Shared learning database

NHS Bolton
Published date:
October 2012

Developing holistic patient health promotion assessment and referral pathways in hospital settings. Such settings are underused in health promotion yet represent a significant opportunity to make every contact count.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To create a simple holistic patient health promotion assessment tool with an advice/support/signposting pathway. The assessment aims to cover current health priorities including: Smoking, alcohol use, diet, physical activity, weight management, mental health and sexual health. The form design needed to have input from healthcare staff as the design evolved and they also had to believe in the usefulness of using the form in a real world environment. It was hoped that a single pathway would incorporate as much NICE Public Health guidance as possible.

Healthcare have to believe they have the capacity to use the form within their existing workload. The overall aim of which is to ensure lifestyle questions are asked and asked together. Lifestyle questions are often scattered through a range of health service forms. Questions on smoking may be asked if it has prominence on a particular form. A question about diet or alcohol may not be asked if on another form without the same priority to be completed. Asking lifestyle questions can create some anxiety within staff and also cause defensive answering in the recipient. It is important for staff to be confident and to prepare the recipient carefully with an introduction to the assessment that helps to alleviate any suspicion and defensiveness and thus create a more trusting and honest interaction.

Health promotion in a hospital setting is often ad hoc and does not generally benefit from any priority or dominance amongst medical and clinical issues. Health impacts resulting from lifestyle issues are likely to increase, so it is imperative to put in systems that will contribute to addressing them.

The main objective was to create a pathway that was not too onerous to practice and one which has the backing and belief of the individuals who would be using it i.e. healthcare staff. It was also important to ensure that various services within and outside the NHS worked with each other on this pathway or they would simply end up in competition with each other fighting for staff time for their particular topic and ultimately various settings will be full of different pathways for very similar issues.

As most lifestyle issues are interrelated it seems sensible to include them all together in the same pathway. Someone who initially was interested in smoking cessation may end up discussing alcohol consumption and vice versa.

Reasons for implementing your project

Work already done in embedding smoking cessation assessment and practice had proved to be successful and more patients were being identified as smokers and being offered advice and/or signposted to local services. In fact at one time the hospital referred more people to stop smoking services than the entire collection of primary care services. As cash incentives for primary care to identify and refer smokers this difference diminished. Increasingly epidemiological evidence is showing that the gains being realised through people stopping smoking are being undermined by increases in diet/weight and alcohol related harm. To remain singularly focussed on smoking would mean that other lifestyle health issues would be given less attention or ignored completely.

We had already developed smoking cessation brief advice referral forms, a training package to help give staff the confidence and skills to ask about smoking and we also had the next level of primary care smoking cessation support linked into the system enabling staff to get inpatients started on a quit attempt whilst still in hospital. The next step was essentially to use the smoking cessation pathway as a template, expand it and simply include other lifestyle issues.

How did you implement the project

Utilizing research evidence and collating NICE guidance helped to build a business case for commencing developing the pathway. Individual hospital departments also had their own specific service guidance and targets to achieve such as National Service Frameworks. Initial engagement was with individual teams, then teams together in order to assess overall usefulness of a standardised approach. That is, will one form and pathway suit all?

The main barriers to this were time and other competing demands for assessments and history taking. The initial costs were for the time of the health Improvement Specialist leading on the project and some small amounts of printing.

Key findings

Progress to date has been measured by number of staff attending the Health Promotion Brief advice training Level I session. To date this numbers 1477 staff. Evaluation of the training sessions is also measured as is, the amount of assessments and referrals completed and the rate of increase in both. It is hoped that eventually outcome data will be available so that we can assess what changes were or were not implemented by the people signposted or referred to onward services. This can also then be fed back to the referrers. Referral data has been available since the regular use of the assessment pathway. To date the pathway has only really been operating in preoperative assessment clinics so this is rather limited. This in part was due to it being necessary to set up a bespoke referral management database to manage the need for inputting information from the referral and to manage the onward transfer of the referral details to Health Trainer teams. Increasing referrals initially would have meant difficulty in managing them appropriately if a functioning database was not in operation. Outcome data has not been readily available to date as this is inputted into the Health Trainers' main database known as the Birmingham database. Using two databases is not ideal for this type of pathway. It is more desirable to utilise one database to handle both referrals and report outcomes for the referrals. As the Birmingham database is generally not used by Health Trainers for local management of referral information it is probably not particularly effective as the sole database for local health promotion pathways. A singular database that can record all the activity within a health promotion pathway and produce reports on various metrics is the ideal. The challenge now is to roll the overall pathway out within the wider hospital settings and into various primary care settings.

Key learning points

Staff training is the key to success. Simply designing an assessment form and asking (or telling) staff to complete it is unlikely to be successful. You have to win hearts and minds in order for staff to find time to do the assessment in the face of demands of many others. Staff need to believe in the process to ensure a good intervention. There is added value to training staff to complete the health promotion assessment. Staff use information on health improvement to base an assessment of their own lifestyle. Post training evaluations show that the training makes them consider lifestyle changes themselves. 77% of staff (n=160) stated that the training made them more aware of their own health needs. As most NHS trusts are keen to see their staff improve their health, its an effective way of indirectly getting information across to staff. Keep your training in-house if you can. External trainers tend to be available in sporadic bursts as funding is identified and allocated. Training in health promotion needs to be a constant. Use whatever is being shared. Don't reinvent wheels. Try ensuring all services work together. If they don't, each service will pursue their own interests, causing unrealistic demands on staff especially for training. Patient interventions proliferate and increase confusion about which pathway is the current preferred one e.g. if the alcohol team want to train all staff and use their form, then the stop smoking service wants to do the same. Demand on staff time to attend both training sessions can't be met plus there are two different pathways to follow. Training sessions, leaflets, forms etc will undoubtedly keep changing with services. You will need to accept the need for a certain level of evolution and short term lifespan in everything you produce. Use national resources that don't change as often such as Department of Health and NHS Choices.

Contact details

Gary Bickerstaffe
Health Improvement Specialist (Health Settings)
NHS Bolton

Secondary care
Is the example industry-sponsored in any way?