Alcohol - Health Committee Contents


Examination of Witnesses (Question Numbers 120-139)

PROFESSOR MIKE KELLY, DR LYNN OWENS AND DR PAUL CASSIDY

7 MAY 2009

  Q120  Sandra Gidley: Yes, but lots of patients do not go to their GP that frequently, so you do not really know them as well as you might think.

  Dr Cassidy: 90% will attend every five years and about 70% every year. It is surprising how much you do get to know your patients.

  Q121  Sandra Gidley: Do you know people quite a lot if they only go once every five years?

  Dr Cassidy: You know their families, you know their context. There are some who are more passing in and out.

  Q122  Dr Taylor: Could this be extended to other sorts of fields, other venues? Could it be done in A&E?

  Dr Owens: Yes. It is done in A&E. I think we have to be very clear about who we are talking about and what level of GP. There has to be really good and accurate assessment as to the patient's level of risk in terms of their drinking. If they are a low-risk drinker, you need much less time than if they are a high risk drinker. You also have to look at the consequences of their drinking that have already occurred. Clearly, if a female is attending an emergency department with a broken ankle because they fell off a bus and they are someone who drinks just above sensible limits, your intervention will be very different for them than for someone who is attending an emergency department with chest pain, for example, who drinks 10 units a day. Then you would require a more extended brief intervention. That is where we are still building the evidence base, although there is some good evidence that that can be highly effective in moderating a patient's drinking but, more importantly, helping them to increase their wellbeing and functionality as secondary outcomes to how they manage their drinking behaviour.

  Q123  Dr Taylor: Who is going to do this in a chaotic stressed A&E department?

  Dr Owens: It is about making the best use of a highly skilled workforce. You can have an individual as a clinical lead, or someone who is there in terms of good leadership, like myself, a nurse consultant, or a consultant within the department, but support others to deliver the more minimal interventions as part of their everyday work. For example, a triage nurse does give brief advice around alcohol consumption, particularly to a young person attending because they feel they might have had their drink spiked. That is something that a nurse would do within her normal role, whether or not they acknowledge for themselves that they are giving brief advice—and perhaps they do not. For the second scenario patient, clearly they would require something quite different, and that is where the role of alcohol specialist nurses within the acute setting may come in.

  Q124  Dr Taylor: We are going to come on to that a little bit later. The ordinary A&E staff should be able to give the very brief advice.

  Dr Owens: Yes.

  Q125  Dr Taylor: And then somebody on call to come in and give the extra.

  Dr Owens: Yes.

  Dr Taylor: Thank you very much.

  Chairman: We are moving on to a few questions around primary care now, Dr Cassidy.

  Q126  Mr Scott: Dr Cassidy, as a family GP you must see evidence of the impact alcohol has on families the whole time. Could you tell us a bit about that.

  Dr Cassidy: When we look at the attributive fraction that alcohol leads to diseases, it affects the whole disease spectrum in many ways. It is leading to extra high blood pressure and extra strokes, so there is a physical effect on the family. Clearly when we look at the dependent end, that is when we start seeing more problems, more child protection issues, families struggling to cope in our local societies or the communities and using alcohol as a coping strategy which is then, unfortunately, self-defeating.

  Q127  Mr Scott: Perhaps the impact on children.

  Dr Cassidy: Yes. It would be mainly through the parents. For children who are in families with parents with alcohol dependency, it is a well-known phenomenon that they become carers looking after their parents. It is a regular occurrence; it is not an infrequent occurrence. They are issues that we are involved with. Certainly, once you get to child protection and conferences, I think it is up to about 50%. A lot of child protection cases have alcohol or substance misused involved.

  Q128  Mr Scott: What about domestic violence?

  Dr Cassidy: The link with alcohol?

  Q129  Mr Scott: Yes.

  Dr Cassidy: I do not have the figures for the exact number, but it is a common forensic primary care scenario that we see some families where there is a mixture of violence, substance misuse, alcohol, and sometimes mental health issues. It is a difficult triad to try to manage and see your way through the system. Again that is one of the reasons why sometimes there is a pessimism in primary care, because of the complexity of some of these cases which clouds your mind when you think about alcohol. There is a sense that sometimes things do not improve and it is chronic and difficult at this dependent end.

  Q130  Stephen Hesford: We have heard evidence that GPs basically see 90% of NHS interventions—

  Dr Cassidy: Over five years. They would see 90% of their population base over five years.

  Q131  Stephen Hesford: They are traditionally the gatekeeper for the service. You would imagine that GPs are best placed to do the early intervention for alcohol-related problems, that in fact you would want them to be best placed, but the evidence is that they are not.

  Dr Cassidy: No. Quite the reverse, in fact.

  Q132  Stephen Hesford: How well, in your experience, talking to your colleagues, do you think GPs are currently doing in that regard?

