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In the UK GPs’ surgeries are the principal venue for screening and brief interventions, but programmes are also mounted at other medical settings such as emergency departments, sexual health clinics, inpatient wards, and ante-natal clinics, as well as at non-medical settings such as criminal justice, social care, community and housing services.

Typically screening takes the form of a few standard questions meant either to be asked of all adult patients/clients, or instead ‘targeted’ at those in certain categories where alcohol-related harm is most common or who are undergoing procedures where screening seems ‘natural’. In the UK programmes have focused on patients whose medical complaints might be due to excessive drinking, or those newly registering with a GP or undergoing a general health check.

For example, AUDIT-C is a popular screening questionnaire which assesses typical current drinking patterns. It asks:
1 How often do you have a drink containing alcohol?
Answers: Never; monthly or less; 2–4 times a month; 2 or 3 times a week; 4 times a week.
2 How many standard drinks containing alcohol do you have on a typical day?
Answers: 1 or 2; 3 or 4; 5 or 6; 7–9, 10 or more.
3 How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
Answers: Never; less then monthly; monthly; weekly; daily or almost daily.

A score of from 0–4 is given for each question. A total of 5 or more indicates increasing or higher risk drinking.

People whose responses indicate risky drinking are then engaged in a discussion about their drinking for what may be just a few minutes or one or two longer sessions. Content often includes feeding back the results of the screening test and using a motivational interviewing counselling style and associated techniques to elicit a commitment to cut down and/or drink more safely. Patients whose screening results indicate very serious problems may instead be referred for a fuller assessment and possible treatment.

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Another US primary care study listed above found organisational features strongly related to screening and intervention rates. Seemingly partly reflecting complex provider and organisational characteristics, at different provider organisations the proportion of patients screening positive for risky drinking who were advised about their risks ranged from none at all to nearly all. Associated with more frequent implementation were stable parent organisations supportive of screening and intervention, the presence of an influential, on-site coordinator for the programme, the clinic’s access to and willingness to take advantage of the study’s technical assistance, and the staff’s ability to implement the necessary changes in operational procedures. Related in the other direction were competing organisational priorities and lack of time – perhaps in reality both to do with organisational priorities.

Further confirmation of the importance of organisational features comes from (study listed above) the very different context of Brazilian primary care clinics, where ‘community link’ workers without medical training play an important role. The more a clinic was seen by its staff to have a good organisational climate, the greater the implementation of screening and brief intervention and the more confident staff were about these activities. The results suggest that certain types of organisations are much more capable and willing than others to make the changes needed to embed screening and brief intervention, and that this can depend on generic features like their commitment to staff development, relationships with and concern about their catchment population, and leadership quality.

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We can add a final chapter to the story of these US clinics – whether the effort to implement screening and brief intervention was worthwhile in terms of reduced drinking, and, by extension, whether the degree to which implementation was promoted by organisational features could also have helped reduce drinking and alcohol-related harm. This chapter can be added because another set of clinics did not implement and were not trained in the brief interventions and the more detailed screening procedures promoted by the study.

In fact, patients at trained clinics did reduce drinking more than those at the untrained clinics, but the effect was very small and under some assumptions, not statistically significant. Undermining confidence in the findings and in their applicability to all risky drinking patients was the fact that patients at trained clinics were only followed-up if they had actually received the intended interventions, and that many could not be re-assessed. As at the VA clinics described above and more generally in primary care (free source at time of writing), it seems possible to stimulate appreciable increases in implementation rates of screening and brief interventions without being able to substantiate any corresponding change in drinking.

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Via discussions with practitioners, the most ‘meaty’ of the reports (listed above) explored the exigencies of implementing alcohol screening and brief intervention in three ‘case studies’ involving respectively housing, probation and social work sectors in England. The conclusion was that in these and other non-health settings, ‘IBA’ (identification and brief advice) is unlikely to be implemented in the form of standardised screening methods and structured advice, due largely to the practice contexts demanding different approaches.

