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Public Health Local Service Agreement 2015/16

This service specification should be read in conjun ction with the Public Health Local Service Agreement (PHLSA) contract document. In addition to the service specific elements set out in this specification all Terms and Conditions set out in the PHLSA must be adhered to by providers deliverin g this service

STOP SMOKING SERVICE 1. Introduction This specification describes the scope and requirements for the provision of stop smoking services by General Practices and Pharmacies. Over 1000 people died from smoking related disease in East Sussex in 2013 (East Sussex JSNA, 2014). Smoking is the single greatest cause of death in England today. There are approximately 84,000 smokers in East Sussex and most (66%) want to quit (DH, 2012; East Sussex JSNA, 2014). The most effective method for stopping smoking is via NHS approved Stop Smoking Services. Most smokers attempt to quit using the least effective method – cold turkey (unaided) (DH, 2012). Since April 2014 upper tier local authorities are responsible for public health services including stop smoking services. To ensure smokers have access to the most effective method of quitting East Sussex County Council (ESCC) has commissioned a specialist stop smoking service of qualified and skilled advisors whose role is supporting quitting attempts through 1-2-1, group, phone and web behavioural support through Quit 51. This service specification sets out additional stop smoking services to be provided by General Practices (GP) and pharmacies to their patients. GP and pharmacy providers will be supported to undertake this role by the East Sussex Specialist Stop Smoking Service (ESSSS). ESCC will ensure that clients have the opportunity to access the service that best suits their needs through provision of stop smoking services using both specialist and primary care providers, such as practice nurses and community pharmacists, National Centre for Smoking Cessation and Training (NCSCT) certified in line with national training standards. Very Brief Advice (VBA) Stop smoking interventions delivered by health and social care professionals (HSCPs) that advise on the best way of quitting and offer referral to stop smoking services are clinically effective and cost-effective. Despite the effectiveness of stop smoking services, rates of take-up remain low. Traditionally, brief interventions have been recommended to trigger quit attempts. However, it is not enough to only provide advice to stop; in order to be effective, brief interventions also need to include an offer of help. Smokers, who are offered help by their GP rather than only advice to stop, are twice as likely to make a quit attempt. The importance of recommending both support and treatment is further highlighted by a study which showed that compared with no advice or advice only from GPs to smokers, the odds of quitting are 68% higher if stop smoking medication is offered and 217% higher with the offer of support (PHE, 2014).

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Figure 1: Very Brief Advice

Very Brief Advice on Smoking 30 Seconds to save a life

ASK

AND RECORD SMOKING STATUS Is the patient a smoker, ex-smoker or a non-smoker?

ADVISE

ON THE BEST WAY OF QUITTING The best way of stopping smoking is with

a combination of medication and specialist support.

ACT ON PATIENT’S RESPONSE

Build confidence, give information, refer, prescribe. They are up to four times more likely to quit

successfully with support. REFER THEM TO THEIR LOCAL NHS STOP SMOKING

SERVICE General Practice GP teams have daily contact with a significant number of smokers and therefore play a key role in smoking cessation. Across England most smokers see their GP at least once in any given year. Whilst some practices are very proactive in this area, the Smoking Toolkit Study (STS) data indicates that the delivery of effective very brief advice (VBA) is not currently systematic or standardised. Figure 2 shows that the vast majority of smokers either receive no intervention from their GP or ineffective ones; the top three sections in the bars indicate VBA (PHE, 2014). Easy accessible electronic training for GPs and other HCA’s regarding VBA is available via the NCSCT via their website www.ncsct.co.uk. Figure 2: Smokers reports (%) of contact with, advice from or support offered by their GP

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Community pharmacists As Community Pharmacies are frequently people’s first point of contact with health services, nationally, seeing over 1.6 million people per day, they are a valuable setting for referring and/or supporting smokers who want to stop. Pharmacies are often a key healthcare facility located in areas of high deprivation and so can play a vital role in improving the health of specific communities. 2. Background and evidence 2.1 Health impact

Reducing the prevalence of tobacco use is one of the most effective interventions in improving and protecting the public’s health. Tobacco use is the single greatest cause of preventable deaths in England – killing over 80,000 people per year (1000 people per year in East Sussex) (East Sussex JSNA, 2014). Smoking prevalence in East Sussex is estimated at 18.4% which is in line with the England average (18.4%). Whilst it is estimated that there are around 84,000 smokers in East Sussex, there is variation in smoking rates across the county. Rother has a significantly lower prevalence at 12.9% and Hastings a significantly higher prevalence at 26.2%, this is 8 percentage points higher than the England average (PHOF, 2014). Smoking can contribute to many diseases but is most commonly linked with coronary heart disease, stroke, lung cancer, asthma and chronic obstructive pulmonary disease. For those who smoke, quitting can be the single most effective method of improving health and preventing illness. Smokers are also more likely to suffer complications during and following surgery. Stopping smoking both before and following surgery can reduce post- operative complications and reduce length of stay in hospital (Smoking and Surgery Factsheet ASH. 2014). Smoking is also the primary reason for the gap in healthy life expectancy between rich and poor and is a key factor in health inequalities. Smoking prevalence is highest in deprived communities but reductions in smoking prevalence have been slower in these communities than in other population groups. Reducing the prevalence of smoking among routine and manual workers, some minority ethnic groups and disadvantaged communities will help reduce health inequalities more than any other measure to improve the public’s health. Among men, smoking is responsible for over half the excess risk of premature death between the social classes (Jarvis and Wardle, 1999). 2.2 Policy context

The new Public Health Outcomes Framework, Improving Outcomes and Supporting Transparency (2012), sets out the desired outcomes for public health and how they will be measured. Tobacco Control actions feature in the following domains: Domain 1: Improving the wider determinants of health • Improvements against wider factors which affect health and wellbeing and health

inequalities. Domain 2: Health improvement • People are helped to live healthy lifestyles, make healthy choices and reduce health

inequalities.

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The following indicators are used to measure the impact of services and interventions which aim to reduce the prevalence of smoking in adults: • Smoking status at time of delivery • Smoking Prevalence – Adults over 18 • The East Sussex Health and Wellbeing Board (ESHWB) is committed to reducing

smoking and has set this as a key priority within the Health and Wellbeing Strategy 2013 – 2016 in seeking to ‘Enable people of all ages to live healthy lives and have healthy lifestyles’ (ESHWB, 2013).

