Clinical guidelines for alcohol treatment

4. Assessment and treatment and recovery planning

How to assess a person's alcohol use and other needs, and agree their treatment and recovery goals, as well as interventions and actions to meet those goals. It covers risk assessment and regular reviews of treatment and recovery and risk management plans.

4.1 Main points

Assessment should involve the assessor and the person working together to reach a shared understanding of the person’s problem alcohol use and their wider needs, strengths and goals.

Services should provide straightforward access to assessment which should start as soon as possible after referral.

Assessment should include a focus on engagement. To help the person engage in treatment, the assessor should use an empathic and non-judgemental approach and integrate motivational interventions into the assessment process.

Services should use validated assessment tools to support assessment, but these should not take the place of a structured clinical interview with the person.

Assessment involves the person choosing an alcohol use goal. Severity of dependence and complexity of need provide broad indicators for appropriate alcohol use goals, but these should always be mutually agreed between the person and the assessor.

Services should offer an initial assessment that includes:

• an overview of the pattern and severity of the person’s alcohol use and severity of their dependence
• any need to assess the person for medically assisted withdrawal
• identifying any other urgent treatment needs and any immediate risks
• agreeing an initial alcohol use goal and an action plan to address urgent needs and risks

Services should then offer a comprehensive assessment that builds on the initial assessment that includes:

• reviewing the severity and pattern of the person’s alcohol use, the severity of dependence in more detail, and any other substance use
• assessing the person’s strengths and recovery resources
• assessing needs in the areas of mental health, physical health, social factors and criminal justice
• agreeing a treatment and recovery plan that includes goals for treatment and for broader recovery

Comprehensive assessment may take place over several sessions, but this should not delay the start of treatment.

Based on the assessment, the assessor or allocated keyworker, with support from the multi-disciplinary team, should agree a treatment and recovery plan with the person based on a personalised formulation (see 4.3 for definition of formulation). The treatment and recovery plan will set out their treatment and recovery goals, as well as interventions and actions to meet those goals.

Risk assessment, including safeguarding, is an important part of any assessment and should result in a detailed risk management (safety) plan based on a personalised risk formulation (see 4.4.6 for definition of risk formulation).

The keyworker, supported by the multidisciplinary team, should regularly review the treatment and recovery plan with the person and adjust the plan at any time it is clear that it’s not helping the person to meet their goals. The keyworker should also regularly review the risk management (safety) plan and adjust this at any time the risks change.

Where appropriate, assessment, treatment and recovery planning, and risk management (safety) planning should include contributions from:

• clinicians from the multidisciplinary team in the alcohol treatment service
• other professionals working with the person
• family members, partners or friends
• peer supporters who can help welcome the person to the service and support them throughout

4.2 Introduction

4.2.1 Assessment in community alcohol treatment services and other considerations

This chapter describes assessment, and treatment and recovery planning for harmful (high risk) drinking and alcohol dependence in specialist community alcohol treatment services for adults. There will be additional considerations for assessment for specific pharmacological interventions, populations and settings which you will find in other parts of these guidelines including:

• assessment for pharmacological interventions, including medically assisted withdrawal (chapter 10 on pharmacological interventions, chapter 11 on community based medically assisted withdrawal and chapter 12 on specialist inpatient medically assisted withdrawal)
• assessment and formulation for psychosocial interventions (chapter 5 on psychosocial interventions)
• primary care (chapter 15)
• acute hospital settings (chapter 16)
• criminal justice settings (chapter 17)
• pregnancy and perinatal care (chapter 24)
• parents (chapter 26)
• older people (section 25.8 in chapter 25)
• young people (chapter 23)

4.2.2 Terminology

Community alcohol treatment practitioners in several different roles can carry out an assessment depending on local arrangements, so this chapter refers to the ‘assessor’ rather than specifying a professional role. More than one practitioner will be involved in some assessments. For example, if the main assessor is not a clinician, clinicians may carry out some components of the assessment. In these situations, the chapter refers to the assessor who continues to carry out the core assessment and co-ordinate the involvement of other professionals as the ‘main assessor’.

4.3 Aims

Assessment in community alcohol treatment services involves gathering and considering information on the person’s needs, risks and strengths. This includes diagnosing the presence of alcohol dependence or harmful drinking, identifying co-occurring health conditions and social factors that need addressing, and longer-term recovery goals. The assessor and the person use the information to develop a shared formulation.

A formulation is a framework to understand how the person’s alcohol problem began and developed, the factors that maintain it and potential resources to address it. It is the basis for agreeing a personalised treatment and recovery plan (also see definition of formulation in the glossary).

You can read more about formulation in section 5.4 in chapter 5 on psychosocial interventions.

Assessment also aims to engage the person in treatment. It is an important opportunity to begin building a therapeutic alliance and to address potential barriers to engagement such as personal anxieties or practical constraints.

Where appropriate, assessment should involve:

• relevant healthcare and support services and organisations
• partners, family and friends
• peer-support networks

4.4 Principles

4.4.1 Principles of care

Assessment and treatment and recovery planning should be based on the principles of care outlined in chapter 2.

In particular, the assessor should:

• build a trusting relationship and work in a supportive, empathic and transparent way
• respect the person’s confidentiality, privacy, and dignity
• understand how stigma and discrimination associated with alcohol use can affect how the person comes into treatment, their self-esteem and their ability to recognise the full impact of their problem alcohol use
• work in a trauma-informed way (see section 2.2.8 in chapter 2 on principles of care)
• work in a culturally competent way (see section 2.3.2 in chapter 2 on principles of care)

4.4.2 Staff competence

Assessment for harmful drinking and alcohol dependence in alcohol treatment services is a skilled intervention. Practitioners should be trained and competent to deliver it and they should receive regular supervision from individuals competent in both the intervention and supervision.

4.4.3 Access to assessment

Services should provide straightforward access to assessment, which should start as soon as possible after referral. Studies have shown that rapid access to assessment and treatment improves engagement in treatment (Passetti and others, 2008). You can collect a person’s initial information remotely by phone or online, but the assessment should involve an in-person meeting wherever possible.

You should time appointments to take account of a person’s commitments, such as childcare and employment, and offer the appointments in a location they can access easily. Offering appointment windows (such as a whole morning or whole afternoon) rather than a set time can increase accessibility.

Several socially excluded groups, including people experiencing multiple disadvantage (see definition of multiple disadvantage in the glossary), are less likely to approach services or engage with standard assessment processes. Services need to develop targeted and flexible ways of helping people from those groups access assessment such as assertive outreach or ‘in-reach’ to services or community organisations like homelessness support services. Offering assessments in primary care settings can make them more accessible and acceptable to people who would not approach an alcohol treatment service because of fears around stigma.

The service will also need to offer home visits for people who cannot access the service due to disability, physical health conditions (including advanced liver disease) or mental health conditions.

People with lived and living experience should be involved in planning engagement and assessment pathways to increase the likelihood they will increase access for different groups of people.

You can read more about flexible engagement processes in chapter 25 on developing inclusive services and chapter 9 on alcohol assertive outreach and a multi-agency team around the person.

4.4.4 Engagement

Assessment is often the first face-to-face contact the person has with the service and it is an opportunity to begin building a therapeutic alliance. An empathic, non-judgemental approach based on the principles of trauma-informed care and cultural competence can help to build trust and support engagement.

Assessment and engagement can be thought of as the first phase of the person’s treatment and recovery journey that involves the treatment service, and the person may begin to make changes during this process. The assessor can support engagement by using a motivational approach. See section 4.9.3 below on motivation, readiness and belief in the ability to change.

If you provide welcoming introductory communication before a person’s first appointment, as well as clear information about the service, the process of assessment and confidentiality, it can help to encourage their attendance from the earliest stage. Friendly reminders about appointments (via text if that’s useful to the person) can support attendance. There are many reasons why a person may miss an appointment. So, non-judgemental follow-up of a missed appointment, with another appointment offer and a query about what might make it easier for them to attend, can help them to stay engaged. You should communicate information avoiding clinical language and in accessible formats considering:

• language
• literacy
• sensory disability
• cognitive disability
• neurodiversity
• digital literacy and access

Interpreters (including sign language) who are not known to the person should be available to make sure there is equal access to assessment.

The environment should be comfortable and private and the service should consider varying needs. For example, whether the waiting room and room for the assessment are easily accessible and comfortable for people with mobility needs.

The assessment should take the form of a structured clinical interview (a conversation aimed at assessing the person’s treatment and recovery needs). The assessor will need to record information in a structured way, but a ‘checklist’ approach to assessment is not a good way to engage the person. Assessment and formulation should be a collaborative process, where the assessor and the person develop a shared understanding of their treatment and recovery needs. It is more effective to use open questions, reflective listening and dialogue. If the assessor is able to respond quickly to the person’s own priorities, such as the need for medically assisted withdrawal or a social need such as debt advice, this may improve their engagement.

4.4.5 Multidisciplinary and multi-agency assessment

Assessment will often require input from more than one practitioner. Where the person needs a medically assisted withdrawal or has complex, high risk physical or mental health conditions, the assessment will require input from a specialist clinician from the multidisciplinary team (MDT). Designated leads (or appropriately competent practitioners) for child safeguarding, adult safeguarding and domestic abuse should be available to advise on relevant components of individual assessments, in line with national guidelines and organisational procedures.

You can find a list of relevant legislation and statutory guidance in annex 1.

The assessor should have access to supervision and advice from the MDT or wider clinical team and will agree with the MDT when input from specialist clinicians is needed. The main assessor will usually continue with the core assessment, incorporating the specific components carried out by members of the MDT or wider clinical team.

Where the person is working with other services, the assessor should ask these services to contribute relevant information to the assessment. They may also invite a keyworker from another service to attend an assessment appointment if this will help the person to attend. Where a person has complex needs and is working with more than one service, care plans (treatment and recovery plans) will need to be aligned or integrated.

You can read more on multi-agency treatment planning in section 4.10.4 on treatment and recovery planning in this chapter.

4.4.6 Risk assessment and safeguarding

Assessing risk should be part of any assessment. The aim of risk assessment is to develop a risk management (safety) plan that prioritises and manages or eliminates risks to the person with problem alcohol use and to others. All assessors should be competent to identify immediate risks at initial assessment and to work with the person, with other services and to manage risks and support safety appropriately.

A risk assessment should be based on a person’s individual needs and how to support immediate and longer-term safety. As part of assessment, the assessor should develop a personalised risk formulation with the person. A risk formulation is a collaborative process between the person and the assessor that aims to summarise the person’s current risks and difficulties and understand why they are happening, to inform the risk management (safety) plan.

Formulation typically includes taking into consideration historical factors and experiences, more recent problems, and existing strengths and resources which could be protective against specific risks, in the same way as other parts of the comprehensive assessment does.

Risks are constantly changing, so assessors should review and develop the initial action plan (see section 4.8 below) with the person following comprehensive assessment and as the person’s risks change. Keyworkers, supported by the MDT or wider clinical team, should regularly review risk management (safety) plans, involving the person in reviews.

Assessors conducting risk assessments should:

• confirm the person’s history with other relevant services the person has accessed
• work with any services the person is currently attending to assess risk
• make referrals to other services if needed as part of the risk assessment and risk management (safety) plan

Assessors should assess the ability of the person and any of their support networks to contribute to managing risks. Family members or supportive friends may have an agreed and specified role.

Services need organisational procedures for escalating and managing immediate risks and assessors should have access to advice and supervision from relevant members of the MDT or wider clinical team.

Services should have organisational policies and procedures for addressing child safeguarding, adult safeguarding, domestic abuse and mental capacity which are aligned with the relevant national legislation and statutory guidance. Clinical policies and processes should also include the management of self- harm and suicide risk.

You can find a list of relevant legislation and guidance in annex 1.

You can read more about risk management planning in section 4.10.5

4.4.7 Involving and supporting partners, family and friends

Involving supportive partners, family members or friends at assessment can encourage the person to attend and contribute important information. It is essential that assessors get consent from the person to contact partners, family or friends as some people will not want their family to be involved. If the person does not choose to involve them initially, the assessor can repeat the offer later in assessment because some people may become more open to this as they engage. There is evidence that involving family members in treatment is linked to improved outcomes (Copello and others, 2009).

Partners, family members and friends may have support needs in their own right and may be entitled to a carer’s assessment. The assessor should offer information and support, whether or not they want to be actively involved in the person’s treatment.

4.4.8 Involving members of peer support networks

People with lived experience can play a valuable role in supporting people to attend assessment. In some services, members of peer support networks or organisations meet with people informally in the waiting room before their assessment, or the assessor introduces them as part of the assessment process. The person with lived experience can share their experience of treatment and recovery and show that it is possible to move forward. In some areas, people can access peer support organisations before accessing the treatment service and the peer support organisation may introduce them to the treatment service.

