referring people. They can pick up increasing risk and high risk drinkers and refer for Brief Interventions but they are not identified as often as dependent drinkers. It often depends on the doctors and their recent training. They do not have referrals from outside the hospital. Links to external organisations They have links to the local alcohol services: the CAT and ADS (Alcohol Drug Service) (the route is dependent on the AUDIT score). Because of the hospital s location they also have patients from Wigan and Salford. So they link to local services in those areas e.g. Willow. Links also exist with mental health services. Clinical governance The post s direct line manager is the manager of the CAT who looks at appraisal and service development. The worker attends the Greater Manchester alcohol liaison nurse forum. The worker goes to the CAT once a week for a team meeting and admin tasks. No formal governance comes from the hospital side; however, the Liver Nurse and AHW support each other. The Nurse Consultant in Gastroenterology can also be supportive but this is not a formal relationship. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes. The liver nurse has just re-written the protocol and it has been approved by pharmacy. It is on the intranet. It is obvious when people don t look at it you can see odd prescribing programmes. They try and get staff nurses to point it out to doctors. Pabrinex use is also covered in the protocol. Investment The PCT (Primary Care Trust) supports the cost of the nursing post. Evidence on effectiveness They are just starting to report monthly activity to the Trust Board for the hospital. Patients that do not attend appointments are high in A&E referrals: about 50%. A&E gave out a leaflet explaining what to expect and this has helped increase referrals. On the wards it is not so bad appointments are rarely missed. However, on Orthopaedic wards, after initial contacts clients are not always followed up before they leave. Data gathering The AHWs are now recording activity: numbers seen, number of triages, length of stay. They are aware it is something that they should have been doing but they are just tackling it. 14

15 Liverpool Location: Royal Liverpool Hospital / Liverpool Community Health Length of operation: Over 10 years Number and type of staff Two nurse prescribers (one band 7 nurse and one band 6 nurse) with input from a nurse consultant. Ownership of the service The nurses in Liverpool are employed by the PCT. If they were employed by the Acute Trust the nurses line management would come from within that Trust. The operational management of the service could be improved by this change. Role The service was set up to respond to alcohol-related attendance and admission and to optimise medical management of these patients to reduce length of stay or prevent admission. Additionally, the nurses were to offer brief advice to risky drinkers. In theory the team should have a 70/30 split in patients receiving IBA and those being case managed. However, in practice they are seeing mainly people drinking at dependent levels. IBA training sessions are run across the hospital and usually ward nurses are delivering these interventions anyway. The specialist nurses manage a caseload and run daily treatment clinics. In the A&E Department new patients are provided with a full medical assessment and those with physical health problems are managed in partnership with, for example, hepatology. Clients having a detox visit daily to have their withdrawal symptoms monitored and obtain the medication. Role summary: Providing patients with choices Supporting quality of care Optimising medical management Being a champion and clinical leader Providing support and advice to contemporaneous care givers Effective utilisation of resources Training The AHWs provide training to junior doctors and medical students at the university. They provide regular training to nurses and other professionals within the hospital. Activity 845 in-patients per year, 15 sessions per week in primary care and 25 sessions per week in emergency treatment clinic in A&E and 15 out-patient sessions per week. 15

16 Source of referrals The strongest links are with the A&E department, Medical Admissions units, Hepatology and Gastroenterology, Maternity and ante-natal care is in a different hospital and this is a major gap in the service provision. Mental health is in a similar position. Otherwise they take referrals from all directorates and the wards make referrals via a computerised system. The ward referrals are usually those drinking dependently. They run an outpatient clinic based at the hospital, a primary care clinic and an emergency access clinic. Referrals into these clinics come directly from GPs or other primary health care professionals. Links to external organisations The service follows clients up for at least two sessions and up to six after they have completed their detox and then discharges them or refers them on to other services. The Tier 3 service in Liverpool is the Windsor Clinic. The relationship between the ASN (Alcohol Specialist Nurse) service and the clinic has historically not been good; however they expect the links to improve. They do not generally refer many clients on to them: about 6 in Clinical governance The nurse consultant provides formal clinical supervision. All nurses work to a competency framework based on DANOS and the NHS knowledge and skills framework. A multidisciplinary group of clinicians, managers and commissioners from acute and primary care reviews developments. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes protocols for fixed schedule dosing and symptom triggered dosing. Investment Two nursing posts Evidence on effectiveness The project began as a research project with a doctoral thesis and a paper was published in 2005 on the effectiveness of the team. Results: Reduction in health loss Reduction in health service consumption Preventing admission of 23 patients covers the entire cost of the ASN service Admission of 258 patients prevented over 18 months. The model has been tested in a controlled cohort study (2008). Results: Reduced AUDIT score (p = ) Reduced SADQ score (p = ) Less A&E attendances (p = 0.023) Lower length of hospital stay (p = ). * p values Wilcoxon 16

17 Data gathering The project has an electronic referral system which facilitates data collection. JMU have developed a service specific database. 17

