Primary Care brief interventions ‘cost effective’: a future priority?

21 Sep

iba-gpThis post originally appeared on Alcohol Policy UK

A new study has reported the levels of alcohol brief intervention in Primary Care are ‘extremely low’ in England and investment through training and incentives would be cost-effective. The study therefore raises questions over what has happened with efforts to implement brief interventions in Primary Care and whether they will be considered as part of the forthcoming national alcohol strategy.

In England, brief interventions became widely known as ‘Identification and Brief Advice’ (IBA) following national efforts to support their implementation including the ‘Direct Enhanced Service’ (DES) in 2008. The DES allowed GP practices to claim a payment for each new patient screened using a validated initial ‘identification’ tool such as the FAST or AUDIT-C, though raised questions over to what extent it resulted in geunine interventions. In 2015 the DES came to an end but was integrated into the main GP contract and it was claimed monitoring would continue, though no findings have been shared by PHE as yet. Meanwhile IBA was also included as part of the ‘NHS Health Checks’ programme offered to all adults aged 40-74 and is now part of a national CQUIN to incentivise IBA in hospitals.

The new research though suggests that investing in training and incentive payments would be cost-effective at raising delivery rates of Primary Care IBA, where the evidence for its delivery is strongest, and thus deliver sufficient health returns to justify the investment. In 2016 research indicated less than 7% of risky drinkers reported receiving advice from their GP compared to 50% of smokers, despite 95% of people reportedly being comfortable to discuss their alcohol use. Last year two reports highlighted similar concerns over missed opportunities for further Primary Care activity in Scotland.Prevention

Implementation issues… and innovative responses?

In 2015 a report had called for action to bolster IBA delivery including a national training centre and attention to properly assessing what was happening ‘on the ground’. The report argued that the IBA agenda was at a ‘turning point’ and without further efforts to embed IBA, longer term implementation would fail. Whilst the picture of the extent and nature of IBA delivery in Primary Care remains hard to assess, gauging the level of training amongst Primary Care roles also largely comes down to guesswork. No formal training requirements have existed, though various local training programmes have been employed alongside the option of IBA e-learning.

Cuts to public health budgets have no doubt hampered the potential for local training provision in more recent years, yet a range of IBA projects had been developed across other settings. In Scotland, a national target reportedly delivered around half a million alcohol brief interventions (‘ABIs’) in conjunction with a national training programme, whilst investment in the Welsh programme had seen a popular ‘Have a Word’ identity. In England, several areas adopted ‘IBA Direct’ projects as a street based engagement approach whilst an IBA commissioning toolkit was also promoted. Efforts to implement IBA within the Army have also been seen alongside calls to train the ‘wider public health workforce’. The rise of online interventions and apps has certainly been notable, with some based specifically on brief intervention principles.

Not to forget Primary Care?

Depsite the wide range of projects and settings, researchers may continue to point to the long-running question of where brief interventions can work and under what circumstances. Indeed previous research on IBA in non-health settings was unable to determine the likely effectiveness, and therefore some may argue Primary Care delivery, including by nurses, should remain the focus for any investment. The new study may certainly add weight to that argument and to calls that cuts to public health initiatives are a false economy. Whether brief intervention approaches will feature in forthcoming national alcohol strategies remains to be seen, but many will feel they still have an important role to play as part of the ‘intervention mix’ needed to reduce alcohol misuse and harms.

‘Health Matters’: PHE resources on brief intervention CQUIN

23 Oct

This post originally appeared on Alcohol Policy UK.

Public Health England (PHE) have released a new ‘Health Matters: preventing ill health from alcohol and tobacco use’ resource calling on practitioners and commissioners to ‘play their part’ in reducing alcohol harms through Identification and Brief Advice. A case study of an IBA CQUIN in mental health settings in South London also provides insight into local implementation efforts.

In 2016 it was announced mental health and hospital trusts in England would be incentivised to deliver brief interventions for alcohol and smoking as part of the NHS Commissioning for Quality and Innovation (CQUINs). PHE says CQUIN No.9 Preventing Ill Health by Risky Behaviours is ‘an important opportunity to improve patient health across England’ via the opportunity to ‘identify and support inpatients who are increasing or higher risk drinkers and to identify and support inpatients who smoke, and importantly to embed these interventions into routine care for patients.’

PHE have included a set of infographics which demonstrate the case for implementing alcohol IBA including a potential Return on Investment (ROI) of £27 per patient over four years. PHE say if ‘implemented well the CQUIN has the potential to reduce future hospital admissions and reduce the risk of a number of chronic conditions such as heart disease and, stroke and cancer’, but ‘for it to be effective we need all health professionals, commissioners and local authorities to play their part.’

Many local areas will have already been seeking to implement IBA across a range of settings, either via previous locally commissioned CQUINs or other service provider agreements, or perhaps optimistically by simply training staff roles or dissminating ‘scratch-cards’. Other areas may have focused on the embedding digital interventions, IBA across other settings or novel approaches such as IBA direct.


Efficacy Vs Effectiveness?

IBA has been a central component of alcohol prevention strategies in the UK and in other countries, but whilst there may be good evidence from research trials, the extent of effective routine implementation remains questionable. As such, debates over whether the benefits of brief interventions seen in research trials can be translated to busy front-line settings continue. Indeed such questions may be complicated by the difficulties in researching complex behavioural effects across different settings and population groups, and studies that have had more mixed implications such as SIPS.

Certainly then PHE’s recognition of the need to see such a scheme as ‘well implemented’ in order to see the desired effects seems well warranted. Questions over the actual delivery of ‘brief advice’ conversations beyond simply numbers of people screened or given a leaflet are not possible to answer. Indications from patient studies suggest very few risky drinkers recieve brief advice from their GP practices compared to smokers, despite a national requirement for practices to deliver IBA to new registrations or via health checks. As such calls have been made to do more to consider measures of implementation beyond reported numbers including a ‘national centre’ of IBA, similar to the NCSCT which exists for smoking.

Meanwhile PHE and others have continued to produce resources and toolkits for implementing alcohol strategies which may be seen as important in sustaining local efforts to deliver preventative alcohol interventions, whilst some areas have focussed on ‘Making Every Contact Count’ (MECC) approaches. For others the crucial question may be how achievable ambitions to deliver non-urgent preventive interventions are if pressures on front line services continue to mount.

Armed forces deploy brief interventions: will it work?

25 Aug

This post originally appeared on Alcohol Policy UK. Ministry of Defence (MoD) have released figures on an initiative to deliver alcohol brief interventions across the armed forces via dental check ups, identifying 61% of military personnel drinking at a risky or harmful levels.

The MoD has previously come under fire over a lack of action to address high levels of alcohol misuse amongst the armed forces. In 2015 Professor Neil Greenberg, lead on military health at the Royal College of Psychiatrists and a former Navy Commander, said an approach based education alone was not effective. Subsequently an MoD alcohol working group was instigated to “review policy and data to identify what more we can do to tackle alcohol misuse in the armed forces”.

Alcohol brief interventions (ABI), often referred to as Identification and Brief Advice (IBA) in England, have been increasingly sought as a strategy to promote behaviour change amongst at-risk drinkers, as advised by NICE and national health bodies. Much debate has been had though over how and where they should be delivered, with question marks over to what extent various national and local efforts may have been successful.

The MoD report highlights Armed Forces personnel are expected to attend a dental inspection between every 6 to 24 months, therefore presenting an opportunity to deliver ABI to the whole workforce. The initiative used AUDIT-C, a 3 item assessment tool utilising the first three questions of the full AUDIT. Scores of 5 or above on the AUDIT-C indicate a level of risk and/or harm, though it is considered less effective at distinguishing different levels of risk or probable dependence in comparison with the full AUDIT.

The MoD sought to offer all personnel with a score of 1+ (any level of drinking) an alcohol advice leaflet, reporting 80% (n = 80,662) as receiving one. Of the 61% personnel who scored 5-12 on the AUDIT-C, 63% (n = 42,074) were given an ‘Alcohol Brief Intervention’ (ABI), though the report states it is ‘not currently possible to measure how many of these ABIs have been delivered’. Indeed a key question for all ABI initiatives has been to what extent the reported interventions have been delivered, particularly in view of time time limitations and other issues such as a lack of training.

For those scoring 10-12 on the AUDIT-C, a total of 2% (n = 2,502), the MOD states personnel should have also been ‘advised on the importance of seeking further advice from their GP or a local alcohol support service’ in addition to the ABI. Overall, higher alcohol risk levels were associated with being young and single, being of more junior rank and being of white ethnicity, with navy personnel indicating the highest AUDIT-C scores. MoD ABI fig

Will dental ABIs reduce alcohol misuse in the military?

The report states the MoD is undertaking other initiatives to reduce alcohol misuse, including ABI beyond its dental settings. Measuring the specific impacts of such schemes is notably difficult, though having such data on the levels of alcohol misuse may prove useful data for any future evaluation. However as with wider debates over approaches to reduce alcohol misuse, researchers tend to highlight the need for ‘multi-component’ programmes and supply side controls rather than relying on single initiatives to have a sustained impact.

The MoD’s alcohol working group is likely to face many specific challenges in shifting what MPs have described as a heavy drinking culture within the armed forces. The availability of subsidised alcohol, attitudes and expectations of personnel towards alcohol and the many other complex factors influencing health and wellbeing are all likely to play important roles in seeking such changes. Observers may see a committent to ABIs as welcome, but will hope that they are not relied upon as the sole strategy for addressing alcohol misuse in the military services.

See the MoD report here, or a 2013 letter in The BMJ’s Journal of the Royal Army Medical Corps and a 2011 report on ‘Alcohol use and misuse within the military: A review’ [pdf].

Brief intervention reports highlight role of GPs but delivery still questionable

10 Aug

This post originally appeared on Alcohol Policy UK.

ABI reports SHAAPTwo new reports on alcohol brief interventions (ABIs) in Scotland have been released, highlighting the importance of GP settings and key factors influencing delivery.

The reports, published by Scottish Health Action on Alcohol Problems (SHAAP), are:

The delivery of ABI in Scotland, or ‘Identification and Brief Advice’ (IBA) as often known in England, has been a central component of national alcohol strategy across the UK, though debates over the quality and extent of implementation have been ongoing.The report on the practice and attitudes of General Practitioners is based on interviews across Scotland, which identified facilitators for the effective delivery of ABIs as falling into two key categories; systemic factors and patient-centred factors. These included key issues such as sufficient time, training and effective IT systems. Barriers were also identifiable in terms of structural and individual level issues, with the availability of cheap alcohol and normalisation of heavy drinking perceived as significant issues.

ABI report GP attitudes

The report on financial incentives reviewed available literature, examined a number of local systems and interviewed stakeholders. Available evidence indicated a limited and mixed picture, but with some indication of potential for incentives to encourage activity. Exploring local systems also presented a diverse picture and a lack of evidence to account for variations found. Stakeholders too presented contrasting views on the role of incentives, including in relation to the truth behind common concerns such as ‘gaming’ systems to generate income rather than ensuring quality intervention delivery. The report identifies a significant evidence gap remains despite the the ambition of Scotland’s ABI programme.

Professor Aisha Holloway, University of Edinburgh, said:

“Delivering Alcohol Brief Interventions (ABIs) is not just about the operational mechanisms associated with the national ABI programme i.e. funding, training and IT systems. It is also about GPs having the time to provide person-centred care to understand the complexities of external social and personal issues that people are facing that can trigger harmful/hazardous consumption.”

Dr Niamh Fitzgerald, Institute for Social Marketing, University of Stirling said:

“Whilst Scotland’s national programme of Alcohol Brief Interventions is amongst the most extensive of any country, it has contributed little in terms of research on how best to incentivise practitioners to talk to patients about alcohol. As Scotland rolls out its new national strategy, there is also an opportunity for Scotland to lead not only in terms of practice, but in developing globally innovative research on how to optimise such conversations to benefit patients.”

England and Wales – IBA CQUINs & ‘Have a Word’

Whilst attention of late has focused on Scotland’s battle for minimum unit pricing (MUP) – for which a final verdict is anticipated this year – the refresh of Scotland’s national alcohol strategy is likely to include further commitments to brief intervention delivery. SHAAP and the report’s authors will be hoping it includes attention to the issues and questions raised by the reports.

Meanwhile in England, no information has yet been released on the impact of the termination of the specific ‘DES’ incentive scheme in 2015 has had, if any. GP practices are still required to offer all new patients brief intervention under the general contract, though similarly key concerns have revolved around to what extent more than recording of screening results has been happening. Public Health England (PHE) have released a range of ‘Have a Word’ resources, originating from the Welsh national brief intervention programme.

Beyond Primary Care settings, efforts to incentivise IBA across hospitals and mental health trusts across the country should be underway as part of the NHS Commissioning for Quality and Innovation (CQUINs) payments framework from 2017-2019. The CQUIN separates alcohol IBA delivery into two equally weighted metrics – firstly screening using a validated tool, and secondly the delivery of alcohol ‘brief advice or referral’, with appropriate data collection for each.

In other settings, debates about whether brief intervention can be justified or have any significant effects have not stopped local implementation efforts. Various studies have also looked at a range of questions over IBA in non-healths settings, including the role of training.

PHE, NICE and other organisations have also encouraged local areas to seek IBA delivery across a range of settings. Last year an ‘IBA commissioning toolkit’ was released, encouraging systematic approaches and highlighting other case studies. Many in the field though will still agree with the authors of the SHAAP reports – important questions still remain over the ‘what, where, and how’ for effective IBA, as well as the very real challenges in implementing it.

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.