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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 widespread voluntary change among 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

Hot topic plan

After introducing the topic we examine:

From Should the SIPS trial mean the end of ‘brief interventions’?, whether real-world screening/brief intervention really does reduce consumption sufficiently to improve health.

From Strong management levers can extend intervention, whether these programmes can be implemented widely and well enough to improve health across an entire population.

From The abandonment of universal screening, how UK policy has responded to these findings, focusing on the retention of the ambition to conduct universal screening.

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 UK and US researchers 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.

To a degree these doubts are inherent in the nature of brief interventions. Such minimal interventions not very far from the normal practice against which they are compared, conducted with not-necessarily motivated patients, could not be expected to produce large, easy-to-detect effects on drinking, and even more so on health outcomes only marginally affected (if at all) by small drinking reductions. The point about them is that they are undertaken ‘opportunistically’ during contacts made for other reasons and when clinicians and patients have other, more immediate priorities, inherent barriers to implementation. Demonstrating effectiveness in a widely implemented programme was always going to be difficult, and a ‘not-proven’ verdict a likely conclusion – one which does not exclude the possibility of there being real and positive effects, but which judges not yet established to scientific standards.

After optimism fuelled by some success in controlled trials leading to the embedding of screening and brief interventions in national policy, a rethink is happening, which can be understood as the emergence of these inherent limitations as the evidence base expands into more real-world trials. 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 government was waiting on to inform 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.”

For NICE, not even a brief intervention: the terse warning which matched brief interventions in the SIPS trials

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.

‘Do just the minimum,’ is the message austerity-hit commissioners might receive

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 produced similar findings. 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 the underlying findings.

Expected health gains and cost-savings rely on unreal foundation

Among the possibilities left open by SIPS, one was particularly damaging. Rather than being equally effective, perhaps all the interventions – including the brief warning – were equally ineffective. Without a no-intervention comparator, there was no way of knowing whether the interventions played any part in the outcomes. If in the circumstances of the trials, advising drinkers was simply ineffective, it would explain why piling on yet more advice in the longer interventions made no difference.

This is not, however, an officially accepted interpretation. Underlying current policy in England is NHS England’s expectation that 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, and more if other health service costs are taken into account.

That estimate was based on a simulation model which has now been published. Analysts estimated that over the next 30 years, screening and advising newly registering primary care patients would cumulate to a saving of £215 million in alcohol-related provision such as hospital admissions, yet 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). It meant that via these programmes the health service would improve health 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 UK policy ( below), but even over ten years it would not reach most of the adult population. Also simulated was screening every patient the next time they see their GP; it would cost more, but much more would be gained.

Both sides of the ‘save £27 per patient’ estimate are highly uncertain. First, the costs of screening and brief intervention might be considerably greater. To induce GP practices to screen every patient at registration or at the next visit might take substantial incentive payments and/or costly procedures to check the work really has been done to an acceptable standard, neither seemingly costed into the calculations. But the main doubts lie on the other side – whether the benefits in terms of reduced drinking leading to improved health would materialise in routine practice.

The missing link: evidence of real-world effectiveness

Whatever the screening strategy, screening and brief intervention programmes could only create the calculated gains if they really did change drinking in ways which improved health, in turn prolonging and/or improving patients’ lives. In respect of this key element in the calculations, the evidence relied on in the simulation analysis is not robust enough to be confident of the calculated benefits. 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. With the cachet of the Cochrane Collaboration behind it, this analysis became an influential foundation for cost-effectiveness calculations and policy.

Its answer to the question was encouraging: “Thus not only do brief interventions appear to be effective at reducing alcohol consumption in primary care patients, but this body of published work also seems to be relevant to the real world of clinical practice.” This conclusion 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 few if any of the trials can be considered to have truly been conducted in real-world conditions. Notably (more in these background notes), ‘real-worldness’ was assessed only for the brief intervention phases of the trials. Before this came the selection of sites and of patients at those sites willing to participate, and the screening process which brief intervention relied on to select its recipients and to provide a basis for the conversation. Once patients were in the trials, more whittling down of the samples 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. With it seems at least 18 months and in some cases nearly three years in the study, nurses from the 49 practices in the trial screened just 498 patients. Even on the assumption of only a year to undertake this work, it meant the average practice screened fewer than one patient a month. Over the entire trial, fewer than three risky drinkers were identified per practice. With loss to follow-up, the 12-month results relied on just 78 of the roughly 131 patients approached by the nurses, forming what must have been a tiny proportion of all the adult patients seen during the trial. Results from such a highly selected sample cannot be assumed to be representative of what would happen in a widely implemented national or local programme – and if they were, they were not encouraging below.

We simply do not know whether screening and brief intervention improves health

Based on simulation exercises, a later review also suggested that primary care screening and brief intervention programmes are effective and cost-effective health improvers, but some of these simulations must have faced the same limitations in the ‘real-worldness’ of their source studies as the Cochrane analysis. When the reviewers 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.

Other trials and trials in other settings have 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.

