15. Primary care and community health services
Source: gov.uk (2025-11-28)

How primary and community health services can routinely identify health risk from alcohol use and respond appropriately. GPs and their teams identify and manage alcohol related health conditions, provide harm reduction interventions and work with specialist alcohol services.

15.1 Main points

A significant proportion of patients in primary care and community health services are drinking at levels that risk harm to their health.

Alcohol harms are highest in people experiencing the highest levels of social and economic deprivation.

Primary care and community health services can reduce risk of alcohol related harm by:
- routinely identifying people with alcohol use disorders using a validated screening tool and providing brief interventions
- referring patients who are or who may be alcohol dependent, and those with alcohol related health conditions to specialist alcohol treatment services
GPs and their teams can help to reduce alcohol-related harm by:
- opportunistically identifying alcohol use disorders in the context of potential alcohol-related health conditions and advising on risks of alcohol use to prevent harm in people with relevant conditions
- identifying, managing and arranging further investigations for patients with alcohol-related physical and mental health conditions
- providing advice on alcohol use in pre-conception, pregnancy and the perinatal period and referring pregnant women who are drinking harmfully to specialist antenatal care and alcohol treatment services
- identifying child and adult safeguarding concerns and contributing to multi-agency safeguarding plans
- offering harm reduction advice and interventions to patients who continue to drink at harmful or dependent levels
- working with specialist alcohol treatment services and sharing information with the patient’s consent
- contributing to multidisciplinary, multi-agency care planning, risk management and safeguarding for patients with multiple and complex needs
- helping family members to access support where they need it
- reducing barriers to accessing primary healthcare and considering the needs of all people with problem alcohol use, including people who experiencing the highest levels of social and economic deprivation and communities experiencing the worst health outcomes
Some primary care teams include GPs or nurses with appropriate competencies to provide specialist alcohol treatment interventions (for example, medically assisted withdrawal), and they may be commissioned to offer these.

There should be strong strategic leadership and senior level commitment to support primary care and community health services to carry out their role in preventing, reducing and managing alcohol related harm in their patients. An appointed alcohol lead can help to prioritise effective interventions and pathways for the full range of alcohol use disorders.

15.2 Introduction

The chapter describes the crucial role that primary care services and community health services can play in:
- preventing, identifying and managing alcohol-related harms
- contributing to their patients’ treatment and recovery
15.3 Primary care services and community health services

Guidance in sections 15.3 to 15.5 is for staff in any primary care or community health services.

Primary care services include GPs and their teams, community pharmacists and opticians. GPs may be supported by wider multidisciplinary teams or networks.

Community health services cover a wide range of services and provide care for people of all ages. Some community health teams support people with complex health and care needs. Examples include:
- district nurses
- specialist nurses for long term conditions
- falls prevention services
- community occupational therapy
Community health services also include health promotion services such as health visiting services or sexual health services. These services can be run by the NHS, local authorities or third sector organisations.

National and local arrangements vary, but in many areas community services work across health and social care and include a wide range of professionals such as:
- GPs
- community nurses
- community pharmacists
- social workers
- mental health nurses
15.4 Routine identification of alcohol health risk

Guidance in section 15.4 is for staff in any primary care or community health services.

The UK chief medical officers’ low risk drinking guidelines (https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking) recommend that to keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis.

Severity of alcohol health risk is related to levels of consumption. Initial identification of alcohol-related health risk is categorised as:
- hazardous (also called increasing risk) drinking
- harmful drinking (also called higher risk) drinking
- alcohol dependence
The appendix at the end of this chapter explains these different types of alcohol-related health risk and alcohol use disorder and recommends appropriate interventions.

Almost a quarter of the UK population drink in a way that increases lifetime risk to their health.

People drinking at hazardous (increasing risk) levels and most people drinking at harmful levels do not need specialist alcohol treatment but may benefit from identification and brief intervention, sometimes known as screening and brief interventions. Alcohol brief intervention (ABI) is a general term used to describe a short, structured intervention that supports people drinking at hazardous or harmful levels to reduce their consumption towards lower risk levels.

In England, the term ‘identification and brief advice’ (IBA) is commonly used to describe alcohol risk screening and brief intervention.

Any trained health or social care practitioner can offer alcohol identification using a validated tool and structured brief advice in about 10 minutes.

15.5 Identification of alcohol use disorders and brief interventions

Guidance in section 15.5 is for staff in any primary care or community health services.

15.5.1 The importance of identification and brief interventions

In this guideline, we use the term alcohol use disorder (AUD) to describe harmful (higher risk) drinking including alcohol dependence. People drinking at hazardous levels do not have an alcohol use disorder but their pattern of alcohol use increases lifetime risks to their health.

People with AUD or drinking at hazardous levels use many different health and social care services, including primary care services and community healthcare services. This provides a crucial opportunity for health and care staff to identify them and offer a brief intervention or referral to specialist alcohol treatment where required. Offering brief interventions for people who are drinking at hazardous or harmful levels can help prevent further health harms. Primary care services are in a unique position to identify alcohol-related health risks and act early so potentially improve a patient’s prognosis.

Chapter 3 sets out guidance on providing identification and brief interventions. It includes guidance on several validated AUD identification tests and on appropriate interventions based on the patient’s level of alcohol related health risk. Best practice is that identification and brief advice are embedded within standard assessment processes. Where AUD identification tools are not included in standard assessments healthcare staff can offer brief opportunistic interventions in line with the Making every contact count (https://www.hee.nhs.uk/our-work/population-health/our-resources-hub/making-every-contact-count-mecc) approach. Healthcare practitioners should be trained and supported to ask the appropriate questions about alcohol use and provide simple brief interventions.

