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Acute Care Alcohol Health Workers

Report evaluates the effectiveness of alcohol health workers in hospitals

A new study of alcohol health workers (AHWs) has found that while many hospitals now employ specialist staff to deal with alcohol problems among patients, the work is often precarious and underfunded. The study also found that currently there is limited evidence of their effectiveness.

In its 2012 Alcohol Strategy, the Government stated that hospital-based alcohol health workers played a ‘vital’ role in improving the future health of patients, and called for more alcohol liaison nurses to be employed. However, the report, funded by Alcohol Research UK and carried out by researchers from Leeds Beckett University and the University of York, concludes that while positive steps are taking place, more investment and better research is needed to support this important role.

Dr Sarah Baker from Leeds Beckett University – and formerly with the University of York – carried out the research with Charlie Lloyd, from York’s Department of Health Sciences.

Dr Baker said: “Hospital-based alcohol health workers are integral to the successful delivery of preventative and treatment-based alcohol intervention. On-going financial and managerial support needs to be in place to ensure that these positions have the necessary resources to achieve their full potential.”

The research

AHWs are specialist staff working in hospital – usually nurses – who identify and work with patients drinking at levels that may impact or have already impacted their health. While a range of policy documents, including the Government’s Alcohol Strategy (in England) recommend the expansion of AHW provision and it is clear that there has been a rapid spread of such posts across the acute care sector, there has been very little recent research exploring their nature and coverage.

The new report provides an overview in regard to AHW provision and its main conclusion is that the position of AHWs can be characterised as precarious. This is for a number of reasons. First, they are relatively new and many are still responding to initial problems and finding their place within the hospital. Second, partnership funding was the most common funding arrangement (36% of services surveyed) and this could lead to a lack of clear ownership of the service. This was particularly problematic when Acute Trusts had no financial involvement. Third, funding was short-term and insecure. Fourth, some AHWs were poorly managed and felt invisible and isolated.

While 94% of responding hospitals had a dedicated AHW, hospitals without an AHW may have been less likely to respond and so this may be an overestimate. Services included in the survey represented considerable variation. The number of AHWs per hospital varied between 0.6 and 6 FTE. While the number of AHWs was correlated with the number of alcohol-related hospital admissions, it was by no means a complete explanation. The majority of services were available between 9am and 5pm on week days, although some services covered evenings (38%) and weekends (42%).

AHWs covered a range of roles, including screening and brief interventions, liaison with outside agencies, education, detoxification, protocol and care pathway development, follow-up and discharge planning, and management of ‘frequent fliers’ (patients who are repeatedly admitted to hospital). However, there was variation in how AHWs spent their time across these tasks. There was a tendency for AHWs to migrate up the alcohol problem ladder, focusing increasingly on dependent drinkers. 71% of the patients seen by AHWs were dependent drinkers.

It was hard for AHWs to monitor their work effectively. While screening figures could be relatively easily collected, the complex work done with dependent drinkers was harder to measure. Measuring outcomes was very difficult for all aspects of their work.

Implications

The precarious nature of AHW services raises questions about whether, and how, these services could be given a firmer footing. The Government’s Alcohol Strategy simply ‘encourages’ all hospitals to employ Alcohol Liaison Nurses, but this may not be encouragement enough if a minimum national service is to be developed. Given strong financial pressures and the immediacy of ill-health and disease, the more preventive role played by AHWs may require financial incentives from the centre.

The variability in provision raises questions about standardisation. Of course, local services need to reflect local needs. However, the considerable variation in AHW provision does not simply reflect local needs: it is likely to reflect the presence or absence of local champions and the degree to which alcohol is taken seriously by commissioners. There may be worth in drawing up minimum requirements for AHW teams – or alcohol teams – in hospitals.

An important issue here is the strength of the evidence base. If AHWs convincingly were shown to decrease admissions and save money, the argument for a properly resourced service is greatly strengthened. While the multi-faceted nature of their role and the frequently delayed nature of their impact makes outcome evaluation challenging, nonetheless this should be a priority for future research.

More immediately, there seems to be a clear need for better management and peer support. There is a worrying tendency for AHWs to feel undervalued and isolated in their posts. It may be that this is partly a consequence of the cross-cutting nature of the role, which is largely peripatetic. However, proper ownership of AHW services by NHS hospital trusts, with attendant management would be likely to go some way towards improving this situation.

Conclusion

There are clear indications, not just from the present study (Thom et al., 2013), that the extent of AHW provision has greatly increased in recent times, reflecting the rising saliency of alcohol as a pressing health issue. However, the evidence from this study suggests that provision is variable and precarious. The time seems to be ripe for a proper review of the AHW function and how it can be properly supported and integrated within the hospital setting. However, it is difficult to make a strong case for AHW provision when the evidence-base is weak. Evaluating multi-faceted services such as those provided by AHWs is challenging but there is a pressing need for more outcomes research in this field.