Hopsitals gear up for brief intervention CQUIN delivery

Hospitals across England are preparing for the introduction of the ‘preventing ill health by risky behaviours – alcohol and tobacco CQUIN’, which requires alcohol and smoking brief interventions to be delivered to hospital inpatients from 1st April 2018.

Public Health England have produced a series of resources to support implementation including infographics, videos and a frontline staff briefing. Since April 2017 certain Mental Health providers have being delivering brief interventions through the Commissioning for Quality and Innovation CQUIN scheme 2017 to 2019, which PHE report 88 per cent (51/58) of eligible providers indicated they had signed up to deliver. PHE have also published two case studies including one at University Hospital Southampton where IBA is being delivered to patients by pharmacy technicians, and another at South London and Maudsley NHS Foundation Trust.

Alcohol brief interventions in England are often referred to as 'Identification and Brief Advice' (IBA), consisting of a validated assessment tool to 'identify' risky drinking and offer 'brief advice' to encourage a change in alcohol use to within or closer to the lower risk guidelines. Drinkers identified as likely to have some level of dependency should be signposted to local services, though the key aim is identifying those who may be drinking at increasing or higher risk levels who typically don't need further professional help to cut down. PHE says the Return on Investment for delivering IBA is £27 per patient over four years.

Real world challenges?

Implementation of such schemes has of course proven complex in reality and many debates have been held over to what extent the benefits of brief intervention identified in research trials can be replicated in busy real world settings. Efforts to embed routine IBA within Primary Care settings have arguably had mixed success at best. From 2008-2015 GP practices were incentivised to carry about IBA for new patients under a 'DES' scheme, although observers have suggested the scheme recieved low prioritisation in the context of the wider system and increasing pressures on Primary Care. Indeed a 2016 study reported just over 6% of at-risk drinkers recalled being offered any advice about their drinking, compared to over 50% of smokers.

From an implementation perspective, it may be noted that more than incentives alone are required - training, pathways and organisational and other factors also crucial so that front line roles feel motivated and perhaps 'nudged' to ensure routine delivery. Previoius calls have been made to do more to consider measures of implementation beyond reported numbers, including a ‘national centre’ of IBA, similar to the NCSCT which exists for smoking.

Next steps

Full details for hospitals gearing up to deliver the CQUIN are set out within the CQUIN specification, including the required quarter 1 deliverables:

1. Establish information systems that enable alcohol and smoking interventions to be recorded.
2. Train relevant staff to confidently deliver alcohol identification and brief advice and tobacco very brief advice.
3. Establish a baseline level of performance against all 5 core parts of this CQUIN, which are outlined below.

From quarter 2, deliverables are:

1. Tobacco screening, which involves asking and recording patients’ smoking status.
2. Tobacco brief advice, which involves advising patients who smoke on the best way to quit.
3. Tobacco referral and medication offer, which involves offering patients who smoke stop smoking medication and referring them to an evidence-based stop smoking intervention.
4. Alcohol screening, which involves asking and recording patients’ level of alcohol consumption.
5. Alcohol brief advice or referral, which involves advising patients, who are consuming alcohol at increasing and higher risk levels, on the benefits of cutting down and referring patients who are potentially alcohol dependent to further support.

With regards to training and resources, hospitals will be developing their own approaches. A short IBA e-learning training module is still available, whilst hospitals with Alcohol Care Teams are likely to deliver face to face training. Printed resources are likely to be varied in practice, though electronic copies of IBA tools and the IBA blog are still available. The majority of hospitals are likely to opt for the AUDIT-C, notably the first 3 questions of the full AUDIT and commonly found in 'scratch-card' form (see below). To what extent IBA delivery will include the use of full AUDIT or conversations that extend beyond simple brief advice is unlikely to be significant.

However should even simple brief advice be offered routinely to at-risk drinkers across hospitals in 2018/19, and PHE be able to capture and evaluate this activity successfully, they will certainly consider the CQUIN a significant public health programme and hope beneficial impacts will be seen across the healthcare system. PHE are developing a comprehensive evaluation plan to try and capture the impact of the scheme given its significance, including efforts to go beyond the data and identify actual experience of IBA on the wards.

See here for PHE CQUIN page inlcuding the Health matters infographics, the template briefing document for frontline staff, the Health matters blog and Health matters videos.