Alcohol misuse (health and wellbeing needs in South Tyneside)

• Alcohol is a prominent commodity in the UK marketplace. It is widely used in numerous social situations. For many, alcohol is associated with positive aspects of life; however there are currently over 10 million people drinking at levels which increase their risk of health harm. Among those aged 15 to 49 in England, alcohol is now the leading risk factor for ill-health, early mortality and disability and the fifth leading risk factor for ill-health across all age groups.
• Many people consume alcohol responsibly and view it as part of an active social life; however when drinking more than the recommended limits alcohol misuse can negatively impact on people's health and wellbeing, as well as that of their families and the wider community.
• The majority of adults who consume alcohol in South Tyneside are not dependent on alcohol. Only a very small minority of our population match the public image of the term "alcoholic" and are dependent on alcohol. Most adults who drink alcohol live fully functioning lives; have jobs, families and positions of respect in the community. However, a large proportion of our population who may consider themselves 'social drinkers' are drinking at levels that place them at greater risk of alcohol related harm. They are at risk of developing long-term health conditions because of the amount they regularly drink and this doesn't have to be large amounts of alcohol. For instance, if a woman drinks two bottles of wine a week she is consuming around 20 units which puts her at risk.

• The public health burden of alcohol is wide ranging, relating to health, social or economic harms. These can be tangible, direct costs (including costs to the health, criminal justice and welfare systems), or indirect costs (including the costs of lost productivity due to absenteeism, unemployment, decreased output or lost working years due to premature pension or death).
• Harms can also be intangible, and difficult to cost, including those assigned to pain and suffering, poor quality of life or the emotional distress caused by living with a heavy drinker. Many of these harms impact upon other people, including relationship partners, children, relatives, friends, co-workers and strangers.
• The Department of Health's national alcohol strategy published in 2012 included proposals to cut 'binge drinking'; alcohol-fuelled violence, and the number of people drinking to damaging levels by:
  • Consulting on a minimum unit price for alcohol - while the price of alcohol has increased by 36% since 2005, it remains 60% more affordable than it was in 1980
  • Introducing stronger powers for local areas to control the density of licensed premises including making the impact on health a consideration for this. Since 2013 directors of public health (DPH) have been included as responsible authorities under the Licensing Act 2003.
• The UK Supreme Court has ruled that Minimum Unit Pricing is legal in Scotland (November 2017).  The impact of this across the rest of the UK is unclear; however this will be closely monitored.

• South Tyneside is consistently higher than the England average across the range of alcohol related indicators; however there are some areas that require a more concentrated effort. 

These include:

• alcohol related mortality
• hospital admissions due to alcohol related cardiovascular disease
• hospital admissions due to  alcoholic liver disease
• alcohol specific related unintentional injuries
• Key issues in relation to alcohol include its:  
  • affordability
  • availability
  • accessibility
• We know that as a result of the above people drink too much alcohol and they do not often associate it with harm. There are numerous myths and perceptions around alcohol and people are not always aware of the levels or frequency they are drinking at. It's important to realise that the harms of alcohol have a huge effect on the economy and levels of crime as well as health.
• There is a clear link between alcohol abuse and homelessness which has a significant impact on public service cost, and the perceived impact of welfare reform and Universal Credit on alcohol consumption.
• Identification and Brief Advice is one of Public Health England's high impact changes to encourage people to drink less.  There is a very large body of research evidence supporting Identification and Brief Advice (IBA) in primary care (including at least 56 controlled trials (Moyer et al., 2002). A Cochrane Collaboration review (Kaner et al., 2007) provides substantial evidence for the effectiveness of IBA.
• IBA can also be effectively implemented in a number of settings including:
  • A&E Departments - possibly with the use of Alcohol Liaison Nurses or Alcohol Health Workers
  • Specialist settings - e.g. maxillofacial clinics, fracture clinics
• For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002).  Patients who received IBA in A&E made 0.5 fewer visits to the A&E during the following 12 months (Crawford et al., 2004).
• Future commissioning arrangements for training provision will need to consider the continuation of capacity building within the broader system to deliver on IBA, whilst strengthening the current arrangements to include monitoring the impact. 
• South Tyneside is the 5th highest in the Country for adults in specialist alcohol treatment services. And while this highlights the above average rate of alcohol harm, however in part, the high rate can be seen as a high quality of local service provision.  

