National enhanced service - patients who are alcohol misusers
2 May 2003 (updated November 2003)
Introduction
1. All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.
Background
2. Evidence shows that:
(i) 1 in 25 adults in the UK are dependent on alcohol (see reference 1)
(ii) 0.7 million men and 0.6 million women drink at ‘risky’ or ‘hazardous’ levels (see reference 2)
(iii) problem drinkers consult their GMPs twice as often as other patients (see reference 3)
(iv) alcohol misuse is associated with a range of physical health problems. (see reference 4) (see reference 5)
(v) heavy drinking is closely linked with psychiatric morbidity, including clinical depression (see reference 6)
(vi) up to 65% of all suicide attempts are linked with excessive drinking (see reference 7)
(vii) alcohol is a major contributor to accidental death – it is a factor in an estimated 20 per cent to 30 per cent of all accidents (see reference 8)
(viii) 1 in 7 acute hospital admissions are alcohol related (see reference 9)
(ix) 20 per cent of general hospital beds are occupied by people with alcohol-related problems (see reference 10)
(x) brief interventions can reduce alcohol consumption by over 20 per cent (see reference 11) and so reduce the number of patients who become dependent on alcohol and the need for more intensive treatment in the future.
Aims
3. To improve the quality of care provided by practices to patients who misuse alcohol. The service will achieve this by:
(i) incentivising and training GPs to advise and treat alcohol misuse patients
(ii) undertaking more specialised treatment of alcohol dependent patients.
4. This national enhanced service will fund:
(i) the development and production of an up-to-date register. Practices should be able to produce an up-to-date register of all patients who admit they are alcohol misusers. This register will be used as an audit tool
(ii) practices to be able to undertake brief interventions and offer support to carry out behavioural change
(iii) follow-up treatment. A range of treatments may be prescribed including a set number of counselling sessions which may be done in conjunction with or by referral to local alcohol services or through the patient’s attendance at a day programme or residential rehabilitation centre, both of which would require referral
(iv) detoxification regime. For those where a detoxification regime is required, this may be provided by the primary care team (and could be undertaken in partnership with alcohol support services) in the community or home setting
(v) routine use of assessment tools
(vi) liaison with local specialist alcohol treatment services
(vii) appropriate training. This must be available to the primary care team to enable team members to understand the problems experienced by people who misuse alcohol and their families, and to communicate effectively with them. Training should include detecting problem drinkers, carrying out brief interventions, and managing follow-up treatment, including counselling
(viii) review. All practices involved in the scheme should perform an annual review which could include an audit of:
(a) those identified and recorded as alcohol misuse patients
(b) the advice and/or treatment offered to patients who, following screening, have been shown to misuse alcohol
(c) the number of patients who have reduced their alcohol consumption
(d) feedback from patients who misuse alcohol and their families.
Accreditation
5. Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.
Costs
6. In 2003/04 each practice contracted to provide this service will receive an annual retainer of £1,000 plus an annual payment per patient (paid quarterly in arrears) of £200. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
(1) Office of Population Censuses and Surveys (OPCS). The prevalence of psychiatric morbidity among adults 16-64, living in private household, in Great Britain. London, 1994
(2) Office of National Statistics (ONS). Living in Britain: Results from the 1998 study. London: HMSO, 2000
(3) Deehan, A et al. Low detection rates, negative attitudes and the failure to meet “Health of the Nation” targets. Drug and Alcohol Review 1988; 17
(4) In 1997, there were 4,907 deaths in the UK from alcohol specific diseases (such as alcoholic psychosis, chronic liver disease and liver cirrhosis). Department of Health. Statistical bulletin: Statistics on alcohol 1976 onwards. 1999; 24
(5) The number of deaths where alcohol is a significant contributory cause rather than the sole cause (such as high blood pressure, stroke, heart disease, oral and upper digestive cancers) is far greater and is estimated at between 25,000 and 40,000 a year. Cited in Alcohol Concern. Britain’s ruin. 2000
(6) Health Education Authority. Health update: alcohol. 1997
(7) Department of Health. Health of the Nation key area handbook: Mental health. London: HMSO, 1993
(8) Honkanene R. Alcohol in home and leisure injuries. Addiction 1993; 88
(9) Pirmohmed M et al. Alcohol abuse and the burden on the NHS. Quarterly Journal of Medicine 2000
(10) Mullally S. Alcohol – A nursing issue: A message from the Chief Nursing Officer. Alcoholism 2000
(11) Freemantle et al. Brief interventions and alcohol use. Effective Health Care Bulletin 1993; 7,