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Alcohol-related risk reduction scheme

The following Read codes should be used to record activity from 1 April 2014 and to enable CQRS to calculate payment from the GPES extraction:

Initial screening

For this DES, screening applies to all patients registered between 1 April 2014 and 31 March 2015, who are aged 16 or over at the time the short case finding test is applied. For the purposes of this DES, the test must be applied within the financial year in which the patient registered.

388u. FAST alcohol screening test
38D4. AUDIT C Alcohol screening test

There are currently no codes available which indicate a positive FAST or AUDIT-C test result therefore practices should add a value to a field associated with the code. A value of three or more is regarded as positive for FAST and a value of five or more is regarded as positive for AUDIT-C.

Full Screening

If a patient is identified as positive, the remaining questions in the ten-question AUDIT questionnaire should be used to determine increasing, higher risk or likely dependent drinking.

The following code will need to be used:

38D3. AUDIT Alcohol screening test

Again, Practices are required to add a value to a field associated with the code to record the score. The scores are as follows:

Brief intervention

Those patients identified as drinking at increasing or higher risk levels (scores 819) should be offered brief advice. The recommended brief advice is the basic five minutes of advice used in the WHO clinical trial of brief intervention in primary care, using a programme modified for the UK context by the University of Newcastle, How much is too much? The tools from this programme have been further refined.

The following codes will need to be used for recording the intervention offered:

9k1A. Brief intervention for excessive alcohol consumption completed

Brief lifestyle counselling

In some areas, patients drinking at higher risk levels (scores 1619) may receive brief advice or brief lifestyle counselling (2030 minutes) within the practice, or be referred to, for example, a community-based counselling service for this advice, but this distinction is not recognised for the purposes of this DES.

Practices will need to use the following code:

9k1B. Extended intervention for excessive alcohol consumption completed

Referral for specialist advice

Patients identified as possibly alcohol dependent (scores of 20 or more) should be considered for referral for specialist services. Although providing brief alcohol advice is still recommended, on its own, brief advice has not been shown to be effective for this group of patients.

The following code should be used for recording specialist referral:

8HkG Referral to specialist alcohol treatment service

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Anxiety and depression Read Codes

68970 Anxiety screening using questions
6896. Depression screening using questions
38QN. Generalised anxiety disorder 2 scale
388w. Generalised anxiety disorder 7 item score
388f. Patient health questionnaire (PHQ-9) score
388P. HAD scale: depression score
388g. Beck depression inventory second edition score
8CAZ0 Patient given advice about management of anxiety
8CAa. Patient given advice about management of depression

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Guidance

Background and purpose

The Government is committed to addressing the issue of physical and mental illness associated with increasing alcohol consumption. There are four recognised levels of drinking risk, namely sensible or low risk, increasing risk, higher risk and possible alcohol dependence. This enhanced service (ES) requires practices to case find newly-registered patients aged 16 or over, drinking at increased or higher levels. Once identified as at risk, patients should receive simple brief advice and where identified as alcohol dependent be considered for referral to specialised services. These patients should also be assessed/screened for anxiety and/or depression and if found to be suffering with both/either of these, to be provided with treatment and advice as appropriate, where this is accepted by the patient.

Introduction

This ES is for one year from 1 April 2014.

There is no requirement for practices to set up a register of increasing or higher risk drinkers. Area teams will seek to invite practices to participate in this ES before 30 April 2014. Practices wishing to participate will be required to sign up by no later than 30 June 2014.

Initial screening

Screening applies to all patients registered between 1 April 2014 and 31 March 2015, who are aged 16 or over at the time the short case finding test is applied. For the purposes of this ES, the test must be applied within the financial year in which the patient registered.

Practices are required to screen newly registered patients aged 16 or over, using one of two shortened versions of the World Health Organization s (WHO) Alcohol Use Disorders Identification Test (AUDIT) questionnaires: FAST or AUDIT-C, with each taking approximately one minute to complete. FAST has four questions and a value of three or more is regarded as positive. AUDIT-C has three questions and a value of five or more is regarded as positive

Full screening All patients with a positive score should be screened using the remaining questions in the ten-question AUDIT questionnaire to determine if increasing, higher risk or likely dependent drinking. The values associated with each of the positive risk scores are as follows:

Practices will be required to add a value to the field associated with the code in the patients record.

Patients with a score between eight and 15 should be offered brief intervention, patients with a score of between 16 and19 should be offered brief intervention or brief lifestyle counselling and patients with a score of 20 or more should be considered for referral to specialist services (see relevant sections below).

Brief intervention

Those patients identified as drinking at increasing or higher risk levels (scores 8 - 19) should be offered brief advice. The recommended brief advice is the basic five minutes of advice used in the WHO clinical trial of brief intervention in primary care, using a programme modified for the UK context by the University of Newcastle, How much is too much? Public Health England (PHE) alcohol learning centre also has a structured brief advice tool and the Change4Life website contains literature to support brief advice.

Referral for specialist advice

Patients identified as possibly alcohol dependent (scores of 20 or more) should be considered for referral for specialist services. Although providing brief alcohol advice is still recommended, on its own, brief advice has not been shown to be effective for this group of patients.

Assessment/screening for anxiety and/or depression

Where patients are identified as drinking at increasing or higher risk levels (score of eight or more), the practice will be required to assess/screen for anxiety and/or depression.