Across the three sectors, “the extent to which organisational structures and working practices are conducive to incorporating and sustaining IBA intervention, emerged clearly … as a key requirement if IBA training is to be followed by delivery … A shift away from a standardised ‘manual’ approach towards a more flexible menu of optional contents and methods of delivery may be required to suit the diverse and changing needs of professional groups and their organisations.” ‘Parachuting in’ a set intervention seemed unlikely to work because “the individual and the organisation/agency [are] parts of a network of services and systems of care (or control) which may differ from one occupational setting or service context to another, from one geographical area to another, and over time.”

Complicating implementation in the three studied sectors was the dual caring and ‘enforcement’ role of the practitioners – one apparent to their clients, who know these workers held sway over their freedom, their children, or their homes. Practitioners felt that baldly raising the issue of drinking by asking questions set down in a research-validated screening questionnaire was likely to provoke defensive and misleading responses and jeopardise trust; exploring the reasons for excessive drinking and ways to reduce this takes tact and judgement in the context of an established, trusting relationship. In practice, what seems like a simple set of questions followed (if the scoring indicates) by brief advice which could be rolled out by any modestly trained practitioner, to these practitioners looked like a far more complicated interaction requiring advanced judgement.

In housing there was a further complication: concern for the resident’s welfare had to be balanced by the need also to support and protect neighbours and the neighbourhood, dual roles thought to create barriers to communication and disclosure, especially because underpinned by the ultimate sanction of evicting a resident for antisocial behaviour. Instead of themselves screening and intervening, staff’s main role was seen as responding to drinking when raised as a problem by signposting to additional help, a strategy in line with their general approach to support.

At the time of the study the probation sector was grappling with the aftermath of reorganisation, and fewer alcohol interventions were recorded than had been expected. Officers’ alcohol-related caseloads focused on court-ordered treatment for dependent drinkers. Among the less problematic drinkers commonly targeted by screening and brief interventions, “resistance … to disclose or discuss their drinking was noted among almost all staff,” leading them to abandon “systematic and standardised” screening in favour of a less formal approach to discussions about drinking.

For most social work and social care staff, alcohol-related problems were common among their caseloads, but (like housing staff) they focused on relatively severe problems too entrenched (they felt) for brief interventions. Associated with this focus, usually workers offered referral to specialist services rather than dealing with problems directly. Clients may have been reluctant to address drinking, but so too were the staff: “There was widespread anxiety … about encouraging service users to articulate risk around increasing alcohol use. Participants feared that this would require them to intervene more substantially, a responsibility which did not sit comfortably with a role of screening and giving brief advice.” In other words, screening was seen as opening a ‘can of worms’, in response to which both brief advice and their skills and confidence in offering fuller support were seen as inadequate. Trust and rapport with clients were see as threatened by interventions not led by service users and “There was much concern related to the issue of disclosure in terms of the statutory role that social workers perform in relation to risk assessment and, in particular, they referred to how this aligned with their safeguarding roles.” As in the other sectors, some staff said they would not implement standardised programmes but would adapt depending on clients’ needs. Standard approaches of the kind tested in research “did not sit easily within naturalistic conversations and sensitivity was needed as to when to broach the subject of drinking”. The demand to implement widespread, standardised screening and brief intervention “seemed to them to be in conflict with some of the core principles of their roles and to undermine the fundamental structures and working practices of social work”.

Another arm of the same study (research report listed above along with related journal article) sought the views of trainers, experts, and trainees from four English regions on the role of training in delivering alcohol screening and brief interventions in sectors such as youth services, housing, probation, policing, social services, and other local authority services. It can be thought of as a test of whether the type of training they received helped them do screening and brief intervention (or more generically, identification and brief advice – ‘IBA’) despite the barriers revealed in the sector case studies described above.

On page 12 the research report delivered its verdict: “Training does not result in IBA delivery.” Had the researchers only gone as far as the trainees’ views they might have declared the training a success. Levels of satisfaction were high and 8 in 10 who responded to a survey said the training helped them apply IBA practices within their work. This rosy picture was substantially dimmed when the researchers went on to ask about actual implementation. Despite appreciating the training, “very few had put their training into practice”. Of the 82 who answered this question, nearly 6 in 10 had not done so at all and nearly all the rest used their IBA training infrequently – only nine did so at least once or twice a month.

