ALCOHOL EDUCATION FOR GENERAL PRACTITIONERS IN THE UNITED KINGDOM — A WINDOW OF OPPORTUNITY?

BRIAN R. McAVOY

Department of Primary Health Care, School of Health Sciences, The Medical School, Framlington Place, Newcastle upon Tyne NE2 4HH, UK

Received 30 July 1999; in revised form 8 November 1999; )

ABSTRACT

Alcohol misuse is a major public health problem. In the UK, general practitioners are perceived as key players in prevention and management of alcohol problems, but may not be prepared sufficiently to undertake this work. A systematic review of the literature by computerized search of the Medline database, hand search of review article citations and a survey of relevant educational and training organizations and agencies were undertaken. Although there is no shortage of educational materials, there has been little evaluation of their effectiveness. A need for more training and support has been identified, but this requires better co-ordination and a more multidisciplinary approach. Forthcoming changes in the National Health Service and the organization of continuing professional development offer a unique opportunity to advance this agenda.

INTRODUCTION

Alcohol misuse is a major public health problem. Based on 1992 figures, heavy drinking costs the British economy nearly £3 billion a year, including some £700 million in lost workplace productivity (UK Alcohol Forum, 1997). The annual costs to the health service are around £400 million, with up to 30% of male admissions and up to 15% of female admissions to general surgical and medical wards having alcohol-related problems (UK Alcohol Forum, 1997). In addition to medical and psychiatric problems, alcohol misuse inflicts considerable damage on society through its association with crime and road traffic accidents (Faculty of Public Health Medicine, and Royal College of Physicians, 1991).

Primary care has long been seen as an appropriate setting for health promotion and general practitioners (GPs) are ideally placed to prevent and manage alcohol misuse (World Health Organization, 1992Go), but how well-prepared are GPs to undertake this onerous task? A recent review (Deehan et al., 1998Go) of opportunities and obstacles in primary care to tackling alcohol misuse concluded that ‘Primary care is not unwilling, but needs to be provided the means, through training and support, to fulfil its rich potential.’

The present paper will describe the current status of UK medical education and training related to alcohol misuse, identify effective educational programmes and outline opportunities for the future. A computerized search of the Medline database up to 1998 was undertaken using the text words ‘alcohol’, ‘general practitioners’, ‘primary care’, ‘medical education’ and ‘training’. A hand search of bibliographies of relevant review articles was also carried out. The WHO Regional Office for Europe and UK organizations and agencies involved in education and training around alcohol misuse were contacted for details of their programmes and materials.

OVERVIEW OF UK EDUCATIONAL PROGRAMMES

Walsh (1995) gave a national overview of undergraduate and postgraduate training in the UK, Canada, the USA and Australia. More recently, profiles of medical education in 11 European countries, including the UK, have been published (McNeill, 1999Go). In the UK, there has been no centrally funded approach to improve medical education about alcohol problems, unlike in the USA and Australia (Walsh, 1995Go). Consequently, education and training are fragmented and uncoordinated at all stages of a doctor's career — undergraduate, postgraduate and continuing medical education (CME). Nationally, there is no standardized system for the education and training of GPs in relation to prevention, early detection and management of alcohol problems (McAvoy, 1997Go).

Undergraduate programmes
Paton's (1986) questionnaire survey of 26 Medical Schools in 1984 revealed that they all arranged some formal teaching about alcohol, but that only one used a multidisciplinary approach; one had a regular seminar (run by the Medical Council on Alcoholism) and one had three formal sessions. The rest relied on an ad hoc approach by psychiatrists, physicians, pharmacologists, GPs and pathologists. Only occasionally were casualty officers, behavioural scientists or psychologists involved.

Glass's (1989) questionnaire survey in 1987 involved 13 separate departments in 28 Medical Schools. Of the 70% responding, 54% provided formal teaching (lectures, seminars and/or symposia). The average time devoted to substance abuse teaching was 14 h over 5 years, with an average of 6 h being spent on alcohol — equivalent to 1 min per week over the entire period of training. Only 21% of clinical and non-clinical departments ensured that students were examined on the topic.

The most recent survey in 1996 involved 14 specialties/ departments in 23 Medical Schools (Crome, 1999Go). Seventy-three per cent of Deans and 68% of Heads of Psychiatry responded. The average time spent on formal training in substance abuse problems has dropped to 6 h over the 5 years. Psychiatry has doubled input since 1987, but this is offset by diminished input from other departments.

