Tackling the impact of problem drinking

As the UK’s drinking culture exerts increasing pressure on the NHS, nurses in settings from emergency departments to GP practices and community care are on the front line of alcohol abuse, using brief interventions and outreach education to change patients’ behaviour.

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Rugby-loving bloke Pete Hawkins says he enjoys a pint or two. But every day at work he sees evidence of the damage that alcohol can do.

As a senior staff nurse in the emergency department of Southmead Hospital, Bristol, much of his job involves coping with the effects of our boozy culture. This can mean anything from dealing with the immediate impact of alcohol poisoning, to facing anti-social behaviour – including physical and verbal abuse – from patients.

‘Not being a city centre hospital, we don’t get the same spike at weekends,’ Mr Hawkins explains. ‘But often what we’re seeing is people suffering from the effects of longer-term alcohol abuse. We see a lot of older people, and middle-aged women who are drinking at home, and who have maybe fallen down stairs as a result. Or people whose drinking is exacerbating conditions like COPD.’

In emergency departments up and down the land, the impact of alcohol is increasingly being felt. Evidence that we, as a nation, have a drinking problem is stacking up – and there are suggestions that the NHS simply is not doing enough to tackle the issue.

In December, at the height of the Christmas party season, the Nuffield Trust health charity published a report detailing the scale of the issue in the NHS in England. This found that emergency admissions specific to alcohol has increased by over 50% in the past nine years, and are now topping 250,000 a year. It also found that the rate of people attending emergency departments with probable alcohol poisoning has doubled in six years.

Few people would deny that Scotland has a particular problem with alcohol – but nurses across the health and social care system are doing their bit to help.

The country has taken a number of steps to change its relationship with alcohol, including setting targets around alcohol brief interventions (ABIs).

Since the national strategy on alcohol was published in 2009, more than 300,000 ABIs have been delivered, most of them by nurses.

Although most of these brief, tailored conversations take place in GP practices, antenatal clinics and emergency departments, they are also happening in other settings such as prisons, custody suites, and higher education institutions.

According to NHS Lothian lead practitioner in alcohol brief interventions Eleanor McWhirter, Scotland’s second largest health board, conducting such conversations has become second nature for nurses and midwives.

‘It’s become embedded in practice,’ she says. ‘No matter where you are, you probably can’t escape the alcohol questions.’

She says ABIs are a matter of early intervention: encouraging people to think about their alcohol intake before they reach dependency, but also to think about making informed choices about drinking at any level.

‘We’re talking about risky drinking,’ she says. ‘And we train nurses so that they are confident about asking the questions in the right way. For nursing staff, it’s about having a consistent message. For example, the new guidelines on drinking alcohol are just a cut-off; drinking any amount of alcohol can have a detrimental effect on people’s lives, whether it’s their relationship, their job, or their health.’

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As well as ensuring that NHS Lothian’s nurses are trained and supported in delivering ABIs, Ms McWhirter's job includes working with local universities to ensure nursing undergraduates receive training before they go out on placement.

She also wants nurses to be confident about signposting to specialist services, and points out that NHS Lothian has drug and alcohol hubs where people can self-refer.

'We train nurses so they are confident asking patients about alcohol'

Scots drink around one fifth more than their neighbours in England and Wales, and experience more alcohol-related deaths and harm too. Since the alcohol strategy was published, however, there has been some progress. Scotland’s drink-drive limit is now the lowest in the UK, steps have been taken to ban off-sales promotions, and legislation to introduce a minimum unit price for alcohol has been passed (although it has not yet been implemented because of legal challenges from the drinks industry). There are also national targets around ABIs and access to specialist services.

‘We all recognise in Scotland that we have a problem with alcohol,’ says Ms McWhirter, a former charge nurse in an Edinburgh psychiatric hospital. ‘But we’re taking serious steps to address it.’

