Archive | Primary Care RSS feed for this section

SIPS Primary Care research: not just a leaflet

28 Jan

SIPS: largest ever UK study into alcohol brief interventionsThe SIPS trial, a £4 million study applying brief intervention approaches in key settings, has published the Primary Care results in the BMJ. The A&E and Probation results will follow shortly.

I’m not going to try and summarise the results here – the BMJ article is easy enough to garner and a Findings bulletin also interprets them in a simplified form. Instead I wish to consider some implications for those interested in delivering IBA.

However I should point out that I will be writing on the assumption that SIPS findings did show that brief intervention is effective. But I certainly expect to return to the discussion that this may not be the case. These charges are not so much based on a question of brief intervention efficacy, but whether SIPS can be seen to validate effectiveness in real world settings.

So assuming we accept the SIPS findings as evidence that brief interventions can be effective in practice, I will explore some key implications. Not surprisingly, of headline interest is the finding of no significant difference in outcome between the 3 intervention approaches tested (all 3 showed a reduction at 6 at 12 months). The three main intervention approaches were:

  1. Feedback [of screening result] + Patient Information Leaflet (PIL)
  2. Feedback + five minutes of structured advice using the SIPS brief advice tool + PIL
  3. Feedback + 20 minutes of ‘Brief Lifestyle Counselling’ (BLC) + PIL

Level 2 might be considered standard IBA, with 1 being the most minimal intervention, and 3 being more ‘extended’ brief intervention. So do SIPS findings suggest that “less is more”?

To some degree it would seem so, but they DO NOT suggest that giving out a leaflet is all that’s needed. Crucially, the simplest intervention included ‘feedback’ in addition to the leaflet. Feedback generally means informing a person that their answers to the screening question suggests their drinking places them at risk. Often we teach people to follow this with “How do you feel about that?”, encouraging contemplation and often leading nicely into ‘brief advice’. So is ‘advice’ beyond feedback unnecessary?

In many cases, simple screening + feedback and leaflet could well be enough as the trial suggests. However, although we have a lot of evidence that IBA works in Primary Care, there is still relatively little known about how. It it is probable though that IBA works largely by triggering at-risk drinkers to start to think about their drinking, rather than the element of helping them to cut down (e.g. brief advice or leaflet).

To me this makes sense; we know well that IBA is based on the ‘stages of change’ behaviour change theory where ‘contemplation’ about whether a behaviour (smoking/diet/exercise/drinking) is crucial as the start of the process. So can we really forget about offering brief advice or extended brief motivational approaches?

With all these things, there is a risk of a reductionist ‘one size fits all’ approach. Many risky drinkers will not be wanting ‘advice’ straight after being told something that could have come as a bit of a shock. Their ‘contemplation’ phase may well need some time to process.

Sometimes though, a person may move quickly into ‘preparation’ (i.e. deciding to cut down), or already be thinking about it and welcome some help. Perhaps because these people are smaller in number, the benefit of brief advice in SIPS did not come out as statistically significant. We must also note previous studies have shown the benefit of advice or ‘brief counselling’ over no intervention.

So common sense should apply to IBA delivery in many ways – make sure proper screening is followed with ‘feedback’ (not just a leaflet), and if someone seems to want some help, there’s a good chance they’ll appreciate it. One further finding that was statistically significant in SIPS was that patients receiving the longest intervention were most positive about their experience with the practitioner.

I think the results can be seen as good news if we accept them at face value. In many cases, IBA may commonly only require the shortest and easiest forms of “advice”- feedback and a leaflet. Sometimes a bit more may be helpful, but it is nothing new to suggest asking the questions in the first place is what really counts. The debate about how we interpret the SIPS findings is probably just beginning.

Advertisements

IBA – are all settings equal? Presentations and experiences

27 Oct

Two recent events explored evidence, experience and views on delivering IBA across different settings. The first – ‘IBA: are all settings equal?’ – was held in partnership between the Alcohol Academy and DrinkWise NorthWest in July. More recently the Academy teamed up with the Nottingham Recovery Partnership to deliver ‘IBA: Making Every Contact Count?’.

Both events aimed to bring together alcohol leads and practitioners to assess how IBA implementation is going – and how and whether it should be extended across further settings. Of course, ‘all settings are not equal’ because the evidence base and policy focus is on IBA in Primary Care. Yet there is clearly both an enthusiasm and investment in delivering IBA across a wide range of settings.

A few of the key presentations and discussion points are outlined below, but all presentations can be accessed here and here. Continue reading

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

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.