Examination of Witnesses (Question Numbers
108-119)
PROFESSOR MIKE
KELLY, DR
LYNN OWENS
AND DR
PAUL CASSIDY
7 MAY 2009
Q108 Chairman: Good morning. Welcome
to our second evidence session on our inquiry into alcohol. Could
I ask you for the record to introduce yourselves, please.
Dr Cassidy: Dr
Paul Cassidy. I am a GP in Gateshead. I am also Associate Medical
Director in the PCT and I am a research assistant at Newcastle
University. I have been working in the alcohol field for about
10 years.
Professor Kelly: My name is Professor
Mike Kelly and I am the Director for the Centre for Public Health
Excellence at NICE.
Dr Owens: I am Dr Lynn Owens.
I am a Nurse Consultant and Alcohol Clinical Lead within Liverpool
PCT and an Honorary Research Fellow at the University of Liverpool.
Q109 Chairman: Welcome. I have a
general question to all three of you in relation to alcohol and
the National Health Service. Last week we heard a lot of statistics
about alcohol related problems. I wonder if I could ask each of
you to give us an idea of how alcohol impacts on your little parts
of the National Health Service from a personal experience point
of view.
Dr Cassidy: It is a routine part
of my clinical work. One of the dilemmas is that, often, when
GPs think alcohol, they think alcohol dependence. They are the
patients who seem to give us the biggest problem, because we have
problems getting them into treatment and it is a chronic illness.
I see the non dependent drinkers, of whom there are a lot, in
everyday practice, and the challenge for me is to pick those people
up. The impact is often felt on the more dependent end, but there
are the more subtle effects of raising people's blood pressure
or leading to small injuries that affect the normal patient who
comes through the door. Certainly it is a common and routine part
of clinical practice.
Dr Owens: I work in both primary
care and the acute hospital trust. As Paul says, within primary
care you have an opportunity very much to help patients recognise
that what they are presenting with to their GP could be a direct
consequence of what they are drinking—minor things like
gastritis—and it is an ideal opportunity to give patients
advice, information to help them change their lifestyle and do
some positive things that prevent future ill health. In the acute
trust we tend to see more of the more complex and dependent patients.
We know that within Liverpool up to 70% of our A&E attendances
at weekends are alcohol related. Those attendees tend to be the
younger age group and are to do with drinking behaviours, getting
into fights, accidents and injuries. We also see patients attending
with end organ damage and severe medical co-morbidities directly
attributable to their alcohol consumption. We have to take that
opportunity to ensure that patients understand the role that alcohol
has played in their becoming sick. As Paul says, it is not always
cirrhosis or something that almost everybody knows is caused by
alcohol; it is things like strokes, neuropathies cancers, atrial
fibrillation. There are lots and lots of other very serious medical
conditions that make people come to hospital for help. At that
point, they are very desperate. Traditionally we have not had
services that are able to respond quickly enough to be able to
give them real choices of effective treatments to help them at
that point.
Professor Kelly: As you know,
of course, NICE does not deal with patients in a direct sense,
but NICE presently is undertaking a series of reviews in three
areas relating to alcohol. One which I am leading on is on the
prevention of alcohol misuse. The second is a clinical guideline
on the management and treatment of people with alcohol problems.
The third is dealing with alcohol dependency and the psychiatric
sequilae. There are three big pieces of work underway presently
and due for completion in May 2010. My brief on the public health
side of things is to determine the extent to which screening,
bio-chemical markers, clinical indicators and so on—but
particularly screening questionnaires—are effective at picking
up these problems early; secondly, whether brief interventions
are a cost-effective response; and, thirdly, what are the key
barriers to change that arise, both in terms of service configuration
and organisation as well as behaviour change as far as patients
or members of the public are concerned. We are also going to look
at the impact of price and availability and advertising, and the
degree to which that, as a sort of very upstream impact, leads
to the sorts of problems that my two clinical colleagues were
talking about.
Chairman: We will be picking up on one
or two of those issues as we go ahead this morning.
Q110 Charlotte Atkins: Professor
Kelly, I will start by putting this question to you first, in
view of the work that you have been doing. What more could be
done by the NHS to prevent the development of alcohol related
problems? I do not know what has been demonstrated by your own
work, but what is your view on that?
Professor Kelly: Our own work
at the moment is midway through. The committees that are doing
the guides are meeting this morning in Manchester, so I am absent
from that to be here at a rather different committee. In terms
of the overall approach, the first thing, I think, is that the
National Health Service has to recognise alcohol as the major
priority, for the reasons the statistics that were spelled out
to you at the last session make clear, but, also, the National
Health Service has to see this as a key priority and to own the
problem, to take the problem. It is not someone else's responsibility.