Appeals have been made for a flexible ‘core’ curriculum or a set of guidelines (Glass, 1989Go), increasing the emphasis on the importance of alcohol teaching at every opportune stage in the undergraduate experience (Office of the Chief Scientist, 1987Go), and integrating such teaching through the curriculum (Ritson, 1990Go). It has also been suggested that each Medical School should make a designated teacher responsible for developing integrated teaching about alcohol (Office of the Chief Scientist, 1987Go) and that one department, for example general practice, community and family medicine, psychiatry or public health, should take lead responsibility for organizing systematic coverage (Royal College of General Practitioners, 1986Go; Glass-Crome, 1994Go). More recently, establishment of academic departments of addiction studies in Medical Schools has been suggested as a way forward (Crome, 1999Go).

Postgraduate programmes
Once again, training and education are fragmented and limited. The various Royal Colleges have produced reports acknowledging the importance of alcohol abuse (Royal College of General Practitioners, 1986Go; Royal College of Physicians, 1987Go; Royal College of Psychiatrists, 1987Go), but it has been reported that a vice-president of the Royal College of Physicians had stated that ‘alcohol is not specifically mentioned in any of the specialty training programmes' (Walsh, 1995Go). All the Royal Colleges have been urged to recognize the need to integrate relevant information, skills and assessment into postgraduate courses and examinations (Glass-Crome, 1994Go).

A Diploma in Addiction Behaviour has been developed in London with the aim of ‘training the trainers' (Glass, 1988aGo,bGo). Training and education in relation to prevention, early detection and management of alcohol problems in general practice undoubtedly occurs during the 3 year vocational training period, but the nature, amount and timing of this are determined by individual course organizers and trainers.

Continuing medical education
As is the case with earlier career experiences, training and education for established practitioners is ad hoc and fragmented. Anderson's (1985) questionnaire study of GPs in Oxfordshire and Berkshire in 1984 found that 66% of respondents reported less than 4 h total postgraduate training, CME or clinical supervision on alcohol. A similar study of GPs in Leicestershire, Derbyshire and Nottinghamshire in 1995 showed that this figure had dropped to 42% — still a significant proportion (McAvoy et al., 1999Go). Indeed, although only 21% of the sample reported feeling effective or very effective at helping patients reduce alcohol consumption, 58% stated that they would feel so with adequate training and support.

The postgraduate education allowance (PGEA) is the principal component of CME for GPs, but much of the educational activity is ‘didactic, uni-profession and top-down’ and shows little evidence of ‘any convincing benefits for patient care’ (Department of Health, 1998Go). The system allows doctors to play to their strengths rather than identify true educational needs (Stanton and Grant, 1997Go), and is therefore unlikely to facilitate improved training and education on alcohol. The recently published Chief Medical Officer's review of continuing professional development in practice (Department of Health, 1998Go) suggests a radical alternative to PGEA: Practice Professional Development Plans (PPDP). These would ‘integrate and improve the educational process, developing the concept of the "whole practice" as a human resource for health care, resembling the health promotion plan in general practice, and increasing involvement in the quality development of practices.’

EFFECTIVE EDUCATIONAL PROGRAMMES

Australia and the USA have pursued a more systematic approach to alcohol education, and there is clear evidence of associated increases in alcohol-related teaching hours and elective opportunities. Walsh (1995) has reviewed the role and effectiveness of medical education about alcohol and highlighted the dearth of research demonstrating impacts on medical behaviours or evaluating the cost-effectiveness of different educational strategies. Evaluations of most training programmes show increases in knowledge but rarely changes in the behaviour of participants (Cartwright, 1980Go; Rundall and Bruvold, 1988Go). Moreover, although it is often assumed that improved attitudes must lead to improved clinical performance, this is not supported by research evidence (Roche, 1996Go). Walsh (1995) also observed that experiential teaching approaches have been recommended and strategies which incorporate feedback methods offer considerable promise. Saunders and Roche (1991) noted the trend towards great emphasis on skills development, especially clinical interaction skills. They also pointed out that ‘this emphasis is underpinned by an increasing behavioural orientation, whereby concern is focused on fostering clinical competence in specific skills, e.g. identification, history taking and interventions.’

