General Practice will no longer be incentivised to deliver 'Identification and Brief Advice' (IBA) for new patients from April next year following changes announced to the General Medical Services (GMS) contract.
Instead of the alcohol Direct Enhanced Service (DES) funding, NHS Employers states 'the associated funding will be reinvested in global sum' - the total amount paid to Primary Care. It will then be a 'contractual requirement for all practices to identify newly registered patients drinking alcohol at increased or higher risk levels'.
On the one hand, this means all practices will be obliged to identify at-risk drinkers when new patients join a practice. On the other, removing the requirement to record 'identification' to generate the payment will presumably not help focus attention on IBA. Nor will the changes help address questions over whether 'identification' of at-risk drinkers actually results in patients receiving 'brief advice', although the current DES guidance states it is for local commissioners to quality check.
NHS England have committed to monitoring recorded activity via the General Practice Extraction Service (GPES), so will be able to assess the impact of the change.
The alcohol DES: 2008-2015
Since 2008, practices have been able to take part in the alcohol 'Direct Enhanced Service' (DES) and claim a payment (currently £2.38) for each new patient screened using a validated initial 'identification' tool such as the FAST or AUDIT-C. Originally only planned for two years, the alcohol DES was then extended each year. However its value has been much debated with questions over whether the scheme has actually resulted in sufficient quality IBA, or led to a 'box ticking' exercise to generate a payment.
One often raised issue is that the DES payment is collected when a patient completes FAST or AUDIT-C and recorded by the practice, regardless of the score or 'brief advice' being delivered. The original guidance only stated that practices 'should' subsequently complete a full AUDIT and offer brief advice to at-risk drinkers, or referral for those indicating dependency. Not surprising then that recording of 'brief advice' or 'referral' activity on the same systems usually appear significantly lower.
In 2011 Haringey's local alcohol service HAGA produced a comprehensive DES report after finding 75% of local practices were using incorrect screening questions, and that only 50% of practices were offering face-to-face Brief Advice. Informal mystery shopping accounts also indicate a very mixed picture - some practices may simply hand out screening tools without any follow up, whereas some might ensure staff are suitably trained and appropriate pathways are in place.
In fairness to the limitations of the DES, wider pressures on Primary Care roles, as well as broader attitudinal barriers around alcohol are also likely to be significant. Meanwhile IBA has been integrated as part of the NHS Health Checks programme and is increasingly being delivered by Community Pharmacies.
Clearly there is some way to go before we are likely to see a picture of quality IBA being routinely delivered in Primary Care. Research points to the importance of incentives, but it is also clear that more than incentives alone are required - training, pathways and organisational and other factors also crucial. Little has been done to really explore what would further motivate belief in the value of IBA by busy frontline roles.
Meanwhile the role of IBA in local alcohol strategies seems increasingly popular as it continues to be sought in a range of further settings where the evidence is less clear. Also under question is whether more minimal or 'lite' versions, online approaches or other channels of engaging at-risk drinkers can be considered as 'evidence based' approaches to 'brief intervention'...