In a sense, it is all our responsibilities involved in the Health
Service. Second, we need to acknowledge and recognise that the
problem is something which is potentially changeable. The reason
why I can say that with confidence is that we have seen changes
over time. in the last 25-30 years, in patterns of alcohol consumption,
patterns of alcohol use and patterns of alcohol-related disease
which are the consequence of cultural and other kinds of changes
that have gone on, and that means you can change it back. It is
not an inevitable juggernaut that is in some sense unstoppable.
There are things which may be done in order to move things on.
Third, we need to implement and make as effective as possible
those things which we know to work. I will talk about that subsequently,
when talking about brief interventions and screening. We have
here an evidence base and a set of technologies for which, in
public health terms at least, the evidence is very good. It is
not always the case in my field—we often have to deal with
very patchy and uncertain evidence—but in this field it
is pretty good. Given what we know, although our committees have
not yet pronounced on what they are going to say, the existing
evidence, which is all of course in the public domain, makes it
clear that we have these effective technologies. We need to make
them available and useable. It is also important that we integrate
approaches to alcohol within a broader approach to the ways in
which people live. That is to say, only focusing on alcohol as
the problem may not be the most efficient way to work in the primary
care setting. It is linked to a range of other things around the
way people live, work and spend their leisure time. The response
to the problem has to be built into that; it is not simply focusing
on that as a problem and stigmatising the alcohol abuser as a
consequence. It follows from that that any direct interventions
in an NHS setting have to be done in a non judgmental way. One
might say that ought to go without saying, but it is an important
thing to remember as part of the process. The evidence at which
we have looked suggests that you can embed this in routine care.
It does not have to be hived off until you have very serious problems,
it does not need to be hived off to a group of very particular
specialists necessarily, but if routinely doctors and nurses are
to do this, it needs to be backed up with appropriate training
and it needs also to be borne in mind that we must not give GPs,
in particular, but also nurses too much overload, yet more things
to be done in a general practice consultation. So long as it is
done in a balanced way, it looks as if we have some promising
things to hand.
Q111 Charlotte Atkins: You talked
about picking up problems early. You obviously inferred that the
NHS could not do it on its own. Is there any evidence of the effectiveness
of multi-agency centres based in schools to try to pick up problems?
Related to that, do you find that alcohol tends to go through
families and, therefore, is the possibility to pick up the alcohol-related
problems of young people based on the experience of their parents?
Professor Kelly: We did produce
NICE guidance, in 2007 I think it was, for the school sector on
picking up alcohol problems with children, children in secondary
schools in particular. In so far as we were able to make sense
of the available evidence there, there is good reason to suppose
that you can focus on that particular group of the population,
youngsters in the school system, as a way of detecting early problems
and either referring into appropriate early treatment or dealing
in a more universal kind of way—the "stop and think
moment" for the person who is drinking too much, so to speak.
I am not aware of work on multi-centres, but my colleagues might
be—certainly we have not looked at work up until now—as
a way of dealing with this. As far as I am aware, and I will double
check, I do not remember us coming across that in the evidence
base so far. That said, there is all sorts of lateral evidence
that would lead one to suppose that that might be a highly effective
strategy, because, in general terms, multi-faceted, multi-agency
working in public health tends to be a great deal more effective
than single-agency working or a single focus. I would not be at
all surprised, if such evidence were available, therefore, that
it would be supported with that kind of approach. To go on to
the question of families, I believe it is the case that patterns
of drinking are learned as much as anything. One of the places
they are learned is in the family settings, with role models.
That is not at all surprising, given other things we know about
the way people learn in families. The interesting question you
have raised is whether that should be used as a basis for case
finding. I am much more familiar with case finding that is done
in that way in relation to something like heart disease, where
a successful strategy you can use, having identified a family
where heart disease exists in a first-degree relative, a brother
or parent or something like that, is that is a good reason to
go to seek that case out again. It is working laterally rather
than directly from the evidence, but the lateral thing that your
question presupposes would be a very important hypothesis to take
forward, I would say.
Q112 Charlotte Atkins: Would other
panellists like to come in on this issue of prevention and what
you think works within the NHS?
Dr Owens: I think it is really
important to take a whole approach. Clearly you have had evidence
about price and promotions. I think we need to re-design our city
centres, so that they are mixed economies and they are not just
for young people binge drinking, and then we need to provide good,
sound, clear advice to individuals about their drinking at the
earliest opportunities possible. That should start as early as
health in schools, when you visit your GP for routine vaccinations
and things like that, and then to help individuals recognise at
a very early stage, when they are becoming sick, of the role that
alcohol might be playing in that, because I am constantly surprised
by reports from patients who have really quite significant co-morbidities,
that alcohol and its role in their co-morbidity has never been
discussed—from many patients they have been sick for 10
years. I think there is this stigma. We have to have a system
whereby we do not stigmatise patients, where we do not make them
feel that they are to blame, where we treat them very much as
individuals and are able to give them individual advice and individual
care based on their medical co-morbidity and their particular
drinking pattern.