18 Bristol Location: Bristol Royal Infirmary Length of operation: Started in 2002 as a 2 day per week job on the Hepatology ward. Number and type of staff 1x Band 7 Alcohol Specialist Nurse for in patient services employed within the division of medicine. The nurse is full time with a background in hepatology. 1x Band 6 Brief Interventions Nurse for Accident and Emergency. The current post holder has a background as an adult mental health nurse and has completed the online Brief Interventions training provided by the Alcohol Learning Centre. This is a full-time post managed by the A&E matron. Ownership of the service University Hospitals Bristol NHS Foundation Trust which runs the Royal Infirmary. The funding is from NHS Bristol. Role The ANS offers: Assessment and management of in-patients with harmful drinking patterns and acute unplanned alcohol withdrawal. Clinical advice and support on alcohol detoxification, patient safety and comfort and discharge planning. Liaison/referral to other agencies. Teaching and education to other ward staff. Management of a nurse-led alcohol clinic. Support to the rehabilitation of those with chronic liver disease, ensuring the right advice and support for those with cirrhosis. Identification of patients at increasing risk and high risk drinking and delivering Brief Interventions in order to change drinking behaviours and minimise short- and long-term harm to health. The A&E nurse sees patients in the department on an opportunistic basis to try and deliver Brief Interventions about alcohol and to help direct and signpost patients to more appropriate areas for support in the community when required. The nurse also runs a clinic each afternoon. Both nurses deal with a lot of other issues related to alcohol misuse such as homelessness, child protection, mental health problems and domestic abuse etc. As a result of these issues, links and contacts have been set up with various support agencies around the Bristol area and they continue to do so in order to be able to provide a service. They also provide support for staff in managing patients with issues around alcohol misuse, such as managing withdrawal. Training Training and support is provided for A&E and other ward staff, e.g. training on how to carry out Paddington Alcohol Tests. Training is provided formally and on an ad hoc basis by the hepatology nurse to medical students, junior doctors, nurses, allied health professionals etc. The nurse arranges local alcohol awareness days and provides formal teaching on violence and aggression course at UHB. The nurse also provides sessions on the annual Hepatology Nurses Study day. 18

19 Activity The in-patient service receives approximately 700+ referrals per year. The A&E service is new patients have been referred to the service since October Source of referrals A&E, Medical Admissions Unit, Hepatology ward, Surgery and Trauma and Orthopaedics departments. Links to external organisations The nurses refer to local external agencies for support and withdrawal. Clients are also encouraged to refer themselves. They have excellent relationships with statutory and non-statutory bodies but the problem is that they can wait weeks. One man who has been in three times for alcoholic hepatitis, has been encouraged to seek help and referred to the NHS addiction unit but will now have to wait four months. Clinical governance Patient feedback has been obtained in the past and is planned for the future. The consultant hepatologist offers weekly supervision to the alcohol nurse specialist (this is on top of the consultant s existing job plan) and the individual also has a line manager within the nursing division (senior matron). The consultant hepatologist also acts as the clinical effectiveness lead and thus links into clinical the governance system at both divisional and Trust level. The Trust Steering Group also reviews the ANS role via bi-monthly meetings (e.g. operational issues, effectiveness and governance). The A&E nurse is managed within the A&E. There is a Trust alcohol steering group and both nurses attend this group. They are also seeking a formal Trust strategy on alcohol. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes - both fixed dose and symptom triggered regimens in line with recent NICE guidance. Investment 80,000 pa. Evidence on effectiveness They look at abstinence rates in cirrhosis cases because this is a sign of success with those clients. They are achieving abstinence in 47% of cirrhotic cases at six months after intervention. A local document Calling time on alcohol-related harm: Evaluation of an Alcohol Nurse Specialist within United Bristol Healthcare Trust has been produced. The research documented reductions in length of stay, reductions in finished consultant episodes within the Trust in the frequent flyers cohort and reductions in A&E attendances. Research by the Psychiatry team showed a reduction in violence and aggression. Recently they have reduced the length of stay for acute uncomplicated alcohol withdrawal further by the introduction of a symptom triggered withdrawal regimen in the Hepatology unit. They also receive good feedback from the patients. Their research showed that 31.9% of referrals had never had any alcohol help previously and that referrals to the Addictions unit from the Liver Nurse are much more likely to attend than if referred by GPs perhaps because they spend more time with them. 19

20 Data gathering The nurses have a standard form a self-designed Excel spreadsheet. They went for a rigorous approach to data collection but the nurses are very busy and it is difficult to keep on top of the data. 20

21 Middlesbrough Location: James Cook Hospital Middlesbrough and North Tees University Hospital Length of operation: Started 2007 Number and type of staff 1 full time Team Leader 1 full time Alcohol Liaison Nurse (Scale 7) 5 x 0.5 equivalent Substance Misuse Workers 1 full time Administrator. The Liaison Nurse is seconded to the team from the hospital Trust. Substance misuse workers have, as a minimum, a qualification in basic counselling skills, motivational interviewing skills, drug/alcohol awareness, an understanding of drugs harm minimization and training in Identification and Brief Advice (IBA). The grade 7 nurse has worked on the Gastroenterology Unit for a number of years, has numerous associated qualifications and will be undertaking prescribing training / qualification. Ownership of the service The service is commissioned via the Safer Middlesbrough Partnership (SMP) and is funded using PCT mainstream and Alcohol Early Implementer monies. The Albert Centre, a voluntary organisation, employs the PADS (Primary Alcohol Drug Service) substance misuse workers. The Liaison Nurse is employed by the hospital Trust but seconded into the PADS service. The agency feels that the staff being employed by the voluntary sector makes the service more cost effective but recognises the need for the input from nursing staff hence the appointment of the nurse. Role The service operates Monday to Friday and on Saturday and Sunday mornings. They perform substance misuse assessments to hospital inpatients and ensure that clients access the most appropriate community service quickly. (They see drug and alcohol clients but the split is approximately 95% alcohol and 5% drugs.) The substance misuse workers would generally be delivering IBA and extended BI. The role of the new alcohol liaison nurse is to work predominantly with the dependent drinkers. The nurse has been employed to support the management of alcohol detoxes in the hospital and advise medical staff on prescribing for detoxification. The plan is that they will eventually develop a pathway into the specialist prescribing service for continuation of detoxification making sure that chlordiazepoxide regimes are compatible Training PADS provides training to a range of professionals. The aim is to build the confidence of the medical staff in screening and Brief Advice. Training is delivered on a needs basis. They link into the mandatory training for new doctors every quarter. They provide training to nursing staff on the induction programme and also target specific wards on a monthly basis. They also link into the training for medical students. Training covers: alcohol awareness, AUDIT screening tool, IBA, referral pathways, harm minimisation. 21

