Guidance

Alcohol commissioning support: principles and indicators

Updated 4 October 2018

1. Introduction

1.1 Harm caused by alcohol

There are currently over 10 million people in England drinking at levels that increase their risk of health harm. Of these, 595,000 adults potentially need specialist treatment for alcohol dependence. Addressing the harm caused by alcohol misuse is a priority for Public Health England (PHE). Alcohol is the leading risk factor for ill-health, early mortality and disability among men and women aged 15-49 years in the UK and the harm from alcohol affects a range of other public health outcomes.

Alcohol is a causal factor in more than 200 medical conditions, including circulatory and digestive diseases, liver disease, a number of cancers and depression. Alcohol-related harm disproportionately affects the poorest people in society.

The increase in risk for these conditions is greatest among the 1.9 million adults in England drinking at harmful levels (in excess of 35 units per week for women and 50 units per week for men). However, even increasing-risk drinkers (those regularly exceeding the lower risk guidelines) are at significantly increased risk of developing long-term conditions.

Binge drinking can lead to injuries, anti-social behaviour and other societal harm. Alcohol misuse also causes losses to business and the local economy through absenteeism, poor performance and work-place accidents.

Alcohol causes harm to others. It is associated with family and relationship problems, and was a component in 18% of the assessments of children in need by children’s social care in England during 2016 to 2017. Alcohol is a significant contributory factor in offences of violence and disorder including domestic abuse.

1.2 Effective responses to alcohol harms

There is a range of harms and at-risk groups and evidence points to a response that is multi-faceted and integrated and aimed at individual drinkers and whole populations. The Organisation for Economic Co-operation and Development suggests that combining alcohol polices can create a critical mass effect, changing social norms around drinking to increase the impact on alcohol-related harm.

Effective local systems are coherently planned by local government, NHS and criminal justice partners to provide effective interventions to address the full range of drinking behaviours and harms to individual drinkers, families and communities.

PHE has developed the alcohol CLeaR system improvement tool to support local government and its partners to review local structures and delivery arrangements, and evaluate what works well to reduce alcohol-related harm.

Planning is essential. Successful plans need to be based on the assessment of local needs, to address the harm, costs and burden on public services from alcohol misuse.

1.3 Principles and indicators for commissioning

This guidance outlines the important principles that local areas can consider when developing plans for an integrated system. These principles have indicators to help commissioners put them into practice.

2. Effective population-level actions to reduce alcohol-related harms

Local evidence-based, population-level approaches reduce alcohol-related harm by control and influence over supply and marketing, coordinating community action, and utilising monitoring and surveillance data.

2.1 What you will see if you are meeting the principle

You will see population-level approaches that support raising awareness and reducing the aggregate level of alcohol consumed and as a result, the whole population’s risk of alcohol-related harm will be reduced.

2.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle:

Local health improvement campaigns are planned, based on and targeted at identified needs in the local population.

The expected outcomes of these campaigns are understood, routinely evaluated and supported by the evidence base.

Where local alcohol social marketing campaigns are employed, they reflect and amplify national campaign messages when appropriate.

The public health team actively contributes to the local vision for alcohol licensing as set out in the statement of licensing policy and works in effective partnership with the other responsible authorities.

Local crime, health and social care data is used to map the extent of alcohol-related problems as part of licensing policy.

Hospital and ambulance data is shared routinely to inform improvements in community safety and licensing activity.

The licensing authority can demonstrate how local licensing policies (including the use of tools and powers) have contributed to successfully managing the night-time and day-time economy.

Commissioners make good use of existing legislation to prevent under-age sales, sales to people who are intoxicated, non-compliance with any other alcohol licence condition and illegal alcohol imports.

Local partnerships use voluntary and industry-led schemes to achieve their local vision to reduce alcohol harm.

3. Large scale delivery of targeted brief advice

Targeted interventions aimed at individuals in at-risk groups can help make people aware of the harm and change their behaviour, preventing extensive damage to health and wellbeing.

3.1 What you will see if you are meeting the principle

There is large scale delivery of identification and brief advice (IBA) to people who are most at risk of alcohol-related ill health.

