Tag Archives: leadership

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?

IBA – who should do it and how do we convince them?

4 Dec

we not meOne of the big IBA challenges is that those who we really need to do IBA are not likely to see it as part of their job role. We need doctors, nurses, Criminal Justice roles and other front line professionals to routinely ask (screen) about alcohol – of course these are not exactly people with plently of spare time on their hands.

So the challenge facing IBA delivery is not just to equip front line roles with the knowledge, skills and resources to do IBA, but also motivate them to embrace it as a worthwhile cause – despite all the other pressures they face. Continue reading

How to decide what to do, whatever the evidence.

7 Jun

At the recent Cyrenian’s conference on the potential for delivery of alcohol brief interventions in untested or unproven community settings, Dr. Andrew Tannahill’s presentation with the above title, may be of interest. Rather than an ‘evidence rules’ approach decision-making, his thesis (part of his work for NHS Health Scotland) advocates 10 principles to underpin an ethics-based approach to deciding how to improve population health and reduce health inequalities. The alternative motto of this approach, he claims is ‘ethics rule: evidence serves’.

Importantly, evidence remains an important part of the decision-making framework, but so does logic and theory about the probable and possible impact of any decision or intervention made. The 10 principles can be organised into 3 categories:

1. Four principles fundamental to main health outcomes and how the organisation goes about its
business: Do good, Do not harm, Fairness, Sustainability
2. Five principles to do with other outcomes and/or how the organisation goes about its business:
Respect, Empowerment, Social responsibility, Participation, Openness
3. Principle of Accountability – for consequences of decisions and actions, use of resources, value for
money, etc

Dr. Tannahill’s presentation goes through each of the principles and considers how it might be applied to the rollout of IBA in new or untested settings and is well worth a look.  You can also read his journal paper on the framework.

Personally, I find it offers an answer to concerns I have had about how to balance the need for evidence with the great need to do something effective about alcohol consumption.  A solely evidence based approach is not always possible – many, many aspects of what we do are not evidence-based, and it seems to me unlikely that we will ever have really robust, hard evidence for many ‘interventions’ by many practitioners.  Dr. Tannahil’s approach offers part of the answer.  A shorter answer may be that – if we choose to do new things – we have a responsibility to contribute to knowledge about them – by clearly describing why and how and what happened – and to be honest with ourselves and others about exactly what the level of evidence is.