What was the aim of the project?
The aim of the service was to trial a GP Alcohol Liaison Nurse post to provide alcohol interventions for dependent alcohol service users in three GP surgeries, in line with NICE guidance on opportunistic screening, brief intervention and delivering psychological interventions in GP surgeries.
Who was involved in the project?
To set up this trial, South Gloucestershire Council worked with:
- Three GP surgeries in South Gloucestershire
- South Gloucestershire Clinical Commissioning Group (CCG) and
- Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) as the commissioned agency to deliver the work.
What was the aim of the evaluation?
The evaluation aimed to gauge the effectiveness of the GP Alcohol Liaison Nurse post, whether the project delivered the following outcomes:
- Understanding of the factors influencing successful completions. A successful completion is defined as the service user becoming either alcohol-free or an occasional user.
- Awareness of the factors contributing towards unsuccessful exits. An unsuccessful exit is defined as when the service user became disengaged with the treatment and therefore left the system.
- Seamless support for the service users who experience transition from secondary care to primary care and community treatment.
- Positive impact on secondary care, such as reduction in hospital admissions.
- Satisfaction by the service users and improvements that can be made to aid future service planning.
- Identification of demographic patterns of service users, such as gender, age, ethnicity, and whether the service users predominantly live in the priority neighbourhood areas.
Who was involved in the evaluation?
The evaluation was completed by Nasrul Ismail, Performance & Commissioning Officer, South Gloucestershire Drug & Alcohol Action Team (DAAT) with support from Elly Barnard, Evaluation Officer, Avon Primary Care Research Centre (APCRC) and John McGinnity, Team Manager of Specialist Services, AWP.
What did they do?
Nasrul used the quarterly performance monitoring data from AWP as the basis of the evaluation. This included data collection on referrals, types of interventions delivered by the nurse, Client Evaluation of Self Treatment (CEST) to measure changes in psychological and social functioning, treatment motivation and treatment engagement, and referrals to the community services as part of the local alcohol pathways.
Confidence questionnaires with GPs were undertaken to measure the primary care confidence in the service.
Service user satisfaction questionnaires were completed prior to the service users exiting the service.
What did they find?
- All of the service users who responded either agreed or strongly agreed that they planned to reduce or stop their drinking habit following interventions, and that their day to day life had improved following interventions from the Nurse.
- All of the GPs surveyed either agreed or strongly agreed that the Nurse alleviated their time pressures, gave them greater confidence in delivering alcohol detox and provided advice on medications and clinical protocols to reduce risk associated with alcohol detox.
- 40 service users successfully completed their treatment.
- 56 service users started their treatment. The majority of them either falling within the hazardous or harmful drinkers category.
- The highest numbers of interventions delivered include Identification and Brief Advice (IBAs), 1:1 keyworking sessions, and relapse prevention.
- 18 service users underwent GP supported detox.
- Every £1 investment into the alcohol service yields a return on investment of £4.30 (Department of Health, 2009). Using this model, it was estimated that the pilot project saved £172,002 through the alcohol interventions for this group of drinkers.
If the service users re-present within six months, this will reduce the successful exits rate. The re-presentation rate has always been lower than the national rate – in Quarter 4 of 2016/2017, the re-presentation for alcohol was 1.9% against the national rate of 8.7%. It is hoped that this trend continues to realise the return on investment.
Who was the evaluation shared with and why?
The evaluation was shared with the following stakeholders:
- South Gloucestershire Joint Commissioning Group.
- South Gloucestershire Alcohol Stakeholders’ Working Group.
- AWP management team.
- South Gloucestershire CCG, in particular the Admission Avoidance Working Group in order to consider co-commissioning the service.
- Bristol CCG, as they wish to replicate the same service in GP surgeries across Bristol.
- University Hospitals of Morecambe Bay NHS Foundation Trust, as they wish to establish similar services in Cumbria as part of the local alcohol pathways.
