3. GP PRACTICE BASED SCREENING & BRIEF INTERVENTIONS

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1 South East Community Health & Care Partnership (SE CHCP) 16 th March 2009 Author Hamish Battye Paper No. 09/21 HEAT TARGET H4 ALCOHOL BRIEF INTERVENTIONS 1. PURPOSE 1.1 The purpose of this paper is to report on proposals to take forward Alcohol Brief Interventions within the CHCP. 2. BACKGROUND 2.1 A new HEAT target has been set by Scottish Government for NHS Boards for 2009/10 onwards (HEAT stands for Health Improvement, Efficiency, Access and Treatment): Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines by 2010/ The delivery model for achieving this target within NHS Greater Glasgow & Clyde was agreed by the Greater Glasgow & Clyde Alcohol Action Team in December 2008 and comprises screening and brief intervention programmes in the following settings: GP practices via the Scottish Enhanced Services Programmes (SESP); non-gp settings; and, acute hospital settings. 2.3 The details of this approach are set out in the paper attached, including the care pathway for brief interventions. 2.4 This paper outlines the delivery programmes for screening and brief interventions in GP and non-gp settings, and specifically the utilisation of funds allocated to CHCPs. 3. GP PRACTICE BASED SCREENING & BRIEF INTERVENTIONS 3.1 The NHS Board has commissioned screening & brief intervention from GP practices via the Scottish Enhanced Services Programmes. A number of GPs and practice staff have been trained in delivering brief interventions, and data on activity within practices will be returned to the NHS Board. Currently it is this activity only that counts towards achievement of the NHS Board s 1

2 HEAT target. For 2009/10 the NHS Board is aiming for 25,000 screenings within primary care. There is no figure set for individual CHCPs. 3.2 Within South East Glasgow CHCP there are currently: 22 practices who have opted in; and, 7 practices that have as yet neither opted in or out. 3.3 The CHCP is in discussion with practices that have not yet opted in to ensure appropriate population coverage and targeting those in greatest need. 4. SCREENING & BRIEF INTERVENTIONS IN NON-GP SETTINGS 4.1 Currently activity in non-gp settings does not contribute towards the HEAT target but it is anticipated this activity will be included in 2010/11. The commissioning framework attached envisages that CHCPs should develop a network of CHCP trained staff to deliver screening & brief intervention to a range of priority groups. Such a network of staff might include: Primary Care Mental Health Teams Health Visiting District Nursing Occupational Therapy Physiotherapy Podiatry Community Dentistry 4.2 Settings in which screening & brief intervention should be delivered include: Children s Services Adult Mental Health Services Learning Disability Services Older People and Physical Disability Services Criminal Justice Services 4.3 The CHCP has commenced this programme in older people s services with 16 staff already trained. 4.4 The aim is to train up to 40% of CHCP staff by 2011 this equates to 350 staff within the South East CHCP. The alcohol brief intervention training course (1 day) will be delivered every two weeks (excluding holiday periods) at a set venue, and will also be offered free to other partners (e.g. police, housing staff, and other council departments). 4.5 In total the NHS Board is aiming for 15,000 screening & brief interventions to be delivered by CHCPs across Greater Glasgow & Clyde. There is no break down yet by CHCP. 4.6 To achieve this level of training and screening & brief interventions the CHCP has been allocated 160,000 over the two year period 2009/ /11 (costs for training venues, materials and other incidentals have already been met from 2008/09 funds). These funds will be deployed as follows: 2

3 000 ABI training co-ordinator (full time seconded post) 40 Administrator (fixed term post) 20 Allocations to support specific care group or community 20 based initiatives TOTAL Scope exists within the allocation for specific care group or community based initiatives to be planned at a later stage Responsibility for the management of this programme will rest with the Head of Planning and Health Improvement and the Head of Addictions reporting on a regular basis to SMT, including through the CHCP s Governance Sub Committee The Alcohol Brief Interventions Training Co-ordinator post would be linemanaged by the Head of Addictions. 5. RECOMMENDATIONS 5.1 The Committee is asked to: note the delivery model for screening & brief intervention as agreed by the Alcohol Action Team and the utilisation of resources to the CHCP; and, request a progress report in due course. HAMISH BATTYE Head of Planning & Health Improvement JOHN GOLDIE Head of Addictions 16 March

