Smoking Cessation regional CQUIN final version 10.2.12

Providing Smoking Cessation Support to People Using

London Mental Health Trust Services

Background

This CQUIN applies to all Trust mental health services that work with adults and older adults, including all types of inpatient and community services, adult learning disability and substance misuse services. IAPT services may also wish to implement this CQUIN (or elements of it), although we recognise that current IAPT minimum data set does not currently support formal recording of smoking status.

Goal no. / Description of goal / Quality Domain(s) / Indicator number / Indicator name / SHA regional indicator / Indicator weighting
Improve the physical health of users of mental health service by providing smoking cessation support / Preventing People from dying prematurely
Enhancing quality of life for people with long term conditions
Treating and caring for people in a safe environment and protecting them from avoidable harm
QIPP reducing unnecessary admissions and crisis presentations to acute and mental health services / 1 / Training to enable professionals to give effective stop smoking advice to their service users / Regionally suggested / 40% of local element
2 / Recording of smoking status / Regionally suggested / 20% of local element
3 / Care planning for smoking cessation / Regionally suggested / 40% of local element

This CQUIN has been developed in collaboration with experts who have experience of successful smoking cessation CQUINs including South West London and St George’s Mental Health NHS Trust, The London respiratory team, public health colleagues in NHS London and ONEL, Oxleas Quality Improvement team, Kick It Stop Smoking Service (Hammersmith & Fulham) and NHS Surrey & Smoke Free Minds and with contributions from the London CQUIN steering group, a pan London partnership of Commissioners, quality expert clinicians, managers and service improvement leads.

Introduction

Having a mental health problem increases the risk of physical ill health. People with mental health problems such as schizophrenia or bipolar disorder die on average 16–25 years sooner than the general population[1]. One of the key objectives of the Government’s mental health outcomes strategy is that more people with mental health problems will have good physical health and that fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health[2]. The public health outcomes framework published in 2011 identified smoking cessation in mental health populations as an important public health intervention[3], while reduction in premature mortality amongst people with a severe mental illness is also a key objective in the public health outcomes framework, for 2013-2016[4].

As indicated in the mental health outcomes strategy, increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems, including those who misuse alcohol or drugs, smoke 42% of all the tobacco used in England. Many wish to stop smoking, and can do so with appropriate support. Over 40% of children who smoke have conduct and emotional disorders. This is particularly important as most smoking starts before adulthood. People with mental health problems need good access to services aimed at improving health (for example, stop smoking services).

There are a number of resources which have been developed based on robust evidence and practical experience to increase the access mental health service users have to stop smoking advice and support. These include:

  • Alex Higgins (2010) Stop Smoking Interventions in Mental Health Settings: A Systems Approach, Smoke Free Solutions
  • Irene Cormac and Lisa McNally (2008), How to implement a smoke-free policy, Advances in Psychiatric Treatment, 14: 198-207 (accessible at:
  • Lisa McNally,Quitting in Mind. A guide to implementing stop smoking support in mental health settings. (accessible at:

These resources can help to achieve this CQUIN and provide information, implementation guidance and resources needed to implement a robust system of local protocols, procedures and pathways across Mental Health Trusts and primary care services.

This CQUIN is intended to improve the physical health of people who use mental health service by providing smoking cessation support. It comprises three elements:

  1. Staff training
  2. Recording of smoking status
  3. Care planning for smoking cessation.

Staff training

The training element of the CQUIN aims to create a ‘critical mass’ of trained staff that will not only allow capacity for routine brief stop smoking intervention, but will also make that intervention more likely by addressing the place of smoking within the ‘culture’ of the organisation. Training needs to be face-to-face and interactive, and where feasible team based ) if it is to adequately address this latter issue. The training programme should provide instruction in a recognised brief intervention protocol (e.g. Ask, Advice, Act) as well as the procedures required to record smoking status and the outcome of intervention in care records. Training should also address key issues such as medication and the interaction with nicotine and smoking cessation, new developments in pharmacotherapyand smoking within the ‘culture’ of mental health care.

There are standards for smoking cessation training which cover three ‘levels’ of smoking cessation advice, in line with government guidance on how to develop effective smoking cessation services[5]. These are:

  • Level 1 – Brief interventions
  • Level 2 – Intensive one to one support and advice
  • Level 3 – Group interventions.