- South Gloucestershire NHS Sustainability and Transformation Plans (STPs) as part of the preventative agenda.
As the pilot project was deemed to be a success, it will be mainstreamed into an Integrated Primary Care Service in South Gloucestershire, following the recent commissioning process. This will be the case from 1 September 2017. This will mean that there will be an increased support for users with alcohol issues across GP surgeries in South Gloucestershire.
In particular, eight GP surgeries have been identified that will act as ‘clinical bases’, where the substance misuse workers will be based up to three days per week to provide Identification and Brief Advice for primary alcohol users, and extended brief interventions for highly complex primary alcohol users. If service users who have been through the programme require additional support to prevent a relapse, they can opt for the structured treatment which combines pharmacological and psychosocial interventions. If further assistance is required, they can also be considered for residential rehabilitation.
In addition, there will be the provision of clinical nurses who will be responsible for providing clinical input for alcohol intervention including detoxification and relapse prevention. They will also offer support to GPs and practice staff. This new service commenced on 3 April 2017 and will continue for three years.
To ensure that the GP Alcohol Liaison Nurse service continues to be effective, South Gloucestershire Counci will evaluate the service via their annual needs assessment. For a longer-term evaluation, they will await Public Health England to conduct their Value for Money study to determine the cost-effectiveness of the service – this study tends to take place once every two or three years.
What has changed as a result?
The offer of the service was increased to eight GP surgeries across South Gloucestershire. For service users who are not registered at these eight surgeries, support will still be available at the Treatment Centre in Warmley, and four community hubs covering the localities of Kingswood, Yate, Severn Vale, and Thornbury.
What social media activity was used during the project?
Social media was not used to publicise the pilot project, as the service was only available to three GP surgeries and access to the nurse will be made via the GPs. Going forward, the service will be publicised via social media as part of the new service launch.
Successes and challenges
- Ensured evidence-based service planning, which assisted the commissioners in designing the new substance misuse services in South Gloucestershire as part of the recent recommissioning process.
- Commissioners had increased awareness of the service users’ complexities and their demographics. Such an awareness led to treatment pathways being designed that were more intuitive according to the local need.
- GPs became more aware of the service users’ complexities and feel more confident to assist patients with alcohol dependencies with the help of the GP Alcohol Liaision Nurse.
- Improved availability of service for the service users. For example, a service user mentioned that the service provided him with “‘An opportunity to discuss my [situation] openly in confidence.”
- Improved engagement with GPs. For instance, a GP mentioned, “The service has also helped improve the confidence of GPs in the practice in handling alcohol problems.”
- Improved awareness of the factors contributing towards successful and unsuccessful exits of service users from the service.
- Identification of return on investment of £4.30 for every £1 spent to deliver the service.
Obtaining patients’ data from the practices in order to determine if the service users reduced their repeat visits to the GPs as a result of the involvement of the GP Alcohol Liaison Nurse. The Public Health & Wellbeing Division has no access to the database so in this instance, the South Gloucestershire Drug & Alcohol Action Team will be exploring this further with the service provider and the CCG.
- Department of Health (2009) Signs for Improvement – Commissioning Interventions to Reduce Alcohol-related Harm.
- HM Government (2012) Government’s Alcohol Strategy.
- Ismail, N. (2015) South Gloucestershire Substance Misuse Needs Assessment, to Inform the 2015/2016 Treatment Plan.
- Kaner, E. et al. (2013) Effectiveness of Screening and Brief Alcohol Intervention in Primary Care [SIPS Trial]: Pragmatic Cluster Randomised Controlled Trial, British Medical Journal, 346.
- NICE (2011) Commissioning Guides 38: Services for the Identification and Treatment of Hazardous Drinking, Harmful Drinking, and Alcohol Dependence in Children, Young People and Adults.
- NICE (2011) Guidance Quality Standard 11: Alcohol-use Disorders: Diagnosis and Management (2011).