Country Profile - UK

UK primary care perspective

In the UK there has been no centrally funded approach to improve medical education in alcohol problems, unlike in the United States and Australia. (1) Consequently education and training are fragmented and unco-ordinated at all stages of a doctor's career - undergraduate, postgraduate and continuing medical education (CME). Nationally there is no standardised system for the education and training of general practitioners in relation to prevention, early detection and management of alcohol problems. (2)

Undergraduate

Paton's questionnaire survey of 26 Medical Schools in 1984 revealed that they all arranged some formal teaching in alcohol but only one used a multidisciplinary approach; one had a regular seminar (run by the Medical Council on Alcoholism) and one had three formal sessions. The rest relied on an ad hoc approach by psychiatrists, physicians, pharmacologists, general practitioners and pathologists. Only occasionally were casualty officers, behavioural scientists or psychologists involved.(3)

Crome's questionnaire survey in 1987 involved 13 separate departments in 26 Medical Schools. (4) Of the 70 per cent respondents, 54 per cent provided formal teaching (lectures, seminars, symposia). The average time devoted to substance abuse teaching was 14 hours over 5 years, with an average of 6 hours being spent on alcohol - equivalent to 1 minute per week over the entire period of training. Only 21 per cent of clinical and non-clinical departments ensured that students were examined on the topic. Appeals have been made for a flexible 'core' curriculum or a set of guidelines,increasing the emphasis on the importance of alcohol teaching at every opportune stage in the undergraduate experience (5) and integrating such teaching through the curriculum.(6)

It has also been suggested that each Medical School should make a designated teacher responsible for developing integrated teaching in alcohol (5) and that one department, for example general practice, community and family medicine, psychiatry or public health, should take lead responsibility for organising systematic coverage. (7) (8)

Postgraduate

Once again, training and education are fragmented and limited. The various Royal Colleges have produced reports acknowledging the importance of alcohol abuse but it has been reported that a vice-president of the Royal College of Physicians had stated that 'alcohol is not specifically mentioned in any of the specialty training programmes'.(1) A Diploma in Addiction Behaviour has been developed in London with the aim of 'training the trainers'. Training and education in relation to prevention, early detection and management of alcohol problems in general practice undoubtedly occurs during the 3 year vocational training period but the nature, amount and timing of this are determined by individual course organisers and trainers.

All the Royal Colleges have been urged to recognise the need to integrate relevant information, skills and assessment into postgraduate courses and examinations.

Continuing Medical Education

As is the case with earlier career experiences, training and education for established practitioners is ad hoc and fragmented. Anderson's questionnaire study of GPs in Oxfordshire and Berkshire in 1984 (9) found that 66 per cent of respondents reported less than 4 hours total postgraduate training, or clinical supervision on alcohol. A similar study of GPs in Leicestershire, Derbyshire and Nottinghamshire in 1995 showed that this figure had dropped to 42 per cent - still a significant proportion. (2)

The postgraduate education allowance (PGEA) is the principal component of CME for general practitioners but much of the educational activity is 'didactic, uni-profession and top-down' and shows little evidence of 'any convincing benefits for patient care'. (10) The system allows doctors to play to their strengths rather than identify true educational needs, and is therefore unlikely to facilitate improved training and education on alcohol. The recently published Chief Medical Officer's review of continuing professional development in practice suggests a radical alternative to PGEA - Practice Professional Development Plans (PPDP). These would 'integrate and improve the educational process, developing the concept of the 'whole practice' as a human resource for health care, resembling the health promotion plan in general practice and increasing involvement in the quality development of practices'.

Effective Educational Programmes

There is no shortage of educational materials. The Medical Council on Alcoholism (MCA) is an independent organisation and registered charity which encourages health professionals to identify drinking problems among their patients, and to offer treatment and support. The MCA organises educational events for student and postgraduate participants, publishes Alcohol and Alcoholism: the International Journal of the MCA, Alcoholism, a quarterly newsletter, and alcohol abuse detection leaflets and drinking diaries designed for use by general practitioners. The MCA has produced a list of 8 learning objectives for medical undergraduates, covering the following areas:

• Alcohol
• Alcohol and the individual
• Cost of alcohol misuse
• Clinical problems
• Psychiatric implications
• Identification and recognition
• Management
• Policies

It also distributes Alcohol and Health. A Handbook for Medical Students to all UK undergraduates and Hazardous Drinking. A Handbook for General Practitioners.

