Memorandum by the Royal College of General
Practitioners (AL 17)
1. The College welcomes the opportunity
to contribute evidence to the Parliamentary Health Committee's
inquiry into alcohol.
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the `voice' of GPs on
issues concerned with education, training, research, and clinical
standards. Founded in 1952, the RCGP has over 36,000 members who
are committed to improving patient care, developing their own
skills and promoting general practice as a discipline.
3. The College recognised the impact of
alcohol and we are committed to measures to reduce alcohol harm.
As well as the increased risk of violence and anti-social behaviour,
alcohol is a major contributing factor for many health disorders.
Heavy drinking can lead to heart and liver problems, strokes,
brain damage, memory loss and various forms of cancer. Research
shows that GPs can be highly effective in helping people to cut
down both their overall alcohol consumption and episodes of binge
drinking. We have commented on each area of the terms of reference
below:
The scale of ill-health related to alcohol misuse
4. There are estimated to be more than seven
million hazardous and harmful drinkers (23% of the adult population)
and more than one million moderately or severely dependent drinkers
(4%) in England. There are different types of services for these
groups, ranging from simple measures to provide information and
raise awareness to acute clinical or mental health interventions
for severe cases.
The consequences for the NHS
5. We recognise that alcohol has a significant
impact on the NHS. However, to reduce alcohol harm it is necessary
to target resources where they are needed, and to do this it is
necessary to have appropriate information. Many Primary Care Trusts
(PCTs) have not accurately assessed the alcohol problems in their
area and a quarter of PCTs have not assessed need at all.[105]
Without such assessments, PCTs cannot know what services they
should be providing, nor assess whether what they do provide is
sufficient or cost effective.
6. Many PCTs do not have a strategy for
alcohol harm, or a clear picture of their spending on services
designed for this purpose. This is slowly being addressed, but
still too much responsibility lies with Drug and Alcohol Teams
(DAATs), many of whom do not have the capacity or capability to
respond. Many DAATs do not have the sufficient links with primary
or acute (hospital) care to commission effective alcohol interventions
in these areas. The links with acute trusts have been historically
difficult to establish, and whilst the Public Service Agreement
(PSA) should support partnership and alliances with acute health
organisations, there are many competing priorities for hospital
trusts can hamper progress. There is also much scope for better
integration of hospital services with follow-on and support services.
This would help improve recovery rates and prevent patients relapsing
into their previous drinking patterns.
Central government policy
7. Until this year, neither the Department
of Health nor the NHS had any specific objectives in relation
to alcohol for which they were directly accountable. April 2008,
however, the Department became jointly responsible, with the Home
Office, for a new Public Service Agreement (PSA 25) on alcohol
and illegal drugs. The PSA is to be monitored annually until 2011
and includes five indicators used to measure progress. One of
these requires the Department to secure a reduction in the rate
of increase of alcohol-related hospital admissions. The other
indicators measure the effects of illegal drug use and of alcohol-related
social disorder. Most PCTs in the country have elected to identify
the reduction in alcohol related admissions as a key indicator.
8. However, Drug Action Team expenditure
(DAT) expenditure far outweighs alcohol expenditure despite significant
disparity in health need and social and economic impact. Models
of Care for drugs have been rigorously implemented and performance
managed as a process. However, this is not the case for alcohol,
where service performance management is inconsistent nationally
and there is not an equitable and coherent performance monitoring
system as yet. Models of care for alcohol misusers (MoCAM) has
not been benchmarked or measured since implementation.
The role of the NHS and other bodies including
local government, the voluntary sector, police, the alcohol industry,
and those responsible for the advertising and promotion of alcohol
9. The available evidence suggests that
early intervention programmes such as screening and "brief
advice" can bring substantial savings by reducing the need
for later more intensive treatment. At present significant work
is required at a local level to exploit opportunities to identify
and advise people who are drinking above sensible levels. Alcohol
screening questionnaires and the provision of "brief advice"
offer a quick and effective means first to identify and then to
engage with those who are drinking excessively but who may not
realise the damage they are doing to their health. There is evidence
indicating the cost-effectiveness of such early intervention programmes.
10. However, screening and brief advice
is only sporadically provided by GPs and health workers, and rarely
used in other parts of the health service, such as accident and
emergency (A&E) departments. There is an urgent need for a
competency framework for practitioners and accessible training
for all health and social care professionals. This training should
be mapped to the learning needs and competencies associated with
Level 1 through to Level 3 provision.
