Key studies and reviews on local, regional and national systems for implementing alcohol screening and brief intervention. Context is that Britain’s National Institute for Health and Care Excellence insists commissioners and managers “must” provides the resources needed for brief intervention to become part of everyday work. Can these interventions be widely implemented, and even if they are, will they improve public health? See the rest of row 1 of the matrix for more on screening and brief interventions.
S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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K Scottish national implementation drive worked best in primary care (NHS Health Scotland, 2011). Numbers of patients talked to about their drinking testified to what can be done in primary care when national policy is backed by funding, training, resources and per-patient payments (2017). Still, most risky drinkers were not screened and the quality of screening was suspect. Implementation was patchy in antenatal services (2010) and emergency departments; more on both settings in study below. For discussions click , and , and scroll down to highlighted headings.
K In Scotland barriers formidable outside primary care (2015). Experiences of staff who implemented Scotland’s national programme (main evaluation report above) in emergency departments and ante-natal services suggest system planners should be prepared to flexibly adapt researched interventions. Related review . For discussions click , , and , and scroll down to highlighted headings.
K In GPs’ surgeries (2013), emergency departments (2014) and probation offices (2014), the policy-critical SIPS trials in England seemed to justify commissioning only terse and basic feedback to patients on the implications of their screening results. Doing more raised costs and hardened barriers to implementation, yet could not be shown to gain anything in consumption reductions. For discussion and scroll down to highlighted heading.
K Simulation study suggests lives cost-effectively improved in England and health costs reduced (2013). Predicted substantial health service cost-savings and low-cost health benefits from alcohol screening and brief advice in primary care, but some key assumptions which generated these estimates were questionable or are now outdated. Review of similar studies below.
K No demonstrable reductions in patients’ drinking after training Welsh GPs in multi-issue lifestyle counselling (2013). Integrated training for GPs on counselling for drinking, smoking, diet and exercise meant more patients were talked to about these behaviours, but behaviour-change success rates generally and specifically in respect of drinking were not significantly improved. For discussion and scroll down to highlighted heading.
K Small per-screening payments not shown to increase primary care screening rate in England (2019). The clearest impact of a national programme of financial incentives to screen primary care patients in England was the plummeting screening rate after the incentives were withdrawn. For discussion and scroll down to highlighted heading.
K Large payments can dramatically raise screening rate in UK primary care (2017). From 2011 the main system (the QOF) for financially incentivising quality in UK primary care promoted screening for risky drinking among seriously mentally ill patients. The effect was to quadruple the screening rate relative to other patients. Similar findings in respect of bipolar disorder. For discussion and scroll down to highlighted heading.
K Pay primary care to screen and advise – and keep paying (2016). EU-funded ODHIN trial tested strategies to promote screening and brief interventions for risky drinking in primary care in five European countries including England. Payments per patient boosted screening and intervention rates especially when combined with training and support, but rates fell back after payments ended. Also from the same study, a cost-effectiveness analysis (2018) and clinicians’ views (2016) on what aided or impeded implementation. For discussion and scroll down to highlighted heading.
K US national programme achieves unprecedented quantity; quality and impact uncertain (2006). Processes and results of the implementation strategy of the US health service for ex-military personnel – in coverage, the most successful large-scale programme to date. However, drinking reductions were minor (2010) or absent (2010; 2014) and screening missed most (2011) risky-drinking patients. For discussion and scroll down to highlighted heading.
K Dutch programme fails to engage primary care and may have been counterproductive (2012; free source at time of writing). Just 3% of invited practices joined the study, half those offered training did not complete even a minimal programme, and the result was that patients were slightly less likely (2012) to remit to non-risky drinking. Practice engagement levels “reflect the effects of such a programme when conducted in a naturalistic setting” and training and support “did, in fact, increase the odds that patients would continue with hazardous or harmful drinking”. For related discussion and scroll down to highlighted heading.
R Unclear whether health improvements justify screening and intervention costs (2014). Simulation studies estimate that these programmes are cost-effective health improvers, but evaluations which actually measured health gains “do not allow any firm conclusions to be drawn”. UK simulation study above. For related discussion and scroll down to highlighted heading.
R Abandon the ambition to achieve population-wide health gains? (2017; free source at time of writing). Achieving health gains across an entire population was the raison d’être of screening and brief intervention programmes, but citing an assessment (2012) from the UK’s most eminent brief intervention researcher, this review concluded that “After more than three decades of study in primary care, it now seems unlikely that brief interventions alone confer any population level benefit”. For discussion and scroll down to highlighted heading.
R Maximise implementation by preparing organisation and patient (2015; free source at time of writing). Meta-analysis amalgamating results of relevant studies found that implementation strategies had boosted alcohol screening and brief intervention rates yet not significantly affected drinking. Greatest impacts were seen from multi-strand strategies which went beyond incentivising or training clinicians to adapt the organisation to the programme being implemented (eg: re-allocating tasks; extending consultations) and also prepared patients by for example handing out alcohol education leaflets. Screening benefited from involving staff such as nurses as well as doctors.
R Strategies to implement alcohol screening and brief intervention in primary care (2011). Contextualises implementation strategies at the level of the organisation undertaking the work and of the surrounding economic, political and social environments.
R Real-world implementation in primary care requires flexibility (2010). Case studies of system-wide implementation programmes from England, Spain and New Zealand highlight the need for pragmatic flexibility in response to the local context. Related study . For related discussions click and and scroll down to highlighted headings.
G In guidance on alcohol problem prevention (NICE, 2010) and treatment (NICE, 2011), the UK’s official health technology advisor stresses that evidence-based alcohol screening and brief intervention must be resourced as integral parts of health and social care practice. For discussions click , and , and scroll down to highlighted headings.
G Commissioning integrated alcohol prevention and treatment systems in in England (Public Health England, 2018). National health body responsible for supporting substance use work offers advice on commissioning alcohol services, including “large scale delivery of identification and brief advice (IBA) to people who are most at risk of alcohol-related ill health”.
G Scottish guidance on embedding screening and intervention in routine practice (Scottish Government, 2017). Instructs local health and social care commissioning and planning bodies to plan for routine alcohol screening and brief intervention and stipulates what this should mean in practice. More on practice models and required staff competencies in “competency framework” (NHS Health Scotland, 2010). For discussions click , and , and scroll down to highlighted headings.
G ‘Toolkit’ for commissioning (2016). From south London’s Health Innovation Network, an online resource bringing together the evidence base and guidance for alcohol identification and brief advice plus tips for commissioning across a range of settings, a framework for incorporating quality in the commissioning process, and case studies. For related discussion and scroll down to highlighted heading.
G Supported among others by Public Health England, guides from the charity Alcohol Concern (now absorbed in Alcohol Change UK) for: community health settings (2015) such as primary care, pharmacy, midwifery, health visiting, drug services, and sexual and mental health services; hospitals (2015) including emergency departments; and criminal justice services (2015). Will help commissioners set expectations and standards for the services they commission.