2003 Volume 22, Issue no. 2

editorial
articles
web watch

Editorial

Clare Gerada's paper reminds us that we live in a time of change, opportunity and danger for the NHS. The danger is of failure to adapt, a behaviour which leads to extinction. Faced with constraints of manpower and other resources, and changing expectations of health professionals and patients, primary care is developing new patterns of service. Alcohol services must deliver care in ways, which adapt to this changing environment. There is no shortage of opportunity in the new situation. The renewed emphasis on patient focus, expert patients, interagency co-operation and skill mix are all trends that the alcohol field will welcome and in many cases can claim to have pioneered. The signs that serious preparation is under way for the long awaited English national alcohol strategy are also very welcome.

The paper by Mike Abell is also about change but change at an individual level. Advocates of expert patients could find no better example than Alcoholics Anonymous, who would probably object to the word patient, but illustrate what can be achieved when a sufferer takes responsibility for their own condition.

This is also a time when the MCA faces change, not least in our financial situation. The need for the MCA is undiminished but if it tries simply to carry on unchanged it like the dinosaurs will become extinct. We too must adapt.

John Kemm
Editor

Articles

Alcohol and Substance Misuse in the new NHS

Report of the MCA Lecture delivered at the Annual General Meeting by Clare Gerada FRCGP, Director RCGP Drug and Alcohol Misuse Training Project

General practice is a vital component of the NHS. More than ninety five percent of the population is registered with a general practitioner. Eighty percent of all NHS patient contacts with the NHS are in general practice. One fifth of all NHS spending (£8.3 billion) is on primary care. General practitioners act as the gateway to all specialist services. Therefore general practice must play an important part in caring for those who misuse alcohol and other substances.

Change in the NHS

The past decade has been a time of massive change for the NHS. A new GP contract was introduced in 1991 and negotiations on the next one should be completed by 2003. GP fund holding has come and gone; Personal Medical Service pilots and GP prescribing pilots have encouraged the development of innovative patterns of care; Primary Care Groups have developed into Primary Care Trusts; the influence of GPs on commissioning of secondary care is growing. In very many ways the interface between specialist and generalist is changing.

Other important changes in the NHS have been the publication by the GMC of "Supporting doctors, protecting patients", the introduction of the NHS plan, the arrival of National Service Frameworks and clinical Czars. The modernisation agency is driving change throughout the service. Repercussions from the Shipman case have lead to appraisal and revalidation. NHS Direct, walk in clinics and out of hours co-operatives have all changed the way in which patients access care. Patients must be able to have an appointment with a General Practitioners within 48 hours.

All this change in primary care and other parts of the NHS have implications in which services for those who misuse alcohol and other substance can be delivered. The addiction field has also been subject to change. At a national level the UK Anti Drug Co-ordination Unit (UKADCU), the National Treatment Agency, the Drug Prevention Advisory Service (DPAS) the Substance Misuse Advisory Service (SMAS) and the Task Force (drugs) Drug Advisory Teams (DATs) have all been established primarily to support better services for drug users. Reports from the audit commission and the home affairs committee have given further impetus. A National Drugs Strategy was published in 1998 and a National Alcohol Strategy is promised for 2004.

The significance of all this change for the provision of services for people with drinking problems can be summarised.

• Primary care is important
• Service users are important
• Service targets are important
• There must be joint working with joint budgets In the new world service users must be brave, honest and consistent.

More change to come

The forces that will shape primary care in the new NHS can already be identified. The new alcohol strategy is likely to put increased emphasis on brief interventions, largely through primary care, and on community based services. Primary Care Trusts are fast learning to use their new powers. They are taking responsibility for running primary and social care services such as community nursing services, twilight hour services, community care services and school nursing. They have responsibility for clinical governance and will set clinical standards and monitor progress.

The NHS plan foresees new roles for general practitioners and nurses. The new role of the GPSI (general practitioner with a special interest) is being developed. The special interest may be in addiction or in other areas. These GPSIs are a new group of intermediate practitioners who are not trainees and not clinical assistants. They will function independently carrying their own risk and being able to support local colleagues. Nurse prescribing and other extended roles are becoming more important. There is a stated intention to create 1000 new mental health workers to work in primary care.

