NHS Devon Locally Enhanced Service for Stopping Smoking This Local Enhanced Service (LES) Specification details the agreement between Devon PCT (the commissioner) and community pharmacies (the service provider) for the provision of stop smoking services. LES Timelines Time Plan Date Start 1 st April 2010 End 31 st March 2011 Review Annual Renewal On yearly evaluation 1
1. Background Smoking is the single greatest cause of preventable illness and premature death in the U.K. A person who smokes cigarettes regularly more than doubles their risk of dying before the age of 65. More than any other identifiable factor, smoking contributes to the gap in life expectancy between the most deprived and the most affluent. Across Devon the prevalence of smoking is estimated as 21% generally and 26% for routine and manual groups 1 (R/M). However, this figure varies across wards and there are 76/201 wards 2 where tobacco attributable mortality is higher than expected. In Devon around 1 in 8 women smoke in pregnancy 3 (12%). Smoking during pregnancy is estimated to contribute to 40% of all infant deaths 4 Helping a patient to stop smoking is one of the most cost effective of all medical interventions. Compare the numbers need to treat (NNT) to prevent one death over ten years for various interventions listed below: Intervention Outcome NNT Statins Prevent one death over five years 107 Antihypertensive therapy Prevent one stroke, MI, death over one year 700 Cervical cancer screening Prevent one death over ten years 1140 GP brief advice to stop smoking Prevent one premature death* 8 Add pharmacological support Prevent one premature death* 38-56 Add behavioural support Prevent one premature death* 16-40 *Over half of all continuing smokers will die prematurely from a smoking-related disease. For every two long term quitters, one premature death will be avoided. (Doll & Peto) (Bobak, Alex. GP with a special interest in smoking, presentation at UK National Smoking Cessation conference, London 2005 & Willis, N. NHS Stop Smoking Services: Service and Monitoring Guidance, Department of Health October 2007) 2. Aims of the Locally Enhanced Service for Stopping Smoking The main aim of this LES is to support the reduction of smoking prevalence in the geographical area covered by NHS Devon. To enable smokers to access a choice of high quality support to stop smoking to best suit their needs. The LES also aims to: Provide high quality, accessible, convenient and comprehensive stop smoking services across the county Ensure that robust data is collected by NHS Devon in order to measure outcomes and effectiveness of the service, as required by the Department of Health 1 Office for National Statistics (2009) Smoking and drinking among adults, 2007. 2 What a Waste. Premature Deaths due the smoking the picture in the South West. SWPHO September 2008 3 Vital Signs monitoring data. 2008/9. NHS Devon 4 Salihu H et al (2003). Levels of excess infant deaths attributable to maternal smoking during pregnancy in the United States. Journal of Maternity and Child Health, 7(4) pp 219-227 2
Support the achievement of 4-week quitter targets 3. Service Outline 3.1 The Provider (pharmacy) will: Provide one or more in-house Stop Smoking Advisers, trained and registered with NHS Devon. Advisers must attend face to face level 2 intermediate adviser training initially. Thereafter training updates must be completed annually to ensure best practice. Updates may take the form of face to face training provided at NHS Devon pharmacy forums or written updates Offer clients stop smoking appointments with a suitably trained healthcare professional within their own pharmacy premises. Guidelines for the content and frequency of these appointments are at Appendix C. Provide a suitable area for consultation with clients. This does not have to be in a separate consultation room, but may be a quiet area within the shop. Advertise the availability of support to stop smoking within the pharmacy (posters, referral cards & leaflets available from the Stop Smoking Service, Devon Stop Smoking Service, Cullompton Integrated Centre for Health, Willand Road, Cullompton EX15 1FE. Tel. 01884 836024. Refer those patients deemed unsuitable for support within the pharmacy to the NHS Devon Specialist Stop Smoking Service, tel 01884 836024. Complete an NHS Devon stop smoking monitoring form (Appendix A) for each patient entering the service. Monitoring forms should be returned to the PCT when the intervention is completed, regardless of the outcome. As monitoring forms contain patient details they must be faxed to 01392 267885. (Safe Haven Fax) Perform a Carbon Monoxide breath test (smokerlyzer) to confirm patients have quit smoking at four weeks after their quit date. Results to be recorded on the monitoring form. (DH Service & Monitoring Guidance 2010-11 requires 85% of four-week quitters to be validated with a CO breath test). Make contact with patients lost to follow-up before returning monitoring forms to NHS Devon. This will require an attempt to make contact with the client at different times of the day, with up to three attempts made if unsuccessful. Agree to undertake additional training (if deemed necessary by NHS Devon) if quit rates are less than 35%. 3.2 The Commissioner (NHS Devon) will: Provide accessible training (outlined in Appendix B) to all healthcare professionals to support the delivery of this LES. Provide training to any member of service provider staff who requires it to equip them to be an intermediate adviser. Provide one Carbon Monoxide monitor ( smokerlyzer ) and disposable mouthpieces to every pharmacy in the scheme. The CO monitor will remain the property of NHS Devon. Offer calibration and servicing of CO monitors, and provide replacement mouthpieces, as required. These will be available at NHS Devon forums and training events, or on request. 3
