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Delivering alcohol IBA in non-health settings?

29 Sep

IBA questionsIn this guest post Dr Fizz Annand takes a quick look at recent research she was involved in exploring alcohol brief intervention as ‘IBA’ in non-health settings.

A team of researchers from the Drug and Alcohol Research Centre based at Middlesex University have completed a literature review as part of a larger research project funded by an Alcohol Research UK grant. A short ‘insight report’ of the research can be found here.

The evidence base for the effectiveness of IBA in health settings particularly primary care and to a smaller extent A&E, is well documented and because of the proven effectiveness in these settings there is a push to extend the delivery of alcohol IBA into other, non-health settings. This is despite there not being anywhere near the same weight of evidence to do so.

Some studies in schools, criminal justice, pharmacies and universities have shown promise in terms of the feasibility of IBA delivery, however in order to deliver, staff in these settings have needed extra support in order to be able to embed it into their everyday practice. Some studies on computerised or web-based versions if IBA show potential with students or people not in touch with services but more evidence is needed.

In most other settings evidence is weak or non-existent. The workplace has been proposed as an obvious context where benefits could be felt by both workers and employers given the impact of alcohol on productivity. Occupational Health teams could provide a structure in which IBA could be delivered as part of wider health screening and support. In order to convince employers of the benefit a business case would have to be demonstrated.

The researchers highlight the potential for financial rewards to operate as incentives to implementation however it is unclear how much the incentives should be.

A number of barriers to implementation were documented in the studies which included:

  • Lack of buy-in from organisations
  • Staff not feeling it’s their job, or that they have sufficient skills
  • Workload pressure
  • Reluctance to engage on part of staff and/or clients and concerns about confidentiality

Whilst IBA training was rolled out in many organisations, this alone did not necessarily result in widespread implementation of IBA. Very little monitoring or evaluation of the implementation was undertaken.

The researchers concluded that there’s good reason to feel optimistic that IBA in non-health settings can be delivered. Thought does however need to be given to how to adapt the implementation to take account of organisational, professional and context- specific issues that hamper implementation and, in particular, the sustainability of initiatives in the long term. Financial incentives may generate interest in delivery, and monitoring/evaluation will allow measurement of implementation, activity and ultimately help to justify the use of resources.

A full version of the report ‘Delivering Alcohol IBA Broadening the base from health to non-health contexts: Review of the literature and scoping’ can be found here.

Follow Fizz on Twitter @FizzAnnand or see here for contacts.

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.

#UKalcohol – Twitter discussion on IBA/brief interventions

30 Jul

A planned Twitter discussion on addressing alcohol harms will take place on Wednesday the 13th August at 8pm (= 20.00 BST = 19.00 GMT = 3pm/15.00 EDT) on the theme of alcohol brief advice and brief interventions.  This follows on from an initial discussion on alcohol-related hospital admissions which you can read here.

Who can take part?

The aim of the #UKalcohol discussions is to identify and discuss key issues facing those working in the alcohol field – either as commissioners, researchers, service providers or policy roles. It is hoped a different ‘theme’ will be addressed each month, reflecting key areas of interest.

#UKalcohol discussion 13th August: alcohol brief advice, brief interventions

The 2nd planned discussion is intended to cover the broad theme of design, delivery, support and monitoring of alcohol brief advice in addressing alcohol-related risks and harm.

The following issues may be used as needed as prompts/themes for discussion:

  1. What is brief advice, what is a brief intervention, does it matter?
  2. How widely should we implement brief advice/interventions on the basis of current evidence?
  3. What is needed to support brief advice/interventions in practice? How do the needs of different settings differ?
  4. How should brief advice/interventions on alcohol fit with attempts to address other lifestyle issues?
  5. What monitoring and evaluation of these interventions is needed and is it feasible?

Partnership

This 2nd discussion is being brought to you by the UK Centre for Tobacco and Alcohol Studies with the support from a range of partners and stakeholders who will be jointly supporting the alcohol Twitter discussion, and may initiate further themed discussions in future.

