| Statement 1 – health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol |
| Quality of implementation |
| Differences in perceived quality of training between different types of organisations (e.g. primary care vs third sector) |
| Training sometimes focussed on the effects of alcohol and where to find information and services rather than promoting respectful and non-judgemental care |
| Online training viewed as inadequate compared to face-to-face training |
| Services do not always report on how training is used, meaning information may not be available on quality of implementation |
| Training gap surrounding binge drinking in young people |
| Extent of implementation |
| Training coverage reported as very patchy within and across some boroughs, professional groups, and organisations |
| Some groups reported to have low coverage of training (e.g. nurses, health visitors, drug workers), while others had high coverage (e.g. medical doctors, adult services, local authority employees) |
| Barriers to implementation |
| Absence of training providers |
| Resources and prioritising |
| Time and workloads |
| Inability to access training provision |
| Emphasis on other substances for young people |
| Poor governance of third sector organisations |
| Facilitators to implementation |
| Professional development plans |
| Financial incentive plan (e.g. CQUIN) |
| Prioritising training (making alcohol a top priority) |
| Making training a strategic priority for CCGs |
| Statement 2 – health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice |
| Quality of implementation |
| Financial incentive may encourage widespread screening but may also lead to a tendency to screen patients without providing necessary advice or referral. Payments also only received for new registrants, and there was no payment for intervention after screening |
| Mixed evidence that services use appropriate screening tools |
| Good integration of screening into existing systems and audits reported in some localities |
| Extent of implementation |
| Reports of outreach programmes being conducted outside of healthcare settings |
| Routine practice in specialist services; good implementation in secondary care and in other settings with a specialist healthcare professional |
| Poor implementation in young people’s services and when GPs see young people |
| Barriers to implementation |
| Capacity and workload |
| Lack of accountability and consistency or recording information across settings |
| Services for CYP focus on other substances. Interventions in schools may miss those in need. CYP may also not be honest and there are difficulties involving parents |
| Facilitators to implementation |
| Use of the same screening tool across services |
| Easy to use apps to facilitate interventions |
| Writing screening/brief interventions into trust policy |
| Financial incentives |
| Passionate individual members of staff |
| Public health awareness campaigns to raise staff awareness |
| Experience and history of delivering interventions |
| Statement 3 – people who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and can access specialist alcohol treatment |
| Quality of implementation |
| Reports of inappropriate referrals to A and E from GPs |
| Appropriate referrals are better when a specialist is available |
| Absence of a clear pathway for referrals for CYP |
| Extent of implementation |
| Patchy implementation, better in areas with specialists in primary care and areas with financial incentives |
| Poor/zero implementation for CYP. CAMHS is the default service for CYP |
| Barriers to implementation |
| Poor information about and communication between services, lack of confidence referral is being made to the correct place |
| Services being houses in unattractive buildings and areas |
| Service users reluctant to access services in mixed drug and alcohol service facilities due to stigma |
| Lack of a named person in services for clients to contact |
| Lack of understanding and confidence in how to tackle alcohol, or not knowing where to refer to |
| Demand outstripping supply and waiting lists being long |
| Regular re-commissioning of services |
| Inappropriate referral due to staff wanting to offload work they consider outside of their remit |
| Facilitators to implementation |
| Financial incentives (e.g. CQUIN) |
| Specialist staff (e.g. mental health nurse) to make better assessments and improve referrals |
| Statement 4 – people accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff |
| Quality of implementation |
| Very high compliance in NHS settings |
| Third sector provision reported to be compliant after being audited by commissioners |
| Parity in quality between NHS and third sector provision is unknown |
| Extent of implementation |
| Full implementation in NHS settings |
| Key staff reported to be appropriate trained in third sector services |
| Barriers to implementation |
| None reported |
| Facilitators to implementation |
| Professional development structures |
| Writing training into contracts |
| Commissioners asking for evidence of appropriate training |
| Statement 5 – adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures |
| Quality of implementation |
| Common measures used across NHS settings ensures measures are valid |
| Validity of measures in in third service provision is achieved through random checks of care plans by commissioners |
| Extent of implementation |
| High level of compliance as staff are trained in drug and alcohol treatment |
| Barriers to implementation |
| Some providers may be resistant to showing commissioners their case files during audits |
| Facilitators to implementation |
| Several different screening tools are available |
| Formal processes are established to use the tools |
| Measuring outcomes facilitated a change in service quality |
| 360-degree appraisals |
| Strong management can create an atmosphere of professionalism |
| Statement 6 – children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures |
| Quality of implementation |
| Zero (no specialist services exist) |
| Extent of implementation |
| Zero (no specialist services exist) |
| Barriers to implementation |
| CYP services are highly structured and rigid, particularly in relation to using validated measures |
| Forms often incomplete as CYP can be unreliable to return to services |
| Integration and communication between services (e.g. social workers, youth offending service) |
| Services have lost their impetus (e.g. National Treatment Agency for Substance Misuse) |
| Referrals threshold into CAMHS is so high that they always decline referrals from GPs |
| CAMHS not seeing itself as part of the mainstream healthcare system |
| Different measures used in different services |
| Facilitators to implementation |
| Compliance is high in Youth Offending Services as attendance is not optional |
| Putting the focus on the key worker to fill out assessments |
| Statement 7 – families and carers of people who misuse alcohol have their own needs identified, including those associated with risk of harm, and are offered information and support |
| Quality of implementation |
| Needs are often acknowledged but may not be directed towards formal use of the service |
| Where services for families are used, there are reports that they are very successful |
