NICE proposes stricter logging of alcohol use by GPs in new draft quality standard

A draft NICE quality standard asks GPs to formalise recording of patients’ alcohol use so they they do not miss out on interventions.

The institute is asking service providers to ensure that ‘systems are in place’ for the use of validated alcohol questionnaires when asking people about their alcohol use.

It said that thousands of people asked each year could be missing out on brief interventions to help curb problem drinking, or a potential referral to specialist alcohol services.

However, GP experts said that while the tools recommended by NICE are useful, it may have some implications for GP workload.

A new draft quality standard, which sets out priority areas for quality improvement for the care of adults with alcohol-use disorders, includes a statement about accurately recording alcohol use, and using validated questionnaires including the Alcohol Use Disorder Test (AUDIT) or abbreviated versions ‘when time is limited.’

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: ‘Many of us are asked about our alcohol use when we interact with health services, but if an appropriate questionnaire is not used, people with alcohol problems could be slipping through the net and may not be receiving the support they need.

‘We know a large number of people who are dependent on alcohol are not receiving treatment and this could be for a variety of reasons, but as part of a health and care system that continually learns from data, we do know that using a validated questionnaire provides commissioners with the information they need to organise appropriate services.’

Dr Martyn Hull, a Birmingham GP and clinical director at the drug and alcohol treatment provider Turning Point, told Pulse the quality standard was ‘spot on’ but that there are pressures on primary care that have to be acknowledged.

He said: ‘Technically, the NICE quality standard is spot on. AUDIT is a validated screening tool in primary care which is effective in the identification of a number of areas of alcohol related harm.

‘However, the AUDIT tool takes 10 minutes to complete and the reality is that if a patient has come in for something else – there simply is not time to go through the questions. We must acknowledge the pressures on primary care.’

He added that the tool picks up 90% of patients with an alcohol problem and the benefit is ‘primarily in identifying increasing or higher risk drinkers’ who may not be known to services.

‘Most GPs will know which of his or her patients are dependent drinkers and if these individuals are not engaged with treatment services it is probably because they don’t want to go into treatment.

‘There are particular points when use of the AUDIT tool works particularly well. We would like to see greater use of the AUDIT tool as part of new patient assessments, or chronic disease reviews or as a self-assessment while people are waiting in A&E but this needs to be properly funded.’  

Professor Colin Drummond, professor of addiction psychiatry at King’s College London, told Pulse that it was good to see NICE emphasising the importance of using a validated alcohol questionnaire.

He said: ‘I am pleased to see that NICE is refreshing this alcohol quality standard as it is now more than 10 years since it was first published and much has changed in the alcohol treatment and care landscape.

‘It is good to see that NICE is emphasising the importance of using a validated alcohol questionnaire when asking people about alcohol use, in order to make clinical decisions on delivering brief alcohol interventions or onward referral to specialist alcohol services.

The Audit-C tool only incorporates three questions, he added, so therefore ‘should be relatively easy to incorporate into routine clinical care for case identification and making informed clinical decisions’.

Colin Angus, senior research fellow at the Sheffield Alcohol Research Group, said that similar screening efforts are proven to be effective as primary care is a setting ‘where interventions can work.’

He told Pulse: ‘We know that we hugely under screen for alcohol problems. For example, a few years ago, we found smokers were almost eight times more likely to have had some kind of intervention from their GP about their smoking, than somebody drinking at risky levels was to have had an intervention about their drinking and there’s little evidence that this has changed for the better in the interim.

‘Even more than that, the data suggests that much of the screening effort that does go on is misdirected – with screening rates for alcohol problems being much higher among younger age groups, while alcohol consumption and harm are highest in older adults.

‘This is a huge missed opportunity, as we know that screening can pick up patients with alcohol problems who would otherwise fly under the radar, at least until they wind up with serious health consequences, and primary care is a setting where we know that interventions can work.’

Dr Richard Piper, chief executive at addiction charity Alcohol Change, said: ‘Professional alcohol treatment is commissioned by local authorities across England and provided for free to everyone who needs it. And it works.

‘However, there is currently a big problem: only around one in six of the people who could benefit from alcohol treatment, actually take it up. Alcohol Change UK wants to see significantly improved pathways from primary care, including better use of validated tools such as AUDIT – using these simple questionnaires more frequently, and making use of them more consistently.

‘NICE’s guidelines released today start to address this and are to be widely welcomed.’

A consultation on the five statements has now begun and feedback can be made via nice.org.uk until 28 February.

Earlier this month, NICE also said that GPs should support patients with depression from minority ethnic backgrounds to access help in languages that they can understand.