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Background The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners’ Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use. Methods We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide. Results A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team. Conclusions Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.

Supplemental digital content is available in the text., Objective Major gaps remain in our understanding of primary care patient safety. We describe a toolkit for measuring patient safety in family practices. Methods Six tools were used in 46 practices. These tools were as follows: National Health Service Education for Scotland Trigger Tool, National Health Service Education for Scotland Medicines Reconciliation Tool, Primary Care Safequest, Prescribing Safety Indicators, Patient Reported Experiences and Outcomes of Safety in Primary Care, and Concise Safe Systems Checklist. Results Primary Care Safequest showed that most practices had a well-developed safety climate. However, the trigger tool revealed that a quarter of events identified were associated with moderate or substantial harm, with a third originating in primary care and avoidable. Although medicines reconciliation was undertaken within 2 days in more than 70% of cases, necessary discussions with a patient/carer did not always occur. The prescribing safety indicators identified 1435 instances of potentially hazardous prescribing or lack of recommended monitoring (from 92,649 patients). The Concise Safe Systems Checklist found that 25% of staff thought that their practice provided inadequate follow-up for vulnerable patients discharged from hospital and inadequate monitoring of noncollection of prescriptions. Most patients had a positive perception of the safety of their practice although 45% identified at least one safety problem in the past year. Conclusions Patient safety is complex and multidimensional. The Patient Safety Toolkit is easy to use and hosted on a single platform with a collection of tools generating practical and actionable information. It enables family practices to identify safety deficits that they can review and change procedures to improve their patient safety across a key sets of patient safety issues.

Background People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services. Objectives The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages. Design This was a mixed-methods study. Setting The study setting was prisons in England and Wales. Participants Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part. Results Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners. Limitations Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point. Conclusions We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment. Future work The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.

Background In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion. Methods An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews. Results In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful. Conclusions As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.

BACKGROUND There is a growing interest in using mobile apps to support communication, safety, and well-being. Evidence directly from people with dementia regarding the usability, usefulness, and relevance of mobile apps is limited. OBJECTIVE This paper describes the protocol of a study that will evaluate an app designed for supporting communication, safety, and well-being among people living with dementia. The study aims to understand if the app can enhance safety through improved communication among users. METHODS The study will use participatory qualitative methods over 3 cycles of evaluation with co-designers (service users, their families, and care practitioners). The study will be developed in partnership with a specialist home care service in England. Purposive case selection will be performed to ensure that the cases exemplify differences in experiences. The app will be evaluated in a walk-through workshop by people living with early-stage dementia and then trialed at home by up to 12 families in a try-out cycle. An amended version will be evaluated in a final walk-through workshop during cycle 3. Data will be collected from at least 4 data sources during the try-out phase and analyzed thematically. An explanatory multiple case study design will be used to synthesize and present the evidence from the three cycles, drawing on the Normalization Process Theory to support the interpretation of the findings. RESULTS The study is ready to be implemented, but it was paused to protect vulnerable individuals during the COVID-19 pandemic in 2020. The findings will be particularly relevant for understanding how to support vulnerable people living in the community during social distancing and the period following the pandemic as well as for providing insight into the challenges of social isolation that arise from living with dementia. CONCLUSIONS Evaluating a mobile app for enhancing communication, safety, and well-being among people living with dementia contributes to the key ambitions enshrined in policy and practice—championing the use of digital technology and supporting people with dementia to live safely in their own homes. The study will involve co-designers living with dementia, so that the voices of service users can be used to highlight the benefits and challenges of assistive technology and shape the future development of apps that enhance safety by improving communication. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/19543

