Commissioning for Effective Smoking Cessation Delivery North East Smoking Cessation Conference

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Commissioning for Effective Smoking Cessation
Delivery North East Smoking Cessation
Conference

• Martyn Willmore Performance Improvement
  Delivery Manager, Fresh
• Sarah Edwards Associate Delivery Manager

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To be covered today...

• World Class Commissioning and the eleven
  competencies for stopping smoking
• Summary of Commissioning Tools and Levers
• An introduction to the Integrated Service
  Framework for Stop Smoking Services
• Targeting Routine and Manual Occupational Group
• Recommendations for commissioners and providers
• Discussion

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WCC for Smoking linking the 11 Competencies

• 1. Locally Lead the NHS
• Vision, Strategy and whole system leadership role
  of the PCT and its responsibility to give clear
  signals to health care providers about its
  intentions including primary, community,
  secondary and tertiary and their links to social
  care, and local government well-being issues
  where relevant
• 2. Work with Community Partners
• - Do the priorities expressed in the JSNA, LAA
  and CSP make solid links to tobacco control and
  smoking cessation, so that the case for change is
  shared collaboratively between LAs, PCTs, Acute
  Trusts and 3rd Sector strengthening the
  business case and local agenda? Strategy
  reflects the range of partners existing and
  potential.
• 3. Engage with public and the patients
• - Can the Stop Smoking Services demonstrate the
  values that patients and the public hold? Have
  patient and public views, satisfaction and
  outcomes been tested through reputable and
  reliable methods?

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WCC for Smoking linking the 11 competencies

• 4. Collaborate with clinicians
• Use of evidence base for smoking cessation in a
  way that promotes acceptance and ownership
  amongst clinicians.
• Evidence grading in the Service Monitoring
  Guidance 2009
• 5. Manage knowledge and assess needs
• Needs assessment through referenced,
  authoritative sources of data and intelligence.
• eg. disease Incidence, prevalence, health
  inequalities...
• Sufficient context taking account of ethnicity,
  age, demographic structure
• Use of intelligence/data to help identify and
  de-commission ineffective interventions,
  (hypnotherapy, smoke free homes)
• Use of the data and intelligence to engage
  community partners ie. 3rd Sector/Social Care
  interventions. Carers high prevalence of
  smoking/unemployed.
• 6. Prioritise investment
• - Clarifies the outcomes and gains to enable view
  of short, medium and long term benefits.
  (Prevention not a priority treating adults)

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WCC for Stopping Smoking linking the 11
competencies

• 7. Stimulate the Market
• Assess and monitor the state of the market to
  respond to commissioning signals and intentions.
  (pre-qualification activity, marketing testing)
• Doesnt direct but allows providers to respond
  and instead focuses on the outcomes sought
• 8. Promote Improvement and Innovation
• Uses tested and credible measures that can be
  used to monitor quality and improvement including
  in this the requirements they make of providers.
• Distinguishes between service models and
  technologies that can result in performance
  improvement and those which are truly innovative
• 9. Secure Procurement Skills
• Signpost providers to measures, accreditation
  systems and other quality hallmarks that can be
  used in service specs and invitations to tender
  (avoiding any assumptions about the provider).
  Gold standard monitoring guidance, NICE guidance.
• Balance and focus on evidence of outcomes and
  process measures, in such a way that will inform
  appropriate contract length. eg.12 months, 3
  years.

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WCC for Stopping Smoking linking the 11
competencies

• 10. Manage the local health system
• Uses evidenced based information to inform the
  scale and scope of care of service, clinical
  outcome and patient safety SO THAT...
• the best service model or configuration delivers
  acceptable outcomes for the community.
• 11. Make Sound Financial Investments
• - uses clear and comparative benchmarking
  information, to assist in obtaining value for
  money
• - Financial costing is modelled taking
  into account fixed and variable
• costs as the service increases or
  decreases. Eg. costs per quitter.

