Blue Light Approach

Aims:

This website is aimed at raising the awareness of health professionals and workforces who engage with change resistant drinkers. This includes the Police, Hospital staff, Social Workers, Housing providers, Specialist Substance Misuse providers and Anti-Social behavioural teams.

The Blue Light Approach:

Alcohol Concern developed the Blue Light approach in recognition that the way in which Specialist Substance Misuse services have been commissioned create barriers to engaging with change resistant drinkers and those with long term dependency.

Evidence suggests 94% of dependent drinkers are not engaged with Specialist treatment services. (1)

Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences. Alcohol dependence is also associated with increased criminal activity and domestic violence, and an increased rate of significant mental and physical disorders. (2)

Alcohol consumption is a contributing factor to hospital admissions and deaths from a wide range of conditions. Alcohol misuse is estimated to cost the NHS about £3.5 billion per year and society as a whole £21 billion annually. (3)

The Blue Light approach has demonstrated that there a numerous reasons why long-term dependent drinkers are unlikely to possess motivation for change, and that motivation, is not required to have positive impact on the lives of these individuals. (1)

Case Story

The one thing you can do more than any other is to demonstrate that you believe the person can change.

If we do not demonstrate a belief in the possibility of change, then we will reinforce a sense of hopelessness in clients (1)

Rationale

Half a Million people are Dependent on Alcohol in UK.(4)

40% of apparently non-changing higher risk and dependent drinkers try and change each year. (6)

At the most basic level we must challenge the notion that nothing can be done to help problem drinkers who do not want to change. Motivational interventions have been proven to be effective with this client group.(7)

By perpetuating the notion that ‘nothing can be done’ we will:

+ Fail this client group

+ Extend the suffering of their victims

+ Increase the burden on public services, and

+ Marginalise alcohol services as agencies that have little to offer the most risky and vulnerable clients. (1)

In a sample of Domestic Homicide Review Cases Alcohol Concern found that alcohol played a significant contributory role in 75% cases and in most of the cases the perpetrators and sometimes victims were treatment resistant drinkers. (1)

Alcohol admissions for all ages per 100,000 population has exceeded the national level for the past 6 years in Exeter, Torridge and North Devon. (8)

There is also a correlation between alcoholism and claiming of benefits. The rate of claimants on benefits due to alcoholism per 100,000 population in 2016 across the 8 districts in Devon. (8)

A series of training needs analyses with non-specialist workers identified a need in “how to work with difficult to engage drinkers”. (1)

The Empowerment Model

The Blue Light approach is based on an empowerment model of Health Promotion, which is the process of enabling people to acquire more control over their lives. (14)

Empowerment can be defined as an approach which attempts to enhance health or prevent disease through the provision of information, the development of self-efficacy and skills to put knowledge into practice, and the opportunity to take control over one’s life. (14, 16)

Empowerment strategies seek to build capacity in individuals and communities, thereby enabling them to take control, via decision making and advocacy, over the determinants of their health.

Research

There is very little in the way of evidence on how to work with change resistant drinkers. (1,2, 29)

 The peer reviewed approach is a guide towards best practice.

Findings from Sandwell, Lincolnshire and Medway.

Key findings from the Sandwell evaluation (18)

  • Improved joint working between agencies.
  • Opportunities to challenge poor practice.
  • Support to commissioners to identify unmet need, and gaps and blockages in care
  • pathways.
  • Estimated cost saving of just over £135,264: a reduction of 55%” in the 1st year. Against
  • an additional investment cost of £25,000.

Key findings from the Lincolnshire evaluation (19)·

  • In a sample of 7 cases from 10 who had been involved with the Blue Light team for at least 6 months, there was a 66% decrease in Police incidents.
  • Costs to the Police in the 180 days prior to the Blue Light approach were £34,176 and in the 180 days post initiation of the Blue Light programme costs to the Police dropped to £11,481.

Key findings from an independent Medway evaluation (20)·

  • The Model appears to be effective at reducing demand on services·
  • good value for money·
  • effective multi-agency practice
  • 62% of BL clients had a positive or neutral outcome, only 15% of cases had a negative outcome

Motivational interviewing and brief interventions have been proven through meta-analysis to be effective in decreasing alcohol and drug use in adults and adolescents. This helps to build self-belief amongst this client group. (27, 28, 30).

