Ending the stigma of alcohol services

Alcohol community nurse Jill Emmerson set up a service in GP practices to engage hard-to-reach patients who would be too embarrassed or ashamed to use conventional treatment services. The project has reduced hospital admissions and improved the health of patients. Ms Emmerson was a finalist in the Community Nursing category of the Nursing Standard Nurse Awards 2015.

Nursing Standard thanks Kellogg’s All-Bran for sponsoring the Community Nursing category in our Nurse Awards 2015

A nurse who offers alcohol advice and treatment in GP surgeries has reduced hospital admissions and increased patients’ engagement with alcohol services.

Alcohol community nurse Jill Emmerson has expanded the GP Alcohol Project (GPAP) to 18 practices in Middlesbrough. Her work has proved so successful that negotiations are under way to include three more GP practices, and there is a waiting list of surgeries wanting to join.

Ms Emmerson, runner-up in this year’s Nursing Standard awards in the Community Nursing category, got the idea for the project while working in a single GP practice providing alcohol treatment.

‘I realised there was a lack of face-to-face intervention in surgeries,’ she says. ‘There was a revolving door of patients attending hospital and the GP. I wanted to find out why they did not attend treatment services.’

Working closely with James Cook University Hospital, Ms Emmerson managed to reach people who were going to emergency departments most frequently. She identified the ten GP practices that had the most alcohol-related hospital admissions and set up a six-month pilot in April 2013.

At first, she delivered her new service in six of the ten practices, offering one session a week in surgeries.

‘I wanted to provide a service in GP practices to avoid the initial feelings of stigmatisation,’ she explains. ‘Patients fear being judged about their alcohol use.

‘By intervening in GP surgeries, I also wanted to increase awareness of the effects of alcohol at an early stage with a focus on preventing later problems.’

Clinical commissioners had already noticed that patients referred to alcohol treatment services by their GP had low attendance rates.

Ms Emmerson pursued a two-pronged approach – treatment for those who needed it, and intervention and education for patients not quite at that threshold. The pilot aimed to increase the number of people engaging with alcohol services, including those who had never received treatment for their alcohol misuse before.

‘The GP practices had to be persuaded,’ says Ms Emmerson. ‘They feared an influx of drunk people in their waiting rooms. We had to point out to them that the people we are trying to help are actually their patients. And we have never had a complaint.’

Another important partner to bring on board was the receptionists – gatekeepers to the decision-making GPs. ‘Not only have we got reception on board, but they are good at highlighting people they feel might have an alcohol problem,’ says Ms Emmerson.

‘There were also fears that patients would not like being bothered in the waiting room and would not like being asked questions about their alcohol use. What we have found is that patients are happy to have a five-minute chat while they are waiting for their appointment.’

Jill Emmerson helps patients get over their fear of being judged

Picture credit: Jim Varney
Audit tool

Under GPAP, patients are approached in the waiting room and asked a series of questions using AUDIT C, a three-item alcohol screening tool that can help identify people who are hazardous drinkers or have active alcohol use disorders.

As a nurse prescriber, Ms Emmerson is able to offer more intensive support and treatment for the patient and assess their immediate health needs. She can also provide detoxification and relapse prevention medication as required.

The success of the pilot led to further funding and the expansion of the scheme to include an early interventions specialist worker. He now does the initial contact work in GP surgeries, while Ms Emmerson focuses on her nurse-led treatment clinic offering venepuncture, detox, prescribing and referral to specialists.

Patients are supported for up to five sessions at the GP practice. If they have not achieved the goals they have set – whether it is detoxification, controlled drinking or abstinence – they are guided into the next stage of treatment.

Charles Cornford, lead GP for alcohol services in Middlesbrough, says the social stigma surrounding alcohol problems often makes patients reluctant to access conventional services.

From nine litres of cider to abstinence

Mr A was referred to the GPAP by the practice nurse in his surgery after he said he thought he was drinking too much.

On assessment he disclosed that he was drinking nine litres of cider (67.5 units) daily and had been for two years since his marriage broke up. He was desperate to stop.

He had never accessed treatment or attended hospital before. At the initial assessment, Ms Emmerson prescribed him thiamine, as his dietary intake was poor. Through the GPAP service he reduced his drinking over three weeks to six litres (45 units) daily, and made lifestyle changes. He felt he could not cut down any more without experiencing withdrawal symptoms.

Mr A’s blood results showed early signs of liver damage. He was referred to the hospital’s liver harm clinic for further investigations.

As a result of this, Mr A began a seven-day detox in hospital and was then transferred to a community detox facility with medical support to complete. Ms Emmerson then prescribed him relapse prevention medication.

Nine months later, Mr A remains abstinent from alcohol.

