Transcript presentation on `alcohol & NICE: a rapid review` [ppt.]

ALCOHOL & NICE
a rapid overview
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)
Trevor McCarthy
January 2014
NICE
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NICE
NICE
so 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)
Trevor McCarthy
January 2014
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
Trevor McCarthy
Bad Science 2009
January 2014
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.
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
Hierarchy of Evidence 2
 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
Trevor McCarthy
January 2014
Hierarchy of Evidence 3
 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)
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
Remember this?
(10 years ago)
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
Trevor McCarthy
January 2014
 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
Trevor McCarthy
January 2014
2007
Review of
AHRSE
commitment
made in 2004
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
March 2012
1.1 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 harm
to ourselves and others.
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
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’
Trevor McCarthy
January 2014
Trevor McCarthy
January 2014
NHS White Paper
July 2010
Trevor McCarthy
January 2014
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: OECD
Coalition health bill will undermine NHS, says OECD thinktank
Guardian 23 November 2011
Trevor McCarthy
January 2014
NICE: Alcohol Prevention Guidance
NICE Public Health Guidance 24
Published June 2010
12 recommendations
Trevor McCarthy
January 2014
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
Trevor McCarthy
January 2014
Practice Recommendations (4-8)
4
5
6
7
8
Licensing
Resources - screening & brief interventions
Supporting children & young people 10 - 15
Screening people aged 16 & 17 years
Extended brief interventions - 16 & 17
Trevor McCarthy
January 2014
Practice Recommendations (9-12)
9
10
11
12
Screening adults
Brief advice for adults
Extended brief interventions for adults
Referral
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
NICE: Alcohol Use Disorders:
Physical Complications
NICE Clinical Guideline 100
Published June 2010
38 clinical recommendations
7 research recommendations
Trevor McCarthy
January 2014
NICE: Alcohol Use Disorders:
Diagnosis, assessment and management of
harmful drinking and alcohol dependence
NICE Clinical Guideline 115
Published February 2011
Comprehensive treatment recommendations
6 research recommendations
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
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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
Trevor McCarthy
January 2014
NICE commissioning guide: August 2011
Trevor McCarthy
January 2014
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.
Trevor McCarthy
January 2014
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 Doubt
Naomi Oreskes & Erik M Conway 2010
Trevor McCarthy
January 2014
Prejudice Based Policy
You cannot reason
people out of positions
they didn’t reason
themselves into.
Bad Science BEN GOLDACRE
Trevor McCarthy
January 2014
The presence of
those seeking the
truth is infinitely to
be preferred to those
who think they’ve
found it.
TERRY PRATCHETT
Monstrous Regiment
Trevor McCarthy
January 2014
If you can’t make decisions in life, you’re a bloody
menace. You'd be better becoming an MP!
Trevor McCarthy
January 2014
Trevor McCarthy
January 2014
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 ………………………..
Trevor McCarthy
January 2014
The poor
end up
paying
for the
mistakes of
the entitled
This Week BBC July 2009
Trevor McCarthy
January 2014