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Can brief alcohol interventions improve health population-wide?

This entry is being updated and revised. The following text is not a final version.

Though they started with the engagement and treatment of dependent drinkers, the advent of brief interventions represented a radical realignment away from achieving abstinence among a (relatively) few ‘alcoholics’, to reducing harm and preventing more serious problems among the bulk of non-dependent heavy drinkers (1 2). Instead of narrow and intensive, the strategy was (and remains) to spread thin and wide, deploying easily-learnt interventions delivered in a few minutes by non-specialist staff.

More importantly, the targets were no longer to be drinkers forced to or who chose to seek help, but the far greater number whose sub-critical consumption generated no impetus for intervention. They were to be identified by biochemical tests, a few screening questions, or clinical signs, while coming into contact with services for other reasons, creating the package variously known as ‘screening and brief intervention’ or ‘identification and brief advice’. The expectation was not that each individual receiving this minimal package would improve, but that the packages could be broadcast so widely that even if only a small minority responded to a small degree, the result would a worthwhile improvement in health across a population of drinkers. Unlike treatment, the population was the target for change, not the individual.

Among these drinkers there was no platform of existing serious harm from which to justifiably insist on abstinence, and no joint-enterprise created between a patient acknowledging the need for help and the clinician offering that help. Motivational interviewing, with its focus on non-confrontationally generating motivation to change, came to be seen as an appropriate style for the interventions, though simpler advice-giving and didactic approaches are also common.

Especially in the absence of effective population-level measures like increased price and diminished availability which materially obstruct continued heavy drinking, screening and brief intervention offers a relatively inexpensive strategy to generate voluntary change, which in theory can reach a large proportion of at-risk drinkers. Usually these are defined as exceeding national drinking guidelines or scoring as risking alcohol-related harm on screening tests. From the start, primary care was seen as the key delivery vehicle, since it reached entire populations, not just those with identified serious illness. Partly because this setting has been a focus for the research, it also has the strongest research record of reducing drinking through brief interventions. As the key setting in public health terms, primary care is the focus of this hot topic.

National policies embrace brief interventions just as doubts increase

From their origins in research in the 1970s and 1980s, screening and brief intervention have come to form major planks in national public health and alcohol strategies, and their implementation has been promoted through high-profile national programmes backed by funding, training and implementation targets, now in the UK transitioning to the embedding of this work in routine medical practice. But just as their policy and practice significance has reached a peak, doubts have been building up over whether the initial promise to substantially contribute to improved public health will be realised. The doubts broadly fall into two categories: whether real-world screening/brief intervention really does reduce consumption sufficiently to improve health; and whether these programmes can be implemented widely and well enough to improve health across an entire population.

Contrasting with the faith placed in brief interventions in national UK policy is the downbeat verdict of a UK and US expert who have themselves researched brief interventions. In 2017 they bluntly summed up the evidence as they saw it: “After more than three decades of study in primary care, it now seems unlikely that brief interventions alone confer any population level benefit, and their ultimate public health impact will derive from working in concert with other effective alcohol policy measures.” What made them reach this conclusion was the lack of convincing evidence that in real-world circumstances, brief interventions do reduce alcohol-related ill-health, coupled with the difficulty of persuading GPs to focus on not-very-heavy drinking when the same patients often have multiple lifestyle risk factors, and both they and the doctors may be more concerned with existing problems, rather than the possibility that their drinking will cause harm.

Scepticism is apparent too among the doctors who would have take on or champion this work. With sufficient incentives and sanctions, medical staff can be persuaded to screen and advise at very high rates, but this comes at a cost – not just in resources, but in what could have been done with the same time if practitioners and patients had been freer to decide their priorities. In 2012 an editorial in the Lancet medical journal caustically observed that “lecturing” patients about their lifestyles takes up time in the average 12-minute GP consultation which could have been used to more fully address why the patient attended in the first place, or some other condition or lifestyle threat – uses which might more cost-effectively improve health than a diversion to drinking. Perhaps, the Lancet hinted, brief interventions are themselves a ‘diversion’ from politically risky but more effective public health strategies, like eliminating cheap alcohol by setting a high minimum per unit price.

