Smokefree LCFT: implementing a nicotine management policy in a community and mental health foundation trust

Aim

Lancashire Care NHS Foundation Trust (LCFT) aimed to implement NICE guidance PH48 through the introduction of a nicotine management policy across its community and inpatient mental health services in January 2015.

Objectives

• To remove smoking, including using any tobacco products or e-cigarettes, from all trust premises from 5^th January 2015
• To contribute to meeting the Trust’s objective to achieve parity of esteem for people with a mental health condition by addressing the key contributor to the difference in life expectancy between people who have a mental health condition, and the general population
• To gain Executive Management Team support for the project (gained May 2014)
• To establish a nicotine management policy implementation group
• To ensure policies and procedures in place to support staff and service users to go smokefree
• To obtain extra funding so nicotine replacement therapy was available as soon as it was needed
• To mobilise smoking cessation services to train and engage staff (across more than one local authority service)
• To develop a robust communication plan

Although implementing NICE guidance PH48 was a specific project, it is an integral part of LCFT’s parity of esteem agenda. It, therefore, complements on-going work to improve the physical health of people with a mental health condition. For example, the Trust uses the Rethink physical assessment tool as part of routine assessment on the wards. The trust is also implementing the Making Every Contact Count programme at level 1, brief advice, and level 2, brief intervention. This aims to ensure staff have the knowledge, skills and confidence to provide brief advice to service users and members of the public visiting our sites. All of these initiatives contribute to a culture change within the organisation that emphasises the importance of taking a population approach to health and wellbeing. As a health and well-being organisation LCFT is, therefore, working hard to ensure that staff take primary and secondary approaches to preventing ill-health. 

The starting point was recognising the impact of tobacco on society in general and some of the service users specifically. This is demonstrated by the following facts:

•  “Smoking is the largest single cause of premature deaths and preventable ill-health in England”. In England in 2011, among adults aged 35 and over there were around 79,100 deaths (18% of all deaths of adults aged 35 and over) estimated to be caused by smoking.
• One in two long-term smokers die prematurely as a result of smoking, half of these in middle age. On average, each smoker loses 10 years of life and experiences many more years of ill-health than a non-smoker.
• Smoking prevalence rates are significantly higher among people hospitalised with a mental health condition, where up to 70% of patients smoke and around 50% are heavy, more dependent smokers.
• People with mental health conditions have worse physical health than the general population.  For example, a UK study has highlighted that men and women living with schizophrenia die an average 15 and 10 years earlier than the national average and the death rate from respiratory disease is three times higher in this group. Another UK study found the risk of death was two to three times greater for people with schizophrenia than in the general population. Of the excess deaths, 70% were due to smoking-related diseases. This is an indefensible health inequality.
• The government has made clear its commitment to reducing this health inequality.
•  “Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders".

The PH48 guideline was circulated at time of publication and every inpatient unit completed their own assessment of compliance using the NICE baseline assessment tool. These reviews identified: escorted leave was used for smoking; there was little guidance pre-admission regarding smoking; not as many staff as desired had been trained in smoking cessation and smoking shelters were common in the grounds of inpatient units.

Lancashire Care NHS Foundation Trust provides health and wellbeing services for a population of around 1.4million people. The services provided include community services such as health visiting, podiatry, sexual health and dentistry as well as inpatient and community mental health services. The Trust covers the whole of the county and employs around 7,000 members of staff across more than 400 sites.

When developing the nicotine management policy, the trust acknowledged the importance of identifying possible problems or issues that might arise. Feedback was sought from staff and service users throughout the policy development process and as a result, the policy changed several times. LCFT were able to learn from Cheshire and Wirral Partnerships NHS Trust who were already smokefree and use the name ‘nicotine management policy’. This emphasised that the policy was designed to support people who have an addiction.

We developed an implementation plan, based on the Scottish model (ref: “Good Places, Better Health” adopted by the Scottish Government in 2008 - http://www.scotland.gov.uk/resource/doc/254447/0075343.pdf ), which encompassed the key elements needed for implementation; a new nicotine management policy, communication strategy, supporting materials, involvement of staff and service users.

All staff are encouraged to complete level 1 smoking cessation training. Some staff are also trained as level 2 Stop Smoking Champions who can provide advice, support and nicotine replacement therapy (NRT) to service users. It is an ongoing challenge to ensure that a sufficient number of staff have this training, and being able to confidently manage NRT is seen by the trust as key to successfully implementing the policy.

An animation was produced for staff to address their concerns, and services users have produced an animation for their peers addressing their concerns. This initiative challenges the culture of smoking in mental health services. It has faced the types of recently published in the BMJ on this topic. Despite this, the Trust is continuing to implement the policy because of its importance in redressing the health inequalities experienced by people with a mental health condition.

We were grateful for the shared learning and advice received from Cheshire and Wirral Partnership NHS Foundation Trust and South London and Maudsley (SLaM) NHS Foundation Trust who had already implemented the guidance. (SLaM were referenced in the PH48 guideline as having successfully implemented smoke free psychiatric wards).

The project has incurred costs, availability of NRT (estimated to be £274,915 for the first 12 months), cost of new signage, removal of smoking shelters, training staff up in smoking cessation and all the promotional material.

Animation for service users https://youtu.be/sPq6Z9yWP3Y

Animation for staff http://www.youtube.com/embed/-5yYbVDw_dw

During the first six months of implementation, LCFT carried out two staff surveys to understand staff perceptions, capture best practice that can be shared across the trust and identify problems so that changes could be made to processes, policies and procedures. (In January 2015, there were 89 responses. In May there were 138 responses).

Based on the survey results, staff drop-in sessions were arranged to provide an opportunity to raise questions and share good practice.

The trust monitors:

• the number of cigarette-related incidents reported on Datix
• expenditure on nicotine replacement therapy by ward
• the number of staff trained as level 2 champions
• the number of complaints made. There were six complaints in January 2015, six in February and then either two or three in each of the following months. The complaints were mainly from service users.

The trust is continuing to monitor the smokefree policy and provide support for staff and service users. This on-going evaluation has led to service users developing an animation that provides information about the policy to service users and carers.

Although we are only implementing NICE guidance, this is an extremely unpopular and difficult area of work. Nationally, there needs to be a cultural shift about the role of smoking in mental health services. There are very few trusts who have successfully implemented this guidance and raising the profile of PH48 and those who are implementing it will benefit the health and wellbeing of people with a mental health condition.

The wider impact has been surprising and disconcerting. The trust received negative publicity from its local paper, the Lancashire Telegraph, when this initiative began. There is an assumption that whilst smoking is unacceptable in most of society, this is not the case in mental health setting. We are in a challenging advocacy role as we explain why we are implementing NICE guidance and why this is of benefit to both staff and service users. This work reveals the ongoing stigma attached to people who use mental health services.

 Through this initiative we are highlighting this challenging aspect of the mental health services culture. We are challenging clinical practice as well as attitudes in the local community.