Negotiating Alcohol Problems in Primary Care Consultation: Power, Evidence and Practice

Alcohol Insight Number 19

Research and Development Grant

Introduction

Alcohol-related problems cause management difficulties for many GPs. It is now well established that:

  • There is good research evidence that certain interventions can reduce alco­hol-related problems.
  • GPs believe this work is important, but often believe patients are unwilling to change their behaviour.
  • A variety of social factors cause GPs to be selective about the kinds of pa­tients they intervene with.

This study, carried out by Professor Carl May, Dr Eileen Kaner and Dr Tim Rapley from the University of Newcastle upon Tyne, aimed to identify and describe the clinical and social factors that regulate the discussion of alcohol-related problems, and how such factors promote or inhibit effective engagement with certain types of patients. Through a series of one-to-one qualitative interviews, we explored twenty-nine GPs’ experiences of the detection and management of alcohol-related problems in the primary care consultation and asked them to describe, in detail, some of the consultations they have had where they have discussed alcohol with patients. We then presented the findings of these individual discussions to three task-groups containing nineteen participants. Two of these group interviews were with doctors who had taken part in the one-to-one interviews. The other group interview was with a primary care team. In the group interviews the participants discussed, challenged and enhanced our findings.

Findings

Irrespective of their knowledge of alcohol brief interventions, the vast ma­jority of the GPs were able to describe various elements (though not neces­sarily the same) of brief interventions as a routine and normalized compo­nent of their work, but the GPs’ detection of alcohol-related problems was variable.
The GPs believe that this work is important, but they feel due to their prac­tical experience that until patients are willing to accept that their alcohol consumption is problematic they can achieve very little. They work to in­troduce alcohol as a potential problem, re-introduce the topic in future con­sultations, and then have to wait until the patient decides to change their behaviour.

GPs’ own consumption and their perceptions about the problems experi­enced by, or the receptiveness of, different groups of patients can result in variable engagement with alcohol issues. Patients’ social class, sex and age can influence the GPs’ diagnosis and intervention work. When working with specific groups of patients, like the elderly or middle class professionals, some GPs would forget to ask about alcohol or be surprised that a patient was drinking excessively.

That a mosaic of clinical, organisational, practical and social factors cause GPs to ask questions like ‘what needs to be done?’, ‘what can be done?’, ‘how can it be done, and when?’ in relation to each specific patient over multiple consultations.

Implications

The development of future educational interventions for clinicians in primary care should be launched not solely on the basis of education, skills-building or dissemination of the current evidence-base but rather on the basis of ena­bling GPs to recognise the array of skills they already have and currently use when working with alcohol and alcohol related problems.

Educational interventions need to take account of the very practical prob­lems and dilemmas that GPs face on a day-to-day basis and seek to explore the range of solutions that the participants currently employ. They should seek to empower GPs to recognise and enhance their current good practice. Above all, such sessions should seek to generate a range of very practical tips, strategies and advice and should supply them with a checklist of po­tential courses of action to act as sources of support and reminders for their future practice

Research Team

Professor Carl May, Dr Eileen Kaner and Dr Tim Rapley from the University of Newcastle upon Tyne.

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