• A recent PHE publication Why Invest, sets out what needs to be done to reduce the harms caused by alcohol. These are:
  • Improve awareness of alcohol harm among young people and delay the age of first use
  • For people who drink, make lower risk drinking the norm and an easy choice to make
  • Target those who are most at risk
  • Respond to and reduce the harm experienced by those who have already developed problems
• These are largely in line with the aim of South Tyneside's most recent Alcohol Strategy (2013 - 2016), to prevent, minimise and respond to the harmful behaviours and consequences associated with alcohol misuse to individuals, families and communities in South Tyneside.
• At a local level Balance, the alcohol office for the North east, is working with local authorities across the North East to encourage people to reduce their consumption which in turn will reduce the impact that alcohol is having on our region and locally. We will support Balance in three key areas of activity:
• Educating and informing - giving people the information and support to be able to make informed choices related to alcohol
• Sharing  best practice - looking at successful projects or ways of working that is having a positive impact
• Calling on Government for Change - such as lobbying for Minimum Unit Pricing and adopting evidence based measures which will reduce the harm caused by alcohol misuse

Local opportunities

• South Tyneside Council has an ambition to be an outstanding place to live, invest and bring up families and is preparing a new Local Plan to help it achieve this vision. The Plan will set the planning policy basis for assessing all planning applications and development proposals in the Borough, and as such this presents an opportunity to make a positive impact on issues around licensing, for instance which can help minimise the harm caused by alcohol misuse.
• The Children and Families Board has refreshed and re-launched its Best Start in Life Strategy. This has three key priorities:
  • Safer and stronger families
  • Enterprise Learning and Skills
  • Healthier Communities
• This strategy presents a real opportunity to be clear in addressing what South Tyneside could look like if the local population is supported to drink less alcohol.

• A recent Best Start in Life Conference was held by Balance exploring the impact of alcohol in childhood. More children in the North East and nationally are choosing not to drink alcohol, however Balance estimates that in the North East around 16,500 11 - 15 year olds drink on a regular basis and 9,300 have been drunk in the previous month.
• A survey of North East adults found that many believe providing children with alcohol can help them handle drinking when they're older. However, a separate survey with children suggests a stark difference between the myths and the reality.
• Over half (54%) of adults believe providing children with alcohol in a supervised situation will ensure they know how to handle drinking when they're older. Yet a separate survey with children found:
• Children aged 11 - 15 are four times more likely to be an "at risk" drinker if their parents allowed them to drink alcohol.
• The same survey of 11 - 15 year olds also found that 87% of children whose parents DO NOT allow them to drink choose not to - including 76% of Year 10s .
• Drinking alcohol can damage a child's health, even if they're 15 or older, affecting normal development of vital organs and functions, including the brain, liver, bones and hormones. Chief Medical Officer (CMO) guidance states that children who start drinking alcohol at an early age are more likely to develop alcohol problems in adolescence and adulthood. This is why CMO guidance recommends to children and their parents that an alcohol-free childhood is the healthiest and best option, and if children drink alcohol, it should not be until at least the age of 15 years.
• Learning from the conference will feed into local work focussing on alcohol in pregnancy and childhood so that people are aware of the guidelines and messages given to pregnant women.   

