Where should we focus attention to support hospital staff to engage in more alcohol prevention?
The North East region of England has the highest levels of health harms caused by heavy alcohol use in the country. Alcohol-related illness and deaths affect people in the poorest communities the most.
When people die from alcohol-related conditions such as liver disease, there have often been missed chances during other hospital visits to prevent or stop their alcohol use from getting worse.
Alcohol harm prevention could include asking patients about drinking, offering advice to help them cut down, or signposting patients to a service where they could get more support. Since the Covid-19 pandemic alcohol related illness and deaths have increased, and pressures on hospital resources and hospital staff have also worsened.
What is the issue?
Current NHS clinical guidance require that non-specialist healthcare staff ‘should be competent to identify harmful drinking (high-risk drinking) and alcohol dependence’. This includes having the skills to assess the need for an intervention or to provide an appropriate referral.
Despite this guidance however, evidence from before the pandemic suggests a range of barriers exist to hospital staff consistently engaging in preventive practices.
These barriers include time pressures, limited knowledge and awareness of alcohol preventative care, and a lack of training, skills, and financial support.
Many studies also highlight that the delivery of preventative support for alcohol preventative care in secondary care is hindered by wider social cultural challenges such as the stigma of heavy alcohol use and widespread belief that problematic alcohol use is an individual patients’ personal responsibility to manage.
In this study we aimed to:
- Understand possible reasons why most hospital staff in the North East do not consistently engage in preventative work to reduce the health harms of alcohol use post-Covid-19
- Identify areas where attention should be focused to support hospital staff to engage in more alcohol harm prevention.
We interviewed 30 hospital staff (10 doctors and 30 nurses) in eight hospitals in the North East between June and October 2021. The interview data was analysed and separated into themes.
The research was carried out post-Covid so it provided us with an opportunity to see how our findings compared to literature and the situation pre-pandemic.
We found that some factors already known to prevent staff supporting people with alcohol use were the same as those before the pandemic. These are staff’s need to focus on the acute presenting condition, time pressures, and staff’s knowledge and skills about how to support people who drink heavily.
Our study findings also suggest that growing economic disparity means that more people are potentially presenting with alcohol related harm, the lack of prioritisation of alcohol at a national level (a form of structural stigma) and that job roles related to addressing alcohol harm are often voluntary, are the greatest barriers to implementation of evidence-based care in this area.
The findings suggest things are not getting better post-Covid, despite the increase in alcohol related harm.
In conclusion, some issues can be addressed at a local policy and practice level e.g., via improved training and support, but system-wide action is needed to enable preventative alcohol work to take place in hospital settings.
Research summary
- The study team included representation from the North East and North Cumbria Integrated Care System, Primary Care, Secondary Care, Public Health, and academia.
- A unique aspect of the research process is that we trained six junior doctors in qualitative interview skills.
- These six junior doctors and the study principal investigator carried out 30 semi-structured interviews with non-specialist alcohol staff (10 doctors and 20 nurses) from eight secondary care hospitals (one for each NHS Trust) in the North East.
- The interview questions were ordered using the National Institute for Clinical Excellence quality standard for alcohol use disorders diagnosis and management.
What did the research find?
We found that hospital staff recognised that harmful alcohol use is common in the patient populations they work with. They also identified that alcohol harms, while already high in the North East prior to the pandemic, appear to have increased post-Covid-19 pandemic.
Most staff do not consistently ask patients about alcohol harm, provide support or signpost on to other specialist services which could help them. This is not unique to the North East and is in keeping with the international research evidence gathered prior to the pandemic.
In our sample, we identified both contextual factors and mechanisms which prevent staff from consistently doing preventative work.
Plain language explainer of terms:
Contextual factors: These are the things that surround an event or situation, and that can influence it – like location, social factors, economic factors, culture, policies.
Mechanisms: This refers to systems or practices or structures or ‘things that people do or don’t do’ that have an influence.
