IMPLEMENTING BRIEF INTERVENTIONS IN PRACTICE: RECENT DEVELOPMENTS FROM SOUTH OF THE BORDER

1. IMPLEMENTING BRIEF INTERVENTIONS IN PRACTICE: RECENT DEVELOPMENTS FROM SOUTH OF THE BORDER Nick Heather PhD Division of Psychology, Northumbria University Presentation at SHAAP One-day Conference, Edinburgh, 7/2/08

2. DEVELOPMENTS TO BE COVERED • Cochrane Review of effectiveness of BI • DH SIPS (Trailblazer) project • Safe, Sensible, Social (renewed alcohol strategy) and other DH publications • Roll-out of SBI across England • NICE project • National Audit Office review of treatment (including SBI) • Social marketing campaign to reduce regular excessive drinking • Inclusion of SBI in Quality and Outcomes Framework (QoF)?

3. COCHRANE REVIEW • Effectiveness of brief alcohol interventions in primary care populations • Eileen Kaner et al. • http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004148/frame.html

4. Has SBI been evaluated in ideal-world scenarios? • Over recent years, there has been a growing view that most of the BI trials have been tightly controlled efficacy studies and not particularly representative of routine clinical practice

5. Is the evidence relevant to real world practice? • Babor et al. 2006: ‘There has been little systematic research to evaluate the effectiveness and cost of SBI under conditions approaching typical clinical conditions’

6. Thus we decided to conduct a Cochrane Collaboration review

7. Aim • To assess the effectiveness of brief intervention, delivered in primary care (general practice or accident & emergency settings), at reducing excessive alcohol consumption

8. Efficacy-Effectiveness • Efficacy studies • Tightly controlled protocols • Ideal world – atypical practice • High internal validity – limited applicability • Effectiveness studies • Pragmatic trial – reflect the ‘noise’ in practice • Closer to the real world – routine practice • High external validity – broader applicability

9. Conclusions • In risky drinkers, BI reduces average weekly drinking by 41g (about 4-5 units per week) compared to controls • As little as 5 minutes of structured advice enough • No significant benefit of longer BI or EI • BI is highly effective in men, we need more evidence in women • There is no significant difference in outcomes between efficacy and effectiveness trials • Most of the evidence is skewed to the effectiveness domain • BI evidence is highly relevant to routine PHC

10. Aka The Trailblazer project Alcohol Harm Reduction Strategy for England (2004): “The DH will set up a number of pilot schemes by Q1/2005 to test how best to use a variety of models of targeted screening and brief intervention in primary and secondary healthcare settings, focusing particularly on value for money and mainstreaming” (p.37) National research consortium with expertise in screening and brief interventions in the alcohol field Three different settings and three different regions of England as different tools may be necessary in different settings Funded by DH; £3.2 million, Screening and Interventions programme for Sensible drinking (SIPS)

11. Research Project Group IOP Prof C Drummond (CI) Dr P Deluca Ms K Perryman St George’s Dr J Myles Dr A Oyefeso Mr T Phillips York Prof M Bland Mr S Coulton Prof C Godfrey Mr S Parrott Newcastle Prof E Kaner (DCI) Prof C Day Dr E Gilvarry Dr P Cassidy Dr D Newbury-Birch Prof Nick Heather Imperial College and St Mary’s Hospital Dr M Crawford Prof R Touquet Alcohol Concern Mr D Shenker

12. Aims To identify the most appropriate, acceptable and cost-effective: • screening methods for AUD • brief intervention techniques for AUD • methods of implementation Across 3 health and social care settings: • Primary Health Care (PHC) • Accident & Emergency Departments (AED) • Criminal Justice Services (CJS)

13. Research Programme Design • Three cluster randomised clinical trials (PHC, AED, CJS) • Each with a purpose-designed project to assess: • Identification of the most effective screening approach (universal vs targeted and 2/3 screening tools) • Identification of the most effective and cost-effective intervention approach • Barriers and facilitators to implementation • 6 month follow-up