Identification and prevention

• Continue to support co-ordinated regional approaches to lobbying via Balance and advocate reducing alcohol-related harm through national, regional and local policies.
• Ensure interventions such as media campaigns and health education programmes are delivered in both universal (schools and workplaces) and targeted settings to increase knowledge and change attitudes to alcohol
• Ensure there is a clear understanding of the objectives around Making Every Contact Count relative to alcohol awareness and supporting behaviour change within the local population

Intervention and treatment

• Monitor, review and evaluate the delivery, quality and effectiveness of training
• Ensure pathways into treatment are robust and that information is made available to service providers and local residents, to identify and treat alcohol dependence as soon as possible

Licensing

• Continue working closely with the licensing department to help inform licensing reviews from a Public Health perspective
• Contribute to future updates and revisions of the Statement of Licensing Act Policy ensuring relevant health data recorded to support the development of the policy  

Crime and disorder

• Consider the priorities and the relationship to alcohol related crime, taking a partnership approach to deliver key actions in the Community Safety Plan 

• The Chief Medical Officer (CMO) published new alcohol guidelines that state drinking any level of alcohol regularly carries a health risk for everyone. Men and women should limit their intake to no more than 14 units a week to keep the risk of illness like cancer and liver disease low.
• Most people have heard of units of alcohol and the sensible drinking message. However, evidence shows that people do not always understand what constitutes a unit; it is difficult to keep track of units (principally because the more a person drinks the less reliable their recollection is). Therefore many people could be drinking more than they think and results in less accurate assessments of the levels of drinking in a population.

• 14 units equal:
  • 6 pints of 4% beer
  • 6 (175ml) glasses of 13% wine
  • 14 glasses of (25ml or one shot) of 40% spirits
• Both men and women are advised to have at least two alcohol free days a week and spread drinking evenly over three or more days.
• Evidence shows that there were almost 24,000 alcohol-related deaths in England, an increase of 1.3% since 2015. Deaths from alcohol-specific conditions increased by 2.1% to 16,196 in 2014 to 2016 compared to the previous 3 year period. The rate of alcohol-specific deaths increased by 1% in the latest 3 year time period to 10.4 per 100,000 in the population (LAPE)
• 10.8 million adults in England are drinking at levels that pose some risk to their health (GOV.UK: Health matters: Harmful drinking and alcohol dependence)
• An analysis of 67 risk factors and risk factor clusters for death and disability found that alcohol is the third leading risk factor for death and disability after smoking and obesity.
• Alcohol dependence can be a long-term condition, which may involve relapses even after good quality treatment. Dependent individuals also experience many health problems and are frequent users of health services.

• The short-term risks of alcohol misuse include:
  • Alcohol poisoning, which may include vomiting, seizures (fits) and unconsciousness;
  • Injuries requiring hospital treatment, such as a head injury;
  • Violent behaviour that might lead to being arrested by the police;
  • Unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs);
• Long-term alcohol misuse is a major risk factor for a wide range of serious conditions, such as:
  • high blood pressure
  • stroke
  • pancreatitis
  • liver disease
  • liver cancer
  • mouth cancer
  • head and neck cancer
  • breast cancer
  • bowel cancer  
  • depression
  • dementia 
  • sexual problems
  • infertility 

• As well as having a significant impact on your health, alcohol misuse can also have long-term social implications. For example, it can lead to:
  • family break-up and divorce
  • domestic abuse
  • unemployment
  • homelessness
  • financial problems

Age

• Among those aged 15 to 49 in England, alcohol is the now the leading risk factor for Ill-health, early mortality and disability and the fifth leading risk factor for ill-health across all age groups (Public Health England, 2016 Burden of alcohol).
• The ONS's new alcohol-specific deaths indicator accounts for around 80% of the deaths included in their alcohol-related deaths dataset. At the UK level in 2016 alcohol-related deaths totalled 9,214 compared to 7,327 alcohol-specific deaths.
• There are more hospital admissions related to alcohol consumption in the older age groups than in the younger age groups (2010 / 11).
• In England, the average age at death of those dying from an alcohol-specific cause is 54.3 years. The average death from all causes is 77.6 years.
• On average, teenagers drink twice as much now as they did in 1990.

