People with repeated admissions for alcohol-related problems made up more than a quarter of England’s alcohol admissions. Measures from administrative records show a higher number of admissions, occupied bed days, average length of stay and total admission costs over a five-year period among alcohol frequent attenders (AFAs) with alcohol-specific diagnoses when compared to non-alcohol and non-frequent admissions (Blackwood et al 2021).
Attendance at Glasgow Royal Infirmary Emergency Department (ED) showed that the top eighty frequent attenders (of almost 100,000 attendances) accounted for 1.95% of total attendances and comprised many individuals with experience of substance use, alcohol use, mental health issues and homelessness (Kyle et al., 2021).
In England, Neale et al. (2016) conducted qualitative research with frequent attenders (ten or more attendances in one year) at ED (gender ratio: 1.5:1 male-female). They concluded that those attending for alcohol-related reasons “tend to experience alcohol dependence associated with multiple and complex needs, but also report diverse patterns of drinking and other substance use, and varied health and social problems.” The need for help with practical issues regarding homelessness, accommodation and finance was identified.
Men predominate in these populations, but the experiences of women are significantly different and require consideration. Close to these studies on AFAs are those studies which investigate alcohol-specific deaths, which suggest a similar profile to AFA.
Health professionals report that responding effectively to AFAs is difficult. Proposed service developments encompass “assertive outreach for high-need, high-cost alcohol-related frequent NHS hospital attenders” (Drummond et al 2018).
Conducting this study in the West of Scotland was relevant given the significant impact of alcohol consumption and the level of health inequalities in Scotland compared to the rest of the UK. The study was informed by inclusivity, patients’ voices, and service enhancement agendas.
AFAs were defined as people who made at least ten ED attendances in the previous year, or three hospital admissions in the previous three months. As such, they represent the tip of an iceberg in respect of the impact of alcohol on health services. Participants were purposefully recruited from the Alcohol Liver Frequent Attender (ALFA) nurse project at the Royal Alexandra Hospital (RAH) Paisley, Scotland. Interviews were conducted by telephone during COVID-19 restrictions in 2021.
Twenty AFAs (seven female, thirteen male) were interviewed using a semi-structured interview schedule to gather information about their alcohol-related problems, their reasons for attending hospital services, and their views on their use of services. A measure of alcohol dependence was recorded (Leeds Dependence Questionnaire, Raistrick et al, 1994).
Participants’ interviews were recorded and transcribed. Thematic analysis revealed overarching themes reported by most participants. In addition, a content thematic analysis was conducted for gender.
The mean age of the study group was 43.2 years: 41.42 years for females and 41.00 years for males. On average, participants in this study were younger in comparison to other relevant studies: interviewees in the larger “Edinburgh Ill Drinkers” study including inpatients in medical or alcohol services, as well as outpatients, had a mean age of 47 years, (Black & Gill, 2016). In the Glasgow study of alcohol-related deaths (Dargan, 2013) subjects were older still at 54 years.
Further demographic data suggested that participants appeared to be relatively stable compared to those reported in other UK studies on AFAs. Consistent with local demographics, none reported current homelessness, although the level of unemployment was high relative to the local population. The study population was predominantly “White Scottish” like Dargan (2013) and Black & Gill (2016) but distinct from Neale et al. (2016) where more diverse ethnic backgrounds were noted in a study conducted in London.
Regarding alcohol dependence, the Leeds Dependence Questionnaire showed 20% of participants scoring “high,” 50% “medium,” and 30% “low” dependence. For some this implied active use of behaviour change processes in reducing drinking and engagement with support services.
Over-arching themes were identified from thematic analysis:
- Harmful and dependent drinking
- Motivation, self-efficacy, and locus of control
- Mental health
- Physical health
- Family and relationships
- Livelihood and employment
- Justice system
- Service perspectives
These themes reflect the findings of other studies on AFAs, reflecting the complexity of needs reported by participants.
Thematic content analysis of gender revealed that women and men reported distinctly different experiences. Women reported drinking in the context of a mental health crisis more commonly than men whilst men more commonly reported physical deterioration through chronic drinking problems.
All participants referred to the impact of their mental health on their alcohol consumption. Women spoke of negative experiences of out-of-hours mental health assessment whilst in crisis. Given the strong association with mental health crisis in this study, services should review their provision, particularly for women with alcohol problems who are in crisis.
Study participants indicated that the negative impact of problem drinking in families was significant across generations. However, participants noted the support of families and significant others in their recovery.
Recovery communities and mutual aid form a significant dimension of recovery from alcohol related problems, often in the absence of formal treatment. Based on a significant body of supporting evidence, and reports from a substantial proportion of study participants, their use is recommended.
Conclusions and recommendations
AFAs represent a population of long-term, harmful, and dependent drinkers, who present with wide-ranging and complex needs, sometimes in crisis.
It is recommended that consideration be given to designing a dedicated service targeting the complex needs of AFAs and to support recovery. Such services should take account of study findings particularly with reference to gender and mental health. Such a hospital-based intervention would provide an additional opportunity to engage in change processes for a population who have had experience of alcohol/substance problem services. Further, development of family/significant others’ support and information services are recommended.
AFAs should be informed of and encouraged to consider mutual aid/Alcoholics Anonymous participation.
Barrie K, Heydtmann M, McKean R. (2023) A Qualitative Study of the Views of Alcohol Frequent Attenders at Royal Alexandra Hospital, Renfrewshire.
Scottish Health Action on Alcohol Problems. shaap.org.uk
Written by Ken Barrie, Senior Lecturer, University of the West of Scotland.
All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.