2.3 Evidence Base

Stop smoking services (SSS) based on the NHS model are highly effective in both cost and clinical terms. Smokers are four times more likely to quit using SSS support and medication than going ‘cold turkey’ or using nicotine replacement therapy over the counter (PHE, 2014). The evidence base is summarised in the ‘National Institute for Health and Care Excellence Public Health Guidance 10 Smoking Cessation Services’ and ‘Local Stop Smoking Service and Delivery Guidance’ (PHE, NCSCT 2014). 3. Aims and Outcomes Aims: To enable GP Practices and Pharmacies to provide SSSs to their patients which: • Offer choice of treatment options appropriate to clients • Offer the most effective evidence based treatments available • Support people to successfully quit smoking • Achieve high levels of client satisfaction

Outcomes: The service will support people to successfully quit smoking for 12 weeks. Quitting will be measured at 4 weeks (and payment based on 4 week quitters) and follow up will occur at 12 weeks. It is anticipated that many clients will permanently stop smoking and as a result, will have improved health outcomes and lower levels of healthcare utilisation.

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4. Service Outline and Standards 4.1 Description of the service and its outputs Interventions should have clear structure and content as detailed below. An optimum session frequency suggested as follows (see Table 1): Table 1: Suggested contact frequency and length One-to-one behavioural support sessions (support for the f irst six weeks may be delivered through a combination of telephone or face to face support)

Session Minimum time allocated (minutes)

Session 1: Pre-quit 30

Session 2: Quit date 20

Session 3: 1 week post -quit 15

Session 4: 2 week post -quit 15

Session 5: 3 weeks post -quit 15

Session 6: 4 weeks post -quit 15

Total 1 hour 50 minutes Total minimum contact time equates to 1 hour 50 minutes (from pre quit prep to four weeks after quitting). This may be delivered through a combination of face to face or telephone intervention. Providers are expected to attempt CO monitoring at the 4 week quit review session with a minimum of 85% of cases. The local protocol outlines the stages that should be undertaken to support a smoker to quit. Service providers should: • Offer weekly support for at least the first four weeks of a quit attempt • Ensure carbon monoxide (CO) verification is attempted (see Service Standards for

minimum requirement) • Ensure advisors are aware of other local health partners that clients can access and

how to signpost/refer e.g. drug and alcohol treatment services. 4.2 Outline of service: A description of the initial consultation – 20 - 30 minutes approx • Inform client about structure and process of sessions • Assess motivation and discuss readiness to quit using motivational interviewing tools • Discuss – current smoking habits. Smoking history (including previous quit attempts),

previous use of NRT/Zyban/Champix • Assessment of nicotine dependence and appropriate feedback to client • Provide information regarding all pharmacotherapy options • Explain process for provision of pharmacotherapy e.g by direct supply, FP10

prescription or under a PGD • Set & record quit date on Quit Manager/Gold Standard Monitoring Form (GSMF).

(Appendix 2) • Discuss possible withdrawal symptoms and management. • Assist client in developing coping strategies and a stop smoking plan • Discuss monitoring and CO

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• Describe and discuss the ‘not a puff’ rule • Take and record CO level • Provide additional supplementary resource material e.g. booklets, leaflets, CD’s etc. • Enter client details on Quit Manager/GSMF, as appropriate. Refer to occupational

classifications (Appendix 2) • Obtain client signature/verbal consent to treatment, follow-up, collection of anonymised

information and sharing outcome with GP (Appendix 2). • Make follow-up appointment via Quit Manager or diary sheet and record on client

appointment card. • Provide client with contact details for access to advice and support between

appointments and amending appointments. Follow-up Session 2 – 15 minutes • Assess use of NRT/Zyban/Champix. • Confirm quit date and record (on GSMF or Quit Manager database). • If quit date not yet set, reassess motivation to stop, discuss rationale of aiming to be

smoke free rather than cutting down. Explain policy in relation to continuing supply of NRT – set quit date.

• Provide supply of NRT /GP script request (record on Quit Manager or GSMF as appropriate).

• Record CO reading. • Praise client’s achievements. • Support client through early quitting period. • Discuss withdrawal symptoms and reinforce coping strategies. • Discuss exercise referral scheme and weight management issues if appropriate. • Make next appointment. • Reinforce the ‘not a puff ‘rule. • If client Did Not Attend (DNA) contact by phone and where possible, leave a

message/text. • A minimum of three contact attempts must be attempted if clients DNA including phone

call, text, letter. • Each contact and all contact attempts should be recorded on Quit Manager database

or GSMF as appropriate. Review sessions – 15 minutes • Evaluate use of treatment. • Further supply of NRT/GP script request. • Record smoking status. • Take and record CO reading. • Guidance on weight gain and withdrawal symptoms. • Discuss benefits of quitting. • Reinforce the ‘not a puff’ rule. • Make appointment for follow-up. • Record on Quit Manager/ GSMF. Four and twelve weeks post quit date – 15 minutes (session number will vary depending on when QD set) • Confirm smoking status. • Congratulate Client! Offer Congratulations Card. • Record CO reading on Quit Manager/GSMF.

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• Complete 4-week follow up within Department of Health parameters (25 – 42 days post quit) on Quit Manager or client monitoring form. If GSMF is used ensure all sections of the monitoring form are completed & send directly to Quit 51. Retain GSMF, if still seeing client.

• Reinforce the continued ‘not a puff’ rule. • Send Quit letter to patients GP or record on patient’s record if a GP surgery. • Inform client about 52-week follow-up (phone call from Quit 51). • Definition of 4 week quitter (from NCSCT PHE monitoring guidance). A CO-verified four-week quitter = A treated smoker who reports not smoking for at least days 15–28 of a quit attempt and whose CO reading is assessed 28 days from their quit date (-3 or +14 days) and is less than 10 ppm. The -3 or +14 day rule allows for cases where it is impossible to carry out a face-to-face follow-up at the normal four-week point (although in most cases it is expected that follow-up will be carried out at four weeks from the quit date). This means that follow-up must occur 25 to 42 days from the quit date (Russell Standard). A self-reported four week quitter = the above without CO validation. Every effort should be made to record CO reading to validate 4 week quit status. Final Session – 15 Minutes • Discuss any problems the clients may have. • Record CO reading on Quit Manager/GSMF. • Offer advice on staying stopped and relapse prevention. • If client requires further supply of NRT issue GP prescription request. • Give client contact numbers and explain procedure to re-access service, if necessary. • To ensure clients accessing the service are motivated to quit clients will normally only

be able to access the service four times in any 12 month period. However if the client is committed to stopping the advisor should use professional judgment when assessing readiness to stop and begin a new treatment episode if appropriate i.e. re-sign client and agree new quit date. Care should be taken to ensure the client is not using NRT for prolonged periods without a break (seek advice from specialist advisors or team leader if uncertain).