• Children and adolescents are at increased risk due to:
  • Alcohol seriously impairing brain development in young people
  • Changes in physiological development;
  • Inexperience;
  • Experimentation and generally higher tolerance of risk;
  • Early exposure leading a greater chance of developing illness in later life;
• Children affected by parental alcohol misuse are more likely to have physical, psychological and behavioural problems. Alcohol plays a part in 25 to 33% of known cases of child abuse. Health Matters, 2016

• Older people are considered to be at increased risk due to:
  • Physiological changes (increased susceptibility);
  • The higher risk interaction with prescribed medication;
  • The stresses of ageing including the risk of isolation.

 Gender

• In England, alcohol dependence is more common in men (6%) than in women (2%). This gender difference is found to be the case all over the world and is one of only a few key gender differences in social behaviour.
• Levels of alcohol consumption vary with age and gender. Among men, the prevalence of drinking more than 14 units a week increases with age and is most common among men aged 65 to 74 years. Thirty-nine per cent of men this age drink at this level (Health Survey for England 2014)
• Among women, the proportion that drink more than 14 units a week declines between the ages of 25 and 44 years, and is the highest among women aged 55 to 64 years with 21 % of women this age drinking at this level. 
• For men and women, binge drinking, defined as exceeding eight units in one day for men and six units in one day for women, is highest in the youngest age groups, peaking in the 25 to 34 years group and then reduces with age. Nineteen per cent of men and 11 % of women were exceeding these daily values on at least one occasion in the previous week in 2014 (Health Survey for England 2014).
• The average weekly alcohol consumption is 16.4 units for men and 8.0 units for women.26% of men drink more than 21 units in an average week. For women, 18% drink more than 14 units in an average week.
• Men account for the majority of alcohol-related admissions (65%), which reflects a higher level of harmful drinking (higher risk) among men compared to women overall (stats on alcohol 2017, NHS digital).  Alcohol has been identified as a causal factor in more than 60 medical conditions, including circulatory and digestive diseases, liver disease, a number of cancers and depression.
• In 2013 - 2015 the incidence rate of alcohol-related cancer in men was 50.90 per 100,000 higher than the national rate of 39.29. Physiological differences mean that women may be at greater risk than men. Pregnant women are also generally identified as a population at risk. The Department of Health recommends that pregnant women, or women trying for a baby, should avoid alcohol altogether. The National Institute for Health and Clinical Excellence (NICE) advises that the risks of miscarriage in the first three months of pregnancy mean that it is particularly important for women not to drink alcohol at all during that period, If women do choose to drink, to minimise risk to the baby, the government's advice is to not have more than one to two units of alcohol once or twice a week, and not to get drunk. Miscarriage, stillbirth, premature birth, small birth weight, and Foetal Alcohol Spectrum Disorder (FASD) are all associated with a mother's binge drinking which means consuming more than six units on one occasion whilst pregnant.
• In relation to health, for every 100 admissions for alcohol attributable admissions in England South Tyneside can expect 149. This is the fifth highest alcohol related admissions rate in the country, and the third highest for females.
• The adverse effects of alcohol are common to both sexes. However, evidence suggests that many of these effects pose a greater risk to women's physical health at lower consumption levels than men.[1] The Royal Medical Colleges reported that studies conducted into alcohol-related harm in women were consistent in suggesting that the consumption level at which relative risk of mortality starts to rise is around 16 grammes of alcohol per day, or approximately 2 units. A woman will attain consistently higher blood ethanol concentrations than men following a standard oral dose of ethanol, regardless of body weight. This occurs primarily because their body water, and hence the compartment in which the ethanol distributes, is significantly smaller than in men.
• Later life poses unique issues surrounding alcohol for women. Older women have less lean muscle mass and continue to lose this with age, which makes them more susceptible to effects of alcohol. Similarly, the liver enzymes which process alcohol and medication lose effectiveness with age, and the central nervous system becomes more sensitive; this poses a greater problem for older women who drink, as older women tend to take more medication.
• In 2016, the UK Chief Medical Officers (CMO) published updated Low Risk Drinking Guidelines, based on an analysis from an expert group of the available evidence on alcohol's health effects. The CMO note that evidence produced since the previous drinking guidelines suggests that drinking alcohol increases women's breast cancer risk, that this risk starts from any level of alcohol consumption, and that this risk rises with alcohol consumption.

