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Sunday 23 October 2016
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Alcohol issues

General practice plays a key role in supporting patients with alcohol issues but it is also important to recognise when colleagues are struggling

Alcohol Concern’s Dry January campaign, 2015, was widely supported by healthcare professionals throughout the country. In primary care, clinical commissioning groups (CCGs) encouraged practice staff to join with patients and abstain from alcohol for 31 days. Of those who took part in January 2014, nearly three quarters reported less harmful drinking during the rest of the year. Other benefits noted were sleeping better, having more energy, losing weight and saving money.1
This initiative also drew attention to key issues relating to alcohol consumption in the UK. While most people drink responsibly, the health of a quarter of the adult population is endangered by excessive drinking. As a result the following have becone causes for concern:

  • Liver disease, a third of which is alcohol-related, has become a leading cause of premature death among working age adults.
  • Binge drinking has led to an increasing number of young adults developing alcoholic liver disease.
  • More people are at risk of diabetes, cardiovascular disease, breast cancer and cancers of the gastro-intestinal tract as well as mental illness.
  • Harmful drinking has increased among young women, including those who are pregnant. This has led to a rise in children born with fetal alcohol spectrum disorders.
  • More older people are drinking at levels harmful to their health.

Our drinking culture has huge societal and economic consequences. Alcohol-related violent crimes and alcohol-related hospital admissions, as well as chronic diseases directly attributable to alcohol, cost society around £21 billion a year. The impact on individuals and their families can be devastating, resulting in job loss and fractured relationships. Since alcohol misuse is a risk factor for domestic abuse, children and vulnerable adults may also suffer.
When the coalition government produced its alcohol policy in 2012 the overall approach required concerted action by the government and industry as well as local agencies. Since the May 2015 election the strategy has been reviewed and updated but its central message and intent remains. The aim is to bring about a change in people’s behaviour so that it is no longer considered acceptable to drink in ways that cause harm to individuals themselves, or to others. The measurable targets are to reduce:

  • The amount of alcohol-fuelled violent crime.
  • The number of adults drinking above low risk guidelines.
  • The number of people binge drinking.
  • The number of alcohol-related deaths.
  • The number of young people aged 11 to 15 drinking alcohol and a reduction in the amount they drink.2

Playing your part
General practice is integral to the success of the government’s alcohol strategy. Since 90% of patient contacts occur in the community, it is in GP surgeries where problem drinking can most easily be identified. The general medical services contract now requires that newly registering patients are screened for problem drinking and alcohol use disorders. (Table 1)

Targeted screening provides primary care clinicians with the opportunity to raise awareness, give advice or provide brief interventions. This will help facilitate delivery of the service pathway for alcohol-related disorders (Figure 1). This should include patients whose chronic conditions, such as hypertension, liver disorders, and common mental health problems (e.g. anxiety or depression), may be caused or exacerbated by alcohol misuse.

Giving routine advice about the interaction of alcohol and certain medications also provides an opportunity for discussing a patient’s alcohol intake.
Clinicians need to be alert to those patients who may also be at risk of alcohol misuse as a result of traumatic life events, such as bereavement, breakdown of relationships, and redundancy. Among older people, loneliness, boredom and isolation may compound other problems and make them more susceptible to alcohol misuse.
It is also vital that safeguarding issues are considered in relation to family members and others, where a patient’s behaviour has been, or is likely to be, deleteriously affected by their alcohol dependence.
Practices can assist their staff in managing patients with alcohol disorders by:

  • Ensuring they are trained to identify, treat and where appropriate, refer patients to specialist services.
  • Having sufficiently flexible systems to allow for follow-up appointments where brief interventions and/or regular support are part of the treatment pathway.
  • Facilitating inter-agency working and involvement of GPs/clinicians in care planning.
  • Maintaining up-to-date information on relevant local services, including those provided by the third sector.
  • Providing opportunity for staff to participate in regular continuing professional development (CPD) and have access to mentoring and support.
  • Highlighting the relevance of policies and procedures relating to safeguarding for children and vulnerable adults.

Helping colleagues
Issues relating to alcohol misuse may affect the health and wellbeing of staff as well as patients. Healthcare professionals are not immune to the stressful events, ill-health and prevailing drinking culture that can lead to alcohol abuse.
While individuals themselves have a responsibility to look after their own health, this often requires a level of insight that is eroded as dependency increases. It is therefore vital that the practice culture is one of openness, where staff recognise that their own health, or that of a colleague could compromise patient care. By creating a supportive environment practices can enable staff to identify the early signs of stress or ill-health in others, especially where this may be impacting on their performance, as well as contributing positively to the recovery or the return to work of a sick colleague. (See Box 1: case study)

All staff need an awareness of the practice’s policies and procedures relating to alcohol and substance misuse, including how to raise concerns that will enable them to assist in reducing any potential risks to patients. It is also important to emphasise that where unacceptable behaviour arises as a result of alcohol or substance misuse, it will be dealt with under the practice’s disciplinary policy.
Managers should be alert to warning signs that may indicate a problem, particularly when several are present and persist over a period of time, for example:

  • Frequent unscheduled absences, including sick leave, especially with implausible explanations.
  • Deterioration in punctuality and poor time keeping.
  • Unreliable or unpredictable behaviour.
  • Increasing social withdrawal or isolation from colleagues.
  • Gradual changes in personality.
  • Performance issues, including mistakes and patient complaints.

As alcohol dependency increases, the problems become more obvious, for example:

  • Unkempt appearance.
  • Smelling of alcohol.
  • Noticeable clumsiness.
  • Arriving to work hungover.

Prevent situations from escalating by investigating serious concerns promptly. The relevant professional bodies, as well as your local CCG, can be approached for guidance together with advice on training.
Alcohol Concern is now promoting Dry January 2016. This gives you an opportunity to highlight the facts about alcohol consumption, and the help available locally and in-house for those trying to reduce their intake. Will your practice support this enterprising initiative to benefit your patients, staff and wider community?

Anne Ward Platt, BA(Hons) PGCE, director, WP Medical & Professional Services.

1. Alcohol Concern. Academic research reveals Dry January leads to less drinking all year round. (accessed 1 July 2015).
2. Department of Health and Jane Ellison MP. Policy paper: 2010 to 2015 government policy: harmful drinking. (accessed 1 July 2015).
3. Word Health Organization. International Classification of Diseases, version 10. (accessed 1 July 2015).

Alcoholics Anonymous
Alcohol Concern
UK SMART Recovery
Sick Doctors Trust
National Institute of Alcohol and Alcoholism
National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical guideline 115