Can you tell us how you became interested and involved in tobacco dependence?
I have always been passionate about addressing health inequalities, and helping people with their tobacco dependence is an important part of this. For the last 10 years I have worked in public health nursing and social prescribing. The COVID-19 pandemic reignited my interest in acute care, and I am very lucky to now have a public health focussed role that is based in an acute trust.
Can you tell us who you approached first to help you plan and deliver your tobacco dependency service?
Much of the strategic focus had been completed prior to my coming into role, with the support and oversight of the Associate Director of Strategy, and the Treating Tobacco Dependency (TTD) Programme manager.
Crucially, the NBT Trust Smoke Free policy had been reviewed to become a ‘Tobacco’ Smoke Free Policy, laying a firm foundation for the TTD service for inpatients. This reviewed policy refers to the use of tobacco, not Vapes/e-cigarettes, which are a recognised effective tool to support tobacco dependency treatment. Additionally, the updated policy makes provision for the introduction of designated vaping areas for use by patients, staff and members of the public visiting the site.
Similarly, a nicotine replacement therapy (NRT) protocol had been created in partnership with the Director of Pharmacy, providing clear guidance and governance on the future supply of NRT by TTD Advisors. There was also strong clinical support from one of the Respiratory Consultants and Directorate Deputy Director of Nursing.
Why do you feel this is an important programme to roll out within your trust and how do you think it is benefitting the population of your region?
Bristol has the highest smoking rate (16.4%) in the Southwest and is above the England average. For routine and manual occupations, Bristol’s smoking rate (33.1%) is second only to Manchester amongst the core cities in England, reflecting the legacy of the tobacco industry in Bristol.
Smoking significantly contributes to the extensive approximate 10-year gap in life expectancy, and 16-year gap in healthy life expectancy, between those living in the most affluent and those living in the poorest areas of the city.
We have a firm evidence base on how to support patients to stop smoking and with sufficient investment in our service we can make a substantial contribution to decreasing the health inequality in life expectancy and we can improve the quality of life of patients and their families within Bristol, North Somerset, and South Gloucestershire.
The associated savings in healthcare costs, by reduced length of stay and reduced readmissions can also be reinvested to improve overall population health.
Can you explain what you did within the first 3 months of the programme launch?
We undertook a recruitment campaign to recruit Band 4 TTD Health Advisors. By month 3 we had 2 of 4 Advisors in post.
We started on the respiratory ward where we had strong clinical support to develop the service model. The first TTD Advisor and I have worked hard to develop relationships with the nursing staff, doctors, and allied health professionals to promote the service within the respiratory speciality.
We have since expanded the service to the acute medical unit and have started trying to build relationships with their multidisciplinary team.
As the TTD Lead, I have worked with Pharmacy to improve the supply of NRT on wards, to establish patient storage of PRN products and to ensure patients receive a 2-week supply of combination NRT on discharge.
How were you able to identify and record the smoking status on admission?
We needed to create a system to allow us to see when a smoker was admitted to the hospital. We have created an electronic referral on the Electronic Patient Record (EPR), Careflow. We also complete a daily review on the EPR and paper records to identify newly admitted patients who will benefit from our service but who may not have been referred electronically.
We have worked with a junior doctor from the clinical transformation team to ensure that smoking status is captured electronically when patients are admitted via A&E. This enables business intelligence to run daily reports of all patients who smoke that are admitted to the Trust via A&E.
Can you describe how you have managed to embed the service to ensure visibility across the Trust?
We have used existing links to form strong relationships with the Community Smoking Cessation Services, tobacco control leads in Public Health, community pharmacy leads and the ICS Tobacco Control Lead and Population Health manager.
We have been working with facilities management and comms to create our first ‘vaping quit zones’ on the main NBT Trust site and are putting in place new smoking related signage across the site.
We have designed and ordered a bespoke polo shirt uniform for the team to provide a clear team identity and visibility on the ward.
We immediately started to record data, from seeing our first patient in June, and are ready to submit our first data return to NHSE in August.
We are ensuring that we feed back 28 day quit status to the referring clinician and area to improve and maintain communication with the tobacco dependence team. This also provides the referrer with an insight into the value of treating and supporting the patient with a tobacco dependency.
What were your main barriers/difficulties in the early stages of starting the programme and how did you overcome these?
I would say workforce remains a significant challenge. It has been challenging to recruit and retain advisors within the 12-month fixed term contracts that are available. We have worked closely with recruitment to improve the onboarding process, to ensure we do not lose applicants to other opportunities, as happened with 2 applicants. Similarly, we have provided an extensive induction process to create a sense of belonging within the team, early on.
It has been difficult to form relationships with ward staff, as there are so many staff. Linking with ward managers, supervisory sisters and ward admin staff has really helped, as has securing the opportunity for TTD Advisors to shadow ward admin, nurses, occupational therapists and doctors’ ward rounds.
The limited supply of NRT on the wards and PRN NRT products not being included in TTAs has been challenging. We have worked very closely with Pharmacy to overcome these difficulties together and the TTD team has a much greater understanding of how crucial the support of ward pharmacists is to the success of the service.
Is there anything you would do differently if you had the opportunity to start from the beginning?
I would have limited the service provision to the respiratory ward for a longer period of time, before expanding to other areas. This would have enabled us, to fully embed the service, regardless of the number of referrals received.
We could have utilised this delay to provide teaching to ward staff regarding the use of NRT products and their roles in supporting the TTD service to provide an effective service to patients This would have given us the opportunity to fine-tune the pathway and treatment provision prior to rolling out to other areas.
What would be your top 3 tips for others about to embark upon the programme?
- Ensure you have supportive governance and trust executive level support, including an up to date vape-friendly Tobacco Smoke Free Policy, which reflects the impact of smoking on the public health outcomes of your local ICS population health footprint.
- Try to negotiate substantive employment contracts for your TTD lead and TTD Advisor posts to provide security and consistency for the service provision.
- Plan to start collecting NHSE outcome data straightaway, so that you can demonstrate the positive impact your service is having on patient health outcomes from month 1 of service delivery.
How do you feel the programme is benefitting the Trust and most notably, patients with a tobacco dependency?
The service is acting as a conduit to remind all healthcare professionals of the damage that smoking has on patient health outcomes, that smoking hasn’t ‘gone away’ and that with the right support we can empower patients to stop smoking. It has helped raise awareness of the need to create a Smoke Free environment for all and the challenge and organisational-wide support needed to achieve effectively. The implementation of the TTD programme has also highlighted the need for the availability of effective TTD support for members of staff, who are also part of our ICS population.
Our first data entry for month 1 will demonstrate a self-reported quit rate of 35%, which we anticipate will have a significant positive impact on readmission rates.
Do you have any recommendations on how to maintain and sustain the programme to ensure it is embedded within the Trust in the longer term?
Similar to the 3 top tips already mentioned, support from executive leaders and lead clinicians is essential.
It will be advantageous to create other, qualitative, personalised patient outcome measures. For example patient activation measures can be used to capture the full impact of the service, including for those who may not quit on their first admission, but for whom the cumulative support from the service increases self-efficacy and enables an eventual quit.
We need sufficient investment in staffing capacity and permanent contracts to be able to offer every inpatient TTD support and ultimately we hope our service will evolve into a 7 day a week service.