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How can we commission alcohol pathways that are fit for purpose? Dr Carsten Grimm Bradford Districts CCG Board Member Declaration of Interest Current roles and affiliations Honoraria • • • • • • • • Clinical Lead Alcohol Services Locala (former Kirklees Community Health Services, NHS provider arm) Cluster Lead Alcohol Misuse and Gambling Certificates, RCGP England RCGP Clinical Commissioning Champion Associate IHWB UK • • • • • • Turning Point Lundbeck BayerSchering KJ Physiotherapy & Medical Consultancy Ltd RCGP England Doctors.net UK Richmond Pharmacology Pfizer NHS via various primary and secondary care trusts LMC Bradford & Airedale Ltd Gable, R. S. (2006). Acute toxicity of drugs versus regulatory status. In J. M. Fish (Ed.),Drugs and Society: U.S. Public Policy, pp.149-162, Lanham, MD: Rowman & Littlefield Publishers “It is also very important that the recommendations are not just aimed at young binge drinkers, but at the silent majority of heavy drinkers whose drinking puts them at risk of serious damage to their health.” Ian Gilmore Alcohol consumption and liver disease in Europe 1970 - 2000 Adapted from Mayhew L & Lee B. ActivAge Project HPSE-CT-2002-00102. 2005; 77. http://www.iccr-international.org/activage/docs/ActivAge-WP4SynthesisReport.pdf Can we change society? The Resource Legend of the NHS • There is no money • There is no staff • Clinicians are expensive The Bradford Model - £1.2m pa - Four elements (PCAS, PCDS, polish drinkers, top up of hospital liaison team) - In addition to Bradford CDAT - Lifeline and Project 6 The Kirklees Model • • • • • £1m pa Three partners Lifeline, Locala, Community Links Strong links into shared care Locality model and remaining main service How to commission the perfect pathway You don’t! • Pathways are operational • Need to be able to adjust to local need • Lead provider model or Accountable Care Organisations must have flexibility to create their own • Look at what works – smoking cessation! Disorder Severity No intervention Brief intervention Treatment in primary c. How to measure outcomes • • • • PbR Audit-O Reduction in hospital admissions Reduction in liver disease Public Health Tendering Model • • • • Part of Local Authority Must retender every 5 years Intrinsic preference to “lowest possible bidder” Lack of clinical input Translation into service model • Downshift to minimum qualified staff • Abandonment of principle of Clinical Leadership • Upshift of responsibilities What is the problem? A 2010 survey of GPs showed the following barriers to alcohol screening and intervention: • • • • • Lack of time Inadequate training No incentives in the current contract Worries about cost and availability of alcohol services The perceived normality of heavy drinking amongst health professionals What works • Primary care based services • Organic growth with long term commitment (5-10 years) • Link to CVD risk • Shared care & clinically led service • Housing support • Peer led groups What doesn’t work • • • • • Link with liver (yet) Link with dementia PH commissioned clinical service Link with illicit drugs agenda Tiered (1-4) approach to diagnosis and service commissioning • Piecemeal commissioning Computers are rubbish… …that’s why kids use them all the time. Google “RCGP alcohol” Quarterly National Training Days in London Local Training Days available Summary • The majority of people with alcohol use disorder can be treated in primary care • Primary care is arguably best placed to bridge the gap between physical health need management, accessibility and specialist treatment options • Look at the CCGs now – it is an issue for hospitals Thank you! [email protected]