22 Activity Approximately 1,000 referrals per year in 08/09 with about 75% attendance rate. This is on course to rise in 09/10 with over 800 referrals in the first 7 months. Source of referrals They cover all directorates within the hospital. The main referrers are: A&E department, Acute Assessment Unit, the Trauma Unit, the Gastroenterology Unit, the Short Stay Unit and the Infections Unit. All wards are visited daily to enquire whether any patients qualify for referral into the service. They don t have a clinic in A&E; however, the Cardiff model is used in A&E to classify admissions and the PCT have added extra fields so that identification of alcohol related problems is common. The A&E staff are trained in IBA and would refer those who are not admitted into hospital to community services or the open access service. The acute admissions department offers an outpatient clinic and they see patients in that clinic and are trying to develop links with GUM (genitourinary medicine) clinics and cardiology clinics. They are also doing work around frequent flyers: an alert generates a referral to the PADS assessment service Links to external organisations Referrals can be made to either The Albert Centre or the specialist prescribing service based on the AUDIT score (a score of 25 or above would lead to referral into the specialist prescribing service) but this is a general rule and professional opinion is also used to guide the onward referral. Clinical governance The service is monitored via commissioners within the SMP and also via a treatment provider forum within the SMP structures. The PADS service is line managed and supervised by one of the Albert Centre s Operations Managers and follows the policies of the Centre Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Not currently but it s something they are working on. They are waiting for the NICE guidance to be published. The hospital started doing symptom management only because the PCT wouldn t fund them to do detoxes. That meant that patients would only receive PRN (as required) medication rather than a regime. They use the sedation policy. Investment In it was 70k for 2 full time equivalent workers plus admin support. 175k has been added for increased provision as part of the Early Implementers programme. Evidence on effectiveness A local research project showed that those patients who had had an assessment and input from the PADS service were in hospital for an average of 2 days less. They contact a minimum of 15% of service users via telephone/ questionnaire for feedback. This information is passed to the commissioner. Statistical analysis of data informs service delivery times and to some extent development needs. 22

23 Data gathering The service has its own data gathering structure which can provide detailed activity information. 23

24 Nottingham Location: Queens Medical Centre, Nottingham Length of operation: Since 2002 Number and type of staff Originally there were two full time posts but this has just risen to six including one which works with drugs The team also has admin support. The AHWs are: 1 x band 7 nurse 3 x band 6 nurses 1 x band 5 nurse. Ownership of the service Originally one post was managed by the Mental Health Trust who ran local substance misuse services and the other was managed by the Trust which runs Queens Medical Centre. Role The primary aims were to dovetail people in to services. The need was identified by the consultant hepatologist and consultant at the substance misuse service. The hepatologist would identify problem drinkers, try and refer them but they would be lost to the system. Liver disease clinics were set up. Assessments for Tier 3, saw people on the ward and would then see them on Newcastle House the next day. In the first 4-5 years they undertook a significant number of out-patient detoxifications which had a short term positive effect in clearing beds. At points the workers have actually gone on to wards and dealt with injecting lorazepam in to a patient with DTs. This helped them become accepted on the ward. They have also made sure people had Pabrinex because of concern about the number of people with Korsakoff s syndrome. Frequent flyers who attended A&E more than three times in a month are case conferenced. IBA work is undertaken but the main focus is with the more dependent drinkers. Training Training is done via the School of Nursing and via the intensive care nursing course at the University of Nottingham. They also input to the doctor s training rotation as well as teaching 3rd year student doctors once a year for half a day. Activity Around 800 referrals per year with an average of 2.5 sessions per client. 24

25 Source of referrals Medical Admissions wards provide the highest proportion. Hepatology and Gastrology provide about 20% of clients: mainly people who are in for surgery. Other referrers include: Maternity, Gynaecology and Obstetrics. A&E refers but they would see them on a ward rather than in A&E. Tier 3 services refer to them for blood tests and other medical concerns. Pharmacists have also been very helpful in alerting the team to people who might be being missed or to detox clients. They have worked with the psychiatric liaison team but they had to be careful of boundaries to avoid being drawn into large numbers of overdose cases. Links to external organisations The service is integrally linked to the local substance misuse services but they have also developed links with treatment services in Leicestershire and Derby because of the number of patients who come from out of area. Clinical governance This was a cause of concern. The manager was the drug service manager: but because it was a new role they did not fully understand what the post-holder was doing. At times for risky people they have had to alert two groups of people: hospital and drug service managers. The team are responsible to the Consultant Hepatologist for the outpatient liver clinic. Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? Yes the AHWs were instrumental in writing it. Investment Five nursing posts as above. Evidence on effectiveness They have spent a long time working on this. The Consultant Hepatologist felt that the team cut violence and aggression in detoxification patients by 40% because of the protocol. They believe that they are saving bed days, but this has not been calculated. Data gathering They have developed their own database which is similar to the NDTMS (National Drug Treatment Monitoring System) data structure. 25

