Joanna Robinson and her team at Walsall tPCT show that locally enhanced services based on national smoking cessation guidance can benefit people who are trying to give up smoking

Walsall Teaching Primary Care Trust (tPCT) has developed and operates a locally enhanced service (LES) to reimburse GPs who provide smoking cessation services to patients in Walsall. The LES was set up in line with the smoking indicators in QOF21 and was developed to ensure that smoking cessation services operating through primary care are delivered in accordance with NICE guidance2 and national smoking cessation guidelines,3 thereby providing a superior and uniform service across the borough.

Background

The LES guideline was developed by Rachael Humphreys (who was the Tobacco Control Coordinator, and is now Head of Health Promotion) using the Department of Health NHS smoking cessation services monitoring and guidance document.4 The proposed LES content was finalised following consultation with local GPs, healthcare assistants, practice nurses, practice managers, pharmaceutical leads, and clinical governance. (To access a copy of the Walsall LES guideline, please contact Joanna Robinson at joanna.robinson@walsall.nhs.uk.)

The purpose of the LES and the locally developed guideline was to improve the effectiveness of Walsall's intermediate (primary care based) smoking cessation services by raising the quality of intervention delivered to a minimum standard4 across the borough. Another aim was to increase service provision and, therefore, patient choice.

This LES continues to provide the following benefits:

  • improved patient care arising from service continuity
  • rewards for GPs who ensure the continuity of the quality of smoking cessation services for patients
  • a robust monitoring mechanism for smoking cessation services that are required to meet national and local targets.

All existing and new service providers were asked to sign up to use the LES guideline. This ensures compliance to the guidance and helps with monitoring the effectiveness of service providers.1 The implementation of this guideline was designed specifically to:

  • increase the number of quit attempts
  • decrease the number of patients not quitting and lost to follow-up
  • increase the number of patients successfully quitting at 4 weeks and beyond.

Successful implementation should, therefore, contribute to an overall reduction in premature mortality in the population, and a reduction in inequalities in health.

Implementation

In order to implement the LES guideline, the tPCT undertook a consultation process with primary care based smoking cessation service providers including GPs, practice managers, practice nurses, and healthcare assistants.

Advice on and support to develop the guidance were obtained from the tPCT primary care management team and the clinical governance department. Following the consultation process, the guideline and LES were ratified through the tPCT management team and the local medical committee.

There are currently 66 general practices signed up to the LES and 117 advisors who are trained to deliver the service.

Provision of support in general practice

Only patients who were motivated to stop and who had set a quit date were considered by GPs or appropriately trained practice staff for the 4-week treatment programme. The practice assessed each patient's suitability for nicotine replacement therapy and bupropion, and these treatments were prescribed in accordance with NICE guidance. Each practice involved kept thorough patient records for their patients as spot checks could be made at any time by the Tobacco Control Coordinator, who would ensure procedures were being adhered to.

As from 1 April 2003, individual practices who registered as part of the LES received a payment of £20 per patient supported through a 4-week quit attempt by the practice nurse or health visitor who had been trained to provide smoking cessation support by Walsall tPCT (Box 1). Only practices that had members of staff who participated in the Walsall smoking cessation training course and who were, therefore, accredited were eligible to receive this payment. The two-day training courses were held four or five times a year.

All patients using this LES are carbon monoxide validated at the 4-week and 12-month follow-up appointments. It is the responsibility of the practice to ensure that they have a carbon monoxide monitor and that it is fully calibrated and in working order.

The Tobacco Control Coordinator provides each individual practice with a quarterly report detailing:

  • the number of patients supported through a quit attempt (setting a quit date)
  • number who quit at 4 weeks
  • number who were lost to follow-up
  • results from the 12-month follow-up appointment.

This information is also reported to the PCT on a quarterly basis to monitor progress towards targets.

