Guidance and Resources – Alcohol dependency

In case FM&PH - Alcohol dependency

Additional Reading materials

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

Recommended Essential Resources

· NHS Choices section on alcohol misuse provides a basic outline on issues relating to this problem

·       https://youtu.be/FeJezOanhlQ

Additinal Reading/Resources

· GMC (2013) Good Medical Practice. This outlines the duties of a doctor

· Alcohol related liver disease- causes, symptoms and pathology. Youtube video by Osmosis pathology

· Alcohol consumption: levels and pattern in KSA 

· WHO global status report on alcohol (KSA)

· ACAS is a national organisation which advises employers. The following link provides guidance on dealing with someone who has a drug or alcohol problem.

CASE COMPONENT

Case Introduction – Alcohol dependency

In case FM&PH - Alcohol dependency

Dr Wang is a GP partner at a well-established busy practice with 12 000 registered patients. There has been increasing pressure in the practice for the nurses to take on prescribing courses so they can run minor illness surgeries. This is especially important as the practice has been unable to recruit another salaried or partner GP due to a current national shortage of GP applicants.

Everyone at the practice has been working hard due to staff shortages, and Dr Wang herself has taken on an extra session to try to cover increasing workload.

It has been the end of a long day. Dr Wang sees the practice nurse, Julie Ann coming out of the bathroom and thought she smelled of alcohol. She then goes into the bathroom and discovers an empty vodka bottle in the bin.

What should she do next?

The short answer is to discuss concerns with the practice manager and/or another partner at the practice.

GMC good medical practice and Duty of Candour guidelines state that:

“Senior clinicians have a responsibility to set an example and encourage openness and honesty in reporting adverse incidents and near misses. Clinical leaders should actively foster a culture of learning and improvement.”

“If you have a management role or responsibility, you must make sure that systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams. These should include systems for conducting audits and considering patient feedback. You must make sure that any concerns about the performance of an individual or team are investigated and, if appropriate, addressed quickly and effectively.”

Looking at this scenario, responding to risks to safety is important.

The GMC (2013) in Good Medical Practice states:

“You must promote and encourage a culture that allows all staff to raise concerns openly and safely” “You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.”

“If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or us. If you are still concerned you must report this, in line with our guidance and your workplace policy, and make a record of the steps you have taken.”

Dr Wang must now take steps to ensure patient safety is maintained.

Dr Wang and the practice manager were involved in Julie Ann’s last appraisal. She is aware that Julie Ann, aged 52, lost her husband 9 months ago. She informed Dr Wang at her last appraisal that she had been receiving treatment for depression, with the support of her GP, which had been successful. She felt able to cope with her workload and did not feel that her treatment, or depression, was affecting her work.

Dr Wang discusses the issue with practice manager immediately, and also with one of the other GP partners. A meeting with Julie Ann is agreed, and she decides to write a plan for the interview, in order to ensure all issues are discussed.

What should Dr Wang cover in the interview with Julie Ann?

The ACAS Code of Practice

The ACAS code deals with disciplinary situations relating to employee misconduct or poor performance. It is recommended that the practice has a separate performance and capability procedure; they may address performance issues under this procedure.

Investigation

A suggested plan would be as below:

Before the interview:

· Discuss the issues once again with the practice manager

· Ensure that the meeting is in a quiet room where you are not going to be disturbed

· Also inform all staff that you and Julie Ann must not be disturbed for the time of the interview

· Ensure all phones are off the hook

· Write down the key areas to be covered

· Ensure the practice manager is able to attend, and to record minutes of the meeting

· Advise Julie Ann that she can bring someone else in with her to support her

During the interview:

· Allow Julie Ann the time to explain her side of the story

· Do not interrupt and explore what her thoughts are and what she hopes will help with the situation

· In a non-judgemental way, express your main concern of patient safety and the risk that Julie Ann poses to patients

· Allow time for Julie Ann to respond to this

· Explore solutions with her and then agree on a shared management plan

· Signpost to any local alcohol services and also advise her to see her GP promptly

· Agree to review again in a few weeks

The following link gives further explanation for how you will approach the situation:

acas: Dealing with someone who has a drug or alcohol problem

Dr Wang arranges a meeting for first thing the next day. She phones Julie Ann to inform her of the meeting.

