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5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

A GP’s reflections on

A GP’s reflections on brief intervention in primary health care in Denmark an interest in or knowledge of how to intervene in a deeper way that, for instance, would have included follow-up visits. In other words their interventions were very ineffective. Eventually the patient was advised to contact an outpatient clinic. These clinics were mostly non-governmental, founded by the temperance movement, but financed by the county. At that time the GPs did not know what we now know of as ‘brief intervention’. Many felt that their efforts to help were too brief and that the handling of alcohol as a health problem did not live up to the standard of how health problems in general were taken care of. In 1985 a method aiming at ‘controlled drinking’ was described in studies from a Danish hospital (Vendsborg & Sønderbo 1985). The goal was to lower alcohol consumption—though not necessarily requiring abstinence—by using cognitive techniques. Controlled drinking seemed feasible for Danish GPs as it followed the clinical tradition: Detecting the problem, planning the treatment by identifying a few key issues and following-up of the results. Everything could be done in the GP’s clinic and in accordance with the conditions of general practice. In those years, the WHO Collaborative Project elaborated the AUDIT instrument and the reports advocate screening and brief intervention (SBI) as an effective method in primary health care (PHC) (Babor & Grant 1992; Saunders & Wutzke 1998). Even though the principles of controlled drinking fitted easily into the concept of brief intervention, some studies and experience in daily practice showed that implementation of SBI was not easy (Barfod et al. 1996; Sørensen et al. 1997; 524 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 Zachariassen 1998). One could ask why the implementation of something that actually could support the idea of controlled drinking did not work? After all, GPs had asked for training and informative materials. Barriers to the implementation of brief intervention Firstly brief intervention was not gener- ally acknowledged as a form of treatment that could be offered to patients. Secondly the principles of screening, as stated by the WHO and the Danish National Board of Health (Sundhedsstyrelsen), were not respected concerning alcohol problems. The GPs were not accustomed to following routine screening in the way brief intervention was described by the WHO. A shift in method seemed necessary (Beich et al. 2002). One main issue from the WHO Collaborative Project was to tailor the recommendations to national and regional conditions. This would have meant implementing the methods of managing alcohol problems in PHC according to the habits and conditions of the GPs clinical practice. Participating in phase III and IV of the WHO Collaborating Project made it clear that in Denmark, and some other countries, the method of screening alcohol problems in PHC should be replaced by early identification (EI). Accordingly, the headline describing the handling of alcohol problems in Danish PHC changed from ‘Screening and Brief Intervention’ to ‘Early Identification and Brief Intervention’. It is much more suitable within the Danish GP tradition to use opportunistic screening: Only when a patient shows a symptom, a condition or a problem that can be related to alcohol use is the question of alcohol habits asked.

Thirdly, GP’s were reluctant to use screening because alcohol is still considered by the GPs to be “a touchy subject”. Moreover some GPs think that the national recommendations concerning the risky limits of alcohol consumption could be relaxed. The recommendations at present are 21 units a week for men and 14 units a week for women (a Danish unit is 12 grams of alcohol). As the Danish authorities are now considering lowering the recommended limits, this factor may become an even bigger point of contention. Motivational Interviewing and brief intervention About 10 years ago it became more and more obvious that a GP that wanted to help the patient to change their lifestyle had to learn a new method that was different from the paternalistic role that GPs had performed for generations. PHC became increasingly aware of the possible gain from practicing the methods of motivational interviewing (MI) (Miller & Rollnick 1991). The fact that MI recognized the ambivalence in decision-making in behavioural matters helped the GP in two crucial ways: • it supplied an efficient method for helping the patient change his/her behaviour. • it moved the responsibility for changing behaviour from the GP to the patient, where it obviously belongs. In recent years, MI has been well described in the Danish literature (Miller & Rollnick 2004; Mabeck 2005). Nevertheless, becoming accustomed to helping people change their drinking habits by using motivational interviewing is difficult for Danish GPs. Training and practice with A GP’s reflections on brief intervention in primary health care in Denmark motivational interviewing under supervision are the most effective ways of improving GP’s skills in helping people change their behaviour. Some training courses are now being offered, though they are far too few. The efficacy, effectiveness and cost-effectiveness of brief intervention are under discussion. It is believed that the personality and the conviction of the professional addressing the clients’ alcohol consumption is more important for the result than the exact method being used (Nielsen & Nielsen 2001). Hence the methods to be used in PHCs are still under discussion. Thoughts on how to improve the handling of alcohol problems in Danish general practice The involvement of all clinical staff might be a crucial factor for success in the handling of alcohol problems in primary health care settings . The recognition of the usefulness of nurses is widespread among Danish GPs. Lately, nurses and staff members with appropriate training have more and more responsibility in caring for patients with arterial hypertension, obesity, chronic obstructive lung disease (COLD) and diabetes. It is said that nurses could be more efficient than GPs in advising on lifestyle measures, if given the same education and training in MI. This is, however, not the only reason why GPs should take advantage of the skills of their staff. Two reasons for involving clinical staff are mainly political: First: More work is expected to be done by GPs. The service in hospitals has decreased owing to increased demands and insufficient resource allocation through a NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 525