Title: An Evaluation of Alcohol Treatment Centres: Implications for Service Delivery, Patient Benefit and Harm Reduction
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Welfare Centres, Safe Havens and Alcohol Treatment Centres are designed to receive intoxicated patients who would normally attend Emergency Departments (ED), to lessen the burden that alcohol-misuse, an avoidable healthcare cost, places on unscheduled care and care for those who have become vulnerable. They are typically located close to areas characterised by excessive intoxication and are open at times when levels of intoxication peak. They therefore offer the potential to mitigate some of the pressures on ED at times when it is experiencing a sustained increase in demand. The need to reduce pressure in ED is clear. Most admissions to ED are alcohol-related at peak times and they cause the ED clinical environment to suffer, as well as staff morale. Staff become stressed causing a detriment to care and patients can become aggressive or fearful. This project aims to estimate the effectiveness, cost-effectiveness, efficiency and acceptability of centres in managing alcohol-related ED attendances. The proposed evaluation method, organised into three work streams (WS), is that of a natural experiment, comparing areas in which centres have been implemented or are planned to control cities matched using Home Office iQuanta “similar families”. Mixed methods are used to address specific research questions. WS1 will use ethnographic studies; interviews with stakeholders, policy makers and practitioners; interviews with patients attending centres and surveys of ED and centre users. In WS2 routine data will be analysed to quantify the effect of centres in respect of key performance indicators and in WS3 an economic evaluation will consider the cost of centre implementation. WS1 will consider the impact of centres on working practices of front-line professionals in the emergency care system, with particular reference to well-being. Interviews with centre users will inform the development of a survey for this group to assess the acceptability of centres. Surveys will assess the impact of centres on ED users’ perceptions of the ED environment, compared to control EDs where there is no centre implementation. The inter-agency relationships between the police, health, ambulance and the broader community, required for successful implementation, including opportunities for shared funding, will be scrutinised. WS2 will assess any improvements to effectiveness across partners (e.g. ambulance handover times, patient episode duration in ED, police resource effectiveness measured through a reduction in city centre violence) and explore whether the effects of improved capacity (e.g. fewer police and ambulance resources in ED bottlenecks) due to centre provision impacts on community safety and therefore alcohol-related violence. In WS3 we will ask what are the costs of setting up and running centre and what cost savings may be realised elsewhere? In addition, the project will seek to capture the variability that exists in night time economy provision for managing the intoxicated. The research will inform local and national decision makers on opportunities for a national roll-out across UK cities and will share what is known about what works through the study of effectiveness, efficiency, processes, barriers and opportunities.

Lay abstract: Drunkenness is a common night-time problem in many UK towns and cities and intoxicated patients are at risk of choking, injury, unconsciousness and death. Traditionally, the very drunk have either been escorted to a hospital Accident and Emergency (A&E) so that their health can be monitored or drunken offenders went into police custody. Recently the police issued guidance for all UK forces stating that those who are drunk cannot be housed in custody due to possible health complications, unless a clinical decision maker determines that it is safe to do so. A&E is one of the few clinical services available in the evening and this is where most of those who need clinical input end up. This places additional demand on overstretched emergency services at a time when they are experiencing unprecedented levels of demand. Ambulances have to wait longer in order to hand over patients to A&E staff because clinical staff are busy elsewhere, police officers (accompanying drunk offenders to A&E) are delayed, taking them away from their duties in the city centre, and other patients in A&E may wait longer to receive clinical attention. These delays mean there are fewer police officers on patrol deterring violence and fewer ambulances available to respond to emergency calls. In addition, the behaviour of drunk patients is often disorderly, they lose control of their body and therefore vomit and defecate uncontrollably. This affects the A&E environment, waiting rooms and other patients, including children, can become distressed. Welfare Centres, Safe Havens and Alcohol Treatment Centres are services that provide a safe environment in which drunk people can be assessed, treated in some, monitored or referred to A&E. They are usually developed through partnerships that including local government, police, healthcare and other agencies that are all affected by the problem of drunkenness. The primary goal is usually to safely divert as many drunks as possible from A&E into centres to improve the provision of care in A&E, provide a facilities where police, ambulance and others can quickly hand over drunks to clinical staff and therefore improve patient experiences of care in unscheduled care. We plan to evaluate the effectiveness and cost effectiveness of centres in meeting these goals and to understand the broader impact on the working lives of staff, including stress and morale. A mixed methods evaluation will be conducted. This includes an ethnographic study where researchers shadow practitioners to understand how they work in the context of managing drunks, a survey of patients to understand how Alcohol Treatment Centres improve patient experiences in A&E together with interviews with patients and staff, the analysis of routine data and simulation modelling to understand any impact on key performance indicators in health, police and ambulance services. Outputs from the research will be of broad relevance to decision makers and will include journal articles, presentations at conferences and a model for further service development that will likely be of considerable interest across the UK and internationally (while similar services exist across Europe, Australia and North America none have been formally evaluated). A primary goal of this project is the provision of evidence that is useful for practitioners involved with managing night time environments.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;ORAL AND GASTROINTESTINAL;STROKE