Title: Programme of Research for Alcohol Care Teams: Impact, Value and Effectiveness (ProACTIVE)
Funder: Department of Health and Social Care

Abstract: Alcohol causes over 60 different physical, and mental health conditions. In England, more people are being admitted to hospital and dying from alcohol-related disease than ever before. We know much about what helps people with severe alcohol dependence who go to specialist addiction services, but much less is known about the 1 in 10 people admitted to acute hospitals who are also AD, but not necessarily seeking treatment. As patients may come into hospital for a wide range of other reasons, their alcohol use is often not recorded, missing opportunities to help empower them to make changes needed to improve their health. Alcohol Care Teams (ACT) have gradually developed in response to local need, but all in different ways. As part of the National Health Service (NHS) long-term plan, a structure and set of competencies to deliver these services have been defined, and ACT are being developed in 25% of hospitals with the greatest need. The next step is to understand which models are most effective, how they are perceived by patients, and if they are a good use of NHS resources in helping improve outcomes and reduce health inequalities. We have designed a programme that will help answer these questions to inform policy decisions about the next steps for ACT. We will start by mapping the ACT provision across the country, then develop a way of categorising all the different kinds of work that an ACT does and get agreement on what these are so that teams can all use the same language to describe what they do, enabling them to be directly compared. We will then use data from several sources, to look at the impact of different kinds of ACT on hospital admissions with alcohol dependence. As outcome data are not routinely collected, we will also recruit patients from different hospital sites to get actual patient-level follow-up data after six-months to record any changes in alcohol consumption, general health and wellbeing and NHS hospital use. Given the different stages of development of ACT, this will be a real-world experiment across six hospital sites, to help us identify what works best, for whom. Estimating costs of different ACT and how they relate to patient outcomes will help inform which are the best value for the NHS. As alcohol dependence is a condition about which many people feel a great deal of shame, and there are no large patient-led charities to drive the research agenda in this area, we have included patient and public co-production as central to our research plan. We will include a strong qualitative evaluation and use hospital case-studies, and interviews with decision makers, staff and patients to understand the challenges for ACT at national, regional and local level. We will bring together the results of different strands as they emerge to best inform the next stage of the research as well as the final recommendations. This programme will enable us, for the first time, to define the necessary components of an ACT, where and how they work best, and with which group of patients. It is the start of growing the evidence base for which interventions are most helpful in this under-served patient group. Central to this is the development of an ACT patient and public involvement network, which is currently lacking, as well as providing evidence and tools to policy makers and commissioners about the best use of NHS funds in this area by the end of the current programme.

Lay abstract: Alcohol-related hospital admissions continue to rise, with estimates that 10% of patients admitted to acute hospitals may be alcohol dependent. Yet, there remains considerable variation in provision of Alcohol Care Teams (ACT) in England, and a limited evidence base for understanding their clinical effectiveness. The NHS long-term plan has invested to ‘optimise’ ACT through the development of existing services and the establishment of new teams in 25% of hospitals in greatest need by 2024. The ProACTIVE research programme is a multi-disciplinary, integrated, mixed-methods study designed to evaluate the impact of ACT at macro (policy), meso (health system) and micro (patient) level. It will identify the ‘optimal’ models of ACT, define the components which best support the identification, and cost-effective management of hospitalised adults with alcohol dependence (AD), and will facilitate the rapid dissemination of the results. The ProACTIVE team is uniquely placed to deliver this national evaluation, combining expertise in health service and delivery methods, data and implementation science, clinical management of AD, and advocacy of lived experience. ProACTIVE has four interconnected work packages (WP): WP1 will build the first comprehensive national database of ACT provision in England, identify local stakeholders, define the range of components of care, agree a taxonomy for ACT interventions, and explore the reliability and linkage of nationally available data; WP2 will evaluate the clinical and cost-effectiveness of ACT, using a quasi-experimental naturalistic study of three ‘optimal’ ACT and three ‘minimal’/no ACT sites, following-up patients for six months to evaluate the micro level impact of ACTs. Meso level ACT impacts (e.g., re-admission rates, length of stay) will be assessed by an interrupted time series analysis using nationally available data. A parallel exercise will assess the cost-effectiveness of ACT at both meso and micro levels. As ACT effects may take time to emerge (e.g., impacts on health inequalities), a model will be built to generate estimates of how the health outcomes vary across socioeconomic groups, and the impact of introducing (or removing) an ACT on alcohol-related health inequalities; WP3 is a qualitative evaluation of?ACT using an organisational ethnographic case study?design to identify factors at macro, meso and micro levels that have shaped the composition, delivery, and impact of ACT. The integrated PPI team will ensure that each element of the research embraces co-design principles and integrates the experience of patients into the enquiry; WP4 will facilitate timely synthesis of findings from each phase of the evaluation, using the ‘Context and Implementation of Complex Interventions’ framework, and work with stakeholders to generate guiding principles for an optimised ACT, and toolkit for best practice in developing sustainable, patient focussed services. Given the NHS programme timelines, an ambitious timeframe of three years has been chosen to facilitate decision-making for future investment in ACT. Defining necessary components of an ACT – where and how they work best, and with whom is essential groundwork to grow the evidence base for which interventions are effective in this underserved patient group. Central to this, is the development of an ACT PPI network to co-produce evidence and tools with patients, policy makers and commissioners about the best use of NHS funds in this area.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH