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Briefing on IBA & LGBT people – a key group to ‘target’?

9 Oct

LGBT IBAA short briefing highlights the potential for IBA to reduce alcohol related harm amongst lesbian, gay, bisexual and transgender (LGB&T) people. It describes LGBT groups as a ‘high-risk group’ for alcohol misuse given research that shows higher prevalence.

The briefing provides a short background of IBA as a short alcohol intervention, and considerations for ensuring IBA can reach LGBT people. For those already seeking IBA implementation, it may highlight another setting or area to consider engaging front line roles with training and support, or opportunity to build IBA into service commissioning.

Of course the debate about which wider settings should IBA be sought in goes on, and the challenges may not be wholly different from many other settings where IBA is sought. At the same time, it urges all staff delivering IBA to ‘ensure their approach is culturally sensitive and LGB & T-inclusive’, given discrimination that LGB&T service users often report when using mainstream services.

The briefing though may be of most use in encouraging LGBT specific services to incorporate IBA as something to potentially benefit their service users. As the briefing advises, ‘IBAs can readily be incorporated into initial screening and triage for new service users; into case or care plan reviews with existing service users; or into outreach interventions in LGBT social settings.’

Of course any practitioner delivering IBA should show key skills that both underpin brief intervention and non-judgmental person-centred approaches relevant for ensuring people of any sexual orientation feel well treated . The reality though is that more training, support and resources are needed for quality IBA to be adopted more widely. And with LGBT people likely to make up between 1.5 – 7% of the adult population, as a ‘high risk’ group for alohol misuse it makes sense to support LGBT services specifically in IBA delivery.

 

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Can we quit “binge drinking”?

19 Nov

pg-08-alcohol-Rex_235373s ‘Binge drinking’ is probably the defining alcohol term of the last few decades. Hype over alcopops, dramatic media headlines and the variety of ‘binge Britain’ based low budget TV shows are testament to its enduring popularity. As such, people often frame their ideas of problem drinking around ‘binge drinking’ (and of course ‘alcoholics’). Both potentially problematic terms.

In terms of where  people ‘fit’ with regard to their alcohol use then, it’s important to recognise the alcohol use/misuse spectrum. That is that drinking ‘categories’ are fluid, and so individuals don’t fit or stick neatly into boxes. People, their circumstances and their consumption are often in various states of change, and labelling or subjective terms carry many risks.

Most adults are ‘low risk’ drinkers, but at certain times of the year their drinking might go up. Generally though they will re-set their consumption of their own accord, or when an occasion (such as Christmas) has passed. The same can even be said for dependency in some ways – most people who do experience some level of dependency recover on their own, usually without any formal support or treatment.alcohol & language

So where do ‘binge drinkers’ fit in all this? And can it ever be a useful term?

Taking the technical definition of drinking twice the daily guideline or more in one go, ‘binge drinkers’ can actually ‘fit’ into any of the main drinking ‘risk’ groups – depending on frequency. Someone who ‘binge drinks’ once a year on their birthday but generally keeps within the guidelines will be a ‘low risk’ drinker overall. But someone who ‘binges’ regularly, most days of the week, will probably be showing at least some signs of dependency.

‘Binge drinking’ overlooks one crucial risk factor: frequency

Of course the media obsession with ‘binge drinking’ means that it’s so commonly used to describe drinking patterns, but as highlighted, frequency of drinking can be just as relevant as the amount consumed on a given occasion. People tend to recognise the role of alcohol free days for ‘giving the body a break’, but for many people it may be reducing the risk of dependency that is more relevant. In fact my own experience of increasingly frequent ‘binge drinking’ resulted in increasing tolerance and other symptoms of dependency.

At the time though I was actually quite proud to be a ‘binge drinker’ in some ways – drinking was part of my identify. I saw alcohol largely as positive, and I gave little consideration to the damage it might have been doing – until I actually did develop related health problems. These problems actually triggered contemplation, and eventually I went a long period without drinking at all. The main benefit of IBA though may be to trigger contemplation before problems or dependency develop.

Binge drinking will continue to be used, and perhaps more accurately to describe ‘drinking to get drunk’, rather than a fixed amount. But like with the term ‘alcoholic’, we should seek to avoid describing individuals as such, unless they choose that term themselves. Using a validated assessment tool like the AUDIT gives us a more useful way to identify what risk someone’s drinking they may pose, so may help us quit “binge drinking”.

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Should we ease off GPs not doing alcohol IBA (properly)?

27 Aug

IBAPrimary Care is the key setting for alcohol brief intervention or ‘IBA’. Most the evidence base revolves around delivery in Primary Care settings and in England ‘DES’ payments are made for new registrations screened (and then in theory offered brief intervention when appropriate). IBA is also is part of the NHS health checks being offered to all 40-74 year olds. But..

“Alcohol, OK, so you drink 20 drinks per week on average?” “Yes”. “Right, OK that’s around 20 units per week, which is within the government guidelines of 21 for men”

Whoops. That was from a Practice Nurse when I joined a new surgery not that long ago. Sadly, anecdotal reports of poor or simply incorrect IBA practices are not unusual from those who know what it should look like. But we have nothing else to go on other than ‘activity’ data to get a picture of what’s really going on.