Lessons of history

To British readers, all this should come as no surprise, because Britain hosted the very first brief intervention tested in general medical practice, and the results were disappointing. It had been conducted in Dundee in 1985, led by a prominent brief intervention researcher over two decades later involved in the SIPS trials ( above), to which its results were remarkably similar. Whether screening had been followed by a warning from the doctor much like the SIPS warning ( above), or a brief intervention featuring assessment feedback, a self-help booklet, and further consultations, drinking reductions did not significantly differ. Unlike SIPS, another set of patients had been allocated to no advice on drinking at all, and they too did no worse than the other patients. For the researchers, “The results … provide little support for the hypothesis that the DRAMS scheme [the brief intervention] is superior to simple advice and to no intervention in helping problem drinkers seen in general practice to reduce alcohol consumption.”

Predating SIPS by a few years, another British trial might also have given pause for thought. It was the one assessed by the Cochrane review ( above) as the UK trial most relevant to routine practice. After suffering from low recruitment to the trial and low rates of screening and brief intervention, it found a 5–10-minute brief intervention by primary care nurses no more effective than usual, unstructured advice, despite costing nearly £29 more per patient. On some measures a larger sample might have produced a statistically significant difference, but on the key measure of reductions in drinking, the results were virtually identical: a drop after a year of about 7 UK units a week.

The two trials were relatively real-world, since both screening and intervention had to be done by routine primary care clinicians, unaided by research staff. For similar reasons, the SIPS trials themselves were billed as “pragmatic”, relatively real-world trials. On the basis of all three trials, the implications could range from any post-screening intervention being ineffective, to abandoning brief interventions as normally conceived and letting GPs or nurses issue a simple health warning in their own words of the kind which long pre-dated scientifically constructed interventions.

One way to improve the fit between screening and brief interventions and the reality of general practice is to defocus from alcohol and address the multiple lifestyle risks often presented by patients. Whether this would work was tested by a Welsh trial of a brief intervention during which patients and GPs or practice nurses chose which risk-behaviours to focus on. Patients at risk due to their diet, lack of exercise, smoking, or drinking were asked to join the trial after screening, in this case by research staff. A report published in 2013 compared outcomes in respect of these same risk-behaviours three months and a year later for patients in practices randomly allocated to be trained in the intervention versus those not trained. When the criterion was clinically relevant change on at least one of the assessed behaviours, there was no statistically significant difference; at the 12-month follow-up, proportions improved were virtually identical, regardless of the training offered the practices. On drinking in particular, this was also the case, except that at 12 months the trend was for greater reductions in drinking among patients at untrained practices. There were some significant positive effects on exercise and diet, but of doubtful clinical importance. When health was directly assessed, none of the measures of lifestyle-related health significantly favoured trained practices.

In the Netherlands, it was worse – not just no effect, but a negative one, from a trial said to The intervention increased the odds that patients would continue with hazardous or harmful drinking “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 briefly intervene with risky drinkers. Of 77 primary care practices, 40 had been randomly allocated to be offered extensive training and support to implement this programme. With this support, two years later 36% of their risky-drinking patients had reduced their consumption to a low-risk level. But in the remaining practices the corresponding figure was 47% – a statistically significant difference in favour of not trying to train and support GPs to offer screening and brief interventions: “Therefore, we concluded that the intervention did, in fact, increase the odds that patients would continue with hazardous or harmful drinking.”

Equivalence of outcomes would have been more understandable. 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, this might have been enough to precipitate whatever changes in drinking were going to happen. But in this case there was not equivalence but a negative effect which could not be dismissed as a chance occurrence, a worrying mystery. An explanation might be found in the fact that the generally incomplete training left doctors feeling less confident than before of their abilities to deliver alcohol-related care below.

Strong management levers can extend intervention

Whatever the verdict on the efficacy of brief interventions, they can only directly have an impact if actually experienced by the patient. Studies reviewed below show that 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. Though this weakens the ability of these programmes to create population-wide health gains, patchy delivery and modest impacts do not necessarily mean a programme is worthless. In a health care system which (like primary care) repeatedly sees the same patients, low rates of intervention can cumulate over the years to a programme which touches a high proportion of patients. If effects persist, seeing just a small fraction of patients each year may still create appreciable public health gains.

The Veterans Affairs record

Sanctions and incentives strong enough to overcome obstacles to widespread screening and intervention bring with them another risk: that quality will be so poor that patients do not benefit, and even that the numbers needed to qualify for the rewards and avoid the sanctions will be generated in the absence of meaningful intervention. Strong sanctions and incentives can generate the desired activity, but can also tempt services and practitioners to shortcut quality and ‘game“ the system.

The US Veterans Affairs (‘VA’) medical service for former military personnel offers what looks like a large scale example of these processes. Its management and performance systems were able to create world-leading implementation rates. Despite this achievement, evaluations show that many risky drinkers were screened but not identified, and that at best, impacts on drinking were minor, and possibly non-existent. Results from this early phase of the national VA system offered no encouragement to its continuation, but may change as the system beds in and is developed. Unfold Unfold supplementary text supplementary text for more on these studies.

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.

‘Perverse incentives’ to record phantom interventions

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. A close, on-the-ground look behind the statistics conducted in the London borough of Haringey provided a revealing account of just how big the theory-practice gap can get: Unfold supplementary text unfold supplementary text to take a look.

Persuasion and support is not enough

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. It was a surprising result: “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.” On at least one measure, the training had been counterproductive; it left the doctors feeling less confident of delivering alcohol-related care than before they had been trained – perhaps, speculated the researchers, because training had generally been incomplete and most GPs missed the sessions intended to bolster confidence.

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.

The abandonment of universal screening

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.

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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