An evaluation to assess the implementation of NHS delivered Alcohol Brief Interventions in Scotland

Dr Tessa Parkes on behalf of evaluation team Faculty of Public Health Conference, Aviemore, Nov 11th 2011

Focus of presentation

Background and context Aims of evaluation Data sets and methods Highlights of findings, focusing on

learning from ABI implementation Implications

Background and context

Mounting concern at higher than recommended alcohol consumption and negative health outcomes

Delivery of alcohol brief interventions (ABIs) is a significant component of the Scottish Government Alcohol Strategy – HEAT 4 2008-2012

Theory of Change developed to map desired outcomes and provides theoretical underpinning for seven projects tracking implementation of key actions/reach of strategy/attributable outcomes

Main aims of evaluation

In what ways are ABIs being implemented at NHS Board level and at service delivery and practitioner levels?

To what extent are ABIs being implemented?

What can be learned from implementation of ABIs to ensure that momentum is maintained and ABIs are embedded into mainstream delivery as part of the core business of the NHS in Scotland from 2011?

Data sets and methods

Data sets Methods/Approach

National level key informant / health board ABI lead interviews and key documents

Qualitative

NHS Board Progress Reports Quantitative

Case study board monitoring data from three case study health boards

Quantitative & Financial modelling

Interviews in the three case study boards at board level for all priority settings and practitioners and patients in primary care

Qualitative

Findings

Views on HEAT H4

Recognition of ‘window of opportunity’ that enabled alcohol interventions in the NHS to become a priority

Mixed views on appropriateness of targets as a means of driving policy and practice forward

Consensus on primary care as a priority setting but not the same consensus in A&E and antenatal care

National supports were highly valued but lack of a (non-delivery) development year was very challenging

Delivery of ABIs across Scotland

Progress made over time towards respective targets of ABIs delivered by each of the 14 health boards during 2008/09, 2009/10 and 2010/11, in accordance with the HEAT H4 target

Implementation of ABIs in primary care

Substantial variation across boards in LES contracts accentuating different elements of ABI delivery

Practice sign-up mostly good but some boards experienced difficulties getting practices on-board

Reliance on Keep Well/Well North in some boards

Numbers of practices involved did not increase over time in all boards and expected levels of delivery did not always occur

Practitioner views – primary care

Practitioners generally supportive of an active role in addressing alcohol related harms

View that primary care was a valid setting for ABIs and preventive intervention

Less favourable comments related to practicalities such as time constraints, the nature of LES contracts and compulsory training

The majority of GPs stated they were comfortable raising the issue of alcohol

Patient interviews - primary care

Few patients actively welcomed discussions on alcohol but all reported experiencing the consultation as tactful and sometimes handled with considerable skill and sensitivity

Most patients appeared to accept that these conversations were part of a health worker’s role

Impact varied – for some it had triggered change and for others it did not seem to have done

Implementation in A&E

Substantial variability across Scotland

Having a history of work in this area, with lead roles and collaborative structures or relationships already in place, facilitated implementation

Significant resistance to ABIs

Considerable ‘ground work’ required and need for ‘light touch’ approaches to avoid heavy reliance on front line staff e.g. screen and refer-on

Implementation in antenatal settings

Commonly the last setting to begin implementation of ABIs but considerable enthusiasm and success noted in some board areas

Time constraints prominent again, other priorities co-exist

Few women report drinking alcohol during pregnancy when asked so numbers of ABIs delivered low

Reach

Population-wide approach seen as significant to avoid stigma - ‘everyone is in the target group’

Keep Well/Well North viewed as excellent mechanism to extend reach, esp. in terms of older men

Gaps in coverage - geographic, age and gender

Pragmatic and opportunistic approach needed, innovation apparent in many areas

(Tentative) impact

• Some ‘disappointment’ about numbers - despite target being reached - some felt numbers were growing over time as momentum gained

• Differences across boards in terms of impact on referrals to specialist alcohol services

• Cannot assume impact of ABIs on increased referrals

• Emphasis needs to be placed on follow-up e.g. of patient outcomes/journeys to better discern impact

Mainstreaming ABIs

Boards want work to continue given efforts thus far – needs time to ‘bed-in’ - ‘hard lessons’ learned

Many other settings viewed as having potential

Potential to integrate health improvement programmes

Investment in training responsible for building support for ABIs at grassroots level

Reviewing progress, proving benefits and celebrating progress are essential next steps

Some implications….

Cultural change takes time

Ensure local and community-driven priorities are considered in tandem with national HEAT priorities

Specialist roles are essential to success

Continued support needed for training/professional development

Incentivise partnership working and integrated approaches

In summary

Aim of HEAT H4 is to embed ABIs into routine practice – Many successes to celebrate and rich learning– Scotland has a significant contribution to make to

international evidence base – Substantial variation across the country

Lots of learning for post H4 and other HEAT targets – Key tensions e.g. data reporting and monitoring – Funding and infrastructure support needs to continue to be

adequately resourced to ‘bed-in’ developing levels of skills and confidence

– Importance of training for the cultural change and buy-in

Acknowledgements

Evaluation Team– Douglas Eadie, Oona Brooks, Stuart Bryce and Susan MacAskill from ISM– Dr Iain Atherton, Dr Josie Evans, Stephanie Gloyn, Stephen McGhee and Bernie Stoddart

from SNMH – Dr Dennis Petrie and Homagni Choudry from School of Business, University of Dundee

Project Advisory Group– Louise Bennie, Sarah Currie, Alison Douglas, Iain MacAllister, Donna MacKinnon and

Evie McLaren from Scottish Government– Fiona Myers, Clare Beeston, Andrew McAuley, Jane Ford, George Howie, Catriona Loots,

Jackie Willis and Brian Orpin from NHS Health Scotland – Clare Harper, Roz Vidler, Margaret Quinn and Paul McAleer from ISD

Health boards, the three case study boards and the local leads and all evaluation participants

Report reviewers: Professor Stewart Mercer, Dr Rhona McInnes and the reviewers in the three case study boards