We identified the following key contextual factors:
- Widespread poverty in the North East region contributes to many patients presenting with complex health needs, including heavy alcohol use, so staff find it hard to know who to prioritise asking about alcohol
- The need to focus on the acute presenting condition
- Limited time to engage in preventative work
- The lack of a visible commitment to reducing alcohol related harm at a national level meaning roles related to alcohol are often voluntary rather than formalised (we termed this structural stigma)
- Other staff were perceived to feel that alcohol use was something patients had brought on themselves and thus they did not offer support to these patients (we termed this relational stigma).
- It was also perceived that this relational stigma prevented patients from openly disclosing their heavy alcohol use with staff or asking for help.
We identified the following key mechanisms:
- Staff do not always know how to speak to patients about alcohol or where to refer them to for further support
- Some staff indicated that they didn’t necessarily see it as their responsibility to ask about alcohol and felt others were better placed to do this
- A few staff suggested they had little positive feedback about how patients were helped when they were offered advice or signposted to support around alcohol, meaning they did not see the value in offering this preventative care.
These challenges to offering preventive care overlap, and many of these barriers will not be easy to change quickly. However, our findings contribute to calls for a multi-layered response to reducing alcohol harm and wider cultural change for how alcohol use and substance use is perceived.
Why is this important?
It is sometimes suggested that training alone could improve the delivery of preventative care for alcohol related harm.
However, our findings suggest that there is a need to address contextual factors – in particular pushing to ensure alcohol is prioritised at a national level, so the structural stigma towards people who struggle with alcohol use is removed.
Who is this evidence useful for?
The evidence is useful for developing policies to support the reduction in alcohol related harm. For example, drug and alcohol commissioners based in local authorities, people working in roles to reduce health inequalities in integrated care systems, other researchers who are looking at ways to reduce alcohol harm in secondary care settings.
Recommendations for policy and practice
Results of the study (and the wider study it was part of) have already directly shaped the regional strategy for the reduction of alcohol harm, a key element of which is the integrated alcohol workforce strategy for the NENC which aims to better support the NHS workforce to prevent alcohol harm through:
- Increased awareness of the Chief Medical Officer alcohol guidance
- Improved pathways to community-based alcohol treatment and recovery support
- Improved workforce training and development.
Find out more about this work
Read the full research paper: Understanding the challenges of identifying, supporting, and signposting patients with alcohol use disorder in secondary care hospitals, post COVID-19: a qualitative analysis from the North East and North Cumbria, England | BMC Health Services Research | Full Text (biomedcentral.com) – published July 2024
Contact Lead Researcher Dr Kat Jackson, Senior Research Associate, Newcastle University Email: kat.jackson@newcastle.ac.uk
‘Stigma kills’
The findings highlighting the importance of stigma have led to a strategic drive for senior leaders to acknowledge the impact alcohol has on their organisation and the communities they serve, and to take action to work in partnership to reduce this.
Nationally, there is cross-system support to tackle relational stigma, initially though a co-ordinated multi-agency media campaign – which is being supported in our region by our NHS Integrated Care Board (ICB) for the North East and North Cumbria (NENC).
Stigma Kills is a campaign created by the NHS Addictions Provider Alliance, a collaborative of addiction services working to ensure quality, knowledge, and care in addiction services across the UK.
You can read more about the campaign, here.
You can watch the campaign video, here.
Please note, this research didn’t directly lead to the development of this campaign. However, the research contributed to the campaign being promoted throughout the health and care system in North East and North Cumbria. The authors welcome the campaign.
How was this work was funded?
The project was funded by the North East and North Cumbria Integrated Care System Prevention Programme.
Professor Amy O’Donnell (AO) one of the co-authors is Deputy Theme Lead – Prevention, Early Intervention and Behaviour Change within the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. AO and the lead author Kat Jackson (KJ) are also part-funded by a NIHR Advanced Fellowship (ADEPT: Alcohol use disorder and DEpression Prevention and Treatment, Grant: NIHR300616). The NIHR have not had any role in the design, implementation, analysis, write-up and/or dissemination of this research.