Background There is a growing interest in using mobile apps to support communication, safety, and well-being. Evidence directly from people with dementia regarding the usability, usefulness, and relevance of mobile apps is limited. Objective This paper describes the protocol of a study that will evaluate an app designed for supporting communication, safety, and well-being among people living with dementia. The study aims to understand if the app can enhance safety through improved communication among users. Methods The study will use participatory qualitative methods over 3 cycles of evaluation with co-designers (service users, their families, and care practitioners). The study will be developed in partnership with a specialist home care service in England. Purposive case selection will be performed to ensure that the cases exemplify differences in experiences. The app will be evaluated in a walk-through workshop by people living with early-stage dementia and then trialed at home by up to 12 families in a try-out cycle. An amended version will be evaluated in a final walk-through workshop during cycle 3. Data will be collected from at least 4 data sources during the try-out phase and analyzed thematically. An explanatory multiple case study design will be used to synthesize and present the evidence from the three cycles, drawing on the Normalization Process Theory to support the interpretation of the findings. Results The study is ready to be implemented, but it was paused to protect vulnerable individuals during the COVID-19 pandemic in 2020. The findings will be particularly relevant for understanding how to support vulnerable people living in the community during social distancing and the period following the pandemic as well as for providing insight into the challenges of social isolation that arise from living with dementia. Conclusions Evaluating a mobile app for enhancing communication, safety, and well-being among people living with dementia contributes to the key ambitions enshrined in policy and practice—championing the use of digital technology and supporting people with dementia to live safely in their own homes. The study will involve co-designers living with dementia, so that the voices of service users can be used to highlight the benefits and challenges of assistive technology and shape the future development of apps that enhance safety by improving communication. International Registered Report Identifier (IRRID) PRR1-10.2196/19543

Background Continued healthcare professional training can lead to improvements in patient care if delivered effectively but there is a lack of research exploring the key factors that underpin successful training. The aims of this research were to first identify what healthcare professionals and experts in training/behaviour change perceive to be effective training, second to produce a framework for delivering training optimised for effectiveness, and third create a taxonomy of training intervention components to be used for designing, reporting and evaluating healthcare professional training. Methods Two semi-structured qualitative interview studies were conducted: Study 1 participants were 18 healthcare professionals who had attended training to implement collaborative care for the management of depression and anxiety in patients with long term conditions; Study 2 participants were 16 experts in training or behaviour change. Data were analysed using framework analyses. A preliminary framework of what constitutes effective training was developed from Study 1 data, then tested and adapted using Study 2 data. Intervention components identified as effective by participants in both studies were defined and grouped to form a taxonomy of training intervention components. They were mapped onto 38 intervention descriptions to assess breadth of coverage. Results Three core concepts (interpersonal, intrapersonal and system factors) and five themes (social interaction, credibility, relevance, information processing, practicalities) that captured what participants perceived to underpin effective training were identified. These were organised into the Perceived Effectiveness of Training framework. A list of training components linked to each theme was developed from the data and a taxonomy of 171 defined training intervention components organized into three phases and grouped into clusters was developed. Conclusions This research identified key attributes that constitute effective training as perceived by a sample of healthcare professionals and experts in training/behaviour change. The framework can be used to design and deliver training that is optimised for effectiveness, or as a basis for training evaluation. The taxonomy can be used as a resource to identify effective training components and offers a common language to describe training interventions. Future research may be useful to further explore in what contexts these components are most effective.

Despite 340 000 000 primary care consultations annually in the UK, most of the literature on patient safety has focused on hospital-based services. To improve safety in primary care settings, we must know what methods, tools and indicators are available to measure and monitor patient safety. In collaboration with patient safety experts at the University of Dundee, we were able to identify a number of existing tools, and many of these were adopted for use in the Patient Safety Toolkit.

BackgroundDescription of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients.AimTo examine patient-reported experiences and outcomes of patient safety in primary care.Design and settingCross-sectional study in 45 general practices across five regions in the north, centre, and south of England.MethodA version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included ‘practice activation’ (what a practice does to create a safe environment); ‘patient activation’ (how proactive are patients in ensuring safe healthcare delivery); ‘experiences of safety events’ (safety errors); ‘outcomes of safety’ (harm); and ‘overall perception of safety’ (how safe patients rate their practice).ResultsQuestionnaires were returned by 1244 patients (18.4%). Scores were high for ‘practice activation’ (mean [standard error] = 80.4 out of 100 [2.0]) and low for ‘patient activation’ (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]).ConclusionPriority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation.

