Primary 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?
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.
Should we ease off GPs not doing alcohol IBA (properly)?
27 Aug“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?
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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