Alcohol Concern, the national agency on alcohol misuse, is a registered charity working to reduce the costs of alcohol misuse and to develop the range and quality of services available to problem drinkers and their families. It focuses on education, services, special groups, policy, information, publications and the workplace. It has produced a National Alcohol Training Strategy for all staff who work with people with alcohol problems. In a joint project involving the Standing Conference on Drug Abuse (SCODA) and Alcohol Concern, the Quality in Alcohol and Drugs Services (QUADS) group has produced a draft quality standards manual for alcohol and drug treatment services. The National Alcohol Training Forum, established by Alcohol Concern, has produced Talking it Through - a national vocational training pack for alcohol counsellor training.

In addition there are generic training packs such as Helping People Change (Health Education Authority) and Skills for Change (World Health Organisation).

Finally, the UK Alcohol Forum has recently published Guidelines for the Management of Alcohol Problems in Primary Care and General Psychiatry.

In his review of the rôle and effectiveness of medical education in alcohol, Walsh concluded that 'with a few exceptions, such as the emphasis on feedback training in skill development, most recommendations about alcohol medical education reflect the findings of process evaluations and/or educator opinion. They are not sufficiently informed by theory or based on studies with rigorous methodologies'.Furthermore it is clear that the education of health care providers will require a complex set of responses. Traditional and limited 'educational' responses will not, of themselves, suffice. (A Roche, personal communication).

Conclusion

Although there is no standardised system for the education and training of primary care workers in relation to prevention, early detection and management of alcohol problems, there are well established educational and training models and materials and explicit competencies and training recommendations available. The proposed changes in the NHS and the review of continuing professional development in general practice offer a unique window of opportunity for advancing this agenda in UK primary care.

1998.Pr B.R. McAvoy

References:

1. Walsh RA. Medical education about alcohol: review of its role and effectiveness. Alcohol and Alcoholism 1995; 30: 689-702

2. McAvoy BR. Training general practitioners. Alcohol and Alcoholism 1997; 32: 9-12

3. Paton A. Alcohol Concern 1986; 2 14-16

4. Glass IB. Undergraduate training in substance abuse in the United Kingdom. British Journal of Addiction 1989; 84: 197-202

5. Office of the Chief Scientist. Alcohol related problems in undergraduate medical education. London: DHSS, 1987

6. Ritson EB. Teaching medical students about alcohol. British Medical Journal 1990; 301: 134-135

7. Royal College of General Practitioners. Alcohol - a balanced view. Report from General Practice 24, London: Royal College of General Practitioners, 1986.

8. Glass-Crome IB. Alcohol misuse as challenge to medical education: a belated remedy. British Medical Bulletin 1994; 50: 164-170.

9. Anderson P. Managing alcohol problems in general practice. British Medical Journal 1985; 290: 1873-1875.

10. Department of Health. A review of continuing professional development in general practice: a report by the Chief Medical Officer. London: Department of Health,

The trouble with training: substance misuse education British Medical Schools revisited;
What are the issues?

My 1987 survey of substance misuse education in British Medical Schools highlighted inadequacies and inconsistencies in the extent and quality of undergraduate substance misuse training. At that time, the average time allocated to formal training in addiction (lectures/seminars) over five years was 14 hours. At that time respondents were concerned about the lack of specialists in the field. Recommendations were made for a core curriculum where addiction behaviour would serve a model multidisciplinary speciality training. Co-ordination by an individual and/or department was suggested.

The continuing difficulty in engaging general practitioners and generalists in the care of substance misusers, suggested it was time to revisit the issue. Furthermore, the failure to achieve Health of the Nation targets, notably increasing alcohol consumption in women and smoking in teenagers, makes review more pressing.