4.4.9 Harm reduction interventions

Assessors should work on the principle of Making Every Contact Count (MECC) and use assessment as an opportunity to offer harm reduction information and interventions. Harm reduction information includes (but is not limited to):

• the risks of stopping drinking suddenly and advice on reducing safely for people with alcohol dependence
• the decrease in tolerance after a period of abstinence and the risks of drinking at pre-abstinence levels (see definition of tolerance in the glossary)
• increased risk of overdose when drugs and alcohol are taken together
• other harms related to mixing drugs, for example cocaine and alcohol are more toxic when taken together

People with alcohol dependence should usually be prescribed thiamine (oral or intramuscular depending on their likely risk level) to reduce the risk of developing Wernicke’s encephalopathy (WE), which can cause temporary or permanent brain damage.

You can read about prescribing and administering thiamine to reduce the risk of developing WE in section 10.4.3 in chapter 10 on pharmacological interventions.

You can find guidance on harm reduction interventions in chapter 8 on harm reduction.

4.4.10 Unplanned withdrawal

All assessors in alcohol treatment services should be competent to identify withdrawal symptoms and recognise when a person is in acute withdrawal, which for some people can lead to severe complications such as:

• seizures
• delirium tremens
• Wernicke’s encephalopathy

All staff should be trained and supported to recognise these severe complications and to alert emergency services where the person experiences them.

You should read guidance on identifying risk and managing complications in withdrawal in chapter 10 on pharmacological interventions.

4.5 Tools to support assessment

The National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends that assessors use validated tools at assessment such as those listed below. Tools are intended to support assessment, but they should not replace a structured clinical interview, which provides more detailed information on needs, risks, strengths, and goals. A clinical interview also allows for conversation, which the person may experience as more engaging than being asked standard questions.

4.5.1 Alcohol use disorders identification test

To identify level of risk of alcohol harm and possible dependence, the assessor should use a validated tool that measures frequency and quantity of alcohol consumed, such as the Alcohol use disorders identification test (AUDIT), available on the Alcohol use screening tests page.

AUDIT is the gold standard identification tool recommended for specialist services. In wider healthcare settings, shorter or abbreviated tools may also help to identify people who need specialist assessment.

You can read more about AUDIT and shorter or abbreviated tools in chapter 3 on identification and alcohol brief interventions.

4.5.2 Tools to assess the severity of alcohol dependence

To assess presence or severity of dependence (mild, moderate or severe), assessors can use a validated tool such as the following.

Severity of Alcohol Dependence Questionnaire

The MDApp website has a version of the Severity of Alcohol Dependence Questionnaire (SADQ). It is a 20-item self-administered questionnaire measuring the severity of alcohol dependence based on drinking habits and symptoms experienced after drinking.

Leeds dependence questionnaire

The Greenspace website has a version of the Leeds dependence questionnaire (LDQ), which includes questions on alcohol and other substances. It is a 10-item, self-completion questionnaire designed to measure the presence and severity of dependence on any drug, including alcohol.

4.5.3 Alcohol Problems Questionnaire

The Alcohol Problems Questionnaire (APQ) is a validated 44-item questionnaire to assess the nature and extent of problems associated with harmful alcohol use and alcohol dependence (see definitions of harmful alcohol use and alcohol dependence in the glossary).

The APQ is available on page 486 and 487 of the full guideline for NICE CG115.

4.5.4 Withdrawal assessment tools

Specialist clinicians, competent to assess the need for medically assisted withdrawal should use a validated scale to assess the severity of withdrawal. The MD+calc website has a version of the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) you can use. This is a 10‑item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate people throughout withdrawal.

In acute hospital settings, the Glasgow modified alcohol withdrawal scale (GMAWS) is an example of a withdrawal assessment tool.

4.5.5 Tools to measure outcomes

To measure treatment outcomes, the practitioner should use a validated outcome measurement tool such as the following.

TOP

The treatment outcome profile (TOP) is the outcome monitoring tool used by substance misuse services in England. It is included within the ‘adult combined review forms’, available in the Data collection resources section on the National Drug Treatment Monitoring System (NDTMS) website. It can be used as a stand-alone outcome measure and it can be used outside England.

SURE

King’s College London’s Substance Use Recovery Evaluator (SURE) is a patient-reported outcome measure to measure recovery from drug and alcohol dependence.

4.6 Tests to support assessment

4.6.1 Blood tests

Blood tests should not be used routinely for identifying and diagnosing harmful drinking or alcohol dependence. However, services should consider testing service users’ blood:

• as part of the assessment for medically assisted withdrawal (see chapter 11 on community based medically assisted withdrawal)
• as part of the assessment for some relapse prevention medication (see section 10.5 of chapter 10 on pharmacological interventions)
• to help identify specific alcohol related physical health needs where indicated by the healthcare assessment (see section 4.18.11 on assessing physical health below)
• as part of regular review of the person’s health where they continue to use alcohol at a harmful or dependent level, and this is clinically indicated

If a community treatment service is unable to provide the required blood tests, there should be an agreed pathway for tests to be carried out in the alcohol treatment system or the wider health care system.

4.6.2 Transient elastography

NICE guideline Cirrhosis in over 16s: assessment and management (NG50) recommends that people drinking at harmful levels (35 units or more per week for women, 50 units or more per week for men) for 3 months or more should be referred for liver fibrosis assessment using transient elastography (fibro-scan). Some areas use other tests.

You can find more information on screening tests for liver disease in section 4.9.11 and in section 19.5.2 in chapter 19 on co-occurring physical health conditions.

4.6.3 Breath alcohol

Several factors influence how quickly alcohol is absorbed into and eliminated from the body. So, breath alcohol concentration can vary between different people who have consumed the same amount of alcohol. On average it takes about one hour to eliminate one unit of alcohol in adults, but this may be quicker in some people with alcohol dependence.

Breath alcohol should not normally be measured as part of an initial assessment or for monitoring outcomes. Also, practitioners should not use arbitrary cut off levels for breath alcohol concentration to determine whether a person can access health services. But breath alcohol should be measured as part of assessment for medically assisted withdrawal. It should then be measured during medically assisted withdrawal to confirm that the person has not consumed alcohol. You can find guidance on assessment for community medically assisted withdrawal in chapter 11.

Clinicians should consider the therapeutic value of breath alcohol measurement and explain this to the person before requesting a breath sample. Breath alcohol measurement can sometimes help to add information to a comprehensive assessment if it is carried out with the full agreement of the person and the results discussed with them. For example, it can help to assess a person who appears sedated, has slurred speech or is confused. A negative result will exclude alcohol as a cause, but a positive result does not exclude other possible causes such as intoxication with other substances, head injury or stroke.

Clinicians should not use breath alcohol measures to contradict a person’s self-reported alcohol consumption. It is best to measure breath alcohol before asking how much the person has drunk on that day, then interpret the result together with the person.

The clinicians taking breath alcohol measurement need to understand their responsibilities as outlined in The Driver and Vehicle Licensing Agency (DVLA) general information for medical professionals about assessing fitness to drive which helps healthcare professionals and doctors understand their roles and responsibilities for assessing fitness to drive. Clinicians should also be aware of General Medical Council (GMC) guidance Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA, which advises clinicians on actions to take if the person does not report their condition and continues to drive.

You can read guidance on this in section 8.12 in chapter 8 on harm reduction and in annex 2.

4.7 Alcohol use goals

4.7.1 Setting goals

At initial assessment, the assessor and the person should agree an alcohol treatment goal which they should review together during the comprehensive assessment. Severity of dependence and complexity of need provide broad indicators for appropriate alcohol use goals, but these should always be individually tailored and mutually agreed between the person and the assessor. It is important the goal is in line with the person’s wishes, as there is evidence that this is associated with positive outcomes (Henssler and others, 2020). The practitioner should provide information on the risks and benefits of different alcohol use goals in general and as they apply to the particular person. They should use an approach based on motivational intervention principles and techniques when supporting the person to choose their alcohol use goal (see section 5.5.6 in chapter 5 on psychosocial interventions for more on motivational interventions).

The goal will then be regularly reviewed as part of the treatment and recovery planning process and adjusted where appropriate.

4.7.2 Abstinence

The alcohol clinical guidelines development group recommend abstinence as the appropriate goal for most people with moderate or severe alcohol dependence. The group also recommend abstinence as the appropriate goal for most people with mild dependence and for people drinking at harmful levels who have significant physical health or mental health conditions that can be made worse by alcohol use (for example, alcohol-related liver disease or clinical depression). Any person choosing a goal of abstinence should be supported to work towards that.

However, if the person makes an informed choice to opt for a low risk drinking goal (see below), they should be supported in that goal. If there are considerable risks involved, the assessor should advise that abstinence is most appropriate and should support a negotiated approach where the person can consider abstinence if they do not achieve low risk drinking. People initially preferring a low risk drinking goal can switch to an abstinence treatment goal at a later point.

4.7.3 Low risk drinking

Low risk drinking may be an appropriate goal for most people with mild dependence and people drinking at harmful (higher risk) levels who:

• do not have significant physical or mental health conditions
• have adequate social support

If the person meets the above criteria, a low risk drinking goal may be appropriate unless they prefer a goal of abstinence, or there is some other reason for abstinence.

Low risk drinking is defined in this guideline as drinking within the UK chief medical officers’ low risk drinking guidelines. These recommend it is safest not to drink more than 14 units a week on a regular basis, and if a person drinks as much as 14 units per week, it is best to spread drinking evenly over 3 or more days. For women who are pregnant or think they could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to the baby to a minimum.

This definition of low risk applies to the general population. For some people, drinking any alcohol at all is a risk. For example, abstinence is vital for the health of people with advanced liver disease, including cirrhosis.

A goal of low risk drinking is commonly known as controlled drinking (see definition of controlled drinking in the glossary). There is some evidence that tools such as the Impaired Control Scale may be appropriate for helping to identify the suitability of a controlled drinking goal (Heather and Dawe, 2005). Low drinking goals should be regularly reviewed.

4.7.4 Harm reduction

Some people with severe alcohol dependence or with significant and complex needs might not opt for a goal of abstinence or structured treatment, even after discussing benefits and risks of different alcohol use goals. For these people, the alcohol clinical guidelines development group recommend an initial goal of harm reduction. However, the practitioner should ultimately encourage a goal of abstinence. Complex needs include co-occurring physical and mental health conditions.

People experiencing homelessness may find a goal of abstinence unachievable until they are in stable housing.

A harm reduction approach will involve advice and interventions to reduce harm to a person’s safety, and their physical and mental health. It may (although will not necessarily) include some reduction in alcohol use as a specific goal. Evidence shows a reduction in health harms when people reduce consumption, even though they may still be drinking at harmful or dependent levels (Witkiewitz and others, 2020).

A harm reduction approach can be helpful in building therapeutic rapport and self-efficacy and provide an opportunity for motivational interventions (see chapter 5).

The practitioner should provide information on the health or safety risks related to continuing to drink at high levels. And at an appropriate time for the person’s circumstances, the practitioner should encourage them to consider the benefits and any risks of a goal of abstinence.

You can read more guidance on harm reduction in chapter 8.

4.7.5 Reviewing goals and monitoring the person’s health

Regular review of treatment and recovery goals is an essential element of the treatment and recovery planning process, and the goals should be adjusted where appropriate. There should be regular reviews of a person’s health when they continue to drink at harmful levels or experience alcohol dependence, and this should inform the consideration of their alcohol use goals.

4.8 Initial assessment

4.8.1 Offering an initial assessment

Services should offer an initial brief assessment (sometimes referred to as triage assessment) to all adults referred to community alcohol treatment services, Following initial assessment, services should consider people whose AUDIT score is 16 or over for comprehensive assessment, which is the next stage of assessment. This should follow immediately after initial assessment.

4.8.2 Aims and outcomes of initial assessment

The aims of initial assessment are to:

• introduce the person to the service
• gain an overview of the pattern and severity of the person’s alcohol use and severity of dependence
• gain brief information on past use of alcohol treatment services
• identify any urgent treatment needs, including the need for assessment for medically assisted withdrawal
• identify any urgent risks to be managed
• identify any co-occurring physical or mental health conditions or support needs requiring assessment or intervention from specialist clinicians

Outcomes of initial assessment should include:

• agreeing an initial alcohol use goal with the person
• deciding whether the person needs to be assessed for medically assisted withdrawal
• agreeing an initial action plan to address any urgent needs, manage urgent risks, and set out the next steps in the assessment process

With the person’s consent, the assessor should contact their GP and any relevant services they are attending so they can contribute to the assessment.

