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Wednesday 28 September 2016
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Using SMS technology to engage with smokers

Systems & Information

TIM ROBERTS

Stop Smoking Manager
Kick It Stop Smoking Service, Hammersmith and Fulham

Tim manages Kick It Stop Smoking Service in Hammersmith and Fulham. He runs the service as an enterprise after successfully tendering for a three-year contract. This is keeping him busy, but he just about finds time to play football, learn the guitar and take on trekking challenges, such as the recently  completed Tour du Mont Blanc

Rewind to late 2008, and smoking cessation was rising up the agenda in Hammersmith and Fulham. The stop smoking service had a new management team and the Primary Care Trust (PCT) board was keen to see them achieve improved performance figures.

At the same time, a QOF+ scheme (a local extension of the Quality and Outcomes Framework) had recently been introduced in primary care, part of which rewarded practices for asking/recording patients' smoking status and making referrals to the stop smoking service.

With potential benefits to both GP practices and the PCT, a decision was made to drive smoking cessation performance increases through primary care. With limited extra resources, the challenge was to find ways of delivering these improvements.

First, stop smoking clinic capacity was increased by training practice staff members and bank staff to run stop smoking clinics within the borough's surgeries. Second, plans were put in place to "recruit" smokers to fill the appointment slots in the clinics.

The preferred route was to fill the clinics with direct referrals from GPs. However, this depended on proactivity of GPs, which was variable, and excluded "well" patients who rarely saw their GP. Other methods, such as mail-outs and phone campaigns, were attempted but were too resource-intensive.

Most of the borough's practices had software installed to enable SMS appointment reminders, so it was decided to use this software as a vehicle for communicating with smokers. Mobile phone ownership is above 100% in the UK, as many people have more than one phone. Therefore SMS-based communications campaigns have excellent reach. They are incredibly efficient: as long as the GP practice routinely records mobile phone numbers, the specialist software enables thousands of SMS messages to be sent out at the click of a button.

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Delivery
A two-stage SMS campaign was planned and delivered in February and March 2009, and 22 out of 30 of the GP practices in the borough decided to take part. The aim of the first stage was to populate patient records with an increase in confirmed smoking status data, which would in turn help paint a wider picture of smoking prevalence in the borough.

Previously, GPs and practice nurses were (sometimes) asking patients about smoking during consultations/new patient checks, and some practices were phoning patients and writing out questionnaires. SMS messaging offered a more efficient and convenient method for updating records and earning QOF/QOF+ points.

For this stage of the campaign, an SMS was sent out to all patients without a recent smoking status, asking them if they smoked. Patients receiving the text had to reply "SMOKER", "EX SMOKER" or "NEVER". Patient records were then updated.

The second stage of the campaign aimed to recruit confirmed smokers from each practice into the stop smoking service (specifically to the in-practice clinics). All smokers (both those who replied "SMOKER" in stage one and those who already had a recent, positive smoking status on their record) were sent an SMS offering a referral to a clinic.

Those interested were asked to text back "QUIT". On receipt of this text, the patient was contacted by telephone by the in-practice stop smoking adviser to make an appointment.
Both stages of the campaign were designed and managed by a specialist mobile health company, which provided external technical support (though each practice sent out their own messages, personalised with patient names). The pre-existing software, which links in to patient databases, made sending the texts a very simple task that could be done quickly and easily from a PC.

Take-up
In the first stage of the campaign, 6,085 patients were sent SMS messages and 45% of these replied with their smoking status. The results came in very quickly – patients received the SMS message instantly and 80% of the incoming SMS messages were received in three hours, and 95% in 24 hours.

At the end of stage two, 253 smokers had signed up for stop smoking advice in the in-practice clinics. It would take 13 days of outreach promotion, or around four separate media marketing campaigns, to recruit a similar amount of smokers. Some of the smokers contacted by text would have been irregular service users and probably unaware that their GP practice offered a stop smoking advice service.

The minimal costs involved in running this specific campaign (less than £5,000 in total) were funded by the stop smoking service. However, this excluded the initial outlay of providing the software in GP practices (which was funded by the PCT).

The cost per referral was much lower than other promotional campaigns (eg, advertising in the media and outreach campaigns). On top of this, the GP practices could use the new smoking data towards their QOF/QOF+ points and the data served as a useful contribution to calculations of the overall smoking prevalence rates in Hammersmith and Fulham.

Delivering a successful SMS campaign involves certain challenges. Keeping an up-to-date record of client phone numbers requires ongoing work from the GP practice. In Hammersmith and Fulham, some practices were easier to engage than others, though those that put the most effort in got the most rewards in terms of full stop smoking clinics and more financial payments.

Not everyone wants to communicate about their smoking habits by text, so SMS campaigns should be seen as complementary to face-to-face methods. There are also potential confidentiality issues to clear, though in Hammersmith and Fulham a pragmatic view was taken that texting a mobile was no different to writing a letter or making a phonecall. This view was put to the local Caldicott Guardian who agreed.

A second GP SMS smoking cessation campaign is now underway in Hammersmith and Fulham. SMS communications, as part of a wider package of initiatives, have helped increase stop smoking activity in primary care in the borough dramatically: 668 smokers set a quit date in GP practices in 2008, compared to 1,593 in 2009.

The stop smoking service here is also using SMS technology in other areas, eg, appointment reminders, as a point of access into the service ("text QUIT to …"), two-way communication with clients and also a pilot on sending motivational SMS messages to smokers.

SMS technology is widely used in the private sector but, surprisingly, is relatively redundant in the NHS. However, there are convincing reasons to invest locally in this area, and GP practices, PCTs and stop smoking services are recommended to look into how SMS messages can be used to aid the promotion and provision of their services.

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