26 A thematic review of projects Introduction 26

27 A thematic review of the projects This section looks across the eight projects and compares each service s approach to specific aspects of the role. Models - What do workers do? Alcohol Health Workers and Liaison Nurses operate on a continuum with solely IBA work at one end to entirely medical interventions such as detoxification at the other. Some services, most obviously Turning Point in Hertfordshire, have been set up to do IBA and do not have the skills to do medical work and are therefore focusing on their core work. Many of the other posts appear to be stretched between the two roles. At least four interviewees recognised that they had been established with an expectation that they would undertake more IBA work but that the priorities of the hospital had pulled them towards medical support or work with dependent drinkers. The majority of posts were working at the medical end of the continuum. Area Proportion of client work focused on IBA Proportion of client work focused on medical work Bolton 15-20% 80-85% Bristol One nurse focused on this element One nurse focused on this element Doncaster 0% 100% Hertfordshire 100% 0% Liverpool Minority of work Majority of work Middlesbrough 20% under 20 on AUDIT 80% 20+ on AUDIT Nottingham Minority of work Majority of work Westminster 45% of work 55% of work Both these roles are legitimate and very difficult to turn into just one role. The concern is that commissioners have set up posts at one or other end of this continuum but believe they are meeting all the needs. Within the medical role different tasks were identified. These encompassed: Detoxification the most commonly identified task. This can cover both detoxification on a ward and hospital initiated detoxifications which are completed at home. Linking chronic drinkers into local services. Advice and information about alcohol and its effects to people with liver disease. A further division is between the use of in-hospital work and the use of out-patient clinics. Both models are used and often both are used as part of a single clinical role. Those offering out-patient clinics may see clients for several weeks after discharge e.g. in Doncaster clients are seen for 6-8 weeks as out-patients. Bristol, however, argued that this approach could overlap with the role of community alcohol services. A further extension of this role is highlighted in Nottingham where community alcohol services can refer people to nurse out-patient clinics for blood tests. 27

28 Number of staff The number of staff ranged from one to a team of six in Nottingham. The numbers seem unrelated to factors such as population or level of alcohol related harm. Area Number of staff Population Staff per capita Alcohol-related Hospital admissions rate per 100,000 pop 07/08 Bolton 1 262,400 1:262,000 1,897 Bristol 2 410,500 1:205,000 1,940 Doncaster 1 290,300 1:290,000 1,654 Hertfordshire 4 1,058,600 1:264, Liverpool 2 436,100 1:218,000 2,612 Middlesbrough ,400 1:30,000 2,517 Nottingham 5 615, :123,000 1,778 Westminster 2 231,900 1:116,000 1,273 It is likely that, at present, the number of workers is a function of local funding, lobbying from providers and support within the commissioning system rather than an assessment of need. This study cannot provide robust data on how many workers are required. In most cases, it was possible to identify unmet need in terms of areas of work, e.g. Brief Interventions are underdelivered in most cases, or in terms of wards which are not referring, e.g. older people. Nottingham s team has grown from two to six workers but it is too early to say whether this is meeting the need. In Hertfordshire, commissioners are now considering increasing the number of workers by providing nursing staff for detoxification work. The most useful data in this regard is the number of clients seen by each worker. Area Approximate no. of alcohol referrals pa Number of workers Number of alcohol referrals per worker Bolton per annum Bristol per annum Doncaster 250 pa 1 (0.5 alcohol) 500 per annum Hertfordshire 3,000-4,000 pa per annum Liverpool per annum Middlesbrough 1, per annum 1 Nottingham is taken to cover the City plus the three neighbouring boroughs which also use the hospital. 28

29 Nottingham (now rising to 6) 400 per annum Westminster 1,000 pa per annum However, even this data is problematic because workers operate in different ways. The Doncaster post is concentrated on detoxification and will see fewer clients but more intensely, whereas the Hertfordshire workers will see most clients only briefly. Nonetheless these figures suggest that it is reasonable to expect: A nurse offering detox support to see patients per year An IBA worker to take referrals per year. How viable is this role for a lone worker? Only one of the areas had one worker in the strictest sense, i.e. Doncaster. However, Hertfordshire has a team of four spread across four hospitals and Bolton has one worker with informal support from another post in the hospital. Other posts, such as St Mary s have been lone roles in the past. The researchers expected that staff would identify lone working as a problem. This was not always the case. Workers tended to recognise that lone working could pose problems but that the key was to recruit people who worked well in that setting. One interviewee commented: It is hard to go in on your own, it is not a job that one person can do there are issues of support and stress management when dealing with difficult staff or patients. Another said: Lone working can be very daunting. Another commented: The volume of work sometimes makes the role a bit difficult and if there was more than one person in post I could do more in depth work at the bedside including more motivational work and a more in depth assessment. However, another project commented: Who is running the programme is crucial They are not really lone workers they are an addition to the hospital team. Interviewees were more positive than negative about the possibility of lone working. However, this reflects the fact that many of the interviewees are pioneering incumbents. This does not prove that this is a model that can be replicated across the country. Staff competencies All of the posts interviewed are either voluntary sector workers or nurses. The choice will depend primarily on what will be required of the workers. The IBA workers in Hertfordshire and Middlesbrough do not need a medical background and are operating satisfactorily. If detoxification support is required then clearly a nursing qualification is required. As one service suggested: We think that the staff being employed by the voluntary sector makes the service more cost effective and we recognise the need for the input from nursing staff hence the appointment of the ALN. However, a couple of qualifications need to be made. Firstly, in the interviews there was a bias to feeling that appointing a nurse was the best approach because they would find it easier to integrate into a hospital setting. I don t feel that a non-nurse could do the role. It would depend on their experience. I feel that nurses and doctors would relate better to a nurse and if not a nurse the degree of experience in working with drinkers would be the key. It is not necessarily a general nurse. It could be a mental health nurse. Even a service using voluntary sector staff stated: The staff are happy to hand over clients with alcohol: a nurse would be useful however. Nurses can give validity. But you don t need to be nurses. 29

