No ifs, No butts; Clatterbridge’s Journey to a smoke free trust (using NICE guidance as a road map and a partnership approach as the vehicle)

The broad project aims are to;

• Translate the 'What to' of NICE guidance into a 'how to' template to realise the benefits of evidence based smoking cessation support in an oncology setting, so that patients who smoke will receive the best advice and cancer treatment available.
• Develop an oncology specific training resource.
• Deliver evidence-based guidance for smoking cessation measured against NICE guidance PH48 and Smoking: Harm Reduction Quality Standard 92.
• Achieve 2018 /’19 CQUIN for risky behaviours; Alcohol and Smoking.
• Support and encourage all radiographers to provide smoking cessation VBA and support to all identified smokers.

Key objectives include;

• Increase practitioners’ confidence and competence in delivering VBA. Screen all patients smoking status and record this electronically in record and verify system.
• Directly Supply NRT to patients (given 7,000 new patients a year, a smoking prevalence of 30% in an oncology population and half of these patients want to give up. Target: supply 20 NRT packs per week).
• Implementation of a standardised referral pathway to refer patients to existing smoking cessation services (Target: 20 referrals per week).
• (Verify) Validate a patients’ smokefree status using a Carbon Monoxide Monitor.
• Raise staff and patient awareness of the implications of smoking during treatment.
• Improve quality of life and treatment outcomes for the patient and survivorship agenda.
• Have a robust process that can easily be rolled out to other departments and organisations.
• A further beneficial outcome may be an increase in smoking cessation undertaken by staff – a staff survey identified that 18% of staff smoke. This will be measured via staff survey.
• Sign up to the ‘NHS SmokeFree pledge’.

The Five Year Forward View states the sustainability of the NHS requires “a radical upgrade in prevention and public health”.

The biggest avoidable risk factor associated with the development of cancer is smoking. Consequently SCS play a key part in oncology, given the increased focus on survivorship and should be part of a seamless care pathway for the patient.

Significant benefits exist for patients abstaining from smoking. Stopping during anti-cancer therapies can reduce acute treatment effects, improve effectiveness and reduce the probability of disease recurrence. Health care professionals such as therapeutic radiographers can be champions to promote smoke-free norms and behaviours to support the survivorship agenda in the oncology arena.

Only 20% of trusts delivering anti-cancer therapies are compliant with NICE smoking cessation guidance; (Hutton et al 2016) despite the majority of trusts having smokefree policies in place, there is incongruence between policy and practice.

It is clear that public health needs to be integrated into the patient pathway. For 10 years, NICE has recommended that health professionals identify smokers and refer them to support services (NG92).

Priorities:

The project team undertook research to gather local intelligence, beyond their day role and shows an example of action leadership.

Cubbin (2016) investigated professionals’ attitudes at the trust. Patient perception was investigated by focus groups and patient public partnership.

An internal audit against NICE (PH48) was completed; this informed a wider national audit (Hutton et al 2016).

A systematic review of smoking cessation support in oncology was completed (Conlon et al 2017).

These findings were grouped into organisational, practitioner and patient and became work streams of the project.

Aims:

Organisational:

• Gain acceptance for new policy and its implementation including senior / executive support.
• Mandate smoking cessation training.
• Chose to adopt an approach that would win hearts and minds all trust staff to make a contribution to the smoking cessation.  
• Clinical leadership was required to deliver the organisational change, based on the evidence.

Practitioner:

Support and empower radiographers to understand the considerable patient benefit derived from the provision of VBA in their clinical practice.

Leadership:

The approach was catalysed by strong leadership of individuals who adopted a networking and strategic approach. Identifying policy and key influences to gain support for the project.

A partnership approach to implementation was adopted that included a core team from key organisations; CCC, Wirral Council, Sheffield Hallam University and SC service.

Policy tells us the ‘what to do’. The acquired knowledge allowed the development of template of how to implement the policy in terms of practitioner and patient behaviours.

Delivered a workshop based on LEAN methodology principles with key stakeholders to map the current situation and explore future state. This approach gave a fuller appreciation of the process allowing the identification of barriers and facilitators. A key outcome from this was the identification of ‘quick wins’(expand NRT formulary, smoke free messages on TVs (healthy waiting room) and ‘bigger ideas’/long term plans. e.g. 5 year workforce plan.

The distributed leadership / ‘no more heroes’ model approach was adopted for this project. The rationale for this was;

Limited resources and the project spanned organisations therefore progress was via collaborative influence rather than authority.

