Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) provide mental health, learning disability and eating disorder services in County Durham, Darlington, Tees Valley, York and most of North Yorkshire. The Trust ambition to go smokefree followed publication of the NICE Guidance PH48: Smoking cessation in secondary care: acute, maternity and mental health services and involved introduction of a Trust wide smokefree policy.
The objectives of the smokefree policy are to protect the health of mental health service users whilst promoting a healthy working environment and accessible smoking cessation support for staff. The Trust looked for innovative ways to support smoking cessation whilst implementing the NICE guidance, one of these being the offer of free e-cigarettes on admission to hospital for service users requiring nicotine management.
Aims and objectives
The main aim of the project was to support the reduction in years lost by going completely smokefree Trustwide in all buildings and grounds by the provision of dedicated nicotine management and smoking cessation support to service users. Key project objectives identified by the Nicotine Management and Smoking Cessation Group included:
- All buildings and grounds to become smokefree
- To support the reduction in service users and staff smoking rates
- To reduce second-hand smoke exposure
- To improve the health of both service users and staff
- To increase staff knowledge related to smoking and its effects on health
- To review all smoking cessation/nicotine management aids
- To review and update the current smokefree policy
- To have service users and carers to support the project
- To develop information leaflets for service users, carers and staff
- To develop detailed communication plans
- To challenge myths and provide latest evidence to support smoking cessation in mental health services
Reasons for implementing your project
An internal review against the NICE PH48 Guidance was conducted in 2015 and demonstrated the need for a project to support guidance implementation. A Project Lead was identified and following the set-up of a dedicated Nicotine Management and Smoking Cessation Steering Group, smaller sub groups were then identified to support the delivery of the NICE Guidance recommendations which would allow the Trust to go smokefree.
This smokefree ambition was based on NICE Guidance PH48 which sets out a series of recommendations for reducing smoking amongst service users, carers and staff.
Service users and carers were offered the opportunity to support the sub group work and became regular attendees to support the implementation of the policy. The Smokefree Policy was updated and renamed as the Nicotine Management policy and various information leaflets were developed following Trustwide consultation to support the smokefree agenda.
Communication was key throughout the 12-18 month preparation phase and the communications team developed a robust communications plan to support the agenda. Staff were offered the opportunity to complete varying levels of training to support the smokefree agenda and over 1500 staff completed the National Centre for Smoking Cessation and Training (NCSCT) Very Brief Advice (VBA) training online. A further 187 staff trained to NCSCT Level 2 practitioner standards which then enabled them to carry out comprehensive assessments for service users on admission to hospital.
Clinicians, staff and patients were offered the best evidence available to give them the confidence to support smokers requiring nicotine management and the Trust were keen to look at innovative ways to support patients including reviewing all current e-cigarette options. Benefits realised:
- reduction in service user and staff exposure to second hand smoke
- reduction in number of staff smoking (FFT results 10% to 8%)
- increased staff time available to support service users
- immediate access to nicotine therapies on admission
- access to free disposable e-cigarettes
- potential for reduction in medications dosages i.e. clozapine
- potential for reduction in side effects following reduction in medication dosages
- increase in ward based activities to support rehabilitation
- regular clinical audits to assess smoking rates across all trust sites
- policy developed and implemented, along with leaflets and pharmacy guidance (co-produced with service users and carers)
How did you implement the project
A key element of the NICE Guidance PH48 was to identify senior level board support to lead on the implementation of the guidance. This was undertaken early in the process to ensure clear direction and was a crucial part of the project.
NICE Guidance PH48 is clear on the steps required to go fully smokefree, including early identification of smokers on admission (or before), rapid access to NRT/support, Trust leadership, trained staff, communications, etc. We also drew on the experiences of other Trusts Nationally that had gone smokefree in particular accessing support from staff at the South London and Maudsley NHS Trust.
Work then commenced to:
- Identify funding to support the project and fund the identified increase in pharmacy costs for nicotine replacement products, inclusive of the option for varenicline and bupropion
- Identify service users and carers wishing to support the project
- Link with commissioners to support the project
- Update the current Smokefree Policy
- Develop a detailed communications plan
- Develop the training programme and start the delivery of training to staff inclusive of behavioural support
- Identify any alternative nicotine delivery devices and identify funding to support a free supply to service users who smoke on admission
The updated Nicotine Management Policy now encourages access to NRT within 30 minutes of admission and offers the option for all models of e-cigarettes to be considered should a service user decline NRT in the first instance.