‘Jill’s initiative has allowed screening and brief advice to be delivered within waiting rooms,’ says Dr Cornford. ‘The access to a nurse for patients who otherwise would have difficulty in accessing appropriate help has been enormously successful.’

The GPAP now comprises three full-time members of staff and two part-time volunteers.

There has been a huge improvement in engagement in alcohol services by patients in the first 11 of the 18 practices. ‘The other seven practices are newer to the project and improvements are catching up to the others,’ says Ms Emmerson.

Kathryn Stapylton, clinical sister for substance misuse services at James Cook University Hospital, says the new pathways allow patients to be referred to the liver harm reduction service.

‘The pathways divert those patients who are likely to attend A&E or become emergency admissions to access management and treatment of alcohol misuse in the outpatient setting,’ Ms Stapylton says. ‘It also has the benefit of earlier detection and management of physical health problems and provides psychosocial assessment and appropriate interventions, such as motivational interviewing and prescribing to prevent further deterioration.’

She adds that there are ‘clear streams in place for those patients being referred back to community care’, and points out the importance of good communication between primary care and secondary care.

Patients with chaotic lifestyles who are not engaging with the community teams are discussed at a monthly enhanced case conference, where it is decided which agency should act try to reach the patient: the hospital-based clinical sisters, the community alcohol team or social services.

‘Jill joins the conferences and plays a significant part in managing these patients in the primary care setting,’ says Ms Stapylton.

Jill Emmerson at Fulcrum Medical Practice in Middlesbrough. Initial brief advice worker Steve Saxton makes patient contact (posed by model) in the GP waiting room

Picture credit: Jim Varney
Success rates

In the first year of GPAP there was a 44% reduction in hospital admissions, rising to 66% in 2014/15. In the six months up to March 2015, 221 patients engaged with the project; 67 patients achieved goals within the project, such as controlled drinking or abstinence. More than 91 patients transferred to Middlesbrough Recovering Together service, which focuses on either recovery or further treatment of alcohol problems. Only 19 patients dropped out.

No stigma

Mrs B was referred to the GPAP by her GP after revealing she had been drinking two bottles of wine a night since being bereaved a year before. On assessment, her AUDIT score was 34, which indicated dependence. Attempts to stop had led to withdrawal effects such as sweating, shakes and agitation.

At the initial assessment, Ms Emmerson prescribed thiamine and took bloods for liver function. At this point, Mrs B disclosed that she was actually drinking a 28-unit bottle of vodka daily.

Attending the clinic, she gradually reduced her alcohol intake safely. Ms Emmerson arranged for a member of the Middlesbrough Recovering Together (MRT) team to attend one of her appointments to explain services to Mrs B. She wanted to continue addressing her dependence, so a transfer to MRT Lifeline was arranged. She has since become abstinent from alcohol.

‘Mrs B told me several times she would never have attended an alcohol service due to the stigma, but she didn’t feel that at the GP surgery,’ says Ms Emmerson. ‘By the time of transfer, she felt more confident to attend a different building.’

There is also evidence that around 60% of GPAP patients who have attended the emergency department or been admitted to hospital have reduced their reliance on these services, compared with the ‘revolving door’ pattern of use that existed before the project.

Ms Stapylton adds: ‘Those having to be admitted are staying in hospital for less time due to their admission being in a more controlled and expected manner.’

Ms Emmerson says the fall in admissions is evidence of an improvement in patients’ health, and she expects long-term problems will also be prevented by the project. She is especially proud of the high number of brief interventions in GP waiting rooms. ‘More than 500 have been completed, and only two people have refused.’

I am proud that patients gain confidence to continue their treatment journey

The brief intervention she developed is not only successful, but can be ‘easily replicated elsewhere’, according to Laura Serrant, professor of community and public health nursing at the University of Wolverhampton, who was on the specialist judging panel of Nursing Standard’s awards.

Despite having a waiting list of surgeries wanting to join the GPAP project, Ms Emmerson is already developing plans to engage all GP practices in Middlesbrough. A pathway is set up with hospital alcohol services so discharged patients will be given an appointment at a clinic in the project. The GPAP is also part of plans for pharmacies to provide initial brief advice and follow up.

Ms Emmerson is the lead within local GP practices for providing nalmefene, the first drug approved by the National Institute for Health and Clinical Excellence to help drinkers with mild dependency to cut down on their intake.

Other developments include providing peer mentors to smooth the transition from the GP surgeries to alcohol misuse services, which might further reduce the number of people dropping out from treatment.

‘Time and time again we are informed by our patients that they left their alcohol problem until it became unmanageable due to the fear of being stigmatised by walking into a treatment service,’ says Ms Emmerson. ‘I am proud we are able to provide a service that patients can access at their own GP practices and gain confidence to continue their treatment journey with our help’.

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