4 Appendix 1 Greater Glasgow and Clyde Alcohol Action Team Meeting Date: Report/Presentation Title: Friday 19 th December NHS Greater Glasgow and Clyde Alcohol Opportunistic Screening and Brief Interventions: Commissioning Framework Final Alcohol LES Opt In Primary Care Guidance Pack Date: November 2008 Author: Neil Hunter, Joint General Manager, Glasgow Addiction Services Paul Rimmer, Support Services Manager, Glasgow Addiction Services Purpose of Report/ Presentation: Summary Information: Areas for Consideration: This paper highlights the proposed model for the delivery of the alcohol screening and brief intervention within NHSGG&C. The delivery model is based on the SIGN 74 guidance ( Sept 03, Scottish Intercollegiate Guidance Network). The key focus of this paper will be to provide guidance to NHS GG&C / Addictions Partnership, Acute Services/Addiction Services, CHP/CHCP s and Locality Planning Groups for Alcohol and Drugs for the delivery of the alcohol screening and brief intervention. Members to note content of three enclosures. 4

5 1. Purpose and Focus This paper highlights the proposed model for the delivery of the alcohol screening and brief intervention within NHSGG&C. The delivery model is based on the SIGN 74 guidance ( Sept 03, Scottish Intercollegiate Guidance Network). The key focus of this paper will be to provide guidance to:- NHS GG&C / Addictions Partnership as the lead for delivery of key elements of the Scottish Enhanced Services Programme for GP led screening and brief interventions across NHS GG&C and for the establishment and support of an NHS wide training and development network Acute Services/Addiction Services as the lead for the delivery of screening and brief intervention programmes across Acute settings CHP/CHCP s on the delivery of screening and/or brief intervention in a range of non practice settings (see section 7). Locality Planning Groups for Alcohol and Drugs on the planning, development and evaluation of screening and/or brief intervention programmes as part of the development of comprehensive responses to alcohol misuse in a range of health and social care settings 2. Background Alcohol Screening and Brief Interventions can take place in any setting where a patient/service user appears to be within the target group i.e. displays evidence that he/she is drinking alcohol at hazardous or harmful levels, which are having an impact on the patient s ability to carry out the activities of daily living, (e.g. Repeated admissions to Orthopedic for repeated falls, presenting at GP with acute anxiety or frequent work absences with no clear physical cause or young mother smelling of alcohol in morning visit by Health Visitor) A brief intervention (BI) is a short, evidence based, structured conversation of usually 5-10 minutes duration, during which the health care worker seeks in a nonconfrontational way to motivate the individual to assess the amount of alcohol consumed and the impact it is having on the patient s life. It encourages the patient to think about and plan changes in their drinking behavior and supports the individual to make the necessary changes. The main premise of the model suggests that a Brief Intervention should, where possible, be opportunistic i.e. usually while the patient is presenting with other physical or mental health problems which have a high correlation with possible alcohol problems (see Section 5 and Appendix 1) There will be some circumstances where an opportunistic intervention cannot take place, due to either the severity of the presentation or time constraints during an appointment. More serious alcohol problems, e.g. where the patient has not been able to make necessary changes following a previous brief intervention, or where the patient has a degree of alcohol dependence and has declined help from a more specialised agency may benefit from an extended intervention utilising motivational interviewing techniques which can take 15 to 20 minutes. Where an opportunistic screening is taking place during a routine clinic setting the practitioner will be required to manage their clinic scheduling accordingly. Alternatively, where the health care worker believes that the patient will return for a follow up appointment, it may be more appropriated to offer this as an alternative. 5

