Alcohol - Health Committee Contents

Examination of Witnesses (Question Numbers 108-119)


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.

previous page contents next page

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

© Parliamentary copyright 2010
Prepared 8 April 2010