Addressing health inequalities contributes towards success and for the homeless a housing first approach is recommended. (21)

Kings Health Partners (KHP) developed a multi-agency approach to working with the homeless population who like Blue Light clients are over-represented in frequent admission rates to accident and emergency departments in hospitals. (22)

The evidence from KHP shows that this multi-agency approach upskilled a multi-agency workforce, promoted collaboration and led to reduced hospital admissions and sustained housing provision. Development of trusting relationships is key to engagement with this client group and sustained and consistent contact. (22)

Areas for development

Recommendations for system leaders in developing a Blue Light approach to working with change resistant drinkers, suggest the following:

  1. Individualised goal setting for clients that are realistic to that individual
  2. Consider the use of joint care plans that are shared amongst agencies
  3. Agree a process for closing cases
  4. Consider partnership investment in an outreach function
  5. Induction for new group members
  6. Training should be made available to the partner workforces and consideration be given to widening the scope of the tools to other complex clients (such as those misusing drugs and those with severe mental health conditions).
  7. Agree a process for monitoring the progress of each client and demonstrating the effectiveness of the model adopted
  8. Consider how to include family members in the approach (also supported by NICE CG115) (20)Alternative approaches

    Not all Blue Light client interventions end with positive outcomes. More research is needed to better understand effective ways of supporting those with severe mental illness and those living with alcohol acquired brain injury. Where required, there is evidence to suggest that coercive approaches through the criminal justice system can also be effective in promoting participation in treatment. (23,24)

    The new NHS 10-year plan aspires to limit alcohol related A&E admissions through the adoption of Alcohol Care Teams. However, they will only be funded in the top 25% of hospitals with greatest need. (25)

    Additional evidence-based interventions that contribute to reducing the burden on society can be found by reading: The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies An evidence review. (26)

    References

    1. Ward, M. and Holmes, M. (2014) Blue Light Project: Working with Change Resistant Drinkers. 1st edition ed.: Alcohol Concern.

    https://alcoholchange.org.uk/help-and-support/get-help-now/for-practitioners/blue-light-training/the-blue-light-project

    1. Public Health England Guidance (Feb 2018) Alcohol and drug prevention, treatmentand recovery: why invest? https://www.gov.uk/government/publications/alcohol-and-

    drug-prevention-treatment-and-recovery-why-invest/alcohol-and-drug-prevention-treatment-and-recovery-why-invest

    1. Miller, W R and Rollnick, S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press.
    2. Ward M. (2012) Review of alcohol related hospital admissions 2011–12. SW London Sector
    3. Service specification (2012/13) Alcohol Intensive Case Management Service. Cited in Blue Light Manual.
    4. Haringey Clinical Commissioning Group (2013) Haringey profile, Alcohol-related hospital admissions. Public Health Intelligence. Haringey Council.[Accessed 08 February 2019]

    https://www.haringey.gov.uk/sites/haringeygovuk/files/

    haringey_alcohol_admissions_march_2013.pdf

    1. South West Public Health Observatory (2011) Alcohol Attributable Hospital Admissions (NI39) in the South West. Cited in Blue Light Manual.
    2. National Drug Treatment Misuse Service (NDTMS) (2018) Alcohol dependence prevalence in England. Public Health England https://www.gov.uk/government/statistics/

    substance-misuse-treatment-for-adults-statistics-2017-to-2018

    1. Public Health England (2017) Public Health Profiles. Hospital admissions for alcohol-specific conditions, all ages, directly age standardised rate per 100,000 population. [Accessed 10 February 2019]

    https://fingertips.phe.org.uk/profile/health-profiles

    1. Naidoo, J. and Wills, J (2011) Developing Practice for Public Health and Health Promotion. 3rd edition ed.: Elsevier.
    2. Rubak, S, Sandbaek, A, Lauritzen, T. and Chritensen, B. (2005) Motivational Interviewing: A Systematic Review and Meta-analysis. British Journal General Practice [online]. 55 (513), pp. 305-312. [Accessed 08 Feb 2019].
    3. Michie, S., Van Stralen, MM and West, R. (2011) The Behaviour Change Wheel: A New Method For Characterising and Designing Behaviour Change Interventions. Implementation Science [online]. 6 (1), p. 42. [Accessed 01 February 2019].
    4. National Institute for Health and Care Excellence (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical guideline (CG115). [Accessed 10 February 2019]

