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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