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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.

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IBA Primary Care case study: a rare new example

29 Jul

preventionIn 2011 a ground-breaking document (in the IBA world at least) was released by a brilliant local service in Haringey. The document was a step-by-step guide to implementing the DES incentive scheme for IBA for new registrations in Primary Care. However what was arguably most impressive was the work revealing the local ‘DES picture’, which was not pretty reading.

The review found, to give just a few examples, that 75% of practices were using incorrect screening questions, and that only 50% of practices were offering face-to-face Brief Advice to identified risky drinkers. However such issues are likely to be commonplace if anecdotal reports and mystery shopping are anything to go by. The Haringey work though subsequently enabled action to significantly improve local IBA delivery.

So it seems apparent that the DES scheme itself does not result in good quality IBA – much more is needed to make that happen. Not a surprise really, but part of the problem has been a lack of available reports to identify this.  Any new pieces of work evidencing local IBA experiences and action in relation to the DES are therefore to be welcomed.

A new case study – Cruddas Park Practice

I recently came across a valuable piece of work in the North East – a report from a pilot [pdf] which aimed to assess the practicality of implementing IBA into a busy GP practice. Again, this seemed to be the result of prior some work looking at the local picture. A survey of GPs carried out by Balance found that GPs were typically only addressing alcohol in response to clinical indicators, rather than routinely as IBA is intended. Time pressures and competing priorities were the recurring reasons offered for this.

The report provides a valuable insight into a local effort to properly implement IBA and supporting pathways into a busy GP practice. It looks at the compelling local need, and evidence base, but most of all, it gives a real insight into how perceptions and practice in relation to IBA can be changed by a relatively simple project.

Some of the best insights from the report related to the feedback from the staff who delivered IBA. It is always heartening to hear a busy practitioner relay a real life positive attitude to IBA, like this example:

“One guy had a health check and his cholesterol was up, he was drinking most days, now he has cut out drinking through the week. I told him his attitude was great. He had never thought about it until he came to the GP, he is sleeping better, he feels better. He thanked me and it made me feel good.”

Of course the reality is its not straightforward. This quote really captures probably the biggest overall challenge to IBA:

“Sometimes the timing is an issue, for people who screen mid way it’s not too bad, but if people score high you need to spend more time with them. It takes a double appointment – about 20 minutes. Or I add it into an annual check it takes an extra five minutes. It’s hard to judge how long it will take until you ask the questions. You definitely need longer – especially if they need to discuss the issues more, you don’t want to hurry people if they are listening.”

There is one issue I feel I should point out with the report itself. It suggested higher risk drinkers (16-19 AUDIT scores) were offered referral for advice or extended brief interventions as the main output, rather than offering ‘brief advice’ as a starting point and only then offering referral if needed or sought. The evidence doesn’t suggest EBI is superior to IBA for higher risk drinkers in most cases – see Clarifying Brief Interventions for more.

However the report is still a highly valuable and rare example of the type of attention that’s needed to convert patchy or inadequate IBA to a standard that really makes a difference. Good, simple IBA isn’t that hard after all.. is it?

Talking or Testing? Which is easier?

4 Sep

I recently read a brilliant insight from Dr. Richard Saitz on the INEBRIA Google Group – he was commenting on a discussion about doctors objecting to IBA delivery on the grounds that it is ‘additional work’.  His insight was:

“BUT I have never heard a physician object to doing an electrocardiogram or checking a blood pressure or listening to a heart or ordering a mammogram…So…”additional work” must be code for “additional work for a stigmatized problem” or for something about which people have attitudes about….”

As Richard is a doctor himself, this got me thinking about how we need to get into the psyche of doctors if we want them to implement IBA.  That psyche is undoubtedly formed and normed throughout their lives and especially in education and early years of post-graduate training.

It reflects a wider problem I think which is a reluctance to accept a social model of health where a genuine curiosity about someone’s life and health is helpful in diagnosis and treatment (in the broadest sense).  Why the emphasis on the physical?  My experience is that doctors would love to have a (better) biomedical test for over-consumption of alcohol, even though screening tools are very good, non-invasive etc., because they really don’t want to have to talk to people about it…what does that say?

