GPs working in the most deprived areas of Scotland have special experience of the problems of alcohol, not through choice but because of the huge, recent, and increasing importance of excessive alcohol consumption as a cause of premature death, physical illness and social harm affecting young patients.
The issue of excessive alcohol use has cropped up in several Deep End meetings. At a meeting to discuss anticipatory care, based on health checks for cardiovascular and other risks, it was noted that alcohol is a bigger cause of premature deaths in young adults in very deprived areas than cardiovascular disease. At another meeting practitioners observed the increasing need for palliative care in the community for patients with alcoholic liver disease and their families.
At a meeting funded by the Scottish Government Health Department, Deep End practitioners met with a range of professional colleagues, including members of community addiction teams, to share experience and views of alcohol problems in adults under 40.1 The general view was that the NHS allocates fewer resources to address alcohol problems than might be expected, given their impact on individuals, families, the NHS, and the economy. In Glasgow, dedicated Community Addiction Teams cope with less than half of the estimated number of people with severe drinking problems, leaving others to seek care where they can find it, including general practice.
For people needing help there are many possible entry points to the system. There needs to be clarity about the paths they may then follow. Pathways are important for planning, integrating, and evaluating services, but people with alcohol problems often lead chaotic lives, so there is also a need for continuity and flexibility based on ongoing relationships with professionals whom they know and trust.
The role of GPs is to assess risk, provide brief interventions, minimise harm, manage physical problems and comorbidity, and act as a signpost to other NHS, local authority, and voluntary services. Effective links between services are the key to integrated care. General practices and community addiction services should actively review their links in terms of professional relationships, communications, and records of joint working. Shared information concerning the progress of patients through systems is essential, and can be helped by improvements in IT, although there are issues concerning confidentiality (whether people are content to have their personal information shared) and professional engagement (GPs vary in how they respond to information communicated from third parties).
The meeting raised many unanswered questions including the effectiveness of brief interventions in young adults, and arrangements for detoxification, joint working, sharing information and practice-attached alcohol workers. Practitioners were only too aware, however, of the limited effect of service improvements on their own.
Through their work in caring for individual patients with alcohol problems GPs and their colleagues in primary care are daily witness to an unfolding epidemic. This collective experience and knowledge needs expression, to inform public debate and influence health policy. In the week prior to the debate in the Scottish parliament on minimal alcohol pricing, 40 Deep End practitioners united for the first time to make their views known via a letter to The Herald newspaper (14 September 2010):
‘Scotland’s statistics are shocking, but “statistics are people with the tears wiped off”. The current debate about alcohol pricing can lose sight of the misery and devastation that affects our patients and their families, especially the lasting effects on children. Drunken disorder is only the most obvious problem. Every one of us knows of tragic cases of young adults whose lives, and whose family lives, have been ruined by alcohol. Women are particularly vulnerable. No one should die young and yellow from chronic alcohol poisoning.
This is not an issue that can be left to personal responsibility or the massed efforts of health practitioners trying hard to stem the tide. Any measure, such as minimal alcohol pricing, which makes it more difficult for people to consume regular excessive amounts of alcohol should be seized, as a public health measure of the highest importance. Cross party support is the least we should expect from our politicians, especially those representing the most deprived constituencies, in confronting this very real and lethal epidemic.’
Politicians in Scotland and England have still to engage seriously with the issue of minimal alcohol pricing. If this is not the solution, what do they suggest? GPs at the Deep End will continue to advocate for political action, following Sigerist’s dictum:2
‘The social causes of illness are just as important as the physical ones. The … practitioners of a distressed area are the natural advocates of the people. They well know the factors that paralyse all their efforts. They are not only scientists but also responsible citizens, and if they did not raise their voices, who else should?’
- © British Journal of General Practice, January 2011