4.8.3 Initial assessment of alcohol use, severity of dependence and need for medically assisted withdrawal

Assessing alcohol use and severity of dependence

The assessor should carry out a brief clinical interview to assess the person’s alcohol use and severity of dependence. This should include:

• alcohol use (approximate number of units and pattern) over the last 1 to 4 weeks
• examination of a typical drinking day (number of units and pattern of alcohol use)
• features and severity of dependence including psychological dependence using tools such as SADQ or LDQ
• brief summary of the duration of problem alcohol use in the person’s life
• history of withdrawal symptoms, including any complications
• past periods of abstinence or low risk drinking and previous treatment outcomes

See section 4.5 above for information on tools to support assessment.

Need for assessment for medically assisted withdrawal

Services should consider offering an assessment for medically assisted withdrawal to people drinking more than 15 units per day or scoring 20 or more on AUDIT and anyone else who experiences withdrawal symptoms when they stop drinking.

When assessing the severity of alcohol dependence and determining the need for medically assisted withdrawal, the assessor should adjust the criteria to take account of how dependence can affect different groups, including:

• women
• older people
• children and young people
• people with established liver disease who may have problems with the metabolism of alcohol

You can read more information on adjusting criteria for these groups in chapter 10 on pharmacological interventions.

Initial assessment should determine whether there may be an urgent need for medically assisted withdrawal, for example if the person is physically unwell or has previously experienced severe complications in withdrawal.

Doctors, nurses or pharmacists responsible for assessing and managing medically assisted alcohol withdrawal should be competent to diagnose and assess alcohol dependence and withdrawal symptoms. They should also be competent to use drug regimens appropriate to the setting (community or inpatient) in which medically assisted withdrawal is managed.

Treatment services should ensure there are processes to support quick and seamless internal referral for an assessment for medically assisted withdrawal by an appropriately competent clinician, if the assessor does not have appropriate competencies.

You can find guidance on assessment for medically assisted withdrawal in chapter 10 and section 11.5 in chapter 11 on community-based medically assisted withdrawal.

4.8.4 Initial assessment of risks and urgent treatment or support needs

You should read this section with section 4.4.6 on risk assessment and safeguarding above.

Assessors should carry out an assessment of immediate needs and risks at the first meeting with the person. They will need training and therapeutic competencies to ask the assessment questions and to respond sensitively to the answers, and their approach should be trauma-informed.

Assessors should record if the person is in contact with other services and any medication they are prescribed.

Assessors should identify urgent risks or urgent needs, including:

• blackouts and risky behaviour while intoxicated
• suicidal ideation, intent or attempts, self-harm or severe self-neglect
• acute mental health conditions
• malnourishment
• substance use including illicit drug use, prescribed or over-the-counter medication whether obtained legally or illicitly and herbal medicines
• child safeguarding
• adult safeguarding
• mental capacity concerns
• domestic abuse (either as a survivor or a perpetrator)
• risk to others such as serious violence, sexual violence, sexual exploitation, stalking, human trafficking and modern slavery
• social support needs, including homelessness, urgent financial and debt problems
• criminal justice involvement and continuity of care needs for people leaving prison
• physical health or mental health conditions needing specialist assessment or intervention
• pregnancy and perinatal mental health needs (see chapter 24 on pregnancy and perinatal care)

There is further information on most of these risks and needs in section 4.9 below.

Complications in withdrawal

If the person is or may be experiencing withdrawal-related complications, the assessor should arrange for the person to be transferred to a hospital immediately.

Complications in withdrawal include symptoms worsening to very severe shaking and heavy sweating and:

• seizures
• suspected incipient Wernicke’s encephalopathy (WE)
• delirium tremens

There is guidance on these conditions in section 10.4 in chapter 10 on pharmacological interventions.

Information about children

The assessor should ask the person about their own children, other children in the home and children they are in close contact with, including ages, and dates of birth of children and the level of contact they have with them. They should also record information on other adults living in the home or visiting regularly. The service may need this information, for example if a safeguarding referral is necessary and the person disengages from treatment.

It will help provide a fuller picture if the assessor can confirm information with other services involved with the person.

4.8.5 Agreeing an alcohol use goal

The assessor and the person should agree an initial treatment goal for alcohol use. They can revisit this during the course of the comprehensive assessment. Alcohol use goals are described in section 4.7 above.

4.8.6 Family and support networks

With the person’s consent, they can invite a supportive partner, family member or friend to contribute to the ongoing assessment and action plan. Where appropriate, the assessor should offer information and support to the person’s partner, family member or friend.

If the person is in agreement, the assessor should actively support them to access local peer support networks or mutual aid (such as Alcoholics Anonymous (AA) or SMART Recovery) (see section 5.5.4 for guidance on helping people to access mutual aid and peer-based support in chapter 5 on psychosocial interventions).

4.8.7 Initial action plan

Following initial assessment, the assessor and the person should agree an initial action plan based on the person’s initial alcohol use goal, immediate needs, and any risks identified. The plan will include:

• an initial alcohol use goal and a broad plan for treatment to be reviewed at comprehensive assessment
• arranging assessment for medically assisted withdrawal if needed
• specific risks, actions to manage risks, and who will take the actions
• prescribing thiamine supplementation (see section 10.4.3 of chapter 10 on pharmacological interventions)
• referrals to and communication with other services
• the date of the next appointment for comprehensive assessment
• the likely date the person will begin structured treatment if they have agreed to that

The plan should also include dates for when actions will be completed as this is important for achieving positive outcomes.

4.8.8 Information

The assessor should offer accessible information about:

• the nature and treatment of harmful drinking and alcohol dependence
• available treatment options
• harm reduction (see section 4.4.9 on harm reduction interventions)

4.9 Comprehensive assessment

4.9.1 Access to comprehensive assessment

Alcohol treatment services should consider offering a comprehensive assessment for anyone referred to the service, who scores 16 or more on the AUDIT, building on information already gathered at initial assessment.

An AUDIT score of 16 or over for a person referred to specialist alcohol treatment is a broad indication of their need for a comprehensive assessment. However, AUDIT is not a diagnostic tool, so the assessor should use their clinical judgement because some people scoring lower than AUDIT 16 may also need a comprehensive assessment. For example, this might include people with alcohol dependence who have reduced their alcohol use before accessing treatment, but who would still require treatment and recovery support.

Other people who score under AUDIT 16 may need comprehensive assessment if their alcohol use contributes to other conditions or risks, or makes them worse. For example, this might include:

• people with severe and significant mental health conditions, or at risk of suicide, who require a ‘no wrong door’ approach (see section 4.9.9)
• people with severe physical health conditions, including advanced liver disease
• parents whose alcohol use might cause risks to their children

Alternatively, people scoring under AUDIT 20 who do not have any co-occurring conditions or complex needs may not always need further comprehensive assessment. But they will benefit from initial assessment and a psychosocial intervention.

A comprehensive assessment of need may take place over several sessions, but this process should never delay the person receiving treatment that they need as identified at initial assessment.

Services should prioritise people based on risk and urgency of treatment need and should ensure that people get treatment immediately where necessary. Examples include someone urgently needing medically assisted withdrawal, or a mental health crisis intervention. Where this is the case, the assessor can schedule appointments for ongoing comprehensive assessment around urgent treatment interventions. Where the person has no urgent treatment needs, comprehensive assessment should follow immediately after their initial assessment.

4.9.2 Aims and outcomes of comprehensive assessment

The comprehensive assessment builds on the initial assessment and provides an opportunity to explore the person’s goals and develop a package of support that provides structure and care to maximise their recovery.

The aim of comprehensive assessment is to gather and consider information, so the assessor and the person can agree a treatment and recovery plan (see section 4.10).

The assessment process will involve developing a shared formulation. Formulation provides a framework to understand:

• the person’s problem alcohol use
• how it began and developed
• the factors that maintain it
• potential resources to address it

You can read more about formulation in section 5.4 in chapter 5 on psychosocial interventions.

With the person’s consent, it is helpful to collect information from other professionals they are involved with, and where appropriate from family members. One benefit of this is that it can reduce the number of questions the assessor needs to ask the person, who may already have been asked to go over painful aspects of their life on several occasions. People with lived experience often report that they get asked the same questions about their life repeatedly by different services, and that this can be difficult and off-putting.

The outcomes of comprehensive assessment will include a:

• collaboratively agreed personalised treatment and recovery plan
• risk management plan

Both plans should be regularly reviewed and adjusted to take account of the person’s progress through treatment and changes in their circumstances.

4.9.3 Motivation, readiness and belief in the ability to change

It is important to consider a person’s motivation and readiness for change at assessment and throughout treatment. The assessor can gain some understanding of the person’s motivation by asking what has led them to seek treatment and what they hope to get from it. This information can help to inform the treatment and recovery plan.

Exploring motivation and readiness for change can help to:

• set goals and select interventions that reflect the person’s priorities, and their current level of motivation
• inform how the assessor might enhance the person’s motivation
• identify specific barriers to readiness for change and actions to reduce them

Since motivation is continually changing, practitioners should continually review a person’s priorities, plans and goals.

The World Health Organization’s International Classification of Diseases (11th revision) defines alcohol dependence by including features such as impaired control, physiological changes, and increased prioritisation of drinking behaviours. It is common for people entering treatment to believe that they will not be able to change. This might mean they seem to be initially resistant to recovery or even engagement in treatment.

Assessment should be based on the principles and techniques of motivational interviewing.

The main elements of motivational interviewing include:

• helping people to recognise problems or potential problems related to their drinking
• helping to resolve ambivalence and encourage positive change and belief in the ability to change
• adopting a persuasive and supportive rather than an argumentative and confrontational position

4.9.4 The areas of need and strength that comprehensive assessment covers

Comprehensive assessment involves the assessor working with the person using a clinical interview approach to explore multiple areas of need, including:

• motivation, readiness and belief in ability to change
• alcohol use
• substance use, including illicit drug use, prescription and over-the-counter medication (whether obtained illicitly or prescribed), herbal medicines and smoking tobacco
• individual strengths and recovery resources
• gambling harm
• mental health, including cognitive function
• physical health
• pregnancy and the perinatal period
• criminal justice involvement
• social factors, for example housing, income and debt
• employment support needs
• partner and family relationships including domestic abuse
• support needs of adult family members
• impact of parental alcohol use on children and young people and children’s support needs

We expand on each of these areas of need in the following sections.

4.9.5 Alcohol use

Reviewing changes in alcohol use

The comprehensive assessment should explore any changes in the person’s alcohol use since the initial assessment or last appointment. The assessor should review:

• the person’s alcohol use (approximate number of units per day and pattern) over the last 1 to 4 weeks (see chapter 8 on harm reduction for information on units)
• a typical drinking day for the person (number of units and pattern of their alcohol use)
• features and severity of dependence including psychological dependence using tools such as SADQ or LDQ (see section 4.5 on tools to support assessment above)
• alcohol use throughout the person’s life
• history of withdrawal symptoms, including any complications (including seizures, delirium tremens and Wernicke’s encephalopathy)
• alcohol-related problems, using an appropriate tool such as APQ (see section 4.5 on tools to support assessment above)
• past periods of abstinence or moderate drinking and any previous treatment outcomes

The assessor should review any risks related to their alcohol use identified at initial assessment and include them in the risk management (safety) plan.

Using a drink diary

Regularly completing a retrospective drink dairy can help to provide a fuller picture of the person’s alcohol use. This involves the assessor and the person in treatment recording the number of units per day and pattern of alcohol use over the preceding week or weeks before each appointment. Services in the UK also find it helpful to use a prospective drink diary where the person monitors their own drinking by completing it each day. However, there is no research evidence on using a drink diary in this way, so its reliability and validity is unknown.

There are also online and phone apps that people can use to record their daily alcohol use. For example, the free Alcohol Change UK Try Dry app.

Exploring the context of alcohol to develop a formulation

The assessor and the person can explore the following elements to develop a shared formulation to understand the person’s alcohol use.

Factors that may:

• predispose the person to harmful drinking or dependence (for example, adverse childhood experiences, family history of alcohol use)
• trigger alcohol use (for example, depressed mood, interpersonal conflict)
• maintain alcohol use (for example, social networks where harmful drinking is the norm, ongoing stress from social circumstances or discrimination)
• be protective and support recovery (for example, supportive family and social networks, rewarding activities as alternatives to drinking)

Reviewing past attempts at abstinence or moderate drinking can help identify factors linked to past successes and identify obstacles to maintaining change. Exploring previous periods of abstinence may also provide insights into withdrawal symptoms and whether the person experienced these when taking withdrawal medication.