Next steps

If you are interested in participating in the proposed Twitter discussion either as an individual or on behalf of your organisation simply sign in via Twitter on Wednesday the 13th August at 8pm and use the #UKalcohol. Discussion may be subsequently captured and shared via Storify.  You can also follow @ukctas to see tweets about this in advance.

If you’d like to ask any questions or help with Twitter please do get in touch via niamh.fitzgerald@stir.ac.uk or james@alcoholacademy.net.

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?

Should Drinkaware support IBA?

25 Feb
Whats in your glass kit

Drinkaware’s ‘What’s in your glass?’ kit used in the Berkshire Pharmacy project.

Drinkaware, the industry funded education charity recently held their annual conference and showcased some projects focused on behaviour change. However for several of them I was left wondering ‘where does IBA fit in?’ – a question I think applies more generally to the organisation.

Drinkaware’s activities have come under fire from some groups for not being evidence based, or worse counter productive. Understandable from a policy perspective when ‘educational’ approaches are regarded as among the least effective approaches for reducing alcohol misuse. This is in contrast to IBA, which if delivered well, is probably considered the most effective individual level intervention to affect behaviour change. So why do Drinkaware not recognise it?

On the one hand, it could be argued that IBA as a ‘brief intervention’ is not an educational approach – which Drinkaware cannot extend beyond as a term of their funding. On the other hand, IBA is about supporting informed decision making, so is arguably just a targeted and effective ‘educational approach’. In fact recently Drinkaware included the AUDIT-C on its website which the Chief Exec cited this as one of its recent successes at the conference.

One interesting project claiming to have changed drinking behaviour was something called the ‘What’s in your glass?’ project. Teaming up with Berkshire Public Health,  24,000 ‘What’s in your glass’ kits were distributed by 150 pharmacies across Berkshire. The kits were clearly appealing, well marketed, and … free! The evaluation claimed positive outcomes for people who took the kits, although it used its own questions to assess behaviour change rather than something validated like AUDIT.

But what I couldn’t understand was what should other areas take from this when Pharmacies are increasingly being used as a key opportunity for IBA? I approached the speaker after and she suggested that the kits work well as an engagement tool as staff were often not confident about asking about alcohol. Good point, although shouldn’t we be building Pharmacist’s skills and confidence to ask about alcohol so they realise asking in the right way isn’t a problem? Perhaps there is room for both IBA and ‘engagement tools’, and maybe such tools are even a useful nudge for IBA?

If so, should we welcome such Drinkaware projects that produce resources that might help engage people in alcohol discussion? Although NHS alcohol leaflets can be ordered for free, it does seem as though more access to unit and other resources would support IBA delivery. Or should we be careful of diluting effective IBA with less evidenced ‘educational’ approaches paid for by the industry? Are Pharmacists more likely just to give a ‘What’s in your glass?’ kit to someone and overlook IBA opportunities?

Drinkaware want to build the trust of the health community – perhaps they need to establish an independent working group to decide what Drinkaware’s role is in relation to its projects or resources that may support – or hinder – IBA, and be clear on their position.

Clarifying Brief Interventions: 2013 update – beware ‘IBA lite’?

16 Jan

goodIn 2010 the first Clarifying brief interventions briefing mainly aimed to shed light on the differences between ‘IBA’ as simple brief intervention and EBI as Extended Brief intervention. This was in response to an apparent lack of clarity between the two approaches, and perhaps a false assumption that EBI was ‘better’ then IBA as a general approach.

For the 2013 Clarifying Brief Interventions update the focus appeared quite different. Although the IBA agenda has clearly moved on, the focus appears to have shifted to  simpler approaches, or ‘IBA lite’ as posed in the new briefing. These minimal or ‘lite’ approaches appear to reflect the challenges of implementing IBA across front line settings. Using shorter screening tools and providing just a feedback statement + leaflet takes very little time. ‘IBA lite’ also relieves practitioners of the need to offer ‘brief advice’ which may often be perceived as lengthy or difficult. The appeal of IBA lite is therefore obvious.

