Shared learning database

Manchester Mental Health and Social Care Trust
Published date:
January 2012

To implement NICE guidance and develop an evidence-based streamlined pathway for service users with alcohol use disorders both within the organisation and with partner organisations.

To maximise all opportunities to deliver interventions relating to alcohol use disorders and to ensure high quality care across all services in particular during in-patient admission.

To design and deliver training solutions to support the above using a range of methods to ensure staff have the knowledge and practical competence to deliver the improvements detailed by NICE.

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

In April 2011 Manchester Mental Health and Social Care Trust expanded to incorporate some of the provider services historically contained within Manchester PCT. These included Public Health Development and Community Alcohol services. The Trust was already the main provider of secondary care alcohol services which included a specialist community alcohol treatment unit and consultant psychiatrist. The addition of these new services led to the full pathway of care being offered within one NHS organisation.

Manchester has a high prevalence of alcohol misuse therefore the amalgamation of all these services provided the ideal opportunity to ensure the provision of evidence based care across the whole pathway. Evidence demonstrates that a significant proportion of the Trusts population misuses alcohol leading to physical and mental health complications and poorer prognosis.

Prior to these service changes occurring NICE had published a range of guidelines relating to alcohol use disorders. The Trust had already undertaken work to introduce these guidelines and this was expanded to include the newer services.

The Trust has a NICE implementation group that reviews all new pieces of guidance published monthly. During the scoping exercise undertaken to produce the gap analysis it was identified that in relation to in-patient staff these staff required additional skills to be able to support the management of service users admitted to Trust wards.

The aim of the work was to ensure that NICE guidelines and NICE pathways were embedded into Trust services in relation to alcohol use and to ensure the service users of the Trust received evidence based care. The gap analysis undertaken by the NICE implementation group highlighted the following in particular in relation to in-patient services.

- Assessment of alcohol use using validated screening tools
- Safe management of the physical withdrawal from alcohol
- Prevention of the development of severe withdrawal phenomena
- Management of severe withdrawal phenomena
- Provision of brief intervention at ward level
- Knowledge of when to offer support to meet on-going service user needs.
- To foster links with community services and provide on-going support after admission

The objective of the working group was to provide a training programme and series of events to support the implementation of the guidance by equipping staff with the knowledge and practical skills required. Furthermore the group would ensure audit against standards.

Reasons for implementing your project

The Trust undertakes a gap analysis to provide a baseline position against all new pieces of NICE guidance. The analysis undertaken showed a requirement to change practice, develop training and purchase equipment. This was required across all professional groups. The analysis also showed the need to utilise the specialist knowledge available within the trust to better effect.

Across the nursing profession the trust has a standard competency assessment that ensures staff have the required knowledge and skills to administer medication. Through the use of these assessments the lead nurse for medicines management had highlighted a need for improved knowledge demonstrated by some staff around the management of alcohol use disorders.

Further concerns were identified as learning following on from untoward incident reviews. These held recommendations that staff skills and attitudes needed to change to improve the quality of care provided in relation to the treatment of service users with alcohol use disorders.

The medicines management team reviewing and auditing Trust prescribing guidelines highlighted possible deviation from guidelines for alcohol detoxification. This became more evident following on from changes to recommended prescribing regimes following on from the reviewed pieces of NICE. Reviewing practice highlighted immediately that wards did not routinely stock breathalysers and where these were in place staff were not all trained to use the equipment, did not always know where to refer to for further advice and were not trained to undertake interventions that would improve outcomes.

A summary of the above information was produced for the Trusts clinical governance committee with the recommendation for a working group to oversee the changes required.

How did you implement the project

A working group was convened that included the required consultant psychiatrist, specialist alcohol services nurses, public health development, dual diagnosis, operational and medicines management representatives.

The group considered the available information and agreed a range of interventions to address the issues raised. These were then agreed as a work programme that included:

- Review of all Trust guidelines
- Production of a care pathway for alcohol services (part of the Trusts design, develop and delivery of high quality clinical care strategy)
- both skills and attitudes and equip staff with the practical knowledge relative to their working environment.
- The training programme commenced with 2 clinical effectiveness events. The first of these events highlighted NICE, the clinical requirements and gap analysis. The second event dealt with the more controversial area known as malignant alienation and was specifically aimed at in-patient staff. Ward based training was initially piloted for adult and later life wards before being rolled out across the service.
- Equipment such as breathalysers, public health and referral information were produced or purchased for in-patient wards

The barriers to the success of the work ranged from the usual operational difficulties such as releasing staff from wards, competing priorities and cost of new equipment and training materials through to the attitudes of some staff groups. The latter was addressed at the clinical effectiveness day which was mandatory for all wards to send representation. This event highlighted not only the training requirements but also the need for robust case supervision across all professional groups where particularly challenging service users were concerned. A further barrier was the need to manage sensitively the outcomes of recent untoward incidents.

Key findings

Evaluation of the work to date has been through a range of methods. The Trust uses the incident reporting system, DATIX to also support the collection of quality improvement data. Reports via DATIX have shown the use of alcohol withdrawal scales, breathalysers and the management of the intoxicated patient as per NICE guidance. Furthermore prescribing improvements have been confirmed by the ward pharmacists who attended the ward based training as part of the multi-disciplinary team. These improvements are essential in the safe management of alcohol use disorders on admission to an acute psychiatric ward.

All the training events have been well attended leading to a further event for consultant medical staff and an event for staff working within the acute hospital also. The clinical effectiveness events scored highly as beneficial training days and the event focussing on attitudes in particular has led to further work around clinical supervision by matrons and dual diagnosis specialist staff within the in-patient environments as well as a review of the implementation of the Trusts values in these areas.

All in-patient wards now have access to breathalysers and more importantly staff are trained and able to use the breathalysers, the withdrawal rating scales and therefore manage the person effectively. Staff are also able to deliver brief interventions to service users when on the wards and support their longer term health and wellbeing at this critical point when in services. Public health information and support is now available on wards, which is beneficial to service users but also the staff of the Trust.

Key learning points

The success of this project has been due to a range of factors.
- The working group was composed of respected specialists in the area from a range of professional backgrounds. This ensured that all staff groups were engaged as well as that all material produced was suited to the wide audience. The staff involved also spanned the full pathway of care therefore a seamless service was designed that placed the service user at the centre of care.
- The training produced attempted to take into account the various learning styles. Training was both classroom and practical, hands on training and examples were frequently used that explained to the staff attending the importance of their role.
- The project utilised learning from incidents and audit sensitively however did not shy from showing how the quality of care needed to improve. NICE was used to support the process and practice benchmarked against this gold standard.
- The working group ensured operational services were involved at each step and that all training was agreed with them and equipment purchased through their budgets. The linking of the quality of care provided, incidents occurring on the ward and cost incurred has been a strong lever to ensure change in services.
- One of the main success factors has been the integration of public health development and community alcohol services. This has shown clearly how evidence based interventions at all steps of the pathway can lead to improvements for individual service users as well as to the population of Manchester.

Contact details

Emma Street and Petra Brown
Lead Nurse and Chief Pharmacist
Manchester Mental Health and Social Care Trust

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