Alcohol within Primary Care in the North East Neil Martin Research and Information Manager

Introduction The aim of the project was: To find out more about General Practitioners’ – and other Primary Care health professionals’ - opinions and perceptions around the subject of alcohol, and to identify barriers and incentives to delivering alcohol-related interventions via Primary Care

Methodology The work comprised of three core work strands, undertaken between Spring 2012 and Spring 2013: –An online survey 1 of North East GPs, 101 respondents (self-selected) –6 depth interviews with representatives from North East Clinical Commissioning Groups (CCGs) –24 depth interviews with North East GP Practices 1. Based on: Wilson GB, Lock CA, Heather N, Cassidy P, Christie MM, Kaner EFS. Intervention against excessive alcohol consumption in primary health care: a survey of GPs’ attitudes and practices in England 10 years on. Alcohol and Alcoholism 2011, 46(5),

Alcohol in a Practice Setting Positioning of Alcohol: All practices consider alcohol to be an issue manifesting in different ways: alcohol dependency and alcohol specific diseases presentation of conditions caused or exacerbated by alcohol as a lifestyle issue Priorities influenced by: patient/clinical need; alcohol not in Quality and Outcomes Framework CCGs see impacts other than health but priorities in service re- design, A&E attendance and hospital admissions

Alcohol in a Practice Setting Please rank these behaviours in terms of importance when it comes to health promotion:

Alcohol in a Practice Setting Processes used to tackle alcohol in a practice environment Consumption addressed opportunistically and routinely Practices primarily adopt a nurse-led approach for IBA Resistance to undertaking alcohol screening more routinely CCG shared views and were also conscious of barriers: Time pressures Payment Effectiveness Service provision

Alcohol in a Practice Setting Which of the following scenarios, if any, would prompt you to discuss alcohol use with a patient?

Alcohol in a Practice Setting Tackling the issues Advice on safe drinking and health impacts provided to patients Dependency tackled by referring to specialist support Major challenges: under-reporting of consumption under-estimate health impacts of alcohol difficulty of accurately measuring alcohol consumption personal motivation fundamental to successful treatment lack of suitable support services CCGs perceive the need to co-ordinate services

Alcohol in a Practice Setting Reasons for avoiding early intervention for alcohol:

IBA within Primary Care Appropriateness of alcohol screening and brief advice General support for undertaking of IBA Familiar with evidence of effectiveness Some uncertainty about the strength of the evidence Interest in receiving more information about effectiveness of IBA Availability of long-term data which clearly illustrates health benefits of would help strengthen the pro alcohol IBA message

IBA within Primary Care GP experience of delivering alcohol screening and brief advice Screening How AUDIT-C is introduced and delivered is felt to be important General confidence in ability to provide brief advice on alcohol Brief advice Opinion mixed on how well the brief advice is received by patients Patients often surprised to learn they drink at harmful levels Some patient groups do not take consumption seriously

IBA within Primary Care Limitations of alcohol screening and brief advice Patient’s motivation to make a change often acknowledged as fundamental to success – ‘readiness to change’ Lack of motivation seen to be driven by: relaxed social attitudes omnipresence of alcohol public policy towards alcohol IBA seen to need support of public policy Smoking was frequently cited as an example of how attitudes and perceptions can be realigned

IBA within Primary Care Benefits of alcohol screening and brief advice Benefits for the practice: less demand on appointments - saves time and resources provides a delivery model - recognised protocol Benefits for the patient: raises awareness of the health impact of alcohol gives patients a chance to improve their health,

IBA within Primary Care A CCG perspective – Making screening for alcohol work within Primary Care Feeling that a joined up approach is required, reflecting: change in patient attitudes to alcohol necessary support services are available Strategies to overcome the implementation barriers: raising profile of IBA inclusion of alcohol screening in the QOF – routine delivery increasing the level of remuneration for screening providing GPs with support in terms of how to integrate screening evidence base

IBA within Primary Care Factors that would encourage early intervention for alcohol

IBA within Primary Care A CCG Perspective – Making Alcohol a Greater Priority See the importance of adopting a preventative approach Would benefit from information to ‘remind them’ of its importance: social impact of alcohol impact of alcohol on health budgets Examples around what could be done to reduce hospital admissions Need to change attitudes and behaviour in regard to alcohol Importance of the political agenda

Reducing harm How effective do you think the following government policies have been in reducing alcohol related harm in England?

Policy interventions How effective do you think the following policy measures might be in reducing alcohol-related harm in England?

Summary of findings Wide support for IBA but need for reinforcing the evidence Competing priorities within Primary Care Nurse Practitioners taking lead role Gaps in alcohol services Societal attitudes and government policy regarding alcohol

Alcohol IBA within Primary Care ………Next Steps Mary Edwards Programme Manager

Where are we now? Questions asked about: To what extent is alcohol IBA a priority in the various strategies? What models of delivery/specifications of IBA do we have across the North East? How effective are we at monitoring; evaluating and sharing the findings from IBA initiatives?

Some of the findings …….. 7 /12 areas across the North East had an alcohol primary care contract (LES) in place with either GPs or Pharmacies for the delivery of IBA Of those that didn’t - they all felt that IBA was an important part of a holistic approach to reducing alcohol-related harm All areas identified on-going initiatives and planned IBA developments within the Hospital setting Take up rates - It was difficult to get a full picture of both LES and DES contracts – capacity issues and potential cost implications Evaluations - Models of care-coordination and care pathways at differing stages of development across the region

A mixed picture of activity in relation to alcohol IBA across the North East But the following principles were agreed during the course of the various meetings : The evidence base around the delivery of Identification and Brief Advice (IBA) in a Primary Health setting is strong and needs to be communicated more effectively Nurses, Health Visitors, pharmacists are well placed to deliver IBA - It is important to target key messages effectively within Primary Health setting and via established routes

Principles continued… It is important to work with partners i.e. Local Medical Committees, particularly when it comes to agreeing the content and focus of Primary Care Contracts relating to alcohol IBA All local leads to advocate for the inclusion of a specific commitment to alcohol screening and brief advice via Primary Care in local Health & Well Being Strategy documents – with outcomes monitored and recorded

There is a need to address the bigger picture Need to change pro-alcohol culture at population level Need to help people understand harms alcohol can cause Need to systematize delivery and explore different delivery points

Questions