Improving Delivery of the
Direct Enhanced Service in
Haringey
Dylan Kerr, Alcohol Nurse Manager, HAGA
Laura Pechey, Brief Interventions Specialist, HAGA
What is IBA?
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Identification and Brief Advice
Also known as Screening and Brief Interventions (SBI)
Identification of risk using a screening tool
Short structured interaction for Increasing and
Higher Risk drinkers
• Delivered by Tier 1 practitioners
• Extended Brief Interventions for Higher Risk drinkers
• Referral pathway for dependent drinkers
Efficacy of IBA
• Extensive evidence base: more than 56 controlled trials
(Moyer et al 2002; Cochrane Review 2007)
• 1 in 8 people who receive simple alcohol advice will reduce
their drinking to within Low Risk levels (Moyer et al., 2002)
• Significant reduction in alcohol-related and alcohol-specific
hospital admissions across regions
• On-going Screening and Intervention Programme for Sensible
Drinking (SIPS) project in primary care, A&E and criminal justice
settings
Why IBA in Primary Care Settings?
• Key setting
• “Trust transfer”
• Alcohol-related GP attendance (i.e. GP
“frequent flyers”)
• Removal of stigma
• High impact (i.e. patient numbers reached)
Roadblocks within Primary Care
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Time
Whose responsibility?
Commitment
Skills and training
Varied quality and style
Process
Tools
Lack of clear, up-to-date and concise DES
guidance document
Local Enhanced Service
• Alcohol Harm Reduction Strategy (2004)
• Local package targeted at meeting needs of
population
• Screening of existing patients and deliver of Brief
Advice
• Payment locally agreed
Direct Enhanced Service
• Introduced in 2008
• Government incentive
• Screening of all new registrations (+16)
• FAST or AUDIT-C tools
• £2.33 payment for screening
Haringey: The Local Picture
Local Alcohol Profiles
• Highest male mortality rate in London from alcohol-attributable
causes (NWPHO 2008)
• 2nd worse liver disease mortality rate in London (NWPHO 2008)
• Patients at North Middlesex A&E (2007 ten-day review)
– 52% of male patients drink at Increasing Risk levels
– 21% of female patients drink at Increasing Risk levels
– 13% of patients dependent drinkers
• Dept of Health drinking estimates (2010):
– 37,153 adults Increasing Risk drinkers (16.5% of Haringey pop)
– 11,379 adults Higher Risk drinkers (5%)
– 6,132 dependent drinkers (2.3%)
– 26,923 binge drinkers (12%)
Alcohol-Attributable Hospital
Admissions
DES Review
09-10 DES Returns
• 29 practices in Haringey provided the Alcohol DES
during 2009-10
• % of new registrations screened under DES varies
considerably
• Only 2% of the newly registrations screened positive
and required a brief intervention (347 patients)
• 1/2 identified zero patients requiring a brief
intervention
• We would expect 25% of patients to be drinking at
Increasing or Higher Risk levels (around 5,038 newly
registered patients)
AUDIT-C Screening 2009-2010
% of patients screening 'positive' using Audit C, Haringey
practices participating in the DES 2009-10
100%
% of screened patients
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Practice
Sum of % screened 'positive' so given full AUDIT
Screening Relative to Intervention
100%
90%
% patients screened
80%
70%
60%
50%
40%
30%
20%
10%
0%
8
10
12
14
15
16
17
21
24
22
27
29
19
9
7
13
6
2
11
3
1
18
practice
% screened giv en brief interv ention
% screened 'positiv e' so giv en f ull AUDIT % screened negativ e
23
28
26
25
4
20
5
Purpose of Review
• To understand the reasons for wide variation
in outcomes reported by Haringey practices
• To identify the areas where practices need
additional support and training
Practice Selection
• Practices who provided a particularly high or low no. of
brief interventions
• Practices who reported 20-40% positive scores as
expected
• Practices with particularly unusual results or which
appear to be taking a different approach to the DES
and may have learning to share with others
Key Findings
1. Incorrect screening process
2. Re-registrations
3. Interventions and referral pathways widely
lacking or inadequate
4. Coding
Improvements Made So Far
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Review new registration forms
Standardised local IBA tools in use
Rolling programme of IBA training
IBA Pathways agreed with practices
Training HCAs & nurses in Extended Brief
Interventions
• Flagging 8+ scores to GPs
• Uniform appointment booking for scores 20+
• Reviewing coding with Practice Managers
Best Practice Guidance
• Review cited as example
of best practice in J. Currie
Intensive Support in
Reducing Hospital
Admissions (2010)
• We hope that the learning
from the review will
improve practice
nationally
Local Primary Care IBA
Initiatives
Social Marketing Project
• Stalls in 12 locations over 12 months
• Alcohol Social Marketing
• Identification & Brief Advice delivered
• Extended Brief Interventions appts
• Training in IBA for primary care
Extended IBA Project
• Two GP practices participating
• Patients on identified disease registers
• Identification & Brief Advice delivered
by HCA/GP/nurse
• Extended Brief Interventions clinics run
by HAGA
• Training in IBA and EBI
References
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Cabinet Office. (2004) Alcohol Harm Reduction Strategy for England.
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Currie, J. (2010) Intensive Support in Reducing Hospital Admissions: A Report Describing
Intensive Support Provided to Ten London Primary Care Trusts (pct)/Drug and Alcohol
Action Team (DAAT) Partnerships, London Regional Alcohol Group.
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Kaner E, Beyer F, Dickinson H, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders
J, Bernand B. “Brief interventions for excessive drinkers in primary health care settings.”
Cochrane Database of Systematic Reviews 2007, Issue 2. Art No.: CD004148 DOI:
10.1002/14651858.CD004148.pub3.
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Moyer, A., Finney, J., Swearingen, C. and Vergun, P. (2002) “Brief Interventions for alcohol
problems: a meta-analytic review of controlled investigations in treatment -seeking and
non-treatment seeking populations,” Addiction, 97, 279-292.