Saunders and Roche (1991) also maintained that the major determinants of effective practice behaviour are ‘not the level of knowledge or positive ‘attitudes' to alcohol and drug-affected patients, but skills-based competence, self efficacy (role confidence) and realistic expectations of response to intervention.'

The above authors identified a ‘need for training in detection and early intervention skills' and called for trainees to be given ‘minimal exposure to late-stage, severely dependent individuals and maximum exposure to patients with earlier-stage problems, and those who have achieved stable recovery.' They recommended explicit training in the skills of history taking, the provision of feedback and in the delivery of specific interventions. However, although there is evidence that smoking cessation training can change doctors' smoking-related practices (Wilson et al., 1988Go; Cummings et al., 1989aGo,bGo; Kottke et al., 1989Go, 1992Go; Allen et al., 1990Go), a randomized controlled trial comparing traditional didactic teaching methods to interactive skills training for brief alcohol interventions with senior medical students found no difference between the two approaches (Roche et al., 1997Go).

There is no shortage of educational materials. The Medical Council on Alcoholism (MCA) is a UK independent organization and registered charity which encourages health professionals to identify drinking problems among their patients, and to offer treatment and support. The MCA organizes educational events for student and postgraduate participants, publishes its international journal Alcohol and Alcoholism, its quarterly newsletter Alcoholism and Alcohol Abuse Detection leaflets and Drinking Diaries designed for use by GPs. The MCA has produced a list of eight learning objectives for medical undergraduates, covering the following areas: (1) alcohol; (2) alcohol and the individual; (3) cost of alcohol misuse; (4) clinical problems; (5) psychiatric implications; (6) identification and recognition; (7) management; (8) policies. It also distributes the Medical Students' Handbook: Alcohol and Health (Morgan and Ritson, 1998Go) to all UK undergraduates, and Hazardous Drinking, a Handbook for General Practitioners (Pollack et al., 1990Go).

Alcohol Concern, the national agency on alcohol misuse, is a registered charity working to reduce the costs of alcohol misuse and to develop the range and quality of services available to problem drinkers and their families. It focuses on education, services, special groups, policy, information, publications and the workplace. It has produced a National Alcohol Training Strategy for all staff who work with people with alcohol problems (Alcohol Concern, 1993Go). In a joint project involving the Standing Conference on Drug Abuse (SCODA) and Alcohol Concern, the Quality in Alcohol and Drugs Services (QUADS) group has produced a draft quality standards manual for alcohol and drug treatment services (Quality in Alcohol and Drug Services Group, 1998Go). The National Alcohol Training Forum, established by Alcohol Concern, has produced Talking it Through — a national vocational training pack for alcohol counsellor training (Kent, 1995Go).

In addition there are generic training packs such as Helping People Change (Health Education Authority, 1994Go) and Skills for Change (World Health Organization, in preparation), both aimed at primary health care professionals.

Finally, the UK Alcohol Forum (1997) has published Guidelines for the Management of Alcohol Problems in Primary Care and General Psychiatry.

In his review of the role and effectiveness of medical education about alcohol, Walsh (1995) concluded that ‘with a few exceptions, such as the emphasis on feedback training in skill development, most recommendations about alcohol medical education reflect the findings of process evaluations and/or educator opinion. They are not sufficiently informed by theory or based on studies with rigorous methodologies.’ Furthermore it is clear that the education of health care providers will require a complex set of responses. Traditional and limited ‘educational’ responses will not, of themselves, suffice (A. Roche, personal communication). Moreover, the considerable alcohol-related morbidity within the profession may be a significant contributing factor to the limited effectiveness of any alcohol education for GPs (McNeill, 1999Go).

Prospects/Needs for the future
As mentioned earlier, changing the behaviour of primary health care providers is a complex process. In the words of Anderson (1996), ‘Education can play a role in changing their patterns of practice. Other interventions that need to be incorporated into an overall plan include changes in reimbursement, setting minimal standards of care, providing specialist referral services and changing the expectations of patients. Changes in clinical practice require a long-term commitment by medical educators.’

The review by Davis et al. (1992) of the effectiveness of CME emphasized the importance of addressing predisposing, enabling and reinforcing factors when attempting to change medical behaviour, especially in areas which involve counselling. Grol's (1997) work on beliefs and evidence in changing clinical practice concludes that ‘There are many approaches to choosing clinical care for patients ..., all of which have some value and may be useful and effective, depending on the changes aimed at, the target group, the clinical setting, and the barriers and facilitators found there.’ Indeed, educational initiatives play only a part in the behaviour change of doctors (Smith et al., 1998Go). There is a need to embrace co-ordinated, multidisciplinary approaches which address lifelong learning.