Maintain a list of all registered intermediate advisers and keep them updated via regular newsletters and training updates. Cascade best evidence and any updated information on clinical effectiveness and new products etc. to all registered advisers and service providers. The Specialist Stop Smoking service will accept referrals for the out of hours service e.g. evening groups, as well as for clients with special circumstances, e.g. pregnancy, mental health issues. Remunerate the pharmacy for monitoring forms completed and returned, as specified in the payment schedule, within three months of claims being submitted. Monitor the quit rates of individual pharmacies, reporting back on a quarterly basis and where appropriate include a breakdown by specific groups. Provide specific training and support for pharmacies that have a quit rate of less than 35% (DH Service & Monitoring Guidance 2010-11). 4. Monitoring & Evaluation The key indicators for measuring performance and the success of the stop smoking service, which should all be recorded on the monitoring forms, are: o Number of smokers setting a quit date o Number of 4-week quitters (still stopped smoking 4 weeks after the quit date 5 ). o Number of pregnant women quitting smoking o Quits by specific groups including gender, age, profession, ethnic background and postcode. 5. Payment overview 5.1 Training Payment for initial training will be: 50 per pharmacist 30 per other member of pharmacy staff Payment for training will be paid automatically, based on the signing of an attendance sheet. A maximum of two staff per pharmacy will be paid per financial year. Training updates will be carried out by email or newsletter and no payment is attached to them. 5.2 Invoice service and dispensing fees and NRT reimbursement A standard invoice for service fees and dispensing fees (SS3) should be completed and returned to NHS Devon monthly. 5.3 NRT supply NRT may be dispensed under this scheme for a maximum of 12 weeks. It is recommended that this is dispensed for 2 weeks, 2 weeks, 4 weeks and 4 weeks. A dispensing fee of 1 per supply may be claimed when this dispensing procedure is followed. The first two prescriptions are limited to two weeks worth of NRT to minimise drug wastage. However, in recognition of the fact that GPs may prescribe 28 days supply on te first prescription, The PCT has agreed to waive the patient prescription charge for the second set of items. So the patient will pay a maximum of three sets of prescription charges, once every 4 weeks. The supply of Varenicline (Champix) and Bupropion (Zyban) is not covered under the community pharmacy LES. However, the adviser can support a patient using such medication by providing a prescription request letter for the GP. 5 DH Service & Monitoring Guidance 2010-11 defines this as measure as 28 days from the client s quit date -3 or +14 days. Where CO monitored, the CO reading should be <10ppm. 4
5.4 NRT charge / exemption The client should be charged 7.20 (or the current prescription charge) per item of NRT dispensed (i.e. if a combination of 2 items is supplied this would constitute two charges). Patients who are exempt from prescription charges should complete the Payment Exemption Form (SS2), which should be retained in the pharmacy for 7 years for audit purposes. The Payment Exemption Form does not need to be returned to the PCT. 5.5 Reimbursement for NRT The pharmacy will be paid the cost price for the NRT product. (Drug tariff cost + 5% VAT). If the patient is exempt from prescription charges, and has signed an NRT payment exemption form, full payment will be received from the PCT. If the client is charged a service charge by the pharmacy, then this is to be deducted from the PCT payment to the pharmacy. 5.6 Subsequent Quit Attempts If an attempt to stop is unsuccessful, the scheme will not normally fund a further quit attempt within 6 months. If external factors interfere with an individual s attempt to quit, then it may be reasonable to try again sooner with the advisor s agreement. 5
Local Enhanced Service Stop Smoking This document constitutes the agreement between the service provider and NHS Devon in regards to the local enhanced service for stop smoking. Service Provider Name and Address / Pharmacy Stamp Trained intermediate advisors please complete on separate sheet if required. Pharmacies can sign up to provide the service without trained intermediate advisors in place. However, trained intermediate advisors must be in place to provide the service. Payment Schedule Payment for successful 4-week quitters 50 Signature on behalf of the service provider: Signature Name Date Job Title Signature on behalf of the PCT: Signature Name Date Job Title The agreement is to cover a 12 month period commencing 1 st April 2010 Payments will only be made once the PCT is in receipt of a signed copy of this sheet. SS1 Please complete this form and fax it to Lucy Morris on 01392 267886 6