This reluctance, fear, distaste for actually communicating effectively with patients is very pervasive, and GPs who are very caring, lovely and wise still do not seek out people’s own story, their perspective, their ICE (ideas, concerns and expectations) in consultations as well as they could.  Why?  Well there are many reasons.  But our research in the NHS found that they were not taught it, and even if they were, it was not modelled by others so it wasn’t valued/encouraged.  Our system simply does not prioritise it.  My guess is that the reason underpinning that is probably that we don’t have deep enough pockets to prove it helps, or failing that ‘market it’ anyway (as Pharma do).

So a reluctance to communicate effectively in general makes it hard to feel comfortable with an open conversation about alcohol that IBA really entails.

Your thoughts?

IBA ‘mystery shopping’ experiences: the good, the bad and the…

12 Sep

Recently I posted about opportunities to ‘mystery shop’ IBA when signing up to new GP practice. Whilst there are some issues to consider, generally I think this can be a really valuable way to make a difference. As we seem to know IBA is often poorly delivered in Primary Care, so we need to take every opportunity we can to help improve it.

So here is summary of some of my three actual ‘mystery shopping’ experiences, which interestingly ranged from good to bad. And something in-between…

Continue reading

‘Mystery shopping’ for IBA in Primary Care?

14 Aug

Chances are that if you sign up to a new GP practice any time soon you’ll be given the chance to answer some questions about your alcohol use. If you’re reading this, chances are you’ll also probably know more about IBA than the person asking you the questions, or following them up. This presents a unique opportunity to unofficially ‘mystery shop’ and see what’s really happening out there in practice. If it’s bad, coming clean and providing some feedback could make all the difference, as I’ve found out. Continue reading

Is self-completing the AUDIT OK for IBA?

22 May

Potential IBA’ers often ask if they can hand out the AUDIT or other screening tool for people to self-complete. Although better than not doing so, generally its a wasted opportunity if the person is able to go through it with them.

The main issue is what happens after a person has self-completed a screening tool rather than worked through it with a practioner. Where a practitioner has gone through the AUDIT with the drinker, this should flow nicely into ‘feedback’ and ‘brief advice’. The practitioner will probably have gotten a feel for the person’s alcohol use and a sense of whether they might be starting to contemplate their alcohol use.

Going through the AUDIT may be a crucial chance to build rapport with the drinker, and perhaps reassure them that you are adopting a non-judgemental and empathic approach. Other benefits, such as being able to check or clarify units knowledge are also missed by self-completion approaches.

In contrast, handing back a completed AUDIT seems to me a bit like handing in some homework and waiting for the teacher’s verdict. Not exactly in line with motivational principles. Worse still, I know some GP practices have been handing out screening tools for new registrations to self complete, but fail to follow it up with drinkers. This is unacceptable, especially given they are receiving a payment as part of the DES.

One of the key things some of the evidence seems to show is that screening itself appears to be a significant trigger for ‘contemplation’ that leads to change. Feedback and brief advice can capitalise on that process, helping the drinker to weigh up the pros and cons and perhaps identify a plan. Self-completing AUDIT  seems to mean that opportunity may be missed.

Nonetheless, self-completing an AUDIT is still likely to be beneficial when accompanied by feedback and an information leaflet. It’s also the foundation of online brief intervention approaches which are gaining recognition as having a valuable role to play in the overall IBA agenda. So in conclusion, someone self-completing an AUDIT + feedback can be valuable, but talking through it and being ready to guide someone (i.e brief advice) would be an opporutunity that I wouldn’t want to miss.

A breath of fresh air: when GPs do IBA

20 May

Recently I spoke at an alcohol event on the new national alcohol strategy, but I almost struggled to compose myself. It wasn’t nerves though, it was excitement. Speaking before me, a local GP had shown a level of enthusiasm for IBA beyond what I’d seen anywhere else. As an audience member, he was trying to convince me about the need for widespread IBA – I nearly burst into early applause several times!

I don’t want to knock GPs – I’ve had and worked with some excellent ones, but it’s no secret that overall they’re not exactly grabbing the IBA agenda with both hands. Despite overwhelming evidence of IBA effectiveness (especially for Primary Care) and payment incentives, GPs are not routinely delivering IBA. Of course there are many reasons behind it, and in part these need to be addressed through stronger policy, better commissioning arrangements and proper support/training and referral options.

Dr Dadabhoy wasn’t complaining about any of these barriers though. Given the cost of alcohol misuse to society and individuals, and the effectiveness of IBA, there should be no “that’s not my job” excuses. For that I applaud him.

See Dr Dadabhoy’s presentation on alcohol management and IBA in Primary Care here.