Leading change

A nurse led a smoking cessation programme board at Tees, Esk and Wear Valleys NHS Trust implemented a move towards a smoke-free trust, given the demonstrable evidence of the benefits of such an initiative, particularly when recognising the local unwarranted variation of significantly higher numbers of mental health patients at the Trust identified as smokers, compared to the national average. A regional approach was taken with support from the Health Improvement: Alcohol, Drugs & Tobacco Division at Public Health England (PHE) to tackle this disparity and support all Trusts to become smoke free by 2020.

Where to look

NICE guidance PH48 (December 2013), specified the importance of smoke-free mental health trusts, supported by policies and procedures to help staff, service users and carers abstain from smoking throughout the sites. There is a trend towards reducing medication dosage if undertaking smoking cessation, leading to a reduction in side effects for those with a mental illness. This reflected the focus on parity of esteem between mental health and physical health, and the recognition that those with Serious Mental Illness (SMI) are likely to die on average 12 years younger than someone within the general population who does not have a SMI.

Given the national importance, the nurse lead on the smoking cessation and nicotine management team at the Tees, Esk and Wear Valleys NHS Trust started the initiative. Having the national guidance provided support to the senior nursing leadership. The nurse set up an internal smoking cessation group, and engaged with PHE and the Strategic Clinical Network for mental health around a regional approach to going smoke-free to try to address the higher percentage of mental health patients identified as smokers – the unwarranted variation – recognised anecdotally at the Trust and with support from national reports (Action on Smoking and Health (Ash), 2016).

What to change

Prior to the change, smoking was prohibited on-site but, in reality, as with many organisations, was widespread. The nurse lead and her team worked with colleagues from across the Trust to support, explain and re-new the existing policy to go smoke-free. Both staff and service users who smoke took up the offer of behavioural support and access to alternative nicotine products to help them abstain from smoking on-site. This included early identification of smokers on admission, rapid access to Nicotine Replacement Therapy (NRT)/support, trained staff and relevant resources. The nurse leaders were advocates of this approach and supported nursing colleagues to implement as a part of their routine care, with support at all levels of this approach.

How to change

Firstly to bring about the start of a cultural change staff working at the Trust who smoked were encouraged to quit as part of a concerted push around Stoptober in 2016. Also, all staff were encouraged to undertake Very Brief Advice (VBA) training around smoking cessation (1530 frontline staff trained in VBA in the first 12 months 2016-2017) to ensure they were giving the right advice and access to support. Additionally in excess of 190 staff members were trained as Level 2 stop smoking advisors across the Trust, able to provide on-going behaviour support to service users around quitting. This supported the development of a new Trust policy whereby service users who smoke are given access to NRT within 30 minutes of admission, which will help avoid unnecessary distress for those using services or barriers to accessing care during their stay.

Adding value

At this time it is too early to fully measure the quantifiable impact of this change, given that the Trust only went fully smoke-free in summer 2016.  A full review was carried out by FUSE (The Centre for Translational Research in Public Health) and PHE (Public Health England).  The review has identified some good practice but also many barriers to the full implementation of smoke-free policies, assessment of their progress and sustainability. Audit data on this work will be available soon as it is complex to try to identify the baseline figures as well as comparable parameters ‘before and after’. Initial findings are suggesting a reduction in smoking prevalence since programme initiation:

Better outcomes – In a 2016 Friends & Family Test (FFT) 10% of staff who responded identified themselves as smokers. In early 2017 only 8% of staff identified themselves as smokers. Latest FFT data indicated that only 7% of staff identified as smokers in August 2017. The 2018 FFT has completed and the Trust is currently awaiting the final data prior to distribution to staff. Within ‘Trust A’ in the evaluation, the proportion of inpatients for whom smoking status was unknown fell from 39% to 13% over the last 18 months of the study period. There is wider evidence from the clinical audit of smoking status, that smoking prevalence fell within the Trust from 43% in 2015 to 21% in 2018.

Better experience – Both patients and staff have reported that the support provided as a part of the policy has been well-received and a mechanism for change – which is a positive indicator of experience.

Better use of resources – The training and skills provided to staff as part of the initiative have supported them to offer a more holistic approach to care without the need for referral onwards which again will have several benefits to service users and their families. The evidence of the evaluation suggest the monthly cost of prescribing NRT products is not excessive, varying between £3,000 and £4,000 per month within each Trust.

Challenges and lessons learnt for implementation

The nursing leadership team identified that when putting in an initiative such as this, strong leadership across all levels in the Trust supports successful implementation. This involves key stakeholder engagement and winning hearts and minds. It also became evident very early on in the project that staff perceptions and attitudes towards smoking could be a barrier for the implementation of the nicotine management policy and NICE guidance. Addressing this culture change early was a key to success.

Also important was the understanding that although the trust would take 12 months to go smoke-free it may take many more years for the implementation phase to have progressed to being truly embedded and advocated.

For Trusts looking to go smoke-free, the nurse leadership team here have recommended planning at least 12-18 months in advance.

Events for service users, carers and staff to attend gives people the opportunity to discuss their concerns has also proven to be invaluable. Taking this a step further the nursing leadership team also recommend service users and carers  being given the opportunity to be part of the project from start to finish for example by attending regular meetings to support the policies development and implementation.

For more information contact:

• Lesley Colley, Project Lead Smoking Cessation and Nicotine Management / Project Lead North East of England Smokefree Prisons, Tees, Esk and Wear Valleys NHS (Mental Health) Trust, lesley.colley@nhs.net