6 It is proposed that screening and BI is carried out in any setting in an opportunistic manner, where time allows within the appointment slot. This approach maximises the opportunistic aspects of the screening and delivery of the brief Intervention. If Health Care Providers (HCPs) do not have enough time to carry out an optimum brief intervention after screening and are unable to recall the patient to provide this service themselves, then it is proposed that the patient is referred to an appropriate locally based service. Each CHCP area of NHSGG&C will be required to have a network of suitably trained staff who will be available to provide a brief intervention following an initial screening. Priority areas will include primary care services and acute hospital settings. All services will be supported by locally available self help and web based materials. 3. GP screening and intervention Scottish Enhanced Services Programme (SESP element) This element of our NHS GG&C wide approach will see significant increases in the screening of patients in both General Practice and other primary health care settings. Training and delivery, as part of an NHS wide programme, will be aimed at GPs, Practice Nurses and other professionals within the practice (e.g. health counsellors) The GP will screen and deliver brief intervention during consultation (opportunistic). This must take place under optimum conditions i.e. 5 to 10 minutes for the intervention, excluding the screening. The GP may choose to deliver the brief intervention him/her self if there is sufficient time, or may carry out an alcohol screening test and refer to a Practice Nurse or other practice based HCP for immediate optimum intervention (This is only opportunistic if carried out immediately). The GP will screen and deliver Brief Intervention during a future pre planned consultation. (the GP is required to allocate enough appointment time for an optimum intervention to take place) The Practice Nurse or other HCP in clinic setting will carry out screening and brief intervention within other settings (e.g. Blood Pressure or smoking cessation clinics, or when new patients are registering with the practice as part of the new patient interview.) (opportunistic) 3.1 Key features This part of the model is mostly opportunistic and allows the GP to deliver brief intervention immediately after screening. If the GP is unable to carry out a brief intervention due to time constraints, then the patient would be asked to see a the care worker who has been trained to deliver brief interventions immediately. Where appropriate, the GP or other health care worker can ask patient to return for another appointment when the appointment time can be extended if required 4. Health Care professionals and other CHCP/CHP based staff The delivery of screening and brief interventions is already a high CHCP/CHP priority and part of the HEAT targets. 6

7 The development of an extensive network of CHCP trained staff able to deliver screening and Brief Intervention to priority groups would be a medium to long term objective. It will have an extensive education and training programme implications and require a refocusing of professional time utilisation. This network needs to exist in Primary Care Mental Health Teams Health Visitors District Nursing Occupational Therapy Physiotherapy Podiatry Community Dentistry We will also expect to see screening and brief interventions extend into other settings within CH(C)P s including:- With adults whose parenting responsibilities bring them into contact with Children s Services Adult Mental Health Services, embedding screening into core assessment Learning Disability Services Older People and Physical Disability Services, building on existing awareness programmes Criminal Justice Services, capitalising on the requirements of SER s to identify alcohol and drug use Our future training programmes will ensure we have adequate numbers of people in each of these settings to lead and develop the adoption of standardised screening, skills development in brief intervention methods and increased awareness of local and region wide alcohol services. 4.1 Key features CHCP staff would be fully trained in screening and Brief Interventions. Our intention would be to train 40% of HCP s in primary care (2800) over 3 years. Where interventions are not delivered opportunistically patients can be cleared and signposted to a local CHCP based brief intervention from within the local network. We will develop a range of local services including NHS and non statutory sector agencies able to deliver BI s The model is aimed at normalising and mainstreaming screening and brief interventions. 4.2 Screening and referral on to helping services The ideal is to deliver screening and interventions together. We recognise in some settings this will not always be possible. Screening for hazardous or harmful alcohol use is in itself useful in order to identify patients and service users who may benefit from an intervention, even though that intervention may not be delivered at the same time as the screening itself. In some settings or circumstances time or other problems may prohibit a full intervention. Screening alone can help practitioners suggest and direct patients to helping services and resources. After a positive screen there are options for providing help for patients, these include:- 7