Considerable work has been undertaken by the World Health Organization (WHO) Regional Office for Europe. Anderson (1996) has described educational principles and models which have been found to be effective in improving the clinical skills of doctors and nurses. The educational principles include: (1) learner-centred teaching strategies; (2) case studies; (3) evidence-based learning; (4) longitudinal experience; (5) linkages. The educational and training models include: (1) CME; (2) faculty development programmes; (3) on-site consultation (facilitation); (4) systems approach; (5) training courses on helping people change.

A WHO (1992) Working Group has produced a report on the role of general practice settings in the prevention and management of the harm done by alcohol use. This identifies 12 competencies needed for successful management of potential or established alcohol-related problems. These include acquiring knowledge about alcohol and its effects and appropriate diagnostic and clinical skills, and developing the ability to choose and implement appropriate intervention and care plans.

The report also made seven recommendations on education and training in alcohol and alcohol-related problems, for adoption by medical colleges or faculties of general practice within the Region. These focus on knowledge, skills and attitudes, and advocate a co-ordinated, multidisciplinary, research-based approach at all stages of medical education.

The way ahead
The WHO Working Group recommendations are consistent with a number of current UK educational training activities, but there is a need to develop better coordination and a more multidisciplinary approach.

One way ahead is through the curricular changes which are being introduced in Medical Schools in response to Tomorrow's Doctors (General Medical Council, 1993Go), the General Medical Council's recommendations on undergraduate medical education. There has been a move towards more community-oriented teaching, greater input from primary health care and general practice and provision of student-selected modules or ‘options’. All of these provide opportunities to expose students to the problems of alcohol misuse and how these are dealt with by primary care workers, community alcohol teams and specialists.

From the perspective of primary health care, the recent changes in the National Health Service (NHS) heralded by the White Papers, The New NHS (Secretary of State for Health, 1997Go), A First Class Service. Quality in the New NHS (Secretary of State for Health, 1998aGo), Saving Lives: Our Healthier Nation (Secretary of State for Health, 1999Go), and the consultation paper Our Healthier Nation (Secretary of State for Health, 1998bGo), coupled with the Chief Medical Officer's review of continuing professional development in general practice (Department of Health, 1998Go), offer exciting opportunities.

The establishment of primary care groups will facilitate moves towards interdisciplinary learning, and training around prevention, early detection and management problems should be part of primary care teams' practice professional development plans (Jones, 1998Go). Such plans should involve input from the full range of health professionals involved, including those working in hospitals and community alcohol teams.

Alcohol misuse contributes to the four main areas of illness targeted in Our Healthier Nation — heart disease and stroke, accidents, cancer and mental health. Opportunities for improved integration between education and service development in the area of alcohol misuse will be provided by National Service Frameworks, Health Improvement Programmes, Health Action Zones and Healthy Living Centres. Such initiatives have the potential to bring together GPs and specialists, health care providers and patients and medical and non-medical professionals, enhancing the learning of all concerned. Capitalizing on current developments would enable the UK to make a significant contribution to the international sharing of experience envisaged in advancing professional education on substance abuse (Glass, 1988bGo).

CONCLUSIONS

Although there is no standardized UK system for the education and training of GPs in relation to prevention, early detection and management of alcohol problems, there are well-established educational and training models and materials and explicit competencies and training recommendations available. The more systematic approach to alcohol education pursued in Australia and the USA has resulted in increases in alcohol-related teaching hours and elective opportunities, but a greater emphasis is required on the development of clinical interaction skills.

ACKNOWLEDGEMENTS

I wish to thank Professor Ilana Crome, Dr Eilish Gilvarry, Professor Nick Heather, Dr Eileen Kaner, Mrs Katie Lock and Dr Louise Robinson for helpful comments. This article is based on a paper presented at a Consensus Forum on Undergraduate and Postgraduate Medical Education on Alcoholism in Lisbon on 3 October 1998, sponsored by Merck Lipha.

FOOTNOTES

Current address: Royal Australian College of GPs, College House, 1 Palmerston Crescent, Melbourne, Victoria 3205, Australia.

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