Background: To map and contact all alcohol treatment services in England offering Tier 2, 3 and 4 interventions and describe the characteristics of their service-users.Methods: A national cross-sectional survey of alcohol treatment providers in England, designed to gather information about the characteristics of clients referred, assessed, and treated in the financial 2003/4.Results: A total of 696 alcohol treatment agencies were mapped, of which 388 (55.7 %) responded to the survey. The majority of clients were men, particularly within residential and non-statutory agencies. A higher proportion of residential clients were highly alcohol dependent, homeless and neurologically impaired, whereas, community clients were more likely to be offenders or to have mental health problems. Non-statutory services were more likely to see homeless clients, offenders, and clients with mental health problems and neurological deficits than statutory services who, typically, see a more dependent population.Conclusions: Fin...

Background: Although there is currently a high level of need for alcohol treatment in the United Kingdom, there has been a lack of research into alcohol treatment to date. This study reports on what the current challenges to alcohol treatment services in England are, what resources might help to improve services, and which groups are poorly served by alcohol treatment services, as perceived by service providers.Methods: Qualitative data was obtained in three open-ended questions from a sample of 207 alcohol treatment agencies that responded to the national alcohol needs assessment postal survey.Results: Lack of funding, a general lack of resources to provide services, inadequate access to detoxification and rehabilitation services, and a lack of trained staff to deliver services were key challenges presented. More staff, improved access to detoxification and rehabilitation services, better premises, more funding allocation, improved links with other services, and better resources in general to provide ser...

Background: To map and contact all specialist alcohol treatment services in England and to investigate the characteristics of responding agencies.Methods: A national cross-sectional survey of alcoh...

Background: Over the past 25 years, many trials of screening and brief alcohol intervention in primary care have reported positive effects in terms of reducing excessive drinking. However, it is still not clear how applicable this evidence is to routine primary care. In addition, there is a need to identify an efficient screening strategy for busy medical practices. Lastly, the evidence-base in unclear on whether brief structured advice or motivational counselling is the required form of brief intervention to produce positive behaviour change. This SIPS trial is a pragmatic evaluation based in regular primary care practices and involving general practitioners and nurses who deliver screening and brief alcohol intervention during their day-to-day work The aim of the trial is to evaluate the effectiveness and cost-effectiveness of different models of screening to identify excessive drinkers and differing intensities of brief intervention to reduce excessive drinking in routine practice. Method: GPs and nurses from 24 practices in England were recruited. Practices were randomly allocated to one of three brief intervention conditions: a leaflet-only control group (n = 8); five minutes of brief structured advice (n = 8); and twenty minutes of brief lifestyle counselling (n = 8). Practices were additionally randomised to either universal or targeted screening and to use either a modified single item (M-SASQ) or the FAST screening tool. Practices in each of the three intervention conditions were asked to recruit at least 31 hazardous or harmful drinkers who received a short baseline assessment followed by brief intervention. Patients were subsequently followed up at six and twelve months after the intervention. Results: Six month follow-up data will be completed by February 2010. With just one month remaining, the follow-up rate is currently 86% and has included 560 patients. The majority of the follow-up work has been via telephone although postal and email follow-up have also been used. Discussion: The presentation will report not only drinking outcomes following brief intervention but also quality of life measures and health service use data. The findings will answer the key question of whether brief intervention is effective in routine practice and if structured advice is sufficient to change drinking behaviour in non-treatment seeking patients or if motivational counselling is more impactful. Finally the costeffectiveness of these approaches will be outlined.