30 The second problem is that commissioners have appointed nurses with the expectation that IBA will be part of their role. Yet by appointing a nurse this facilitates the post-holder being pulled away from IBA to medical interventions. Operating times Most work was undertaken during normal working hours from Monday to Friday. As the majority of these posts are dealing with inpatients late night work is less relevant. Nottingham felt that evening work was not as useful as daytime work because patients were much more likely to have visitors in the evening. Those services targeting A&E specifically had more varied hours. Hertfordshire s staff were working late on Friday and Saturday night and felt that this worked well in A&E. Who should employ the post? The posts reviewed are either employed by a voluntary organisation or by an NHS Trust/PCT, but in only two cases are the posts owned by the Acute Trust which ran the hospital. The question is where best to place these roles. Area Bolton Bristol Doncaster Hertfordshire Liverpool Middlesbrough Nottingham Westminster Ownership of post Mental Health Trust Acute Trust Acute Trust Voluntary Organisation PCT Voluntary Organisation Mental Health Trust Mental Health Trust If the role only requires IBA and a voluntary sector worker is to be used, then the choice is straightforward. However, if a nurse is to be used, should they work for the trust which manages the general hospital or the mental health trust which generally provides the substance misuse services? Views were split on these and most interviewees could see both sides: I feel that the post should belong to the hospital but the person being seconded from the substance misuse services is also helpful. They can come in as external workers as with psychiatric liaison and that can work. However, it does help if the Acute Trust owns the contract and owns the post. An Acute Trust employee said: I am employed by the Acute Trust...I think this helps to support the objectives of the role but I suppose there are pros and cons. I think it helps me to have greater influence in the management of ward patients and the correct management of detox and the protocol for detox has been accepted and is used. I think that s because I am part of the team here at the hospital I feel as though I am a part of the Gastroenterology team. Another interviewee who worked for a Mental Health Trust said: I have not had recent problems with the ownership. I found it difficult at first, knowing how things are done Hard to say which is best the links with CAT are good being part of both teams is helpful...there were problems with 30

31 access to computer systems particularly when I was on my own had difficulty accessing notes as well as just admin and documents. Another Mental Health Trust employee highlighted similar problems: At first there were problems e.g. I couldn t write in the notes: this was sorted out. Authorisation to use the computer system was also a problem. All publications and press releases required two logos and approval from two bodies There were arguments about who should pay to put up a noticeboard in A&E. However, interviewees also saw the benefits of being linked into the Mental Health Trust that manages local alcohol services. One said: I could see people on the ward and then see them at the alcohol service the next day. It is impossible to say which is the best management framework; however, it is important that if people are to belong to an agency or trust other than the Acute Trust, they are aware of the potential problems that may exist such as access to notes and computer equipment. Champions in the hospital system Some posts have identifiable champions in the hospital system. Most obviously: Professor Touquet in St Mary s Paddington, Dr Lynn Owens in Liverpool or Dr Moriarty in the Royal Bolton Hospital. Other interviewees could also identify supportive leads e.g. Doncaster. Bristol argued strongly that this was a need. However, not every service had an identifiable champion within the hospital e.g. Hertfordshire: this seems to be a facilitative not a necessary factor. Where do clients come from? None of the interviewees felt that they were covering all areas of the hospital equally. Area Bolton Bristol Most likely source of referrals in the hospitals Gastroenterology and Medical Assessment ED, Medical Admissions Unit, Hepatology Ward, Surgery and Trauma and Orthopaedics Areas which are thought to be under-referring Maternity Doncaster Medical Assessment Ante-natal clinics Hertfordshire Primarily referrals come from A&E (80-90%). Acute Admissions Unit and Gastroenterology are the other main source. Not sure but we certainly don t see everyone Not identified Liverpool Hepatology and Gastroenterology Orthopaedics and Maternity Middlesbrough Nottingham Westminster A&E department, Acute Assessment Unit (Ward 15), the Trauma Unit (Ward 37), the Gastroenterology Unit (Ward 8), the Short Stay Unit (Ward 33) and the Infections Unit (Ward 1). Gastroenterology and Medical Assessment Gastroenterology and Medical Assessment Not identified Not identified Older people In general Gastroenterology/Hepatology and Medical Assessment Wards are the commonest source of referrals. Older people were far fewer in number; however, one interviewee felt that if 31