In one local area, working with commissioners we attempted to get local practices to complete a short survey on their IBA delivery – about 8% responded. A subsequent proposal for a collaborative ‘mystery shopping’ approach, based on a successful pilot in sexual health settings, was rejected by the local medical committee – most members (yes some were GPs) didn’t support it. No alternative suggestions were offered though.

Not surprisingly, there can be a sense of despondency amongst those trying to raise the standard of Primary Care IBA. Is there any point in organising good IBA training, resources and pathways if there’s no interest in taking them up? If we can’t get it right in Primary Care, is there hope for any other settings?

Or perhaps there is more chance for IBA in other settings? The news is full of stories about General Practice in crisis. More doctors needed, less being spent, more demand and an ageing population – I’m not going to argue Primary Care isn’t under a lot of pressure. But we can and must expect more in terms of understanding and improving IBA delivery if we are paying for it.

It’s not just my own anecdotal experiences that suggest real world ‘IBA’ isn’t true to nature. Key researchers have called for more work here, and a recent Primary Care review stated: “On videotaped or observed interviews, alcohol-related discussions were often superficial and yielded little information regarding patients’ drinking practices.”

“Well, I don’t know what these [AUDIT] scores mean”  – just another of the comments I’ve heard first hand from a GP! Of course some are doing it well, but I’ve little doubt these are a minority.

One crucial point though, its not really GPs we are talking about here as the key Primary Care IBA role, rather than Practice Nurses or Health Care Assistants. These are the people doing most new registrations and health checks. So when we talk about the issue of IBA in Primary Care, it isn’t really about GPs finding an extra 5 minutes in an already tight window, its about something that is supposed to be planned into other contacts.

Of course if someone is talking to their GP about a commonly alcohol linked issue – high blood pressure, depression, tiredness to name but a few – then IBA should be certainly be offered by the GP. But the real issue is the thousands of Practice Nurse or HCA contacts every day where the IBA box might be ticked on the system, but the actual intervention could be anything – and we’ve no way to tell. Or do we?

Holding practices to account?Primary Care IBA - good enough?

The DES (Direct Enhance Service) alcohol contract has been criticised for not being robust enough by offering payment for screening only, following which brief advice ‘should’ be offered to at-risk drinkers. Perhaps saying ‘at-risk’ drinkers ‘should’ be offered brief intervention isn’t legally binding, but what about a basic duty of care? Furthermore, the current DES contract is clear that local ‘area team’ commissioners can and should hold practices to account:

Area teams are responsible for post payment verification. This may include auditing claims of practices to ensure that not only the initial screening was conducted but that the full protocol described in the enhanced service was followed i.e. that those individuals who screened positive on the initial screening tool were then administered the remaining questions of AUDIT and that a full AUDIT score was determined and that appropriate action followed, such as the delivery of brief advice, lifestyle counselling or where needed, referral to specialist services or assessment/screening for anxiety and/or depression

Where required, practices must make available to area teams any information they require and that the practice can reasonably be expected to obtain, in order to establish whether or not the practice has fulfilled its obligation under the ES arrangements.

So the current DES is clear. Doing AUDIT-C only and giving a leaflet to all risky drinkers isn’t in line with the contract. And commissioners have the right to ask practices to prove they are doing it properly. I’m well aware that good care and interventions mean less form filling and more time with the patient. But until the picture coming through is one of a better overall standard for IBA, practices should be required to demonstrate IBA is a person-centred intervention, not an opportunity to trigger a quick payment.

How ‘opportunisitic’ can IBA be – a step too far?

30 Jul

One of the key characteristics of IBA, and brief intervention in general, is that it is ‘opportunistic’. IBA is delivered by someone who makes use of a chance to ask about alcohol use when the patient or contact is not seeking help or advice around their alcohol. IBA is truly a brief intervention – an opportunity to initiate a risky drinker to think about their alcohol use when they would not have otherwise done so.

But after recently doing IBA with, wait for it… a stranger on a train, I was left asking myself “have I taken this too far?”. Of course they weren’t a complete stranger when I asked them if they wanted to look at their own alcohol use. It came about after I’d got chatting with them (during a long delay) and told them about what I’d been doing (IBA training) and why. Interestingly they agreed, scored as drinking at a risky level and were willing to discuss some of the good and not so good things about their drinking. Along with some light-hearted chat and joking – understandable given the situation – they identified some benefits to cutting down. I closed it by handing over a leaflet with more information on ways to cut down, and we moved back to the more usual topics of light conversation had amongst relative strangers.

So, how do I feel about what happened? We know IBA works very well in Primary Care settings. We are learning more about its role in A&E settings, Criminal Justice environments and other health or community based settings. But how far outside of these ‘common sense’ settings should we go? At an individual level, asides from a lack of evidence, should there be any limits to who and where we can offer to do IBA? A recent post suggested we can use an ethical framework to assess how far we can extend IBA, rather than focusing on research to prove it will work. I think this makes good sense and I believe if IBA can be done, the setting may be less important that the individual’s consent and the IBA delivery skills.