• To support promotion of the service, the advisor if client has successfully quit the advisor should ascertain if the client is willing to be identified in a media campaign, e.g. newspaper article, radio or television interview and complete a media request form (on Quit Manager).

4.3 Service Standards Requirements expected of all primary care providers of stop smoking services • All primary care stop smoking advisor staff working within participating stop smoking

services must adhere to the guidelines of this service. • Providers should systematically offer VBA in line with national guidelines. Smokers who

are offered help by their GP rather than only advice to stop are twice as likely to make a quit attempt.

• The Provider will ensure that the Russell Standard is followed (clinical) for assessing performance in NHS Stop Smoking Services. This will ensure the national standard for criteria for throughput and success rates that will enable meaningful comparisons between the services. The Provider will be expected to achieve a level of success,

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which is consistently within national limits. The Russell Standard is summarised: this equates to: 50% success rate with a threshold of between 35-70%. Smoking status at four weeks from the quit date should be CO validated in a minimum of 85% of cases. Where quit rates fall outside this range practices/pharmacies are expected to work with the specialist service to identify ways of improving outcomes for patients.

• Each service user should receive weekly support for at least the first four weeks of a quit attempt

• CO readings should be taken and recorded at each of the weekly sessions • The Provider shall ensure that staff providing a SSS have received certification -

NCSCT Assessment of core knowledge and practice skills training (previously known as stage 1 and 2 SSS training) ) from the NCSCT and are fully aware of how East Sussex Stop Smoking Services operate.

• To reduce the administrative burden of stop smoking services, an online smoking cessation database ‘Quit Manager’, is provided via the ESSS, Quit 51. Providers must record status of smokers on Quit Manager no later than 48 hours after providing stop smoking service to smoker during quit attempt process (point of care). Providers are normally expected to record all service data on this system. If this is not possible, requests to continue on paper system will be considered by the Commissioner, on an individual basis. All paper client data monitoring forms must be returned to East Sussex Stop Smoking Service, Quit 51 , within five working days following the four week review and 12 week follow up. All invoices relating to service activity must be supported by evidence of client data monitoring forms. If client data monitoring forms are not returned by the Provider, within spec ified timescales and deadlines as outlined in section 7, then payment ma y be delayed. Repeated late returns of paperwork will be investigated by the Co mmissioner.

• Consultations should take place in a room or area that is suitable for the purpose of providing clients and patients with a confidential and accessible service.

• The Provider will display appropriate smoking cessation promotional material, including information on their practice or pharmacy stop smoking service and ESSS, Quit 51. All material should be in an appropriate format, accessible to all. Posters will be supplied and at least one poster should be visible at all times.

• The Provider will actively pursue brief intervention whenever possible with clients or patients.

• Those involved in delivering smoking cessation support will have the necessary skills and competencies, through completion of the NCSCT Assessment of core knowledge and practice skills training (previously known as stage 1 and 2 SSS training) and, Quit 51induction training programmes. These training programmes cover the following elements

o brief intervention skills, o offering intensive advice and support, o smoking in pregnancy advice, o awareness and use of service protocols o use of the QUIT51 system o completion of service related paperwork.

• Support to deliver stop smoking services in pharmacies and Practices is available from the Specialist Stop Smoking Service Quit 51. ,

• To ensure that competence is maintained practices are required to adhere to the NCSCT Competency Framework. Annual update training to meet this requirement is available from Quit 51, and practitioners are normally expected to attend one update session per year (where this is not possible practices should liaise with the specialist stop smoking service on alternative arrangements).

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• Services should be delivered in line with the expected contact frequency and length outlined in Table 1 (section 4)

• Where a client/patient relapses during a quit attempt (and does not wish to begin a new treatment episode), no further pharmacotherapy should be provided until such a time as the client is motivated to make another quit attempt.

• Ensure a minimum of three attempts to follow up DNA clients by telephone, text, letter (ensure attempts are recorded) before coding ‘lost to follow up’.

Pharmacotherapy and supply of Nicotine Replacement Therapy (NRT) Bubroprion (Zyban) and Varenicline (Champix) Offering behavioural support with pharmacotherapy increases a smoker’s chance of successfully stopping by up to four times. Pharmacotherapy is the provision of pharmaceutical products and medicines. The only types of stop smoking medicines approved by NICE are Nicotine Replacement Therapy (NRT), Buproprion (Zyban) and Varenicline (Champix). Current experimental statistics from stop smoking services indicated that Varenicline was the most successful smoking cessation aid between April 2009 – March 2010. Of those who used Varencline 60% successfully quit, compared with 50% who received Buproprion only, and 47% who received NRT only. As all smokers should be given the optimum chance of success in any given quit attempt, licensed pharmacotherapy, currently (NRT), Varenicline (Champix) and Bupropion (Zyban) should all be made available in combination with intensive behavioural support. Varenicline or combination NRT offer smokers the best chances of quitting and, unless clinically contraindicated, should be available as first-line treatments to all clients. Following an assessment of the most appropriate option for each patient accessing the stop smoking service must offer, or recommend as prescription from the patients’ GP, at least one of the following types of pharmacotherapy: • NRT • Combination Therapy (a combination of NRT products) • Varenicline (Champix) A prescription only drug (for non GP providers this must be

recommended) • Buproprion (Zyban). A prescription only drug (for non GP providers this must be

recommended). ESCC is exploring the possibility of introducing a PGD to enable pharmacies to supply Varenicline and Buproprion to patients. It is anticipated that this element of the service specification will be updated to include supply under PGD should this prove feasible to introduce. All patients must have the key risks and benefits of pharmacotherapy explained and offered pharmacotherapy within prescribing guidance. The table in Appendix 3 sets out the types and forms of stop smoking medication showing the dosage and duration for adults and adolescents. It is anticipated that Varenicline or Buproprion will be the chosen treatment option in around 30% of patients accessing the stop smoking service. Best practice for the supply or prescription of pharmacotherapy for smoking cessation must be undertaken in line with guidance set out in Local Stop Smoking Services Service and Delivery Guidance (PHE, 2014) http://www.ncsct.co.uk/publication_service_and_delivery_guidance_2014.php

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NRT Where patients are assessed as suitable to receive NRT: • Patients may obtain up to 12 weeks supply of NRT. • NRT must only be supplied to clients who fit the eligibility criteria for the service. • NRT may be provided on a weekly basis for 12 weeks. • Supply is free to patients who are exempt from prescription charges or have a pre-

payment certificate. A fee equal to the prescription charge should be collected from patients who are supplied NRT by pharmacies where the patient is not eligible for free prescriptions. This fee should be deducted from the claim for supply of NRT and recorded using the client standard monitoring form (see Appendix 2).

