Specialist Alcohol Service Helps to Break Down Barriers
Alcohol causes significant health and socials harm to the Scottish population. People from the most deprived areas in Scotland experience greater inequalities in harms caused by alcohol – they are four times more likely to die from alcohol-specific causes, and nearly nine times more likely to be hospitalised for alcohol-related reasons, compared to those living in the least deprived areas. Those from more deprived areas face many barriers to accessing alcohol services. In addition to problems with alcohol, many individuals also experience co-existing mental health and/or drug problem which can prevent them from meeting the eligibility criteria of many alcohol services. Individuals also often have overlapping physical, social and emotional needs which some alcohol services may struggle to address due to staff lacking the appropriate skills. This group often faces stigmatisation from the people around them, including healthcare professionals; this makes it difficult for them to talk about their alcohol problem and increases feelings of isolation. These barriers make it more likely for this group to not engage with alcohol services, resulting in poorer health outcomes compared to the rest of the population.
Our recent study explored the views and experiences of a specialist alcohol harm reduction service, the ‘Primary Care Alcohol Nurse Outreach Service’ (PCANOS) in Glasgow, which employs addiction nurses who support people with alcohol problems. The users of PCANOS:
- are patients from Deep End General Practitioner (GP) practices (those that serve the most 100 deprived areas in Scotland);
- have an alcohol problem that is already adversely affecting their physical and/or mental health and wellbeing; and
- had low to no engagement with other alcohol services
Many PCANOS users also experience concurrent mental health problems.
How PCANOS works
GP practices are responsible for identifying patients who are eligible for PCANOS. Once identified, a patient is referred to PCANOS and the addiction nurses contact the patient as soon as possible to arrange a home visit where they carry out a full assessment of the patient’s physical and mental health needs. The nurses are highly skilled and provide a broad range of interventions including detoxes, administering of medication, and cognitive behavioural support. If a patient needs specialist support for other health or social problems, the nurses put the patient in direct contact with the appropriate service. The nurses also try to involve the patient’s family in the patient’s care. PCANOS aims to empower patients to take better control of their drinking habits and to reduce their alcohol intake. After 12 weeks, or when patients are ready, the addiction nurses link them to the appropriate community services, for more long-term support.
We interviewed 18 staff, including six GPs and five addiction nurses, and seven patients. All of our participants viewed PCANOS positively. In exploring their responses, we identified three ways in which PCANOS helped to break down the barriers traditionally faced by this patient groups in relation to accessing alcohol services:
- Person-centred care – the addiction nurses visited patients in their own homes and put patients at the centre of their care by asking them what they wanted to achieve. Patients reported that they appreciated this personalised approach – as being in their own home provided a safe environment, fostered the building of trust between them and the nurses, and motivated them to learn how to talk about their alcohol and underlying problems, not just with the nurses but with their families as well. This personalised outreach approach helped to reduce the feeling of stigmatisation and isolation among the patients and motivated them to try to change their drinking habits. All of the patients reported that their drinking had reduced, and that their health or wellbeing had improved since engaging with PCANOS.
One patient said:
“We (the addiction nurse and patient) had conversations about what we were up to. What was happening here, what was happening with my daughter and things like that, even before we started talking about drink. That put me at ease … We really started being able to talk with each other. She wasn’t the finger-waving anti-Christ person that I thought she might have been … We kept this diary and it (patient’s alcohol intake) was going down and down and down and down and down, you know and she’s giving me encouragement.”
- Collaborative working and coordinated care – the addiction nurses worked closely and had good communication with staff from participating Deep End practices; this included GPs and Link Workers. The nurses were responsible for creating a tailored care plan for each patient and coordinated their care, ensuring that at each stage of the patient’s journey, the appropriate care was provided. The nurses communicated with GPs regularly, and involved other staff where needed, which meant that there was multidisciplinary input into patients’ care. For example, the nurses reported linking patients with Link Workers if they needed support for social problems such as housing or employment. The collaborative working enabled patients’ health and social needs to be addressed in addition to their alcohol problem; it also resulted in greater awareness of PCANOS among practice staff and speedy referrals of patients needing support for their alcohol problem. The coordinated care approach meant that patients were not left on their own to navigate through a complex healthcare system.
- No wrong door – the addiction nurses accepted referrals of patients who also had mental health problems. The nurses aimed to support these patients to reduce their alcohol intake enough so that they would be eligible to receive help from mental health services.
While our study did not evaluate the effectiveness of PCANOS, our findings show that the service is much needed as it is addressing a gap in alcohol service provision in Scotland, i.e., supporting people from disadvantaged backgrounds with an alcohol problem. Other health boards should consider introducing PCANOS in areas where this is needed and evaluate the effectiveness of the service in reducing alcohol harms in deprived areas.
Dr Andrea Mohan is a Lecturer from the School of Health Sciences at University of Dundee and principal researcher on Scottish Health Action on Alcohol Problems (SHAAP) recent report on the PCANOS model in Deep End practices.