The Atlas of Shared Learning

Case study

Introducing a comprehensive Tobacco Dependence Treatment policy in South London and Maudsley NHS Foundation Trust

Leading change

A nurse consultant specialising in health and well-being at South London and Maudsley NHS Foundation Mental Health Trust (SLaM), led the introduction of a smoke-free hospital programme. SLaM aimed to help reduce this inequality and create a healthier environment for everyone, staff, patients and all visitors, by making the sites smoke free. This is in line with National Institute for Health and Care Excellence (NICE) guidance which recommends that all hospital sites, including mental health hospitals, should be 100 per cent smoke-free.

Where to look

In the UK smoking is the main cause of preventable illness and premature death, with currently approximately 15.5% of adults identifying as smokers (Action on Smoking and Health (Ash), 2016). However, approximately 68% of people with a severe mental illness who receive services from SLaM were identified as smokers and smoked during their engagement with the Trusts services. The evidence suggests that people with a mental illness who smoke are more likely to be heavier smokers and more tobacco dependent than smokers in the general population (Ash, 2016).

Nationally there have been a number of examples where acute non-mental health Trusts had successfully implemented a smoke-free hospital programme however within Mental health Trusts this appeared to have additional challenges.

As a Trust, SLaM were concerned that the unwarranted variation of their high rates of smoking exacerbated the health inequality already experienced by those with a serious mental illness. In addition the Trust identified that their staff smoking rates were also between 21% and 45%, which was higher than the national average. SLaM committed to improving this figure also so that everyone using or providing their services were encouraged and supported to reduce or give up smoking.

What to change

Following the Health Act (2006), it became common practice for nurses to begin to facilitate smoking breaks for patients from in-patient wards in mental health hospitals in order to meet their needs and in the absence of robust smoking cessation support available. The nurse consultant and her team at SLaM however recognised that more could be done to support patients to give up smoking where they wanted to, and promote health and well being for all patients.

They also identified that resources were being used ineffectively, with some actually supporting people to smoke, such as helping them buy cigarettes and going to smoking shelters. In fact the nurse consultant found that this averaged 2.23 hours of nursing time per day per ward, a significant impact, particularly if other alternatives were available.

How to change

The nurse consultant and her team collaborated with other colleagues across the Trust to adapt the patients’ electronic patient record system so that all patients admitted were routinely recorded for smoking status. In line with national guidance, those identified as smokers were then provided with brief advice about the harmful effects of smoking and the help available to support a cut down or attempt to quit.

New hospital-based Smoking Cessation advisors were appointed and an automated referral system was also built in to the system so that they were alerted to patients as they were using services and could respond to provide the specialist support as required. In addition a new post of ‘Nurse Consultant – Health Promotion & Well-being’ was developed by the nursing team and employed in SLaM to provide leadership for the smoke free initiative.

Following implementation, the nurse consultant and team commissioned the development of an e-learning course at the Trust, to ensure that every member of clinical staff was able to learn about the prevalence and impact of smoking in the mental health population. Overseen by a mental health nurse researcher, the staff also learnt about how to give brief advice and how to make a referral to a specialist.

To support smoking cessation efforts, the nursing team ensured stocks of Nicotine Replacement Therapy (NRT) were available across the Trust and worked collaboratively with pharmacy teams to ensure medicines policies were adapted to allow all registered nurses to administer NRT as a ‘homely remedy’. In this way nurses are able to support the prompt management of nicotine withdrawal on arrival to the smoke free hospital.

Adding value

  • Better outcomes – Evidence tells us that there are immediate and long-term health benefits of quitting for all smokers including improved circulation, reduced stroke risk, significantly decreased risk of cancer and lower risks of anxiety and chronic heart disease (World Health Organisation, 2017). As part of SLaM’s new smoke-free programme, it is anticipated that patients’ mental and physical health will improve as well as their experience of care. In addition, it is recognised that nationally, patients who quit smoking have reduced symptoms and a shorter length of stay in hospital. Further evidence is being evaluated by the Trust.
  • Better experience – Although many patients reported being initially resistant to the idea of being smoke-free, the nursing team now get very positive feedback from patients. Nurses have reported that they feel proud of their achievements in helping patients address smoking as part of their recovery plan.
  • Better use of resources – Nurses are able to support patients to cut down and quit smoking and this is leading to reductions in medications required and overall expenditure. Although the nursing team have observed an increased expenditure on NRT, they are spending less on psychotropic medicines, antibiotics, inhalers and rapid tranquillisation. A lot of this use of resources improvement is anecdotal, but as time progresses, collected data and measurement of success will provide a clearer picture.

Challenges and lessons learnt for implementation

Staff were able to provide care in an environment that promotes health and wellbeing and supports the provision of evidence based treatment and positive lifestyle choices.

One nurse quoted “Quitting smoking is the single most important thing anyone can do for their improved health, that’s what nursing is all about!”

Find out more

For more information contact:

Mary Yates

Nurse Consultant – Health Promotion & Wellbeing

South London and Maudsley NHS Foundation Trust