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‘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.

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.

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.