You can find further guidance on clinical formulation in section 5.4 of chapter 5 on psychosocial interventions.

4.9.6 Co-occurring substance use or dependence

The assessor should collect information on:

• types of substances and medications the person uses (whether legally or illicitly obtained) including illicit drugs, prescribed medications, over-the-counter medication and herbal medicines

• quantity, frequency and pattern of use
• routes of administration (including injecting)
• sources of drugs obtained
• past and current harmful use or dependence (including any experience of withdrawal symptoms)
• tobacco use and any smoking cessation support offered (see section 19.6 on smoking-related diseases and lung health in chapter 19 on people with co-occurring physical health conditions)

You should identify a person’s use of illicit drugs or prescribed or over-the-counter medications at initial assessment and review this throughout their treatment. Common substances used in the alcohol treatment population are cannabis, powder cocaine and prescription medications such as benzodiazepines. As well as the harms specific to the substance, their combined use can increase specific risks such as fatal overdose as well as other health harms (for example, cocaine and alcohol are more toxic in combination) (Pennings and others, 2002).

It is important to establish any need for interventions targeted at the person’s substance use, as well as interventions for their alcohol use. The formulation should enable this process and help to understand the function of the substance use for the person. It is not unusual for people to substitute one substance for another, so you should undertake ongoing review of alcohol and other substance use throughout treatment.

If you establish a treatment need for other substance use, this should generally be managed in the team providing the alcohol treatment. However, if the person has an opiate dependence and requires opioid substitution treatment (OST), then the team managing the OST should take over the person’s care managing their alcohol treatment as well as their drug treatment.

It is not in the person’s interests to have dependence on different substances managed in different teams. Where services are not integrated drug and alcohol treatment services, joint working with the local drug treatment service and aligned treatment and recovery plans will be essential.

If the person uses other substances, you should consider this when planning pharmacological interventions. You can find guidance on pharmacological interventions for people in alcohol treatment with co-occurring drug use or dependence, including benzodiazepine dependence, in chapter 10 on pharmacological interventions.

The assessor should offer relevant harm reduction advice on the risks of concurrent problematic alcohol and drug use. You can find guidance on this in chapter 8 on harm reduction.

Drug misuse and dependence: UK guidelines on clinical management provides extensive guidance on treating people with drug problems, including section 6.5 on alcohol in drug treatment.

4.9.7 Assessing strengths and recovery resources

Assessing the person’s strengths and recovery resources (sometimes called recovery capital) is an important part of assessment. Recovery resources are health life resources, such as:

• health and wellbeing
• education and training
• employment
• financial and housing stability
• supportive family relationships, friends
• social and cultural networks
• recovery oriented peer networks

Evidence shows that most people with alcohol dependence make attempts to reduce or stop using alcohol without the help of specialist services (Tucker and Simpson, 2011). The person may already be drawing on their recovery resources to make changes or have experience of doing so. Assessment should identify strengths and resources that could help them to stop or reduce their drinking and support them to make longer-term changes during and after they complete treatment.

Areas to consider include:

• individual resources (for example, coping strategies, past successes in making changes in alcohol use or in other areas of their life, levels of personal responsibility, mental and physical health, skills and interests such as education, training and volunteering)
• employment or interest in future employment
• economic and social stability (for example, stable finances, safe and stable accommodation)
• family and social network resources (for example, support from and obligations to family, partners, children and friends, or other supportive social networks)
• cultural or faith-based resources (for example, values, beliefs, attitudes, practices and communities)
• participation in peer-support networks, organisations or mutual aid groups

Research suggests higher levels of social support may mitigate poor outcomes for people exposed to stress, including people with problem alcohol use (Moak and Agrawal, 2011).

While there may be more focus on treatment interventions at the beginning of the person’s treatment and recovery journey, the process of helping the person to identify and develop recovery resources begins at assessment and continues throughout their treatment.

Helping people develop recovery resources is an important part of the structured support that keyworkers offer. You can read about structured support in section 5.5 in chapter 5 on psychosocial interventions.

4.9.8 Gambling harm

The Gambling-related harms: evidence review showed that there is evidence of a clear association between increased weekly alcohol consumption with gambling harm. This supports the rationale for screening for gambling as part of a comprehensive assessment. Services should consider using a brief screening tool such as the 3-item short-form Problem Gambling Severity Index (PGSI-SI mini-screen), one of 5 brief screening tools identified by a meta-analysis as having satisfactory diagnostic accuracy for detecting harmful gambling (Dowling and others, 2019).

The relationship between gambling and alcohol use can be usefully explored and understood through the process of formulation and can inform the appropriate intervention. This may include referral to a local or regional specialist gambling service and practical support such as debt counselling may also be required. There are a number of NHS specialist treatment service for people experiencing gambling harm and people with co-occurring alcohol use should not be excluded from these.

The assessor should offer information on the spectrum of harms that can be associated with gambling. You can find further information at the Chapter One website. They should also signpost to treatment and support, such as the National Gambling Helpline (Great Britain only), and gambling self-exclusion tools, including blocking software (for more information see the Self-exclusion page of the Gambling Commission website).

4.9.9 Mental health

The importance of assessing mental health needs for people with problem alcohol use

It is common for people with problem alcohol use to experience problems with their mental health. One study found that 70% of a sample of people from community substance use treatment in England also met criteria for common mental health problems (Delgadillo and others, 2012).

The service and the assessor should act on the principle of ‘no wrong door’. This means that nobody should be turned away from an alcohol treatment service (or from a mental health service) because they have co-occurring problem alcohol use and mental health conditions.

It is important that an assessment of the person’s mental health is always included in a comprehensive assessment for alcohol treatment. A person’s mental health conditions may be undiagnosed or untreated and the assessor should ask questions about their mental health even if the person has no formal diagnosis.

Urgent mental health needs

The main assessor, who may not be a clinician, should be competent and supported to identify any immediate risks including mental health problems that need an urgent response. The assessor should involve the MDT or wider clinical team in any decisions about referring the person for an urgent mental health assessment through local urgent and emergency mental health care pathways.

Section 4.8.4 on initial assessment of risks and urgent treatment needs describes urgent mental health risks.

Ongoing mental health needs

The assessor should confirm the person’s:

• past or current mental health conditions
• involvement with mental health services, including any crisis services and any inpatient admissions
• current mental health risks
• current medication

With the person’s consent, where relevant the main assessor should ask their GP and any mental health service working with the person to contribute relevant information to the assessment.

If the main assessor does not have specialist competence in mental health and have any concerns, they should discuss the person’s needs with the MDT or wider clinical team. Where the person’s mental health requires further assessment, a member of the MDT with specialist mental health competence should carry this out, or the person should be referred to local mental health services. If the person has a severe and significant mental health condition and is not involved with a mental health service, a clinician should offer a mental health assessment and make a referral to mental health services as quickly as possible.

If a member of the MDT with relevant mental health competencies carries out a further assessment of the person’s mental health, they should ask in more depth about:

• any current diagnosis
• history of mental health conditions and any current symptoms or concerns
• existence of any historic or current trauma
• past and current contact with mental health services
• current prescribed medication
• common mental health conditions, including non-severe depression and anxiety
• suicidal thoughts, intentions or suicide attempts, self-harm and severe self-neglect
• symptoms of severe mental illness, such as psychosis and bipolar mood disorder
• protective factors and strategies to manage mental health condition

Where assessors are trained and supervised to use formal assessment tools for mental health conditions, these may be helpful to support assessment. For example, they can use the:

• patient health questionnaire (PHQ-9) to screen for depression
• generalised anxiety disorder assessment (GAD-7)
• eating disorder examination questionnaire (EDE-Q)
• primary care post-traumatic stress disorder screen (PC-PTSD)

Having a co-occurring mental health condition can increase the person’s level of risk. The assessor should consider how alcohol intoxication and withdrawal interact with aspects of the person’s mental health. For example, research has shown that intoxication can increase the risk that a person may act on their suicidal ideation (Kaplan and others, 2013; Ledden and others, 2022). See section on suicide risk and self-harm below for guidance.

Planning treatment for both alcohol use and mental health conditions

People with co-occurring alcohol use and mental health conditions should receive treatment for both conditions. Depending on the competencies of staff in the alcohol treatment service and in the mental health service, and on the severity of mental health condition, treatment for both conditions may be offered by:

• the alcohol treatment service
• the mental health service
• both services working together with the person

The assessor, supported by the MDT, should agree a clear plan with the person and any relevant services for how both conditions will be treated. If the alcohol treatment service and a mental health service will both be working with the person, it is important that they co-ordinate care, share information and align or integrate treatment and recovery plans (care plans). See section 4.10.4 on multidisciplinary and multi-agency treatment and recovery (care) plans and section 4.10.2 on risk management (safety planning).

There should be a named person responsible for leading on and co-ordinating the person’s care. NICE clinical guideline Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120) recommends that if the person has a severe mental health condition, the keyworker from the mental health service should usually lead on co-ordinating care.

There is more detailed guidance on joint working between mental health services and alcohol treatment services in chapter 18 on people with co-occurring mental health conditions.

Monitoring a person’s mental health need while they are in treatment

In some cases, mental health conditions (particularly anxiety or depression) may begin to improve after a few weeks of abstinence or significant reductions in alcohol use. However, for some people, mental health conditions do not improve and there is a risk that if they are not offered mental health support when they need it, they may return to problematic drinking.

The period after medically assisted withdrawal or a significant reduction in alcohol use is best described as one of ‘watchful waiting’. The appropriate member of the MDT in the alcohol treatment service should provide:

• ongoing assessment of the person’s mental health need
• support to manage continued low mood or feelings of anxiety
• a quick start to treatment for the co-occurring mental health condition if it is needed

People who need quick access to mental health treatment

For some people, comprehensive assessment of both their alcohol dependence and their mental health will clearly indicate that waiting to start treatment for mental health is not appropriate. These people will need a mental health support package to be in place before they start medically assisted withdrawal. The main assessor or clinician in the alcohol treatment service and the mental health clinician will need to closely co-ordinate the mental health support and the medically assisted withdrawal.

For people with immediate mental health needs who do not require a medically assisted withdrawal, the same principles apply. The clinicians from both services will need to co-ordinate care, involving the person in planning and decisions about interventions, including any decisions about sequencing interventions.

Pharmacological interventions for co-occurring mental health conditions

There will be specific considerations when delivering pharmacological interventions for some people with co-occurring mental health conditions.

You should read about prescribing for people with co-occurring mental health conditions in section 10.6.5 in chapter 10 on pharmacological interventions.

4.9.10 Suicide risk and self-harm

Risk factors for suicide and self-harm

Research has shown that alcohol, both through intoxication and dependence, is a factor in a significant proportion of deaths by suicide (Kaplan and others, 2013; Ledden and others, 2022).

The National Confidential Inquiry into Suicide and Safety in Mental Health Annual report 2024: UK patient and general population data 2011 to 2021 found that 47% of people in contact with mental health services who died by suicide between 2011 and 2021 used alcohol problematically.

The Office for National Statistics report Suicides in England and Wales: 2023 registrations found that men are about 3 times more likely than women to die by suicide.

England, Scotland, Wales and Northern Ireland have national suicide prevention strategies:

• Suicide prevention strategy for England: 2023 to 2028
• Creating Hope Together: suicide prevention strategy 2022 to 2032 (Scotland)
• Suicide prevention and self-harm: strategy and delivery plan (Wales)
• Protect Life 2 - Suicide Prevention Strategy (Northern Ireland)

Services should be aligned with their national suicide prevention strategies which include information on risk factors for suicide.

People with problem alcohol use often experience other risk factors for suicide which include but are not limited to:

• socioeconomic deprivation, financial difficulty and economic adversity
• a history of self- harm or suicide attempts
• long-term physical health conditions
• mental health conditions
• gambling harm
• drug use
• domestic abuse
• social isolation and loneliness
• bereavement
• interpersonal difficulties

People in alcohol treatment services often experience several of these risk factors.

