Sheffield Health and Social Care NHS Foundation Trust (SHSC) is committed to reducing harm from tobacco to service users and staff and introduced a new Nicotine Management and Smoke Free Policy in 2016. Partnership and collaborative working is helping us to fully operationalise NICE Guidance (PH48) and address complex implementation challenges.
In 2016 over 66% of people admitted to our inpatient wards, and over 40% of people on the mental illness register in Sheffield, were recorded as smoking. This compared with a smoking prevalence of just 16% in the general Sheffield population.
As a city our ambition is to have a smoke free generation by 2025. Addressing the disproportionate harm from tobacco for people with mental health problems is essential if Sheffield is to achieve this vision.
Sheffield Health and Social Care NHS Foundation Trust provides mental health, learning disability, substance misuse, community rehabilitation, and a range of primary care and specialist services to the people of Sheffield.
Our service users and staff do not live in a vacuum, and whilst the actions we take as a Trust can influence changes in behaviour, what is happening in other health settings and the community where people live, work and socialise is also important. We, therefore, worked with our partners as one element within an overall citywide tobacco control strategy.
We started off by establishing a Smoke Free Implementation Group, including service users, and agreed a four-phase approach to implementation. In reality, these phases have not moved neatly from one to another, and work on phases 1 to 3 is still ongoing and important.
Phase 1: awareness raising, engagement and consultation
Activities have included a trust-wide launch followed by road shows and a ‘countdown’ event. Over 1,400 staff and 185 service users share their views via surveys.
Phase 2: capacity building and preparation
This has included Very Brief Advice training; commissioned face-to-face training; ward staff trained to issue Nicotine Replacement Therapy (NRT) within 30 minutes of admission, and the production of communications and resources to support service users and staff. As well as local partners, support from South London and Maudsley NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Experts by Experience Phil Hough and Simon Hough, and the National Centre for Smoking Cessation Training has been invaluable.
Phase 3: implementation, evaluation and adaptation
We have been very fortunate to be part of the NIHR Collaboration for Leadership in Applied Health and Social Care (CLAHRC) Yorkshire and Humber (YH), with links to South London CLAHRC, which has enabled us to work with other Mental Health Trusts and academic partners from the outset of our smoke free project.
Complementing existing Trust feedback and monitoring processes, over 900 staff completed a post-implementation survey to share their views and suggestions.
Interviews with 35 service users on acute adult mental health inpatient wards have provided important insights into the experience of being a patient on a smoke free acute ward and ways we could improve support
Phase 4: embedding
This phase will be reached when completely smoke free environments have become the new norm. Continued attention to phases 1 to 3 will enable us to reach this phase.
What’s gone well
The Policy is making a positive difference. Staff have fed back that they welcome the cleaner, healthier environment, the focus on improving physical health within the context of mental health, practical support available for smoking cessation, and encouragement to staff and service users to be smoke free.
- we have trained over 100 staff as accredited Level 2 Smoking Cessation Practitioners, including our Respect Practitioner Team
- there has been a marked increase in the number of service users referred to smoking cessation interventions
- the Trust’s provision of up to 6 weeks free NRT for staff for temporary abstinence from tobacco whilst at work, or to support a quit attempt has been well received. 70 staff had quit smoking in the 18-month period up to June 2017
- in response to service user representation, electronic-cigarettes are permitted on our wards within certain parameters
Having an agreed city-wide policy statement and local information and national fire service guidance on e-cigarettes in NHS settings has helped in clarifying our position.
What could have gone better and work in progress
One of the biggest challenges has been implementing the policy consistently in acute settings and we underestimated the complexity of this challenge; most of the published literature and evidence comes from secure and forensic settings.
Our Trust approach is one of encouraging compliance and therapeutic engagement, in preference to enforcement. We want to maximise the opportunity afforded by admission to a smoke free ward to treat tobacco dependency, prevent avoidable resistance and reduce the risk of surreptitious smoking.
To help us address the challenges of implementing smoke free mental health inpatient wards our Trust hosted a Public Health England (PHE) and Collaboration for Leadership in Applied Health Research and Care (CLAHRC YH) sponsored conference Pausing for Breath (June 2018). The event, endorsed by the North East, Yorkshire & Humberside (NEYH) Mental Health Trusts Chief Executive Officers (CEO) Forum, brought together clinicians from acute settings across 8 Trusts and people leading smoke free implementation. The programme can be viewed here.
We revisited why smoke free mental health settings are so important, and shared knowledge, experiences, challenges, ideas and identified gaps where further action is required. The learning from this event is now feeding into a Smoking Cessation Task and Finish Group, set up across Trusts by the NEYH Mental Health Trusts CEO Forum.
Within the Trust we are reviewing our progress and action plans using the mental health deep dive assessment tool. We are participating, along Leeds and York Partnership NHS Foundation Trust and Tees, Esk and Wear NHS Foundation Trust, in a Cancer Research UK funded project (led by the University of York) exploring the role of e-cigarettes within mental health inpatient settings.
One of our acute mental health inpatient wards, Maple, is participating in the Royal College of Physicians Quality Improvement Project supporting teams to improve smoking cessation in the acute care setting.
Supporting people with tobacco dependency and facilitating smoke free mental health settings involves complex cultural change and needs to be part of a wider-ranging approach to tobacco reduction. We are seizing opportunities to contribute to new work within the Sheffield Accountable Care Partnership.
Crucially as part of that partnership group we need to establish smoke free norms across all NHS settings, which will then help us to achieve them within mental health settings.
Moira Leahy, Consultant Clinical Psychologist and Smoke Free Lead, Sheffield Health and Social Care NHS Foundation Trust or Pete Stewart, Mental Health Smoking Cessation Nurse Practitioner, Sheffield Health and Social Care NHS Foundation Trust.