15.5.2 Frameworks and requirements for identification and alcohol brief interventions across the UK

There is guidance and support for delivering ABI in each of the UK nations but frameworks and requirements for primary care providers to carry out identification and alcohol brief interventions vary.

In England, the General Medical Services contract requires primary care providers to offer all adults an alcohol risk assessment (identification) when they register with a GP. The NHS Health Check, provided in some areas from primary care services, also includes the requirement that people receiving it are offered an alcohol risk assessment.

The National Institute for Health and Care Excellence (NICE) public health guideline Alcohol use disorders: prevention (https://www.nice.org.uk/guidance/ph24) (PH24) recommends that people whose alcohol risk assessment shows that they are above low risk should be offered brief advice. Or, if their alcohol risk assessment shows they are potentially dependent, they should be referred for specialist assessment.

Large scale provision of ABI is part of Scotland’s national Alcohol Framework 2018 (https://www.gov.scot/publications/alcohol-framework-2018-preventing-harm-next-steps-changing-relationship-alcohol/). In October 2024, Public Health Scotland published its review of the ABI programme (https://publichealthscotland.scot/publications/alcohol-brief-interventions-a-review-of-strategy-and-recommendations-for-policy/), which included recommendations to refresh the programme so that it better meets the needs of individuals in Scotland.

15.5.3 Training and skills for identification and brief intervention

NICE PH24 says that managers of NHS-commissioned services must ensure staff are trained to provide alcohol identification (alcohol risk assessment) and structured brief advice.

Identification and brief advice can be offered by any health or social care practitioner who has been trained. Training can be provided in a session lasting about 40 minutes. NHS England provides a module on alcohol identification and brief advice (https://www.e-lfh.org.uk/programmes/alcohol/) with pathways for primary care services, community pharmacists, dental teams and hospitals.

Training should ensure that health and social care staff have sufficient knowledge and skills to:
- routinely initiate appropriate identification (screening) questions
- understand AUD categories and appropriate responses
- use an empathic, non-judgmental approach
- use non-stigmatising AUD terminology that is person centred and does not label people
- provide effective person-centred brief interventions
- make referrals to specialist alcohol treatment services where appropriate
Clinicians involved in delivering specialist alcohol treatment interventions (for example medically assisted withdrawal) require additional competencies. The Royal College of Psychiatrists and Royal College of GPs’ Delivering quality care for drug and alcohol users: the roles and competencies of doctors (PDF, 404KB) (https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr173.pdf) provides guidance on appropriate competencies for clinicians who provide specialist alcohol treatment interventions.

15.6 The role of GPs and their teams

The guidance in this section 15.6 is for GPs and their wider primary care teams.

Alcohol interventions and support offered by GPs and their teams vary depending on national and local commissioning arrangements, clinical competencies within the wider primary care team and local partnership arrangements. However, all GPs and their teams will provide interventions to:
- prevent, identify and manage alcohol-related harms in their patients
- work with specialist alcohol treatment services to support patients in their treatment and recovery
15.6.1 Expectations of GPs and their teams

All GPs and their teams should:
- routinely identify patients with AUDs at any stage in their alcohol use and offer brief interventions or referral to specialist alcohol treatment as indicated
- with their consent, refer patients who are alcohol dependent, possibly dependent, or have alcohol related health conditions, to specialist community alcohol treatment services
opportunistically identify AUDs in the context of potential alcohol-related health conditions and advise on risks of alcohol use to prevent harm in people with relevant conditions including:
- liver disease
- hypertension
- cardiovascular disease
- obesity
- specific cancers
- anxiety disorders
- depressive disorders
- identify possible alcohol-related physical and mental health conditions and (with patient consent) make or arrange for further investigations
- manage alcohol related physical and mental health conditions in their patients or refer to relevant specialist secondary healthcare care services and work with them to manage the condition
- provide advice on alcohol use in pre-conception, pregnancy and the perinatal period
- refer pregnant women who are drinking harmfully to specialist antenatal care and specialist alcohol treatment services
- identify and act on risks to the person and to others such as child safeguarding and adult safeguarding (see annex 1 on relevant legislation and statutory guidance for more information)
- help family members to access support for their own needs
- offer alcohol harm reduction advice and interventions to people who are drinking harmfully or experiencing alcohol dependence, based on the ‘Making every contact count’ approach
- encourage people with alcohol use disorders to take up the routine screening and vaccinations that are offered to the general population
- ask about social circumstances and offer social prescribing and support (for example, from a link worker or peer support worker) for people who need social support and care
- work with alcohol treatment services (where patients are in specialist alcohol treatment) to support patients to achieve their recovery goals and share information appropriately
- contribute to a multidisciplinary and multi-agency care plans to support recovery and manage risks where patients have complex needs in addition to alcohol problems
- consider the needs of people who drink harmfully and have alcohol dependence who experience health inequalities due to social and economic deprivation
- consider the needs of specific inclusion health groups (see section 15.6.11 below for more information)
Some GPs and their teams who have appropriate competences can also offer specialist alcohol treatment interventions, for example medically assisted withdrawal. There is guidance on specialist alcohol treatment interventions in primary care in section 15.6.10 below.