This is because mental health issues could be contributing to the Patient's level of Alcohol consumption. Practices will need to use an appropriate tool for the assessment / screening, for example using questionnaires such as Generalised Anxiety Disorder Scale-7 (GADS-7) and/or Patient Health Questionnaire (PHQ-9). Patients who are found to be suffering with anxiety and/or depression should, where appropriate, be provided with support and treatment (see below).

Support and treatment for anxiety and depression

Where patients are found to be suffering with anxiety and/or depression, the practice will provide support and treatment, as appropriate. This may include, but is not limited to, self-directed therapy, group therapy, counselling, behavioural therapy and medication. In severe or refractory cases, consideration should be given to referring the patient to specialist mental health services, although it is recognised that mental health services may decline referrals until the patient's alcohol problems have been appropriately addressed.

Where this is the case, referral should be kept under review whilst the patient's alcohol dependency is being dealt with, until such a time as the mental health team will be able to accept the referral. It is recognised that this depends on appropriate and accessible services. Any issues that prevent appropriate management should be raised with service commissioners.

For the purpose of management information counts (i.e. administration of the ES) practices should use the specific Read2 and CTV3 codes relevant to record where support and treatment is provided. However, with respect to the management of individual patients, it is still expected that practices will record the specific drug, support or therapy using Read2 or CTV3 codes, where they exist, or include in free text.

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Monitoring

There is one payment count and 16 management information counts for this service.

Practices will be required to manually input data into CQRS, on a quarterly basis, until such time as GPES is available to conduct electronic data extractions.

The data input will be in relation to the payment count only, with zeros being entered in the interim for the management information counts.

For information on how to manually enter data into CQRS, please see the HSCIC website.

When GPES is available, each extraction will capture data for all 17 counts and report on activities from the start of the reporting period e.g. 1 April 2014 to the end of the relevant reporting quarter. The reporting quarter will be the quarter prior to the month in which the extraction is run, e.g. if the extraction is run in January 2015, the reporting quarter will be quarter three (October to December 2014).

Counts will be cumulative for the year from the point the practice begins to deliver the service. It is important to note that when GPES takes a data extraction for a given period, the extraction only includes activity relating to patients registered at the reporting period end date (i.e. quarter-end/year-end). For example, an annual extraction would only include patients registered with the practice at the year end.

When extractions commence, GPES will provide to CQRS the quarterly counts from the relevant quarter they start in to the end of the relevant reporting quarter. For this enhanced service, reporting will be quarterly and payment will be annual. If a practice has declared achievement (payment and management information counts) for the year on CQRS and the area team has approved it, no GPES-based automated extract will be received as the payment and management information declaration in CQRS cannot be overwritten.

The information extracted on full screening, brief intervention, brief lifestyle counselling and referral for specialist advice will not be used for payment purposes. It will be available through CQRS to support practices and NHS England to validate requirements of the DES as necessary to demonstrate that the full protocol is being followed.

Payment and validation

Area Teams will seek to invite practices to participate in this ES before 30 April 2014.

Practices wishing to participate will be required to sign up by no later than 30 June 2014.

Payment under this enhanced service will be on an annual basis and calculated by identifying "count of newly registered patients, aged 16 and over at the time the short case finding test is applied, who have been screened using either the FAST or AUDIT-C tools in the reporting period.

Payment will be made based on the annual count multiplied by 2.38. CQRS will calculate the annual payment, based on the 31 March 2015 achievement data either via manually entered data or data extracted from GPES. Payment should be made by the last day of the month following the month in which the practice and area team approve the payment.

Where CQRS has not been provided with data (i.e. the practice has not enabled the extraction or the extraction is not supported by their system supplier) the data will need to be entered onto CQRS manually. After CQRS has calculated the practice's final achievement payment, the practice should review 'the payment value' and 'declare the achievement declaration' The area team will then approve the payment (assuming that the criteria for the service have been met) and initiate the payment via the payment agency's Exeter system.

Once practices have submitted their data and the declaration and approval process has been followed, then payment for the service will be sent to the payment agency for processing.

Area teams are responsible for post payment verification. This may include auditing claims of practices to ensure that not only the initial screening was conducted but that the full protocol described in the enhanced service was followed i.e. that those individuals who screened positive on the initial screening tool were then administered the remaining questions of AUDIT and that a full AUDIT score was determined and that appropriate action followed, such as the delivery of brief advice, lifestyle counselling or where needed, referral to specialist services or assessment/screening for anxiety and/or depression.

This information could be available to practices and area teams, as an indicative check, through the management information counts as and when data extractions via GPES are available. The reason for it being 'indicative' is that it is not known whether this aggregated number is directly tied to the same patients in the payment count. The information extracted on full screening, brief intervention, brief lifestyle counselling, referral for specialist advice, assessment/screening for anxiety and/or depression and support and treatment for anxiety and/or depression will not be used for payment purposes. It will be available through CQRS, as and when GPES is available to extract the information, to support practices and NHS England to validate requirements of the ES, as necessary, to demonstrate that the full protocol was followed.

Where required, practices must make available to area teams any information they require and that the practice can reasonably be expected to obtain, in order to establish whether or not the practice has fulfilled its obligation under the ES arrangements.

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Prepared By Jean Keenan