Level 1 training includes assessment and recording of smoking status, assessment of readiness to quit and referral to local smoking cessation services. This training is usually delivered in half a day or less.

Level 2 includes smoking cessation treatments and their outcome, assessment of nicotine dependence and commitment to the quit attempt and pharmacology (including the range of medications available, their use and contraindications). The latter is particularly important for people who are prescribed psychotropic medication as there are drug interactions, for example, withvarenicline which is recommended as being offered with nicotine replacement therapy to help smokers who want to set a quit date.

This year’s mental health smoking cessation CQUIN will assess progress in training a critical mass of staff to level 1. This can include commissioning ‘train the trainer’ sessions and cascading of level 1 training to staff teams. Team based learning where a component of the training is a focus on ‘how can we as a team implement what we have just learnt’ has been identified as particularly effective[6].

The CQUIN has set a target of at least a third of professional staff trained in a recognised brief intervention protocol but the target can be increased locally, particularly where Trusts have previously provided smoking cessation training for staff.

However, Trusts may also want to identify a cohort of staff to be trained to level 2, so that smoking cessation interventions can be provided directly, particularly for people who would have difficultly accessing mainstream smoking cessation services. This might include for example people in all inpatient mental health settings, (especially longer term care) and for those who would find it difficult to engage with mainstream smoking cessation services because of their mental health issuesand those who need outreach to access care.

The level 2 cohort would ideally include staff that have responsibility for prescribing, dispensing and administering medication (psychiatrists, non medical nurse prescribers, pharmacists, and Band 7 and above nurses, particularly ward managers and modern matrons) with representation across service settings. These staff could also act as smoking cessation champions within their service.

Recording of smoking status

The core content of level 1 smoking cessation training includes asking about smoking in an appropriate way, to elicit an accurate response and recording the status and action taken in the patient electronic records.

Experience from other Mental Health Trusts has highlighted problems with the consistent recording of smoking status, particularly because there may be no obvious place to enter this information into client record systems, without requiring an IT fix. In view of this, Mental Health Trusts are advised to record that service users have been asked to about smoking status in the physical health section of client record systems (RiO, for example, does have the facility to record smoking status in the physical health section[7]). Any advice or intervention can also be logged here and in the care plan.

In addition, where applicable, medical staff should record ICD-10 F17 codes for disorders resulting from use of tobacco, including subcodes:

F17.1 Harmful use

F17.2 Dependence syndrome

F17.3 Withdrawal state.

The assessment of achieving the second element of the CQUIN will focus on whether smoking status has been recorded in patient electronic records for patients who have had contact with the service during the last six months of 2012/13. It is anticipated that, while supporting a service user to address their smoking cessation would be an on-going care discussion, recording of the smoking status assessment would most likely be recorded at formal care assessments and reviews including :

  • As part of an initial assessment of someone referred to the mental health service
  • As part of a CPA review, pre CPA planning session or review of care for those not on CPA
  • On admission to an inpatient mental health unit and in primary nurse review meetings
  • During routine care coordinator and outpatient consultations.

Care planning forsmoking cessation

The third element of the CQUIN is intended to assess whetherreferrals are being made to specialist Stop Smoking interventions and to ensure that services users who want to access this support are enabled to do so. Specialist support would normally be provided by local NHS Stop Smoking services which (along with PCTs) have a mandated responsibility to provide quit support to all residents. All London PCTs have a smoking cessation service, but as an initial stage, it is important to assess the accessibility of local NHS Stop Smoking services for local mental health service users who may find travel difficult, or who feel most at ease with familiar and trusted mental health professionals. Establishing contact with local Smoking Cessation services would be an important element of achieving this and the other elements of this CQUIN.

Stop Smoking services have had adequate support and guidance made available to them that enables them deliver quit support to mental health service users. This includes how to collaborate with Mental Health Trusts when working with service users unable to access interventions in community settings (such as inpatients, particularly in secure settings and those who need community outreach). Stop Smoking Serviceshave the option of training Mental Health Trust staff to work directly in specialist Stop Smoking support provision. Staff should assess on an individual basis whether service users who want to give up smoking need any additional support to engage with Stop Smoking services.