The National Institute for Health and Care Excellence (NICE) recommends delivering IBA in all adult health, social care and criminal justice settings. PHE guidance for local leaders working across sustainability and transformation partnership footprints also recommends that IBA is provided in all primary and secondary healthcare settings.

3.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle.

The partnership has an integrated plan that sets out the partners’ agreed roles and responsibilities, including workforce development, making sure IBA is delivered in a range of settings, and having a system in place to monitor this activity.

The services that deliver IBA collect, analyse and report data to demonstrate the level of delivery. Local Making Every Contact Count (MECC) activity includes evidence-based alcohol IBA.

There are specific interventions to raise awareness of the harms of drinking for at-risk groups, such as pregnant women, older people and those with existing long-term conditions or mental health issues.

The NHS Health Check, GP new-registrations procedures and the Preventing ill health commissioning for quality and innovation (CQUIN) scheme include evidence-based alcohol IBA in line with regulations, contracts and guidance.

There is IBA delivery across a range of adult local authority services, criminal justice and healthcare settings.

There are clear pathways to specialist assessment for those who may be dependent and require structured treatment.

There are clear pathways for referring alcohol dependent patients from hospital to specialist alcohol treatment in the hospital or in the community.

4. Specialist alcohol care services for people in hospital

Specialist alcohol teams in hospitals reduce alcohol-related hospital admissions and improve quality of care, saving money for the NHS.

4.1 What you will see if you are meeting the principle

All district hospitals will have 7-day specialist provision for alcohol, in stand-alone teams or as part of a team with a wider remit, including drugs and psychiatric liaison.

4.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle.

There are services to meet the needs of hospital patients who misuse alcohol (or drugs).

Senior medical and nursing support and leadership is provided to the secondary care alcohol (and drug) services to ensure that their role and function is understood and appropriately used by partners in the system.

There are effective care pathways between hospitals and community services to ensure detoxification and psychosocial interventions continue outside of the hospital.

A range of services are working to actively support high-need, high-cost alcohol users and reduce frequent hospital attendances and admissions.

Hospital services collect data to demonstrate service effectiveness, impact on patient care and value for money.

Local partners understand how alcohol and drug services for people in hospital are part of the wider treatment system and awareness of the role they play in addressing need.

Patients leaving hospital who need further treatment and recovery support are encouraged to access community alcohol and drug services.

5. Quick access to effective and evidence-based alcohol treatment

Successful treatment and recovery is optimised by providing welcoming, easy to access and flexible services that cater for the needs of a broad range of people and problems. They reduce risk of harms, raise recovery ambitions and help service users to progress towards their recovery goals.

5.1 What you will see if you are meeting the principle

Treatment services that are evidence-based and deliver a broad range of effective interventions to meet the needs of the local alcohol-dependent population, making sure that:

• all alcohol dependent adults have quick access to alcohol specific-pathways within the treatment system, with services delivered from non-stigmatising settings
• the treatment system has established care pathways with a range of health, social care, criminal justice and community agencies
• there are individually-tailored packages of psychosocial, pharmacotherapy and recovery interventions that can be accessed by the target populations and which deliver good outcomes for dependent drinkers
• safeguarding practice is continuously monitored, regularly reviewed and reported on to ensure the safety of alcohol and drug users, their families and wider social groups
• the number of people successfully completing treatment is increasing and their recovery from dependence is sustained

5.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practices that support the principle:

The alcohol prevention and treatment system is integrated and configured to meet the needs of the local population across community, hospital and prison settings.

There is sufficient capacity in the treatment system to optimally address the needs of the estimated population of alcohol dependent adults in need of specialist treatment, and alcohol services are commissioned to target and treat dependent drinkers, wherever they are located in the community, responding appropriately to presenting risk.

Where the estimated rate of unmet need for alcohol treatment appears high when benchmarked against past performance or against local areas with similar needs, or where numbers in treatment for alcohol dependence have fallen, there is a plan to address this.