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Commissioning Tools and Levers

• Contracts and Service Level Agreements
• content of service specifications, duration,
  monitoring
• Local Enhanced Services (LESs) incentives
• Care Pathways and Pathway redesign
• Practice Based Commissioning
• Quality and Outcomes Framework (QOF)
• Social Marketing
• Partnerships
• 3rd Sector - Section 31. TSIP third sector
  investment programme

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Integrated Service Framework- ISF

• Evolved over the past 12 months pragmatic
• framework that allows smokers to be
• Identified (opportunistically) - in appropriate
  settings.
• Offered a menu of stop smoking support
• Signposted/referred to the support of choice
• Co-ordinated by a central core function
• Sits in line with current NHS Stop Smoking
• Service and Monitoring Guidance 09/10
• Has 4 elements
• core team, settings, level of support and routine
  and manual

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1. Core Team

• Core Team refers to a team comprising of
  service manager, specialist advisors and support
  staff commissioned by the PCT.
• Key objectives are
• Develop and deliver local NHS SSS
• Co-ordinate the network of support in the 6 key
  settings (develop and streamline care pathways)
• Provide specialist support for smokers in high
  risk groups (RM, Pregnant smokers, BME)
• Work in partnership with PH intelligence to
  assess needs and wants of local smokers
• Ensure consistent effective support service
  user evaluation, adhering and advising on
  evidence base

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2. Settings

• Primary care GP practices, dentistry
• Pharmacy
• Community Settings (working with the third
  sector)
• Maternity and Family Services
• Secondary Care
• Mental health
• NB
• Every setting provides opportunities to engage
  with smokers, utilising the skills of
  professionals and including access to stop
  smoking medicines
• Every settings provides commissioners with
  opportunities to develop service pathways
  underpinned by local enhanced service contracts,
  service level agreements etc

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3. Level of support

• Level of support provided is determined by the
  setting and contractual agreement
• All levels can be delivered in each setting as
  long as advisors are trained, resourced and
  supported by a core team
• Very brief 30 second approach ASK, ADVICE and
  ACT
• Brief 5 to 10 minutes of advice and referral
• Intensive min of 1.5 hours of structured
  support including access to SS meds over a period
  of 4-weeks

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4. Routine and Manual

• 2 Public Service Agreements (PSA) relating to
  smoking prevalence
• - To reduce prevalence among the general
  population to
• 21 or less by 2010
• - To reduce smoking prevalence in routine (RM)
  and
• manual groups to 26 or less by 2010
• In addition there is a health inequality PSA
• - To reduce inequalities in health outcomes by
  10 as measured by infant mortality and life
  expectancy at birth
• - Starting with children under 1 year, by 2010
  to reduce by at least 10 the gap in mortality
  between RM groups and the population as a whole
  
• - Starting with local authorities, by 2010 to
  reduce by at least 10 the gap between the fifth
  of areas with the lowest life expectancy at
  birth and the population as a whole

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Routine and manual (2)

• Smoking remains the leading cause of preventable
  death and illness in England
• Smokers are often concentrated in poorer
  communities and are represented in each of the
  settings highlighted in the ISF
• Smoking is a major contributor of infant
  mortality (IM) i.e.
• Smoking in pregnancy increases IM by approx 40
• Smoking prevalence is 1.5 times higher in RM
  pregnant women than the population as a whole
• As smoking is responsible for one-sixth of all
  deaths in the UK it is the area where behaviour
  change would make the greatest impact on health
  inequalities
• Supporting smokers to quit impacts positively on
  the PSA smoking prevalence and health inequality
  targets including infant mortality

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Rationale for supporting RM smokers to quit

• Greatest volume of smokers is to be found in the
  RM group, therefore
• This is where the greatest volume of
  smoking-related health inequalities are found
• The greatest gain if they can be effectively
  supported to quit
• RM are not hard to reach (they will engage
  with services but they do find it harder to stay
  quit)
• There is a clear evidence base, backed by
  national media campaigns, on how to engage and
  support RM smokers
• Not yet available for other harder to reach
  niche groups where numbers of smokers may be
  low
• Because a third of RM smokers live in the most
  deprived 20 of areas, reducing rates in this
  group will help de-normalise smoking in these
  areas, making it easier for niche groups to
  quit when the evidence is available

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Defining RM

• In 2007 there was an estimated 15 million people
  in the RM group
• 26 smoke 28 men and 24 women
• They account for approx 50 of smokers in England
  or 4.25 million smokers
• RM smokers are defined by their occupation
• RM smokers defined by occupational, but most
  non-employed persons (the unemployed, the
  retired, those looking after a home, those on
  government employment or training schemes, the
  sick and people with disabilities etc) are
  classified according to their last main job so
  can be included.
• Exceptions are full-time students, those who have
  never worked or are long-term unemployed.

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Defining RM continued..