8 Asking patients to return at a later, convenient date to discuss there alcohol use. That discussion would use the same principles and format of a brief intervention Arranging for patients to contact a local centralised helpline (see section 6.1), who could arrange for them to meet with a practitioner trained in brief intervention techniques at the earliest opportunity Advising patients of local helping organisations in their area, including self help organisations, Councils on Alcohol, alcohol support services. This will be particularly important for people who may be moving towards harmful alcohol use Offering patients information and educational/awareness materials as part of their screening. Ideally this should have contact details of local organisations (see NHS GG&C leaflet Making Changes and Primary Care Resource Pack) We are developing an extensive network of Health Care Professionals (HCP) and other staff within various settings, such as social care and voluntary organisations to deliver brief interventions following positive screening. If the HCP who carried out the screening was unable to deliver a brief intervention due to time constraints or if the patient required for example, a more extensive intervention then the patient would be signposted/referred to local services or a clearing house to make a further appointment within their local BI network. These networks will be predominantly based within CH(C)P s but need to be available in any relevant NHS and social care setting. As part of our approach in Greater Glasgow and Clyde we have developed with Local Authorities a range of helping services including In each locality there will already be:- Councils on Alcohol and Community Alcohol Support Services providing advice, structured counselling, groupwork, case management, keyworking and specialist programmes for mainly harmful drinkers Self help organisations and groups such as Alcoholics Anonymous and other recovery groups. These self help organisations offer peer support in group and sometimes individual settings to help people establish and maintain stability, control and /or abstinence 5. Web based and self help materials These should complement and reinforce the information provided during the brief intervention and are not a replacement for it. 5.1 Web-based materials. There is a growing body of evidence supporting the effectiveness of web-based treatment for alcohol and other problems (eg Melina Bersamin, 2007; Kypri, 2006; Walters, 2007). There are also other benefits from providing web based support materials. Web-based treatment can be utilised by anyone who has access to a computer linked to the Internet. It can be accessed from anywhere at any time (Saltz 2004). Having materials on line can allow opportunistic use of the materials Materials can support the on going work with the practitioners 8

9 Materials can be accessed outwith office hours Some people may be reluctant to attend services to talk about their drinking behaviours but would be willing to access appropriate information on line. 5.2 Self Help Materials These tools will comprise of leaflets, drink diaries, alcohol converters and self help manuals aimed at encouraging the person to understand their drinking habits and associated health risks. These can be read at home, preferably with other members of the family involved. These materials will also support the staff delivering the intervention and support the counselling process. 6. Target Groups and settings for Screening Evidence suggests that a universal programme of screening across the whole population is unlikely to be cost effective. Instead there are a number of target populations who required to be prioritised for screening for hazardous of harmful alcohol use. 6.1 Clinical presentations SIGN 74 indicates a range of presenting problems that might indicate problems with alcohol consumption. The table below highlights these problems but puts them into groups according to priority for screening for alcohol problems and other potential indicators that may be considered in clinical settings. These priorities are not based on the severity of presenting problems but on identified key opportunities for screening. Priorities for screening and BI Pregnant or trying to conceive Cardiac arrhythmias Depression or anxiety Insomnia Trauma/falls Dyspepsia, gastritis Hypertension Liver abnormalities High risk sexual behaviour Stroke Impotence/libido issues Amnesia, memory disorders Significant changes in weight Unexplained infertility Chronic pain Relationship problems, increased arguing, domestic abuse Priorities for screening and referral on to alcohol problem services Diarrhoea/malabsorption Cardiomyopathy Blood dyscrasias pancreatitis Peripheral neuropathy, cerebellar ataxia Cancers of mouth, pharynx, larynx, oesophagus, breast and colon Acne rosacea, eczema, psoriasis, multiple bruising Acute and chronic myopathies Gout Child neglect issues Other Homelessness Criminal Justice involvement such as driving offences, breach of the peace, shoplifting. Misuse of emergency services Smokers Young adults 9