    https://www.nice.org.uk/guidance/cg115

    1. Tosh, G, Clifton, AV, Xia, J and White, MM (2014) General Physical Health Advice for People with Serious Mental Illness. Cochrane Database of Systematic Reviews [online]. [Accessed 28 January 2019]
    2. Ward, M and Bailey, M (2017) The Sandwell multi-agency management group for high impact problem drinkers. Interim evaluation.
    3. Tones, K. and Tilford, S. (2001) Health Promotion: Effectiveness, Efficiency and Equity. 3rd edition ed. Cheltenham: Nelson Thornes Ltd.
    4. Child, H (2016) Blue Light Project Year 1 Working with treatment resistant drinkers. Lincolnshire County Council and Partners.
    5. Scott, M (2018) Blue Light evaluation. A brief evaluation of the Medway Blue Light programme. TONIC.
    6. Hall, K., Gibbie, T. and Lubman, D.I. (2012) 27. Motivational Interviewing Techniques – Facilitating Behaviour Change in the General Practice Setting. Australian Family Physician [online]. 41 (9), pp. 660-667. [Accessed 03 February 2019]
    7. McQueen J, Howe TE, Allan L, Mains D, Hardy V. (2011) Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database of Systematic Reviews (online), (8). [Accessed 03 February 2019]
    8. Miller, WR, Benefield, RG and Tonigan, JS (1993) 30. Enhancing Motivation for Change in Problem Drinking: A Controlled Comparison of Two Therapist Styles. Journal of Consulting and Clinical Psychology [online]. 61 (3), pp. 455-461. [Accessed 03 February 2019].

    https://www.cochranelibrarycom.ezproxy.uwe.ac.uk/central/doi/10.1002/central/CN-00094335/full

    1. Bretherton, J and Pleace, N (2015) Housing First in England. An evaluation of nine services. Centre for Housing Policy. University of York.
    2. Dorney-Smith, S, Hewett, N., Khan, Z. and Smith, R. (2016) Integrating Health Care For Homeless People: Experiences of the KHP Pathway Homeless Team. British Journal of Healthcare Management [online]. 22 (4) [Accessed 01 February 2019].
    3. Alcohol Concern and Alcohol Research UK (2018) Tackling alcohol-related anti-social behaviour through Civil Injunctions and Criminal Behaviour Orders: A missed opportunity? [Accessed 12 February 2019]
    4. Peters, R. A. and Scott Young, M. (2011). ‘Coerced Drug Treatment’, in Kleinman, M., Hawdon, J. and Golson, G. (eds), Encyclopedia of Drug Policy, Volume 1, Sage Publications, p. 144. [Accessed 01 February 2019].

    https://www.researchgate.net/publication/261697419

    1. National Health Service (2019) The NHS Long Term Plan. [Accessed 01 February 2019].

    https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf

    1. Public Health England (2016) The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies An evidence review. [Accessed 12 February 2019].

    https://assets.publishing.service.gov.uk/government/uploads/system/uploads/

    attachment_data/file/733108/alcohol_public_health_burden_evidence_review_update_2018.pdf

    28 Gordon, R., Flecknell, M., Fournier, T., Dupont, D., Gowlett, K. and Furlong, K.E. (2017) Partnering for Patti: Shaping future healthcare teams through simulation-enhanced interprofessional education. Canadian Journal of Respiratory Therapy [online]. 53 (4), pp. 81-87. [Accessed 09 February 2019].

    1. Vachan, B. and Leblanc, J. (2011) Effectiveness of Past and Current Critical Incident Analysis on Reflective Learning and Practice Change. Medical Education [online]. 45, pp.894-904. [Accessed 09 February 2019].

    30.Ward, M and Booker, L (no date) An evaluation of the Nottinghamshire Alcohol Related Long Term Condition Team: An example of good practice with change resistant drinkers. Alcohol Concern.[Accessed 08 February 2019].

    https://ranzetta.typepad.com/files/the-nottinghamshire-alcohol-related-long-term-condition-team.pdf

    1. Saunders, L (2016) High Impact Complex Drinkers: Final Report. Public Health,Surrey County Council.[Accessed 12 February 2019].

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    1. Fenton, E (2015) Motivational Interviewing: The RULE Mnemonic. Available from: https://www.youtube.com/watch?v=ZwPsUcCggUw&t=3s. [Accessed 11 February 2019]
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