After an onrush of optimism fuelled by some success in tightly controlled trials, and the embedding of screening and brief interventions in national policy, a rethink is happening. Not least in impelling this rethink are the results of what was seen as a definitive trial of relatively real-world screening and brief intervention in England, one the government was waiting on to determine its stance on incentivising this work in primary care – the SIPS trial.

Should the SIPS trial mean the end of ‘brief interventions’?

For the future of alcohol screening and brief intervention in Britain, studies do not get more important than those highlighted in an Effectiveness Bank bulletin issued in May 2012. It summarised findings released by the SIPS project, funded by the UK Department of Health in 2006 to evaluate different ways of identifying risky drinkers through routine screening, and different forms of brief advice to prompt them to cut back. These preliminary findings were followed by formal journal publications from the primary care, probation and emergency department arms of the study. In each case the results can be interpreted as justifying reversion to an unsophisticated warning about excessive drinking rather than what has commonly come to be defined as a ‘brief intervention’.

“Thank you for taking part in this project. Your screening test result shows that you’re drinking alcohol above safe levels, which may be harmful to you. This leaflet describes the recommended levels for sensible drinking and the consequences for excessive drinking. Take time to read the leaflet. There are contact details on the back should you need further help or advice.”

Unexpectedly, across all three settings and whatever the intervention, a year later the proportion of risky drinkers had fallen by about the same amount. Most basic but no less effective was a 30-second warning ( panel), which for Britain’s National Institute for Health and Care Excellence would not count as a brief intervention at all, and which the researchers intended as a ‘control’ condition against which the more sophisticated and longer interventions could shine. Instead, supplementing this with an individualised brief intervention based on relatively sophisticated counselling techniques and scientific understandings made no difference. Another important finding was that implementation often required specialist support and patient throughput was low, suggesting there will be difficulty in reaching a large proportion of the population. Incentivised with per patient payments, most primary care practices managed to implement the interventions, but 10 needed help from research staff and nine of 24 practices did not recruit the targeted 31 patients over the 15 months of the trial. The average practice identified just two risky drinkers per month.

Experts have stressed that the findings do not mean handing over an alcohol advice leaflet is all it takes. Screening plus the script of SIPS’s ‘control’ intervention incorporated assessment, strong feedback on that assessment, an implicit call to action to stop “excessive” drinking above “safe”, “recommended”, and “sensible” levels, and a reminder in the form of the leaflet, ingredients of a potentially effective intervention. Interventions came after patients had been quizzed by researchers about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. Also, while what the interventions were intended to be is clear, what was actually done is not.

In the end these niceties seem to have mattered little. UK policy and expert opinion continue to advocate the more extended interventions the SIPS trials failed to vindicate, while others will be convinced the trials have shown that for brief interventions, very small and very basic really is beautiful. Do just the minimum, is the message austerity-hit commissioners might receive, encouraged by the “Less is more” take on the study from the Department of Health’s Director of Health and Wellbeing.

Such views are backed by studies which have found little evidence that longer or more elaborate brief interventions have greater effects (1 2 3 4 5). From the UK these studies include a trial in primary care which contrasted five minutes of brief advice with a 20-minute counselling session plus referral for treatment if indicated. Conducted in England and Scotland, it found no significant differences in drinking reductions, alcohol-related problems, quality of life, cost-effectiveness or costs to society. An earlier study in Wales piloted similar interventions and also found no significant differences in drinking reductions, alcohol-related problems or quality of life. Conclusions were similar in another trial which tested a 5–10-minute brief intervention delivered by primary care practice nurses against usual, unstructured advice from nurses in other practices. Some of these studies judged that probably the longer interventions were cost-saving or gained quality-adjusted years of life at an acceptable extra cost, but these findings could not be relied on due to the statistical insignificance of differences they were based on.

Is there any effect at all in real-world trials?

The SIPS trials left one rather damaging possibility. Rather than being equally effective, perhaps all the interventions – including the brief warning – were equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. If in the circumstances of the trials, advising drinkers was inherently ineffective, it would explain why piling on yet more ineffective advice in the form of the longer interventions made no difference.

Underlying current policy in England is NHS England’s expectation that implementing alcohol screening and brief intervention will save the health service money because less drinking will mean fewer alcohol-related illnesses and injuries, in turn leading to fewer hospital admissions. The result is an estimated annual saving of £27 per briefly intervened patient over four years, and more if other health service costs are taken into account.