The briefing however highlights the limited evidence to support ‘lite’ approaches, but accepts that it may be a good starting point. If people are being ‘identified’ and informed of their risk level they are more likely to consider their drinking. But considering one’s drinking and making a change to it are not the same. Behaviour change is often much more complex, and the opportunity to further affect the drinker’s motivation to change is lost with ‘IBA lite’.

Take for instance a drinker who after ‘IBA lite’ decides they would like to reduce their risk, but feels it will be too difficult to cut down. They are not aware of some very simple strategies that could help them, or that they can change via ‘small steps’ rather than needing to take one giant leap. Helping identify simple strategies or manage expectations are some of the obvious benefits of offering ‘brief advice’.

However, it cannot be said that IBA, as in including the offer of verbal brief advice, is the most ‘superior’ form of brief intervention. Nor can the same be said for EBI including more motivational techniques. The truth is there is still much more to be learned about the effective elements of brief intervention, and it what circumstances they might apply. In Scotland, more emphasis on empathy and motivational enhancement was placed in their national brief intervention programme, although in England ‘IBA training’ has been provided widely and to no common framework.

Future brief intervention research is increasingly focussing on not if, but how it works. This needs particular attention to the challenges faced on the ground. In the meantime, we still need to be aiming for something more than the easiest minimal approaches. ‘IBA lite’ may be a start, but my sense it is probably not close enough to what really helps most drinkers to enact a change in their drinking.

Can ‘nudge’ help IBA delivery?

17 Dec

IBA works to reduce risky drinking, but despite significant efforts, regular good quality IBA delivery seems some way off. However there may be some simple ‘nudges’ for supporting IBA delivery that are being overlooked. nudge

‘Nudge theory’ became popular following the Coalition Government’s favour for policy approaches that did not restrict choice or require legislation. It set up a ‘nudge unit’ and its controversial public health responsibility deal. However reports have warned that nudge alone is not enough to change behaviour at population level, though it may have a useful role to play.

IBA itself is not really a ‘nudge’, it is a more conscious and collaborative form of intervention. ‘Nudges’ are more about changing the environment to affect non-conscious decision making. Popular ‘nudge’ examples include placing healthier food choices in more visible places or designing buildings with stairs more accessible than the lifts. In an Amsterdam airport, an image that looked like a fly embossed in the men’s urinals apparently resulted in an 80% reduction in ‘spills’ by focusing the men’s aim! Use of incentives may also be considered ‘nudging’, but there has been lots of debate over what may be ‘nudge’, ‘shove’ or ‘push’.

However, policy and actions to encourage IBA delivery by front-line roles is often in line with ‘nudge’ theory. For instance, incentives and recording systems may mean that screening (identification) tools,  like the AUDIT, may pop up on a nurse’s computer screen. Or GP practices collect a payment when offering IBA to new patients when they register.

Incentives may have gone some way to initiating IBA delivery, but have not proved enough in isolation. We need to make front line role’s work environments as conducive to doing IBA as possible. For example, having resources as easily accessible as possible. Having to print off screening tools or leaflets each time is off-putting and time consuming.

Some areas have produced ‘IBA packs’ for front line roles. Packs typically include all the tools and materials needed for IBA and posters or local referral options. Having resources already printed out makes it more likely for roles to initiate IBA and offer appropriate information. Ordering free alcohol materials from the DH orderline is not the easiest of processes.

There could be other ‘nudges’ we are missing out on. In some hospitals all staff have been given a credit card sized lanyard with the three AUDIT-C questions to wear alongside their staff badge. Roles often cite concern over asking patients about their alcohol use. Perhaps wearing a badge stating “I try to ask all patients about their alcohol use” could ease this pressure and remind them about IBA.

Just as reports have found for nudge in general, it’s not the solution, but it may be a part of 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?