Q113 Charlotte Atkins: Dr Cassidy,
do you see your role as helping to prevent alcohol problems developing
or do you just see your role as being primarily to treat the effects
of alcohol?
Dr Cassidy: This is one of the
central paradoxes of this topic, because GPs' thinking is dominated
by the dependent end. When we talk to GPs and do qualitative research,
there is a cynicism and a pessimism about the topic because people
focus on that end. We know the majority of problem drinking, 23%
of the population, is hazardous/harmful, and it is a much smaller
percentage, 3.6%, who are dependent. We can get the biggest gains
early on with the hazardous/harmful. We use the expression "numbers
needed to treat": we need to treat eight patients with a
brief intervention to get one of them to drink healthily. That
is similar to that for smoking cessation with the use of patches'
nnt of 10. The evidence is that it is incredibly effective. Most
GPs would acknowledge that there should be something they should
do, but they struggle to do it, and there is a cynicism and pessimism
because of the focus on dependent drinkers. There is a need to
help the system work with dependent drinkers so that we can feed
people through quickly. If GPs are going to screen more and more
patients, they are going to give up on hazardous/harmful drinkers
but they are going to pick up a lot more dependent drinkers, and
if they pick up the dependent drinkers and nothing gets done with
them, they will feel very discouraged. When we talk to GPs, there
are many other barriers as well, such as time, materials, perhaps
some financial incentives in the system. It has been very heartening
to hear that in the new GP contract there is now a new direct
enhanced service for alcohol for new patients, so I think there
are some system changes we can make for general practice to make
it easier. GPs would want to work with the Government and the
PCTs. If they think they are doing everybody else's jobs, they
get turned off as well. That is why issues of units, labelling
on bottles, licensing laws, taxation issues also affect GPs' thinking,
because if in the consultation you are battling against all these
social trends, it can be very discouraging.
Q114 Dr Taylor: I found it staggering
to learn from our briefing that even a five- to -minute focused
discussion could be so effective. You have already said it helps
one out of eight. What other evidence is there that these brief
interventions are effective or cost-effective?
Professor Kelly: This is one of
those areas in public health that stands out with the quality
of the evidence and the quality of the direction which the evidence
gives us. I will not say it is exactly unique, but it is remarkable
in some respects. I will give you some examples. Brief interventions
are effective in reducing the following: alcohol consumption;
injury; mortality; morbidity; and the social consequences. There
are currently 27 systematic reviews, including those from the
United Kingdom, demonstrating that degree of effectiveness; in
other words, that is a pretty strong scientific basis. That it
works in primary care: there are another six systematic reviews
that demonstrate that unequivocally. That it is effective for
both men and women: it is the same evidence, of course. That it
is highly effective for adults: again, it is in the evidence.
Where we are less sure—but given the forcefulness of what
we do know one can have some confidence that it is probably not
a major problem—is whether it is as effective as you go
down to younger groups. That is not necessarily completely clear,
but it seems quite likely that it would be. We do not have too
much in relation to differences by socio-economic grouping. But
alcohol is a bit unusual in terms of a public health problem,
in that it does not follow quite the same pattern of health inequalities
that we see in some other areas. In that sense, it is perhaps
less of an issue. The other thing, Dr Taylor, of course, is that
even very brief interventions, just the "stop and think moment",
have been demonstrated to be effective too.
Q115 Dr Taylor: Whatever do you say
in this very previous five minutes? How do you think it is so
effective?
Dr Cassidy: The key, the magic
of the consultation in primary care, is that we know our patients.
We have long-term relationships, so they trust us. If we reflect
back to them and challenge their thinking that their drinking
does not lead to harm, that has enormous power. Also, if you are
able to offer simple steps, simple guidance based on this trusting
relationship, it seems to work.
Q116 Dr Taylor: That is why it is
effective in primary care.
Dr Cassidy: Yes. We are not quite
sure—and our big trailblazer Department of Health research
is looking into it—how much extra work and counselling you
need to add. Do you get any added value by putting more effort
in? In a normal primary care consultation you are really just
working for about a minute's worth of time, whereas extended interventions
are about 20 minutes/30 minutes, and that is when you may need
to refer to a nurse or an alcohol councillor. We are still not
100% sure if it is worth doing that in a cost-effective way.
Q117 Dr Taylor: Is it really scare
tactics?
Dr Cassidy: No.
Q118 Dr Taylor: It is not.
Dr Cassidy: No. It is working
for patients. It is understanding their agenda. It is an education.
It is a more motivational approach to public health.
Q119 Sandra Gidley: I would contest,
in the way you are describing it, that you can do that in a minute.
Dr Cassidy: You can if you know
your patient.
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