In relation to the indicator for this element, the numerator/denominator are designed to avoid problems previously experienced in other areas where referral rates to Stop Smoking services were calculated in relation to service users identified as smokers (and which can therefore provide a potential disincentive to accurately record smoking status as increase the denominator and thus the overall challenge of hitting the specified target). Instead, based on a sample, the indicator identifies the number of service users who have agreed and adopted a care plan intervention for smoking cessation as a proportion of all service users who have been in contact with the Mental Health trust over a six month period. There should be formal agreement and ongoing collaboration between Mental Health Trusts and local Stop Smoking services to monitor and ensure that people who want to stop smoking are supported to implement their smoking cessation care plan and to access stop smoking support.

Detail of Indicator 1: Stop Smoking Training

Description of indicator / Mental Health Trusts to implement a comprehensive programme of training in smoking cessation for staff so that at least a third of professional staff have been trained in a recognised brief intervention protocol.
Numerator / Number of all inpatient and community mental health professional staff who have received smoking cessation training (level 1) in quarters 1-3 in 2012/13.
Denominator / Number of all inpatient and community mental health professional staff employed by the Mental health Trust at the end of quarter 3 in 2012/13.
Rationale for inclusion / Rates of smoking are 2-4 times higher among people with a mental health condition.
42% of all tobacco smoked nationally is by people with mental health conditions. Evidence has found that smoking related illness is significantly higher among people with mental health problems than among the general population and is a key contributor to the 15-25 year premature mortality of people with SMI.
There are significant interactions between prescribed psychotrophic medicines and nicotine, which impacts on medicines effectiveness and the serum levels of some medicines. There is also evidence that smoking is associated with the worsening of mental health problems.
New clinical evidence has found that for those who smoke nicotine and cannabis, more severe forms of obstructive airways disease occur, with more rapid lung deterioration and that this occurs at a younger age than usual.
Research has suggested that staff in Mental Health Trusts are significantly less engaged in smoking related interventions than their counterparts in general healthcare settings. Widespread training within Mental Health Trusts that instructs staff in brief intervention & advice, as well as challenging the place of smoking within the culture of mental healthcare, is likely to increase engagement in smoking cessation work and promote the physical health of people with mental health problems.
Data source and frequency of collection / Mental Health Trust training records
Organisation responsible for data collection / Mental Health Trust
Frequency of reporting to the Commissioner / Once in quarter 4
Baseline period / date / n/a
Baseline value / n/a
Final indicator period / date (on which payment is based) / Quarters 1- 3, 2012/13
Final indicator value (payment threshold) / Proportion of staff who have received smoking cessation training (level 1)during 2012/13, quarters 1-3, that is equal to least 33% of professional staff employed by theMental HealthTrust at the end of quarter 3 in 2012/13.
Final indicator reporting date / By 31/01/13
Rules for partial achievement of indicator at year-end / Payment proportionate to staff trained:
  • 90% of allocated CQUIN payment if 30% of staff trained
  • 80% of allocated CQUIN payment if 25% of staff trained
  • 70% of allocated CQUIN payment if 20% of staff trained

Rules for any agreed in-year milestones that result in payment / Q1: Plan training. No weighting recommended.
Q2 –Q3: Payment allocated based on total staff trained: 100% of allocated CQUIN payment if at least 33% of inpatient and community mental health professional staff have received smoking cessation training by the end of quarter 3.
Rules for delayed achievement against final indicator period/date and/or in-year milestones / n/a