Alcohol treatment services in all settings offer evidence-based, effective recovery-orientated interventions in line with NICE guidance CG115 and CG100 and NICE quality standards QS11, including, where appropriate, quality statements 4, 5, 7, 8, 9, 10, 11, 13.

Treatment interventions are appropriately tailored to levels of severity of alcohol dependence and complexity of need.

Heavy drinkers with high levels of need who are frequent users of hospital and other local services are identified, engaged and supported into appropriate treatment through a co-ordinated multi-agency response.

There are clearly defined and well-functioning care pathways between community alcohol (and drug) services and acute hospital trusts including alcohol care teams, mental health provision, criminal justice agencies as well as social care and safeguarding services (both children’s and adult).

Where acute hospital trusts and mental health trusts are implementing the Preventing ill health (alcohol and tobacco) CQUIN, there are effective referral pathways into community alcohol treatment for patients identified as alcohol dependent.

Explicit information governance and joint working agreements are in place across all services to promote effective care delivery and risk management through the routine sharing of information.

There is rapid access, appropriate assessment and care planning to support parents as well as joint working with children and family services.

Links between domestic abuse and alcohol misuse are considered in assessment care planning and reviews.

There is joint working with (and effective pathways to) services for domestic abuse victims and perpetrators.

Appropriate data is used to identify armed service veterans who have substance misuse problems and they know about local alcohol and drug services and are able to access them.

People’s recovery journeys are initiated early and helped by them having access to a range of recovery support interventions and services such as peer support, mutual aid, family and parenting support, employment, training and housing.

All treatment providers report data to the National Drug Treatment Monitoring System (NDTMS) and this data is analysed locally to inform improvements. Where structured alcohol treatment is provided in settings that do not report into NDTMS, such as by alcohol care teams, there are mechanisms to feed data on this activity into local needs assessment and planning processes.

Alcohol treatment provider information systems comply with the NDTMS minimum data set and there is appropriate investment in IT systems to meet the clinical and NDTMS needs of providers where required.

There are sufficient staff with alcohol specialist expertise in the treatment system.

Treatment providers have workforce plans that describe how specialist staff are trained and supported to make sure they have appropriate competence and supervision to deliver specialist interventions.

6. Working with partners to commission effective alcohol and drug services

This section is relevant to alcohol and drug commissioning and is repeated in the adult drugs commissioning support pack. In addition to the indicators set out below, commissioners and their partners will also need to comply with all relevant legislation, regulations and other statutory requirements as appropriate.

6.1 What you will see locally if you are meeting the principle

Effective integrated policies and commissioning of services that achieve positive outcomes for individuals, families and communities by:

• co-ordinated policies to promote less risky drinking and drug use, and to prevent harm
• effective partnership working between local authority-led public health, the NHS (clinical commissioning groups and NHS England health and justice commissioners), mental health services, Jobcentre Plus, Work and Health Programme providers, adult social care, housing and homelessness agencies, children’s services, criminal justice agencies and emergency services
• a commissioning system operating transparently according to assessed need
• improving connections between treatment providers and mutual aid organisations
• full involvement of service users and local communities, including through Healthwatch

More people in treatment are supported into work by an effective partnership between the treatment and employment support sectors. There is an integrated support offer involving greater support around training, education, voluntary work and general improvement of skills and work experience.

People with alcohol and drug problems have the best possible access to warm, safe and affordable homes, suitable for their needs in the community that local conditions will allow.

6.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practices that support this principle.

Embedding in local systems

There is an explicit link between the evidence of need and service planning within alcohol and drugs needs assessments, alcohol and drug commissioning strategies, clinical commissioning group strategy, and the joint health and wellbeing strategy.

Mechanisms are in place for reporting on alcohol and drugs to the health and wellbeing board, to the police and crime commissioner and to local safeguarding systems for vulnerable adults and children.

Public health commissioners have partnership arrangements with key agencies including clinical commissioning groups, clinical networks, NHS England area teams, children’s and adult social care and criminal justice agencies.

Integrating local authority and health planning to reduce alcohol and drugs harm has been supported by introducing place-based sustainability and transformation partnerships and integrated care systems.