Mental health

• An estimated 44% of community mental health patients have reported problem drug use or harmful alcohol use in the previous year.
• There is a strong association between alcohol misuse and suicide. The National confidential inquiry into suicide and homicide by people with mental illness found that there was a history of alcohol misuse in 45% of suicides among the patient population during period 2002 to 2011 (Health Matters, 2016)

Socioeconomic and environmental factors and other determinants

• Alcohol kills people early and is a cause of health inequalities. Compared with those living in most affluent areas, people in the most deprived fifth of the country are 3 - 5 times more likely to die of an alcohol-specific cause.
• People of lower socioeconomic status show greater susceptibility to the harmful effects of alcohol (52) and are more likely to die or suffer from a disease relating to their alcohol use (53). In the English population, rates of alcohol-specific and related mortality increase as levels of deprivation increase (54) and alcohol-related liver disease is strongly related to the socioeconomic gradient (55) (Figure 11)
• Lower socioeconomic groups often report lower levels of average consumption, as shown by the decreasing lines in Figure 11. Yet experience greater or similar levels of alcohol-related harm. This is particularly true for mortality from chronic liver disease. This gives rise to what has been termed the 'alcohol harm paradox' whereby disadvantaged populations who drink the same or lower levels of alcohol, experience greater alcohol-related harm than more affluent populations. GOV.UK: Alcohol: Public health burden evidence review

• The following statistics are from a self-reported survey (ONS 2017 Adult drinking habits in Great Britain; 2005 to 2016):
  • As a proportion of the whole population, those in employment are most likely to drink at least once in the week (62%) leading up to interview. Economically inactive people (a group represented by students and the retired) are most likely to drink on at least five days in that week (12%), but are also most likely to abstain from drinking (30%). Unemployed drinkers are most likely to binge drink (39%) on the heaviest drinking day in the week. Institute of Alcohol Studies: Alcohol knowledge centre
  • Those in employment in the managerial and professional classes drink most frequently (12%). Although routine and manual workers are most likely to abstain from drinking (20%), they are also most likely to binge drink on the heaviest drinking day in the last week, highlighting a greater disparity in drinking behaviours compared with other workers.
  • There is a positive correlation between income and the frequency of alcohol consumption.
  • Low-income earners are also least likely to drink on at least five days in the week (7%); those on the highest incomes are most likely to do so (13%). Although the range is small (six percentage points), the proportion of drinkers who binge drank was lowest among low-income earners.
  • High levels of alcohol misuse are associated with clients who were unemployed and/or had difficulties with housing.

Impact of alcohol misuse on children and families

• Alcohol misuse impacts not just on the drinker but also those around them. Children affected by parental alcohol misuse are more likely to have physical, psychological and behavioural problems.
• Parental alcohol misuse is strongly correlated with family conflict and with domestic violence and abuse. This poses a risk to children of immediate significant harm and of longer-term negative consequences.
• In a study of 4 London boroughs, almost two-thirds of all children subject to care proceedings had parents who misused substances including alcohol.
• In a study of young offending cases where the young person was also misusing alcohol, 78% had a history of parental alcohol abuse or domestic abuse within the family.
• Alcohol misuse also affects carers and adult family members. The Care Act 2014 recognises this and recommends an assessment of their own needs.
• The impact of harmful drinking and alcohol dependence is much greater for those in the lowest income bracket and those experiencing the highest levels of deprivation.