This estimate was based on a then unpublished simulation model which has now been published. Analysts estimated that spread over the 30 years after the intervention, screening and advising newly registering primary care patients would cumulate to a saving of £215 million in alcohol-related costs such as hospital admissions, while screening and brief intervention itself would have cost the same services just £95 million. Patients who received the brief interventions would in total gain 32,000 extra years of life adjusted for quality (QUALYs). The combined result would be that the health service would improve health by implementing the programme, and at the same time save money – seemingly an unmissable bargain.

The next-registration screening strategy modelled by the analysis is directly relevant to current policy in the UK below. The simulation suggests this strategy would be a worthwhile start, but over ten years would not reach the majority of the adult population. More would be spent but much more gained too from screening at the next visit.

However, both the modelled strategies would only create the calculated gains if they really do reduce drinking and/or change drinking patterns in ways which reduce harm and prolong and/or improve patients’ lives. This they might do, but the evidence relied on in the analysis is not robust enough to be confident of this key element in the calculations. It derived from an amalgamation of the results of primary care brief intervention trials which attempted to answer the crucial question of whether effects would transfer from tightly controlled research studies to routine practice.

To this the answer was encouragingly affirmative, a conclusion which rested largely on the finding that impacts in the more real-world trials did not significantly differ from those of trials further divorced from routine practice, but how real-world any of the trials were has been questioned. Notably (more in these background notes), the ‘real-worldness’ of the amalgamated trials applied only to their brief intervention phases. Before this came the selection of sites and of patients at those sites willing to participate in the trials, and the crucial screening process. Once patients were in the trials, further whittling usually did or may have happened, further reducing confidence in the applicability of the findings to patients overall.

For example, the British trial assessed as most relevant to routine practice recruited only a quarter of the practices it approached (many said they had no time) and just over 1 in 10 contributed data to the analysis. The results cannot be assumed to be representative of what would happen in a typical practice, and if they were, the conclusion would have to be that the kind of brief intervention recommended today cannot be shown to save more health service resources than usual, unstructured advice from a nurse, despite costing nearly £29 more per patient in 2001/2002 prices.

There have been trials which more closely approximated what can be expected to be routine practice, but it seems these have foundered due to non-implementation of the interventions and/or did not find significant effects.

In the Netherlands, it was worse – not just no effect, but a negative one, from a trial said to “reflect the effects of such a programme when conducted in a naturalistic setting” – in other words, what happens when a close to real-world attempt is made to train and support GPs to identify and advise risky drinkers among their patients.

Of 77 primary care practices, 40 had been randomly allocated to be offered extensive training and support to implement alcohol screening brief intervention. With this support, two years later 36% of their risky-drinking patients had reduced their consumption to a low-risk level. But in practices not encouraged and supported to conduct brief interventions, the corresponding figure was 47% – a statistically significant difference in favour of not trying to train and support GPs to offer screening and brief intervention: “Therefore, we concluded that the intervention did, in fact, increase the odds that patients would continue with hazardous or harmful drinking.” One possible reason was that all the patients including those at non-supported practices were mailed personal feedback and advice on their drinking.Given poor implementation of the intervention programme ( below), this might have been enough to precipitate whatever changes in drinking were going to happen.

The complaint that it is invidious to focus on alcohol when patients often have others and multiple lifestyle risks was a addressed by a Welsh trial of a brief intervention in which GPs or practice nurses and patients choose which lifestyle behaviours to focus on. Patients were asked to join the study when they were at risk due to their diet, lack of exercise, smoking, or drinking. Outcomes three months and a year later for patients in practices randomly allocated to be trained in the intervention were compared with those not trained. At issue was whether patients had improved on in respect of any of these behaviours sufficiently to expect their health also to have meaningfully improved. When the criterion was change on any one or more, there was no statistically significant difference and at the 12-month follow-up the proportions who had improved were virtually identical regardless of the training given the practitioners. On drinking in particular this was also the case, except that at 12 months the trend was for greater reductions in drinking among patients seen at the untrained practices. There were some significant beneficial effects on exercise and diet but of doubtful clinical importance. None of the clinical assessments of lifestyle-related health a year after patients had been to the practices significantly favoured the trained practices.

