Brighton and Hove City Council and BSUH NHS Trust
Smoking Cessation Case Study
This case study is from Anna Fairhurst, Smoking Cessation Lead at the Royal Sussex County Hospital in Brighton. The hospital contributes to the Royal College of Physicians National COPD Audit Programme and has been noted as a top performer for smoking cessation advice and prescribing of pharmacotherapies.
We were keen to understand more about how the smoking cessation service was founded and how it is organised, and indeed learn more from the perspective of a smoking cessation lead. As you read this case study you will see that Anna is the only full time smoking cessation professional contracted at the Trust and has been involved in expanding the service she now leads.
What principles underpin the smoking cessation service at the Royal Sussex County Hospital?
Smoking is the leading cause of death and illness in the UK. It was estimated that there were over 50,000 smokers in Brighton & Hove in 2013 (REF?). Smoking can contribute towards the development of many diseases, but is most commonly linked with coronary heart disease, stroke, lung cancer, asthma and chronic obstructive pulmonary disease. For those who smoke, quitting is often the single most effective method of improving health and preventing illness
The primary objective of a Hospital Smoking Cessation service is to help reduce the number of smokers by providing evidence-based treatment and behavioural support to smokers making quit attempts.
‘Hospitalisation offers patients an opportunity to encourage smokers to stop smoking as it offers a “teachable moment” where patients are more receptive to intervention and are more motivated to quit. The hospital’s no-smoking environment creates an external force to support abstinence. Patients are ideally placed to be given information about treatment options and supported through withdrawal process’. (Interventions in Secondary Care – NHS Smokefree REF?).
The British Thoracic Society has produced a number of smoking cessation resources. Was there anything in particular that helped you make the case for your service?
BTS had published a document Case for Change: ‘Why Dedicated, Comprehensive and Sustainable Stop Smoking Services are Necessary for Hospitals’ (British Thoracic Society June 2013 REF), suggesting that a dedicated ongoing stop smoking service in every hospital will have a potentially enormous gains for the Hospital in terms of cost saving on patient related use of resources and also in terms of staff smoking.
Public Health Brighton and Hove City Council applied this proposal at The Royal Sussex County Hospital in Brighton. Previous to that Public Health had already provided funding for a part-time post in the acute hospital over a number of years. This was a well-established service following the initial development of smoking cessation service for hospital patients in 2000. The BTS proposal helped to extend the service to full-time as we had existing positive evidence from the acute sector that providing a cessation service for in-patients worked well.
How did you start to plan the new service?
I initially met with Public Health commissioners at City Council who were involved in setting up a contract and funding requirements. Following the authorisation and agreement of contract, as the smoking cessation lead I was involved in discussions with hospital commissioners to gain their formal agreement. This contract included the clinical aspect of a service for In-patients at the acute hospital and the provision of training and education for Primary care - GP surgery and Pharmacies across the City which would eventually enable a seamless service between secondary and primary care.
What tools or documentation do you use to ensure everyone at the hospital knows about the service?
An Action Plan developed to better promote the service at the hospital. This resulted from meetings and communicating with senior doctors and nurses through-out all departments at the hospital.
Pathway for patients
We set up a smoking cessation pathway for patients, including setting up a hospital smoking cessation steering group to develop a tobacco control strategy with involvement of colleagues from Estates and Facilities.
A smoking cessation referral form was developed and then rolled out to all departments. This was followed by an On-line referral form designed to provide ease of access for referral. The development of this form included meeting with the senior consultant in Emergency Department where they were setting up a single clerking proforma to include smoking history. We followed this by setting up a robust system for documenting smoking status, advising on stopping and making referral
Are you involved in training staff?
I rolled out the provision of Brief intervention face-to-face training for all front line healthcare staff and promotion of training on the Trust website. I attended department meetings to help cascade information on service and referral pathways. Gaining the support from department leads to enable successful service provision was key.
I made contact with Trust Communications and sent service information and regular updates to all staff on the communication channel. NCSCT training has been added to the Trust website and staff are encouraged to complete this.
What evaluation was planned?
As there was already a service provision on a part-time scale hospital staff were positively encouraged to see an increase to service. The vast majority of staff were positive about the service and were actively proactive.
Evaluation was set up based on the national 4 week quit benchmark. The contract stipulated specific targets to be delivered on a quarterly basis. These targets were successfully met which met the service quarterly quality requirements.
What were the key outcomes?
The initial 3 year contract was successfully delivered and met the service quarterly quality requirements. Due to proactive engagement with department staff I managed to gain support for brief intervention training for nurses and doctors, pharmacy team, physiotherapy and occupational team. Being full-time allowed me the benefit of being visible on a daily basis as I carried out my ward rounds. This served as a reminder for staff to make a referral. I meet with Council commissioner and Public Health colleagues regularly on a quarterly basis to provide feedback and monitoring data. The contract has been extended for a further 3 years.
I work closely with the respiratory team in the hospital. The Cardiac Rehabilitation Service Manager was also fully engaging and all their staff were encouraged to complete Level 2 Intermediate training with me. I am included in the Cardiac Rehabilitation Service education programme which runs on a monthly basis at 2 different venues. Cardiac rehab staff deliver a service for patients for follow up exercise and education for 6 weeks post discharge, offering a good opportunity to continue the cessation message which is a crucial component of full recovery following cardiac treatment.
Our cardiologists, respiratory physicians, oncologists, vascular surgeons and senior doctors within HIV medicine have all been extremely proactive through- out this period.
Have you met with any specific challenges?
The challenges I have met with have been mainly on-going staffing issues with a constant turn-over of and shortage of staff. The added pressure of attempting to provide an additional service on top of their normal daily duties for patient care promoted negativity and a reluctance to engage in yet another service to make referrals.
Additionally smoking staff were extremely reluctant to engage and saw this as an additional task. With the support of department managers we have tried to alleviate this negativity by offering time off during their shifts to attend cessation service to help them quit when they are ready to do so. This was the only incentive available to them.
You have been working successfully for a number of years now. Have things changed? What advice would you give to those looking to set up a service?
Smoking cessation service is still being seen by some senior management as a public health service which sits within primary care. Currently there are staffing shortages among both doctors and nursing staff – this remains a big challenge.
Our current management is responsible for 4 other acute hospital Trusts across the patch and I am not aware of any development of cessation services elsewhere to promote a similar service.
I am currently satisfied with service development as it was set up a number of years ago. More recently funding and time available to staff have to complete training has become an increased factor due to staff turn-over. Additionally this contract is a large and working solo is a challenge.
For future participants I would suggest that we should continue to remain positive giving out positive messages taking the service forward so that hospital staff can continue to engage.
If you would like to find out more, please contact:
Smoking Cessation Service Lead
Brighton and Hove City Council/BSUH Trust
Royal Sussex County Hospital
Brighton BN2 5BB