Moving away from the issues to finding the solution in an approach that focused on listening, empathy and integrity.

Policy:

The group revised the smokefree policy guided by guidance and standards and adopted examples of good practice from other organisations.

Policies in isolation don’t necessarily translate into practice. Levels of resistance were found within individuals and groups It was important to give people confidence that they could and should make a difference by increasing their engagement with patients who smoke.

Developed an oncology specific training resource including video of VBA conversations in a radiotherapy setting.

Assessed confidence in delivering interventions by pre and post-delivery of training resource using a Likert scale questionnaire.

Communication:

Worked with Healthier Futures to create a ‘The time is now’ campaign cutting through ‘existing noise’ of campaigns and messages.

The group developed an input to the induction of all new staff to the trust.

Inspiring staff to want to make their Trust smokefree.

The group challenged colleagues thinking of what they see as in and out of scope by putting opinion pieces in professional body magazines relating to smoking cessation and the role of vaping as a harm reduction strategy.

Since implementation the quality of the service to patients has improved and is now on the journey towards compliance with NICE guidance, with some areas for further development.

A proactive approach that involves a level of empathy and listening will have longer term benefits for patients health which itself will have financial savings by reducing further requirement for intervention.

AHPs into Action:

• Impact 1: Improve the health and wellbeing of individuals and populations – 40 radiographers have received training in delivering VBA. This has led to an increase in confidence, (pre intervention 45% of staff were likely to ask smoking status, this increased to 90% post intervention including having a conversation using VBA.
• Impact 3: Support, integration, addressing historical service boundaries to reduce duplication and fragmentation… This project has been delivered largely resource neutral by utilising and connecting existing resources. Pre-intervention 0% of staff was familiar with referring to an external service this rose to 100% post-intervention.
• Commitment 2: keep care close to home…as a regional cancer centre the project set up a link on the staff intranet that allowed a patient’s local SCS to be identified and a referral made.
• Commitment 4: care for those who care… this initiative includes patients’ carers and staff.
• Priority 1 – AHPs can lead change - this was an AHP lead project with development of a small team of AHPs who lead on specific work streams.
• Priority 3 –evaluate, improve and evidence the impact of contribution. Appreciative inquiry method of evaluation - What works building on this and doing more of this. builds relationships within organisation.

Measure of the numbers of patients identified/ referred and the monitoring of these throughout their treatment. Establishing links with SCS to complete the feedback loop.

Patient experience was captured by questionnaires and individual interviews. This insight showed that patients expected to be asked their smoking status and given support.

Pre-intervention 35% of staff were aware that NRT could be provided via PGD, awareness rose to 95% post-intervention.

The trust now has a smokefree policy that is compliant with the evidence base including relevant NICE guidance (PH48, QS92).

The policy acknowledges the emerging evidence of e-cigarettes and their role as part of a harm reduction strategy.

Employed the RSPH and PHE Impact tool kit. By quantifying numbers of patients referred and accessing support use the NICE return on investment tobacco tool to estimate financial benefit.

It is not always necessary to have funding to conduct research and service improvement projects.

• What is essential is a mix of enthusiasm, experience and time. This approach also supports professional development of individuals involved in the project working alongside more experienced colleague;
• Katherine Conlon (Weston Park) was a graduate (pre-employment) and was appointed and supported to undertake the systematic review.
• Hannan Hussain (The Christie) newly appointed radiographer grade (B5) was recruited to join the CoRIPs research sub-group to support the focus groups.
• Catherine Kelly and Lauren Williams (Clatterbridge) (newly appointed Senior Radiographers, B6) led on the development of the radiotherapy pilot.
• Critical success factors for change often involve strong leadership, support of critical enablers (such as exec lead) within the organisation and a robust team of champions (radiographers). Without the support of one senior manager the new policy may not have gained acceptance and the project may have stalled.
• There were a lot of challenges and barriers along the way the project team required individual resilience and a collective tenacity. A real strength of this team is the infectious enthusiasm and the ability to galvanise each other, passing the baton on when required.
• We celebrate success along the way as a team, while keeping an eye on the goal of translating all the good work into measurable patient benefit.
• Multi-disciplinary team approach – not one profession holds all the knowledge and skills.
• Don’t let perfect be enemy of the good – this implementation reflects a pragmatic approach to starting to deliver patient benefit. We have a good service now it is implemented we can continue to refine and improve.
• The project team were delighted with all support received.