Dr Tessa Parkes on behalf of evaluation team

1. An evaluation to assess the implementation of NHS delivered Alcohol Brief Interventions in Scotland Dr Tessa Parkes on behalf of evaluation team Faculty of Public Health Conference, Aviemore, Nov 11th 2011

2. Focus of presentation • Background and context • Aims of evaluation • Data sets and methods • Highlights of findings, focusing on learning from ABI implementation • Implications

3. Background and context • Mounting concern at higher than recommended alcohol consumption and negative health outcomes • Delivery of alcohol brief interventions (ABIs) is a significant component of the Scottish Government Alcohol Strategy – HEAT 4 2008-2012 • Theory of Change developed to map desired outcomes and provides theoretical underpinning for seven projects tracking implementation of key actions/reach of strategy/attributable outcomes

4. Main aims of evaluation • In what waysare ABIs being implemented at NHS Board level and at service delivery and practitioner levels? • To what extentare ABIs being implemented? • What can be learned from implementationof ABIs to ensure that momentum is maintained and ABIs are embedded into mainstream delivery as part of the core business of the NHS in Scotland from 2011?

5. Data sets and methods

6. Findings

7. Views on HEAT H4 • Recognition of ‘window of opportunity’ that enabled alcohol interventions in the NHS to become a priority • Mixed views on appropriateness of targets as a means of driving policy and practice forward • Consensus on primary care as a priority setting but not the same consensus in A&E and antenatal care • National supports were highly valued but lack of a (non-delivery) development year was very challenging

8. Delivery of ABIs across Scotland Progress made over time towards respective targets of ABIs delivered by each of the 14 health boards during 2008/09, 2009/10 and 2010/11, in accordance with the HEAT H4 target

9. Implementation of ABIs in primary care • Substantial variation across boards in LES contracts accentuating different elements of ABI delivery • Practice sign-up mostly good but some boards experienced difficulties getting practices on-board • Reliance on Keep Well/Well North in some boards • Numbers of practices involved did not increase over time in all boards and expected levels of delivery did not always occur

10. Practitioner views – primary care • Practitioners generally supportive of an active role in addressing alcohol related harms • View that primary care was a valid setting for ABIs and preventive intervention • Less favourable comments related to practicalities such as time constraints, the nature of LES contracts and compulsory training • The majority of GPs stated they were comfortable raising the issue of alcohol

11. Patient interviews - primary care • Few patients actively welcomed discussions on alcohol but all reported experiencing the consultation as tactful and sometimes handled with considerable skill and sensitivity • Most patients appeared to accept that these conversations were part of a health worker’s role • Impact varied – for some it had triggered change and for others it did not seem to have done

12. Implementation in A&E • Substantial variability across Scotland • Having a history of work in this area, with lead roles and collaborative structures or relationships already in place, facilitated implementation • Significant resistance to ABIs • Considerable ‘ground work’ required and need for ‘light touch’ approaches to avoid heavy reliance on front line staff e.g. screen and refer-on

13. Implementation in antenatal settings • Commonly the last setting to begin implementation of ABIs but considerable enthusiasm and success noted in some board areas • Time constraints prominent again, other priorities co-exist • Few women report drinking alcohol during pregnancy when asked so numbers of ABIs delivered low

14. Reach • Population-wide approach seen as significant to avoid stigma - ‘everyone is in the target group’ • Keep Well/Well North viewed as excellent mechanism to extend reach, esp. in terms of older men • Gaps in coverage - geographic, age and gender • Pragmatic and opportunistic approach needed, innovation apparent in many areas

15. (Tentative) impact • Some ‘disappointment’ about numbers - despite target being reached - some felt numbers were growing over time as momentum gained • Differences across boards in terms of impact on referrals to specialist alcohol services • Cannot assume impact of ABIs on increased referrals • Emphasis needs to be placed on follow-up e.g. of patient outcomes/journeys to better discern impact

16. Mainstreaming ABIs • Boards want work to continue given efforts thus far – needs time to ‘bed-in’ - ‘hard lessons’ learned • Many other settings viewed as having potential • Potential to integrate health improvement programmes • Investment in training responsible for building support for ABIs at grassroots level • Reviewing progress, proving benefits and celebrating progress are essential next steps

17. Some implications…. • Cultural change takes time • Ensure local and community-driven priorities are considered in tandem with national HEAT priorities • Specialist roles are essential to success • Continued support needed for training/professional development • Incentivise partnership working and integrated approaches

18. In summary • Aim of HEAT H4 is to embed ABIs into routine practice • Many successes to celebrate and rich learning • Scotland has a significant contribution to make to international evidence base • Substantial variation across the country • Lots of learning for post H4 and other HEAT targets • Key tensions e.g. data reporting and monitoring • Funding and infrastructure support needs to continue to be adequately resourced to ‘bed-in’ developing levels of skills and confidence • Importance of training for the cultural change and buy-in

19. Acknowledgements • Evaluation Team • Douglas Eadie, Oona Brooks, Stuart Bryce and Susan MacAskill from ISM • Dr Iain Atherton, Dr Josie Evans, Stephanie Gloyn, Stephen McGhee and Bernie Stoddart from SNMH • Dr Dennis Petrie and Homagni Choudry from School of Business, University of Dundee • Project Advisory Group • Louise Bennie, Sarah Currie, Alison Douglas, Iain MacAllister, Donna MacKinnon and Evie McLaren from Scottish Government • Fiona Myers, Clare Beeston, Andrew McAuley, Jane Ford, George Howie, Catriona Loots, Jackie Willis and Brian Orpin from NHS Health Scotland • Clare Harper, Roz Vidler, Margaret Quinn and Paul McAleer from ISD • Health boards, the three case study boards and the local leads and all evaluation participants • Report reviewers: Professor Stewart Mercer, Dr Rhona McInnes and the reviewers in the three case study boards