Arrangements are in place for joint commissioning where there is a shared responsibility for commissioning and planning, such as with the NHS for secure settings

A fully integrated system of health improvement, treatment and recovery for people with alcohol and drug problems has been developed by a formal strategic partnership involving relevant stakeholders and agencies.

The general public, service users and staff in other services understand the alcohol and drug services available locally, the pathways between services and points of entry for treatment.

Quality governance mechanisms assure the quality and safety of alcohol and drug treatment services and are embedded in public health systems.

Needs assessment

The needs assessment includes a comprehensive section on the full spectrum of alcohol and drug-related harm and it acknowledges the impact of alcohol and drug work across the public health and NHS outcomes frameworks.

There is a shared understanding of the level of demand and need, based on a range of local and national data across a range of public services.

The following are identified locally:

• gaps in delivery of primary, secondary and tertiary prevention for alcohol and drugs
• the extent of unmet need for alcohol treatment among the estimated population of adult dependent drug users in need of structured treatment
• unmet need among specific populations such as people with co-occurring mental health conditions or substance misusing parents
• the impact of services on health and wellbeing, public health and offending

Health and public health commissioners use hard and soft intelligence to understand need in relation to misuse of or dependence on prescription and over-the-counter medicines, including dependence arising inadvertently from the prescribed use of a medicine.

Data is collected on alcohol and drug interventions provided in hospitals, primary health care and other settings, to inform needs assessment.

Levels of alcohol and drug-related admissions to hospital are analysed, to target interventions.

Specialist alcohol and drugs treatment data is monitored and analysed, to compare current treatment provision with need.

The needs assessment uses a methodology such as asset-based community development to take into account the availability and potential development of existing community support networks and other local assets.

The needs assessment takes account of the needs of the local population including:

• children affected by parental alcohol or drug misuse
• people (predominantly women and girls) vulnerable to alcohol and drug misuse as a result of domestic abuse, sexual assault, child sexual exploitation, or prostitution
• prisoners and continuity of care requirements for alcohol and drug-misusing offenders moving between custody and the community
• people with protected characteristics under the Equality Act 2010
• the carers and family members of people who have alcohol and drug problems
• people with co-occuring mental health and alcohol and drug use conditions .

A mutual aid self-assessment tool has been completed as part of the needs assessment.

Finance

Investment is sufficient to provide a range of prevention, harm reduction and treatment services commensurate with the level of identified need.

Decision-makers have been enabled to understand the potential return on investment from alcohol and drug interventions and the possible cost of under-investment. Tools like the Value for Money Commissioning Support Tool can help commissioners demonstrate the benefits derived from local investment.

Decision-makers understand the effectiveness and cost-effectiveness of their commissioned services and can identify ways of improving these where necessary. The Value for Money Commissioning Support Tool is designed to help local areas understand and improve the cost-effectiveness of local treatment systems.

Commissioners can identify the total level of local investment by all partners.

There is close communication with finance colleagues to ensure that planned and actual expenditure on alcohol and drug prevention and treatment interventions is accurately reported to the Ministry of Housing, Communities & Local Government as part of required local authority financial returns. For help in disaggregating local substance misuse expenditure and estimating unit costs, commissioners can refer to the Value for Money Commissioning Support Tool.

Effective commissioning

Commissioning is based on evidence based guidelines, such as the drug treatment clinical guidelines and NICE guidance, for effective interventions in tackling alcohol and drug-related harm.

There is an alcohol and drugs planning document that describes how best to meet local need, which clearly identifies:

• the level of demand
• existing strengths and assets and ways in which services can be commissioned to build on them
• finance and available resource

Investment in alcohol and drug prevention, treatment and recovery is based on an understanding of expenditure, performance and cost-effectiveness.

Contracts for commissioned services specify the outcomes to be achieved and these outcomes are regularly monitored and reviewed.

Care pathways and services are geographically and culturally appropriate to the people they are designed for.

Service users, their families and carers and people in recovery are involved at the heart of planning and commissioning. This is evident throughout needs assessment and key priority-setting processes both for community and prison-based services.