There is a wealth of evidence on the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption and related harms across a range of healthcare settings. Research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. However, the majority of this research has been conducted in single centres and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. The study design is a prospective pragmatic factorial cluster randomised controlled trial. Emergency Departments (ED) (n = 9) were randomised to a combination of screening tool (M-SASQ vs. FAST vs. SIPS-PAT) and an intervention (Minimal intervention-PIL vs. Brief advice-BA vs. Brief lifestyle counseling- BLC). The primary hypothesis was that BLC delivered by an Alcohol Health Worker (AHW) was more effective than BA or PIL delivered by ED staff. Secondary hypotheses looked at whether short screening instruments were more acceptable and as efficient as longer screening instruments and the cost-effectiveness of SBI in ED. Participants were followed up at 6 and 12 months. The data analysis has shown a significantly higher positive attitude and motivation (p < .001) of the 250 A&E staff involved in the trial (SAAPPQ) compared with staff from primary care and probation settings. This positive attitude also improved after training (p < .001). However, SBI implementation was difficult and in some settings needed external support. The main implementation issues, challenges and solutions will be explored. Overall, a total of 5992 individuals were approached and 3696 were eligible and screened with 1491 screening positive. The initial results indicate a relative high prevalence of alcohol use disorders in this population (40.3%), which varies considerably across EDs (23.8–71.3%). Mean age was 40 years and the majority were male (59.2%). In terms of screening tools, the screen conversion rate was significantly higher for M-SASQ versus FAST and PAT and significantly higher for M-SASQ versus FAST. Adjusting the analysis using multi-level modeling to account for potential clustering effects indicated that M-SASQ was significantly better than PAT at identifying hazardous alcohol users.

© The Author(s) 2018. Medical Council on Alcohol and Oxford University Press. All rights reserved. In the final version of the manuscript “Screening for at-risk alcohol consumption in primary care: a randomised evaluation of screening approaches”, 10.1093/alcalc/agx017, which was published in Alcohol and Alcoholism, Volume 52, Issue 3, 1 May 2017, Pages 312-317, the name of Professor Nick Heather was omitted and should have been included in the list of authors. The authors apologize for this error. Here the online version of the paper has been corrected.

AIMS: The prevalence of alcohol use disorders (AUDs) in the United Kingdom is estimated at 25%, and primary care has been identified as the first line of treatment for this population. However, there is a paucity of evidence regarding the current rates of identification of AUDs in primary care. The aim of the present study was to compare the observed rates of AUDs in general practice with expected rates, which are based on general population prevalence rates of AUDs. DESIGN, PARTICIPANTS AND MEASUREMENTS: Epidemiological data on individuals aged 16-64 years with an AUD was obtained from the General Practice Research Database. General population prevalence rates of AUDs were obtained from the Psychiatric Morbidity Survey. Chi(2) tests and identification ratios were used to analyse the data. RESULTS: There was a significant relationship between type of AUD and identification (chi(2)=1466.89, P

Background\ud Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.\ud \ud Methods and Findings\ud Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.\ud \ud Conclusions\ud SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.\ud \ud Trial Registration\ud Current Controlled Trials ISRCTN 93681536

Objective To evaluate the effectiveness of different brief intervention\ud strategies at reducing hazardous or harmful drinking in primary care.\ud The hypothesis was that more intensive intervention would result in a\ud greater reduction in hazardous or harmful drinking.\ud Design Pragmatic cluster randomised controlled trial.\ud Setting Primary care practices in the north east and south east of\ud England and in London.\ud Participants 3562 patients aged 18 or more routinely presenting in\ud primary care, of whom 2991 (84.0%) were eligible to enter the trial: 900\ud (30.1%) screened positive for hazardous or harmful drinking and 756\ud (84.0%) received a brief intervention. The sample was predominantly\ud male (62%) and white (92%), and 34% were current smokers.\ud Interventions Practices were randomised to three interventions, each\ud of which built on the previous one: a patient information leaflet control\ud group, five minutes of structured brief advice, and 20 minutes of brief\ud lifestyle counselling. Delivery of the patient leaflet and brief advice\ud occurred directly after screening and brief lifestyle counselling in a\ud subsequent consultation.\ud Main outcome measures The primary outcome was patients’ self\ud reported hazardous or harmful drinking status as measured by the alcohol\ud use disorders identification test (AUDIT) at six months. A negative AUDIT\ud result (score