Box 1: Criteria that accredited practice nurses/health visitor must adhere to
  • Follow the minimum standards of service provision outlined in the guidelines on smoking cessation intervention in primary care
  • Conduct an initial consultation, lasting 20–30 minutes, assess motivation and readiness to stop, set a quit date, and advise on the provision of nicotine replacement therapy or bupropion if appropriate
  • Complete monitoring forms only for those motivated to stop and setting a quit date
  • Offer weekly support for at least the first 4 weeks of a quit attempt
  • Carry out a 4-week and 12-month follow-up appointment, face to face, unless exceptional circumstances prevent this
  • Complete all sections of the monitoring form for each client, fully and accurately, ensuring client consent is obtained
  • Return monitoring forms at the end of every month to the Tobacco Control Coordinator
  • Attend smoking cessation update training and local network events at least once a year

Success of the locally enhanced service

There was an increase in the number of quit dates set for April 2003 to March 2004 (first year of implementation) compared with April 2002 to March 2003;5 for April 2004 until March 2005, there was a 228% increase (compared with April 2002 to March 2003).

Improvements in service uptake of primary care based smoking cessation services have been reported each year (Table 1).

Service performance is monitored by quarterly data submissions to the Department of Health, via the Strategic Health Authority.

The uptake of smoking cessation services and subsequent success of a quit attempt, which has been consistent at approximately 51% for the past 4 years, i.e. since 2002, impacts significantly upon the health of the patient.

The 51% quit rate at Walsall tPCT is around the national average of 50%,5 which remains constant; therefore, the 51% quit rate indicates that an effective service is being provided. If our results were to drop below 50%, action would be required to determine why quit rates had decreased below the national average.

Analysis of data for April 2005 to March 2006 showed that 50% of patients accessing services were from the most deprived areas (based on the Index of Multiple Deprivation [IMD]). The West Midlands Public Health Observatory local stop smoking service equity profile also concluded that from April 2003 to March 2005 the lowest proportion of male and female smokers accessing the service lived in the most affluent areas (IMD quintile 1 and 2).6

This represents an inequality in access, which favours smokers living in deprived areas, and so validates the tPCT's efforts to effectively reduce health inequalities. The tPCT is hoping to tackle this issue in due course.

Not only has service uptake increased in Walsall tPCT, but the percentage of patients lost to follow-up has also decreased from 26% (for April 2002 to March 2003) to 22% (for April 2005 to March 2006).

In line with monitoring guidelines,4 carbon monoxide validation rates have seen a dramatic improvement since implementation of the LES: analysis showed that from April 2002 to March 2003, just 63% of successful quitters were validated at 4 weeks, compared with 86% of quitters validated at 4 weeks from April 2005 to March 2006.5

Table 1: Improvements in service uptake 2002–2006*
 
2002–'03*
2003–'04*
2004–'05*
2005–'06*
Quit date set
1207
2407
3328
3963
Quit at 4 weeks
620
1208
1707
2047
Not quit at 4 weeks
278
644
799
1035
Lost to follow-up
309
618
822
881
CO validated
388
861
1301
1765
*Years run from 1 April – 31 March

Summary and future plans

Evidence-based practice is vitally important and the tPCT is constantly striving to ensure that smoking cessation support is delivered in accordance with an national smoking cessation guidelines, NICE guidance, and local protocols, via training provision, correspondence, and feedback to service providers.

Walsall tPCT will continue to provide both update sessions and intermediate training courses in 2007/2008 with an emphasis on recruiting those staff working in areas identified to have the highest smoking prevalence, thus significantly reducing health inequalities within Walsall.

Summary

 

  • The LES was set up to ensure that smoking cessation services in Walsall tPCT are delivered in accordance with national guidance
  • Implementation of the LES has resulted in:
    • a steady increase in patient quit dates set each year
    • a decrease in the percentage of patients lost to follow-up
    • a significant improvement in carbon monoxide validation rates
    • identification of inequality in access to smoking cessation services favouring smokers in deprived areas
LES=locally enhanced service

Acknowledgements

The author would like to thank Stephanie Coyne and Susan Durkin, Service Administrators; Rachael Humphreys, Head of Health Promotion; and Susan Caulfield and Helen Cleary, Specialist Advisors at the Walsall Stop Smoking Service.

  1. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  2. National Institute for Health and Care Excellence. Brief Interventions and referral for smoking cessation in primary and other settings. Public Health Intervention Guidance no.1. London: NICE, 2006.
  3. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax 2000; 55 (12): 987–999.
  4. Department of Health. NHS Smoking Cessation Services. Services and Monitoring Guidance 2001/02. London: Department of Health, 2001.
  5. www.ic.nhs.uk/pubs/
  6. West Midlands Public Health Observatory. Walsall Quit Smoking Service Equity Profile. West Midlands Public Health Observatory, 2005G