15.6.2 Identifying alcohol use disorders in the context of potential alcohol-related conditions and advising on alcohol-related health risk

Alcohol use disorders, particularly when alcohol use is non-dependent, can often go undetected. As well as offering routine identification as outlined in section 15.5, GPs and their teams are in a unique position to identify AUDs by asking about the person’s alcohol use in the context of common health conditions that alcohol can cause or contribute to. Common conditions where alcohol can be a causal or contributing factor include hypertension, dyspepsia, and low mood or depressive disorder and liver disease.

People are often wary of sharing accurate information about their alcohol use because harmful drinking and alcohol dependence are stigmatised conditions. Where the GP or practice nurse can have a non-judgemental, supportive conversation about alcohol use in the context of managing the patient’s health condition, this may help to reduce the difficulty that some people have in talking about their problem alcohol use. Where it seems likely the patient is drinking at harmful levels, the GP or nurse can then take a fuller alcohol history. They should offer a brief intervention to support the patient to reduce or stop their alcohol use, or offer a referral to alcohol treatment services if the person is alcohol dependent, possibly alcohol dependent, or their health condition could be alcohol-related.

The GP or team member should also provide the patient with information on how alcohol use can cause or contribute to their health condition and outline the risks involved in the context of their specific condition. For some patients, general advice on health risks at different levels of consumption based on the UK chief medical officers’ low risk drinking guidelines (https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking) needs to be adjusted based on their specific health condition and level of severity.

15.6.3 Identifying and managing alcohol-related health conditions

Evidence on alcohol-related health conditions

The public health burden of alcohol: evidence review (https://www.gov.uk/government/publications/the-public-health-burden-of-alcohol-evidence-review) found that there are over 60 health conditions associated with harmful drinking and alcohol dependence. Common alcohol related health conditions include:
- alcohol-related liver disease
- cardiovascular disease
- cancers including oral cavity, pharynx, oesophagus, larynx, breast, colorectum
- alcohol related brain damage including Wernicke-Korsakoff syndrome
- mental health conditions including anxiety and depression
- increased risk of self-harm including suicide
The role of the GP and their team in identifying and managing alcohol-related health conditions

GPs and their teams are in a position to identify probable alcohol-related health conditions, and to carry out or refer the patient for investigations. GPs, practice nurses and the wider team can play a vital role in identifying alcohol-related health conditions at an early stage by asking about a person’s alcohol use and by screening for alcohol-related conditions in those people at risk. For example, see liver disease in the section below.

People who drink at harmful and dependent levels often have poor health and may also have poor self-care. So, the GP has a vital role in identifying health conditions and helping the patient to manage alcohol-related health conditions.

Liver disease

Liver disease is responsible for most (about 80%) deaths that are caused wholly by alcohol in the UK.

It is important to screen for liver disease as it often does not show outward symptoms until it is at an advanced stage and the patient is severely ill. GPs, practice nurses and the wider primary care team have a vital role in identifying liver disease at an earlier stage, which can reduce the risk of severe illness and deaths.

The NICE guideline Cirrhosis in over 16s: assessment and management (https://www.nice.org.uk/guidance/ng50) (NG50) recommends that anyone drinking at harmful (high risk) levels for 3 months or more should be referred for transient elastography, such as a fibroscan (harmful levels is 35 units or more per week for women and 50 units or more per week for men).

In some areas where transient elastography is not currently available, the pathways involve alternative tests for detecting cirrhosis including the enhanced liver fibrosis (ELF) test and intelligent liver function test (i-LFT). Screening for alcohol-related liver disease should include a measure of liver fibrosis, in addition to liver function blood tests. This is because normal liver function tests and gamma-glutamyl transferase (GGT) tests do not exclude cirrhosis.

There is more detailed guidance on liver screening tests in section 19.5.2 of chapter 19 on co-occurring physical health conditions.

Primary care services should make or refer people for further investigations or specialist management of liver disease where this is indicated by screening.

Cardiovascular disease

There is a close relationship between drinking alcohol and hypertension (high blood pressure). Risk of high blood pressure starts at lower levels of alcohol use for women (from about 2 units per day) than for men. High blood pressure accounts for most alcohol-related hospital admissions for cardiovascular disease. In England, about half of all hospital admissions where alcohol is a primary or secondary cause, are for cardiovascular disease. Screening and management of high blood pressure among people with AUDs can play a vital role in reducing their risk and hospital admissions.

You can find more information on alcohol and cardiovascular disease in section 19.5.3 in chapter 19 on co-occurring physical health conditions.

Cancers

There is strong evidence for an association between alcohol use and cancer, including cancers of the:
- lip, oral cavity and pharynx
- oesophagus
- larynx
- colon
- rectum
- liver and intrahepatic bile ducts
- breast
The risk is increased in men who also smoke. However, for women who have never smoked, the risk of alcohol-related cancers, mainly breast cancer, increases even when drinking up to about 2 units per day.

You can find more information in section 19.5.1 in chapter 19 on co-occurring physical health conditions.

Patients who drink harmfully and dependently may miss screening appointments. Primary care services can support patients who drink harmfully or dependently by prompting them to take up regular screening and by considering whether proactive screening (for example for breast cancer) might be appropriate.

Alcohol related brain damage including Wernicke-Korsakoff syndrome

Alcohol related brain damage describes various psychoneurological or cognitive conditions that are associated with long term, heavy alcohol use and related vitamin deficiencies (particularly thiamine deficiency).