• The RM group
• Have a higher aged 25 to 45 years compared with
  general population
• Are more likely to have children aged 0 to 5
  years
• Are more likely to live in North of England,
  North West, North East and Midlands than South of
  England
• Are likely to live in the most deprived 20 of
  areas approx a third and out of these 37 smoke
  
• In terms of smoking
• More likely to have started young (16 years or
  less)
• More likely to be heavily addicted (defined as
  having first cigarette within 5 minutes of waking
  

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Marketing insights into RM smokers

• RM workers tend to establish standard routines
  in which smoking is entrenched
• Family and community are very important many
  live in close proximity and socialise together.
  Quitting is therefore isolating and often leads
  to relapse
• Quitting is daunting - RM smokers know from
  experience that quitting is hard and likely to
  end in failure. The short-term benefits are
  minimal when compared to the pain and the fact
  that the longer term benefits will not be felt
  for some time
• Smoking is integral to who they are, it is not
  just something RM smokers do. Becoming a non or
  even an ex-smoker is out of character
• Smoking fulfils many needs
• a fix - helps relax
• a coping mechanism - a reward

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Maximising opportunities to target RM through
wider tobacco control

• Stop smoking services (SSS) should not operate in
  isolation as this will not maximise their
  potential reach and efforts into RM communities
• SSS is only 1 strand of 7 that ensure a
  comprehensive approach to tobacco control
• 3 core strategic elements
• Planning and commissioning
• Developing multi-agency partnership working
• Monitoring, evaluation and response
• 4 operational work streams
• Making it easier to stop smoking
• Tackling cheap and illicit tobacco
• Normalising smoke-free lifestyles
• Communication
• Each work stream feeds into and includes the core
  elements. This ensures activities are
  co-ordinated

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Recommendations

• PCT Commissioners
• Consider joint commissioning with LAs the PSA
  targets are jointly owned and the 7 strands
  includes activities that are health and local
  authority based
• Deploy World Class Commissioning criteria and
  start with SSS as it provides a useful starting
  point then move onto wider tobacco control
• Ensure service level agreements are underpinned
  by evidence and local needs assessment in terms
  of RM this includes
• DH Tobacco Control Marketing and Communications
  Strategy (2008 -2010)
• The NHS SSS and Monitoring Guidance (2009)
• The 10 High Impact Changes for local Tobacco
  Control (2007)

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Other considerations

• PCT Commissioners Reach vs quality
• Services that increase access, particularly for
  target groups
• out of hours,
• convenient accessible locations,
• stimulate demand
• range of options for support
• work within a range of settings
• Services that offer high quality (see DH
  Guidance)
• most successful behavioural support (groups) as
  well as variety of ways
• most successful meds offered first line
  (varenicline combo NRT) as well as the full
  range of products
• Gold standard data monitoring, CO validation,
  client satisfaction, quit rate approx 50,
  other service indicators
• Services that are integrated systematised
  across health social care, no matter what
  organisation is delivering different aspects (see
  ISF)

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Recommendations

• PCT Providers
• Provide SS support to RM smokers through an
  Integrated Service Framework model
• Utilise national branding linking local
  targeted stop smoking support to national RM
  campaigns
• Implement national marketing strategy programmes
  as and when they become live i.e.
• Implement the healthcare professionals programme
  (formerly SCIP)
• Work in partnership with face2face field
  marketers
• Raise awareness of local SSS through national
  campaigns (NSD)
• Link with the RTPM and delivery team
• Gather local RM intelligence feed back to
  commissioners to inform future service
  developments
• Support wider tobacco control work streams
• - i.e. Gather and share other tobacco related
  intelligence availability of cheap and illicit
  tobacco and feedback to strategic partners
  (trading standards) .

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Recommendations

• Third Sector
• National Marketing Strategy advocates community
  activation as a way of generating quit attempts
  in RM smokers
• Voluntary and community organisations are well
  placed as influencers in local communities
• Community is important to RM smokers third
  sector organisations can
• Provide local intelligence and insights to
  compliment national insights
• Provide local support
• Signpost smokers to specialist core SSS

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Implications for commissioners and providers -
Where do you start?

• Depends on what is already in place and how
  effective it is
• If there is no core team makes sense for
  commissioners to start there/providers to develop
  a core function that for purpose
• If core team is already in place commissioners
  could begin with primary care and pharmacy
  moving through the settings, as each element is
  developed with clear care pathways and
  underpinned through contractual processes

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Questions Discussion