• A quit date should be discussed before the initial supply and the patient needs to demonstrate they are aiming to be abstinent within the next two to four weeks.

• Motivation should be re-assessed if client has not managed to abstain from smoking after four weeks of treatment and provide client with a GP prescription request, if they remain motivated to stop completely

• More than one NRT product can be supplied. Please refer to Appendix 3 for approved product list.

• Details of each NRT product provide for each episode of supply must be recorded on the patient monitoring record on Quit Manager or on the client standard monitoring form. This is detailed further in section 7.

• In addition to NRT provided, record any advice given e.g. Client is diabetic, advice to monitor blood glucose levels, letter sent to GP to notify supply of NRT.

Recording NRT supply for sessions • Use the relevant Quit Manager section at point of care, or the client standard

monitoring, if paper records are used. This is to record the supply of NRT under General Supply Licence (GSL) and the patient’s progress

• If paper records are used, paper records should be completed in black ink, signed, timed and dated and all fields completed

• Where direct supply of NRT is operated, full details of the product supplied should be recorded, including dose (rather than step 1 or 2), brand and box size e.g. Nicotinell 21mg box, 1 box = 7 days.

• Please check that the patient’s health has not altered since the initial assessment and that there are no exclusion criteria for NRT. Tick relevant boxes on Quit Manager point of care, or paper monitoring records, as appropriate.

• Enter batch and expiry date and sign accordingly • When supplying NRT direct please be aware that a week’s supply may be more than 1

pack. Please also take account of previous supply and patient’s remaining stock of NRT when issuing further supplies.

GP prescription requests GP prescription requests may be required in the following circumstances: • Request for the GP to consider the supply of NRT where NRT may be contraindicated

for patient • Request for the GP to consider prescribing Burproprion or Varenicline. For pharmacy

staff delivering the stop smoking service, a letter to request the GP to prescribe the relevant pharmacotherapy should be produced.

• Varenicline is contraindicated in pregnancy and cautioned in patients with a history of psychiatric disorders. There is no clinical data for its use in patients with epilepsy.

• Use the relevant Quit Manager section at point of care, or patient standard monitoring record if paper records are used, to record the recommendation for GP prescription

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request for stop smoking medication as appropriate eg. Buproprion, Varenicline, or NRT.

Bupropion and Varenicline • If a patient is considering and is suitable for using Buproprion or Varenicline the stop

smoking advisor should refer the patient to their GP. The GP should assess the patient’s suitability for this on an individual basis. Pharmacy providers may produce a letter of recommendation for the GP to support the supply of stop smoking medicines.

• Buproprion is contraindicated in patients with a history of seizures, eating disorders, CNS tumour, alcohol/benzodiazepine withdrawal, under 18’s, pregnancy, and breastfeeding. It should be used with caution in patients on concurrent medication which could lower seizure threshold, alcohol abuse, previous head trauma and diabetes.

• Once a patient has been prescribed Buproprion or Varenicline any adverse or unexpected side effects should be reviewed by the patient’s GP as soon as possible.

• Use the relevant Quit Manager section at point of care, or client standard monitoring record if paper records are used, to record the recommendation for GP prescription request for stop smoking medication as appropriate eg. Buproprion, Varenicline or NRT.

• The full summary of product characteristics for the products outlined can be found in the electronic medications compendium website: https://www.medicines.org.uk/emc/

Referrals The following referral criteria and possible sources of referral apply to the service: • Any self-referred smoker with motivation to quit aged 12 and over. • For patients recorded on GP practice registers all smokers 15+ who have a recorded

status in the last 24 months. • Providers trained in NCSCT VBA and referral to stop smoking services:

o Self-referred clients o Clients who have been referred by any healthcare professional, including the

specialist stop smoking service. • Where appropriate, the Provider should signpost and refer to additional lifestyles

services such as weight management, and local alcohol treatment services, in line with local referral processes and pathways.

Eligibility All clients/patients should be assessed as eligible, utilising the following criteria: • They are living within the county of East Sussex. • They are aged 12 or over. • They meet smoking cessation service treatment criteria People who do not meet the eligibility criteria are not eligible to access the service. If a Provider has concerns about the suitability of a client who is seeking to access the service, the Provider must seek advice from the ESSSS on their suitability for treatment. The Commissioner must be informed where the Provider is seeking not to offer a service. A Provider must seek prior approval from the Commissioner to provide a service to a client aged under 12 years old who meets the remaining eligibility criteria. Where a client aged below the age of 12 is seeking to access a service, advice should be sought in the first instance from the ESSSS.

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The Commissioner will respond to any requests requiring prior approval within 2 working days. Where approval is granted, the Commissioner will provide a prior approval code which the Provider must quote in its record of activity accompanying the (monthly) invoice. 5. Equipment and Premises

All equipment used in stop smoking services must be used in line with manufacturer guidance and protocols for safe and effective use. CO monitors and associated consumables -mouthpieces, adaptors/T-Pieces are available free of charge to Practice and pharmacy stop smoking service providers from Quit 51 This can be done by telephone on 0800 6226968 or by secure email at contact.quit51@nhs.net. CO Monitor Protocol: All monitors should be calibrated in line with the manufacturer’s instructions for the make and model of the CO monitor being used. Calibration of CO monitors is available from the specialist stop smoking service at annual update sessions. Further advice on calibration of CO monitors is available from Quit 51. Cardboard Tubes or Plastic Straws: Single-use only, change for every Service User/Service Users. Ask the Service User to put their own tube/straw into machine and remove after use.