Wernicke-Korsakoff syndrome is a serious complication of deficiency of thiamine (vitamin B1), for which the most common cause is alcohol dependence. This can result in lasting brain injury, so preventing this complication is vital. Many people with alcohol dependence are at risk of developing Wernicke-Korsakoff syndrome due to thiamine deficiency. They may also have deficiencies in other vitamins.

People with alcohol dependence should be prescribed thiamine supplementation before undergoing medically assisted withdrawal. However, it’s important to offer vitamin prophylaxis to all people who drink harmfully and dependently, whether or not they intend to undergo medically assisted withdrawal.

You can find:
- guidance on prescribing and administering thiamine in section 10.4.3 in chapter 10 on pharmacological interventions
- more detailed guidance on people with alcohol related brain damage in chapter 20
Mental health conditions

GPs and their teams play a vital role in identifying and managing the mental health of their patients. Mental health conditions and AUDs commonly occur together. Research on depression, anxiety and substance use found 70% of people in a sample from community substance use treatment also met the criteria for common mental health problems (Delgadillo and others, 2012). Harmful drinking and alcohol dependence can result from an attempt to manage mental health symptoms or can cause or contribute to mental health conditions, in particular anxiety and depression.

The National Confidential Inquiry into Suicide and Safety in Mental Health Annual report 2024: UK patient and general population data (https://sites.manchester.ac.uk/ncish/reports/annual-report-2024/) found that 47% of people in contact with UK mental health services who died by suicide between 2011 and 2021 used alcohol problematically.

There is also evidence that intoxication is a risk factor for suicide (Kaplan and others, 2013; Ledden and others, 2022).

People with co-occurring mental health and alcohol use conditions often have treatment or support needs in other areas too. In every local area, commissioners, strategic managers and senior service providers should work together to commission and plan services for people with co-occurring mental health and alcohol conditions. They should also work with other services including primary care to establish treatment pathways for this group of people who frequently do not receive the care they need.

GPs and their teams contribute to reducing harm and risk in people with co-occurring mental health conditions and alcohol use disorders by:
- identifying and managing both conditions
- referring patients (with their consent) to specialist alcohol treatment or mental health services (or both)
- contributing to multi-agency care planning and safeguarding
- sharing information with specialist mental health services, alcohol treatment services and other relevant services
- contributing to crisis support, for example when a patient is at risk of self-harm or suicide
Managing suicide risk

People with mental health conditions and co-occurring AUDs are at increased risk of suicide. Both alcohol dependence and intoxication can increase risk of suicide in people with co-occurring mental health and alcohol use conditions.

When working to reduce the risk of suicide, primary care services should work in line with clinical guidelines, including NICE guideline:
- Self-harm: assessment, management and preventing re-occurrence (https://www.nice.org.uk/guidance/ng225) (NG225)
- Coexisting severe mental illness and substance misuse: community health and social care services (https://www.nice.org.uk/guidance/ng58) (NG58)
Collaborative care plans for ongoing care should include arrangements for immediate information sharing with the identified lead professional and quick follow-up if a person at risk of suicide loses contact with a service.

Managing mental health crisis and episodes of intoxication safely

People in a mental health crisis can resort to alcohol to manage their distress. Their alcohol use can also lead to an escalation in symptoms of mental ill-health including:
- psychosis
- self-harm
- suicidal intent
They might present to primary care services in a state of acute intoxication. The underlying alcohol use disorder may reflect episodic binge drinking or a severe dependence that requires rapid medical management. Whatever the case, the immediate priority is to make sure any acutely intoxicated person is safe and not a risk to themselves or others.

People presenting in a mental health crisis, self-harming or with suicidal intent should never be turned away from services, because this could increase risks to themselves or others. Staff should support them to access suitable care, including a place of safety where necessary, and monitor their safety.

There is guidance on treating people with problem alcohol use and co-occurring mental health conditions in chapter 18.

15.6.4 Health promotion and non-alcohol related health conditions

People who drink harmfully or dependently often have poor health and may have health conditions unrelated to their problem alcohol use. They can neglect their health or be wary of taking up routine screening and vaccinations for various reasons, including difficulty in trusting services due to a history of trauma or bad experiences of services.

Healthcare professionals can also miss non-alcohol related health conditions, assuming symptoms are related to a patient’s alcohol use. Primary care staff can help to reduce harm by encouraging their patients with alcohol problems to take up routine screening and vaccinations and by checking they have done this.

15.6.5 Pre-conception, pregnancy and the perinatal period

Alcohol use during pregnancy can affect fetal development throughout pregnancy and cause birth defects and perinatal complications. It can result in fetal alcohol spectrum disorder, a term that describes the wide range of outcomes that can result from prenatal alcohol exposure, including lifelong physical, cognitive, behavioural and mental health difficulties.

The UK chief medical officers’ advice on low risk drinking is that women who are pregnant or think they could become pregnant should completely avoid alcohol. GPs and their teams, alongside midwives, have a vital role to play in preventing harm by providing this information to women who are considering pregnancy or who are pregnant. Women who are or could be alcohol dependent should be advised not to stop drinking suddenly because this can increase risk to the fetus and the mother. Instead, they should be rapidly referred to specialist alcohol treatment for an assessment for medically assisted withdrawal. They should also be referred to a specialist or substance misuse midwife if they are not engaged in antenatal care.

Women who drink heavily during pregnancy and the perinatal period will require a multidisciplinary, multi-agency approach to care planning and safeguarding. Primary care services will have an important role to play as part of this approach, contributing to monitoring their patient’s health during pregnancy and the health of the mother and baby after birth. The primary care team will contribute to safeguarding, and midwives and health visitors will have a particular role in this.