Work force issues will also drive change. Many medical professions including GPs are in short supply. Attempts are being made to recruit staff from overseas. The shortage of GPs will get worse due to the retirement bulge. Fewer doctors are having to do more work. Not only is there an overall shortage but the uneven distribution of doctors means that shortages are concentrated in some areas. There has to be different ways of working with more emphasis on skill mix.

Provision of new ways of accessing service has not reduced the demand on GPs. Each week there are five million consultations with GPs. Compared to this the workload on NHS direct (70,000 calls per week) and walk in centres (590 attendances per week) is very small.

The New GP contract

The new GP contract, which is still to be finalised and costed, will stimulate further change in practice. It will define core services, essential services and enhanced services. Core services should be available from all practices and will cover the treatment of acute illness and palliative care. This would include identification of those with an alcohol problem, provision of brief interventions and harm reduction measures, sign posting and referral to more specialised alcohol services, treatment of immediate complications of excessive consumption and prevention services. Many practices would also opt to provide essential services. Such services for alcohol and drug misusers might include more extended brief interventions, home management of withdrawal symptoms, provision of substitute medication for drug misusers and shared care. For drug services one can already identify a pyramid of primary care services and a similar arrangement might be made for alcohol services (Figure 1).

Figure 1.

Great opportunities

We are moving away from a pattern in which the general practitioner did only general practice to one in which they divide their time between general practice and other roles such as PCT board members and being a GP with special interests. The tensions between the old and new models of general practice (Figure 2). There is a shift towards a nurse led NHS with nurses having prescribing rights, wider responsibilities and better pay for greater skills. The day of the generalist is ending. General practitioners will become more specialised with the rise of the GPSI and polyclinics. Primary care will lead the way in addiction services. It is a time of major change and great opportunity.

My Recovery from Alcoholism

By Mike Abell, Deptford Churches Centre, Speedwell St., London

My story

In 1968 I was 25 years old, single and living with my parents in Dublin. I could consume 12 pints of Guiness daily and some whiskey on top of that and was not sure that I had a drinking problem. I was persuaded to attend my first AA meeting in May of that year but after a few weeks decided to discontinue AA. I felt that I was too young to have a serious drink problem, conveniently forgetting how much I was drinking. I felt I had little in common with AA members I met. They all appeared to be over 50 and spoke about a catalogue of disasters, none of which seemed relevant to me.

In the succeeding eleven years I moved to London, got married and had two daughters. I was admitted to psychiatric hospitals for detoxification, lost the job that I had held for 18 years and was divorced. I was and getting into trouble with the police for drink driving offences and ultimately imprisoned. Although still only aged 36 years I had accumulated a catalogue of personal disasters just as bad if not worse than those related by the AA members in the Dublin meeting.

In prison I had time to think. I decided that I had had enough and that I needed the help of AA. On January 24th 1979 I had my last drink of alcohol and since that date, one day at a time, I have managed to stay sober. This paper describes how AA helped me.

Alcoholic Anonymous

Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement is a desire to stop drinking. There are no dues or fees for AA membership. AA is self supporting from members contributions. AA is not allied with any sect, denomination, political group, organisation or institution. AA does not wish to engage in any controversy and neither endorses nor opposes any causes, The prime purpose of AA members is to stay sober and help other alcoholics to achieve sobriety.

The key source book "Alcoholics Anonymous" was first published in 1939 in the USA. In Great Britain the book was first printed in 1976 and since then it has been reprinted 22 times.

It is estimated that more than 2 million alcoholics in 100,00 groups in 150 countries across the world have recovered using the AA programme.

The twelve step programme

It is rare for anyone who has thoroughly followed the AA path to fail. Those who do not recover are those who cannot or will not give themselves completely to the programme. Usually this is because they are not able to follow a manner of living, which demands that they be rigorously honest with themselves. Even people who suffer from grave emotional or mental disorders can recover if they have the capacity to be honest. The path to recovery comes from following the 12 steps of AA (Figure 1).

The AA programme is underpinned by 12 traditions. Tradition five states "Each group has but one primary purpose - to carry its message to the alcoholic who still suffers". Tradition eleven states "Our public relations policy is based on attraction rather than promotion; we need always maintain personal; anonymity at the level of press, radio and film" Tradition twelve states "Anonymity is the spiritual foundation of our traditions, ever reminding us to place principles before personalities."

