Shared learning database

Yorkshire Ambulance Service NHS Trust
Published date:
January 2014

How Yorkshire Ambulance Service established a region-wide alcohol referral pathway demonstrating a more efficient use of health and social care resources by putting the patient at the centre of the care pathway and identifying health needs at an early stage.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To explore the ways in which an ambulance service could improve the health of patients presenting to their 999 service due to alcohol misuse.

The objective was to develop a pathway for ambulance clinicians so that they can offer referral and signposting to further support towards managing and reducing alcohol consumption and improving the overall risk of the associated health issues and social effects related to alcohol. This in turn may reduce the future need to call 999.

Within the Yorkshire area a robust, standardised and effective pathway was established to refer this patient group. The pathway was developed for all YAS clinicians, with the potential for rollout to both clinical and non-clinical call handling staff, to recognise those patients who have an alcohol misuse problem and refer them on to appropriate specialist alcohol services. In concordance with NICE guideline QS11, quality statement 1, 2 and 3, the pathway is intended to promote the opportunistic screening of patients with alcohol misuse problems and referral to specialist services.

Reasons for implementing your project

Alcohol is one of the leading causes of accidents in the UK. Ambulance clinicians are too often called to pick up the pieces at incidents where someone has become ill or injured as a result of excessive alcohol consumption. The impacts of alcohol range from the physical, social and psychological effects to the economic wellbeing of both the individual and those around them.

Ambulance clinicians are often called to attend a range of patients that may have underlying alcohol misuse issues. Many of these patients would benefit from further involvement, support and engagement with specialist services.

The role of ambulance clinicians is continuing to develop with ever increasing demands on the 999 service and wider health economy, particularly in relation to urgent and emergency care. We believe that the opportunities for ambulance clinicians to have a role in terms of public health are yet to be realised. This pathway promotes the 'Make Every Contact Count' approach, a nationwide initiative to encourage Healthcare Professionals to use every opportunity to help people stay healthy and reduce system-wide costs to the NHS.

In Quarter 1 of 2013/14 the Yorkshire Ambulance Service (YAS) attended 10,178 calls where clinicians had identified that the use of alcohol was suspected. This equated to 5.9% of all calls. (However, this does not assume that the patient's condition is directly related to alcohol use). The cost of YAS attendance due to alcohol use is estimated at £231 per patient. In quarter 1 of 2013/ 2014 the cost to the service was over £2.3 million. This puts significant demand on finances and resource on an already stretched service.

In addition, the YAS frequent caller team advise that over a third of frequent callers have alcohol misuse issues. This has been on an upward trend over the past five years. Inappropriate frequent calls put an additional unnecessary strain on the 999 service.

It was envisaged that referral to the pathway would benefit the long term health of patients. In turn this would help reduce the calls to the service thus freeing up resources. We must be careful not to assume that every call involving alcohol is not justified. Many conditions where alcohol has been involved (assaults/ unconsciousness/ overdose for example) do need the expertise of ambulance clinicians. The debate is around how many of these calls would have been prevented if alcohol was not involved.

How did you implement the project

An alcohol referral pathway was initially established in Sheffield and Rotherham in October 2011. By implementing NICE quality statements 2 and 3 an immediate impact was made on patient care. Clinicians find that the pathway allows them to act on information gathered as part of the patient's history. Prior to this pathway, the patient's potential alcohol issues would not have been addressed other than via a possible GP referral.

YAS has a number of referral pathways in place. As such all referrals are made through a central hub. Therefore, once agreed with the service provider, it is relatively easy to establish a new pathway. A bespoke referral form and operating procedure is produced to collect all the agreed information which is then sent to the provider. This procedure covers:
- Scope
- Duties and responsibilities
- Methodology
- Monitoring and review
A full copy of the SOP can be found as attachment 1.
Once agreed and signed, the pathway is established with clinicians through weekly publications and pathways notice boards. There were some initial concerns from the service providers regarding use of the CAGE tool. However, the importance of the use of a uniform and simple assessment tool was explained. This led to an agreement to use the CAGE tool Yorkshire-wide but to look into the appropriateness of other available tools. Traditionally safe haven faxes have been used to send the referral to the providers with an accompanying telephone call. However, national Information Governance advocates a move towards more secure electronic methods. For the providers to set up agreed secure server connections would entail high costs and it was therefore decided to continue to use fax in the short term whilst an alternative solution was found. We are currently looking into a secure 'share point' for referrals and a national trial of new secure electronic systems that can be used by non-NHS organisations.

The pathway was successfully established Yorkshire-wide on 02 December 2014. Considerable time and resources are needed to run a referral pathway.The cost per call to handle and process the referral is estimated at £9.61. However, this is only for frontline staffing and not for wider costs and support structures. Although utilisation of the pathway does have the potential to increase clinician on scene times, it demonstrates a more efficient use of resources by putting the patient at the centre of the care pathway.

Key findings

Rotherham and Sheffield alcohol pathway pilot area

Since April 2012 to October 31st 2013 there were 120 referrals to alcohol services in Rotherham and Sheffield at an average of over 6 referrals a month.

In the previous 7 months to October 2013 there were 52 referrals with monthly fluctuations between 2 and 11 referrals. An average of over 7 referrals per month demonstrates a continued healthy referral pattern of YAS clinicians.

In October, over half of referrals had a CAGE score of 4 (maximum). However, clinicians are also successful at referring patients with lower scores. As this pathway relies on the patient consenting to being referred, it demonstrates that clinicians are able to engage with patients at various stages of their alcohol misuse.

We evaluated this pilot and subsequently found a patient that had found their experience of the pathway very positive. An excerpt from his story below shows how successful the pathway has been.

"Someone in my state wouldn't often seek help themselves or are often not in a state to do so. I would like to give a message to all ambulance crews to take every opportunity to try and refer patients with alcohol problems; it might seem as if it will fall on stony ground but on every occasion they should try (please don't be put off). The input from the crew was invaluable for me and could be for others too".

The full story can be found in attachment 2. We have also found that the professionals within the alcohol services value the pathway. It helps to safety net patients that otherwise may not have been recognised. An excerpt from that testimony is below;
"The pathway, whilst still gaining momentum at this stage, has highlighted excellent examples of joint working and seamlessness when assisting clients into treatment. There have been examples where clients have been successfully referred and are now actually in treatment programmes". Full testimony can be found in attachment 3.

Yorkshire wide alcohol pathway summary: In the first 28 days of the YAS wide roll out there had been 34 referrals, exceeding the expected one per day. Both clinicians and the clinical hub are finding the referral a simple process. NICE Quality Statement 1 'awareness and training for health a social care staff' is an area we plan to develop further. It is hoped with support from commissioners that a bespoke education package can be developed.

Key learning points

Uniformity of the pathway is very important. Clinicians need to be able to refer patients even when they cross their normal working geographical boundaries. This will reduce the number of missed referrals as staff know the pathway is available everywhere.

Referral systems should be in place to handle the numbers and a central hub should be used. This allows us to effectively capture and handle data and ensures that the pathway is accessible to clinicians 24/7.

Contact details

Tom Heywood
Paramedic Practitioner/Clinical Pathways Advisor
Yorkshire Ambulance Service NHS Trust

Primary care
Is the example industry-sponsored in any way?