Plastic adaptor/t-piece: The adaptor contains a one-way valve that prevents inhalation from the monitor. Changing adaptors depends on manufacturers’ guidance:

• Micromedical: the adaptor should be discarded and replaced every six months • Bedfont (Pico): the adaptor should be discarded and replaced monthly • BMC-2000: adaptor should be changed quarterly, unless usage is heavy, in

which case change monthly. Usage guidance: The following guidance is suggested but the Provider should refer to product specific manufacturer guidance:

• Less than 50 uses per month: change quarterly • Between 51–200 uses per month: change bi-monthly • More than 200 uses per month: change monthly.

Cleaning: The monitors should be wiped down using non-alcohol wipes at the end of every session. Premises: Consultations should take place in a room or area that has been accredited for the purpose of providing clients and patients with a confidential and accessible service.

Safeguarding: The Provider must ensure that clients and anyone using the service, are safeguarded from any form of abuse or exploitation in accordance with written policies and procedures to be agreed with the Commissioner prior to the commencement of the service and that meet the standards and regulations set out in: • The Sussex Multi Agency Policy and Procedures for Safeguarding Vulnerable Adults

produced by the Safeguarding Adults Boards of Brighton and Hove, East Sussex and West Sussex (2007)

• Section 3.13 of the Terms & Conditions of Contract (‘Safeguarding Vulnerable Adults and Children’)

• The Provider will share information with the following relevant organisations: Police, Probation Service, Adult Social Care and Children’s Services, if an individual delivering

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the service or a trained individual discloses information that would indicate a child or vulnerable adult is at risk of harm and/or admitted to an offence for which they have not been convicted.

DBS Check requirement 1 The table below sets out the factors considered when determining the need for DBS checks for all/some staff to delivering all/parts of the service. It is a requirement that DBS checks are refreshed every three years.

Service Smoking

Specified Place GP surgery / clinic / hospital / community pharmacy community venue GP / Pharmacist / HCA / NP

Frequency, Intensity More than 4 times a week Supervised Unsupervised Health Care / Regulated Activity?

Healthcare intervention regulated. Assessment with CO monitor and specialist advice/behavioural support.

DBS type Enhanced (post 2012) Check for Regulated Activity ( Adults). This check involves a check of the police national computer, police information and the adults barred list.

Required for the following staff

For all GP staff delivering the service. Pharmacists – professional DBS rule applies to the Pharmacist but not all pharmacy staff.

6. Accreditation and Training Quit 51 have been contracted by ESCC to provide professional and technical support to local primary care stop smoking service providers. This will ensure that Pharmacies and GP providers consistently meet and evidence defined quality standards of service delivery and performance achievement. Support will include practice visits, telephone support, training and continuing professional development and the provision and maintenance of equipment and consumables. All staff involved in SSS delivery must be trained to the NCSCT training standard and should obtain full NCSCT certification. In addition to the completion of the national online training, it is also recommended that practitioners receive face-to-face training from the East Sussex Stop Smoking Service, QUIT 51, and participate in a period of shadowing and observation before providing support unsupervised. Ongoing supervision and mentoring is important to ensure Providers retain core skills and knowledge and are made aware of developments in the field. • The East Sussex Stop Smoking Service, QUIT 51 will support this process through site

visits, communications and annual update sessions. • Any services provided by staff that have not completed the required training will be in

breach of contract. • ESCC will not make payment for any services delivered by staff that have not

completed the required training.

The Provider is required to:

1 http://www.eastsussex.gov.uk/jobs/workingateastsussexcountycouncil/employmentpolicies/crbchecks.htm

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• Employ suitably experienced, qualified and skilled staff to successfully deliver and manage the service.

• Support, train, supervise and appraise all staff who are employed to ensure they remain competent to deliver an effective, quality service.

• Ensure staff members are trained to submit accurate and timely monitoring and performance data.

• Ensure staff members engage with continued professional development, including appropriate training provided by key partners.

7. Payment and Cost The following payments will be made in relation to partner activity delivered through this agreement:

Activity Payment

Completion of an intervention which meets the following minimum criteria (non quitters):

• The patient has received brief advice regarding their smoking • The patient has set a quit date • CO readings have been taken during any support session they

receive and results have been recorded • Client service data has been submitted detailing the support the

patient has received and the outcome of the intervention This payment will be made for all patients who do not quit (assuming the minimum criteria has been met). Further guidance on intervention delivery is described within section 4 of this agreement.

£20

Completion of an intervention which meets the criteria described above and where the outcome of the intervention is a successful 4-week quit

This payment is subject to the completion of a 12-week review. However, payment will be made at 4-week monitoring stage

£95

• Payment will be made at the end of every quarter in arrears, following submission of 4 week quit data. Patient monitoring data should continue to be collected up to 12 week quit review stage.

• Payment will be made to the Provider if the status of smokers has been recorded on Quit Manager no later than 48 hours after providing a stop smoking service to a smoker during the quit attempt process i.e. at point of care. All fields on the standard client monitoring form must be completed.

• If it is not possible to record smoking status on Quit Manager database, requests to continue on a paper system will be considered by the stop smoking Commissioner on an individual basis. All paper client data monitoring forms must be returned to Quit 51 promptly, following the four week review and 12 weeks review. All invoices will be checked and verified against client monitoring data. If client data monitoring forms have not been received within 5 working days of stop smoking sessions ending, payment may be delayed.

• Where paper records are in use, for accurate reimbursements for NRT direct supply and the prescribing of other stop smoking medicines (Varenicline or Bupropion), it is essential that the Provider completes all sections of the standard monitoring form, as outlined in Appendix 2.

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• Pharmacies can claim reimbursement for NRT products provided directly to clients, where the service is part of the East Sussex Stop Smoking Service. ESCC will pay pharmacies at the rate stated in the NHS Electronic Drug Tariff, as outlined in Appendix 4.

• The Commissioner will investigate frequent late recording and submission of data. 8. Monitoring Audit and Reporting Key Performance and Quality Indicators • Community stop smoking service providers systematically offer VBA in line with

national guidelines. (Smokers who are offered help by their GP rather than only advice to stop are twice as likely to make a quit attempt).

• The Provider will support people to successfully quit smoking for 12 weeks. Quitting will be measured at 4 weeks and follow up will occur at 12 weeks.

• The Provider will ensure that the Russell Standard is followed (clinical) for assessing performance in Stop Smoking Services. This will ensure the national standard for criteria for throughput and success rates that will enable meaningful comparisons between the services across England.