CASE COMPONENT

Further Case Information – Alcohol dependency

In case FM&PH - Alcohol dependency

The Interview

Dr Wang and the partners realise that Julie does not work for the next few days anyway, and her next day of work is on the meeting date. She uses the interview template to explore things further. Julie Ann breaks down in Dr Wang’s consulting room, and is very open with the issues that she now faces. Julie Ann started to use alcohol when her husband received a terminal diagnosis of cancer. She found caring for him very distressing and was unable to sleep properly, waking up in between 3 and 4am in the morning (an early warning sign of depression). She started to use alcohol to self-medicate her sleep pattern.

Once her husband died and the pressure of work increased she had formed a relationship with alcohol which she found comforting. It helped her to sleep, stopped her from feeling so empty inside and she was less aware of the time she spent alone in the house.

She has been drinking heavily for the past 9 months and she has to drink every morning to function or she says she shakes and cannot hold her pen properly. She tells Dr Wang she has not slept for a full 8 hours since her husband died and she wakes up every morning at around 4am, in tears. She has no interest in her appearance and cannot enjoy food. Her concentration is poor and she feels sad for most of her day. She feels that if she did not have work she would have nothing to get up for.

The work has made things worse. Julie Ann feels unsupported in her role, as she doesn’t have a good relationship with her nurse colleagues or the GPs. She also feels out of her depth sometimes, as she doesn’t feel that reception adequately triages patients to the minor illness surgery. She has no friends, either at the practice or outside, and spent most of her time with her husband. Her frail mum lives in Hartlepool, but she rarely visits or calls her.

She says she has tried to cut back her drinking as it makes her sick but sometimes she struggles to think of anything but where her next drink will come from. She divulges that she had a problem with alcohol dependence as a teenager and required help from the community alcohol service then. She has never mentioned this to anyone else before.

Dr Wang acknowledge the issues and advise that she will need to suspend her for a further week, pending discussion with the partners and practice manager, and also send a written warning letter to her. She accepts this.

IN PRACTICE:

If your GP tutor is a partner in the practice, you can discuss with them the issues of being both an employer and if they were also GP to an employee as a patient and if they have ever found themselves in this position.

On Monday Julie Ann comes into work and hands the practice manager a fit note from her GP, stating that she is unable to work for the next 3 weeks due to:

· Alcohol dependency

· Mild to moderate depression

Julie Ann also mentions that the GP has advised her to continue drinking alcohol until she accesses the community alcohol team for alcohol detoxification. He has not issued her with any antidepressants, but has provided her with some vitamins.

A further meeting is held between the GP partners and practice manager, and a decision is made not to take further action until Julie Ann finishes with her sick leave.

After three weeks, Julie Ann rings and tells the practice manager that she has been issued with a further sick note for four weeks. She has started a community detoxification regime and feels supported by the team there.

Dr Wang realises at this stage that Julie Ann is likely to be off work for a prolonged period to receive her treatment she continues to keep her updated of her progress.

4 weeks later, Julie Ann provides a sick note which now states:

· Depression

Alcohol dependency has been removed. She informs Dr Wang she is being treated with cognitive behavioural therapy from a private counsellor at MIND.

CASE COMPONENT

Background Science – Alcohol dependency

In case FM&PH - Alcohol dependency

Aroostook Mental Health Center (AMHC) website outlines the causes of alcoholism

Martin P, Singleton C, Hiller- Sturmhofel (2004) The Role of Thiamine Deficiency in Alcoholic Brain Disease, National Institute on Alcohol Abuse and Alcoholism.

Maletic V, Robinson M, Oakes T, Iyengar S, Ball S, Russell J (2007) Neurobiology of Depression: An Integrated View Of Key Findings. International Journal of Clinical Practice. 61(12):2030-2040.

Treatment guidelines

NICE guidance on alcohol use disorders

NICE (2009) Depression in adults

Patient information leaflets

Royal College of Psychiatrists provides the following patient information on their website

· Alcohol

· Cognitive behavioural therapy

· CASE COMPONENT

·       Case Conclusion – Alcohol dependency

·       In case FM&PH - Alcohol dependency

·       Julie Ann responded well to her community detoxification and managed to remain off alcohol. She also completed CBT. She slowly returned to work with amended duties and then back on the full rota. The written warning remains in her personnel folder but no further action is taken, except monitoring of her performance by the practice manager.

CASE COMPONENT

Formative Assessment – Alcohol dependency