There is a enthusiasm among NHS Lothian’s nurses to deliver ABIs, she says. ‘Our target for 2015-16 is just under 10,000, but we’ve already delivered 22,000,’ she says. ‘It is a part of the way we do things.’

‘It’s a huge burden for the NHS,’ says Alisha Davies, senior research analyst with the charity and one of the report authors. ‘It’s a complex problem and it isn’t easy to fix. Nurses have a role to play, of course, but so do all the other parts of the system. At a national level, governments and policymakers can act on things like introducing a minimum unit price for alcohol. Locally, commissioners can act to make sure the services are there.’

Nurses in various settings, from GP practices to emergency departments, are already making that difference. As well as innovative support and specific projects, such as the assertive outreach support being tested in south London (see box, page 20), nurses are delivering brief interventions, working in alcohol services and caring for patients whose physical and/or mental health has been affected by drink.

Patients who frequently attend emergency departments with alcohol-related problems are being targeted in a new approach aimed at reducing harm.

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Nurses are at the forefront of the assertive outreach team project being tested in south London. Based on a successful pilot in Southwark, the King’s Health Partners project will offer intensive support to patients at South London and Maudsley, Guy’s and St Thomas’ and King’s College Hospitals NHS Foundation Trusts. The first patients will be recruited next month.

‘The project will be targeting people who attend emergency departments frequently with alcohol attributed diagnoses,’ says Julie Winnington, a mental health nurse and clinical liaison lead for addictions, managing the initiative.

‘Those who want to take part will be offered extra support, including frequent contact with an addictions clinician – meetings will take place at least once a week – in a place of their choice, whether that’s at home or in the community.

‘The support will be led by the service user; we’ll ask what’s important to them, whether that’s help with housing, or employment, or a particular health need. We obviously want people to reduce their drinking, but we’re not saying that they have to stop drinking for us to engage with them.’

Ms Winnington was involved in the Southwark pilot. ‘It was brilliant,' she says. 'We were providing support that people wanted – anything from taking someone to an Alcoholics Anonymous meeting, to going to the Imperial War Museum, because that’s where they wanted to meet. It involves working with existing services, not duplication.’

The initiative is being tested in a three-year randomised controlled trial, funded with £1.3 million by Guy’s and St Thomas’ Charity, to compare the intensive support involved in assertive outreach with normal treatment.

Ms Winnington also chairs the addictions clinical academic group, part of the Health Innovation Network and Academic Health Science Network for south London, which is involved with the project. ‘Alcohol is a priority for the Health Innovation Network because the impact of drinking in south London is significant,’ she says.

‘It’s important that nurses are part of the assertive outreach team because we bring that extra layer of knowledge about physical health, as well as skills in building trust.’

It’s hoped that the team – which also includes addictions experts, a consultant addictions psychiatrist and trainee doctor – will reduce numbers of hospital admissions and inpatient stays by 66% and attendances by 50% among users of the service.

‘It builds on smaller projects done elsewhere, but we believe this is the first randomised controlled trial. It could make a real difference.’

‘Where nurses come in is in making every contact count,’ says Dr Davies. ‘Our report shows that about three quarters of people who had an alcohol specific hospital admission only attended hospital the one time in that year. This suggests that if you can catch them at that teachable moment, you might be able to make a difference.’

The problem, however, comes with ensuring nurses and other health workers are supported to do this. ‘We know that nurses are busy, and there aren’t always services they can signpost patients on to,’ she says, pointing out that although the National Institute for Health and Care Excellence recommends commissioning hospital alcohol workers to assess and manage people who drink alcohol at harmful levels, a 2013 Public Health England survey suggested that one in four hospitals do not have such a service.

Andrew Langford, chief executive of the British Liver Trust and a former oncology and palliative care nurse, says it is vital that hospitals at least have easy access and links to alcohol workers. ‘Alcohol is a huge problem for our health services and our population, and we need to make sure we are providing more support and early intervention,’ he says.

