Local Enhanced Service for Alcohol Screening 1. Introduction It is a government priority to address the issue of illness associated with increasing alcohol consumption. The LES is to reward practices for case finding in all patients aged 16 and over. It also aims to deliver a simple brief intervention to help reduce alcohol related risk in adults drinking at increasing or higher risk levels. This LES does not include a requirement to set up a register of increasing or higher risk drinkers. 2. Service Outline Practices will be required to screen both newly registered patients and existing patients aged 16 and over using the shortened version of the World Health Organisation (WHO) Alcohol Use Disorders Identification Test (AUDIT) questionnaire: AUDIT-C. AUDIT-C has three questions, and takes approximately one minute to complete. The LES screening will apply to all patients registered at the practice including newly registered patients who are 16 and over at the time the short case finding test is applied. If a patient is identified as positive in males scoring 5+ and females scoring 4+ on AUDIT C, the remaining 7 questions of the ten question full AUDIT questionnaire should be used to determine increasing, higher risk or likely dependent drinking. A value should be added to a field associated with the code to record the score: 0-7 indicates sensible or lower risk drinking 8-15 indicates increasing risk drinking 16-19 indicates higher risk drinking 20 and over indicates possible alcohol dependence Brief Intervention Those patients identified as drinking at increasing or higher risk levels (scores 8-19) should be offered brief advice. The recommended brief advice is the basic 5 minutes of advice used in the WHO clinical trial of brief intervention in primary care, using a programme modified for the UK context by the University of Newcastle How much is too Much? These resources and others from this programme have been further refined and are available on the following link. www.alcohollearningcentre.org.uk/topics Core guidelines as follows for an alcohol brief intervention: The Primary Care Practitioner should use the FRAMES model which has all the key elements of a brief intervention: Document Title: LES for Alcohol Screening Page 1 of 5
Feedback: identify personal risk or impairment, e.g. alcohol as a cause of gastritis Responsibility: emphasis on personal responsibility to change Advice: discuss ways to cut down or abstain in the context of lifestyle choices Menu: provide a range of alternative options for changing drinking patterns and setting targets Empathic interviewing: listening reflectively without cajoling or confronting Self efficacy: an interviewing style which enhances people s belief in their ability to change Required competencies: The minimum qualifications for Health Care Assistants or Nurses working to this protocol is to access the DH Identification and brief advice e.learning module within the Alcohol Learning Centre web site, which is backed by the Royal College of Physicians, the Royal College of Nursing and the Royal College of General Practitioners.. Direct access to the e.learning module is as follows: www.alcohollearningcentre.org.uk/elearning/iba/ Following identification, the Practice should: Deliver the recommended brief intervention specified above to such patient, Respond to any other identified need in such patient that relates to their levels of drinking, and Provide any treatment that relates to their levels of drinking and which may be required under their primary medical services contract; A requirement that the contractor make relevant entries in the patient's medical record; Referral for Tier 2 and Tier 3 Specialist Services Patients identified as drinking at high risk (scores of 16-19) can be referred to Tier 2 alcohol services in the community: West Berkshire Turning Point tel 01635 237 795 or 07973 159 603 Reading CrI (DAIS) tel 0118 956 7441 Wokingham KCA tel 0118 977 2022 Patients identified as possibly alcohol dependent (scores of 19+ or more) should be considered for referral for Tier 3 specialist service: KCA tel 0118 955 7333 Although providing brief alcohol advice is still recommended, on its own, brief advice has not been shown to be effective for groups of patients who may be alcohol dependent. Document Title: LES for Alcohol Screening Page 2 of 5
3. Accreditation 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 However, the Royal College of General Practitioners are now providing an accredited qualification combined with the e.learning module (as above) and has issued this statement: The College has reviewed the DH e-modules on the Alcohol Website and agreed the following endorsement: The RCGP Substance Misuse Unit is pleased to endorse the Department of Health s Alcohol IBA e- learning module on identification and brief advice to combat alcohol-related harm. The e-module provides the background and context to the UK picture of alcohol related problems and describes the most effective means whereby individual practitioners can intervene. The RCGP Substance Misuse Unit recognises the educational value of completing the module, which, when combined with the RCGP accredited workbook and face to face training, constitutes the RCGP Certificate in the management of alcohol problems in primary care. The RCGP wishes to make it clear to learners that the Department of Health maintain the contents and delivery of the module and the RCGP is not responsible for providing user support or for the update or validation of the materials contained within it. 4. Audit Requirements Practices will be required to provide an audit of: 1. The number of both newly registered and existing patients aged 16 or over who have been screened using the shortened version of the World Health Organisation (WHO) Alcohol Use Disorders Identification Test (AUDIT) questionnaire (AUDIT-C) during that financial year, 2. The number of both newly registered and existing patients aged 16 or over who have screened positive under the AUDIT C during that financial year who then undergo a fuller assessment answering the remaining 7 questions on the full ten-question AUDIT questionnaire to determine increasing risk, higher risk or possible dependent drinking. 3. Demonstration of an increase in the number of both newly registered and existing patients who have been identified as drinking at increasing or higher risk drinkers who have during that financial year received a brief intervention to help them reduce their alcohol-related risk, against the 2011/12 baseline 4. Demonstration of an increase in the number of both newly registered and existing patients scoring 16-19 on the full AUDIT questionnaire who have been referred by the contractor to Tier 2 services in the community for advice and support during that financial year, against the 2011/12 baseline. 5. Demonstration of an increase in the number of both newly registered and existing patients scoring 19+ on the full ten-question AUDIT questionnaire who have been referred by the contractor for Tier 3 specialist service for dependent drinking during that financial year; against the 2011/12 baseline. Document Title: LES for Alcohol Screening Page 3 of 5
5. Monitoring Arrangements Practices should record activity carried out under this enhanced service on their clinical system using the READ codes:- 9k17 9k15 Alcohol screen, AUDIT C completed Alcohol screen, Alcohol Use Disorder Identification Test completed (full AUDIT) Alcohol Consumption 136K 136S 136T 9k1A 9k1B 8H7p 8HkG Alcohol intake above recommended Low Risk (sensible) limits Increasing Risk (hazardous) alcohol use High Risk (harmful) alcohol use Brief intervention for excessive alcohol consumption completed Extended intervention for excessive alcohol consumption completed Referral to Community Alcohol Service (refers to tier 2 services in the community) Referral to Specialist Alcohol Treatment Service (refers to tier 3 specialist service) Monitoring of activity is essential for payment arrangements. The audit detailed above will be required to be submitted to the contract performance team at TVPCA on a quarterly basis for payment. A local CHART query is available in the enhanced services library to collect this data. 6. Price Payments will be made in accordance with the SFE link below http://www.dh.gov.uk/en/healthcare/primarycare/primarycarecontracting/gms/dh_4133079 Payment will be made at 2.38 for both newly registered patients and existing patients aged 16 and over who have received screening using AUDIT C or full AUDIT and on submission of the audit data in section 4 which needs to be received before payment can be made. 7. Duration Practices may opt to provide the LES from 1 April 2012 to 31 March 2013. The LES will automatically cease on 31 March 2013 unless formally extended or terminated before this date. Document Title: LES for Alcohol Screening Page 4 of 5
8. Termination and Change arrangements The LES terminates March 2013 or earlier by either party at three months written notice. Document Title: LES for Alcohol Screening Page 5 of 5