Alcohol - Health Committee Contents

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) Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2009
Prepared 23 April 2009