10 6.2 Target Groups and settings for screening As well as clinical presentations, we would expect that screening people for hazardous or harmful alcohol use should become routine in many service sectors within, across and outwith CH(C )P s including social care settings, All new service users/patients all services should routinely adopt screening for new service users and patients on registration. Existing screening tools should be utilised Adults in mental health settings Adults with a parenting responsibility where there are child care concerns Young people, including students Adults subject to a Social Enquiry Report (SER s already require alcohol and drug use to be assessed but the use of standardised tools will improve this) or in relation to the work of the Domestic Abuse Court. 7. Other linked work streams There are a number of other service developments that are linked to this proposal and need to be incorporated into the developments: The NHS GG&C Acute Alcohol strategy, including screening and the Tier 2 hazardous, harmful, and dependant community training developments. Within GCC this may be delivered by extending community support services. Community Pharmacists could be part of the delivery model as and contracted in the same way as GPs. Further work is required to evaluate how this might be delivered. 10

11 Appendix 1 Brief Intervention A brief intervention (BI) is a short, evidence based, structured conversation of usually 5-10 minutes duration, during which the health care worker seeks in a nonconfrontational way to motivate the individual to assess the amount of alcohol consumed and the impact it is having on the patient s life. It encourages the patient to think about and plan changes in their drinking behavior and supports the individual to make the necessary changes. Its greatest impact is achieved when delivered opportunistically to patients at the time that they present with problems related to excess alcohol consumption. The use of the acronym FRAMES, is used to summarise how brief interventions are structured: feedback, responsibility, advice, agree goals, menu and summary. A fuller description of the FRAMES acronym is available to you in the Training Pack and the following is provided as an aide memoire for the consulting room. Note there will be a need to adapt to circumstances, although bear in mind the concept of FRAMES and avoid the obvious traps of telling people what to do or being involved in confrontations. At this stage when the patient has not asked for help with their drinking, we are assuming that either the patient sees no links between alcohol use or potential/actual health problems or they are at the most, ambivalent about change. 1. Getting started: Setting up rapport by asking if the patient is happy to discuss results. 2. Feedback: Needs to be personalised to the patient. If hazardous or harmful ask what the patient thinks about the results of screening suggesting that the way in which they are drinking may be affecting their health 3. Responsibility: Place the responsibility clearly back on the patient, but allow open discussion to assist the decision making process. 4. Advice: At times when people may be ambivalent in making a change, clear advice and choices are important, it is also important to establish a goal based on advice. 5. Agree goal: This is important in facilitating a possible change in behaviour, and aiding the patient to set a goal for themselves. 6. Menu: Again, in order to change people need to know how to, so a menu of choices is available, these are included more fully in the guide So you want to cut down your drinking? that accompanies this guide. 7. Summary: Sum up, agree goals, and agree how, give self help information So you want to cut down your drinking, signpost to additional support from local alcohol counselling agencies if required. 11

12 Appendix 2 Brief Interventions - Care Pathway Patient presents at:- G.P Practice A&E Dept Maternity Hospital Pharmacist Voluntary Org Or seen at home visit in Opportunistic screening for hazardous or harmful alcohol use (meets clinical criteria or is in priority group/setting (see section 8) Fast rating <3 No action Fast rating >3 Hazardous/harmful level drinking Carry out brief intervention Hazardous/harmful level drinking brief intervention not possible Indicators of dependence Self help material/information pack. Information on local self help organisations/other relevant info. Consider any follow up required Arrange follow up BI with your service if patient sufficiently motivated. Provide self help material information/info pack Refer to treatment service for assessment (e.g. CAT) Give contact details of services where BI and other services are available. Provide self help material information/info pack Give contact details of local BI/support service booking system. Provide self help material information/info pack 12