Staff competencies for identifying and responding to risk of self-harm or suicide

Services should provide training and support for staff so they are competent to:

• understand risk factors for suicide
• ask sensitively about suicidal thoughts, intentions or attempts, and incidents of self-harm
• identify and respond appropriately to incidents of self-harm, suicidal thoughts, intentions or suicide attempts
• understand that self-harm, suicidal thoughts, intentions or behaviour should always be taken seriously, regardless of whether the person is or was intoxicated at the time
• understand how to escalate concerns about the person within their organisation and act in line with organisational procedures
• make sure people can access suitable care, including mental health crisis services, emergency care and a place of safety where necessary

Assessing and responding to risk of suicide and self-harm

Comprehensive assessment should include questions on self-harm and suicide and self-harm, including but not limited to:

• past history of self-harm and suicidal behaviour
• mental health conditions related to self-harm or suicidal behaviour
• current thoughts or plans of suicide
• current thoughts of self-harm or plans to self-harm
• engagement with online suicide-related content
• current or recent pattern of self-harm or suicidal behaviour
• current stressors that may contribute to self-harm or suicidal behaviour

Services and practitioners should work in line with NICE guideline Self-harm: assessment, management and preventing recurrence (NG225), which provides detailed guidance on self-harm, including suicide risk and suicide attempts.

Services and practitioners should always personalise risk management (safety) plans and tailor them to the specific needs of the person and risks they experience. NICE NG225 states that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment, or who should be discharged. Risk assessment should focus on the person’s needs and how to support their immediate and long-term psychological and physical safety.

Identifying and managing immediate risk of suicide or self-harm

Services should have agreed pathways and processes for responding to people who are assessed as at immediate risk of suicide or self-harm. Staff should follow organisational procedures and seek support from the MDT, or an appropriate experienced clinician with mental health competencies.

The assessor should identify whether the person has access to the means of self-harm (for example, tablets) and discuss removing this or reducing other forms of immediate risk with the person.

The assessor or supporting clinician should arrange an assessment from an age-appropriate specialist mental health professional as soon as possible through local urgent and emergency mental health care pathways which will vary across different areas. Where possible, the alcohol treatment service should arrange for the person to be accompanied by a staff member, family member or support person to the emergency setting. If this is not possible, they should arrange for the person to go in an ambulance.

NICE NG225 states that assessment for people at risk of self-harm or suicide should not be denied because the person is intoxicated or has been drinking. Services sometimes turn away people whose safety is at risk and who are intoxicated due to stigma or misunderstandings about suicide and alcohol use. This exclusion in turn increases the risk to their safety. The alcohol treatment service may need to act as an advocate with professionals in the urgent and emergency mental health care pathway to help people access appropriate care, including when intoxicated. NICE NG225 recommends that if the person is not able to participate in the assessment due to intoxication, the mental health professional should provide regular reviews and complete an assessment as soon as possible.

Chapter 16 on alcohol care in acute hospitals provides more guidance on managing self-harm in an acute setting, including when the person is intoxicated.

Where appropriate, the assessor should ask the person for consent to involve family members. If the person does not consent, the assessor and MDT should follow organisational procedures on information sharing and suicide prevention.

The assessor should also tell the person, and if relevant their family member, about local support that they can access in an emergency.

Ongoing treatment and support

The assessor or keyworker should be supported by the MDT when planning care and assessing risk. The alcohol treatment service should try to involve mental health services if the person is considered at risk of self-harm or suicide. Self-harm may indicate that the person has difficulty managing their emotions and they may need specialist treatment from a mental health service, such as dialectical behaviour therapy. The alcohol treatment service and mental health service will need to co-ordinate care. For people with ongoing problems with self-harm, suicide risk or a severe or significant mental health condition, the lead professional should be the mental health professional.

Chapter 18 on people with co-occurring mental health conditions provides more guidance on integrated and co-ordinated care.

4.9.11 Cognitive function

The most common cause of alcohol related brain damage (ARBD) is WE, a serious complication of deficiency of thiamine (vitamin B1), for which the most common cause is alcohol dependence. WE can cause lasting brain injury. There are also other forms of ARBD, such as alcohol related dementia and cognitive impairment as a result of traumatic brain injury.

Assessors should be able to identify potential signs of acute WE, which is a medical emergency.

People with acute WE can have one or more of the following symptoms:

• impaired eye movements (ophthalmoplegia)
• unsteady walking (ataxia)
• confusion and memory disturbance

You should arrange for a person with suspected WE to go to hospital immediately.

You can find guidance on preventing and managing WE in section 10.4.3 in chapter 10 on pharmacological interventions.

Some people accessing treatment with alcohol dependence will have a degree of chronic (non-acute) ARBD. Assessors should ask about signs of memory loss and difficulties with day-to-day functioning. These may be signs that the person has short or long term brain damage.

Trained practitioners should consider using brief measures of cognitive functioning, such as the mini Addenbrooke’s Cognitive Examination (mini ACE) or Montreal Cognitive Assessment (MoCA) test for dementia and should refer people whose scores indicate a need for more specialist cognitive assessment. These referrals could be either within the service if there is a clinician with appropriate competencies, or through standard pathways for neurological conditions or cognitive impairment. People with ARBD should not be excluded from these pathways.

A clinician with relevant specialist competencies should carry out a thorough multidisciplinary assessment of the person, which considers their day-to-day functional ability as well as any cognitive test score. Cognitive testing in a person who is acutely intoxicated is of no value. But clinicians can test a person who is currently drinking as long as they recognise that there will be some acute effects of alcohol such as acute memory impairment that should resolve when the person stops drinking.

People with a cognitive disability that is not caused by alcohol use, such as learning disability or dementia, may also present for assessment. Services may need to adjust assessment and interventions for people who have problems with memory, learning new things, or planning. These problems can be experienced by people with ARBD and by people with a cognitive disability which is not related to alcohol use.

Family members or practitioners from support services should contribute to the assessment where the person agrees. Assessors should work with practitioners from other services and the person to develop a treatment and recovery plan tailored to the person’s needs in a way they can understand.

You can find comprehensive guidance on ARBD, including about adjusting interventions and assessing mental capacity in chapter 20 on people with ARBD.

4.9.12 Physical health

Why physical health assessment is important

People with alcohol dependence and people who drink at harmful levels have more physical health problems and die at an earlier age than the general population. Alcohol use disorders can cause over 60 serious physical health conditions or make existing conditions worse. This includes:

• alcohol related liver disease
• cardiovascular disease
• several cancers, including cancer of female breast, the oral cavity and pharynx, oesophagus, colorectum, larynx, liver, stomach, pancreas, lung and gallbladder
• alcohol related brain damage (see section 4.9.11 on cognitive function above)

You can find a comprehensive list of alcohol related health conditions in chapter 19 on people with co-occurring physical health conditions.

People presenting for assessment may also have physical health conditions unrelated to their alcohol use. Physical health conditions may be undiagnosed or untreated. It is important that people with problem alcohol use can access a thorough assessment of their physical health. Stigma and poor experiences of health services can mean that people with problem alcohol use have not accessed the healthcare they need.

With the person’s consent, the assessor should ask their GP and any other healthcare services working with the person to contribute relevant information to the assessment. They should confirm:

• any past or current significant health conditions
• current medication
• any allergies

Liver screening test

NICE NG50 recommends that anyone drinking at harmful (high risk) levels (35 units or more per week for women, 50 units or more per week for men) for 3 months or more should be referred for transient elastography. Some areas use alternative tests for detecting cirrhosis.

The assessor should refer the person for a liver screening test if they meet those criteria.

You can read more about liver screening tests in section 19.5.2 in chapter 19 on people with co-occurring physical health conditions.

Services should be aware of the local pathway for liver screening and the assessor should refer people where necessary. Where community alcohol treatment services provide transient elastography, they should make sure that staff are trained in performing the scan and interpreting the results. Screening for alcohol related liver disease should include a measure of liver fibrosis (such as transient elastography), in addition to liver function blood tests, because normal liver blood tests do not exclude advanced fibrosis.

Referral to primary care

The main assessor, who may not be a clinician, should be able to recognise physical health conditions that need urgent assessment and treatment and refer the person to a clinician within the service, their GP, or the hospital emergency department as appropriate. Section 4.8.4 on initial assessment of risks and urgent treatment or support needs describes urgent physical health risks.

If the person is not registered with a GP, the assessor should help them to register. In some areas, a member of peer-based support networks may accompany the person to GP appointments for support. Alcohol treatment services and practitioners should be aware of current guidance about eligibility for primary care, so they can advocate on behalf of vulnerable migrants and people who are experiencing homelessness.

You can read more about people’s right to register with a GP in section 21.4.4 in chapter 21 on people experiencing homelessness.

Healthcare assessment

Once a person’s urgent physical healthcare needs have been addressed, the assessor should arrange for them to have a full healthcare assessment (unless they have already recently received one). Some or all of the healthcare assessment may be carried out in the alcohol treatment service.

People with problem alcohol use may be reluctant to approach healthcare services due to past negative experiences, stigma or difficulties in keeping appointments. Some people may find it easier to engage with a healthcare assessment in the alcohol treatment service and the clinician may be able to offer the assessment over several sessions. Depending on local arrangements, clinicians in alcohol treatment services will be able to carry out most of the healthcare assessment but may need to request that the GP or specialist healthcare services carry out some of the relevant tests. Referrals to specialist healthcare services will usually be requested through the person’s GP.

The questions, examinations and tests below are not all that needs to be done. The assessing clinician will need to account for the person’s individual medical history and current circumstances.

Medical history

There is some overlap between the questions asked to assess physical health needs and the questions in an alcohol (and drug use) assessment (including assessment for medically assisted withdrawal).

The clinician may need to ask some urgent questions about the issues below, for example before the person can access a medically assisted withdrawal. They can ask other questions at a later stage. Urgent questions may be about:

• symptoms that are a physical health concern when the person presents for assessment
• past or current medical history, including liver disease, cardiovascular disease, cancers, pancreatitis, respiratory disease, injuries, operations and hospital admissions
• any prescribed medication
• any history or symptoms of cognitive impairment (ARBD or cognitive impairment due to other causes)
• any history or symptoms of malnutrition or poor diet
• tobacco smoking (see section 19.6 on smoking-related diseases and lung health in chapter 19 on people with co-occurring physical health conditions)
• types of substances and medications the person uses (whether legally or illicitly obtained) including illicit drugs, prescribed medications, over-the-counter medication, and herbal medicines
• any allergies or sensitivities
• any current oral health problems and recent dental check-up or treatment
• menstrual and pregnancy history, contraception history and cervical screening, if this is relevant
• concerns about sexual health or (if appropriate) blood-borne viruses, HIV or hepatitis B and C
• history of screening and vaccinations received

General health examinations and assessments

The clinician should carry out the following general health assessments or examinations early in the assessment process:

• gastrointestinal system, including the liver
• cardiovascular system
• respiratory system

The clinician should carry out additional examinations where indicated by the healthcare assessment. These examinations include:

• neurological examination (indications include loss of sensation, forgetfulness, convulsions, blackouts)
• dentition examination (to assess the arrangement or condition of a person’s teeth)

The clinician should measure weight and blood pressure. Baseline measurement can be useful in monitoring a person’s progress and may be needed where there are concerns.

Additional testing

The following investigations may sometimes be required. They may be provided within the alcohol treatment service, by the GP or by specialist healthcare services, depending on local arrangements.

Based on the person’s history, risks, symptoms or findings of previous general physical examinations and MDT discussions, appropriate testing required may include:

• screening for liver stiffness via transient elastography or alternative screening tests (see section on testing for cirrhosis above)
• electrocardiogram (ECG)
• chest X-rays and pulmonary function tests such as measures of peak flow and forced expiratory volume (FEV) and forced vital capacity (FVC)
• pregnancy testing
• blood tests to assess liver function, renal function, thyroid function and haematological indices
• formal cognitive testing and assessment
• urine testing for markers of conditions such as diabetes and infection and where appropriate drugs of dependence

Health information and harm reduction

The clinician should encourage the person to consider the impact of their alcohol use on their health. Test results may be an opportunity to discuss health goals and strengthen motivation to change their alcohol use.

Using the principles of MECC, the clinician or main assessor should offer the person clear, accessible information on health risks related to alcohol use, as well as general health information.

You can find information on health risks related to alcohol use in chapter 8 on harm reduction. This should include information and advice for pregnant women and other people who are pregnant or could become pregnant (see section 4.9.13 below and chapter 24 on pregnancy and perinatal care).

General health information would include:

• nutrition and diet
• smoking cessation and harm reduction and referral to smoking cessation service (see section 19.6 on smoking-related diseases and lung health in chapter 19 on people with co-occurring physical health conditions)
• contraception, safer sex, and referral to sexual health service where appropriate
• information about local NHS dental services or direct referral to special care dental services if appropriate

Pharmacological interventions

Clinicians will need to consider the impact of physical health conditions when delivering pharmacological interventions for medically assisted withdrawal and relapse prevention. For example, the impact of advanced liver disease.

You can find guidance on pharmacological interventions for people with liver disease in section 10.6.6 in chapter 10 on pharmacological interventions.