On the critical question of whether screening and brief interventions improve health, the answer is, we simply do not know

If the benefits in terms of reduced drinking leading to improved health factored into the ‘save £27 per patient‘ estimate are uncertain, the costs too might be considerably greater. To induce GP practices to screen every patient at the next visit might take substantial incentive payments and/or costly procedures to check the work really had been done to an acceptable standard, neither seemingly costed in to the calculations.

A later attempt to assess the cost-effectiveness of screening and brief interventions for risky drinking in primary care found simulation exercises which suggested these programmes are cost-effective health improvers. Some of these simulations must have faced the same limitations in the ‘real-worldness’ of the source studies they relied on as the analysis behind NHS England’s expectations of health service cost-savings. When the analysts focused on evaluations which had actually measured health gains rather than extrapolating these from drinking reductions, they admitted that the results “do not allow any firm conclusions to be drawn”. In other words, on the critical question of whether screening and brief interventions improve health, the answer is, we simply do not know.

Ambition scaled back

Not so long ago virtually universal screening of adult primary care patients was seen as the prime way to start to reduce the burden of alcohol-related harm through screening and intervention. Now the ambition in England and in Scotland has been scaled back to screening new patients and/or those thought in advance to possibly be at risk (so-called ‘targeted’ screening), diluting the hoped-for public health benefits of a mass programme.

This issue too was addressed by the SIPS project. In primary care it found (1 2) that though the targeted method started with fewer eligible patients (1274 v. 1717), it ended up netting more patients who screened as risky drinkers (461 v. 439), because it was more likely to reserve screening for patients who were heavier drinkers. However, over a quarter of the patients who did not meet the targeting criteria turned out to score as risky drinkers. In a targeted strategy, their drinking risks being ignored.

On the assumption that a universal strategy truly would be universally implemented, not missing risky drinkers may be the decisive consideration. But if targeted screening – (favoured by primary care staff – encourages more complete implementation, the balance could shift in its favour. In Sweden, more or less universal screeningwas achieved by making this routine on reception to the surgery. The results were passed to the clinical staff seeing the patients. It meant they raised the issue of drinking twice as often than if they had been left to identify drinking as an issue based on clinical signs and their own judgements.

Such findings have not been enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. These factors could also mean that in routine practice, targeted screening is more completely implemented than universal, potentially eliminating the latter’s advantages identified in the SIPS trial.

The route from screening nearly everyone to today’s less ambitious plans was punctuated by heated arguments over whether it was appropriate or feasible to ask GPs to question patients about their drinking, when this was not why they came to see the doctor and there was no apparent reason to raise the issue. Controversy peaked when in 2003 a review in the British Medical Journal concluded that on average 1000 patients have to be screened to gain just two or three no longer drinking to excess. It was not necessarily that brief advice was ineffective, but that so few patients got to the point of receiving it. Critics hit back, but British studies (referred to in this Effectiveness Bank analysis and detailed in these background notes) confirmed that very low rates of screening and intervention were the norm.

Strong management levers can extend intervention

The US Veterans Affairs (‘VA’) medical service for former military personnel offers a large-scale exception to the implementation shortfalls typical in real-world conditions, but their evaluations show that despite this achievement, many risky drinkers are not identified and there may at best be only minor impacts on drinking.

Faced with a high proportion of risky drinkers among its largely male primary care caseloads, the service mounted possibly the most determined and successful effort yet in a national health service to routinely implement virtually universal screening for risky drinking and to prompt primary health care staff to respond with brief counselling or referral to alcohol services. Deploying powerful management levers which hit the wallets and purses of managers if performance targets were not met, the service screened over 90% of outpatients nationwide using a single question to establish if the patient drank at all, followed if they did by the three questions of the AUDIT-C questionnaire. Though quantity was there, screening quality was called in to question when it was found that 61% of patients who screened positive when sent a postal survey did not do so when the same questions were asked as part of their routine care.

The next step was to prompt clinicians to intervene with positive-screen patients and to embody this too in a performance target. As with screening, this substantially elevated brief intervention rates. It also seemed to reduce drinking, but only as long as there were management expectations on the clinicians not to dismiss the electronic reminders. However, the interventions stimulated in this way reduced drinking only slightly, and without randomising clinics or patients to be counselled or not, the results were vulnerable to bias, leaving as yet no convincing demonstration that this effort had the intended impacts. In turn this may have been due to the inability to assess or influence the quality of the counselling, and even whether, despite the clinician having recorded this, it really happened.

