What’s our strategy for IBA?

8 Feb

dr-matt-andrewsIn this guest post, Dr Matthew Andrews from the Safe Sociable London Partnership calls for further strategic attention to IBA implementation, inviting any interested stakeholders to get in touch.

Identification and Brief Advice (IBA) has incredible potential to prevent and reduce alcohol related harm.  The figure of a 15% decrease in alcohol consumption on average for those who receive an IBA is a compelling and significant impact.  For the individual this can mean reducing alcohol related hospital admissions and risk of alcohol related mortality by a fifth.  For England this could lead to reductions in a wide range of health and social harms.

Despite this, our strategic approach to rolling out IBA in the English population has been lacking.  In the last two national strategies IBA has been noted, but with little strategy for implementation.  The Safe. Sensible. Social alcohol strategy did highlight a research approach, and the development of web-based commissioning tools.  In the 2012 strategy, IBA isn’t raised until after social marketing, the sobriety pilot and licensing amongst others – and all it does, is say is that IBA will be part of the NHS health checks and that Local Authorities should consider it for commissioning in primary care settings. We’re yet to have another national alcohol strategy. Local Alcohol strategies tend to be better, but still, there is very little strategic coherence to IBA implementation.

For years IBA has been highlighted as something to be rolled out, the evidence has been clear and further research has been commissioned; examples of good practice have been collected and shared.  However, no real strategic approach to the implementation of IBA has been set out.

Without a clear strategic direction:

  •  The roll out of IBA in primary care – through both Direct and Local Enhanced Services – did not live up to expectation.
  • Other settings, such as pharmacy, have been the site of IBA initiatives and some research and evaluation work, but we are still unclear of the evidence, practice and approaches that might best work for wider implementation.
  • Since the move of Public Health to Local Authorities, NHS buy-in at commissioning level has initially been limited. The joint commissioning between Public Health and CCGs that we optimistically hoped for a few years ago is still developing.
  • Digital IBA has become increasingly popular.  Although there is definite development and innovation in this space, there is still a fragmented approach across local commissioners – there is little clear guidance and little sharing of good practice despite the evidence base being solid and growing.

If we are to realise the potential of IBA and make best use of the learnings of the past few years, we need a strategic approach to IBA implementation.  This would need to:

  • Make the case: clinically, socially and economically (each being as important for the case as the other).  We need to better make the case for IBA implementation.  Currently we have failed to win over decision makers, commissioners and clinicians sufficiently for the wide-scale, effective delivery of IBA to take place that would show significant impact.
  • Commissioning: we need to be clear that when commissioning IBA it shouldn’t be service by service or project by project, it should be a comprehensive IBA approach – the HIN IBA Commissioning toolkit (Watson, Knight, Hecht and Currie) provides a detailed and effective guide for commissioning IBA strategically and effectively.
  • Training and workforce development: We need to learn from our smoking cessation partners and develop a minimum standard of training, possibly with accreditation, and a professionalised training and skills acquisition pathway around IBA for more junior staff’s professional development and career progression.
  • Digital integration: We need to work with the existing digital field, in practice, research and innovation; and examine and experiment with how digital and traditional IBA can align, complement and enhance each other for the best ‘merged’ IBA pathways to be available to practitioners and the population.
  • Expanding the knowledge and scope: redeveloping a research and evaluation strategy to genuinely enhance and build our knowledge of what works.  A collaborative strategy that sees our researchers and evaluators work with commissioners and practitioners to fill in the gaps and expand the boundaries of our knowledge rather than reinventing the wheel.

We think that now is the right time to build an alliance of interested parties to start scoping out and developing what an IBA Strategy would look like and what it could achieve.

We would be keen to hear from anyone who is interested in supporting or being involved in this. Get in touch here.

This post orginally appeared on the Safe Sociable London website.

Who and where for IBA – are nurses and universities best?

11 Oct

A recent systematic review of alcohol brief interventions looked specifically at whether the ‘setting, practitioner group and content matter?’. Based on data from 52 research trials, the results conclude that alcohol brief interventions ‘play a small but significant role in reducing alcohol consumption’ – but also identifies some differences based on where and by whom.nurse

Perhaps the most significant finding is that IBA delivered by nurses were found to be most effective. This may be seen as promising given the reach of nurses and recognition of the role of IBA in healthcare settings. However the study cannot tell us how much this finding may be as a result of the way in which nurses deliver the intervention versus other factors such as nurses being seen as a credible person to offer alcohol advice.

As such it suggests nurses should be seen as a priority for the delivery of IBA, with efforts needed to address key barriers of time, worry about losing trust of the patient and inadequate training. It also emphasises previous research suggesting ‘a good relationship between the practitioner and the client’ as an important factor.

