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Critical Evaluation of approach to Health Needs Assessment: 'Screen & Manage Hazardous Drinkers within a Community Pharmacy Setting'

Defining Local Need
The level of alcohol consumption in the UK is rising, where nearly 6.4 million people drink up to 35-50 units per week and a further 1.8 million consume more than this per week (Scottish Executive, 1999-2000). The SIGN 74 Guideline (2003) has defined hazardous drinking as "regular consumption of over 5 units per day for men and over 3 units per day for women."The Scottish Health Survey (2003) estimated that 39% of men in Grampian and 31% of women consumed greater than the recommended allowance. There are concerns over the emerging patterns of excessive and binge drinking as abuse of alcohol can result in numerous health related problems, increased rates of crime, and health care costs (Babor et al, 2001).
Policy shapers such as SIGN, Scottish Executive (Plan for Action on Alcohol Problems) and Department of Health (Alcohol Misuse Intervention) have addressed the issue of hazardous drinking in the United Kingdom. The Scottish Executive report aimed as assessing groups such as Scottish Training on Drugs and Alcohol (STRADA). Department of Health in (2004-2005) discussed the formation of Alcohol and Drug Action Teams (ADAT) in order to tackle alcohol related problems within Grampian. In Aberdeen, the Aberdeen Joint Alcohol and Drug Action Team (JADAT), a partnership of multiple public sector organizations in Aberdeen City, was formed for reduction of problems relating to drugs and alcohol (NHS Grampian, Aberdeen City council, 2000). 
According to the Grampian Adult Lifestyle Survey (2002), Aberdeen City has the highest alcohol consumption in Grampian. Therefore, the present service bid proposes to introduce a pharmacy-based screening and intervention service for hazardous drinkers in Aberdeen City, where currently there are no such services.

Critical evaluation of the health needs assessment
A programme called SNAPS (Scottish needs Assessment Programme) was established in 1992 in order to assist NHS Boards in carrying out their health needs assessment. Health needs assessment can guide the appropriate shift to primary care by identifying the most effective resource allocation to meet the needs of population.  For e.g. in the present service bid, pharmacists were chosen to be most efficient resource for helping the local population at risk, to identify and prevent alcohol related hazards. Primary research evidence (Lock et al, 2006; Crawford et al, 2004; Saltz et al, 2003; Scott, 2000) has shown that such interventions delivered through primary care providers can be successful in reducing alcohol consumption. Primary care is viewed as the most promising location to identify alcohol misusers and offer brief intervention services (National survey of GPs in England and Wales, 1998; Lindholm, 1998). Since pharmacies have more frequent contact with the public than other healthcare services, they pose an ideal setting for the screening for hazardous drinkers and offering them a brief intervention. The main role that pharmacists currently play regarding reduction of alcohol related hazards is that of education and advice. In case of treatment of serious alcohol dependence, services by GP's may be required for providing pharmacological interventions. Provision of services related to reduction of alcohol related hazards through involvement of primary health care provider, especially the pharmacists was observed to be a lucrative approach in reducing the morbidity and mortality related to alcohol at the same time considerably reducing the health care costs and reducing the number of GPs visits allowing them to devote time to more serious health related problems. Needs assessment is now a high priority a Scotland, but it is conceptually muddled and technically difficult. SNAPS report showed that the extent of the relationship between reduction of alcohol related hazards and the brief intervention provided by the pharmacist largely remains unknown as it is associated with numerous limitations including the availability of current information sources, lengthy task of formal assessment, lack of interest by the pharmacists etc. Despite these difficulties there is much that can and should be done incrementally to improve the quality of primary health care in reducing alcohol related hazards. One such step would be making the pharmacists' involvement more intense by strictly enforcing the components of clinical governance in the present service bid.
 As part of clinical governance, pharmacists would be obliged to complete continuing professional development (CPD) activities relevant to the area of alcohol misuse and treatment as this would assure that knowledge of the pharmacist remains up-to-date, ensuring evidence-based practice. As part of clinical governance the service would be monitored regularly for effectiveness through annual audits. In order to improve the involvement of the pharmacists, they would be held accountable for the quality and the standard of the service provided.
Service specification
The aims and objectives of the service
The aim of the service is to deliver brief interventions in a persuasive but non-judgmental manner (WHO, 1996), ranging from 5-45 minutes mainly through pharmacists to those involved in hazardous drinking. This service will be initiated in six community pharmacies in Aberdeen City and would operate at all times the pharmacy is open.

Evaluation
After the first 6 months of service provision, all pharmacies will be asked to supply data regarding the running of the service and future improvements would be considered. Further evaluation will consider three aspects, structure, processes and outcomes of the service. The following information would be recorded and monitored:
Number of customers presenting with an NRT prescription; customers approached about the service; clients screened using the FAST questionnaire and time required for questionnaire completion; identified hazardous drinkers; brief interventions provided and time taken; referrals to alcohol support agencies; number of people who were reminded about their follow-up appointment; and those who returned for follow-up appointment.

Clinical governance
Standard Operating Procedures (SOPs) may be used to achieve clinical governance in the pharmacy setting. Written SOPs would be put in place and adopted in each of these pharmacies. This would ensure that good practice is achieved at all times. To comply with clinical governance requirements, strategies for risk management and harm minimization would also be put in place. Clear lines of responsibility and accountability will exist. SOPs and protocols will define the role of each staff member involved in service provision. Annual audits would be carried by a hired external auditor. Standards would be set, against which the practice would be compared, thus reviewing performance of the service. This process would identify factors contributing to poor performance and help improve the quality of care provided. Following implementation of any necessary changes, the service will be re-audited to determine appropriateness of these changes.

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