• The Provider will be expected to achieve a level of success, which is consistently within national limits. This equates to: 50% success rate with a threshold of between 35%-70%.

• Smoking status at four weeks from the quit date should be CO validated in a minimum of 85% of cases.

• The Provider will ensure that staff providing a SSS have received certification for providers from the NCSCT and are fully aware of how the East Sussex Stop Smoking Service (Quit 51) operates.

• Providers must record status of smokers on the QM database no later than 48 hours after providing a stop smoking service to a smoker during the quit attempt process (i.e. point of care). If this is not possible, requests to continue on a paper system will be considered by the Commissioner, at ESCC, on an individual basis. All paper client data monitoring forms must be returned to East Sussex Stop Smoking Service, Quit 51 within five working days following the four week quit and the 12 weeks follow up review.

• All invoices for payment must be supported by evidence of client monitoring data. • The Provider must return client monitoring data within specified timescales and

deadlines as outlined in section 7. Late submission of data may delay payment. • Those involved in delivering smoking cessation support will have the necessary skills

and competencies through undertaking the two day Quit 51 training programme, or online NCSCT training. The training includes the following: brief intervention skills, offering intensive advice and support, smoking in pregnancy awareness and use of service protocols and completion of service related paperwork. Pharmacy and GP staff will be expected to undertake quarterly ESSSS QUIT 51 support sessions and adhere to the NCSCT competency framework.

• A minimum of 1 hour and 50 minutes is required for the first six weeks of the service. This may be met by a combination of face to face or telephone support.

• Where a client relapses during a quit attempt (and does not wish to begin a new treatment episode), no further pharmacotherapy should be provided until such a time as the client is motivated to make another quit attempt.

• Maximum 1 week from initial contact, assessment of smoking status to 1st session with qualified stop smoking advisor.

• Ensure a minimum of three attempts to follow up DNA clients by telephone, text, letter (ensure attempts are recorded) before coding lost to follow up.

16

• All sections of the client monitoring form must be fully completed before returning to Quit 51 for audit and data collection purposes. There should be no blanks, N/A or “client declined to provide information” to be used.

• Providers will ensure equipment is maintained and fully functional and that any routine or on-going queries regarding equipment are directed to the ESSSS, QUIT 51.

Other Monitoring Requirements The service provider will be required to obtain the following monitoring information for all organisations/frontline staff trained and be able to report it to the commissioners as and when required: • Geodemographic data – postcode, age, ethnicity, gender as set out in minimum data

set requirements, appendix 5. • The service provider will also be required to report against Key Performance and

Quality Indicators (KPIs) as set out in section 13 of this document • The Commissioner will undertake an annual review and will consider compliance with

the contract. Any aspect of compliance with this service specification can be considered.

• All reviews undertaken by the Commissioner will consider (not exhaustive): o Outcomes for clients and patients o Benchmarking of current knowledge and practice o Who gains access to the service o Quality of service o Performance against agreed volume and service standards o Client and patient user satisfaction o Learning points identified.

• Periodically the Provider may be required to submit additional reports to relevant or

professional bodies in Eastbourne Hailsham and Seaford; High Weald Lewes Havens and Hastings & Rother CCGs, as requested.

9. Contacts Colin Brown: Health Improvement Specialist; tobacco control and alcohol harm reduction Tel: 01273 335398 / colin.brown@eastsussex.gov.uk Peter Aston, Health Improvement Principal Tel: 01273 337207 / Peter.Aston@eastsussex.gov.uk For information about service sign up, serious incident reporting and claims and payments Tracey Houston (Business Manager) tel: 01273 481932 / fax: 01273 336040 Graham Thomas, Quit 51 Stop Smoking Service, Operations Manager (South) Mob: +44 (0) 7773 598540 / 0800 622 6968 email: grahamthomas@nhs.net Website: http://www.quit51.co.uk

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Appendix 1 Estimated Smokers by GP Practice (in the 20 wards)

Eastbourne Hailsham and Seaford CCG

Practice Code Practice Name JSNA Locality CCG Patients 2

% current smokers

G81050 Arlington Road Medical Centre Eastbourne Central EHS CCG 1,572 15%

G81003 Lighthouse Medical Practice Eastbourne Central EHS CCG 2,411 20%

G81017 Seaside Medical Centre Eastbourne Central EHS CCG 2,200 22%

G81027 Bolton Road Surgery Eastbourne Central EHS CCG 1,115 24%

Y02816 Eastbourne Station Health Centre Eastbourne Central EHS CCG 860 38%

G81056 Enys Road Surgery Eastbourne Central EHS CCG 1,009 14%

G81032 Green Street Clinic Eastbourne Central EHS CCG 1,293 15%

G81002 Grove Road Surgery Eastbourne Central EHS CCG 1,090 17%

G81022 Sovereign Practice Eastbourne Central EHS CCG 2,522 21%

G81004 Downlands Medical Centre Eastbourne North EHS CCG 1,299 14%

Y00080 Harbour Medical Practice Eastbourne North EHS CCG 777 17%

G81049 Manor Park Medical Centre Eastbourne North EHS CCG 988 20%

G81104 Park Practice Eastbourne North EHS CCG 1,706 21%

G81008 Stone Cross Surgery Eastbourne North EHS CCG 1,756 18%

G81685 Crescent Medical Centre Hailsham EHS CCG 349 21%

G81012 Bridgeside Surgery Hailsham EHS CCG 854 21%

G81634 Herstmonceux Surgery Hailsham EHS CCG 315 12%

G81098 Quintin Medical Centre Hailsham EHS CCG 771 15%

G81059 Seaforth Farm Surgery Hailsham EHS CCG 1,465 18%

G81060 Vicarage Field Surgery Hailsham EHS CCG 689 22%

G81099 Old School Surgery Seaford EHS CCG 1,212 14%

G81029 Seaford Medical Practice Seaford EHS CCG 2,352 16%

2 aged 15 years and over who are recorded as current smokers in preceding 27 months

