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Wednesday 28 September 2016
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Smoker’s QOF: a way to boost quitting rates

Patients & Services

JACQUELINE WATSON

Stop Smoking Specialist for Primary Care
Rotherham NHS Stop Smoking Service

Jacqueline is the lead for Stop Smoking Interventions in Primary Care at Rotherham Stop Smoking Service. She enjoys her work, which involves building relationships and partnership working, and has an interest in health promotion, particularly addictions. Jacqueline is pleased to empower GP practices to use the proven system base to increase referrals and quitters, improving the health and wellbeing of the people of Rotherham

Stop Smoking Interventions in Primary Care (SSIPC) is a proven, system-based approach to increasing smoking cessation interventions, increasing Quality and Outcomes Framework (QOF) points and improving the health and wellbeing of patients. NHS Rotherham has introduced this simple but effective approach, which is delivered by Stop Smoking Services and GP practices working in partnership. The approach does not represent a high burden to practice staff.

Background
Smoking is still the biggest cause of preventable illness and death in the UK, responsible for more than 100,000 deaths each year.(1) That's more than 10 people per hour, every hour, every day, and twice the total number of deaths caused by obesity, alcohol and road traffic accidents combined.

Smoking is also the single greatest cause of health inequalities in the UK: the 10-year difference in life expectancy between social classes is largely due to differences in smoking rates.(2) Therefore helping someone to stop smoking is the greatest single influence you can have on their health.

Stop smoking interventions are proven to be very effective (and cost-effective) ways of reducing illness and prolonging life.(2)

Of course, GP practices receive QOF points for smoking cessation interventions as an incentivised activity.(3) The clinical indicators relate to smokers with chronic conditions such as coronary heart disease, stroke or transient ischaemic attack, hypertension and diabetes. QOF points are awarded for recording a patient's smoking status, as well as providing stop smoking advice or referral to a specialist service (see Box 1).

[[JW_Box1]]

Many patients are referred to Stop Smoking Services through their GP practice. However, the evidence suggests that practice staff do not routinely discuss stopping smoking with their patients.(4)

This haphazard approach results in significant variation in support and often results in a scramble at the end of the year, when practice staff try to contact patients to establish their smoking status. Although this approach may boost QOF points, it is of dubious value in terms of helping patients to stop smoking.

What is SSIPC?
SSIPC is a proven, systems-based approach for delivering stop smoking interventions in primary care.(4) The approach works by offering patients three levels of intervention:

  • 30-second very brief advice.
  • 5-10 minute brief intervention.
  • Intensive seven-week stop smoking
  • evidence-based support.

The approach comprises of 10 components that facilitate routine quality stop smoking treatment in the practice.

Senior management need to be fully signed up to the systems-based approach to deliver evidence-based advice and support for smokers who wish to stop smoking.

The whole team needs to be involved in implementing the system for delivering stop smoking support. The Stop Smoking Service works with the practice to develop a stop smoking protocol, provide raising awareness training, provide feedback and resources so that staff are aware of the services in their area, how to raise the issue of smoking with their patients, and how to refer on for stop smoking support.

A big concern of many GPs and practice staff is that raising the issue of stopping smoking will alienate patients. However, the evidence is that smokers, even those who have no desire to quit, expect healthcare providers to advise them to quit because it shows concern for their overall health. When a healthcare provider does not mention smoking, this gives the impression that smoking is not affecting the person's health.(5-7)

The working environment should reinforce messages provided by the healthcare providers. The site should be smokefree, and all patients and public areas should display promotional materials about the stop smoking support available. This promotes a positive message that says:

  • The organisation genuinely believes that cessation is a credible activity.
  • The healthcare professional is likely to ask about their smoking status.
  • Friendly help and support is available.
  • It is ok to ask for help and support.
  • The 10 components of SSIPC are outlined in Figure 1.

[[JW_Fig1]]

Case Study 1 – Dinnington Group Practice
Dinnington Group Practice provides GP services for the whole of Dinnington and Anston. The practice population is 16,816, with 3,297 patients recorded as smokers. Dinnington is an ex-mining village with severe pockets of deprivation.

Rotherham NHS Stop Smoking Service (RSSS) had identified that the number of referrals from the practice was low (only nine during the period April to December 2007). An initial visit to the practice was organised to discuss the outline of SSIPC and how it could help them increase their referrals, quitters and QOF points.

The senior GP agreed to be SSIPC champion, and the practice manager was SSIPC co-ordinator. The practice completed their first questionnaire to establish whether there were any gaps within their present system and how the RSSS could help them develop a new systems-based approach to smoking cessation within their practice.

The questionnaire established:

  • Low levels of awareness of the help available for their patients within Dinnington.
  • Not all staff were aware of the practice's existing protocol for smoking cessation.
  • Awareness of smoking cessation therapies among staff was poor.
  • Feedback from the RSSS was not getting to frontline staff.
  • Most staff had not had any smoking cessation training.

By working in partnership with the practice co-ordinator, an action plan was developed. This included a short training session to provide staff with the systems, skills and confidence to raise the issue of stopping smoking routinely with their patients and refer to the RSSS when necessary.

The practice chose to implement the very brief intervention approach – the three As:

  • Ask if the patient smokes.
  • Advise them of the health benefits of stopping smoking.
  • Act upon their response.(4)

This intervention takes as little as 30 seconds, and so the GPs and their practice staff could easily incorporate this into their appointment slot with their patients.

