1. Welcome to Bradford! A Local Perspective Dr Carsten Grimm Bradford Districts CCG Board Member

2. Declaration of Interest Current roles and affiliations GP partner BDCCG Board Member Clinical Lead Alcohol Certificate, RCGP England Previous roles and affiliations Clinical Lead Alcohol Services Locala (former Kirklees Community Health Services, NHS provider arm) RCGP Clinical Commissioning Champion Associate IHWB UK Honoraria Turning Point Lundbeck BayerSchering KJ Physiotherapy & Medical Consultancy Ltd RCGP England Doctors.net UK Richmond Pharmacology Pfizer NHS via various primary and secondary care trusts LMC Bradford & Airedale Ltd

3. The funny slide of the alcohol talk…

4. Physicians’ barriers to deal with alcohol related problems Lack of knowledge Limited knowledge of screening, diagnosis and management in primary care 3,4 Lack of knowledge Limited knowledge of screening, diagnosis and management in primary care 3,4 Time Time constraints 2 Perception it is time- consuming 1,2 Time Time constraints 2 Perception it is time- consuming 1,2 Attitude Insecurity in dealing with a stigmatised disease 4 Reluctance to confront patients 2,4 Perception that patients do not want to be asked about alcohol 1,2,4 Personal / family experiences 3 Attitude Insecurity in dealing with a stigmatised disease 4 Reluctance to confront patients 2,4 Perception that patients do not want to be asked about alcohol 1,2,4 Personal / family experiences 3 Lack of training Lack of role models 3 Curricular deficits in medical training 2,3 Lack of training Lack of role models 3 Curricular deficits in medical training 2,3 1. Friedman et al. J Gen Int Med 2000;15(2):84–91; 2. National Center on Addiction and Substance Abuse (CASA). CASA National Survey of Primary Care Physicians and Patients on Substance Abuse, 2000; 3. Miller et al. Acad Med 2001;7:410–418; 4. McCormick et al. J Gen Int Med 2006;21(9):966–972 HCP=healthcare provider

5. What does every GP and patient know? 1. Rehm J et al. Addiction. 2011;106(Suppl 1):11-9 J-shaped relationship between alcohol consumption and coronary heart disease Relative risk 0.6 1.6 1.4 1.2 1.0 0.8 Alcohol (g/day) 20 g/day 0255075100125150 72 g/day 89 g/day

6. What do they not know? High blood pressure is 1.4–4 times more common in harmful drinkers 1,2 Harmful drinking contributes to 5–11% of cases of hypertension in men in Western countries 3 Reducing alcohol consumption provokes a significant diminution of blood pressure 3,4 1.Fuchs et al. Hypertension 2001;37:1242–1250 2.Corrao et al. Prev Med 2004;38:613–619; 3. MacMahon. Hypertension 1987;9(2):111–121 4.Xin et al. Hypertension 2001;38(5):1112–1117;

7. Hypertension diagnosis in Primary Care Industrialised, highly structured approach Patients have “full work up” Possible bias towards those who are highly functioning “First class train possy on the way back from London” Source: National Railway Museum

8. My story as a Bradford GP

9. The Cases that changed my practice Three consecutive male patients in their 40’s, newly diagnosed with hypertension All in employment, slightly overweight, very concerned about their health All drinking between 6-10 units regularly (2-5x a week) – AUDIT-C 5 – 11, mainly at weekends All had lifestyle interventions – apparently All dropped their clinic BPs significantly after 4-6 weeks

10. AUDIT-C screening tool Questions Scoring system 01234 How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1 -23 - 45 - 67 - 910+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly MonthlyWeekly Daily or almost daily

11. Audit – alcohol screening and hypertension Population of Bradford Districts CCG 330k, 41 GP surgeries 44.179 coded with hypertension, only 1524 ever received formal alcohol screening (3%) Last 12m 3926 newly diagnosed patients with hypertension, 800 documented formal alcohol screening (20%) Screening appeared to be unlinked and due to new registration No evidence of brief interventions and/or AUD treatment

12. Improve cardiovascular disease in Bradford

13. Step 1: Quality Premium Agree the use of a single screening tool – AUDIT-C Increase the use of AUDIT-C in newly diagnosed hypertension Utilise recently commissioned primary care alcohol service

14. Primary care alcohol service Covering all GP surgeries with dedicated alcohol workers Most have set up regular clinics Very short waiting times, initial assessment often via telephone Electronic, quick and easy referral without artificial hurdles Aiming at the harmful or low dependent drinkers

15. Electronic Referral process

16. Initial findings Significant increase in the use of AUDIT-C (estimated about 60%) GPs feeling more confident to ask the question No increase in referrals to alcohol service Confusion about process and diagnosis Dialogue about improvements of use of S1 (EHR) – utilisation of protocols and active reminders

17. Step 2: Improve referral process Dedicated training delivered to GP surgeries by alcohol service Aim to redesign and simplify S1 template and introduce protocols Identify links into secondary care (hospital liaison teams) Consider re-labelling to Lifestyle assessment (addressing all NICE recommended lifestyle factors)

18. Step 3: BHAIT Bradford Hypertension and Alcohol Identification Trial Clustered Randomised Trial looking at effectiveness of additional assessments and interventions

19. Questions to answer What are the cut offs for alcohol consumption in the population age 60+? Does AUD brief interventions trigger other lifestyle changes? How do we deal with social risk assessments and safeguarding (children, vulnerable people and DVLA)? Can it trigger a rethink of the provision of alcohol services?

20. Summary The majority of people with alcohol use disorder can be treated in primary care Primary care is arguably best placed to bridge the gap between physical health need management, accessibility and specialist treatment options Look at the CCGs now – it is an issue for hospitals

21. Thank you! carsten.grimm@bradford.nhs.uk