Chapter 24 provides guidance on working with women during pregnancy and the perinatal period.

15.6.6 Providing harm reduction information, advice and interventions

Working on the principle of Making every contact count (https://www.hee.nhs.uk/our-work/population-health/our-resources-hub/making-every-contact-count-mecc), primary healthcare practitioners can help to prevent short term alcohol-related harm by providing harm reduction information and advice on the acute risks of intoxication and for people with alcohol dependence.

Intoxication leads to increased risk:
- of sexually transmitted diseases and unplanned pregnancies
- to safety (for example fire, falls and accidents, violence)
- of alcohol poisoning
Combined alcohol and drug use increases risk of:
- overdose and death, when someone takes drugs and alcohol together
- other harms related to mixing drugs, for example cocaine and alcohol are more toxic when taken together
People with alcohol dependence, particularly people with severe alcohol dependence, should be given information on:
- the risks of stopping suddenly (complications of withdrawal) and how they can access medically assisted withdrawal or reduce their drinking safely
- a decrease in tolerance after a period of abstinence and the risks of drinking at pre-abstinence levels
You can find more guidance on harm reduction advice and interventions in chapter 8.

15.6.7 Identifying and responding to risks and safeguarding

Harmful drinking and alcohol dependence is associated with an increased risk of:
- domestic abuse (both as a victim and as a perpetrator)
- sexual violence
- child safeguarding concerns
- adult safeguarding concerns
Being aware of these will help primary care staff to identify any risks to the safety of the patient and people they are in contact with, and to respond to these in line with statutory guidance and organisational procedures. The GP and their team are in a unique position as they have a continuous relationship with the patient and with their family. So, this can help them to identify risks. Primary care teams also play a vital role in a multidisciplinary, multi-agency response to safety planning and safeguarding.

There is information on statutory guidance on safeguarding in annex 1 on legislation and guidance across the UK.

15.6.8 Identifying support needs of family members

A person’s problem alcohol use can put considerable strain on their family members. As well as identifying safeguarding risks (both child and adult), primary care staff can support family members by asking about their own support needs and referring them for a carer’s assessment where appropriate. You can find information on legislation and guidance on support for carers in annex 1.

Primary care staff can support family members by providing information on:
- problem alcohol use
- how problem alcohol use can affect family members
- local or national support services for family members
Local specialist alcohol treatment services often provide information and support for family members and they can signpost people for additional support.

15.6.9 Working with specialist alcohol treatment services

A GP and their team will need to work with specialist alcohol treatment services. This can include:
- referring patients to alcohol treatment services
- sharing information with alcohol treatment services
- contributing to multidisciplinary, multi-agency care planning and risk management
Referring patients to alcohol treatment services

After screening with a validated tool, healthcare practitioners should offer referral for specialist alcohol assessment and treatment to people:
- identified as probably alcohol dependent
- drinking at harmful levels who have an alcohol-related physical health condition (for example liver disease) or mental health condition (for example depression)
- drinking at harmful levels who have not responded to brief interventions
It’s common for people who drink harmfully or dependently to be anxious or ambivalent about approaching an alcohol treatment service. Reasons for this can include:
- stigma and fear of being judged
- difficulties in trusting services due to a history of trauma
- poor past experiences of alcohol treatment
- lack of understanding about what alcohol treatment involves
Most people need some support to approach and engage with an alcohol treatment service.

Primary care staff can help their patients to engage with alcohol treatment by having a conversation with them about what it will involve and acknowledging their anxieties. They could use an approach based on the principles of motivational interventions. There is guidance on motivational interventions in section 5.5.6 in chapter 5 on psychosocial interventions.

The primary care service should have information provided by the local community alcohol treatment service (or at least their website address) to share with the patient. They should also have information on local mutual aid groups (for example Alcoholics Anonymous or SMART Recovery) and local peer-based recovery services. There is more information on mutual aid and peer-based support in chapter 6 on recovery support services.

Some people who are not ready to access specialist alcohol treatment may be happy to access mutual aid or peer-based recovery groups for support. If the person does not want treatment, it’s helpful to raise the option at a later appointment. If the GP or primary healthcare worker already has a relationship with the patient, they may be in the best position to encourage them to attend an alcohol treatment service.

Wherever possible, with the patient’s consent, primary care staff should make a referral by contacting the alcohol treatment service, rather than expecting the person to refer themselves. This allows the alcohol treatment service to contact the person and encourage them to attend and follow up if the person misses the appointment. This approach is associated with increased engagement in alcohol treatment services (Passetti and others, 2008). A referral can also provide the alcohol treatment service with information on the person’s health and on any risks. Since people are often ambivalent about alcohol treatment, it is helpful for the referrer to follow up the outcome of a referral or a planned self-referral.

Ongoing collaboration with alcohol treatment services

With the patient’s informed consent, GPs and their teams and specialist alcohol treatment services should share relevant information about the patient including:
- significant information on health status
- changes in prescribing
- information on risks to the patient and to others
- child and adult safeguarding risks (in line with national safeguarding statutory guidance and organisational procedures)
Where possible, community alcohol treatment services should have access to relevant electronic health records so that so they can access summary health information effectively and quickly.

In England, essential health information is shared electronically through the summary care record held by National Care Records Service (https://digital.nhs.uk/services/national-care-records-service).