The main blockage came at the very first stage. Trainees had found that “in many work contexts, screening using a standard tool such as AUDIT is not seen as appropriate or practical” – yet this was the strategy they had been trained in. For example, social workers dealing with families whose children were at risk preferred to engage the family in a less threatening discussion rather than ask set questions, and screening and advice was considered impossible when police were faced with drunk, disorderly or violent people. For the researchers, flexibility in response to the working context was the key to implementation: “Training needs to be related more directly to organisational cultures, behaviour, and development needs … Prior to delivering training, efforts may be needed to assess and incorporate organisational factors into training programmes.” But there was a line across which adaptation effectively became the abandonment of screening and brief intervention as originally conceived as a public health strategy. As the study progressed, “These questions became as, if not more, important than the original focus on training. They centred on the extent to which the ‘classic’ IBA approach was appropriate to the working practices of different professional groups, and in addition, raised questions regarding the extent to which IBA could be adapted and still be considered as IBA” (emphasis added). In particular, screening and brief intervention which effectively abandons screening becomes simply another way to respond to people already known to have a drinking problem, no longer a way to find those problems across a population, even if they are not apparent.

Scotland’s national drive to implement screening and brief intervention – initially in primary care, emergency departments and antenatal care – has provided an opportunity to explore what helps and hinders delivery and what form delivery actually takes. In health services other than primary care, managers and clinicians said implementation “required a willingness to be flexible and pragmatic about the design of the programme, balancing what was desirable with what was possible. A key lesson is not to be afraid to tweak the model.” Accident and emergency departments were the clearest case, demanding minimal screening approaches. One interviewee explained that they now asked just the first question of the Fast Alcohol Screening Test (FAST), and if the patient admitted to drinking eight (or for women, six) or more standard drinks on one occasion, a conversation on alcohol was indicated. This strategy omits the three follow-up questions intended to identify risky drinkers not picked up by the first question. The researchers cautioned that the perceived “need to adapt the intervention to fit with current practice in each setting in order to make it easier and more acceptable to implement … carries a risk of compromising the effectiveness of the intervention in ways that are currently unknown”.

Since this was one of the priority settings, the Scottish programme also offered a chance to explore delivery in the under-examined antenatal care sector. The themes were familiar from other sectors including probation, housing and social work. The huge sensitivity of drinking while pregnant led midwives (study listed above) to abandon the standard, scripted approaches tested in research in favour of a more individualised and nuanced conversation – and then not initially about current drinking, but the less threatening topic of pre-pregnancy consumption. Only in these ways might the responses of pregnant patients get close to the accuracy and honesty needed to identify risky drinking. Screening rates were low in many health boards, meaning midwives delivered few interventions. In several areas, reported alcohol use elicited through standard questions was lower than expected.

Further driving departure from standard approaches was the conviction among many midwives that the maximum drinking guidelines on which research-based screening and brief interventions were built were inappropriate at a time when ‘no drinking at all’ should be the message. Midwives also felt that the screening and brief intervention programme they were being asked to implement “did not necessarily align” with the Scottish government’s Getting It Right For Every Child agenda or other relevant lifestyle and health agendas. For some staff, screening was irrelevant because “if somebody had a significant problem they would already be known and if they didn’t … but were drinking, they were unlikely to tell you, the others who were happy to talk about it had already reduced or stopped drinking anyway”.

The result was that in the antenatal sector the researchers “found no universal adoption of a validated screening tool across health boards, as many adapted instruments to fit the local context”. Instead, “conversation and asking questions in a locally appropriate language” were the preferred approach. Such flexible approaches with the emphasis on building trust were felt to lead to more frequent and/or more complete disclosures of alcohol consumption.

The Scottish national programme later sought to broaden out from its three initial priority sectors, but the Glasgow area aimed to do this from the start, spawning a study listed above of attitudes to screening and brief intervention among a variety of staff who underwent training to support this expansion. Among other sectors, they came from community mental health and social work teams, including several practitioners working in criminal justice and with children and young people, health visiting and primary care nursing, services supporting women who have suffered or are at risk of abuse, and community services for older people.