Wernicke's Encephalopathy: Diagnosis and Treatment

Alan Thomson, Kent Institute of Medicine and Health Sciences, University of Kent at Canterbury.

Wernicke's encephalopathy is an acute neuropsychiatric condition due to an initially reversible biochemical brain lesion caused by overwhelming metabolic demands on brain cells, which have depleted intracellular thiamine (Vitamin B1). This imbalance leads to a cellular energy deficit, focal acidosis, a regional increase in glutamate and ultimately cell death. The condition has been reviewed in an earlier issue of this letter [1]. In the United Kingdom 90% of cases of Wernicke's Encephalopathy are associated with alcohol misuse.

Wernicke's encephalopathy is a common condition identified in 1.5% of postmortems in general hospitals internationally. The prevalence at post mortem increase to 12.5% in alcoholic patients and to 30% of those with thiamine related cerebellar damage are included. However the percentage of these patients diagnosed before death is only between five and twenty percent. Only ten percent of patients with Wernicke's encephalopathy show the classic triad of signs, confusion, occular palsy (abducens and conjugate) with nystagmus and ataxia of gait.

Failure to diagnose Wernicke's encephalopathy and institute adequate parenteral therapy result in death in 20% of patients. Seventy five percent will be left with permanent brain damage involving short term memory loss - Korsakoff's psychosis. Twenty five percent will require long term institutionalisation. There is a disturbung increase in Korsakoff's psychosis in the United Kingdom and increasingly such cases have been the subject of litigations involving costs as high as £500,000.

Thiamine and other vitamin deficiencies arise because of inadequate intake, loss through vomiting or diarrhoea and reduced storage due to liver damage. This is exacerbated by increased requirement for thiamine as a result of cirrhosis. Both ethanol and malnutrition cause significant inhibition of the active transport mechanism involved in the intestinal absorption of Thiamine. Furthermore cellular utilisation of thiamine may be impaired by damage to apoenzymes by acetaldehyde or free radical activity.

Oral thiamine treatment is often inadequate to ensure the rapid replacement of adequate levels of brain thaimine and parenteral vitamin therapy (Pabrinex) is needed. This has the potential to reduce substantially the significant morbidity and mortality in alcoholic patients due to Wernicke's encepahalopathy.

Reference

Cook CCH, Thomson A (2000) Alcoholism 19(4), 1-3.

Web Watch

This section draws attention to useful and interesting web sites

Driver and Vehicle Licensing Agency www.dvla.gov.uk
This site contains a section medical practitioners which describes the regulations on medical conditions and driving. Chapter 5 of this section covers drug and alcohol misuse and dependency. This site will be very helpful to any doctor having to advise their patients on driving or the DVLA on their patient's fitness to drive.

Alcohol Concern www.alcoholconcern.org.uk
This site describes all the activities of Alcohol Concern with information on services in England and Wales. The fact sheets section is particularly good and there is an excellent range of useful links. Institute of Alcohol Studies www.ias.org.uk Another very useful website with good fact sheets and links.

National Institute of Alcohol Abuse and Alcoholism www.niaaa.nih.gov
This is a US organisation and the website contains a great deal of useful information . This is particularly helpful if you are looking for information on alcohol problems in USA and an American view.

Down Your Drink www.downyourdrink.org
An innovative site designed to help people worried about their drinking. It aims to take them through a course of interactive sessions over 6 weeks that will help them to cut down. Probably not a substitute for human interaction yet, but a very interesting idea. This was described in a previous issue of Alcoholism (2001; 20 (6), 3)

Alcoholics Anonymous www.alcoholics-anonymous.org
This is the official site of Alcoholics Anonymous general office. It explains their view of alcoholism and how they can help both drinkers and professionals working with drinkers.

Alcoweb www.alcoweb.com
This site is run by Merck. It has sections for the general public and a password protected area for medical professionals. It contains a lot of information on the medical effects of alcohol. It also has good information on alcohol statistics for Europe.

And don't forget Medical Council on Alcohol www.medicouncilalcol.demon.co.uk
As well as information on the MCA this site has the full text of the Handbook on alcohol, several years back issues of this newsletter and a great deal of other useful information.