Across an entire VA region’s 30 medical centres, drinking outcomes after brief intervention have been also been disappointing. Using VA records, it was found that patients who screened positive for risky drinking and were re-screened around a year later were no more likely to have stopped risky drinking if their records indicated that had participated in a brief intervention than if they did not. The remission proportions were virtually identical – adjusted for other factors, 47% with advice, 48% without. Results from this early phase of the new national system offered no encouragement to its continuation, though results may change as the system beds in and is developed.

To standardise quality and improve the consistency of delivery rates, the service tried automating brief intervention via a web-based program, but it had no demonstrable impact on drinking over and above the service’s mandated but patchily delivered usual alcohol advice requirements. The program featured the strategy of feeding back to positive-screen drinkers the degree to which they exceeded typical drinking amounts, also featured in real-world trials of web-based brief intervention among college students in Sweden and New Zealand. These too found no or at best very small extra reductions in drinking which might not have been due to the interventions, meaning real-world web-based intervention has largely failed at both ends of the age spectrum in very different populations.

The Veterans Affairs experience shows that incentives can divert clinical practice in desired directions, but at the risk of staff doing enough to attract payments or meet targets, but not enough or not well enough to improve patient welfare. Without professional commitment, the figures may be manipulated to record phantom interventions, believed to have happened at some primary care practices paid for intervening in England, and in Scotland among health staff working in non-primary care settings. Their accounts suggested that targets created “perverse incentives to maximise reporting of [alcohol brief intervention] delivery”.

More anecdotally, among general practices incentivised by payments, quality deficits have been observed in England (1 2) and in Scotland, where some practitioners were said to have adopted a relatively “perfunctory” approach to advising patients. From the borough of Haringey in London, Unfold supplementary text take a look at this revealing account of what can happen.

Elsewhere in the USA, ‘booster’ training and incorporating screening questions in simple-to-implement procedures which matter to the service (in this case, for their quality accreditation) has resulted in over 80% of patients being screened. Recorded brief intervention rates too were elevated to over 60% by making it easy to record an intervention and doing so in a way which included this in quality reviews of the clinician’s performance. Even in the unpromising environment of an emergency department, near universal screening and acceptable intervention rates can be achieved if the need to screen/intervene for each patient is visible to staff and made easy to meet, and staff supervision includes monitoring performance and correcting underperformance.

Though the more complete the implementation the greater the chance of population-wide benefits, patchy delivery and modest impacts do not necessarily mean a programme is worthless. In a health care system which repeatedly sees the same patients, low rates of intervention can cumulate over the years to a programme which touches a high proportion of patients, and minor gains per individual can sum to appreciable public health gains.

Without material, reputational and possibly career-affecting sanctions/incentives, even a determined implementation drive based on raising awareness and education can end in just a trickle of interventions. That was the case in the Netherlands, where ( above) offering training and support to primary care practices to implement screening/brief intervention led their patients to more often continue risky drinking.

It started with an invitation to 2758 general practices to join the study which ended up netting just 77 practices with 119 GPs, an early sign of a lack of interest in the issue. Of the 40 randomly allocated to be offered training and support to implement alcohol screening brief intervention, half did not complete what was considered a minimal programme involving all the GPs attending a training session. Screening and intervention rates did not significantly improve in comparison to practice not offered support and training. A year after being offered support GPs at the practices reported screening only 1 in 8 patients (fewer than before training and support) and counselled 1 in 20. Medical records told a similar story. The researchers had to admit that “Despite this relatively intensive programme aimed at provider, organization and patient, we did not find significant differences in change between the intervention and control groups … The degree of participation in the training sessions and visits was frugal.” It seemed that incomplete training left the doctors feeling less confident of delivering alcohol-related care than before the intervention.

The Netherlands was one of the European nations in a five-nation trial of how to increase the rate of screening and advice for risky drinking in primary care relative to merely giving GPs information on national recommendations and asking them to screen all adult patients. Training/support, paying for each patient screened and each advised, or asking GPs to refer risky drinkers to a web site offering advice, were on their own all associated with roughly a doubling in the proportion of adult patients advised about their drinking. Together, support and payment made the largest difference, increasing the intervention rate by 2.3 times.