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High Weald Lewes Havens CCG

Practice Code Practice Name JSNA Locality CCG Patients 3

% current smokers

G81024 Ashdown Forest Health Centre High Weald HWLH CCG 994 13%

G81030 Belmont Surgery High Weald HWLH CCG 1,113 15%

G81086 Bird-In-Eye Surgery High Weald HWLH CCG 1,033 16%

G81102 Buxted Surgery High Weald HWLH CCG 1,140 14%

G81614 Groombridge & Hartfield Medical Group

High Weald HWLH CCG 499 13%

G81088 Heathfield Surgery High Weald HWLH CCG 1,528 15%

G81097 Manor Oak Surgery High Weald HWLH CCG 426 13%

G81043 Rotherfield Surgery High Weald HWLH CCG 1,066 18%

G81055 Saxonbury House Surgery High Weald HWLH CCG 1,186 15%

G81019 Beacon Surgery High Weald HWLH CCG 1,303 15%

G81037 The Meads Medical Centre High Weald HWLH CCG 1,215 18%

G81040 Woodhill Surgery High Weald HWLH CCG 403 16%

G81007 Mid Downs Medical Practice Lewes HWLH CCG 1,033 14%

G81035 River Lodge Surgery Lewes HWLH CCG 1,421 16%

G81021 School Hill Medical Practice Lewes HWLH CCG 1,105 17%

G81045 St Andrews Surgery Lewes HWLH CCG 1,256 16%

G81061 Chapel Street Surgery Havens HWLH CCG 1,368 26%

G81627 Foxhill Medical Centre Havens HWLH CCG 368 20%

G81100 Meridian Surgery Havens HWLH CCG 1,582 21%

G81016 Quayside Medical Practice Havens HWLH CCG 1,743 24%

G81053 Rowe Avenue Surgery Havens HWLH CCG 897 19%

3 aged 15 years and over who are recorded as current smokers in preceding 27 months

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Hastings and Rother CCG

Practice Code Practice Name JSNA Locality CCG Patients 4

% current smokers

G81077 Collington & Ninfield Surgery Bexhill HR CCG 1,041 18%

G81039 Little Common Surgery Bexhill HR CCG 1,681 13%

G81025 Pebsham Surgery Bexhill HR CCG 1,368 19%

G81041 Sidley Surgery Bexhill HR CCG 3,136 23%

G81048 Carisbrooke Surgery St Leonards HR CCG 1,840 28%

G81105 Churchwood Medical Practice St Leonards HR CCG 1,328 28%

G81064 Essenden Road Surgery St Leonards HR CCG 769 25%

G81643 Little Ridge Surgery St Leonards HR CCG 477 18%

G81074 High Glades Medical Centre St Leonards HR CCG 1,462 27%

G81096 Sedlescombe House Surgery St Leonards HR CCG 665 22%

G81033 Silver Springs Practice St Leonards HR CCG 1,368 23%

G81089 South Saxon House Surgery St Leonards HR CCG 569 25%

G81026 Warrior Square Surgery St Leonards HR CCG 2,159 33%

G81084 Beaconsfield Road Surgery West Hastings HR CCG 920 23%

G81013 Cornwallis Surgery West Hastings HR CCG 664 35%

Y03051 Hastings Medical Practice and Walk In Centre

West Hastings HR CCG 903 44%

G81641 Priory Road Surgery West Hastings HR CCG 613 29%

G81649 The Plaza Surgery West Hastings HR CCG 1,150 37%

G81658 The Station Practice West Hastings HR CCG 1,611 28%

G81031 Harold Road Surgery East Hastings HR CCG 1,922 22%

G81095 Roebuck House - Practice 1 East Hastings HR CCG 869 27%

G81651 Roebuck House - Practice 3 East Hastings HR CCG 720 23%

G81611 Roebuck House - Practice 4 East Hastings HR CCG 630 22%

G81640 Roebuck House - Practice 5 East Hastings HR CCG 400 28%

G81662 Shankill Surgery East Hastings HR CCG 856 28%

G81052 Fairfield Surgery Rural Rother HR CCG 547 16%

G81085 Ferry Road Health Centre Rural Rother HR CCG 685 25%

G81023 Martins Oak Surgery Rural Rother HR CCG 927 14%

G81087 Northiam Surgery Rural Rother HR CCG 719 14%

G81082 Oldwood Surgery Rural Rother HR CCG 642 16%

G81051 Rye Medical Centre Rural Rother HR CCG 1,174 20%

G81057 Sedlescombe & Westfield Surgery Rural Rother HR CCG 797 16%

4 aged 15 years and over who are recorded as current smokers in preceding 27 months

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Appendix 2

STANDARD MONITORING FORM (INSERT SERVICE NAME & ADDRESS) STOP SMOKING SERVICE

Note: All patient data will be kept securely and in accordance with Caldicott guidelines.

Please insert name

PRACTITIONER DETAILS Practitioner Name Venue

Contact tel. no. Practitioner code/ref

CLIENT DETAILS

Surname

First name Mr Mrs Ms other (please specify)

Address

Postcode NHS ID no.

Daytime tel. no Mobile no.

Alternative contact number (friend/relative)

Date of birth Age (in years) Gender Male Female

Exempt from prescription charge – record here only those able to prove that they are eligible to receive free prescriptions Yes No

Pregnant Yes No Breastfeeding Yes No

Occupation code (see notes on page 3 for further information)

Full-time student Never Worked/unemployed over a year Retired

Home carer (unpaid) Sick/disabled and unable to work Managerial/professional

Intermediate Routine manual Prisoner

Unable to code

Sexual orientation (insert number 1-5. See notes on page 3 for further information)

ETHNIC GROUP (please tick relevant group) a. White

British

Irish

Other white background

b. Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

c. Asian or Asian British

Indian

Pakistani

Bangladeshi

Other Asian background

d. Black or Black British

Caribbean

African

Other Black background

e. Other ethnic groups

Chinese

Other ethnic group

f. Not stated

Not stated

HOW CLIENT HEARD ABOUT THE SERVICE (please tick relevant box)

GP Friend/relative Pharmacy Other health professional

Advertising Other (please specify)

Agreed quit date Date of last tobacco use Date of 4-week follow-up

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INTERVENTION SETTING

Community setting Dental setting Prison setting

Community psychiatric setting General practice setting Military base setting

Hospital setting Maternity setting Workplace setting

Psychiatric hospital setting Children’s centre setting Other setting (please describe)

Pharmacy setting Education setting

TYPE OF INTERVENTION DELIVERED

For the purpose of data capturing, the intervention type is the on chosen at the point the client sets a quit date and consents to treatment

