Context of the programme

The NHS England's Alcohol programme aims to establish optimal Alcohol Care Teams (ACTs) within hospitals to improve the care provided to people who have alcohol use-disorders, mainly those who are alcohol dependent. The ACT workstream delivers against the following Prevention commitment in The NHS Long Term Plan (LTP):

This is supported by an NHS evidence-based case study, which offers good evidence that ACTs can provide specialist interventions to alcohol-dependent inpatients and reduce avoidable bed days and readmissions.

The optimal model for ACT services was published in November 2019, jointly with Public Health England (PHE). This explains how the services operate including 7-day provision, where they are positioned within the acute care pathway, staffing needs per hospital site and the range of interventions the service should deliver.

The majority of hospitals in England have some level of alcohol specialist provision (80% according to a PHE audit in 2018) and all hospitals should have protocols for medically assisted withdrawal from alcohol. Currently, there is mixed provision of ACTs, with some sites having no dedicated provision and others having reasonable services; but often not covering all aspects of the optimal model. 

The LTP investment will drive consistent improvement across targeted sites to bring services in line with the published optimal model. The goal is to roll out optimal ACTs to the 25% of hospital sites with the highest rates of deprivation and alcohol dependence-related harm. Where these services are provided they will form an integral part of the integrated whole clinical pathway of care for patients with alcohol use-disorders alongside local authority commissioned partners.

ACTs are liaison services that support patients in hospital who have alcohol use disorders, mainly those who are alcohol dependent. ACTs provide specialist treatment interventions such as facilitating medically assisted withdrawal to ensure that patients can be safely managed during their admission. ACTs also provide psychosocial intervention and liaise with other hospital and community services to contribute to a pathway of care that improves the likelihood that individuals can remain alcohol free.

The key aims of ACTs are to:

• reduce avoidable alcohol-related hospital admissions by reducing severe health risk among dependent drinkers 
• reduce the length of stay for inpatients by improving the management of withdrawal 
• provide appropriate, timely, meaningful education and support for those attending or being admitted with alcohol-related problems 
• facilitate integrated alcohol care between secondary, primary and community care providers
• provide psychosocial interventions to support dependent drinkers to sustain abstinence following discharge 
• improve compliance with the trust’s alcohol withdrawal guidelines 
• educate staff on alcohol use disorder and its management 
• improve information sharing between services (such as secondary care, primary care and community services)
• improve data collection and opportunities for analysis

As outlined, the case for ACTs is based on their significant and measurable impact when working with alcohol dependent patients. ACTs are a preventive service and a prevention priority. By engaging with dependent drinkers at a point where their alcohol use may have resulted in ill health and engaging them with a pathway to stop or reduce their drinking, patients should experience reduced ill-health and less frequent hospital admissions. 

The importance of supporting increasing-risk and higher-risk drinkers who are not dependent is recognised, and they should receive interventions aimed at reducing their health risk from alcohol. However, the appropriate intervention for these patients is alcohol identification and brief advice (IBA). The core service descriptor for ACTs describes how the service should facilitate routine delivery of IBA by non-alcohol-specialist staff throughout the hospital for non-dependent patients with alcohol health risks, however, it is not an efficient use of resources for ACT alcohol specialist staff to deliver IBA themselves.

Alcohol specialist nurses will work in conjunction with other healthcare practitioners, including consultants, to assess patients’ needs and provide a range of psychosocial interventions.

Figure 1: Role of alcohol care teams in the pathway for alcohol dependent patients

Find out more about this model.

Emergency care presentations

The ACT will assess patients presenting to emergency care (including accident and emergency, emergency departments, urgent treatment centres, urgent care centres, and minor injury units) with acute intoxication, in acute alcohol withdrawal or with alcohol-related complications. Patients not ready to be fully assessed (for example, intoxicated) should receive an initial assessment for risks that would require immediate admission.

Patients in acute withdrawal who require medical admission will be assessed by the ACT who will stabilise their condition and manage Medically Assisted Withdrawal (MAW) as appropriate to their needs. Patients presenting with other alcohol-related complications will also be assessed by the ACT, who will contribute to their care plan.

Inpatient admissions

Patients admitted for any condition who are identified as possibly alcohol-dependent via routine assessments will be referred to the ACT to undertake a more comprehensive alcohol assessment. Based on the assessment outcome, the ACT will contribute an alcohol care plan, integrated with the care plan for any other presenting condition.

Alcohol-dependent patients will be referred to specialist alcohol support in the community for continuation of alcohol treatment on discharge, where appropriate. When patients are medically fit for discharge before their MAW is complete, the ACT will advise on the appropriateness of completion of MAW in the community on a case by case basis, based on comprehensive assessment, and availability of services.

This is a new and unique collection. Individual level data is required specifically to monitor activity and impact of ACTs in hospitals in receipt of targeted funding, especially in terms of clinical outcomes and impact on closing health inequalities. The new collection will ensure the NHS can demonstrate delivery of the alcohol LTP commitments, and provide data to underpin service improvement. 

The data collected will also support the NIHR evaluation of the cost-effectiveness of ACTs. This will provide evidence to build  the case for sustainability of these essential services that seek to address widening health inequalities in an already disadvantaged group.

The data that is collected will be used to:

• analyse quantitative metrics and assess progress across each of the sites, providing insights and recommendations
• provide regular cross-site reporting to the national team, to provide assurance and help identify good practice to enable replicability

Information governance approval was obtained through an application via NHS Digital’s Data Standards Assurance Service through to the national Data Alliance Partnership Board. Information governance clearance is based on Section 255 of the Health and Social Care Act to establish and operate the collection including onward analysis of information. Section 251 covers the onward analytical use of the data to support monitoring and future interventions.

The purpose, legal basis, and NHS England Directions for this data collection can be viewed at Alcohol dependence workstream Directions 2021.

Once Arden and Greater East Midlands (GEM) Commissioning Support Unit (CSU) has received site submissions via the Strategic Data Collection Service (SDCS), the CSU will combine the submissions and pseudonymise the resultant dataset.

Following this, patient-identifiable information will be stripped out similar to the process for Secondary Uses Service (SUS) data. At this point, the dataset will be uploaded NHS England’s data warehousing platforms (the National Commissioning Data Repository (NCDR), the the Unified Data Access Layer (UDAL) and the National Data Platform (Foundry)). 

Each of these are highly secure data storage and analysis environments within NHS England. Within the NCDR/UDAL/National Data Platform, the data can be linked to other pseudonymised datasets including SUS. Importantly, the linkages will help determine the effectiveness of interventions in patient populations that traditionally have high rates of alcohol use. Moreover, linkages will confer holistic assessments of patient characteristics, improve understandings of their interactions with various parts of the health system, and provide insights on their health outcomes from different episodes of care.

Analysis undertaken will be made available in the form of dashboards and ad-hoc reports that will support regions and systems to manage performance, identify/promote good practice, explore inequalities, and determine the effectiveness of the interventions. In order to measure the impact of the ACT on reduced ill-health and readmissions, the programme will review admissions and readmissions of patients engaging with the ACT to ascertain if they are being admitted less frequently. Primary and secondary diagnosis codes will be analysed to measure the frequency and nature of readmissions for patients who are in scope for ACT engagement. The analysis of the data will be made available through the Prevention Programme’s established governance routes to regional, systems and front-line services as appropriate.