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How I ...identified patients with alcohol-related poor

chronic

disease

control

How I ...identified patients with

alcohol-related poor

chronic

disease

control

It happens to me regularly: I struggle for months to control a patient's illness before the penny finally drops and it becomes apparent that their control problems are related to their alcohol consumption.

Department of Health figures suggest 150,000 admissions, and between 15,000 and 22,000 deaths, each year are alcohol related. Evidence is increasing that even non-dependent alcohol consumption can cause medical harm ('hazardous drinking').

Treatment works. Brief intervention (three 20-minute consultations) is effective in altering drinking patterns. It is not a cure but it is as effective in changing behaviour as smoking cessation treatment is at helping patients to stop smoking.

In our practice of 16,500 in an urban area of Teesside, we wanted:

•to maximise our QOF points and engage with the local enhanced service for alcohol

•to be able to deal effectively with all problems that patients identified, including alcohol, and

•to continue the development of the primary care team in the practice.

As GP appointments were at a premium, we realised the GPs were not going to be able to deliver the brief interventions.

The practice has about 4,000 patients identified as suffering with a QOF-defined chronic disease. We offer an annual care review to these patients, which consists of a questionnaire and initial health care assistant (HCA) consultation. Problems identified can then be managed appropriately within the primary care team.

How could these systems be altered, given the practice constraints, to improve the intervention offered to hazardous drinkers?

What we did

First we had to find the patients. Rather than using a simple count of units of alcohol consumed per week, we decided to use the fast alcohol screening test (FAST). This has a four-question format with scoring system.

The FAST questions were incorporated into the questionnaire sent to patients before they came for their annual care review. The HCA calculated the patient's score. Patients identified as having potential alcohol issues were given a leaflet, produced by the practice, that outlined the health effects of hazardous alcohol consumption and how it might affect chronic disease control. The leaflet suggested they make an appointment for brief intervention.

Our practice nurses had expressed an interest in developing their skills towards more 'lifestyle focused' consultations and away from mechanically following protocols.

But dealing with hazardous alcohol consumption was not perhaps what they had initially envisaged. We addressed this by sharing our practice 'vision' and arranging a training package provided jointly by the local addictive behaviour service and PCT health promotion unit. The practice nurses developed confidence as their skills became established and they have become proficient at delivering brief interventions. We have developed a list of objectives and tools that can be used in the three consultations:

•the initial assessment consultation

•a planning consultation a week later, and

•a final review at five weeks looking at the effectiveness of intervention and

maintenance of change.

What we achieved

Over the past 12 months FAST screening has identified roughly 400 patients as possibly having hazardous levels of alcohol consumption. This was about the level I had expected. We had planned on 25 to 30 per cent of these taking up places on the brief intervention programme and arranged practice nursing time accordingly.

In the event only about 6 per cent of patients who screened positive attended even the initial brief intervention consultation. A number of patients, upset by the inference that they may be labelled as alcoholic, did consult their GPs. Those attending brief intervention gave very positive feedback.

I feel pleased we have made a start at providing help for our patients with hazardous levels of drinking. This has largely been achieved by altering the skill mix within the primary care team and has not increased pressure on GP appointments.

We have engaged with the local enhanced service for alcohol. The low level of take-up of brief intervention is the area we will be

focusing on for next year.

Nigel Robinson is a GP in Stockton-on-Tees

Competing interests None declared

•A common response to FAST screening was: 'So you think I'm an alcoholic?' We aim to help our HCAs deal effectively with defensive responses.

•The practice leaflet on hazardous drinking will be changed to recommend patients make an appointment for brief intervention rather than suggesting the service is available.

•Appointments for brief intervention will be offered and booked by the HCA at the time of the annual care review. We accept this will result in more DNAs.

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