Veterans

• It is difficult to know the number of veterans in the borough as the Ministry of Defence does not provide any formalised data on discharges. However, the Foresight Report tells us that there is 2 - 3 times the rate of binge drinking compared with civilians at risk and there is a correlation of alcohol and violent offences with 75% of violent offences amongst soldiers are alcohol-related.

South Tyneside's alcohol profile shows a wealth of information across all alcohol related indicators. The key headlines are:

• In 2015 / 16, there were 4,913 alcohol related admissions in South Tyneside.  This equates to a standardised rate of 3,272 per 100,000 adults in South Tyneside, this is significantly higher than both the North East and England rates.
• For every 100 admissions for alcohol attributable admissions in England South Tyneside can expect 149. Four wards, Simonside and Rekendyke, Biddick and All Saints, Bede, and Whiteleas have admission ratios that are significantly higher than the borough.  Three were significantly lower: Boldon Colliery, Whitburn and Marsden, and Cleadon and East Boldon.
• In 2015 / 16 South Tyneside had the fourth highest rate in England for admission episodes for alcohol-related conditions (narrow) with 588 per 100,000 under 40s (directly age standardised)
• In 2015 / 16 South Tyneside had the fourth highest rate in England for admission episodes for alcohol-related conditions (narrow) for over 65s  with 1,361 per 100,000 (directly age standardised)
• Years of life lost indicate the contribution of alcohol misuse to premature death. In South Tyneside 961 years of life were lost to alcohol-related conditions in men per 100,000 standardised population in 2015. This is higher than the national standardised rate of 797 per 100,000 males. In females the local standardised rate is 472 compared to the national standardised rate of 311 years of life lost to alcohol-related conditions in women.
• Incidence rate of alcohol-related cancer (2013-15) is not statistically different to that of the England average.  However the new guidelines on alcohol consumption produced by the Chief Medical Officer warns that drinking any level of alcohol increases the risk of a range of cancers.  This is supported by a new review from the Committee on Carcinogenicity (CoC) on alcohol and cancer risk.
• From around 2000 South Tyneside is seeing an increasing rate of under 75 mortality rate from liver disease in females with 6 of the last 7 releases being significantly worse than the England average. Between 2014 - 16 South Tyneside had a rate of 22.1 females per 100,000 DSR in real terms this would be 46 people.
• While South Tyneside had a similar mortality rate to England in 2007 - 09 it has been significantly higher in six out of seven years since.
• Of the male perpetrators of domestic violence crimes in South Tyneside 59% had alcohol issues.
• The estimated number of alcohol related crimes in 2015 / 16 is 12,400; including reported and unreported crimes:
  • 3,400 for criminal damage
  • 1,100 for violence against the person
  • 7,400 for theft
• In July 2017 Public Health England published the National Alcohol Consumption Survey as a result of the lack of reliable information about alcohol consumption. Public Health England (PHE) commissioned Ipsos MORI to collect data for a sample of local authorities which were chosen to provide coverage of all regions and types of local authority.  The following table demonstrates drinking consumption for South Tyneside in comparison to other areas. 
• According to the survey, South Tyneside are the highest in the country for binge drinking (6 / 8 or more units on a single occasion).  South Tyneside also has a high percentage of respondents recording an Audit score of 8 or more.

• AUDIT was developed and evaluated over a period of two decades, and it has been found to provide an accurate measure of risk across gender, age, and cultures.  Audit consists of 10 scored questions about recent alcohol use, alcohol dependence symptoms, and alcohol-related problems.
• Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. Scores between 16 and 19 suggest brief counselling and continued monitoring. Scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence.

