From its inception, the NHS has seen a period of seemingly relentless rises in alcohol consumption and the associated health and wider social harms, particularly since 1970.1 Our national performance is also deteriorating in the context of wider European trends.2
For liver cirrhosis mortality, which is a key indicator of alcohol harms in the general population, England and Wales have moved from having the lowest rates to a current rate similar to that of other western countries for both sexes and across all age groups. Scotland has moved from a similarly low position to now having some of the highest rates in western Europe. These recent increases are the steepest in western Europe.2
The cultural acceptability of both drinking and drunkenness have been promoted aggressively and expensively by the alcohol industry, and the lack of any strategic alcohol response has been a striking failure. Now, finally, this deficiency has been recognised and we have seen the development of the first national alcohol strategy for England.3
Unfortunately, politicians seem to lack the commitment to introduce potentially unpopular changes that would undoubtedly improve the health of the nation as a result of the known relationships between price, prevalence of heavy drinking and associated harms.1 This problem is compounded by the recent deregulation of local controls on licensing which will lead, in all probability, to increased alcohol availability, consumption and consequent harm.4 Not many reasons to be cheerful!
The troubling and troublesome heavily dependent drinker frequently occupies our attention when thinking about the subject of alcohol in our patient population. Few practitioners currently actively seek to identify the less visible but very much more numerous 30% or so of our patients who are drinking more than is good for their health.5 Yet, this is precisely what is required if we are to help arrest the recent steep increases in alcohol harms. This larger population of hazardous drinkers (defined as those currently drinking anything above two or three drinks in any day) are responsible for greater aggregate harms than the much smaller population of obviously problematic drinkers.6 We need to shift our focus.
A new set of expectations for general practice and other parts of the NHS to combat this growing problem is now being generated. This poses something of a dilemma. One possibility is to define this difficult subject as essentially being somebody else's problem, citing the wider societal reluctance to tackle this problem or the pressure to tackle waiting times or other priority objectives, for example. The costs of this understandable yet essentially pessimistic response will be most substantially and immediately borne by others, although we will all bear the NHS and wider social costs as taxpayers and citizens.
That we have been doing just this for some considerable time, is evidenced by the reluctance to incorporate enquiry about alcohol consumption into core activity, and the slow pace of adoption of alcohol screening and brief intervention.7 The alternative is to seize this as an opportunity to establish precisely what is the proper contribution to be made by general practice, and to identify better strategies for fostering the wide implementation of this practice. This may not be straightforward, however, as it involves engagement with a number of potentially difficult issues.
Some practitioners see intervening opportunistically with hazardous as well as problem drinkers as an entirely proper activity for the primary healthcare team, while others do not. There are different ways to organise this work, although we do not know which is most efficient and effective, nor how to make it routine and unremarkable everyday practice. Hazardous drinking is probably no different from other health compromising behaviours and payment and other incentive mechanisms should be similar. It may also be helpful to distinguish the specific role of the individual practitioner in consultations with patients and their wider role as a manager of the potential contribution to be made by their practice. For example, achieving relatively minor administrative and software adjustments may go a long way to the normalisation of alcohol screening.
The recent policy developments can be seen as a reason for optimism — if they are the beginnings rather than the conclusion of an improving national strategic response. Brief discussions with hazardous drinkers are known to be efficacious in reducing drinking for up to 1 year, and this evidence-base is particularly strong for general practice.8 These are relatively straightforward to deliver, and a variety of models are to be tested in different settings.3
The ‘Models of Care’ process9 (similar to a National Service Framework) is also planned to lead to the long overdue establishment of a genuinely nationwide treatment system for dependent drinkers. Similarly, the introduction of NHS trainers to engage with lifestyle and behaviour change issues should make addressing alcohol issues easier as part of the broader switch from ‘advice from on high to support from next door’.10
If we are pessimistic and unengaged with these issues, then we will be allowing expectations of GP activity to be formed in ways that will be costly both to public health and society as a whole. The formation of a RCGP committee on hazardous drinking may be helpful in advancing practitioner engagement with these issues, and as an advocate for public health. Of course, it is vital that government leads a wider societal effort to address what is clearly a significant social as well as health problem. However understandable the temptation, we should not be deflected by the contradictions of the wider policies and we should focus instead upon our own roles and potential contribution, rather than simply waiting on others. GPs cannot solve this problem by themselves, although such efforts may inspire others. The views of the authors should now be plain, but it is how the practitioner weighs up these potential costs and the benefits that really matters. We must constantly remind ourselves that the patient to be considered is NOT the person whose drinking has already had a devastating impact on their entire lives, but rather the person who is drinking a little more than is good for their health right now.
- © British Journal of General Practice, 2006.