The findings also suggest the less intensive approach of ‘brief advice’ was found more effective than longer motivational interviewing interventions. However concerns over ‘brief advice’ being interpreted as simply feedback and a leaflet -rather than say 5-10 minutes structured advice – should be noted.

Another key finding was that when comparing settings, universities were found to have the greatest effect size alongside primary care – surprising given the limited level of attention to IBA in universities. Perhaps another unexpected findings was a lack of evidence for IBA in A&E settings. Whilst previous studies have found small effects, the review suggests that the specific time pressures within A&Es, lack of privacy and seriousness of injuries may be significant in hampering its value as a setting.

The authors rightly highlight limitations to the research and caution over drawing firm conclusions about role and settings. However it may be fair to summarise that it strengthens the case for shorter ‘brief advice’ to be delivered by nurses in particular. In addition, further focus on the potential of universities as a setting for delivery may also be an important area for development. Meanwhile the possibly limited benefits of IBA delivery in busy A&E settings may need to be weighed up against the level of effort required.

See here for an analysis of the research on the Mental Elf blog.

95% people are ‘comfortable’ talking to GPs about alcohol

30 Sep

iba-gpResults from the 2015 British Social Attitudes (BSA) were recently released, revealing the vast majority of patients felt either fairly (20%) or very comfortable (75%) talking to their doctor about their alcohol consumption.

Just 2% of respondents were either fairly or very uncomfortable doing so, suggesting there is little justification for the commonly perceived barrier that patients may be defensive when offered brief intervention. A further 3% said they did not feel either comfortable or not.

Furthermore over four-fifths (85%) of people say that they “would answer completely honestly”, while 14% say that they would “bend the truth a little”. Whilst the study found people were more likely so say they would answer honestly if they didn’t drink or were lower risk drinkers, 62% of risky drinkers still said they would be truthfull.

This may in part be because many at-risk drinkers are not aware of their drinking as such, but still the results suggest a widespread public acceptance of the role of IBA in health care settings. Unfortunately, despite ongoing efforts to incentivise and support Primary Care roles to deliver IBA, less than 10% of at-risk drinkers report recieving alcohol advice, compared to over 50% of smokers.

‘How’ you ask is important too

Despite such a high percentage of patients being comfortable to discuss their alcohol use, it is important to note that how such questions – and any subsequent ‘advice’ – is carried out is crucial to the effectiveness of brief intervention.

One of the most important things is to ensure patients do not feel they are being judged or picked out individually for alcohol questions. Whilst many practices screen patients at certain points, initiating IBA can be done whenever a spare moment arises.


Patients of course do have the right to decline, and any following conversation should not be pushy or lecturing. Delivering a validated alcohol assessment such as the AUDIT and offering brief feedback on the person’s score appear to be the most important elements – Primary Care roles musn’t think that patients are against this.

IBA in non-health settings: Middlesex research programme findings

17 Jul

A series of reports are available following the conclusion of a Middlesex University project exploring the delivery of alcohol brief interventions outside of health settings.

A growing effort to deliver alcohol ‘Identification & Brief Advice’ (IBA) in a range of different settings has emerged over the last decade, but the actual level of delivery by front line practitioners remains questionable. The reports appear to confirm many of the suspected reasons why IBA delivery has proven difficult, ranging from individual level perceived barriers to failures to adopt ‘system wide’ approaches.

To those in the field, it may be no surprise that simply ‘parachuting’ in training without recognising and addressing many of the contextual issues at play is insufficient. Despite this, training is likely to be an important component of any efforts to secure delivery, and participants generally value the knowledge and skills gained. Different roles in different settings though report varied barriers and opportunities and so training and all important organisational strategies may need to reflect these nuances.

The main report looks at these through work on influences on behaviour change undertaken by Susan Michie and colleagues at UCL. Whilst the more traditional ‘cycle of change’ is often used to consider a drinker’s motivation to change, Michie’s work demonstrates the importance of considering the wide range of factors that influence practitioner’s behaviour as potential IBA agents. For example training may address a practitioner’s ‘capability’, but may not address key issues of ‘opportunity’ (e.g when is ‘identification’ actually going to be feasible) or ‘motivation’ (perhaps recognition of doing IBA or personal satisfaction).behaviour change wheel

Other questions addressed in the research include important questions such as whether in fact IBA should be pursued in various non-health settings. A ‘health in all polices’ approach may be sound, and other added benefits such as possible impact on important indicators like re-offending rates or housing status could also be seen. Yet the evidence base proving the effectiveness of IBA in non-health settings is rather sparse.