  Dr Cassidy: It will vary from different parts of the country. I think there is a commitment to do it. There is a belief that something about alcohol should be in primary care. As I mentioned before, there are a lot of things which inhibit it happening. I work in Newcastle and in the Department of Health big research project we worked on how much is too much, the new programme. We worked very hard to understand the training needs of the practitioners. There is misunderstanding about what works and dependency and hazardous and harmful. There is a need for good training packages, there is a need for structural changes, such as the new GP contract, and, as I alluded to before, a need for change in the whole climate and culture, so that GPs feel they are not doing all the work—so government changes. When you get involved with practices and you do the training, most of them tend to pass some of the work to their nurses, so we think about primary care teams, it is not just the GP. But there is something special, hearkening again to the consultation, in the relationship, because of the huge stigma of alcohol. We have the opportunity to de-stigmatise it and bring it up as a public health issue and bring it to people's attention and then guide people through the different treatment pathways. Sometimes that may be a GP doing it, or quite often it may be referring to a nurse or sometimes an alcohol health worker.

  Q133  Stephen Hesford: Do GPs have what I would call an old-fashioned view, that they do not see drink as a problem? They drink. They drink quite a lot. They just do not get it.

  Dr Cassidy: When you do qualitative research with the GPs that is an issue. If it is 23% of the population, there will be a certain percentage of the people here drinking too much probably—a little bit. You have to bear that in mind. Again harking back, it is making people realise that it is not just about dependency. Over the last 20 years we have moved into thinking about hazardous and harmful, I think, once you have sensible conversations and show people the evidence, how it affects hypertension, how it can affect strokes.

  Q134  Stephen Hesford: Is training a big issue?

  Dr Cassidy: Training is a big issue. That is where primary care organisations have a role to facilitate that. Government can have a role by encouraging PCTs to do that, putting that in performance targets, and having good training materials and changing computer systems so that they work very quickly.

  Q135  Stephen Hesford: We had a brief presentation before the evidence session from our colleagues who are assisting us, and one of the statistics we had then was that in 2004—and I know that is slightly historical—GPs in 70% of the cases where they had a presentation in front of them that is alcohol related, failed to refer on to specialist services for treatment. If that is right, why would that be the case? Is that now historic and are we getting better?

  Dr Cassidy: No. Harking back to the fact that we need more specialist services for the dependent drinker, there is a pessimism: you pick somebody up and there is a long waiting list to refer somebody in for more complex treatment, so you get discouraged and you think, "I'm not going to pick it up. I'm not going to do anything." That occurs in other public health arenas—say obesity, and smoking in the past—but once you get extra resources and help to do it, people will start referring in. We also know the figures. Some people say that 98% of hazardous and harmful drinkers are not picked up in the consultation—so if you just go on stereotypes—you know, the guy with the purple nose the obvious alcoholic. To pick people up at the early end, we have to screen them. We have to use some clever screening questionnaires and integrate that into our practice.

  Q136  Stephen Hesford: You come on to my next point. We have been helpfully provided with information about the Paddington Alcohol Test for early intervention, and we were told about brief interventions before. Do GPs have access to that? Do they routinely use it? It is a brief questionnaire. We have a copy of it here. Should they use it? Should that be available to them?

  Dr Cassidy: GPs have access to lots of screening questionnaires and we are constantly refining and asking the question which one do we use. On the whole, I would guess, GPs would not use that one as much.

  Q137  Stephen Hesford: It is for emergency admission.

  Dr Cassidy: Yes. There are similar ones.

  Q138  Stephen Hesford: You get the idea. There are similar ones.

  Dr Cassidy: Yes. There is one called FAST and there is a very intriguing one which has been looked at in the Department of Health project which is called Single Alcohol Screening Questionnaire—one single question which can help decide whether somebody has a problem or not. It is almost like a pre-screening questionnaire. Those sorts of things are very attractive because people can do them quickly, rather than a big 10-item questionnaire. Although that is the gold standard that a lot of them are based on, it does take a bit of time to do, so people are not going to do that in a normal, routine consultation. We are looking at quicker screening questionnaires.

  Q139  Stephen Hesford: Lynn, do you want to say something?

  Dr Owens: It is very important to say that the screening is a staged approach. NICE are doing work on what screening tools may be best utilised within different healthcare settings. Within primary care, the audit PC, which takes about a minute to administer, is the current advice; in A&E there are things like the PAT. If you get positive results, then you screen further, so it is very much a staged approach. To reinforce what Paul said, primary care is about a whole team, and there are individuals within that team who would be best placed to give different types of intervention. That goes from the receptionist through to the GP to the nurses, the health visitors, the midwives attached to practice. I think we have to see primary care very much as a team approach if we are going to be successful in responding to all patients' needs, because, although a patient may visit their GP surgery, very often it is the practice nurse whom they see for things like hypertension, screening, diabetes, and so we have to utilise that workforce as well.


 
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