Numerous screening methods have been developed to detect hazardous and harmful drinking in a range of health settings. Recent research has focused on developing briefer screening tools to maximize implementation in busy practice settings, particularly emergency departments (EDs) and primary care. However the relative utility of these tools is not fully understood. Further, there is a need to identify the utility of universal screening, in which all patients approaching primary care are screened, compared with targeted screening, which includes only patients with certain “red flag” conditions or presentations. The Screening and Intervention Program for Sensible Drinking (SIPS) program compared the relative utility of different screening tools (e.g., the Single Alcohol Screening Question [SASQ] and the Fast Alcohol Screening Test [FAST]) and approaches (universal versus targeted screening) in primary care. In addition, the utility of the Paddington Alcohol Test (PAT), a targeted screening tool, was compared with SASQ and FAST in EDs. Compared with the Alcohol Use Disorders Identification Test (AUDIT), the FAST had a higher sensitivity than the SASQ in primary care. Although targeted screening in primary care is a more efficient screening method, it misses a large proportion of patients who could benefit from brief interventions. The SASQ performed better in EDs than either the FAST or PAT. These results have important implications for the choice of screening tools in different settings.

There is a wealth of evidence on the detrimental impact of excessive alcohol consumption on physical, psychological, and social health. There also exists a substantial evidence base for the efficacy of alcohol brief intervention (BI) aimed at reducing consumption across a range of settings. Research conducted in emergency departments (EDs) has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness of BI. However, the majority of this research has been conducted in a single center, and there is little evidence of the generalizability of SBI implementation across EDs. This pragmatic cluster randomized controlled trial randomized nine EDs to a combination of screening tools (the Modified Single Alcohol Screening Question [M-SASQ], the Fast Alcohol Screening Test [FAST], or the Screening and Intervention Program for Sensible Drinking modified Paddington Alcohol Test [SIPS-PAT]) and interventions (patient intervention leaflet [PIL], brief advice [BA], or brief lifestyle counseling [BLC]). The primary hypothesis was that BLC delivered by an alcohol health worker would be more effective than BA or PIL delivered by ED staff. Outcomes were assessed at six and 12 months. Overall, 5992 patients were screened for eligibility in 9 EDs; of these, 3737 (62%) were found eligible, and 1491 screened positive for an alcohol use disorder (40%). Of those who screened positive, 1204 (81%) consented to participate in the trial. The mean age of participants was 35 years, and the mean AUDIT score at baseline was 12.4. The majority of the sample was male (65%) and white (88%). At 12 months, 803 (67%) of participants were followed up. No significant differences in follow-up rates were observed between intervention groups. Overall, the proportion of participants positive for an alcohol use disorder reduced significantly by 16.3%. This reflected a significant decrease of 18.8% in the PIL group and 15.1% in both the BLC and BA groups. An adjusted logistic regression model found no significant effects of intervention group, screening approach, or baseline AUDIT score.

Background There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. Methods/design The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. Discussion This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments. Trial Registration ISRCTN 93681536

Background There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients. Methods and design GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial. Discussion The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation. Trial registration Current Controlled Trials ISRCTN06145674.

An individual’s attachment style can be conceptualized as a working model for interactions with others, developed as result of experiences with childhood caregivers. People with hypochondriacal tendencies are preoccupied with thoughts of having an illness and constantly seek medical reassurance. We hypothesized that students with preoccupied attachment would score highly on a measure of hypochondriasis and investigated whether the association would be explained by the general tendency to seek reassurance in relationships. A total of 117 undergraduate students completed questionnaires measuring attachment style; negative affectivity; reassurance seeking in relationships and hypochondriasis. Participants with preoccupied attachment style ( n = 17, 15%) had significantly higher hypochondriasis scores than those with other attachment styles. Hierarchical multiple regression analysis suggested that the association between the preoccupied attachment style and hypochondriasis was explained by the general tendency to seek reassurance in relationships, with negative affectivity, a dispositional variable, also acting as a significant predictor of hypochondriasis.

