Summary of the impact

Professor Nick Heather pioneered the use of opportunistic screening and brief intervention (SBI) by general medical practitioners (GPs) against hazardous and harmful alcohol consumption in their patients and conducted the first randomised controlled trial (RCT) of this procedure. With colleagues at Northumbria University and Newcastle University, he subsequently carried out translational research on implementing SBI in the routine practice of GPs and other frontline professionals. The benefits of SBI have now been recognised nationally and internationally and incorporated in health policies of governments in the UK and in many other parts of the world.

Underpinning research

In the early 1980s Nick Heather pioneered the use of screening and brief intervention (SBI) by GPs for hazardous or harmful drinkers in their surgeries. He was lead investigator of the first randomised controlled trial (RCT) of SBI in general practice, with promising results subsequently confirmed by other trials¹. He then conducted other RCTs of SBI in medical settings, reviews and discussion papers on SBI and has had a career-long focus on encouraging the practical implementation of evidence-based SBI. At the time of joining the staff of Northumbria University in 1997, he was collaborating with Brian McAvoy, Professor of Primary Health Care at Newcastle University, in the English arm of Phase III of the World Health Organisation Collaborative Study on Implementing and Supporting Early Intervention Strategies in Primary Health Care and they appointed Dr. Eileen Kaner as Research Co-ordinator of this work. Funding from the Alcohol Education & Research Council^a enabled them to carry out (i) a survey showing that SBI activity among GPs was low and identifying barriers and incentives for such work², and (ii) RCTs of methods for marketing and supporting SBI in general practice. Heather was then appointed Technical Focal Point for Phase IV of the WHO Collaborative Project which included twelve countries in developing nation-wide strategies for implementing SBI in primary health care^3,b. For the English arm of this project^c, (i) a Delphi survey was carried out of expert opinion on the best ways to disseminate SBI among GPs, and (ii) interview and focus groups were held with patients and practitioners on how SBI should be incorporated in practice.

Following his retirement from the NHS in 2003, Heather collaborated with Professor Eileen Kaner, now Director of the Institute for Health and Society at Newcastle University and Dr. Paul Cassidy, GP at Teams Family Practice, Gateshead in translational research aimed at implementing SBI in routine practice in primary health care and other settings. In 2004, funding was obtained from the Tyne & Wear Health Action Zone (HAZ)^d for a demonstration project aimed at implementing SBI routinely in pilot GP practices in the HAZ. As part of this project a pack was developed, known as How Much Is Too Much?, that included a guide for clinicians, two levels of brief intervention, screening materials, a patient booklet, waiting room posters and training materials for both levels of intervention. In 2006, Heather co-authored a review of the effectiveness of treatment for alcohol problems that had been commissioned by the Department of Health as the evidence-base underpinning Models of Care for Alcohol Misusers⁴; SBI formed an integral part both of the review and the models of care. In 2007 Heather was part of a team that published a Cochrane Review of `Effectiveness of brief alcohol interventions in primary care populations', concluding that SBI consistently produced reductions in alcohol consumption<sup>5</sup>. He was also a member of a Programme Development Group of the National Institute for Health & Clinical Excellence (NICE) that produced public health guidance on `Alcohol Use Disorders: preventing the development of hazardous and harmful drinking'⁶. On the basis of reviews of the effectiveness and cost-effectiveness of alcohol SBI, the guidance recommended that NHS professionals should routinely carry out alcohol screening as an integral part of practice and offer a session of structured brief advice to those identified as hazardous or harmful drinkers. Most recently, Heather was a Principal Investigator of a large cluster RCT funded by the Department of Health (the SIPS project)^e and aimed at identifying the most effective and cost-effective forms of SBI in primary health care, accident and emergency departments and probation services. Findings from SIPS are currently being published.

References to the research

Grants awarded

a. 1995: A Controlled Trial to Encourage Uptake and Utilisation by General Practitioners of Early Intervention Against Excessive Alcohol Consumption. Alcohol Education & Research Council; £118,000

b. 1998: Co-ordination of WHO Phase IV Project on Brief Intervention for Hazardous and Harmful Drinkers in Primary Health Care. World Health Organisation; £18,000.

c. 1999: Strategy for Implementing Screening and Brief Interventions in Primary Health Care in England. Alcohol Education & Research Council; £132,000.

d. 2004: Pilot Implementation of Screening and Brief Alcohol Interventions In General Practice. Tyne & Wear Health Action Zone; £90,525.

e. 2006 Alcohol Screening and Brief Intervention Pilots. Department of Health. £3,986,821