In Scotland, NHS services share health information electronically through the Key Information Summary (https://www.scimp.scot.nhs.uk/key-information-summary) (part of the Emergency Care Summary (unless the patient has opted out))

These electronic health records are put in place by the GP team after discussing them with the patient.

In Wales, some clinicians have access to patients’ digital health records through the Welsh Clinical Portal (https://dhcw.nhs.wales/product-directory/our-digital-services/welsh-clinical-portal/).

In Northern Ireland, Encompass (https://dhcni.hscni.net/digital-portfolio/encompass/) is being rolled out so that health and social care trusts will have access to digital health and care records.

However, some alcohol treatment services may not be able to access these electronic records. In those circumstances, alcohol treatment services and GPs and their teams should make other arrangements to share relevant summary information of patients.

Even where alcohol treatment services can access health care summaries electronically, there may be additional information that needs to be shared between community alcohol treatment services and GPs and their teams. For example, sharing information relevant to the person’s alcohol treatment and recovery plan.

The GP will sometimes contribute to the treatment provided by the specialist alcohol treatment service, for example by contributing information to the comprehensive assessment carried out by the alcohol treatment service.

Depending on commissioning arrangements, GPs can also continue to prescribe relapse prevention medication after a patient has been discharged from the alcohol treatment service. If the patient has completed their specialist alcohol treatment episode and is ready to move on in their recovery journey, they can continue to benefit from medication with regular monitoring and review, along with supportive contact in primary care. Section10.5 in chapter 10 on pharmacological interventions provides guidance on prescribing relapse prevention medication.

Contributing to multidisciplinary, multi-agency care planning and risk management

Some patients with alcohol dependence have multiple and complex needs, such as:
- co-occurring mental health conditions
- history of trauma
- multiple physical health conditions
- alcohol related brain damage
- domestic abuse (as a victim or a perpetrator)
- child safeguarding risks
- adult safeguarding, including extreme self-neglect
Working effectively with people with multiple and complex needs requires a multidisciplinary, multi-agency approach. The GP and their team will have important contributions to make to multidisciplinary care planning and review, and to ongoing risk management, including safeguarding. Members of the team that may contribute to supporting people with multiple and complex needs and their families include:
- practice nurses
- pharmacists
- social prescribing staff
- welfare support workers
- link workers
- peer support workers
- health visitors
15.6.10 Offering specialist alcohol treatment interventions in primary care

Some primary care services are commissioned to provide specialist alcohol treatment interventions for people with alcohol dependence or drinking at harmful levels. Models vary across local areas and include commissioning a:
- primary care team that has members with specialist alcohol treatment competences
- partnership or other local arrangements where specialist nurses from specialist alcohol treatment services provide regular surgeries in primary care settings and share the care of the patient with the GP team
In some areas, there are innovative primary care models aimed at reducing health inequalities. An example is the primary care alcohol nurse outreach service (https://www.shaap.org.uk/publication/alcohol-management-in-deep-end-practices/), which involves specialist addiction nurses working closely with selected GP practices in the most deprived communities in Scotland. The service helps to engage and provide care for patients who had not previously engaged or had not engaged well with community alcohol services.

For more information on reducing health inequalities, see section 15.6.11 below.

Primary care settings with staff with specialist alcohol treatment competencies can provide an important opportunity to treat people who drink harmfully or experience alcohol dependence who may not be willing or able to engage with specialist alcohol treatment services. Specialist practitioners can provide treatment tailored to the individual patient and co-ordinate their care. They can also raise awareness about the needs of patients with alcohol dependence among the primary care team.

Primary care practitioners with alcohol specialist competencies should follow the guidance in chapters 1 to 12 of these guidelines. This includes guidance on:
- assessment in chapter 4
- pharmacological interventions in chapter 10
- community based medically assisted withdrawal in chapter 11
- psychosocial interventions in chapter 5
Where formally commissioned treatment models are in place, commissioners and primary care services should ensure patients have access to the full range of options in the local recovery-oriented system of care.

15.6.11 Addressing health inequalities

People who experience economic and social deprivation are disproportionately affected by the harm caused by alcohol dependence and harmful drinking. For example, the National Records of Scotland report Alcohol-specific deaths 2023 (https://www.nrscotland.gov.uk/publications/alcohol-specific-deaths-2023/) showed that the mortality rate for deaths caused solely by alcohol was 4.5 times higher in the most deprived fifth of the population than in the least deprived. And in England in 2023, the Fingertips alcohol profile (https://fingertips.phe.org.uk/profile/local-alcohol-profiles) showed the mortality rate was twice as high in the most deprived tenth of the population than in the least deprived.

By preventing, identifying and managing alcohol-related health conditions and working with specialist alcohol treatment services, GPs and their teams, particularly those serving socially and economically deprived communities, play an important role in reducing health inequalities. They should work to understand the needs of people experiencing socioeconomic deprivation and reduce any barriers to engaging with their services. For example, link workers or peer support workers on primary care teams can support patients to access:
- welfare benefits and debt advice
- social prescribing
- housing support
- employment support
- peer networks
People with alcohol dependence can be considered an ‘inclusion health group’. An inclusion health group is a term used to describe people who experience:
- social exclusion
- poor access to healthcare
- multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma)
- stigma and discrimination
- poor health outcomes
The guidance Inclusion health: applying All Our Health (https://www.gov.uk/government/publications/inclusion-health-applying-all-our-health) provides more information on the needs of inclusion health groups.