32 those services working with older people routinely screened all patients for alcohol use their referrals would rise by a significant, and possibly unmanageable, proportion. Maternity services seemed to be infrequent referrers, although in some cases this was because a substance misuse liaison worker was in place. NB Links with Psychiatric Liaison Teams In other work commissioners have occasionally suggested to the authors that psychiatric liaison teams could be a logical location for basing Alcohol Health Work posts. Interviewees generally disagreed with this view. It was felt that liaison teams would generate a large number of clients who had taken overdoses where alcohol was involved and that the workers would become drawn into cases which were more properly the responsibility of mental health services. Another felt that psychiatric liaison teams do not see alcohol as part of their work. How are clients referred? Liverpool has a computerised referral system for clients; however, in most cases referrals are made by telephone / personal contact or via a form. For example, Westminster and Hertfordshire have screening tools that can be submitted. In Bolton and Middlesbrough link nurses or champions are in place on wards and can make the referrals. Area Bolton Bristol Doncaster Hertfordshire Liverpool Middlesbrough Nottingham Westminster Is there a referral form within the hospital Link nurses on each ward facilitate referrals. No form, the wards know how to contact the AHWs. They are at full capacity so are not going out to seek more referrals. All the wards have a risk assessment which includes FAST and can be used to refer clients. There is a screening form for staff to complete and then use to refer to the AHWs. Computerised referral system. There are champion nurses on the wards but these are usually health promotion champions and not just alcohol champions. No specific form. PAT form although patients can be referred by phone and other direct contact. Frequent flyers Services recognised the importance of frequent flyers. However, only two had a specific programme for addressing this group of clients. In Nottingham people who attend A&E more than three times in a month are case conferenced. Middlesbrough have an alert that generates a referral for the assessment service. Bristol had tried to flag frequent flyers on the PAS system, so that if a client came through A&E they would be referred to the specialist nurse, however it is not clear why this has not been successful. 32

33 Training role All of the services undertook some form of training work. This work was generally ad hoc. A range of staff were identified as having been trained, these included doctors and nurses but also social workers, occupational therapists and pharmacists. Methods ranged from formal courses, slots on other training programmes, short inputs at staff ward rounds and handovers to opportunistic individual work with people who had referred clients. A sample of approaches is set out below. The nurse is involved in staff training. New staff receive an overview of alcohol and drug services and a full day training course is run on alcohol and drug management in the hospital setting. Training - in the hospital AHWs are still in the junior doctor rotation. It is harder with nurses because of time pressure and because nurses don t have a structured education. But the AHWs occasionally do minutes on the wards focussing on nursing tasks and alcohol e.g. going to handovers for nurses to do brief education. Nurses involved in the care of individuals will be given feedback as an ad hoc form of teaching. They have undertaken training with: Discharge Coordinators Nurses band 4 Sisters band 7 Junior Doctors FY1 Junior Doctors FY2 Registrars Ambulance personnel. They don t teach how to deliver a brief intervention. The sisters have said it is too time consuming, although originally this was the aim. The AHWs do slots in team meetings and handovers. Training is a big part of the role. The worker has staff and students who spend a day shadowing. They recently ran a full day training package covering IBA and long term physical health and detoxification. They were running a rolling four week training programme covering information, detoxification and the effects of alcohol. This ran continually for six months. It ran at a time when staff were able to attend i.e. at shift handovers. However, numbers dropped off towards the end and they stopped it but may start it again soon. They try and run link nurse updates on a quarterly basis. Training is done via the School of Nursing and via the intensive care nursing course at the University. They also input to the doctor s training rotation as well as teaching third year student doctors once a year for half a day. 33

34 Clinical governance One of the interesting features of the posts is that only one has a structure for receiving specific feedback from hospital staff and managers on the quality of the service. We have contract meetings, and other meetings with hospital staff but no formal mechanism. Our Operations Manager has regular meetings with the A&E Consultant, Matrons and Senior Manager within the hospital. Only two of the services identified mechanisms for consulting patients and involving them in planning, reviewing and developing the service. Middlesbrough contact a minimum of 15% of service users via telephone/ questionnaire for feedback. This information is then passed to the commissioner. Hertfordshire make similar contact. However, given the short-term nature of the work this lack of contact is probably to be expected. How are services integrated into the hospital system? Interviewees were asked how they had managed to integrate themselves into the hospital system. Two factors emerged: Interpersonal skills and The development of referral structures. In terms of developing a replicable model the latter is clearly the most helpful, however, the interviewees tended to emphasise the importance of being able to build relationships with the staff. It comes down to personalities. The AHWs need to be able to have a presence and just be able to introduce themselves to hospital staff. There is really good communication between us and hospital staff we are often consulted on issues. We take clients back to wards to show success Feedback to the wards is really important It reinforces that there is change...getting into the hospital magazines and local media getting on TV helped. The cornerstone is the relationship with the staff Keeping yourself known, visiting wards on a daily basis because the staff change all the time Go round to the wards with a leaflet about the service. Show your face, ask if they have anyone and not just on the obvious wards Going into team meetings Find out when wards have meetings and offer a couple of minutes on what you do. You need clear aims and objectives. If the person delivering the service knows what they are trying to achieve they will have more successful services. Nurses also need people who know what the service is trying to achieve to support them. You need someone who has the expertise, organisation, charisma and drive. You need a salesman we do training on selling. You have to be able to engage the staff. How do you approach a consultant in the hallway we role play that. The message from the interviewees was that these posts require more than just alcohol intervention skills. Workers will need to have the assertiveness to sell their service around the hospital. Nonetheless, structural approaches to integrating the role into the hospital also exist. Bolton s use of champions on each ward appears to be a particularly useful approach as is the availability of referral forms or computerised referral systems. 34