Although the move to smoke-free hospital settings is generally a popular initiative, it may be a more challenging and controversial issue in mental health care. A survey was carried out to investigate differences in attitudes between clinical staff in psychiatric and general medical settings to smoke-free policy and intervention.The sample comprised 2574 NHS staff working in two Acute Hospital Trusts and one Mental Health Trust in England. Attitudes were examined on two factors: health care settings as smoke-free environments and the role of staff in stop smoking intervention.The findings indicated that attitudes on the two factors were only moderately correlated. Psychiatric staff expressed significantly less favourable attitudes than general staff to smoke-free health care settings and also to the role of staff in stop smoking intervention. The largest difference between the settings concerned the implementation of smoking bans. While approximately 1 in 10 staff in the general setting disagreed with a smoking ban in their wards or clinics, nearly one in three psychiatric staff was against such a ban in their setting.Staff attitudes need to be carefully considered, particularly in psychiatric settings, in attempts to implement smoke-free policies in health care settings.

Aims: The aim of the study was to explore the relative efficiency and effectiveness of targeted versus universal screening for at-risk alcohol use in a primary care population in the UK.\ud \ud Methods: The study was a randomized evaluation of screening approach (targeted versus universal) for consecutive attendees at primary care aged 18 years or more. Targeted screening involved screening any patient attending with one of the targeted presentations, conditions associated with excessive alcohol consumption: mental health, gastrointestinal, hypertension, minor injuries or a new patient registration. In the universal arm of the study all presentations in the recruitment period were included. Universal screening included all patients presenting to allocated practices.\ud \ud Results: A total of 3562 potential participants were approached. The odds ratio of being screen positive was higher for the targeted group versus the universal group. Yet the vast majority of those screening positive in the universal group of the study would have been missed by a targeted approach. A combination of age and gender was a more efficient approach than targeting by clinical condition or context.\ud \ud Conclusions: While screening targeted by age and gender is more efficient than universal screening, targeting by clinical condition or presentation is not. Further universal screening is more effective in identifying the full range of patients who could benefit from brief alcohol interventions, and would therefore have greater public health impact. \ud \ud Trial registration: Current Controlled Trials ISRCTN06145674.

Aim: To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling.Methods: A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of Results: Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention.Conclusion: Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.

Background A large number of randomised controlled trials in health settings have consistently reported positive effects of brief intervention in terms of reductions in alcohol use. However, although alcohol misuse is common amongst offenders, there is limited evidence of alcohol brief interventions in the criminal justice field. This factorial pragmatic cluster randomised controlled trial with Offender Managers (OMs) as the unit of randomisation will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in probation and different intensities of brief intervention to reduce excessive drinking in probation clients. Methods and design Ninety-six OMs from 9 probation areas across 3 English regions (the North East Region (n = 4) and London and the South East Regions (n = 5)) will be recruited. OMs will be randomly allocated to one of three intervention conditions: a client information leaflet control condition (n = 32 OMs); 5-minute simple structured advice (n = 32 OMs) and 20-minute brief lifestyle counselling delivered by an Alcohol Health Worker (n = 32 OMs). Randomisation will be stratified by probation area. To test the relative effectiveness of different screening methods all OMs will be randomised to either the Modified Single Item Screening Questionnaire (M-SASQ) or the Fast Alcohol Screening Test (FAST). There will be a minimum of 480 clients recruited into the trial. There will be an intention to treat analysis of study outcomes at 6 and 12 months post intervention. Analysis will include client measures (screening result, weekly alcohol consumption, alcohol-related problems, re-offending, public service use and quality of life) and implementation measures from OMs (the extent of screening and brief intervention beyond the minimum recruitment threshold will provide data on acceptability and feasibility of different models of brief intervention). We will also examine the practitioner and organisational factors associated with successful implementation. Discussion The trial will evaluate the impact of screening and brief alcohol intervention in routine probation work and therefore its findings will be highly relevant to probation teams and thus the criminal justice system in the UK. Ethical approval was given by Northern & Yorkshire REC Trial Registration number ISRCTN 19160244