14. Research Programme Design (cont.) • To recruit patients from 24 PHC practices 9 AEDs 24 CJS • Across North East, London, and South East Regions • Aim to recruit over 2,600 patients across the three trials • All health and CJS staff to receive training and support from research team • Staff attitudes to be assessed to identify acceptability of implementing screening and brief interventions • Programme duration: 2 years

15. How will we assess implementation? • Number screened, positives, received intervention • Factors supporting implementation • Factors impeding implementation • Impact: individual, service, costs and benefits • Acceptability: patient, practitioner, commissioner • Sustainability

16. How will we assess effectiveness? • Effectiveness of implementation • Extent of screening and intervention activity • Attitudes to SBI implementation • Patient outcome measures • Alcohol consumption • Alcohol-related problems • Health-related quality of life • Health-related and wider societal costs

17. Toolkit • Screening toolkit and practical guidance for each setting based on optimal tool/method (targeted/universal)/setting combination • Intervention tools and implementation guidance based on findings tailored to each setting • Training package for professionals in each setting • Guide for commissioners of SBI services • Resource website for providers

18. Progress • Recruited 9 AEDs; 24 PHC practices • Ethics and R&D approval • Completed CJS pilot • Site training in Jan 08 • Pilot study report • Feasibility, validity of screening tools, staff attitudes • Interim report: 2008 • Final report: 2009

19. PUBLICATIONS BY DEPARTMENT OF HEALTH • Safe. Sensible. Social. (2007). Renewed National Alcohol Strategy – to assess progress since AHRSE in 2004 • Strong on SBI (see pp. 36-39) • Alcohol Misuse Interventions: Guidance on Developing a Local Programme of Improvement (Nov 2005) • Alcohol Needs Assessment Research project (ANARP) – covered SBI as well as specialist treatment (Nov 2005) • Model of Care for Alcohol Misuse (June 2006) • Review of Effectiveness of Treatment for Alcohol Problems (Raistrick, Heather & Godfrey –Nov 2006)

20. NATIONAL ROLL-OUT OF SBI • Safe. Sensible. Social. The next steps in the National Alcohol Strategy states: “To support the roll-out and take-up of targeted identification and brief advice, a healthcare collaboration will be set up to disseminate the early results of the trailblazer research programmes and share learning on implementation.” • The DH will launch this support system by April 2008. An event has taken place in December 2007 to discuss the scale, scope and operation of this supportive effort. • The DH brought together a range of PCT Commissioners, PCT Public Health officials, GPs, Practice Based Commissioners, Alcohol Co-ordinators and specialist alcohol treatment providers to discuss this effort. • NB. Public Service Agreement (PSA) on Reduction of Alcohol-related Hospital Admissions

21. NICE guidance on brief interventions • National Institute for Health & Clinical Excellence is establishing a new Programme Development Group (PDG) on “The prevention and Early identification of Alcohol Use Disorders in Adults and Adolescents” • To develop public health guidance in conjunction with the Centre for Clinical Practice • Completion of project expected early 2010

22. NATIONAL AUDIT OFFICE STUDY:Reducing alcohol-related harm • NAO is an independent body that reports to Parliament on the economy, efficiency and effectiveness with which government departments have used their funding • Current study will include all types of health service interventions on alcohol – from brief advice provided by GPs to rehabilitation and detoxification services for dependent drinkers • It will examine the extent of local service provision, access to services and the effectiveness of treatment • Will report to Parliament in summer 2008

23. SOCIAL MARKETING STRATEGY FOR HARMFUL DRINKERS • DH has commissioned the COI Strategic Consultancy to develop this strategy • “Harmful drinkers” refers to middle-aged (35+) regular excessive drinkers – NOT young “binge drinkers” • Hazardous drinkers will also probably be included in the strategy • Likely elements of the strategy: • Attempt to reframe understandings of alcohol-related harm • Provision of assisted self-help by a range of media (mail, phone, web-based) • Encouragement of public to ask advice about drinking from primary health care • Draft strategy to be ready May 2008

24. QUALITY AND OUTCOMES FRAMEWORK • Is inclusion of alcohol in QoF the key to routine implementation of SBI? • DH full supportive of this development but it is not their decision • Two attempts so far have been unsuccessful • But remember Robert the Bruce!