Details of the impact

The impact of this research can be demonstrated both nationally in the countries of the UK and internationally. With regard to the UK, in 2008 the Government introduced in England a Direct Enhanced Service (DES) commissioned through the Primary Care GMS Contract in which GPs are directed to offer an alcohol screen to all new registrations aged 16 and over and offer brief advice to reduce drinking to low-risk levels to those screening positive (roughly 1.75 million patients screened per year). The DES and local variations in the form of Local Enhanced Services were supported by a Primary Care Service Framework based on the How Much Is Too Much? SBI pack (see above). Also in England, in 2008 the Department of Health established an Alcohol Improvement Programme (AIP) which ran until 2011 with the aims of addressing alcohol-related harm at regional and local levels and reducing the increase in the rate of alcohol-related hospital admissions. The provision of identification and brief advice was one of the `high impact changes' recommended to Primary Care Trusts as a way of encouraging people to drink less. Another component of the AIP was an Alcohol Learning Centre http://www.alcohollearningcentre.org.uk/ which was an on-line, one-stop-shop to collate, co-ordinate and disseminate learning and promising practice from across the NHS and the Third Sector (between 250-500 visits per day and 50,000 page views per month). It contained alcohol specific documents, guidance and tools, examples of alcohol harm reduction initiatives across England and training resources to support frontline practitioners and commissioners. In Scotland, there was a health service target of delivering 149,449 brief interventions during the period 2008/09-2010/11. This target has been met (174,205 interventions delivered), has been extended for another year and has become an NHS standard in Scotland http://www.healthscotland.com/topics/health/alcohol/local-delivery.aspx. SBI has also formed an important part of recent health policy in Wales and Northern Ireland. More generally, the provision of alcohol SBI is now an integral and mainstream part of health services throughout the UK. In advice to `make every contact count', the NHS Future Forum has recently recommended that NHS staff in England should routinely take the opportunity to talk to patients about lifestyle, including alcohol consumption, even when the presenting problem has no obvious connection with it, and when required, offer motivationally-based advice on lifestyle change http://healthandcare.dh.gov.uk/forum-report/. These recommendations have been accepted by the UK Government and `Identification and Brief Advice' is an important component of the UK Government Alcohol Strategy published in March, 2012 https://www.gov.uk/government/publications/alcohol-strategy. The Alcohol Programme Manager for Public Health England states that Brief Interventions..."has been adopted as one of our principal recommended interventions and has been included in formal health programmes including the NHS Health Check for adults aged 40-75. Professor Heather has been a leader in this field for many years and his research has been influential in shaping our policy."

Following the conclusion of the WHO Phase IV Collaborative Study in 2004, Heather took the lead in setting up the International Network on Brief Interventions for Alcohol Problems (INEBRIA: http://www.inebria.net/Du14/html/en/Du14/index.html) and was President from 2009 to 2012. The aim of INEBRIA is to promote wide implementation of brief interventions in a variety of settings for hazardous and harmful alcohol consumption at local, national and international levels. In addition to offering online support for researchers and practitioners interested in alcohol SBI, from 2004 to the present, INEBRIA has held well-attended conferences in Spain, Germany, Portugal, Belgium, Brazil, the UK, Sweden and the USA (over 700 separate attendees from 40 countries). Owing partly to the influence of INEBRIA, and in combination with the work of many other researchers, SBI has now become an accepted strategy for responding to alcohol-related harm in many countries of the world. In the USA, the federal government in 2007 established a programme entitled Screening, Brief Intervention and Referral to Treatment (SBIRT) at a cost of over $180m http://www.samhsa.gov/prevention/sbirt/. SBIRT services were disseminated across six states and also through physician residency training programmes and grants to colleges and universities. In addition, SBI has been implemented in the entire Veterans' Administration medical system in the USA. Professor of Medicine and Epidemiology at Boston University states that "Screening and brief intervention for unhealthy alcohol use has been recognized as one of the most effective and cost-effective of preventive services and is recommended in primary care by the authoritative US Preventive Services Task Force, an independent group of experts that rely on the highest levels of scientific evidence."

In Sweden, the Risk Drinking Project carried out from 2004 to 2010 had a total funding of approximately €25m and was based on a government initiative to give alcohol issues a more prominent place in routine primary, maternity and occupational health care, involving both physicians and nurses http://www.fhi.se/en/News/News/Striking-results-from-the-Swedish-Risk-Drinking-Project-/

Training in SBI was the major component of this programme. While other countries may not have seen government-sponsored implementation programmes, SBI has been incorporated in medical services to a greater or lesser degree in many countries of the world.

Sources to corroborate the impact

Alcohol Programme Manager, Public Health England, will corroborate the key role of alcohol SBI in government policy on reducing alcohol-related harm in England.

Professor of Medicine & Epidemiology, Boston University, USA will corroborate the importance of the SBIRT programme in the federal government's response to alcohol-related harm in the USA and the international recognition of the effectiveness of screening and brief intervention for alcohol problems in general medical practice.

Co-ordinator, Management of Substance Abuse, World Health Organisation will corroborate the important place of alcohol screening and brief intervention in the WHO Global Strategy to Reduce the Harmful Use of Alcohol and the significant part played by the WHO Collaborative Study on Implementing and Supporting Early Intervention Strategies in Primary Health Care in developing and disseminating alcohol SBI internationally.

Department of Medical and Health Sciences, Linköping University will confirm the adoption by the Swedish government of the Risk Drinking Project to combat alcohol-related harm in Sweden and the widespread acceptance of alcohol screening and brief intervention in research and practice internationally.

President, INEBRIA, c/o London School of Hygiene and Tropical Medicine will corroborate the success of INEBRIA in encouraging high quality research and evidence-based practice in alcohol screening and brief intervention on an international basis.

Primary Care Service Framework for Alcohol http://www.alcohollearningcentre.org.uk/Topics/Browse/PrimaryCare/?parent=4608&child=4617

Alcohol Improvement Programme/ Alcohol Learning Centre http://www.alcohollearningcentre.org.uk/Topics/tags/?tag=Alcohol%20Improvement%20Programme

The Government's Alcohol Strategy 2012 http://www.homeoffice.gov.uk/publications/alcohol-drugs/alcohol/alcohol-strategy?view=Binary

International Network on Brief Interventions for Alcohol Problems (INEBRIA) http://www.inebria.net/Du14/html/en/Du14/index.html