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This professional resource focuses on preventing ill health caused by alcohol and tobacco use and makes the case for why NHS providers should implement the ‘preventing ill health by risky behaviours – alcohol and tobacco CQUIN’.
Scale of the problem
Smoking and harmful use of alcohol are amongst the most significant risk factors in the global burden of disease in England.
Increasing or higher risk drinkers
In England, 10.4 million people consume alcohol at levels above the UK CMOs’ low-risk guideline and increase their risk of alcohol-related ill health.
Alcohol misuse contributes (wholly or partially) to 200 health conditions leading to hospital admission, due either to acute alcohol intoxication or to the toxic effect of alcohol misuse over time. Conditions include:
- cardiovascular conditions
- liver disease
There are nearly 22,500 alcohol-attributable deaths per year. In 2015 to 2016, there were 1.1 million admissions related to alcohol consumption, of which alcohol was the main reason for admission for about 339,000 cases.
The economic burden of alcohol is estimated between 1.3% and 2.7% of annual GDP. Around three-quarters of the cost to the NHS is incurred by people who are not alcohol dependent, but whose alcohol misuse causes ill health.
Alcohol identification and brief advice (IBA) can identify and influence patients who are increasing or higher risk drinkers, but the level of implementation is varied across the country and nowhere near the optimal large scale delivery required to significantly impact on population health.
Tackling smoking provides the biggest opportunity for making services across the entire health and care system more sustainable.
Smoking costs the NHS in England approximately £2.5 billion a year for treating diseases caused by smoking, according to Towards a smoke-free generation: tobacco control plan for England.
Every £1 spent on smoking cessation, saves £10 in future health care costs and health gains according to the NICE tobacco return on investment tool.
The NHS Five Year Forward View makes a commitment to make all NHS trusts, both mental health and acute, smokefree by 2020.
A large number of smokers can be reached through health services and in particular in hospitals. It is estimated that 1 in 4 patients in acute hospital beds in England are smokers and this presents a unique opportunity to offer smoking cessation advice.
A joint survey by Public Health England and NHS England found the prevalence of smoking in secure mental health units was even higher – 64% of patients smoked.
The British Thoracic Society audit of smoking cessation for secondary care in 2016 found that this opportunity to reach smokers through health services is not being exploited.
The smoking cessation audit found that:
- over 1 in 4 (27%) hospital patients were not even asked if they smoke
- nearly 3 in 4 (72%) hospital patients who smoked were not asked if they would like to stop
- only 1 in 13 (7.7%) hospital patients who smoked were referred for hospital-based or community treatment for their tobacco addiction
- half of frontline healthcare staff in hospitals were not offered training in smoking cessation
- only 1 in 10 hospitals completely enforce their fully smoke-free premises - rates of enforcement were even lower for hospitals which provided areas where smoking was allowed
- provision of nicotine replacement therapies and other smoking cessation treatments were ‘poor’ in hospital pharmacy formularies
- only 1.5% of smokers in acute hospital settings go onto make a quit attempt with stop smoking services
Implementing the preventing ill health by risky behaviours CQUIN
The national CQUIN scheme 2017 to 2019: No.9 preventing ill health by risky behaviours offers the chance to identify and support inpatients who are increasing or higher risk drinkers and to identify and support inpatients who smoke. It is intended to complement and reinforce existing activity to deliver interventions to smokers and those who use alcohol at increasing risk and higher risk levels.
The CQUIN applies to community and mental health providers in 2017 to 2019 and extends to acute providers in 2018 to 2019. It covers adult inpatients only (patients aged 18 years and over who are admitted for at least one night), and excludes maternity admissions.
To get set up to successfully deliver this CQUIN, in Quarter 1, providers will need to:
- Establish information systems that enable alcohol and smoking interventions to be recorded.
- Train relevant staff to confidently deliver alcohol identification and brief advice and tobacco very brief advice.
- Establish a baseline level of performance against all 5 core parts of this CQUIN, which are outlined below.
Then, from Quarter 2 onwards, the 5 core parts to this CQUIN indicator are:
- Tobacco screening, which involves asking and recording patients’ smoking status.
- Tobacco brief advice, which involves advising patients who smoke on the best way to quit.
- Tobacco referral and medication offer, which involves offering patients who smoke stop smoking medication and referring them to an evidence-based stop smoking intervention.