Closed group Telephone support Open (rolling) group

Couple/family One-to-one support Drop-in clinic

Other (please specify)

TYPE OF LICENSED PHARMACOLOGICAL SUPPORT USED (please tick all relevant boxes)

Single NRT Combination NRT Champix

Zyban None Licensed NRT plus Zyban/Champix Where more than pharmacotherapy has been used were these:

Used at the same time

Used consecutively (i.e. the client switched use as part of a single quit attempt but not used at the same time)

NRT Products used (only complete if the client used either single or combination NRT)

Patch Gum Lozenge

Nasal spray Mouth Spray Oral strips

Inhalator Microtab Prescribing or NRT supply setting (please tick box this applies to and insert name and location of Pha rmacy /GP Practice

Pharmacy Name & Loc ation of Pharmacy:

GP Practice GP Practice:

USE OF UNLICENSED NICOTINE CONTAINING PRODUCT (NCP)

Unlicensed NCP (e.g. unlicensed e-cigarette) used : Yes No

If yes was this:

Used instead of licensed medication

Used at the same time as licensed medication

Used consecutively to licensed medication (i.e. the client switched use as part of a single quit attempt but not used at the same time)

TREATMENT OUTCOME

Not quit Lost to follow-up Quit self-reported Quit CO verified

Practitioner signature

Client signature

Signing this form indicates consent to treatment and the sharing of outcome data with your GP and/or referrer.Data may also be used for follow-up and service review purposes including by a third party where applicable.

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Appendix 3 Approved NRT products

Brand Product Treatment Duration

NiQuitin CQ 24hr patch 21mg 14mg 7mg

adults (18+): 6 weeks 2 weeks 2 weeks adolescents (12-18) As adult

Lozenge 4mg 2mg adults (18+) 12 weeks adolescents (12 -18) 12 weeks maximum

Gum 4mg 2mg

adults (18+) Use for up to 3 months and then gradually red uce gum use. When daily use is 1-2 pieces use should be sto pped adolescents (12-18) 12 weeks maximum

Nicotinell 24hr patch 21mg 14mg 7mg

adults (18+) 3 months adolescents (12 -18) 12 weeks maximum

lozenge 2mg 1mg

adults (18+) Withdraw treatment gradually after 3 m onths. Discontinue use when dose is reduced to 1-2 lozenge s per day Maximum period of treatment: 6 months adolescents ( 12-18) Not to be used in under 18s without recommendation from a physician

Gum 4mg 2mg

adults (18+) Reduce dose gradually after 3 months. Discontinue use when dose has been reduced to 1-2 pieces per da y adolescents (12-18) 12 weeks maximum

Nicorette Invisi patch 25mg 5mg 10mg

adults (18+) 8 weeks 2 weeks 2 weeks adolescents (12 -18) The dose and method of use are as for adults, as data is lim ited in this age group. The recommended treatment duration is 12 wee ks. If longer treatment is required, advice from an HCP should be sought

16hr patch 15mg 10mg 5mg

adult s (18+) 8 weeks 2 weeks 2 weeks adolescents (12 -18) The dose and method of use are as for adults, as data is lim ited in this age group. The recommended treatment duration is 12 wee ks. If longer treatment is required, advice from an HCP should be sought

Nasal spray adult (18+) 12 weeks For 8 weeks use as required wi thin maximum daily use guidelines. Reduce dose to 0 over followi ng 4 weeks adolescents (12-18) 12 weeks maximum

Inhalator adults (18+) 12 weeks adolescents (12-18) 12 weeks maximum

Gum 4mg 2mg

adults (18+) Reduce dose gradually after 3 months. When daily use is 1-2 pieces, use should be stopped adolescents (1 2-18) 12 weeks maximum. Use for 8 weeks and then gradually reduce the dose over a 4-week period

Cools Lozenge 4mg 2mg

adults and children (12+) One lozenge to be taken t o as required relieve cravings. No more than 15 lozenges a day. Pregnant or those breastfeeding should consult with their GP, N urse or pharmacist prior to initial use.

microtab adults (18+) Gradually reduce after 3 months adolescents (12 -18) 12 weeks maximum. Use for 8 weeks and then gradually r educe the dose over a 4-week period

Nicopatch Nicopatch 21mg 14mg 7mg

adults (18+) 3 -4 weeks 3 -4 weeks 3 -4 weeks adolescents (< 18 years) Should not be used by people under 18 years of age without recommendation from an HCP

Nicopass Lozenge 1.5mg adults (18+) Maximum use 6 months. Treatment should be stopped when the dose is reduced to 1 to 2 lozenges daily a dolescents (<18 years) Should not be used by people under 18 years of age without recommendation from a physician

Varenicline Varenicline (champix)

adults (18+) 12 weeks + 12 weeks - refer to NICE adolescents (12 -18) Contraindicated for under-18s and pregnant women

Bupropion Bupropion (Zyban)

Adults (18+) 8 -9 weeks adolescents (12 -18) Contraindicated for under-18s and pregnant women

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Appendix 4: Reclaiming cost of nicotine replacement therapy (NRT ) for pharmacies Part VIIIA of NHS Electronic Drug Tariff Name of product See

key Quantity Price Brand

Nicotine 1.5mg lozenges sugar free 60 893 C NiQuitin Minis

Nicotine 10mg/16hours transdermal patches 7 997 C Nicorette invisi

Nicotine 15mg/16hours transdermal patches 7 997 C Nicorette invisi

Nicotine 1mg/dose oromucosal spray sugar free 13.2 ml 1212 C Nicorette QuickMist

Nicotine 21mg/24hours transdermal patches 7 997 C

Nicotine 25mg/16hours transdermal patches 7 997 C Nicorette Invisi

Nicotine 2mg lozenges sugar free 72 997 C NiQuitin

Nicotine 2mg medicated chewing gum sugar free 96 826 C Nicotinell

Nicotine 2mg sublingual tablets sugar free 100 1312 C Nicorette Microtabs

Nicotine 4mg lozenges sugar free 72 997 C NiQuitin

Nicotine 4mg medicated chewing gum sugar free 96 1026 C Nicotinell

Nicotine 500micrograms/dose nasal spray 10 ml 1340 C Nicorette

Nicotine bitartrate 1mg lozenges sugar free 96 912 C Nicotinell

Key: the following symbols are used in Part VIIIA

Source:

Special Container

Item requiring reconstitution

Selected List Scheme (SLS)