Methodology

Deans, Heads of Departments of Psychiatry and 13 other specialities in 23 medical schools were surveyed by means of a postal questionnaire during 1996. Departments surveyed were Accident and Emergency, General Medicine, Geriatrics, Medical Education, Neurology, Obstetrics and Gynaecology, Paediatrics, Pathology, Pharmacology, Physiology, Primary Care, Psychiatry, Public Health and Surgery.

Results

The response rate from Deans was 72.7 per cent and Heads of Psychiatry was 68.2 per cent. Psychiatry was perceived to be the major provider of training, and only 10.1 per cent of other departments responded. The overall response rate was 20.5 per cent. Organisation of medical school training: In 18 (81.2 per cent) schools, Psychiatry played the lead role and in 11 (50 per cent) schools one individual was responsible for co-ordination. In 4 (18.2 per cent) centres, there were academic departments of addiction behaviour: of these, 3 have Chairs of Addiction Behaviour.

Training input: Psychiatry provided a mean of 6.7 (range 2-14) hours formal training (lectures and seminars), excluding one model department which provided 30 hours and facilitated and coordinated an additional 30 hours of undergraduate substance misuse education. In 10 (45.5 per cent) of schools training is patchy, limited and requires considerable reorganisation. Although 10 (45.5 per cent) schools provide an average (3) or above average (7) amount, this still remains largely unacceptable.

Informal training was offered in 6(27.3 per cent) specialist addiction units, 11 (50 per cent) general psychiatric units, and 8 (36.4 per cent) general medical units. In only 5 schools elective placements were regularly utilised. Counselling for medical students with substance problems was available in 10 (45.4 per cent) schools.

Post graduate courses: Three centres provide multidisciplinary degree courses in addiction studies at MSc level, while 5 run certificate/diploma level courses. There are three distance learning courses. There is additional post graduate training being offered to medicaI personnel (general practitioners, psychiatrists, dentists, midwives) in 8 centres, law enforcement officers in 5 centres, to social workers and psychologists in 10 centres, counsellors in 6 centres, education authorities in 7 centres, and to clinical scientists in 1 centre. One centre provides a unique opportunity for training primary health care teams.

Limitations to training: Lack of trained personnel and comprehensive service provision to act as placements were seen as an obstacle to training. 40 per cent of respondents considered that extra resources were required to meet Health of the Nation targets. Although 25 per cent Heads of Psychiatry reported that substance misuse was high on the agenda for expansion, a similar number also reported that departments of psychiatry had little say in determining priorities within the medical school and that there were many other competing interests.

Relationship between degree of service provision and training activities: The more comprehensive the service, and the more post graduate training provision, the more likely was medical school training to be above average. Where there were academic departments of Addiction Behaviour (particularly with a Chair of Addiction), were associated with the most comprehensive services, most postgraduate training opportunities and average or above average medical school training.

Discussion

The key finding is that medical students are receiving 6 hours formal training on substance problems during their five year training. These findings may partially explain why most doctors are ill-equipped to deal with substance problems. Psychiatry has doubled input since 1987, but this is offset by diminished input from other departments as compared to 1987. There is little evidence of innovative developments which have substantially influenced the content and context of substance misuse training which most medical students in Britain receive. However, the one department which has demonstrated the scope to effect major change across the breadth of the curriculum, is a model worthy of replication.

The important link appears to be the establishment of academic departments which have the rôle of galvanising experienced clinicians who have protected time from clinical work to engage in training. A securely resource unit with adequate administrative support that can be sustained in the longer term is the way forward. This requires the input of an experienced, motivated leader who can mobilise the diverging interests within a medical school and represent addiction.

Conclusion

Although Psychiatry has an important rôle, integration across specialities, disciplines, institutions and agencies is necessary to provide doctors of tomorrow with an understanding of the varied approaches to substance misuse. The establishment of academic departments of addiction studies in medical schools would influence decision making within university and services, promote scientific credibility and benefit communities.

Pr I. Crome

Reference

Glass IB. Undergraduate training in substance abuse in the United Kingdom.
British Journal of Addiction 1989; 84: 197-202