Detail of Indicator 2: Recording of smoking status

Description of indicator / Smoking status of service users recorded in at least 75% of electronicpatient records.
Numerator / The number of electronic patient records within the sample (see denominator, below) that have service user smoking status recorded.
Denominator / A representative sample ofservice users who underwent an initial assessment during quarters 3 and 4, and existing service users who have had a review during quarters 3 and 4.
Rationale for inclusion / Recording smoking status is essential to identifying which service users may need smoking cessation support. It will also indicate if sufficient numbers of staff have been trained in brief advice and referral training and/or whether this training has been effective in improving recording smoking status in practice.
Data source and frequency of collection / Audit undertaken in the latter part of quarter 4 (date to be regionally negotiated) based on a statistically appropriate sample of electronic patient records for service users who underwent an initial assessment during quarters 3 and 4, and existing service users who have had a review during quarters 3 and 4.
Organisation responsible for data collection / Mental Health Trust
Frequency of reporting to the Commissioner / Once at the end of quarter 4
Baseline period / date / n/a
Baseline value / n/a
Final indicator period / date (on which payment is based) / Quarters 3 and 4 in 2012/13
Final indicator value (payment threshold) / Smoking status recorded in at least 75% of electronic patient records sampled. Achievement of indicators 2 and 3 may be presented via the same audit report, but should otherwise be treated as separate goals within the CQUIN
Final indicator reporting date / March2013
Rules for partial achievement of indicator at year-end / Payment according to proportion of electronic patient records with smoking status recorded:
  • 90% of allocated CQUIN payment if smoking status recorded in at least 70% of patient records sampled
  • 80% of allocated CQUIN payment if smoking status recorded in at least 65% of patient records sampled
  • 70% of allocated CQUIN payment if smoking status recorded in at least 60% of patient records sampled

Rules for any agreed in-year milestones that result in payment / n/a
Rules for delayed achievement against final indicator period/date and/or in-year milestones / n/a

Detail of Indicator 3: Care Planning for Smoking Cessation

Description of indicator / At least 2% of service users are involved in agreeing and adopting a care plan intervention for smoking cessation.
Numerator / The number of service users within the sample (see denominator, below) who have a care plan intervention for smoking cessation with evidence that the service user was involved in agreeing the intervention.
Denominator / A representative sample ofservice users who underwent an initial assessment during quarters 3 and 4, and existing service users who have had a review during quarters 3 and 4.
Rationale for inclusion / Research suggests that the quit success rates in response to stop smoking support among people with mental health conditions is comparable to that found within the general population.
NHS Stop Smoking Services have received guidance on how to work effectively with this specific group and are actively encouraged to treat people living with mental illness as a priority group.
Given that rates of smoking are 2-4 times higher among adults with a mental health condition, it can be expected that at least 40% of a Mental Health Trust service users are smokers (although a higher proportion is likely). Department of Health recommendations are that any Stop Smoking Service should aim to treat at least 5% of its smoking population.
Hence, it is reasonable to expect that a Mental Health Trust can refer a number of smokers to specialist stop smoking support or provide the same support in-house that is equal to least 2% (5% of 40%) of its service users.
The nature and extent of support will depend on both the individual service user’s need and the availability of smoking cessation services in the MHT and through other local providers. Individualised care of this sort should be recorded as an intervention in the service user’s care plan.
Service users are to be involved in agreeing the content of the intervention; this is in line with best practice guidance for the promotion of sustainable recovery and increased self esteem through care planning.Examples of what constitutes evidence of a care plan intervention for smoking cessation to support implementation of this element of the CQUIN will be provided on the CQUIN support website – including for service users referred to a local smoking cessation service and for those who are provided support in-house.
Data source and frequency of collection / Audit undertaken in the latter part of quarter 4 (date to be regionally negotiated) based on a statistically appropriate sample of service users’ electronic patient records. Achievement of indicators 2 and 3 may be presented via the same audit report, but should otherwise be treated as separate goals within the CQUIN.
Organisation responsible for data collection / Mental Health Trust.
Frequency of reporting to the Commissioner / March 2013
Baseline period / date / n/a
Baseline value / n/a
Final indicator period / date (on which payment is based) / Financial year 2012/13
Final indicator value (payment threshold) / The proportionof service users who have a smoking cessation care plan intervention that includes evidence of service user involvement in planning is equal to at least 2% of a representative sample of all service users open to the Trust.
Final indicator reporting date / 31/03/13
Rules for partial achievement of indicator at year-end / 50% of allocated CQUIN payment if at least 1% of all service users have been referred to or supported to access specialist smoking cessation interventions during 2012/13.
Rules for any agreed in-year milestones that result in payment / n/a
Rules for delayed achievement against final indicator period/date and/or in-year milestones / n/a

[1] Parks J, Svendsen D, Singer P et al. (2006) Morbidity and Mortality in People with Serious Mental Illness, 13th Technical Report. Alexandria, Virginia: National Association of State Mental Health Program Directors.