Cost of alcohol

• In 2015 / 16 the cost of alcohol harm in South Tyneside was estimated to be £386 per head of population, the same as the North East, which is more than the England figure of £363 per head of the population.
• Balance recently revealed that the cost of alcohol harm to the NHS and healthcare is estimated at £13.1m which ranks South Tyneside as the 5^th most expensive per head nationally:
  • The cost of the 1,155 hospital admissions wholly attributable to alcohol is estimated at £2.2m
  • 3,182 admissions partially attributable to alcohol cost £4.8m
  • 4,913all alcohol related admissions cost £7.0m
• In 2015 / 16 £8.5m of the local authority social services budget was estimated to be attributable to alcohol:
  • Children: Social services £7.0m
  • Substance misuse services £61,700
  • Adults: Substance misuse support and alcohol misuse services £1.4m
• Crime and disorder is estimated to be £113 per head of population during 2015/16, ranking South Tyneside as 130^th most expensive per head of population:
  • Anticipation of crime: £0.7m
  • Consequence of crime: £15.5m
  • Response to crime: £0.5m

• There is strong evidence available to suggest what level of provision is required in a local area. NICE Guidance PH24 provides recommendations for the prevention and early identification of alcohol use disorders using a population level approach. These approaches can help those who are not in regular contact with services as well as those who have been specifically advised to reduce their alcohol intake.
• Many of the recommendations within the NICE PH24 are clearly supported in South Tyneside.  These include:
  • Supporting the regional work via Balance, the regional alcohol office, around lobbying for minimum unit price
  • Raising awareness through national and regional campaigns via PHE and Balance.
  • Working in partnership with colleagues across the partnership around licensing and trading standards.

• Work is underway in South Tyneside to review the strategic approach the Council and partners are looking to take to reduce alcohol related harm and will be updating the South Tyneside alcohol strategy.   
• An evidence based strategy will help partners to focus limited resources in the right place and make efficiency savings where possible.
• The recently repeated Health Related Behaviour questionnaire will be an opportunity to revisit the impact alcohol has on children and families.  Following a recent Ofsted inspection the toxic trio (mental health, substance misuse and domestic violence) has been highlighted as an area for further development, with particular emphasis on safeguarding children.   
• South Tyneside has a high number of adults in specialist alcohol treatment services. There are 5.2 per 1,000 population, the 5th highest in the country, this highlights the above average rate of alcohol harm, however in part, the high rate can be perceived as a high quality of local service provision. Effective structured treatment for alcohol dependent adults will continue to be an essential element of a local integrated alcohol harm reduction strategy.
• Increased consumption could be tackled with reducing availability. In 2015 / 16 South Tyneside had a rate of nearly twice as many females (605) being admitted to hospital for alcohol-specific conditions compared to the national rate of 367 per 100,000. It is also the third highest in the region.

• As outlined in Section 2, South Tyneside is consistently higher than the England average across the range of alcohol related indicators:
• Following a decrease in 2015, Alcohol related mortality has seen an increase back to its traditionally high levels in 2016. South Tyneside remains the highest in the North East.  This can also be said for hospital admissions due to alcohol related cardiovascular disease.
• Hospital admissions for alcoholic liver disease have historically been significantly higher than the England average and are on the increase.
• Hospital admissions for alcohol specific related unintentional injuries have doubled over two years (14 / 15 - 15 / 16).
• However, it is important to consider that the consequences of high levels of alcohol intake can take a number of years to become visible. South Tyneside trends may reflect a change in drinking patterns and behaviour in the local population, which may need further exploration in order to ensure problems are not stored up for the future.

Training

• First Contact Clinical (FCC) provides a front line training offer in South Tyneside. They deliver a range of training modules designed to equip the workforce with skills and knowledge to be able to deliver health improvement interventions and conversations.
• Training around alcohol includes:
  • Alcohol IBA
  • Alcohol and substance misuse levels 2 and 3
  • Healthy weight and how alcohol can affect weight
  • Make Every Contact Count
  • NHS Health Check (3 levels including VBA and how healthcare professionals can communicate risk and recommend lifestyle changes using evidence based behaviour techniques.

• The training delivered during 2016 through to August 2017 has been reviewed:
  • Highest number of courses delivered were for Make Every Contact Count (MECC) (n=27).
  • The number of courses reflects the individual attendances: MECC (n=340), Alcohol and Substance Abuse L2 and L3 were also well attended with over 100 attendees for each course.
  • The organisations with the most attendees across all courses were South Tyneside Council (n=398), GP surgeries (n=231), pharmacies (n=129) and South Tyneside NHS Foundation Trust (n=126).