11. The RCGP Substance Misuse Unit is working
with the Department of Health to integrate workbook and face-to-face
training up to, and including, competencies associated with those
held by a Practitioner with Special Interest (PwSI) with the Department
of Health alcohol virtual learning centre, which includes an e-modular
programme.
12. Health professionals feel that improved
pathways into specialist treatment will deliver reduced alcohol
related hospital admission rates. There is a need to improve and
integrate alcohol services into universal services in primary
care, which would operate alongside community clinics.
13. We would support the provision of Identification
and Brief Advice (IBA) training as a means to target high risk
groups in a primary care setting. Similar training can be adapted
and linked to the development of pathways between hospital and
community. For example, IBA could be used in A & E units,
possibly with the use of specialist alcohol nurses or alcohol
health workers. It might also be possible to develop IBA in specialist
settings including, for example, maxillofacial clinics, Hepatology
wards, Gastro units or prison healthcare centres. There are also
other settings where emergent work suggests that IBA could make
a difference, including in custody suites and by ambulance services
stationed in town centres in the evenings etc.
14. There is a role to play for Crime &
Disorder Reduction Partnerships (CDRPs) and alcohol should be
prioritised within Local Area Agreements.
15. Changed can be achieved through advocacy.
On a local level, government should engage with local champions
who publicise the harm caused by alcohol. There is also a need
to involve local health promotion campaigns to disseminate and
amplify the messages of the national social marketing campaign.
16. Much good work was undertaken as part
of the regionally led Darzi reviews. For example, Yorkshire and
Humber SHA, as part of the Darzi review, chose alcohol as one
of the thematic areas in the staying healthy group. Their work
took into account an individual's lifecycle as well as both intrinsic
and extrinsic influences on individuals in order to enhance thinking
about what would be the most effective interventions in particular
cases (such as during pregnancy) and how interventions can be
targeted most effectively.
Solutions, including whether the drinking culture
in England should change, and if so, how?
17. The majority of alcohol related harm
is preventable. Specialist alcohol treatment delivers the greatest
short-term impact on admissions and mortality because it targets
the patients at greatest risk of death or serious disease. Identification
and brief advice delivers medium and longer-term reductions in
the kind of "everyday" drinking which leads to coronary
heart disease, liver disease and other problems. Evidence shows
that for every eight people who receive brief advice, one will
change their drinking to within low-risk levels.
18. We should encourage greater service
user involvement in the design and delivery of alcohol services.
For alcohol services, user involvement is currently much less
evolved than it is for drug services. There is a need to understand
the barriers to involvement and how peer mentorship, support and
training can be offered to facilitate user involvement. It might
be possible to adapt the training offered to healthcare professionals
for service users and carers.
19. The Department of Health has invested
heavily in advertising campaigns to promote the Department's current
guidelines on sensible drinking. The RCGP supports the government's
Know Your Limits campaign as we consider it be way of empowering
people to take responsibility for their own health and wellbeing.
However, we are concerned that daily limits are not fully understood
by patients who tend to underestimate the amount of alcohol that
their drinks contain. These campaigns are costly, and although
they have followed good practice guidance, there is some scepticism
as to their impact.
20. In recent years, professional health
alliances, such as the Alcohol Health Alliance, have predicted
that advertising campaigns alone will prove ineffective and have
argued that increasing taxation and reducing access to potent
alcoholic drinks is the most effective way to reduce alcohol harm.
21. For PSA targets to be effective, there
is a need for a consistent set of codes and the design of a minimum
data set as a means of demonstrating improvement and positive
change. Several PCTs are unsure as to the reliability of local
coding and accuracy of baseline figures. This makes it difficult
for PCTs to set local goals for reduction.
22. There is a need for a centrally funded
national training programme linked to the commissioning of comprehensive
range of evidence-based services.
23. I gratefully acknowledge the significant
contribution of Dr Linda Harris, Director of the RCGP's Substance
Misuse Unit, towards the above comments.
Dr Maureen Baker
Honorary Secretary of Council
March 2008
105 National Audit Office report: Reducing Alcohol
Harm: Health Services in England for Alcohol Misuse (2008) http://www.nao.org.uk/publications/0708/reducing-alcohol-harm.aspx Back
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