Toolkit for general practice
The role of general practice staff
The importance of the position of the practice nurses, GPs and other practice staff in supporting children affected by parental drinking lies in the fact that parents bring children to the surgery for a variety of reasons - vaccinations, routine medical matters and general advice as well as when the child has a specific illness. Practice staff will therefore see children who are no longer seen routinely by health visitors unless a reason has already been identified for them to continue contact. Practice staff may also see older children alone.
Newly registered patients are required to have a consultation with their GP within 6 months of registering. This is a prime opportunity for a general screening to include questions about alcohol intake and also about any children in the family.
General practitionersDoctors are likely to know many of their patients who experience problems with alcohol, although they may only be aware of those with severe alcohol problems. They do however have a unique relationship with their patients in that patients tend to trust the private doctor/patient relationship, and are likely to confide a problem with alcohol particularly if asked by their doctor about this.
'Affected others', a term clumsily used to cover friends and family (usually adults) of a problem drinker, often consult their doctor about a family member’s drinking problem and the doctor does also see children and may also see older children alone.
Practice nursesPractice nursing is one of the fastest growing areas of nursing. Practice nurses are directly employed by GPs and undertake a wide variety of roles and responsibilities, which vary enormously from practice to practice. These can include general treatment room duties (dressings, injections, ear care, etc) as well as nurse-led clinics in health promotion (women’s health, prevention of coronary heart disease, child and travel immunisations etc) and chronic disease management (diabetes, asthma, etc).
Practice nurses therefore play an increasingly important role in the delivery of primary care, but levels of decision making and autonomous clinical responsibility vary considerably. Practice nurses as a whole perform a wide variety of tasks which include treatment room sessions, chronic disease management, home visiting, new patient checks, over 75 checks, primary prevention and health promotion work. The range of this work and the proportions carried out in any particular practice are largely a matter of historical accident.
A study carried out in Sheffield† indicates that practice nurses are unlikely to move from one practice to another, but tend to remain in their first practice post and remain for a long period of time. They may therefore be in a good position to pick up on issues for particular patients, such as alcohol use.
However, given the potential isolation of practice nurses, the role of external support via local and regional practice nurse forums, etc is particularly important to ensure both their professional development and effective service development. The new GMS contracts state that all practice employed nurses should have personal learning plans which have been reviewed at annual appraisal.
Training on recognition and early intervention in relation to alcohol issues could form part of a nurse’s learning plan. However, given the many other competing issues recognising the signs of alcohol misuse is likely to continue to be an overlooked area of study.
The Sheffield study showed that, amongst adults, women were seen more than men and the highest number of consultations were with young women (presumably due to ‘well woman’ consultations for contraception, cervical smears, etc). The numbers of consultations were relatively high for women and men in the 50-79 age range, presumably due to the nurses’ role in chronic disease management and assessments for the elderly.
Opportunities for recognition of parental alcohol misuse therefore lie mostly with young mothers attending ‘well woman’ consultations or child immunisations.
Most practice nurses tend to deal with areas such as chronic disease management in a general rather than designated clinic setting. They may therefore be well suited to pick up on alcohol issues because of their ‘opportunistic’ or ad hoc ways of working. Designated clinics suit a pro-active way of working, whereas general clinics allow nurses to react to immediate, felt and perceived needs.
Most practices offer treatment room sessions, the most common being dressings, ear care and phlebotomy. These sessions would also provide opportunities for questions about alcohol intake (particularly around dressings following accidents in the home).
Other members of the teamMost new patient health checks (see above) are being carried out by health care assistants who would need to be included in any training around identifying alcohol issues.
Similarly the practice reception and administration team can be the “eyes and ears” of a practice and, along with the health care assistants, are often drawn from the local community, which might also inform their insights. They are a rich resource for identifying worrying behaviour and often have more contact with the general family than the clinical staff.
Young people’s counselling services could have practice-based counsellors who are members of the Primary Care Team. These counsellors may have clients who are parents of young children and need to be aware of the potential problems of alcohol misuse. They will have more time to address these issues with their clients and are more likely to see people with alcohol related problems.
Graduate mental health workers have a role in identifying sources of information. They have the time and resources to build up the practice library, which can include information on alcohol issues and brief interventions.† The Centre for Innovation in Primary Care (2000) What do practice nurses do? A study of roles, responsibilities and patterns of work?
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