Joint working with primary care and secondary care health services

Good communication between keyworkers and clinicians in the alcohol treatment service and clinicians in primary and secondary healthcare services is essential. Alcohol treatment service clinicians can provide specialist knowledge about alcohol dependence and can act as an advocate for the person, challenging stigma where necessary.

Arrangements for information sharing should be in place between alcohol treatment services and relevant healthcare services. In some areas, alcohol treatment services can access a person’s national electronic health records to make information sharing quicker and more effective.

4.9.13 Pregnancy and the perinatal period

Services should treat pregnant women and other people who are pregnant as a priority for assessment and for treatment. Any delay in starting treatment may increase the risk to the mother and the fetus. They should urgently assess the needs of women and those who are pregnant, even if they are currently drinking below the usual threshold for accessing an assessment, or if they have a history of problematic alcohol use but are not currently drinking. This is to reduce risks to the fetus and the mother.

The assessor should provide information on the risks of alcohol in pregnancy as set out in the UK chief medical officers’ low risk drinking guidelines, which says that:

• if you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum
• drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk
• the risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy

However, it is important to advise anyone who is pregnant or think they could be, not to stop suddenly as this could cause harm to the baby or to them. The assessor should arrange an assessment for medically assisted withdrawal as soon as possible.

You should read guidance on assessment of pregnant women and other people who are pregnant in chapter 24 on pregnancy and perinatal care.

4.9.14 Criminal justice system involvement

Criminal justice considerations in the assessment

This section provides guidance on assessment in specialist alcohol treatment services in the community.

You can read guidance on considerations for assessment and treatment in criminal justice settings in chapter 17 on alcohol treatment in the criminal justice system.

The assessor should ask about any involvement with the criminal justice system. This may include previous or current:

• arrests
• fines
• outstanding charges and warrants
• engagement with probation, including community treatment orders
• licence conditions
• imprisonment
• recent release from prison

Where the person is working with a criminal justice worker or being supervised by the Probation Service, those staff should contribute information to the assessment and treatment and recovery planning.

The assessment should consider the nature of offences as part of risk assessment. For example, if the person committed violent or other serious offences, and whether they might pose risks to other people using the service or staff. The assessment should also include information about child safeguarding or adult safeguarding concerns and whether the person is subject to multi-agency public protection arrangements (MAPPA).

The assessor should consider any links between alcohol use, alcohol dependence and offending. For example, if a person committed offenses when intoxicated or whether their current period of problem alcohol use followed release from prison without adequate support. Treatment and recovery planning may include goals on alcohol use and related offending and will need to take account of any alcohol treatment orders issued by the court, or license conditions.

Continuity of care

People leaving prison should be treated as a priority for assessment, so there is continuity of care between custody and the community. Alcohol treatment services should have agreed care pathways with treatment services in prisons so there is continuity of care which:

• supports treatment engagement
• ensures referral to relevant services
• reduces re-offending
• reduces homelessness
• reduces alcohol related harm

It’s important there is good communication and information sharing between prison services and the local alcohol treatment service before the person is released. This is so they can be offered an assessment appointment immediately after release. Some alcohol treatment services provide in-reach into prisons to strengthen continuity of care. Ideally, there should be a transition meeting for each person leaving prison, involving relevant services for the person to support continuity of care.

The Department of Health and Social Care manages the criminal justice and community single point of contact directory. This consists of contact details of criminal justice organisations and community drug and alcohol treatment providers throughout England and Wales. The main purpose of this directory is to promote successful communication and pathways between organisations, for people moving from criminal justice organisations to community providers and the other way round, as well as supporting effective continuity of care across the system.

You can request access by registering to use the NDTMS website. You can send any further information queries to spoc-ohid@dhsc.gov.uk.

The person may have practical and social needs that should be assessed to help them reintegrate into the community after release from prison. When continuity of care is working well, prison treatment services will be in contact with other relevant services for the person before their release, including mental health services, so their care in the community can be planned. However, the assessor in the alcohol treatment service should identify any urgent unmet needs the person has at assessment and help to address these as quickly as possible.

The alcohol treatment service should have links with statutory, voluntary, community and social enterprise organisations that provide recovery focused services for people who have recently left prison and their families.

The assessor should check whether the person has registered with a GP and should help them to do this if they have not.

Assessors should provide harm reduction information including information about:

• decreased tolerance to alcohol following a period of abstinence and the risks of consuming at the level they did before going to prison
• risks of combining alcohol with other substances, such as increased risk of overdose and increased toxicity of alcohol and cocaine when these are taken together
• increased risk of overdose for people who also use heroin or other opioids

If the person uses heroin or other opioids (including prescribed opioid medication) the assessor in the alcohol treatment service should provide the person with naloxone if they do not have any. If the person has an opioid dependence and requires OST, then the team managing the OST should take over the person’s care and manage their alcohol treatment as well as their drug treatment.

You can read guidance on harm reduction in chapter 8.

4.9.15 Social and economic factors

The public health burden of alcohol: evidence review found that alcohol dependence and alcohol health harms are strongly associated with socioeconomic deprivation.

Poverty and social exclusion may be a cause and a consequence of alcohol dependence and related health harms. These factors can prevent people engaging in treatment, for example if the person has basic unmet needs such as for food, shelter or access to transport to attend the service.

Assessors should ask about:

• debt, financial and welfare benefits problems
• homelessness and housing needs, including unhealthy or unsafe housing conditions, risks to their tenancy or rent arrears
• any community safety problems, such as harassment or anti-social behaviour directed at the person by neighbours
• any use of the person’s accommodation by other people for illegal activities
• employment status and any employment problems

Assessors should identify any social care needs, including:

• the person’s need for a care assessment, for example for home care or personal care (see annex 1 for national legislation and guidance on care assessments)
• what support they have to help reduce social isolation

Assessors should have a wide range of links to local support services and community organisations. This will help them make effective referrals to services and organisations that can help people address the needs listed above.

Wherever possible, alcohol treatment services should invite services providing advice and support to offer in-reach sessions in the alcohol treatment service. This will help increase accessibility for services such as:

• housing
• welfare rights
• debt
• employment

Stigma around problem alcohol use can sometimes affect the service a person receives from support services. So, the alcohol treatment service may need to act as an advocate to make sure people can access the help they need from local support services.

In some areas, members of peer-based support organisations may be able to accompany people to services and help them to do things like fill out forms and attend appointments.

Employment support

People who are not employed may not be well enough or confident enough to seek employment when they are at the assessment stage of their journey. However, it is still useful to ask about any longer-term wishes or goals they have in relation to employment. This can help people access specialised employment support if and when they are ready.

You can find guidance on employment support in chapter 7.

You can find guidance on supporting people experiencing homelessness in chapter 21.

4.9.16 Relationships with partner, family, friends and community

Considering partners, family and friends in the assessment

Assessment should include consideration of:

• relationships with partner, family and friends
• the impact of the person’s alcohol use on relationships with partner, family and friends
• the impact of relationships with partner, family and friends on the person’s alcohol use
• the person’s supportive family and social networks
• risks, including domestic abuse and adult safeguarding

For some people, improving family relationships, including with children, is an important goal and motivating factor.

Reviewing supportive family and social networks

It is important to review the person’s supportive family and social networks early on in the assessment. Research shows that the nature and extent of this can be a significant influence on the person’s recovery journey (Litt and others, 2007). Family and social networks can be protective factors for the person on their recovery journey, support the development of their social functioning and reduce isolation. They can be a source of hope.

The assessor should help the person identify:

• members of their social network (partner, family, friends and community) that could be involved in supporting treatment and recovery
• family members (including children and young people) who may need support
• any contact the person has with people in recovery, peer support organisations and mutual aid (such as AA or SMART Recovery)

This process should begin at assessment and continue throughout treatment. It is an important element of structured support which is normally provided by a keyworker.

With consent of the person with problem alcohol use, there are several ways that family members, partners and friends can be involved in their treatment.

The treatment and recovery plan should address any gaps in the person’s support network, or areas they would like to develop. If the person has very limited social support, it is important that they access a peer support network or mutual aid group as soon as possible. The assessor should help the person to attend one of these organisations. In many areas, a member of one of these groups will be available to accompany the person to a group if the person agrees to this. Some areas have peer mentoring schemes which may provide additional support for the person.

Chapter 5 on psychosocial interventions provides guidance on:

• structured support (section 5.5)
• assessing and strengthening supportive social networks, facilitating access to mutual aid and peer support networks (section 5.5.4)
• involving family, partners and friends in treatment (section 5.8)

Domestic abuse

This section includes guidance on considering domestic abuse as part of assessment. There is more detailed guidance on working with people experiencing or perpetrating domestic abuse in chapter 22.

England, Wales, Scotland and Northern Ireland each have national legislation that defines domestic abuse. The legislation is:

• England and Wales: Domestic Abuse Act 2021
• Wales: Violence against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015
• Northern Ireland: Domestic Abuse and Civil Proceedings Act (Northern Ireland) 2021
• Scotland: Domestic Abuse (Scotland) Act 2018

You can find information on this legislation and related guidance in annex 1.

Treatment services should be aware of the definition in their relevant national legislation and associated guidance.

Domestic abuse can include:

• physical or sexual abuse
• violent or threatening behaviour
• controlling or coercive behaviour (see glossary)
• economic abuse
• psychological, emotional or other abuse

The term domestic abuse includes abuse between intimate partners or ex-partners, as well as abuse between adult family members. For example, sons or daughters abusing their parents. Other forms of abuse carried out by or at the request of family members include ‘honour’ based abuse (including forced marriage and female genital mutilation). Young people under 18 may also use abusive behaviour in their own intimate relationships or towards their parents.

Women, men and non-binary people can be victims of abuse and violence in heterosexual and LGBTQ+ relationships.

There is a high prevalence of domestic abuse among people with problem alcohol use. People attending treatment services may be experiencing domestic abuse or be perpetrators of domestic abuse.

Services should make sure that questions about domestic abuse are routinely part of assessment, whether or not there are potential indicators of domestic abuse.

Alcohol treatment practitioners should ask about and respond to domestic abuse as a routine part of their work and will need training to do this. Trained practitioners should know how to ask and respond sensitively and in a way that prioritises people’s safety. They should also be able to recognise potential signs of domestic abuse and to respond appropriately.

Any questions or discussions about domestic abuse should happen when the person is alone and in a completely private setting. A victim is unlikely to disclose abuse and can be put at greater risk if they are asked about their experience in the presence of the perpetrator, or in some cases other family members or members of their social network.

If a service is using interpreters, these should be independent from the person’s family and social network so that victims can speak confidentially and potential risks from family members are avoided. Human traffickers can pose as family members and offer to interpret to intimidate the person and control what they disclose.

The practitioner should explain the service’s duty of confidentiality and should reassure people that their attendance at the service and their treatment and support will never be discussed with the perpetrator. Practitioners should also explain the circumstances when information can be shared without consent.

Victims of abuse may find it hard to disclose because they are afraid of the perpetrator finding out, being judged, or intervention from local children’s services. They may also (wrongly) believe the abuse is their own fault or they might not recognise the perpetrator’s behaviour as abusive. However, they may appreciate the chance to disclose. When alcohol treatment practitioners use a sensitive, empathic, trauma-informed approach and make efforts to build a trusting relationship, a victim is more likely to disclose their experience and consider accessing specialist support.

People often do not disclose abuse when they first contact services. Practitioners should ask them again as they build a relationship and review treatment and recovery plans or if they see indications that the person might be experiencing domestic abuse. For example, a person may refer to their partner not allowing them to do something or appear fearful.

When a victim discloses current or past experience of domestic abuse, practitioners should:

• respond with empathy and understanding
• identify whether the person and any children are likely to be at immediate risk
• complete the service risk assessment process for domestic abuse in a sensitive way
• offer referral to specialist domestic abuse services for managing immediate risks and/or longer-term specialist support
• discuss the situation with their manager and the accountable person in the organisation (for example, the domestic abuse lead or safeguarding lead, member of the MDT) - they should discuss the risk assessment (safety plan) and what to do next

You should read the guidance on risk assessment and management in section 22.4.9 of chapter 22 on people experiencing or perpetrating domestic abuse.

If a victim and any children are currently at risk, their safety is the priority. Specialist domestic abuse services can intervene to help the person to create a safety plan, provide specialist advice and access to support.

People may be anxious about contacting domestic abuse services, so practitioners should offer to make the initial referral or support the person to make contact. With the person’s consent, they should make referrals to:

• a specialist domestic abuse service
• the multi-agency risk assessment conference (MARAC) or similar multi-agency risk management forum for people at high risk
• other relevant support organisations

If the person does not agree to a referral, the assessor can return to the offer again in a subsequent session. They should offer the person contact details for domestic abuse services, including helplines in a format that the person can conceal easily.

