ALCOHOL & NICE a rapid overview

ALCOHOL & NICEa rapid overview

Trevor McCarthy

January 2014

Trevor McCarthy January 2014

New Commissioning Arrangements

Public Health England & Health and Well Being Boards

Aspiration to align NHS + Public Health + Social Care outcomes

Public Health have not been involved in drug commissioning (untainted)

Alcohol is a Top 3 priority for Public Health (after smoking & obesity)


NICE NICE NICEso good they named it 3 times (so far)

• New Labour 1st policy white paper: The New NHS: Modern, Dependable 1997

• 1999: National Institute for Clinical Excellence

• 1 April 2005 + Health Development Agency → National Institute for Health & Clinical Excellence

• Health and Social Care Act 2012 → 1 April 2013: National Institute for Health and Care Excellence (new responsibilities for social care)


Understanding the evidence base

… science isn’t hard – academics around the world explain hugely

complicated ideas to ignorant eighteen-year-olds every September –

it just requires motivation.

BEN GOLDACRE Bad Science 2009


What are guidelines? Clinical guidelines are systematically

developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Guidelines provide recommendations for effective practice in the management of clinical conditions where variations in practice are known to occur and where effective care may not be delivered uniformly.


NICE guidance• NICE has produced guidance in three areas:

Public health – guidance on promoting health and preventing illness

Health technologies – use on medicines, treatments and procedures

Clinical practice – guidance on appropriate treatment and care of people with specific diseases and conditions in the NHS.

Forthcoming: social care


Hierarchy of Evidence 1

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias



2++ High quality systematic reviews of case control or cohort or studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies - low risk of confounding or bias and a moderate probability that the relationship is causal



2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

(in the absence of evidence – then expertise is OK)


So – What is NICE for?

Fairness: vs ‘postcode lottery’ Effectiveness – scientific validation Cost effectiveness (no longer able to make

recommendations re: cost of medications) Hierarchy of evidence Not set in stone – evidence updates (e.g. PH24) Countering: advertising; anecdotes; special

interest groups; experts; prejudice; inequity


The way I see it, it is my civic duty to live fast, die

skint and leave a dirty big fat bastard of a corpse

Rab C Nesbitt. BBC. Series 10 Episode 2 - 12 October 2011


Remember this?

(10 years ago)


AHRSE 2004 - 4 key strands

1. Improved, better-targeted, education and communication

2. Better co-ordination and enforcement of existing powers against crime and disorder

3. Encourage industry to promote responsible use & take a role in reducing alcohol-related harm

4. Better identification & treatment of alcohol problems


MoCAM: framework describing what should be commissioned in each local area

Evidence based guidance & consensus based – professionals & service users

Mainstream alcohol interventions to develop integrated local alcohol treatment systems

Tier I: all frontline staff able to identify drinkers, provide info, brief interventions

Tier II: all staff deliver extended brief interventions, referrals and joint working


2007Review of AHRSE

commitment made in 2004


Safe, Sensible Social

Aimed to: Build on progress made in implementing

2004 strategy & To minimise health harms, violence &

antisocial behaviour associated with alcohol, while ensuring that people are able to enjoy alcohol safely and responsibly.


March 20121.1 Over the last decade we

have seen a culture grow where it has become

acceptable to be excessively drunk in public and cause

nuisance and harmto ourselves and others.


No-one. Not researchers; not commissioners; not practitioners; not drinkers. No-one else suggests that our alcohol problem arose in the 10 years preceding this (when the current Prime Minister’s party were mainly in opposition). Policy is always political: this is the least substantial, most politicised alcohol strategy yet.


Uniquely Insulting Tone PM foreword: more powers for hospitals not just

to tackle the drunks turning up in A&E 3.12 we will work with the police to tackle the issue

of serving alcohol to drunks 3.16 staff can refuse to treat drunks who are

abusive in A&E Drunks. Not People with alcohol related health

problems. Not People who need help. Not People who have a right to treatment and respect.


The prevention paradox

The majority of alcohol related harms are associated with people whose drinking is hazardous & harmful

Dependent drinkers are likely to experience and be linked with greater degrees of harm

But there is so much drinking that the hazardous & harmful drinkers harm outweighs that of dependent drinkers


Motivational Government

All the alcohol strategies have taken whole population Public Health approaches

Bear down on overall consumption to reduce levels of problems

Strategies decorated with headline criminal justice initiatives

Good luck persuading ‘pre-contemplative’ drinkers to moderate by calling them ‘Drunks’


NHS White Paper July 2010


No top down re-organisation of the NHS?