15.6.12 The needs of specific health inclusion health groups

Within the wider group of people with alcohol dependence, and the wider group of people experiencing high levels of socioeconomic deprivation, there are groups that experience particularly poor access to healthcare and the worst health outcomes. Their life expectancy and the number of years they live in good health are much lower than the general population because of social factors affecting them, including stigma and discrimination.

These groups include:
- people experiencing homelessness
- vulnerable migrants
- Gypsy, Roma and Traveller groups
- sex workers
- people in contact with the criminal justice system, especially prisoners
- victims of modern slavery
Primary care services can help to reduce the extreme health inequalities that these groups of people experience by:
- understanding the needs of people with alcohol dependence, particularly those who experience extreme social exclusion and the poorest health outcomes
- removing some of the access barriers to their services
- tailoring interventions to meet the needs of specific inclusion health groups
The approach of the service and its healthcare staff to people from these groups can help to make the service more inclusive. People with alcohol dependence or who drink harmfully experience stigma in some healthcare services, and research consistently identifies stigma as a major barrier to them seeking help and engaging with treatment (Kilian and others, 2021). So, a non-stigmatising, non-judgemental and trauma-informed approach is vital. You can find more information on a trauma-informed approach in the working definition of trauma-informed practice (https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice).

Primary care managers and practitioners should all understand who is entitled to access their services and avoid mistakenly excluding the most vulnerable people. People in England, Scotland and Wales are entitled to register with GPs even if they cannot provide proof of address or identification, and regardless of their immigration status.

There is guidance on this issue for the UK nations in the:
- Primary medical care policy and guidance manual (https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/) (pages 154 to 155), which provides guidance for England on registering at a GP practice without ID or a permanent address
- Access to healthcare in the Health Literacy Place toolkit (https://www.healthliteracyplace.org.uk/toolkit/access-to-healthcare/), which provides information for Scotland
- Access and entitlement to NHS services and first time registration (https://hscbusiness.hscni.net/services/1814.htm) web page, which provides guidance for Northern Ireland
There are many other actions that primary care staff, managers and strategic leaders can take to reduce the health inequalities these groups of people experience and to improve their health outcomes. The resource list below (section 15.8) includes guidance on health inclusion. Some of the guidance is for England, but much of the content is relevant for primary care services in other UK nations.

15.7 Strategic leadership

There should be strong strategic leadership and senior level commitment to support primary care and community health services to carry out their role in preventing, identifying and managing alcohol-related harm in their patients.

An appointed alcohol lead can help to prioritise effective interventions and pathways for the full range of alcohol use disorders.

Organisational structures for primary care and community health systems vary across UK nations. So, there will be different ways that alcohol harm reduction interventions can be delivered in these. In England, primary care networks and integrated care systems provide important opportunities to address alcohol harm at a whole system level and to reduce the health inequalities experienced by people with alcohol dependence or who drink at harmful (higher risk) levels.

Commissioners, strategic managers and lead clinicians in primary and community healthcare should consider the needs of people with alcohol dependence as an inclusion health group. They should also consider whether they should commission specific services to reduce barriers to access to primary care and to improve health outcomes for people with alcohol dependence, particularly in areas of high social and economic deprivation, for those experiencing multiple disadvantage or specific health inclusion groups. Examples might include:
- targeted outreach services in areas of high social and economic deprivation or for specific socially excluded local communities
- collaboration with homelessness health teams
- interpreting services
15.8 Inclusion health resources

The list of resources below provides information and support for healthcare professionals, including primary care services, on addressing the needs of inclusion health groups.

Inclusion health self-assessment tool for primary care networks (https://www.inclusion-health.org/pcn/) helps primary care networks to assess their engagement with inclusion health groups. It takes about 10 minutes to complete. After completion, the tool provides a guide to tailored actions the primary care network can take to address health inequalities into its everyday activities.

The Migrant health guide (https://www.gov.uk/topic/health-protection/migrant-health-guide) can support primary care practitioners in caring for patients who have come to the UK from overseas. It includes:
- information on migrants’ entitlement to the NHS
- guidance for assessing new patients
- tailored health information for over 100 countries
- guidance on a range of communicable and non-communicable diseases and health issues
The Doctors of the World Safe Surgeries initiative (https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/) supports GP practices that commit to taking steps to tackle the barriers faced by excluded groups in accessing primary healthcare. The initiative provides a range of support, including:
- resources to support practice staff
- simple guides to NHS entitlement
- translated posters for patients
- training for clinical and non-clinical staff on migrants’ entitlement to NHS care
For specific resources on homelessness and health see chapter 21 on people experiencing homelessness.

Improving Roma health: a guide for health and care professionals (https://www.gov.uk/guidance/improving-roma-health-a-guide-for-health-and-care-professionals) supports health and care professionals to improve services by better understanding the health outcomes that some people in the Roma community face.

How to tackle health inequalities in Gypsy, Roma and Traveller communities: a guide for health and care services (https://www.gypsy-traveller.org/resource/how-to-tackle-health-inequalities-in-gypsy-roma-and-traveller-communities-a-guide-for-health-and-care-services) was developed by Friends, Families and Travellers. The guide includes actions to reduce health inequalities in the Gypsy, Roma and Traveller communities and to increase access to primary care.

The UK modern slavery and exploitation helpline and resource centre (https://www.modernslaveryhelpline.org/) provides access to information and support for victims, the public, statutory agencies, and businesses.