None of these differences was statistically significant, but there were statistically significant impacts when the analysis assessed whether among all the combinations of intervention-promoters, certain elements seemed to make a difference. In this analysis, payments emerged as the most important component, while training/support made no significant difference – a pattern of results partly due to combinations of implementation-promoters performing not much better, and in some cases considerably worse, than single-component programmes. However, even the most effective combination would across the entire sample have raised the proportion of risky drinkers seen by the GPs who received advice from an estimated 3% before being implemented to about 9% afterwards.

Without knowing if there were any impacts on the patients, the most the researchers could say was that jurisdictions “could consider” promoting for brief alcohol advice in primary care through training and guidance, financial and performance management arrangements, and strategic leadership.

The UK experience is also that without strong incentives implementation is very poor. Since GPs generally fail to implement, attention turned to practice nurses, but they too screened just a handful of patients. This finding emerged from a British study which offered training and support options to practice nurses (1 2). Out of 270 nurses approached, 212 agreed to use the programme for three months and 128 implemented it, screening 5541 patients and intervening with 1333. The most expensive option (training plus continued support) resulted in the greatest number of interventions and was also the least costly per patient who received a brief intervention. Nevertheless, nurses offered this support (including those who did and did not go on to use the programme) typically screened just 4 patients a month and intervened with one every two months. The biggest shortfall was in the screening rate; just 2% of patients seen by the nurses were screened. Of those found to be at risk (28%) an intervention was delivered to 64%. With training but without support the corresponding figures were 1%, 24%, and 60%. The screening shortfall was partly because universal screening was not attempted. Instead, most of the nurses who implemented the programme “did so opportunistically, that is when they had enough time to undertake the extra screening and intervention activity. Programme implementation also tended to occur in specific contexts such as new patient registrations, well person checks or in chronic disease monitoring clinics.” In other words, screening occurred usually only when the nurses had the time not just for this, but also for any ensuing intervention (typically taking five minutes) or when such checks were a natural ingredient of broader health checks.

This study was one of several UK implementation trials with similar implications described in our background notes on a Dutch trial which found no impacts on drinking or related problems from a primary care brief intervention. In ‘debriefing’ sessions the doctors expressed considerable discomfort with the intervention, fearing that doctor-patient rapport would be damaged by introducing drinking ‘artificially’ when the patient was attending for some other reason and without a naturally emerging clinical prompt. Despite the likelihood that the GPs who volunteered for the study were highly motivated, almost universally they said they would not carry on screening.

A US trial established what it believed was an upper limit on the willingness of primary care doctors to conduct brief alcohol interventions (and also refer patients to the research team) without this being mandated or these being direct financial or career consequences. The doctors were to undertake this work within a liberally timed one-hour health check for patients identified by the research team as possibly risky drinkers. Mechanisms to increase the brief intervention rate included training, feedback, and for each referral, thank-you notes, chocolates, and a contribution to the doctor’s continuing medical education fund. Still just 39% of risky-drinking patients were referred to the researchers after presumably being offered a brief intervention by the doctors.

UK policy and guidance

Even in its more limited targeted form, screening plus brief intervention remains an important policy strand in the UK. In England, directors of public health are expected to include it among attempts to address the population-wide determinants of ill health, in line with guidance from the National Institute for Health and Clinical Excellence on prevention and treatment of drinking problems and associated quality standards and guidance for commissioners. These documents’ insistence that commissioners and managers of NHS-commissioned services “must” ensure staff have enough time and resources to carry out screening and brief intervention work effectively seems a tall order, given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation and the need for specialist support – and this in services which had volunteered to participate in the studies.

The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of primary care practice. That was not done, but screening for risky drinking and follow-on brief intervention – formerly merely required to be incentivized in each local area – were from April 2015 required of every GP practice in England for all newly registered patients as part of the core national contract for primary care services. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses.

The need for a new system for GPs seemed indicated by the results of household surveys conducted in England in 2014. Though in bth cases about 60% had in the past 12 months been to their GP’s surgery, just 6.5% of risky drinkers recalled being invited to discuss their drinking, compared to 50.4% of smokers invited to discuss their smoking, making smokers nearly eight times more likely than risky drinkers to receive a brief intervention or advice of any kind from their primary care service. In fact, risky drinkers were more likely to be advised about their smoking than about their drinking. There was evidence of targeting; for each point on the screening test above the risky drinking threshold the odds of the patient recalling a brief intervention were 17% greater.