According to Public Health England, there are an estimated 10.8 million adults who are drinking at levels that pose some risk to their health, while 1.6 million may have some level of alcohol dependence.

Alcohol is the third leading risk factor for death and disability after smoking and obesity.

Alcohol has been identified as a causal factor in more than 60 medical conditions including cancers of the mouth, throat, breast, stomach, bowel and liver; heart disease; pancreatitis; depression; liver disease and stroke.

According to the Scottish Health Survey 2014, nearly one in four men in Scotland and one in six women drink at harmful or hazardous levels

According to the British Liver Trust, liver disease is the only major cause of death that is still rising year-on-year. The British Liver Trust offers an app to help people monitor their alcohol intake (www.spruceapp.co.uk) and a quick online test that people can take to assess their liver health (www.loveyourliver.org.uk)





‘It has an effect on the working lives of nurses, whether they are in the community, GP practices, emergency department, the operating theatre or liver wards.’

The changing face of liver disease brings real challenges, Mr Langford adds. ‘When I was a charge nurse in the Royal Free Hospital [in London] many years ago, liver wards were populated by red-faced older men with bulbous noses. Today it’s the third most common cause of premature death – the average age is 57 – and it’s no longer unusual to see patients aged in their twenties with advanced liver disease.

‘We also have to consider the support needs of nurses themselves. It is hard when you’re looking after patients who are the same age or younger than you, so there has to be good supervision and support.'

Mr Langford is delighted that the impact of alcohol on health is now being addressed at the highest levels – for example, recent comments by England’s chief medical officer Professor Dame Sally Davies on alcohol and cancer risk, as well as the proposed revised guidance on alcohol intake (www.gov.uk/government/consultations/health-risks-fromalcohol-new-guidelines).

‘Alcohol is a Class A carcinogen,’ he says. ‘It’s not just the obvious impact, like long-term liver damage. It’s also an important contributory factor in cancers including breast, bowel and prostate.’

Public Health England’s chief nurse Viv Bennett says nurses and midwives have important roles in prevention of avoidable disease and in health promotion. ‘Increasing our knowledge about alcohol-related harms and how to support people to make healthier choices about drinking will make a real difference,’ she says.

‘The new UK guidelines provide an opportunity for nurses to get people thinking about what harmful drinking looks like. By making “every contact count” we can increase identification of people at risk of health harm from drinking, providing brief interventions and signposting to further support.’

Dr Davies agrees. ‘The best thing everyone could do is cut down. But we know it’s not as easy as that, so support needs to be there.’

Useful tips for nurses from NHS Lothian lead practitioner in alcohol brief interventions Eleanor McWhirter

1 Prepare by exploring your own attitudes and beliefs about alcohol, and how this might affect the way you approach the subject.

2 Know how to calculate units and be aware of recommended limits.

3 Consider any barriers that might be in the way of raising the subject: do you feel you don’t have enough time, knowledge or resources? Or do you feel it is not your job?

4 It is an issue like any other, so build up the skills that you already use in nursing to develop good, trusting therapeutic relationships, such as being a good listener. Be aware that if you have the knowledge and skills, raising the issue is not such a big deal.

5 Practise the conversation; give it a go, bearing in mind that it’s important to understand and recognise a willingness to change – where the patient is, in terms of being open to making changes. And don’t be afraid to revisit the issue, or leave the door open if the patient wants to come back to you for more information or support.

6 Remember that people expect to be asked about alcohol (along with smoking and exercise, for example) in a healthcare context. Be professional and matter-of-fact.

7 Know your limitations, and be aware of local services so that you can signpost or refer patients as appropriate.

Preparing for another long night shift, Mr Hawkins says: ‘We need a change in culture. Yes, it’s important that the services are there, but we have to get to a point where people realise that they don’t have to get drunk to have a good time.

‘But we also have to deal with the other issues driving people to drink, like feelings of isolation. As a nurse, I see the impact, and it’s not good for any of us’.

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