15.9 References

Delgadillo J, Godfrey C , Gilbody S and Payne S. Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment (https://www.tandfonline.com/doi/abs/10.1080/17523281.2012.660981). Mental Health and Substance Use 2012: volume 6, issue 1 (registration and subscription required for full article).

Kaplan M, McFarland B, Huguet N, Conner K, Caetano R, Giesbrecht N and Nolte K. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System (https://injuryprevention.bmj.com/content/19/1/38.short). Injury Prevention 2013: volume 19, issue 1, pages 38 to 43 (registration and subscription required for full article).

Kilian C, Manthey J, Carr S, Hanschmidt F, Rehm J, Speerforck S and Schomerus G. Stigmatization of people with alcohol use disorders: an updated systematic review of population studies (https://doi.org/10.1111/acer.14598). Alcohol Clinical and Experimental Research 2021: volume 46, issue 12, pages 899 to 911.

Ledden S, Moran P, Osburn D and Pitman A. Alcohol use and its association with suicide attempt, suicidal thoughts and non-suicidal self-harm in two successive, nationally representative English household samples (https://www.cambridge.org/core/journals/bjpsych-open/article/alcohol-use-and-its-association-with-suicide-attempt-suicidal-thoughts-and-nonsuicidal-selfharm-in-two-successive-nationally-representative-english-household-samples/A0BDB904D24BBEDFE4320FA16569D671). British Journal of Psychiatry Open 2022: volume 8, issue 6, article e192.

Passetti F Jones G, Chawla K, Boland B and Drummond C. Pilot study of assertive community treatment methods to engage alcohol-dependent individuals (https://academic.oup.com/alcalc/article/43/4/451/128612). Alcohol and Alcoholism 2008: volume 43, issue 4, pages 451 to 455 (registration and subscription required for full article).

Appendix: identifying levels of alcohol-related health risk and appropriate interventions

1. Low risk drinking

Definition

The terms low risk drinking describes a pattern of drinking at a level that does not significantly increase lifetime risk of alcohol-related ill health.

Drinking levels and AUDIT scores

Drinking levels and alcohol use disorders identification test (AUDIT) scores are used to indicate low risk drinking.

Drinking level: less than 14 units per week (men and women).

AUDIT score: 0 to 7: low-risk - no current AUD (see section 3.3.2 in chapter 3 on identification and alcohol brief interventions for guidance on using AUDIT).

2. Hazardous drinking

Definition

The term hazardous drinking (also called increasing risk drinking) describes a pattern of alcohol use that increases the lifetime risk of harm to the physical or mental health of the person drinking or to others. Hazardous drinking has not yet reached the level of having caused harm and is not an alcohol use disorder but represents a risk.

Drinking levels and AUDIT scores

Drinking levels and AUDIT scores are used to indicate hazardous drinking.

Drinking level: 14 to 34 units a week for women and 14 to 49 units a week for men.

AUDIT score: 8 to 15 in (see section 3.3.2 in chapter 3 on for guidance on using AUDIT).

Effective interventions

Offer identification and brief advice (IBA) (sometimes called screening and brief intervention). This involves assessing alcohol related health risks with the person using a validated tool (such as AUDIT) and offering brief structured advice on cutting down. You can read more about identifying and alcohol related health risk and brief interventions in section 15.5 and in chapter 3 on identification and brief interventions.

3. Harmful drinking

Definition

A pattern of alcohol use that has caused damage to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others. The pattern of alcohol use is evident over a period of at least 12 months if substance use is episodic, or at least one month if use is continuous. Drinking levels and AUDIT scores

Drinking levels and AUDIT scores are used to indicate harmful drinking.

Drinking level: 35 units and above per week for women and 50 units and above per week for men.

AUDIT score: 16 to 19 (see section 3.3.2 in chapter 3 on for guidance on using AUDIT).

Effective interventions

Offer IBA (as described in ‘Hazardous drinking’ above). You can read more about identifying alcohol use disorders and brief interventions in section 15.5 and in chapter 3 on identification and brief interventions.

A minority of higher risk drinkers may need referral for specialist alcohol treatment if they have:
- not benefited from alcohol brief interventions
- an alcohol related health condition
4. Alcohol dependence

Definition

This guideline uses the definition of alcohol dependence in International Statistical Classification of Diseases and Related Health Problems 11th revision (https://www.who.int/standards/classifications/classification-of-diseases).

You can find a summary of this definition of alcohol dependence in the glossary.

What this means

Alcohol dependence involves people continuing to drink despite the consequences. They experience psychological dependence, and with more severe dependence, physical withdrawal symptoms when they stop drinking. Drinking in this way is likely to be causing psychological, physical, and social harms.

Effective interventions

If an alcohol risk assessment with a validated tool (identification) indicates that a person has possible alcohol dependence, you should refer them to specialist alcohol treatment. Alcohol dependence is a clinical diagnosis and a specialist assessment is required to confirm that the person is experiencing alcohol dependence.

In specialist alcohol treatment services, they will receive:
- a specialist alcohol assessment
- psychosocial and pharmacological interventions in the community for most people
- specialist inpatient detoxification or residential rehabilitation for a minority of people with severe dependence or complex needs
The alcohol risk categories described above are general indicators not diagnoses and the scores should not override clinical judgement or your knowledge of the person in individual cases. Some people can experience alcohol dependence even if their alcohol use is lower than the amounts described for hazardous or harmful drinking. If you are concerned about a patient’s alcohol use or health, you should offer to refer them for a specialist assessment, whatever their score is.