In 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?