I’ve always suggested that IBA should ideally be in a confidential environment. But if someone is comfortable to discuss their alcohol use in more public places then why should we neglect them of the opportunity to make a more informed decision about their drinking? Of course I’m not suggesting we all try IBA with every person you get chatting to on a train, but there are some real opportunities to do IBA in ‘creative settings’. I personally enjoy doing IBA and seeing people contemplate their alcohol use, and I feel as long as I do no harm and never push someone, we can be as opportunistic as we like!

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Who needs IBA?

16 Apr

Recognising the ‘right’ group of patients or service users for delivering identification and brief advice is one of the first hurdles to be overcome by non-specialists getting to grips with delivery.  Most IBA guidance, based on reasonable evidence, suggests that those who might benefit from brief advice are drinking at increasing or higher risk levels.  We spend quite a bit of time on training talking about how you can identify these people using screening questions, and crucially, how you can’t identify them by looking, guessing or assuming!

So why is it then that when we follow-up participants some months after training courses, some still report that they have not delivered IBA because ‘my clients don’t need it’?  Some say that all their clients are drinking too much to benefit from IBA; others that their service users do not drink enough to need help, but these conclusions are not necessarily based on screening.  Why?

Well, I have a few theories…firstly I think it is worth acknowledging that this could just be an excuse, perhaps training participants just feel bad if they haven’t delivered and so they want to give us a good reason why.

Or perhaps it is true – though it seems unlikely that practitioners working with the general public, have not come across anyone at all who is drinking more than the recommended limits, but not in a dependent way!

I think the former is more likely, but it is not as simple as them making it up to satisfy us.  I think they are rationalising to themselves as well as us, why they haven’t delivered.  And I think (among other reasons) it comes down to the fact that in order to truly recognise the target groups for IBA, we need to recognise that included in the target group are folk, well, just like us.  Or if not us, like folk we know and like.  Not a stereotype ‘heavy drinker’, never mind ‘alcoholic’.  And that might mean recognising that we, or our family or friends, have a choice to make too…enjoy our drink and accept the risks, or cut the drink and cut the risk…

Delivering IBA is just about giving everybody that information, and that choice.

How did IBA fare in the new national alcohol strategy?

12 Apr

IBA was not mentioned at all in the Drug Strategy 2010 and the focus was very much on “severe alcohol dependence” (3) and recovery.  So I have been waiting with bated breath to see what the alcohol strategy would bring.  Well IBA definitely fares better in the new alcohol strategy than treatment.  The new alcohol strategy makes some positive comments about the evidence base for IBA, encouraging local areas to implement IBA locally.  Reference is made specifically to learning lessons from SIPS; IBA delivered by Alcohol Liaison Nurses in hospital settings, particularly for pregnant women; and alcohol intervention pathways for offenders.  The most concrete gain for IBA in the UK is the introduction of alcohol into the NHS Health Checks which will extend primary care provision beyond new registrations.  The planned social marketing activity focused on young people will also improve prevention work nationally.

Two concerns (I’m sure there are more …):

  • Terminology: Cameron’s foreword reads like a modernised Hogarthian vision of a “Broken Britain” and the language throughout is not much better.  Why are we still talking about the “drunks” “drunken” “the drunks” in punitive terms?  Where is the language of Lower, Increasing and Higher Risk?  One of the major barriers to people accessing support for alcohol is terminology and stigma: how productive is Cameron’s language?
  • NHS Health Checks: Will local areas invest in IBA training for NHS Health Check practices AND clear local pathways into support?  As we know screening, Brief Advice and the pathways from alcohol Direct Enhanced Service (DES) screening are poor or patchy, we need to act now to ensure that this major improvement isn’t scuppered by poor delivery.

So that’s my first ever blog post done!   Hope it makes sense!

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Why an IBA blog?

9 Apr

I have thought long and hard about whether to do this blog. My main reservation was that it may be duplicating existing web resources, but overall I think there is room for a blog that highlights new ideas and relevant updates. I hope this blog will attract a range of contributions and prove of value as a simple space largely aimed to support those delivering IBA.

Another decision I wrestled with was whether to use ‘Identification and Brief Advice’ (IBA) or Screening and Brief Interventions (SBI) terminology. Actually, I lean towards SBI for a number of reasons, namely its used by NICE and has a longer history. However in my experience, it seems IBA now has a wider recognition outside the research field. The Department of Health coined IBA, along with the ‘risk’ terminology and so I wanted to keep the language as consistent as possible for the target audience of this blog.

In defence of IBA, I would also back this as applying to the simpler form or simple ‘brief advice’, not lasting much more than 5 minutes at the most. ‘Brief intervention’ however covers a wider range of approaches including longer lifestyle counselling or ‘brief motivational interviewing’ approaches. Following the release of the recent SIPS trial findings, we know that overall shorter approaches are in most cases as effective as longer interventions. For this reason, emphasising IBA as a short but effective brief intervention approach seems pragmatic to me.

See here for a paper on ‘Clarifying brief interventions’ or here for further links.

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