If the person does not agree to access specialist domestic abuse services or give consent to share information, the practitioner should inform their manager and the accountable professional (such as the domestic abuse lead and/or safeguarding lead) and discuss next steps.

It is always best if a person consents to their information being shared. But in some cases, the practitioner or accountable person will need to share information without the person’s consent. This includes situations where children are at risk or an adult is at serious risk of harm.

The practitioner must follow:

• child and adult safeguarding legislation and organisational procedures
• organisational risk management procedures
• information-sharing protocols
• multi-agency domestic abuse risk management procedures

They should inform the victim they will be sharing information and explain their reasons, unless doing so would put children at further risk.

Established referral pathways and effective joint working with domestic abuse services and relevant partner services will be essential to identify and manage risks, and to help the victim and their children access ongoing support. Increasing safety for adults experiencing domestic abuse and their children requires a multi-agency approach.

Domestic abuse and child safeguarding

This section provides guidance on child safeguarding in the context of domestic abuse. Section 4.9.17 provides guidance on other aspects of child safeguarding.

Children may experience domestic abuse directly. Seeing, hearing or experiencing the effects of domestic abuse also puts children at risk of significant harm. National safeguarding legislation and related guidance in all 4 UK nations takes account of the harmful effects of domestic abuse on children. Practitioners must follow national child safeguarding legislation and guidance and organisational procedures.

In the Domestic Abuse Act (2021) (England and Wales), children and young people in England and Wales are recognised as victims of domestic abuse in their own right. This includes children who have seen, heard or experienced the effects of domestic abuse, and are related to either the victim of the abusive behaviour, or the perpetrator.

It is always best to have consent to share information, but information can be shared without consent for child safeguarding. A practitioner should involve the domestic abuse lead and child safeguarding lead if they are deciding to share information without consent. They should inform the victim and explain their reasons unless doing so would put children at further risk.

NICE public health guideline Domestic violence and abuse: multi-agency working (PH50) includes recommendations for assessing concerns about domestic abuse.

Adult safeguarding

Where a vulnerable adult is at risk of harm, services must act in line with the safeguarding principles in the relevant national legislation and guidance and local organisational adult safeguarding procedures.

You can find links to statutory guidance on adult safeguarding in annex 1 on relevant legislation and guidance.

The assessor should identify any risks to the person as a vulnerable adult, including:

• abuse or neglect by family members or carers
• severe self-neglect
• abuse or exploitation from others, such as financial or sexual exploitation
• modern slavery and human trafficking
• stalking

Assessors should also consider whether the person could be a safeguarding risk to vulnerable adults they care for or are in contact with, in any of the ways listed above.

If the assessor identifies adult safeguarding risks, they should make a referral to adult safeguarding services and work closely with them and other relevant partner services. Staff in alcohol treatment services should know how to make an adult safeguarding referral.

The service should provide accessible verbal or written information on:

• the circumstances in which the service would make an adult safeguarding referral
• what is likely to happen after they make a referral to statutory adult safeguarding services

Assessors should work to maintain engagement with the person and offer support following an adult safeguarding referral if the person does not agree with the referral.

4.9.17 Assessing the impact of parental alcohol use

Assessing the needs of children of alcohol using parents

This section is a short summary about assessing the impact of parental alcohol use on children and young people.

You should read detailed guidance on assessment of the needs of children and young people affected by parental alcohol use in chapter 26.

Although most assessors in adult alcohol treatment services will not meet with the children of the person they are assessing, they should consider the needs of these children, because they are required to do so by statutory guidance.

You can find relevant legislation and statutory guidance under ‘child safeguarding’ in annex 1.

Child safeguarding

All practitioners should be trained to understand, recognise and respond to child safeguarding concerns. They should be aware of their organisational safeguarding procedures and know how to make a child safeguarding referral.

Services should make an initial assessment of the risks to children cared for by the person, or in contact with them, as soon as possible. Parents often have fears about involving statutory safeguarding services or losing their children, so it is crucial that assessors ask questions sensitively, explain why they are asking these questions and why it is their duty to ask them. Services should provide parents with information on the circumstances in which the service would make a child safeguarding referral and what is likely to happen after a referral to children’s social care.

Where a child may be at risk of significant harm as defined by the relevant national legislation and guidance, assessors must act according to relevant national statutory guidance and organisational child safeguarding procedures.

You can find links to legislation and statutory guidance on child safeguarding in annex 1.

Assessors should work to maintain engagement with the person and offer support after a child safeguarding referral.

Support needs of parents, children, young people and families

Assessors should still consider support needs for parents and children, even if the assessment finds no risks to children that meet the threshold outlined in relevant legislation and guidance for a safeguarding referral. Effective support can prevent risks from escalating, promote children’s wellbeing and strengthen family functioning.

Families might benefit from:

• parenting support
• social or therapeutic support for children and young people (including young carers) or for the whole family
• practical support with social and financial needs

The alcohol treatment service should have agreed pathways to targeted support for vulnerable families (early help) and young carers services. It should also provide information on universal services such as children’s centres or youth activities.

There is more guidance on support for parents, children, young people and families affected by parental alcohol use in chapter 26 on parents in alcohol treatment services.

Support for partners, adult family members and friends

Alcohol treatment services should provide information and support to partners, family members or friends affected by a person’s alcohol use, including when the person with the problem alcohol use is not attending treatment. Assessors should offer family members, partners and friends an appointment to discuss the impact of the person’s alcohol use on their own wellbeing and on other family members. The family, partners or friends should have their own appointment separate from the person in treatment, so there is a space for them to disclose information confidentially. The assessor should make it clear that there will be confidentiality for the partner, family member or friend, and for the person with the problem alcohol use.

NICE CG115 recommends that:

“when the needs of families and carers of people who misuse alcohol have been identified:

• offer guided self-help, usually consisting of a single session, with the provision of written materials
• provide information about, and facilitate contact with, support groups (such as self-help groups specifically focused on addressing the needs of families and carers)”

Where family members and friends spend a significant amount of time caring for a person with problem alcohol use, they are entitled to a carer’s assessment to assess their eligibility for support. Staff in alcohol treatment services should know how to make a referral for a carer’s assessment and should refer the relevant person with their consent. The NICE guideline Supporting adult carers (NG150) provides further guidance on this.

You can find links to relevant national legislation and guidance on carer’s assessments in annex 1.

Some partners, family members and friends may only need information or a single support session, but others may be experiencing significant strain and may need further assessment of their needs and support.

You should read section 5.8 in chapter 5 on psychosocial interventions, which describes an evidence-based approach to offering support to partners, family and friends affected by a person’s problem alcohol use.

4.10 Treatment and recovery planning

4.10.1 Overview

Treatment and recovery planning is an essential part of organising and reviewing personalised treatment interventions and recovery support for a person with problem alcohol use.

Treatment and recovery planning in alcohol treatment services is usually co-ordinated by a keyworker with oversight from an MDT. It is a collaborative process (between the keyworker and the person), which can help to build and strengthen the therapeutic alliance.

Treatment and recovery planning may also involve:

• other professionals from the alcohol treatment service or from external agencies
• people from peer support networks
• partners, family members and friends

4.10.2 The role of the keyworker in treatment and recovery planning

The keyworker is a single named practitioner who:

• meets regularly with the person in treatment
• co-ordinates their treatment and recovery planning and delivery of care
• provides structured support

Structured support involves using specific psychosocial interventions that are common to evidence-based psychological treatments for alcohol and drug use.

You can read guidance on structured support in section 5.5 in chapter 5 on psychosocial interventions.

The keyworker is generally the practitioner in most regular contact with the person. The keyworker may be an NHS or third sector alcohol practitioner, or sometimes a nurse, doctor or other appropriate professional.

In some cases, or at certain times, other clinicians in the MDT will deliver the main interventions, such as medically assisted withdrawal or specialised psychological treatments. However, the keyworker will normally still co-ordinate and monitor the overall treatment and recovery plan.

4.10.3 Developing a treatment and recovery plan

After the comprehensive assessment, the assessor and the person should agree a broad treatment and recovery plan. If the assessor does not continue to work with the person, the service will allocate a keyworker, who will further develop the treatment and recovery plan with the person.

The keyworker should be supported by the MDT to develop and regularly review the treatment and recovery plan. The person should be fully involved in the planning process through regular discussions with the keyworker. The keyworker should use a collaborative, trauma informed approach when working with the person on the treatment and recovery plan.

A treatment and recovery plan is a constantly evolving record and action plan that has the following core components:

• the person’s agreed treatment and recovery goals
• specific, clear interventions and actions to help achieve the goals
• clear information on who is taking which actions
• monitoring progress, identifying where actions and goals have been achieved and resetting these as needed
• list of services and community organisations that are or will provide support to the person

The keyworker and the person will agree the person’s treatment and recovery goals and the interventions and actions to help achieve those goals based on the comprehensive assessment of the person’s needs. They will prioritise these needs using a formulation. A formulation is a framework to understand:

• the person’s problem alcohol use
• how it began and developed
• the factors that maintain it
• potential resources to address the problem

If the plan includes pharmacological interventions and the keyworker is not the prescribing clinician, the clinician will need to contribute to the plan.

The formulation and the treatment and recovery plan should be highly personalised, taking into account the person’s individual needs, any risks and strengths. It should also take into account things that shape the person’s experience and their preferred approach to addressing their problem alcohol use, including:

• ethnicity and culture
• faith
• age
• sex
• gender identity
• sexual orientation
• disability

Commissioners and services should make sure that each local system can offer a menu of evidence-based interventions including:

• psychosocial interventions
• pharmacological interventions
• recovery support interventions

Keyworkers should be familiar with the range of treatment options and be able to provide accurate information on each of these in a way that the person can understand. They should discuss the aims of each intervention, and any risks and benefits in the context of the person’s circumstances and their preferences. This should include both verbal information and written information in accessible formats. The keyworker can then support the person to make an informed choice about their preferred treatment and recovery support interventions.

NICE provides a useful guide on information for the public about treating harmful drinking (high-risk drinking) and alcohol dependence. It describes evidence-based interventions and focuses mainly on treatment interventions offered by alcohol treatment services. Although the guide is for England and Wales, it will still be useful in Scotland and Northern Ireland.

The keyworker will also need to provide information on and help people to access local recovery support services and community resources including peer support services.

You can read more about recovery support services in chapter 6.

The person should have access to a copy of their treatment and recovery plan. This will usually be a written document. But keyworkers can also use an audible format (such as a recording) or offer the information visually (such as, node link mapping, videos, or easy read formats). It is important that the plan is easy for the person to understand and contribute to. Treatment is likely to be more effective if the person plays an active role in agreeing goals and designing and reviewing their own treatment and recovery plan.

4.10.4 Multidisciplinary and multi-agency treatment and recovery plans

There may be several professionals involved in helping to address the person’s identified goals in their treatment and recovery plan. This may include other staff in the alcohol treatment service or professionals from other services. Each professional should be named and their contact details included in the plan, along with the keyworker as the primary point of contact.

The keyworker will often need to communicate and share information with several different services and organisations including:

• mental health services
• primary and secondary healthcare services, including liver specialists
• hospital alcohol care teams
• housing and homelessness services
• children’s services
• maternity services
• adult social care services
• probation services and prisons
• financial, benefits and debt advice
• domestic abuse and sexual violence services
• community and voluntary services
• education, training and employment support services
• peer support services and networks

Keyworkers should make sure they have consent from the person before communicating with other professionals. In situations such as safeguarding, where consent is not required, it is still good practice to ask for consent unless this would put a child or adult at further risk. But the keyworker must share relevant information even if the person does not give consent.

Professionals from different services will need to communicate with one another to make sure everyone has clear expectations and to ensure good care co-ordination. They will need to clearly agree who is the lead practitioner, responsible for co-ordinating the person’s care. This will usually be the keyworker from the alcohol treatment service, but in some situations another professional will be the lead practitioner. For example, if the person has a severe and significant mental health condition, the keyworker from the mental health service should usually be the named lead.

Services will need to work together and with the person to integrate treatment and recovery plans (care plans) and risk management (safety) plans (see sections below) so there are no contradictions. They will also need to co-ordinate timetabling of appointments to make it possible for the person to attend them all.