Wider brief intervention questions are also relevant. Research efforts are being focused on questions of ‘how’ and ‘who’ does IBA work for. As cited in one of the papers Professor Nick Heather, who has been instrumental in the emergence and development of IBA over 3 decades, summarises this as:

“What kind of brief intervention, delivered in what form, by what kind of professional, is most effective in reducing alcohol consumption and/or problems in what kind of excessive drinker, in what kind of setting and circumstances?”

Given that seeking to secure routine IBA delivery even in health settings includes a range of distinct challenges, any help knowing where else and how IBA will be most effective will be particularly welcome.

See here to access the full suite of publicaitons.

PHE updated ‘IBA tool’ following new guidelines

6 May

The two sided ‘IBA tool’ appears to have been a popular resource amongst roles delivering IBA, so PHE have released an updated version following the recent change to the recommended guidelines.

Indeed it is easy to see why the tool may have been popular as it neatly includes key ‘components’ of FRAMES based brief advice. Having these prompts and visual aids may take pressure off the practitioner to remember the various things that may be useful to discuss, or perhaps better still, use them as prompts for a drinker to identify things relevant to them. For example:population drinkers England

  • ‘Feedback’ – the tool has several sections that may help the drinker understand what their level of risk is and what that means. The ‘risk category’ table gives an indication of what that may look like in terms of units, whilst the population graph (right)is thought helpful to highlight most people actually drink at ‘lower risk’ amounts.
  • ‘Advice’ – practitioners should of course be careful here. Rather than giving direct ‘advice’, generally better to ask “could you think of any benefits if you did decide to cut down?”. The tool suggests some ‘common benefits of cutting down’ which can be useful prompts.
  • ‘Menu’ of options (goals or strategies) – as above, best to ask “would any these strategies listed here be useful if you did decide to cut down?”. Easy to assume what works for you will work for them, but important they ‘own’ their responses as much as possible (Responsibility).

Not forgetting of course ’empathy’ and ‘self-efficacy’ as the final FRAMES elements – not on the tool because these are skills we try and embed throughout brief intervention – and probably at other times we are in contact with people. As such the evidence behind FRAMES as central to IBA is often questioned, but in a general sense it may be considered useful as a guiding framework.

What about the tool itself?

It is of course impossible to build the ‘perfect’ one size fits all tool when people and drinking motivations are so varied and complex. This is why the tool should just be an aid to facilitating person-centred IBA, rather than the focus.

Interestingly, PHE have done away with the old ‘large white wine’ with 3 units on the side. This is  a good move as people frequently commented on the drink’s visual appeal. Indeed a ‘priming’ effect has been found in studies and is one of the reason why ‘responsible drinking messages’ with pictures of alcohol are controversial. Weren’t thinking about wanting a drink? Perhaps you are now you’ve seen one!

It’s replacement though is the new ‘One You’ campaign promoting healthier living in general. I’m not quite sure on how I feel about this yet, although I do agree alcohol brief interventions need to be considered as part of wider health behaviour initiatives.

One thing that could still probably do with updating is the unit examples. ‘This is one unit’ contains some rather dubious examples – when was the last time anyone was served a 125 ml glass of wine at only 9% ABV? Certainly far less often than a 250 ml 14% one, registering at a considerable 3.5 units.

However these finer points may not be that important when considering the likely impact. We know ‘identification’ and ‘feedback’ are most likely to be the critical ‘active’ elements of IBA, complimented by conversations that feel helpful and supportive to the drinker. Such resources are probably more important for nudging and helping practitioners to start these valuable conversations.

Should we be training everyone everywhere in IBA?

29 Apr

DARCThere are a few places left for an upcoming event exploring whether IBA training should offered en masse, which poses some interesting questions. Flyer here [pdf].

The event, hosted by Middlesex University’s Drug and Alcohol Research Centre (DARC), follows several projects exploring the role of IBA in non-health settings.

The research has found many of same challenges focussed around beliefs and attitudes of non-health staff having alcohol conversations, and of course that training alone doesn’t neccessarily result in routine delivery. Crucially, organisations need to buy in to it so that practitioners are supported and recognised for helping people look at their alcohol use, even if its not in their job description.

There are also many other aspects to consider, not least that people who attend IBA training are given a chance to contemplate their own drinking, or develop skills that may be beneficial in other ways – for example to talk about other health behaviours or things that may need an empathetic approach.

I’ll be on the panel to discuss some of these points and while I won’t be pretending that training is all we need, I will most likely highlight that without it, good quality IBA is unlikely to happen anywhere. And whilst wider alcohol policy is arguably rather weak, IBA is something we shouldn’t give up on.