35 Bristol identified another approach. The post grew organically from within the hospital. A nurse on the Liver Ward pushed for the development of the post; this meant it was automatically integrated into the ward system. Links with external services The key link for all services is to the local community alcohol services. Posts which were part of those services, e.g. Bolton and Nottingham, had a ready link. However, two posts based in Acute Trusts, Bristol and Doncaster reported problems with long waits. Response to young people All of the services interviewed had an adult focus; however, all identified occasional referrals of young people (YP). In general the workers would see the patients and ensure a referral to the local young people s service. It was noted however, that this could involve considerable paperwork including the completion of a CAF (Common Assessment Framework). Will give binge packs out in A&E to YP. If they are under 16 we remove the condom from the pack or give them to parents. Referrals have also been made to the young people s service; there should be a protocol for minors. We do get referrals; however, we have not seen anyone under 16. We would not reject them; we have the local young people s substance misuse service and we direct them there Had to use CAF for the last referral and that was quite a lengthy process. Addaction is available for under 18s, we have seen the occasional 16-17year old but very infrequently. We work with all adults age 16 and over. Those under 19 are assessed and referred to services, where appropriate, specific to their needs and to those services aimed at the under 25 population. We take referrals for young people but we do not see the patients in the hospital we just pass the referrals onto the community team. The young person s service did try to introduce screening and referral and they did a great deal of training and introduced a referral form which was 3 pages long. They got one referral in 12 months so that stopped. Protocols were set up with the young people s service. We directly refer people under 16 and would not necessarily see them. Data collection All the services are collecting client data. In each case this is gathered in a locally developed format. The most interesting aspect of data collection is probably Hertfordshire s reporting of crime data to the police. This was the sole example of such routine links. Evidence of effectiveness Limited work has been undertaken on effectiveness. Some services such as Liverpool, Westminster, Bolton and Middlesbrough have been subject to specific research projects which have demonstrated effectiveness. However, ongoing data collection on the effectiveness of services is generally lacking. Two services reported following clients up through phone calls and Hertfordshire reported receiving positive feedback from this. Three interviewees expressed their belief that the detoxification work was reducing hospital stays, and in the case of Nottingham and Bristol, making the hospital safer. Bristol believed that they had managed to quantify this impact in a local document: Calling time on alcohol-related harm: Evaluation of an Alcohol Nurse Specialist within United Bristol Healthcare Trust. Westminster 35

36 expressed a desire to undertake research into the impact on stays. Liverpool argued that the work also reduced readmissions. Bristol pointed out that a further advantage may be better engagement rates with treatment services than those achieved by other Tier 1 referrers. 36

37 Commentary Introduction 37

38 Commentary This section pulls out themes and recommendations that the Department of Health may wish to consider further. 1. Alcohol work in hospital covers at least two separate roles: IBA with increasing risk and high risk drinkers Clinical work with dependent drinking. Both roles are useful, but the evidence suggests that it is difficult to conflate them into a single role. Non-medical staff cannot take on the detoxification role and medical staff are pulled away from the IBA work. Most importantly, it appears that commissioners can be unclear about the potential differences in this role. It would be useful to differentiate these roles in commissioners minds and provide guidance on which approach should be prioritised and how that decision can be made. 2. These roles require alcohol intervention skills and possibly a nursing qualification. However, the skills to sell the service appears to be equally important. Part of a national or regional response could be the development of a course on how to market the role in the hospital setting. 3. It would be useful to have a model structure for integrating the service into the hospitals and into potential training structures. This would cover guidance on: Appointing lead nurses on each ward; The use of shadowing; The use of informal training / supervision opportunities. 4. Doncaster has a joint drug and alcohol post. Nottingham has appointed a drugs worker to its alcohol team. Middlesbrough undertakes a small amount of drug work. Nothing in this research suggests that this joining together is inappropriate but guidance on this approach could be developed. 5. Being employed by the Mental Health Trust and by the Acute Trust both have advantages. The latter makes integration into the hospital easier; the former provides easy access to alcohol services. It is not possible to say which is better, but it would be useful for guidance to make clear that there are real issues which need to be addressed in rolling out either approach e.g.: How does the worker access hospital case notes and computer systems if they are part of an external trust? How does the worker access specialist supervision within the acute setting? Who pays for what aspect of the service? 6. The number of staff operating in each hospital appears to bear little relationship to assessment of need. Guidance on determining the number of staff to be appointed would be useful. 7. Training is undertaken by all the services. However, it is a very ad hoc process. Guidance and training on how to fulfil this aspect of the role would be useful. In particular guidance on making use of opportunities such as one to one sessions with referring staff and inputs to staff handover meetings. 8. All services are collecting data and all are collecting it in different ways, usually with selfdeveloped databases. A standardised data format would be useful. 9. Workers are making links into community alcohol services. However, two identified problems with waiting times. This is an area for consideration if posts are to be developed. 10. Efforts to assess the effectiveness of these posts are limited and guidance on measuring it would be useful. Specific research into cost savings in terms of bed days would be particularly 38

39 valuable. However, this should also try to quantify other markers of success with chronic drinkers such as a reduction in violence on the ward and length of abstinence post-intervention which is a significant marker of success with liver patients. 11. Frequent flyers are recognised as important, but only two services had a formalised approach to this client group. A structure built around alerts from A&E and case conferences for the most challenging patients would be a useful development. 39