One reason for the greater coverage of smoking interventions is likely to be their incentivising through the substantial sums specified under the Quality and Outcomes Framework applicable to all practices, rather than the (at that time) discretionary and smaller payments in relation to drinking – a double-edged sword, because the greater the payment, the greater the temptation to record interventions which have not happened or which do not meet quality standards.

Under the contract with GPs, screening is to be done with the three or four questions of the FAST or AUDIT-C questionnaires, and followed up for positive-screen patients with the full ten questions of the AUDIT questionnaire. Based on the risk level revealed by the last screening step, patients should be offered brief advice, more extended counselling, or referral to specialist services, though so far results from the SIPS trial have not indicated that brief advice or more extended counselling offer extra benefits compared to a basic warning and leaflet, even for higher risk drinkers. Each step of the process is to be recorded by GPs for a nationally collected dataset and the records are intended to be audited by local commissioners to ensure the required actions were completed. In theory this would enable the identification of practices which, with no financial incentive to screen and advise, either fail to screen or record an abnormally high proportion of patients as not needing further testing or advice.

Similar work has also been incorporated in the NHS Health Check for older adults, intended to be repeated for each patient every five years. From local studies it seems clear that universal alcohol screening and advice has not been incorporated in the checks, though still many patients have been prompted to think about their drinking who might not otherwise have done so. Uptake of the check has sometimes been below expectations, but each year it engages substantial minorities of patients (1 2). Data collected in 2011/12 from Gloucestershire primary care practices showed that 54% of patients who attended a health check were screened for risky drinking, the lowest proportion of all the lifestyle risk factors. Based on the population there were expected to have been 839 referrals for further intervention for problem drinkers, but there were just 17; how many took up the referral was not reported. Alcohol was raised with about 52% respondents to a survey of health-check attendees at risk of cardiovascular disease among GP patients in Stoke-on-Trent, and of these 36% said they had as a result cut down on their drinking. In numbers this was 82 patients, though in the survey just 27 had owned up to drinking excessively. In England’s north-east region, interviews with 29 patients who had attended a health check revealed that 24 could not recall their drinking being discussed.

A key issue which concerned attendees at a conference on alcohol screening and advice in England in 2015 was the quality of GP brief interventions. Based on the evidence in relation to smoking, once the incentives are high enough, this could become a major issue. When brief interventions for smoking were incorporated in the national quality framework, a gap opened up between the interventions recorded by GP practices and those recalled by patients. One explanation is that GPs were more often recording advice which was in fact not given, or not given in such a way that it registered with the patients.

Part of the reason for that concern was a study across the UK of patients who registered with a general practice in 2007, 2008, and 2009. The good news was that primary care records for 76% of the 382,609 newly-registered patients who had been registered for at least a year indicated that they had been asked about their alcohol a validated screening test. Perhaps partly for that reason, recorded consumption was much lower than the levels expected on the basis of face-to-face population surveys. Nearly twice as many patients were recorded by their GPs as not drinking at all, and only 2% of men and 1% of women were recorded as higher-risk drinkers, compared to 8% and 7% respectively in the surveys.

Reverting to universal screening – at least for inpatients – – in England in 2017/18 and 2018/19, mental health and community NHS providers, and in 2018/19 NHS acute hospital services, will be able to supplement their income under the heading of “Preventing ill health” by implementing screening, brief advice and referral in relation to smoking and drinking.

The incentives are offered under the CQUIN (Commissioning for Quality and Innovation) system, and form one of its set of 13 national indicators, six applicable to the services incentivised to extend their interventions for smoking and drinking. If they meet implementation targets for all six, the reward is another 1.5% of their annual grant. Lesser payments are made for improved performance short of the target. For preventing ill health, the total potential reward is 0.25%, of which the drink-related measures compose half, equally divided between screening for risky drinking and advising or referring on as a appropriate. The sums to be gained are not huge: in a £10 million acute trust, amounting over two years to £6250.

Excluding maternity wards, the incentives apply to patients admitted to the hospitals for at least a night, so also exclude emergency department attendances unless these result in an admission. However, NHS trusts are encouraged to embed these interventions throughout their operations.