The Trust`s policy around smokefree sites is more actively enforced, and staff are encouraged to remove any tobacco products brought onto site and only offer for return to service users on final discharge. Changes were needed in terms of Trust culture – both amongst the Trust Board to renew and enforce the existing policy, but also from all staff to support this.
Both staff and service users who smoke needed behavioural support and access to alternative nicotine products to help them abstain from smoking on-site. Some of the challenges in the change process were with staff attitudes, training provision, access and supply of e-cigarettes and service user anxieties regarding the change and how to alleviate these anxieties.
To address the identified concerns we held regular staff meetings, increased training provision and identified smokefree champions, developed an e-cigarette pathway for supply and issue and held a service user conference to allow further discussion.
The Trust has successfully implemented the policy, supporting many service users with nicotine management during their inpatient stay also achieving a 2% decrease in the number of staff smoking identified in the 'friends and family test' in June 2016.
The Trust Homely Remedy pathway supports access to nicotine products without the need for a prescription. TEWV identified two nicotine products available via the Homely Remedy Pathway which are the Nicotine patch and Inhalator which are available within all ward areas.
Other NRT preparations can be made available by registered prescribers. Service users now have immediate access to nicotine containing products to limit withdrawal on admission.
From March 2016 until September 2016 the following was noted:
- Pharmacy services dispensed 2033 NRT items
- Most popular NRT is the patch with 1181 issued
- Second most popular is the nicotine inhalator- one quarter of all NRT products dispensed
- 167 prescriptions made available for the lozenge The Trust NRT costs between October 2015 and September 2016 were £54,397.76 and are now levelling at around £4,000 per month for the combined adult services, learning disabilities services and older person’s services.
Prior to October 2015 the average monthly costs for NRT were around £2,000. Within the Forensics Directorate the NRT spend in the same timeframe was £31,483.39 and the costs are now levelling at around £1,000 per month. Due to the limited admission rates within this directorate these costs are expected to reduce further.
In reference to the use of unlicensed products such as e-cigarettes at a time where MHRA is developing a regulatory approach, NICE guidance states: “NHS Trusts would need to formulate their own local policies on the use of such products, depending on local circumstances and judgement”.
Many Trusts have prohibited their use but following consultation with service users, carers and Trust staff the decision was taken to allow their use within this Trust.
- To use as a harm reduction tool
- To provide nicotine management and smoking cessation support
- Support the reduction in second hand smoke exposure
- Support the reduction in smoking rates
Within the first week of going smoke free over 500 disposable e-cigarettes were ordered to stock identified wards and to date over 1,000 free e-cigarettes have been ordered and made available. Feedback from service users and staff regarding the benefits they have experienced following admission has shown them to be an extremely supportive measure for many vulnerable clients in a time of crisis. Please see additional supporting evidence.
Key learning points
For Trusts looking to go smokefree we would advise to plan at least 12-18 months in advance and ensure senior management “buy in” is available. A dedicated project team is a must, with excellent knowledge of the smokefree agenda.
Events for service users, carers and staff will provide the opportunity to discuss concerns. Service users and carers should be given the opportunity to be a key part of the project by e.g. attending regular meetings, informing development of policies and resources and supporting the cultural changes.
Trusts need to be resilient when introducing the NICE guidance PH48 to ensure success. It became evident early in the project that staff perceptions and attitudes towards smoking were a barrier to the implementation of the NICE guidance. Determination to introduce large scale change against huge opposition proved challenging, but with awareness sessions staff perceptions continue to change thereby enhancing the support available to service users.
One of the main challenges post-implementation was with staff continuing to facilitate smoking. The policy stated that all tobacco and related items would be contraband and removed until final discharge. Staff found this aspect of the policy difficult and continued to return cigarettes allowing service users to continue to smoke throughout the day.
Additional guidance has now been provided and further work continues to challenge this practice and support service users requiring nicotine management support. It is too early to fully measure the quantifiable success of this change, given that the Trust only went fully smokefree in March 2016. However, an evaluation project is on-going which is currently conducted by FUSE, the North East Centre for Translational Research in Public Health along with the Public Health England Knowledge and Intelligence Team, supported by TEWV and NTW who also went smokefree on 9th March. Please see supporting evidence.