The practice has subsequently decided to implement the more intensive approach, and now delivers inhouse support via a locally enhanced service, as well as referring patients to RSSS. The whole process of embedding the new systems-based approach to smoking cessation took about five months. By working together to deliver SSIPC, the practice increased the number of smoking quitters by more than 100%.

The practice's scores in the QOF have more than doubled, and currently stand at 92% for smoking status recorded and 87% for smoking cessation advice and referral to specialist service. Table 1 shows the increase in referrals and four-week quitters.

[[JW_Tab1]]

Case Study 2 – St Ann's Medical Centre
St Ann's Medical Centre is a large central practice with a practice population of 14,301, and 3,286 recorded as having a smoking status. St Ann's Medical Centre is located in one of the most deprived areas in Rotherham.

RSSS identified that referrals to the service from this practice were low: only 37 between 1 June 2007 to 31 May 2008. As with the Dinnington Group Practice, an initial visit to the practice was organised to discuss the outline of SSIPC and how it could help them increase their referrals, quitters and QOF points.

The practice manager agreed to be the champion and the deputy practice manager agreed to be the co-ordinator. The practice completed their first questionnaire to identify any gaps within the system and how we could help them develop a new systems-based approach. The questionnaire established that:

  • Most staff were unaware of any senior-level commitment to smoking cessation.
  • Most staff were aware of the practice's existing protocol for smoking cessation.
  • Most staff had not received any smoking cessation training.
  • Feedback from the Stop Smoking Service was not getting to frontline staff.

Working in partnership with the practice co-ordinator and senior receptionist, the RSSS developed an action plan. As With the Dinnington practice, this included a short training session to provide staff with the systems, skills and confidence to raise the issue of stopping smoking routinely with their patients and refer to RSSS.

As part of the action plan, it was agreed that the RSSS SSIPC lead would visit the practice on a quarterly basis so the practice could feed back information with regard to referrals and four-week quitters. This would be presented in an easy-to-read table displayed in the practice staff area. The champion and senior receptionist ensured that smoking cessation was high on everyone's list of priorities, and that resources and posters were on display and changed on a regular basis.

When auditing the number of GP referrals to RSSS, it was noted that even though practice staff had attended the stop smoking AAA training, the number of GP referrals had not significantly increased. The local SSIPC lead arranged to visit the practice and discuss how to address this.

The practice assured the SSIPC lead that the GPs were routinely discussing smoking cessation with their patients – however, it transpired that GPs were signposting patients to RSSS rather than making an actual referral. After a discussion with the co-ordinator and senior receptionist, it was agreed that the GPs would send patients to reception, where reception staff would complete the referral form and send this to the RSSS.

The whole process of embedding the new systems-based approach to smoking cessation took about four months. By working together to deliver SSIPC, the practice increased the number of GP referrals by more than 100%. Table 2 shows the increase in referrals and four-week quitters.

[[JW_Tab2]]

Key points

  • Without a doubt, offering smokers advice and support to help them quit is the single most clinically and cost-effective preventive action that a clinician can undertake, and doubles the likelihood of a successful attempt taking place.(8,9)
  • SSIPC really works! It offers a proven systems-based approach to increase the frequency and quality of stop smoking interventions in your practice.
  • By routinely discussing smoking with patients, your practice can improve the quality of care you provide and ensure you capture the information needed to maximise QOF points and practice income.
  • Smokers, even those who have no desire to quit, expect healthcare providers to advise them to quit because it shows concern for their overall health. When a healthcare provider does not mention smoking, it gives the impression that smoking is not affecting the person's health.(5)
  • Taking the time to complete an actual referral form (compared to signposting) is very worthwhile, as it increases the number of patients attending stop smoking support.
  • The whole practice needs to be involved – including senior level support.
  • Your local Stop Smoking Service can help your practice implement SSIPC.
  • SSIPC is not a one-off intervention; ongoing support and developing relationships are at the heart of SSIPC.

References
1. Callum C. The UK smoking epidemic deaths in 1995. London Health Education Authority; 1998.
2. Department of Health. Smoking Kills: a White Paper on tobacco. London: DH; 1998. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
3. Department of Health. Quality and Outcomes Framework. London: DH: 2008. Available from: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QO...
4. Hodgson P. Stop Smoking Interventions in Primary Care. A systems based approach. 2008.
5. Conroy M, Makcjrzak N, Regan S, et al. The association between patient-reported receipt of tobacco intervention at primary care visit and smokers' satisfaction with their health care. Nicotine & Tobacco Research 2005;7(suppl. 1):S29-34.
6. Sciamanna C, Novak S, Houston T, et al. Visit satisfaction and tailored health behaviour communication in primary care. Am J Prev Med 2004; 26(5):426-30.
7. Barzilia D, Goodwin M, Stange K. Does health habit counselling affect patient satisfaction? Prev Med 2001;33(6):595-99.
8. Anczak J, Nogler R. Tobacco cessation in primary care: maximising intervention strategies. Clinical Medicine & Research 2003;1(3):201-16.
9. Bao Y, Duan N, Fox S. Is some provider advice on smoking cessation better than no advice? An instrumental variable analysis of the 2001 National Health Interview Survey. Health Serv Res 2006;41(6):2114-35.