An Audit of the Focus on Alcohol-related Harm in Joint Strategic Needs Assessments, Joint Health and Well-Being Strategies and CCG Commissioning Plans

3 March 2014

Note: This report was funded and/or written by our predecessor organisation Alcohol Concern.

Executive summary

Alcohol Concern, with the financial support of Lundbeck, undertook an audit of the priority given to tackling alcohol-related harm in Joint Strategic Needs Assessments (JSNAs), Joint Health and Wellbeing Strategies (JHWSs) and Clinical Commissioning Group (CCG) plans across England. The audit considered the published documents from 25 local authority areas. Fifteen of the top 25 authorities in the country for alcohol-related harm were considered and 5 each from the middle and lowest ranked authorities. The choice of partnerships was based on Public Health England data on the rates alcohol-related hospital admissions and liver mortality.

The indicators reviewed were influenced by Public Health England’s (PHE) Good practice in planning for alcohol and drugs prevention, treatment and recovery but also covered indicators of interest to the lead agencies.

Many positives emerged from this review. All of the JSNAs and JHWSs and the vast majority of the CCG plans addressed alcohol. However, the amount of attention varied greatly. Many of these suites of documents appeared unlikely to meet the PHE suggestion that JSNAs have a “comprehensive section on alcohol related harm”. The degree of attention declined in the areas classified as medium and lower need in the NWPHO dataset.

40% of the JSNAs and 36% of JHWSs specifically identified alcohol as a priority, but those in the middle and lowest need areas were less likely to set it as a priority. In the high need areas which did not set alcohol as a priority, this was usually because they either did not have priorities or prioritised at a thematic rather than condition level.

All but one JSNA (24/25) contained some data on alcohol and the majority of CCG plans (21/34) showed clear evidence of need. While a variety of data sources are used across these documents, the greatest reliance was on LAPE data: usually hospital admissions data. It is important that local action plans are built on a wider dataset than hospital admissions alone. This could include prevalence data, treatment data, licensing information, crime figures as well as specific local research.

24 out of the 25 JSNAs addressed alcohol-related hospital admissions and this emphasis was repeated in the other documents. This highlights the benefits of national indicators; but a downside exists. Areas with lower national rankings for hospital admissions, morbidity and mortality in the LAPE data appeared to give less attention to alcohol in their suite of documents. However, this lower ranking is relative and almost certainly underplays the actual impact of alcohol in the area. Even the lowest risk areas in England will experience considerable harm from alcohol.

PHE guidance suggests that JSNAs reflect “need across the whole spectrum of harm”. Only a few of these suites of documents clearly recognised that alcohol has a varying impact on different groups in the community. Moreover the range of groups considered was relatively small and groups highlighted by PHE such as prisoners and young women at risk of sexual abuse and exploitation were rarely considered.

The most commonly considered sub-group was young people. This may be viewed positively but it is important to ensure that the needs of young people are not over-emphasised in comparison with other groups, leading to the danger of inappropriately stigmatising young people as a major cause of alcohol related harm. The needs of the larger group of young people who are at risk because of parental drinking should also be considered.

In comparison, the needs of older drinkers (55+) who make up a large share of the burden on hospital services were less likely to be mentioned.

The degree of attention given to alcohol treatment and care pathways is hard to assess because no standard exists for judging whether it is adequate. Alcohol treatment was mentioned in the vast majority of JSNAs but far less attention
was given to care pathways.

Key to the effectiveness of this strategic process is that the documents link together and reflect and reinforce the messages in each other. The majority of JHWSs and CCG plans cross-referenced to the JSNA and each other. However,
they were less likely to cross-reference each other regarding alcohol and much less likely to reference alcohol or community safety strategies. Two examples of good practice were noted. Nottingham had a very well-coordinated
suite of documents. Hampshire had also clearly worked well to link documents together in the challenging context of an area with four CCGs.

In general the high need areas addressed alcohol and across the two key plans all had some recommendations about alcohol. However, four high need partnerships did not have any recommendations about tackling hospital admissions. Seven did not have recommendations about IBA and the same number did not have recommendations about treatment. A focus on recovery, peer support and mutual aid is suggested by the PHE good practice guidance but was scarcely
mentioned in any of the strategies.

This does suggest a discontinuity between evidence and actions, particularly around hospital admissions, alcohol Identification and Brief Advice and treatment generally. It is important that the key bodies ensure that the degree of harm caused by alcohol is reflected by the priority or importance given to it in the documents and then by the actions or recommendations included.

A particular challenge in tackling alcohol misuse is to clarify where the lead responsibility lies for commissioning each element of the care pathway for drinkers. Inconsistency existed in the balance between the number and type of treatment and care recommendations in the JHWSs and the CCG plans in different areas. This process offers a real opportunity to clearly state the responsibility for the alcohol care pathway.

None of the JHWSs and only two of the CCG plans allowed the identification of the level of investment in alcohol although this was also true of investment plans generally.

The transfer of public health to local authorities creates a framework for making use of the opportunities offered by the licensing framework to tackle alcohol related harm. While this was reflected in some of the documents, it remains an underused approach, particularly reflecting on the use of powers such as late night levies.

Little evidence was found that the Public Health Outcomes Framework and NHS Outcomes Framework were driving the process with only 6 out of 25 JSNAs mentioning the outcomes frameworks. However, this is probably historical due
to the recent advent of these structures.