| Although pathways for families exist they are rarely used |
| Reactive approach is taken to families; children are supported through safeguarding |
| Extent of implementation |
| Services range from very difficult to access to fairly easy to access. However, actual use of the services may be limited due to limited capacity |
| A&E provide information about support for family and carers |
| Safeguarding covers support for CYP, but this relies on clinicians contacting other services |
| Barriers to implementation |
| People who misuse alcohol often have normal lives and jobs, making it difficult to recognise when they are developing a problem |
| Carers may be appearing to cope and not see the need for support |
| The method used to identify carers’ needs is laborious and intrusive |
| Confidentiality surrounding the alcohol user. This makes it difficult to record data and difficult to audit implementation |
| Training for supporting families and carers takes a long time |
| Lack of resources |
| Family members may have problems being treated in the same place as the service user |
| Facilitators to implementation |
| Writing into organisational policy the provision of information to carers |
| Statement 8 – people needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric comorbidities |
| Quality of implementation |
| Referrals to appropriate settings are improved by a community nurse facilitating the process |
| Short in-patient detoxes may not be long enough and may cause patients to relapse as a result |
| Psychiatric in-patients receive good treatment as they are treated as mental health in-patients for detox |
| Extent of implementation |
| Gaps in services in some areas; moderate-to-good coverage in other areas |
| The appropriateness of the setting may depend on capacity |
| Differential success between in-patient and community detoxing |
| Where a specialist nurse makes the assessment implementation coverage is good |
| Barriers to implementation |
| Poor communication and lack of integration between services |
| Division of services causes confusion as to where to send patients |
| Disagreement over who pays for services |
| Poor visibility of community services in some localities |
| Lack of clarity over who is responsible to deliver services |
| Stigma may prevent patients from accessing certain services |
| Facilitators to implementation |
| Presence of a community nurse |
| Having a long-term relationship with clients |
| Statement 9 – people needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance |
| Quality of implementation |
| Only one drug available in some localities |
| Reports that GPs prescribe detox drugs poorly |
| Regimens are appropriate when prescribed from a specialist service |
| Extent of implementation |
| Generally, very well run in localities where services are run by NHS |
| Variable implementation in locality run by third sector providers as access to appropriate settings can be problematic |
| Good implementation in in-patient setting |
| Barriers to implementation |
| GPs not offering detox because they do not feel confident to do so |
| Lack of training for GPs |
| Cost of drugs on GPs drugs budgets may mean they prefer for specialist services to offer the treatments |
| Facilitators to implementation |
| Change in triage standards gave managers the opportunity to make improvements in NHS services |
| Statement 10 – people with suspected, or at high risk of developing, Wernicke's encephalopathy are offered thiamine in accordance with NICE guidance |
| Quality of implementation |
| Generally thought to be good, but worse among some professional groups such as social work |
| Extent of implementation |
| In NHS specialist services, it was reported that there was full implementation and it was very unlikely that patients would be missed |
| Reports of good implementation in treatment services and poorer implementation in the community |
| Barriers to implementation |
| Lack of awareness of the availability of thiamine |
| Mixed views about the effectiveness of thiamine |
| Confusion about whose responsibility it is to offer thiamine |
| Facilitators to implementation |
| None reported |
| Statement 11 – adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance |
| Quality of implementation |
| Reports of different practice from NICE recommendations |
| IAPT input may help but it is not specific to alcohol |
| Waiting lists reported in some localities |
| Extent of implementation |
| Large gaps exist in provision, with some reports of zero provision in some localities |
| Some services offered in some localities; other services may not be offered at all |
| Relapse prevention medication is offered very sparingly |
| Reports of good implementation where dual-diagnosis staff are present |
| Psychological services are rare within addictions services |
| Barriers to implementation |
| Language barriers mean some communities do not understand what services do or what is available |
| Lack of trust among immigrant communities |
| Waiting lists for psychological services |
| Training skills are poor in addiction services and training is out-dated |
| Shift of emphasis from secondary to primary care resulted in lack of specialist knowledge |
| GP appointment time slots too short to explore mental health needs properly |
| Facilitators to implementation |
| Multilingual healthcare staff |
| Training all staff in relapse prevention |
| Signposting in A and E |
| Statement 12 – children and young people accessing specialist services for alcohol use are offered individual cognitive behavioural therapy, or if they have significant comorbidities or limited social support, a multicomponent care programme including family or systems therapy |
| Quality of implementation |
| Zero (no specialist services exist) |
| Children may be referred to the third sector, where training can be poor |
| Extent of implementation |
| Zero (no specialist services exist) |
| Low confidence among interviewees that this is happening locally |
| Barriers to implementation |
| Family and systems therapy viewed as only useful for a small number of young people |
| CYP’s confidentiality |
| Difficult of outreach |
| CYP do not want to talk about alcohol and drug use in schools due to zero tolerance policies |
| Parents want to feel they are doing a good job and ignore signs of alcohol misuse |
| Facilitators to implementation |
| None reported |
| Statement 13 – people receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care |
| Quality of implementation |
| Care plans may be recorded as paper or electronic notes, which can make it hard to use Treatment Outcomes Profile (TOPs) forms |
| High level of compliance may mask the fact that TOPs forms may not be used properly |
| Extent of implementation |
| Good-to-full implementation in NHS settings |
| High level of compliance in specialist services, but a lack of follow-up when patients leave A and E |
| Barriers to implementation |
| TOPs is time-consuming to complete |
| Lack of acknowledgement of the need for treatment outcome reviews in non-specialist settings |
| Looking at a patient’s combined mental and physical health needs is not commonplace in A and E unless a staff member there is particularly passionate about this view |
| Facilitators to implementation |
| Performance management |
| Financial incentives |