Even after training “designed specifically for multidisciplinary staff including health, social care and other practitioners,” seven out of nine practitioners for whom this information was available and relevant did not engage in screening and brief intervention at all, and another was unsure. The reason was that they felt these activities were inappropriate for their clients. As in the studies discussed above, they were focused on more severe drinking problems than brief interventions were meant to deal with, and saw their roles as referring on for specialist help rather than directly delivering an intervention, no matter how brief. Others worked with caseloads among whom they felt heavy drinking was unlikely: “You wouldn’t just routinely raise it with somebody just because you want to make sure that’s not something that’s there. There would have to be something that would make you feel [it was] appropriate to raise the issue of drinking,” said one social worker – ironically missing the whole point of routine screening, which is precisely to identify excessive drinking when there are no signs of its presence. However, there were caseloads – such as elderly people injured by falling – where raising drinking did seem more appropriate.

Standard screening questionnaires were not usually deployed and the practitioners preferred to discuss drinking if the issue came up rather than to ‘deliver’ a brief intervention. The researchers advised bending to this reality: “Avoiding an excessively narrow conceptualisation of [alcohol brief intervention] seems important here. These practitioners see the need for different varieties of [alcohol brief intervention] but do not define them in this way.” However, the researchers also acknowledged that alcohol brief intervention programmes “can only produce the benefits expected of them, if well implemented” – yet ‘flexible’ conversations and non-validated ‘screening’ methods cannot be assumed to meet quality standards.

Also in Scotland, another study explored the feasibility of extending screening and brief intervention beyond healthcare settings, this time by piloting these activities in community justice settings. In 2010 and 2011 three local authority areas offered training to 121 probation and community service staff to enable them to screen offenders they were supervising for risky drinking using the AUDIT questionnaire. A randomly selected half were also trained to offer a brief intervention based on motivational interviewing to offenders who screened positive for risky drinking.

Among staff there was widespread commitment to dealing with drinking problems, but often they felt the piloted intervention was unsuited to their client groups, largely because they faced more serious issues such as money problems and housing, and addressing drinking was not a high priority. Some staff said if it was a priority it would already have been incorporated in sentence planning, that they would have dealt with it anyway in normal practice and perhaps more adequately than through five minutes of brief advice, that their clients were often too extreme in their drinking to be suitable for a brief intervention, and that excessive drinking was too intertwined with other problems to be dealt with in isolation. Although the AUDIT questionnaire and the brief intervention seemed to have been easy for them to administer and were seen as useful tools, staff were in some ways negative about the appropriateness and likely success of alcohol screening and intervention in this environment.

In England too, probation officers were not convinced of the value of brief interventions for their caseload. The study also tested brief interventions in primary care and emergency departments. Compared to these medical settings, screening and brief intervention were felt to meld more naturally with routine probation work, but staff were less convinced these procedures would be useful and tended to feel they were best reserved for offenders with obvious drinking problems. Of the 197 staff in the trial, 44 did not recruit any offenders to the study, and just 45 were able to implement screening and brief intervention as intended without extra help from researchers and specialist alcohol workers.

Also in England, between 2010 and 2012 a major study examined the effectiveness and cost-effectiveness of a brief intervention for people attending sexual health clinics who had been identified by screening tests as drinking excessively. No impacts were found on drinking. Researchers suspected that the intervention’s impact may have foundered on the mismatch between levels of drinking seen by national guidelines as excessive and the views of this mainly young, sexually active group, who saw their ‘excessive’ drinking – probably usually confined to weekends – as a normal feature of their social life, and generally unrelated to the problems which brought them to the clinics. While in emergency departments and trauma centres excessive drinkers are likely to have suffered an unintended repercussion of their drinking in the form of an injury, for the sexual health caseload, having fun, and perhaps too having sex, were often desired and intended consequences of drinking. Persuading these drinkers that their consumption has led to a problem rather than on balance enhanced their life seemed a difficult task.

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