Commissioning functions are fit for purpose. There is sufficient alcohol and drug misuse commissioning capacity and expertise, including information management.

A workforce strategy and improvement plan ensures that commissioning staff are competent to commission safe and effective services.

Service specifications clearly indicate the level of professional competence required to deliver safe and effective services.

The transfer of care is managed safely and effectively, when the contracted provider changes, with appropriate communication of patient information to enable seamless management of risks.

The commissioning strategy includes the formal evaluation of the range of alcohol and drug interventions.

Services for people in contact with the criminal justice system

There are clear pathways into assessment, treatment and support services for people in contact with the criminal justice system who have drug or alcohol problems and where possible, integrated pathways for people with co-occurring mental health and alcohol and drug use conditions.

There is a collaborative approach with police and crime commissioners and NHS England health and justice commissioners to commission integrated services that support and engage people as they move between prison and community settings, taking the latest guidance into account.

Commissioners have engaged with their local National Probation Service and community rehabilitation company to agree capacity for treatment interventions and specific requirements for offenders who are subject to statutory supervision in the community and on release from prison.

Mutual aid

There is a shared, locally developed vision of recovery where mutual aid is appropriately integrated with all alcohol and drug services including in-patient and residential treatment.

People in treatment have access to a range of peer-based recovery support options, including 12-step, SMART Recovery and other community recovery organisations.

Local services are encouraged to support service users to engage with mutual aid groups through the inclusion of specific requirements in their service specifications.

Housing and homelessness

The housing needs of people with alcohol and drug problems in the community, prison and residential treatment have been identified and are used to inform commissioning plans for housing, homelessness and housing related services.

The housing needs of people with alcohol and drug problems, and their families and carers where appropriate, are assessed at the right time, to prevent homelessness or to help them move on to a suitable home.

There is a range of housing options to meet different needs.

Housing information and advice are readily available for everyone in treatment.

Front-line housing staff are trained to meet the housing and related needs of people who have alcohol and drug problems.

The needs of homeless people and rough sleepers are specifically considered as part of local substance misuse commissioning arrangements.

The health needs of homeless people who misuse alcohol and drugs have been identified and they are supported to access primary care and other healthcare, such as mental health services.

People with lived experience of homelessness are consulted as part of a health needs assessment, to identify gaps in service delivery and solutions.

Where an eligible person is homeless or at risk of homelessness, the local housing authority carries out an assessment and agrees a personalised plan to provide tailored support in line with the Homelessness Reduction Act 2017.

People who are sleeping rough and have alcohol and drug problems are able to access emergency accommodation and support and are contacted and encouraged to access drug and alcohol treatment and mental health services, where required.

Policies and procedures for homeless people with alcohol and drug problems support people to access suitable accommodation on discharge from hospital or residential rehab, or on release from prison.

Employment, training and education

Joint planning arrangements are in place between treatment commissioners and providers and Jobcentre Plus (JCP) and Work and Health Programme (WHP) leads to meet the employment, training and education (ETE) needs of the alcohol and drug misusing population.

Relationships have been established with the JCP partnership managers and community partners, including the specialist drug and alcohol community partners in areas where they are in place.

Worklessness and employability strategies reflect the ETE needs of people who misuse alcohol and drugs.

Commissioners incorporate ETE in their performance monitoring arrangements with treatment providers and providers address ETE in supervision for keyworkers.

JCP, WHP and treatment providers have agreed a process of joint working between agencies, including arrangements for three-way meetings and co-location.

Local single points of contact have been identified in JCP, WHP and all treatment teams and these details have been circulated.

There are employment champions in treatment teams, whose role it is to liaise with JCP and WHP, and to champion ETE.

Treatment providers, JCP and WHP routinely engage with local employers to make the case and address negative preconceptions and stigma about employing people with a history of alcohol or drug dependence.

Discussions about employability are introduced early on in treatment journeys, and commissioners and treatment providers continually review the extent to which the ETE agenda is prioritised in local recovery provision.

Treatment staff encourage clients to consider appropriate disclosure of their alcohol and drug misuse within JCP and WHP to help them get individual support.