40 Appendix Introduction 40

41 Appendix 1 Materials received This section records all the materials received in the course of the project. The actual documents are provided separately. 1 Activity data (Excel spreadsheet) - Bolton 2 Activity data (Excel spreadsheet) - Middlesbrough 3 Activity data (Excel spreadsheet) - Doncaster 4 Activity data (Excel spreadsheet) - Hertfordshire 5 Annual Reports Nottingham 6 First Quarter Report Doncaster 7 St Mary s Alcohol Health Work annual report, Research report into Westminster service (2008) 9 Job Description Brief Intervention Alcohol Specialist - Bristol 10 Job Description Alcohol Nurse Specialist Bristol 11 Job Description Drug & Alcohol Liaison Nurse Specialist Administration Support Worker - Doncaster 12 Job Description Drug & Alcohol Liaison Nurse Specialist - Doncaster 13 Job Description Clinical Nurse Specialist Nottingham 14 Job Description for Alcohol Health Work Project - Westminster 15 Person Specification: Alcohol Nurse Specialist CNWL/St Mary s Hospital 16 St Mary s Accident & Emergency Alcohol Health Work 17 Information for Westminster Treatment Centre staff covering St Mary s AHW sessions 18 Alcohol Health Work data collection via Symphony - Westminster 19 A Protocol for Completion of Hospital Initiated Alcohol Detoxification - Bolton 20 Guidelines For The Management Of Alcohol Issues In The Acute General Hospital Setting Doncaster 21 Non Medical Prescribing Operational Policy for Drug and Alcohol Liaison Nurse Specialist Services - Doncaster 22 Guidelines For The Management Of Patients with Drug Misuse In The Acute General Hospital Setting Doncaster 23 Drug and Alcohol Liaison Nurse Specialist Operational Policy Bassetlaw Hospital 41

42 24 CNWL AOCD alcohol liaison protocol - Westminster 25 A&E Brief Intervention Questionnaire - Hertfordshire 26 Screening, Assessment and Care Planning Forms - Doncaster 27 Report on Results of the Brief Interventions Evaluation Questionnaires - Hertfordshire 28 Key Performance Indicators (Service Outcomes) - Hertfordshire 29 Service Specification Drug & Alcohol Services - Hertfordshire 30 Service Specification for the provision of a Drug & Alcohol Liaison Service - Doncaster 42

43 Appendix 2 Questionnaires Schedule of semi-structured interview questions for the Alcohol Health Worker project Name of service Contact name Contact role 1 What are the aims and objectives of the service? 2 How did you decide to deliver this service with nursing staff or others, such as voluntary sector workers? 3 How viable is this role for a lone worker? 4 How does the service balance out the different roles IBA, detox, medical advice, discharge planning or training? 5 Does the hospital have a protocol for prescribing for and monitoring of alcohol withdrawal symptoms? 6 Which directorates within the hospital does the service cover? 7 Are there any links with Maternity and ante-natal care provision? 8 Is the service available to outpatients other than those attending A&E? 9 How are services integrated into the hospital system? 10 Who is the clinical champion for this service? Has having champions within the hospital helped? 11 What groups of professionals does the service provide training for? 12 Is working for the Acute Hospital or Mental Health Trust better for this role? 13 How is activity recorded (what system is used)? 14 Are there links to the psychiatric liaison team? 15 How are young people served? 16 What clinical governance systems are used? 17 Are there any links with Liver Services? 18 Any other special links with other services such as Mental Health, Burns Units, Sexual Health, Cardiac care? 19 How does the service link with community treatment services out of area? 20 How are you proving that you are meeting needs? 43

44 21 How are you proving that you are reducing costs to the NHS? Schedule of questions for the Alcohol Health Worker project Name of service Address Phone Contact name Contact role Could you please send us, preferably via Service specification documentation Service operating protocols / procedures Diagrams / description of service structures Job descriptions for all staff Data collection system forms Any data reports produced Any annual reports Any publicity material for the service Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? Available? / Unavailable? 44

45 Could you please answer the following questions: 1 Please describe the organisational and staffing structure of the agency including grades, role, competencies, training, qualifications and hours worked. 2 Which body employs the staff (and are they managed by a different body?) 3 Which organisation (or organisations) commissions the service? 4 What are the aims and objectives of the service? 5 What services do you provide? 6 What mechanisms are there for hospital staff and managers to comment on the quality of the service? 7 Give a breakdown of your agency s client activity over a recent 12 month period. (Please break down activity by gender, age, and ethnicity if this data is available) 8 Please comment on any areas of strength or weakness in these figures. 9 Which parts of the hospital provide the referrals and in roughly what proportion? 10 What proportions of your clients are referred on to external agencies and which agencies are referred to? 11 Does your service work with under 19s, if not how are their needs met? 12 What training does the service provide to other professionals? 13 How does the service ensure that staff have the necessary skills to provide the services? 14 What is the total investment in the service? (Please break this down by source and value) 15 Please provide any unit costing that have been developed for the service 16 Are the users of your service consulted on, and involved in, planning, reviewing and developing the service? 17 Overall what do you see as the service s key areas of strength? 18 Overall what do you see as the service s key development needs? 45

46 Alcohol Health Workers Alcohol Concern, 64 Leman Street, London E1 8EU Tel: , Fax: Website: 46