Gillian Gale, Oliver Hill and Lucio Cicolecchia explain a twin strategy that aims to relieve some of the major pressures caused by alcohol abuse
Alcohol misuse costs the UK economy£20bn each year and government policies to tackle it are proving ineffective.
Alcohol abuse, especially binge drinking, has been rising steadily, particularly among young people. Lagging medical indicators, such as liver disease, are also on the rise. According to the London Ambulance Service, since new licensing laws were introduced, alcohol-related calls have risen by 12 per cent - four times the rate of total demand.
Between 2am and 4am on 1 January 2008, the London service received 500 calls an hour - one every eight seconds. Among women, 15 to 24-year-olds are responsible for the highest incidence of calls, outstripping calls from men by two to one. Ambulance crews confirm this trend: "Most are under 25, and of that, 70-80 per cent are females," says paramedic Brian Hayes.
At Mr Hayes' suggestion, the London Ambulance Service piloted an advanced response vehicle in 2005-06 in central London to deal with patients who had abused alcohol. It consisted of a patient transport vehicle with a capacity of five to seven seats and a stretcher.
It was equipped as a standard ambulance and followed the same clinical protocols. The crew were one paramedic and two technicians and patients were delivered to accident and emergency.
Pressure on emergency care in north east London, as well as alcohol-related crime, prompted north east London emergency care network director Gillian Gale to explore alternative models of care to deal with alcohol abuse.
She saw the response vehicle as part of a more holistic model of care. "The ARV could address some of the issues for the emergency care system, but it was necessary to explore how to combine it with a new model of care to implement an effective preventive scheme in the fight against alcohol abuse," she says.
New model of care
Ms Gale asked Apto Consulting to evaluate the business case for an advanced response vehicle service in north east London and integrating it with a new model of care. Apto's review of London Ambulance Service data showed that the pilot was a success. Over 27 weeks, the response vehicle saved 880 hours of ambulance time, equivalent to two to four ambulances per shift, saved money (£246,000, based on unit costs of healthcare) and improved performance - the category A call response improved by 20 seconds.
On its own, the response vehicle addresses only one aspect of the problem - the pressure on ambulance services. Its efficiency in dealing with alcohol-related emergency calls may actually generate spike loads for A&E Under the new model, patients would be collected by the vehicle and delivered to an alcohol partnership centre. This could either be a standalone centre or adjacent to A&E.
This is a fundamental shift from the current approach of a reactive service to much-needed prevention.
The centre would:
identify the patients at risk of becoming alcohol dependent;
remove binge drinkers and alcohol abusers from A&E;
engage across all age groups and demographics;
implement a multi-agency alcohol policy.
There are a number of options for staffing the centre, taking into account the resources, infrastructure and capacity requirements of the local area. It could be staffed with a GP with a special interest in alcohol, a nurse practitioner and a nurse.
The centre would include representatives from:
drug and alcohol action teams;
mental health organisations;
police (alcohol prevention).
Patients would be treated and, once considered clinically safe, be seen by the appropriate stakeholders to receive information, support and referrals for specific problems.
The cluster of stakeholders would improve communication between parties and foster joined-up treatment and policies. The approach is the basis for a service for those most at risk of developing long-term alcohol abuse problems, before they reach a crisis point.
Evidence from brief intervention programmes indicates how effective preventative information is when provided to patients on a one-to-one basis.
The centre would do more than this. It would be ideal for brief interventions and the prevention of alcohol-related abuse or harm.
Advanced response: who benefits most?
The new model of care will have a positive impact on the entire emergency care system. Ambulance services will be helped to achieve their eight-minute target for category A calls. Further time savings relate to the reduction in drop-off time for other ambulances. A&E services will be helped in achieving targets, as resources will not be held up treating alcohol-related cases.
The police will be able to implement crime prevention programmes more effectively - particularly with young people, given the difficulty of engaging with them before they get involved in alcohol-related incidents. At the moment, this only happens when people who have abused alcohol are the victims or perpetrators of crime.
PCTs could integrate policies from all stakeholders with other pressing public health issues, such as under-age pregnancy and alcohol dependence. With its rates of under-age pregnancy consistently higher than in the rest of Europe, the UK desperately needs to be more effective in addressing the problem. Studies list alcohol abuse among the major factors in unwanted pregnancies, with hotspots in disadvantaged areas. The model would enable PCTs to maximise their investment, as it would extend their reach without duplicating functions.