Preventing ill health

• The NHS is taking action to address risky behaviours, with a focus on alcohol consumption by implementing a CQUIN which will complement and reinforce existing activity to deliver interventions to those that use alcohol at harmful and hazardous levels. 

The Better Health at Work Award

• A healthy workplace has considerable benefits for employers and employees.
• In 2016, there were 21 companies across South Tyneside signed up to improve their employees' health and working towards the award.
• Reaching over 13,000 employees, the workforce benefited from a range of activities including safer drinking messages.

Change4Life (C4L) Health and Wellbeing Champion Network

• Over 150 C4L Health and Wellbeing Champions are promoting public health campaigns and messages such as Dry January across the borough. The network is a multi-agency initiative of the Council, Voluntary and Community sector and members of the public.

Partnership Working

• Alcohol is a complex issue that needs a multi-layered response at national and local level; therefore partnership working is crucial to a successfully developed and implemented alcohol strategy, which is one of the key priorities within South Tyneside's Health and Wellbeing Strategy. 
• The following discreet partnership projects are currently underway across the South Tyneside and will inform the future strategy:
• Pathway improvement for gastro patients.
• Blue light strategy
• Community Safety Partnership

Matrix - Young Peoples Drug & alcohol Service

• The Matrix is a 'multi-agency' drug and alcohol service working with young people under 18 and families and carers whose lives have been affected by substance use. Matrix staff are trained to deal with issues affecting young people and offer a confidential service.

Treatment service

• South Tyneside has historically well-developed treatment system including Tier 2 and Tier 3 services.  Services perform well for successful completions and in line with Public Health England key performance indicators.

• Investing in alcohol interventions saves money.  A recent Public health England publication Why Invest demonstrates:
• Every 5,000 patients screened in primary care may prevent 67 A&E visits and 61 hospital admissions Costs £25,000 Saves £90,000.
• One alcohol liaison nurse can prevent 97 A&E visits and 57 hospital admissions Costs £60,000 Saves £90,000.
• Every 100 alcohol dependent people treated can prevent 18 A&E visits and 22 hospital admissions Costs £40,000 Saves £60,000.
• PHE have also illustrated how interventions may lead to better public health outcomes across the public health outcome framework domains, this can be found in this assessments associated slide pack.

Alcohol Treatment and brief intervention

• Interventions aimed at helping individuals can help make people aware of the potential risks they are taking at an early stage. This is important, as they are most likely to change their behaviour if it is tackled early.
• The use of screening is recommended to identify people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder.
• Structured brief advice included in MECC training only takes minutes to deliver and early intervention could prevent extensive damage.
• The public health burden of alcohol: evidence review considers the impact of alcohol on the public health and the effectiveness of alcohol control policies

• A Life Education survey found that almost a third of children think that for adults who drink wine, five or more glasses a night is normal drinking behaviour.
• The Health Related Behaviour Survey has recently been repeated with comparisons drawn from previous survey carried out in 2012 / 13 as follows:

• A point worth noting is 71% of year 8 boys and 46% or year 10 boys said they never drink alcohol, compared with 66% and 40% respectively who said the same in a wider sample.
• The 2012 Lifestyle Survey for South Tyneside, Gateshead and Sunderland identified that the proportion of adults over 18 who are drinking heavily on a single occasion, weekly or more often, is considerably greater than the England rate.
• Treatment service users are continually asked for their views to ensure that the treatment services are meeting their needs and that they are engaged throughout their whole recovery journey. Regular surveys and evaluation exercises ensures this process is met.

• Little is known about the positive impact that local treatment services have on the wider health system, which could be addressed by cross-referencing treatment and other health data.
• Qualitative research may be needed to investigate treatment need for women; and if what is currently being delivered is appropriate.