“The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK,”

Mark Pearson: OECDCoalition health bill will undermine NHS, says OECD thinktank

Guardian 23 November 2011


NICE: Alcohol Prevention Guidance

NICE Public Health Guidance 24Published June 201012 recommendations


Policy Recommendations (1-3)

1 Price: Consider minimum price per unit.

2 Availability: Consider licensing legislation; protecting public’s health as an objective; availability and alcohol-related harm & immediate sanctions on premises in breach

Consider reducing personal import allowances

3 Marketing: Minimise young’s exposure to alcohol advertising - consider complete ban


Practice Recommendations (4-8)

4 Licensing

5 Resources - screening & brief interventions

6 Supporting children & young people 10 - 15

7 Screening people aged 16 & 17 years

8 Extended brief interventions - 16 & 17


Practice Recommendations (9-12)

9 Screening adults

10 Brief advice for adults

11 Extended brief interventions for adults

12 Referral


Recommendation 5 (highlight)

Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.


NICE: Alcohol Use Disorders:Physical Complications

NICE Clinical Guideline 100Published June 2010

38 clinical recommendations7 research recommendations


NICE: Alcohol Use Disorders:Diagnosis, assessment and management of

harmful drinking and alcohol dependence

NICE Clinical Guideline 115Published February 2011

Comprehensive treatment recommendations6 research recommendations


CG 115: PRINCIPLES OF CARE Building a trusting relationship and providing

information Working with and supporting families and carers All interventions for people who misuse alcohol

should: Be delivered by appropriately trained &

competent staff Be the subject of routine outcome monitoring

… to inform decisions about continuing psychological & pharmacological treatments.


CG 115: Identification & Assessment Risk assessment to inform care plan inc. risk to self

(inc. unplanned withdrawal, suicidality and neglect) & risk to others.

NHS funded services – staff who care for people who potentially misuse alcohol should be competent to ID harmful drinking & dependence & to assess need for intervention … if not competent(?) refer to service that can assess.

Assessment in specialist alcohol services:do not refuse treatment to service users who do not agree to a goal of abstinence.


CG 115: Interventions for alcohol misuse• For all people … motivational intervention as

part of initial assessment. • Care coordination & case management• For harmful drinking & mild dependence

offer psychological intervention (CBT, behavioural therapies (MI / MET) or social network & environment-based therapies SBNT) focus on alcohol-related cognitions, behaviour, problems & social networks.

• Assessment & interventions for assisted alcohol withdrawal & Drug regimens

• Interventions after successful withdrawal


NICE commissioning guide: August 2011


NICE PH24 – the immediate response from Andrew Lansley Health Minister*

“Regarding NICE's recommendations on minimum pricing for units of alcohol, it is not clear that the research examines specifically the regressive effect on low income families, or proves conclusively that it is the best way to impact price in order to impact demand.”

Published 2 June 2010

• http://www.dh.gov.uk/en/MediaCentre/Statements/DH_116534

*The Prime Minister disagreed. CAMRA disagreed. NICE disagreed.

http://www.dh.gov.uk/en/MediaCentre/Statements/DH_116534


Merchants of Doubt

“Doubt is our product,” ran the infamous memo written by one

tobacco industry executive in 1969, “since it is the best means of competing with the ‘body of fact’ that exists in the

minds of the general public.”

Merchants of DoubtNaomi Oreskes & Erik M Conway 2010


Prejudice Based Policy

You cannot reason people out of positions

they didn’t reason themselves into.

Bad Science BEN GOLDACRE


The presence of those seeking the

truth is infinitely to be preferred to those

who think they’ve found it.

TERRY PRATCHETTMonstrous Regiment


If you can’t make decisions in life, you’re a bloody menace. You'd be better becoming an MP!


Commissioning Alcohol Services & Pavlov’s Cash Register

• Performance related pay • Payment by Results

• Performance related pay• Payment by Results

• Focus on what works and what is most important• N.B. It’s not the pay ………………………..


The poor end up

paying for the

mistakes of the entitled

This Week BBC July 2009

ALCOHOL & NICE a rapid overview

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