When the keyworker from the alcohol treatment service reviews the treatment and recovery plan with the person, they should involve other professionals who are working with the person. All professionals involved should have information sharing arrangements and should share information in between reviews if there are relevant changes in the person’s situation. Information sharing and care co-ordination can be supported by shared record keeping, so agencies can consider whether it is possible and appropriate to have a single shared set of case records. In each UK nation there are some national shared electronic health records although most of these systems are still developing. Shared electronic health records can make information sharing quicker and more effective Details on electronic care records can be found at the end of the chapter in section 4.11.

The keyworker (or where appropriate, a specialist clinician) from the MDT should contribute to multi-agency case conferences, such as child protection conferences or mental health care planning reviews.

4.10.5 Risk management (safety planning)

Risk assessment is an essential part of any assessment and is the basis for risk management (safety planning). Risk assessment (safety) plans will build on initial action plans (see section 4.8) and are likely to be expanded following comprehensive assessment and adjusted throughout treatment.

The keyworker is normally responsible for co-ordinating risk management (safety) planning with the oversight of the MDT or wider clinical team.

A risk assessment and risk management (safety) plan should be based on a person’s individual needs and how to support immediate and longer-term safety. As part of assessment, the assessor should develop a personalised risk formulation with the person. Wherever possible, a risk formulation should be a collaborative process between the person and the assessor that aims to summarise the person’s current risks and difficulties and understand why they are happening. This will inform the risk management (safety) plan.

Formulation typically includes considering historical factors and experiences, more recent problems, and existing strengths and resources which could protect against specific risks.

The keyworker will carry out risk management (safety) planning alongside treatment and recovery planning. Wherever possible, the person should be involved in the process of developing their individual risk formulation and agreeing to goals and actions to manage risks. Sometimes the keyworker and MDT will identify risks (such as safeguarding or offending risks) that they have a duty to act on even if the person does not agree. The keyworker should discuss these risks and the actions they will take with the person, unless informing the person of proposed actions would increase the risks to the person or others (some cases of child abuse, for example) and follow relevant organisational procedures on sharing information without consent.

A risk management (safety) plan is usually a separate plan to the treatment and recovery plan. It should be clearly accessible on the person’s records to relevant staff. Agreed actions in the risk management plan should normally inform the treatment and recovery plan. If the person continues to disagree with the actions, these will remain part of the risk management (safety) plan but not form part of the treatment and recovery plan, which should be collaboratively agreed.

Where risks are identified, assessors and keyworkers conducting risk assessments and risk management (safety) planning should:

• confirm the person’s history with other relevant services the person has accessed
• work with any services the person is currently attending, to assess risk
• make referrals to other services if needed
• involve family members where appropriate

Risk management (safety) plans should clearly identify the:

• actions to manage the risks and who will take them
• people and factors that can help in managing risk

The risks to a person can constantly change, so keyworkers will need to regularly review a person’s risk assessments and risk management (safety) plans. Changes in any of the risk areas (such as alcohol and drug use, physical health, mental health or social factors) may affect the level of risk in another area. For example, increased risk related to a person’s mental health might increase a child safeguarding risk, even where the person’s alcohol use has not changed. A sole keyworker might not be able to see the interaction of risk across all areas, so it is important that the service provides supervision and involvement of the MDT or senior clinician in reviews. Keyworkers will need to amend the identified risk management actions if risks or related factors change, or if the actions have not been effective.

Where the person is involved with other services, there should be information sharing arrangements and keyworkers and staff from involved services should update one another on changes to risks when they occur. They should seek input from professionals in these other services as part of regular reviews of the risk management (safety) plan. The services that the assessor might need to involve in the risk assessment will vary with each person, but they might include (for example):

• GPs
• mental health services
• child and adult safeguarding services
• domestic abuse services
• criminal justice services
• homelessness and housing support services

Assessors and keyworkers should assess the ability of the person and any of their support networks to contribute to managing risks. Family members or supportive friends may have an agreed and specified role.

Services need organisational procedures for escalating and managing immediate risks and keyworkers should have access to advice and supervision from relevant members of the MDT or wider clinical team.

Services need processes for following up people with complex needs where there may be particularly high risks to health and safety if they disengage from treatment. Follow-up might initially involve phone, text or email contact. If there is no response from the person, services should contact the nominated next of kin, family members or support people (with prior consent). And if there is still no response from the person, services should carry out a welfare check involving a home visit:

• by staff from the service
• with a professional from another involved service, where appropriate
• through a request to emergency services, if necessary

4.10.6 The treatment and recovery planning process

Duration of treatment episode and interventions

The needs of people who engage with alcohol treatment services are very varied, so the length of treatment episodes and specific interventions should always be based on individual need and not on a standard length of time. Arbitrary time limits are not helpful and may increase the likelihood of poor outcomes for the person. A person with personal and social recovery resources who is mildly dependent without additional complex needs, will likely need a much shorter treatment episode than someone with few recovery resources, severe dependence and complex needs.

While services and practitioners should avoid arbitrary or premature decisions about the length of an intervention or a treatment episode, structure and timeframes are still helpful. The practitioner should agree clear and ambitious treatment and recovery goals with the person, with planned timescales for action and regular reviews. This helps the person understand that they can reach their goals and that behaviour change is achievable.

As the practitioner and the person regularly review progress towards their treatment and recovery goals, the appropriate duration for the intervention or treatment episode will become clear. Then they can agree a date for ending, and allocate adequate time to plan for this and also arrange post treatment support.

Goals and goal setting

Goals in a treatment and recovery plan will include alcohol use goals (see section 4.7 on alcohol use goals).

These goals are broadly based on the severity of dependence and complexity of need, but they also need to be discussed and agreed with the person, so they are tailored to individual need and take account of the person’s preferences.

Practitioners should approach goal setting and reviewing based on the principles and techniques of motivational interventions, which can strengthen engagement (see chapter 5 for motivational interviewing).

As well as setting goals related to alcohol use and other substance use, treatment and recovery planning will involve setting several wider goals. So, treatment and recovery goals commonly include:

• withdrawing safely and achieving abstinence
• achieving low risk (controlled) drinking where appropriate
• reducing harmful or risky behaviours associated with the alcohol use (for example, sexual risk taking or gambling)
• addressing any other substance use including illicit drug use, prescription medication and over-the-counter medication, whether obtained illicitly or prescribed
• reducing health (physical and mental) problems
• reducing various health social, family or crime problems
• reducing economic and housing instability (for example, unsuitable housing, homelessness income or debt)
• strengthening relationships with partners, improving parenting skills and strengthening family relationships
• building recovery oriented social networks
• engaging in activities that are meaningful to the person
• engaging with peer support networks and mutual aid organisations such as AA or SMART Recovery
• achieving longer-term personal recovery goals (for example, education, training and voluntary work)
• achieving good quality employment

At the start of the treatment process, it can be helpful for treatment and recovery planning to focus on goals that are an immediate priority for the person. The person can help to make their treatment more effective by choosing goals that enable them to see small or incremental changes in specific areas in a reasonable time. This can:

• promote a sense of achievement
• increase motivation
• enhance self-esteem and self-efficacy
• help to build the therapeutic alliance

Effective treatment and recovery goals are usually SMART (specific, measurable, agreed, realistic and time-limited) and reflect individual personal preferences.

Setting and working towards treatment and recovery goals is a central element of the structured support provided by a keyworker.

You can read detailed guidance on providing structured support in section 5 in chapter 5 on psychosocial interventions.

Reviewing the plan and monitoring outcomes

The keyworker should regularly review the treatment and recovery plan with the person. Where partners, family members or friends are involved in a person’s treatment, it may be helpful for them to contribute to reviews, if the person consents to this. The keyworker should also ask other relevant professionals to contribute (see section 4.10.4 on multidisciplinary and multi-agency treatment and recovery plans). The results of any health investigations and results of outcome measures can also be included.

Keyworkers need to routinely use outcome measures to monitor the effectiveness of the treatment and recovery plan. They should use screening tools, such as AUDIT, or outcome monitoring tools, such as TOP or SURE. See section 4. 5 for a description of these tools and outcome measures.

The practitioner should also seek qualitative feedback from the person on their experience of treatment. This should involve offering a range of feedback options including a:

• verbal conversation
• semi-structured written form
• semi-structured online form (you can give the person a QR code to access this)

The feedback can help to adjust goals or interventions.

Reviewing progress using the treatment and recovery plan and agreed outcome measures can help to engage the person and enhance their motivation. The plan can then be revised or updated based on the review. The keyworker should arrange formal reviews at regular intervals.

As well as conducting these regular formal reviews, the keyworker and the person should monitor progress session by session. Working together on a shared agenda at the start of each session may be helpful so that goals and actions can be adjusted as they go along.

The frequency of reviews will vary according to individual need and stage the person is at in their treatment and recovery journey. For example, if they have complex needs associated with high risks, it will be appropriate to review their treatment more regularly than if they had much lower levels of need and risk. In general, it may be more helpful to review progress at shorter intervals at the beginning of treatment, to see whether the treatment and recovery plan is appropriate for the person or if it needs adjusting. It will also be helpful to review the treatment and recovery plan if the person is clearly not meeting their goals or is experiencing a crisis. The keyworker and the person should agree the date of the next review, so the person has a structured timeframe to work within. But they can make adjustments at an earlier time if these are clearly needed.

At the beginning of treatment, the treatment and recovery plan will normally focus more on interventions offered by the alcohol treatment service and other professionals. The keyworker may be more active in helping the person to access early recovery support such as peer networks and rewarding activities. As the person’s recovery journey progresses there is often a transition, and the person may take on more actions and responsibility for their recovery. These could include engaging in education, training or employment or becoming more active in peer-based networks.

Planning for leaving treatment and recovery check-ups

The treatment and recovery planning process includes preparing the person for leaving treatment. The length of treatment should be tailored to a person’s individual needs and their treatment should not normally end until they have met their treatment and early recovery goals and established support networks. While some people may be able to achieve treatment and recovery goals relatively quickly, those with more severe dependence or more complex needs may need to be in treatment for longer and their progress may not be straightforward.

It is important that the treatment end date leaves time and space to prepare the person for the end of their treatment or for moving on to another stage of their treatment and recovery journey. People can be at increased risk of relapse at transition or ending points without appropriate preparation and support.

You can find more information on recovery in chapter 5 on psychosocial interventions.

Planning for leaving treatment should include agreeing actions for the person as they continue their recovery journey. Keyworkers should arrange with the person for recovery management check-ups, with their consent. Recovery check-ups are regular appointments by phone, online or in person, offered by the keyworker for a period after the person has left treatment. The keyworker and the person should agree a period of time based on individual circumstances, but this will normally be for at least 6 months, and may be for longer. The aim of these recovery check-ups is to provide support and encouragement, acknowledge progress and respond quickly if the person returns to problematic alcohol use or is at risk of it, or has any other significant problems.

It can be helpful for the keyworker and the person to agree a re-engagement plan, with the person’s consent. This can include actions the person can take and who they will contact if they begin to use alcohol problematically again. For example, actions might be to contact the keyworker and attend an AA meeting. It can also include actions the keyworker can take if they are not able to contact the person (such as contacting a family member or another professional or making a home visit). Services should make sure that anybody getting back in touch to re-engage in treatment gets seen as soon as possible, so they can get quick help to stop drinking and maintain their recovery.

Core keyworker skills for treatment and recovery planning

There are several core skills that keyworkers need for assessment and treatment and recovery planning. These include:

• assessment skills
• skills in treatment and recovery planning and care co-ordination
• risk assessment and risk management (safety) planning
• knowledge of harmful drinking and alcohol dependence
• motivational, clinical and planning skills, underpinned by active listening
• ability to build a trusting relationship and therapeutic alliance
• cultural competence (see chapter 2 on principles of care)
• a trauma-informed approach (see chapter 2 on principles of care)
• knowledge of alcohol interventions and ability to choose and recommend appropriate interventions
• knowledge of local pathways and local health, care and community services
• skills in multidisciplinary and multi-agency assessment and treatment and recovery (care) planning
• ability to work effectively with peer support organisations

4.11 Resources: national electronic care records

Each UK nation has some electronic systems for sharing summary healthcare records, although these are mostly still developing. In some areas, alcohol treatment services or clinicians can arrange to have access to these shared records, which will aid information sharing.

In England essential health information is shared electronically through the summary care record held by National Care Records Service.

NHS Scotland services share health information electronically through the Key Information Summary (unless the person has opted out) and anticipatory care planning when those have been discussed with the individual person and put in place by the GP team.

In Wales, nurses have access to information on the Welsh Nursing Care Record and a limited number of clinicians can access the Welsh Clinical Portal.

In Northern Ireland, Encompass is being rolled out so that health and social care trusts will have access to digital health and care records.

4.12 References

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