The base for screening is all adult inpatients and the reward-attracting target is to document the screening of 50%. As well as giving leeway to exclude patients too unwell to participate, this target may in practice allow for a degree of selection. Delivery of brief advice to patients whose screening scores exceed low-risk drinking levels, or for possibly dependent drinkers, offering referral to specialist services, is separately rewarded. Here the target is to intervene with at least 80% of patients who screen as risky drinkers, raising the possibility of ‘gaming’ by using screening procedures which minimise identification of risky drinkers, enabling trusts to scoop the rewards by meeting the intervention target by advising fewer patients.

Scotland pioneers national programme

Scottish national alcohol policy prioritised screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded and similar targets were set for the following years and again exceeded, topping 94,000 in both 2011/12 and 2012/13 and reaching 104,356 in 2013/14 before falling to 99,252 in 2014/15, substantially exceeding targets in the last year before the programme was absorbed into NHS plans agreed between local health boards and the Scottish government, intended to “strengthen the continued aim of embedding [brief alcohol interventions] into core NHS business, ie that [brief alcohol interventions] are part of the day-to-day practice of health professionals and others, not an add-on to their role”.

In the first year (2015/16) of the new system, 97,245 alcohol brief interventions were recorded in Scotland, continuing the trend down since 2013/14, a trend most noticeable in the three priority settings where the programme started in 2008/09 – primary care, emergency departments and antenatal clinics. In those settings what was 84,444 brief interventions in 2013/14 had fallen by nearly a fifth to 67,861 in 2015/16, almost certainly due to a waning in primary care, which accounts for by far the largest number. Still, targets were again substantially exceeded.

The targets relate to meeting the corresponding standard of service intended to sustain and embed alcohol brief interventions in primary care, emergency departments and antenatal clinics, and extend them to other arenas. The recommended brief intervention approach for primary care (1 2) leans heavily on motivational interviewing. Like the English guidance, it ignores the apparent lesson of the SIPS trial that a basic warning and leaflet is as effective as longer and more sophisticated counselling.

An evaluation found that “healthcare staff see the delivery of [alcohol brief interventions] as a worthwhile activity for NHS staff”. But of the three settings, only primary care practices really accepted the challenge: head-count financial incentives, the ability to seamlessly advise after screening, and more of a feeling that this was an appropriate activity, lifted their performance way above emergency departments and antenatal clinics. But even in GPs’ practices it seems most risky drinkers attending the practices were not screened and the quality of the work was unclear. The barriers identified in an international review remained evident, particularly in antenatal and emergency care settings, which accounted for relatively small numbers of interventions. Competing priorities, not enough time, concerns over relationships with patients, feelings that this was not what you should be doing, all hampered implementation. These influences were also evident in the SIPS trials in England, where payments to primary care practices seemed decisive in their greater (though still disappointing) throughput. Nevertheless a simulation model of the health impacts of the Scottish national programme estimated that it had made a small contribution to the decline in alcohol-related harm in Scotland, even if the brief interventions had been successful in only 15% of cases. To reach this estimate the report did however have to make some bold assumptions about the drinking and mortality reductions to be expected from the programme.

Local health boards decide how to generate this activity, and it is clear from interviews with 13 GPs shortly after the system changed that paying for it is an important incentive. All the GPs also said that the biggest and most frequent barrier to an effective brief intervention was lack of time in a consultation lasting barely more than 10 minutes, which primarily has to address the complaints which brought the patient to the surgery. Time is in turn linked to money because sufficient money can help pay for extra time.

A companion study also funded by Scottish Health Action on Alcohol Problems fused on the financial incentives in primary care. It found clear evidence that these affected delivery. If screening was incentivised but not intervention then screenings were abundant, yet led to few patients receiving a brief intervention. In the same case-study area, when the system changed to target delivering the intervention, 41% of recorded screenings were followed by an intervention. Interviewees said money was not the only factor, but it was a key one.

Brief interventions have tremendous public health potential; consistently realising that potential is today’s challenge. See all our relevant analyses by running this hot topic search, or go to the first row of the Alcohol Treatment Matrix to home in on seminal and key studies, reviews and guidance.

Last revised 21 September 2017. First uploaded 01 May 2010

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