New drinking guidelines – IBA implications?

7 Mar

0005623507Y-1440x1920Earlier this year the new adult weekly recommended drinking guidelines sparked a bit of a media frenzy. On the plus side, this raised awareness (in the short term at least), and perhaps got some people talking about them. On the other hand, awareness of the guidelines alone doesn’t tend to lead to behaviour change. Much of the media also pandered to the distraction of the ‘nanny state’, arguably failing to recognise the basic principle of a ‘guideline’ to support informed decision making – one of the reasons why it should not be described as a ‘limit’.

Yet to be answered though is what the implications are for alcohol interventions and other policy areas. Obviously most recent alcohol literature (and alcoholic drinks packaging) will now be ‘outdated’ if displaying the old daily guidelines – although you can find an updated tool here [ppt]. Certainly there will be further work underway about how we calculate and define ‘at risk’ drinkers, but overall we must not get too caught up in trying to pin point exact ‘cut-offs’.

As such the important point is that alcohol misuse is a spectrum, and people are often unknowingly changing their consumption and the actual or potential effects on their health and wellbeing. IBA is about helping people understand where they sit and helping facilitate change where relevant.

So whether we use the alcohol guidelines as a general indicator of our risk level, or something more sophistaced like the AUDIT, it is important not to get too literal about things. A person drinking near 14 units a week (or say a person scoring AUDIT 7 or less) should not consider themselves to be risk free, just as a person drinking 15 units (or scoring AUDIT 8+) should not assume they will certainly suffer alcohol problems. The basic principle of the dose effect applies – the more of a drug one consumes, or the more frequently, the greater the risks – generally speaking.

So in practice, a little common sense applies. When we offer ‘brief advice’ to people, we automatically take into account a wide range of factors – what the person is there for, how motivated they are, how much time we have etc. etc. A change in the guidelines may be just another ‘common sense’ consideration to take into account. For instance we might inform or ask people if they knew that the guidelines have recently reduced a bit, and although any level of drinking carries some risk, sticking to them means a person is unlikely to develop serious negative effects in the long run. running

Drinking is of course just one of many ‘health behaviours’. If someone is getting overly focused on debating specific cut-offs, it could be worth pointing out the many other factors that will influence their likely health outcomes; especially those that they may be able to change.

‘IBA direct’ evaluation shows people welcome IBA in public

21 Dec

An evaluation has shown that taking ‘IBA direct’ to people on the streets of South London was found to be highly effective in engaging people and delivering brief intervention.

The project, branded ‘The London Challenge: are you healthier than your mates?’, took place over three days in August and tested a number of methods to engage passersby and deliver IBA.

Resonant, a specialist behaviour change agency, had been commissioned by NHS Lambeth to deliver the activity in a way which would engage at-risk drinkers in their 20’s as an identified target group. Within the borough, this age range were found to be less likely to access services where they might receive IBA, but many were found to be drinking at risky levels.

As part of the ‘The London Challenge’, four ‘brand ambassadors’ were trained to engage passersby and offer IBA. Free ‘mocktails’ were offered as an incentive to ‘hook’ the public into completing the AUDIT.

Resonant developed the approach based on research and ‘co-creation’ with the target group who identified that answering alcohol questions and receiving ‘brief advice’ was acceptable as long as it was engaging and non-judgemental.

The evaluation was independently conducted by the South London Health Innovation Network (HIN) Alcohol team.

Rod Watson, Senior Project Manager (Alcohol) for the Health Innovation Network highlights some key observations on the evaluation findings:

  • The service evaluation found IBA Direct is feasible and acceptable at being delivered in a public setting by non-health professionals.
  • Over the course of the three days of the project, 402 people received IBA.
  • The brand ambassadors engaged people with professionalism and their approach was central to the large number of people taking part.
  • A small follow up sample of the 402 people who received IBA direct showed a reduction in AUDIT scores six weeks following the intervention. (Note: caution should be exercised here as no control group was used).
  • A participant feedback form was completed by 61 people. Participants rated both the ‘London Challenge’ and the service they received from a brand ambassador highly.
  • All respondents found the setting to be suitable and 90% stated they would take part in this service in a public setting again. There was nothing reported back that indicated any concerns from people about the public setting of the project.

As such the project shows significant potential for delivering IBA ‘direct’ to people in public spaces. Given the challenges facing IBA in other settings, this approach could offer a promising channel to reach new groups of at-risk drinkers.

The full report can be downloaded here:

‘The London Challenge: are you healthier than your mates?’ Service Evaluation of Alcohol Identification and Brief Advice Direct to the Public [pdf]

To find out more about IBA direct please get in touch.