We began as academic ST4 GP registrars at Imperial College in August 2009.
These are posts created by the London Deanery to provide an introduction to academic GPs. Strong partnership between the local PCT and the academic Department of Primary Care at Imperial gave us a rare opportunity for hands-on learning about quality improvement, clinical leadership and health system management on the PCT scale.
Guided by NHS Hammersmith and Fulham’s Clinical Leads for Service Innovation and Improvement, we evaluated and strengthened borough general practices’ performance on alcohol screening and interventions.
Alcohol drinking is a hugely topical issue, with NICE confirming last month the need for a population approach to reduce alcohol-related harm. The need for NHS staff training in alcohol screening and brief intervention formed part of NICE’s recommendation.
Hammersmith and Fulham has one of the largest alcohol problems in London – with the highest rates of increasing and higher risk drinking (35,976 and 9938 estimated respectively) and alcohol-specific hospital admissions in London. With the majority of excessive drinkers currently undiagnosed, it is essential that we concentrate on identifying early those at risk and educating them about healthy behavioural change.
Such education is known to help: one in eight drinkers will reduce their alcohol consumption to safe levels for up to 12 months, having received between five and 20 minutes of brief advice. Primary care is known to be an effective place to target patients and educate them about alcohol drinking. It is therefore vital that Hammersmith and Fulham’s primary care healthcare professionals identify and help those whose drinking is risky at an early stage.
Having been trained by the Alcohol Education and Research Council’s Alcohol Academy, we contacted Hammersmith and Fulham’s 31 general practices to offer their staff training. Contact was made via written, email and telephone communication with the practice managers.
Our interactive training was targeted at multidisciplinary teams. It included: identifying staff’s learning needs around the subject, assessing practices’ current methods of alcohol screening and intervention and helping optimise effectiveness of this, aiding practice strategy development to achieve alcohol QOF Plus points (incentivised quality improvement targets developed by the PCT, in addition to standard QOF, to help address the local alcohol need), gauging staff attitudes to risky drinking and its minimisation, assessing (through self-completed evaluation) staff confidence in screening and intervention before and after training, and advising about (and developing) local specialist services and resources.
Results and evaluation
Practises visited and Staff trained
We visited 26 out of 31 practices (84%) and trained a total of 95 staff.
Two practices were non responders to repeated phone calls/emails/letters, two practices cancelled and did not respond to further contact and one was closed by the PCT prior to our visit. We trained 60 doctors (53 GPs and 6 GP trainees), 15 nursing staff, 14 administrative/managerial staff and four staff with mixed roles within the practice (two did not provide details). 63 of the staff (66%) were receiving alcohol training for the first time.
Staff confidence of alcohol screening and intervention
Analysis of the attenders’ self-completed evaluations showed that our training improved individuals’ confidence in alcohol screening, identifying risking drinking and delivering brief intervention.
Although at first glance the numbers of “more confident” staff seemed underwhelming, closer analysis showed that nearly all of those whose self-rated confidence had not improved after the training, had rated themselves as confident prior to the training anyway. Interestingly, when the current practice of these confident practitioners was assessed during our interactive discussions, these were often the healthcare professionals who were not screening for alcohol problems or delivering brief advice effectively.
Staff attitudes and opinions towards alcohol screening and intervention – analysis of comments made during interactive training
Staff, although welcoming our training, often seemed negative towards their role in this public health initiative. Their concerns included: value of founding evidence, patient reactions, staff/workload/timing issues and quality of specialist services.
The majority of staff agreed that alcohol screening and intervention was a good idea commenting: “[It’s a] Big problem – needs to be addressed”.
However, they challenged the strength of evidence on which the recommendations were based: “Recommended limits are arbitrary anyway” and “What brief advice was used?” “How long did the positive response last?” Concerns were also raised about how their patients would react to being screened and receiving interventions. They felt: “Patients lie about their drinking”, “All people who have a problem don’t want help, especially youngsters” and “Patients get cross with constant public health questions”.
Although many staff rated themselves as confident prior to the training, current practice often seemed inappropriate and ineffective. Some seemed to be asking patients about alcohol opportunistically, case-finding instead of screening for problems: “We ask patients when they come in”.
In some cases, patients were being targeted belatedly: “I ask them when they smell of alcohol”; “It’s obvious when they have a problem”.
Nearly all practices were aware of the different screening tools but there was often confusion about when to employ these appropriately and how to interpret the results: “We use FAST C” (note: the screening tools are called AUDIT-C or FAST).
Only 4/31 practices used effective brief intervention tools via leaflets. Many of the practices felt referring the patient for a blood test would be sufficient to help patients cut down their alcohol use: “My tool is to offer them a blood test”.
Almost all practices raised issues with timing, workload and IT problems that affect their ability to screen and intervene effectively.
Most practices were keen to discuss the practicalities of alcohol screening, wanting to learn how other practices were approaching this issue. Interestingly, many doctors seemed to feel that screening and intervention were best completed by non-medical staff, while non-medical practice staff believed that advice would be far more effective from the doctor.
Most practices felt strongly about the local joint specialist service for drugs and alcohol misuse (Crowther Market). They felt their patients avoided the clinic, because of the service’s clientèle: “Patients don’t want to mix with the sort of people at Crowther Market”. It clearly highlighted that people who have an alcohol problem don’t want to be associated with a drugs service. This may be an issue nationally as these services are often co-located.
Practice staff also seemed to feel under-supported by the service. They suggested that lack of feedback and poor communication with the service made it hard for them to support and manage their patients: “We never know if the patients we have referred ever go.”; “Support for GPs to administer detoxes [is] required”; “Little communication… makes some GPs shy away”.
The service developments occurring during the period of our visits (separating early from severe alcohol services, establishing local community satellite clinics and increasing access through extended opening and walk-in services), were all welcomed by practice staff.
We have increased practice teams’ awareness of alcohol problems within Hammersmith and Fulham, training nearly 100 staff on effective screening and brief intervention methods. We have helped practices to develop their resources by writing QOF Plus information packs and locally-focused patient leaflets in conjunction with the PCT’s communication team and through our electronic distribution of key documents and links to current resources (subsequently supported by NICE’s recommendations). We have liaised with and developed the local specialist alcohol service, helping them set up GP-based satellite clinics and formulating improved communication techniques with primary care.
Our training was received positively by those practices that we visited and nearly all of the staff commented on its benefit in some form. Although most staff recognised the increasing burden of alcohol-related harm on society, health and the NHS, particularly within their local area, and the need to address this issue, many seemed sceptical about their ability, as time-pressured health care workers, to drive positive change.
We found that several health care workers, often those who self-evaluated themselves as “confident” at identifying and dealing with risky drinking prior to our training, had an inadequate understanding of how best to screen for alcohol problems and how best to encourage change. This would support the need for evaluations and training such as ours, and also for revisiting some practices to ensure their improvements; especially those whose assessment of their ability differed from their actual performance.
Although there is an obvious role for medical professionals to identify risky drinking and promote change, if general practices are going to address this public health issue properly, they will need both increased support and resources. Most importantly, a recognition that a team effort is needed and all members of general practice, from the receptionist to the GP, should play a role in both screening and brief advice.
Acknowledgement: We would like to thank our mentor Dr Josip Car, medical director, for his support and Dr Nemonique Sam and Dr Clare Graley for their guidance.
Dr Anna Whiteford, Dr Amanda Allen and Dr Clare Graley