- Alcohol screening, which involves asking and recording patients’ level of alcohol consumption.
- Alcohol brief advice or referral, which involves advising patients, who are consuming alcohol at increasing and higher risk levels, on the benefits of cutting down and referring patients who are potentially alcohol dependent to further support.
All of these activities are directly linked to CQUIN payments.
This CQUIN will help providers to implement the guidance produced by the National Institute for Health and Care Excellence (NICE), on reducing smoking in acute and mental health settings and preventing alcohol use disorders.
The preventing ill health CQUIN supplementary guidance provides advice on implementing this CQUIN.
Alcohol identification and brief advice
Alcohol identification and brief advice (IBA) aims to identify and influence patients who are increasing or higher risk drinkers.
IBA is most impactful when it helps identify and advise patients who are not dependent on alcohol, but whose drinking is increasing their risk of a wide range of ill health linked to drinking alcohol. In addition, the intervention will identify dependent drinkers who need further specialist support.
The Cochrane Library research suggests that IBA can reduce weekly drinking by 12% on average. Reducing regular consumption by any amount reduces the risk of ill health.
Healthcare professionals can arrange the intervention as a short informal conversation, for example, while undertaking routine care or as part of assessment or discharge.
Healthcare professionals do not require a comprehensive knowledge about alcohol harm to deliver IBA well. IBA is effective and in its simplest form comprises:
- Asking the AUDIT C 3 questions verbally and scoring their answers, or giving patients an AUDIT-C scratch card to self-complete.
- Feeding back to the patient what their score indicates about their health risk.
- Providing a patient information leaflet with information about harm, benefit and cutting down to patients who drink above low-risk levels (but are not dependent).
For patients who are identified as potentially dependent drinkers, healthcare professionals will refer them for specialist alcohol assessment.
IBA can be approached efficiently through the use of this CQUIN by broaching the subject of harmful drinking at the same time as addressing smoking with hospital patients.
Very brief advice for smoking cessation: ASK, ADVISE, ACT
Very brief advice for smoking cessation (VBA) aims to identify and support patients who smoke to make a quit attempt.
Healthcare professionals can provide VBA in as little as 30 seconds. The intervention is made up of 3 core components: ASK, ADVISE and ACT; although public health benefits are maximised when healthcare professionals refer patients directly for an evidence-based smoking intervention (in the community or on site) with behavioural support and stop smoking medicines.
Healthcare professionals do not require a comprehensive knowledge about tobacco dependency to deliver VBA effectively, although some basic information may enhance the quality of delivery. A free short online training module on providing very brief advice on smoking is available from the National Centre for Smoking Cessation and Training (NCSCT).
In its simplest form, healthcare staff would:
- 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 – by offering referral to specialist support and prescribing medication if appropriate. Smokers who get expert support are up to 4 times as likely to quit successfully.
A Cochrane Review shows that smoking cessation interventions are effective for hospitalised patients regardless of admitting diagnosis. The quit rates among patients who want to quit and take up a referral to stop smoking services are between 15% and 20%, compared to 3% to 4% amongst those without a referral.
The Ottawa model has shown just how effective hospital-initiated smoking cessation advice can be when offered to every person admitted to hospital regardless of what they are in for.
A study comparing patients who received the ‘Ottawa Model’ for smoking cessation intervention compared to usual care found that the smoking cessation intervention group were:
- more likely to have given up smoking after 6 months (35% versus 20%)
- 50% less likely to be readmitted to hospital for any cause after 30 days
- 30% less likely to visit accident and emergency (A&E) after 30 days
In the longer term, participants in the Ottawa model group:
- were 21% less likely to be hospitalised after 2 years
- were 50% less likely to die by year 1
- had 40% reduction in mortality after 2 years
Examples of implementation
Call to action
The preventing ill health CQUIN provides an important opportunity to improve patient health across England through the delivery of short, simple and evidence-based interventions. For it to be effective, we need all health professionals to play their part.
CCGs and local authorities
Progress the preventing ill health CQUIN locally by including it in all NHS Standard Contracts with eligible providers.
Promote and support delivery of the CQUIN to local providers.
Cooperate with local trusts and community services to ensure smooth pathways exist to refer patients between services.
Make it your responsibility to always ask patients about their alcohol consumption and smoking, and to provide simple and short advice and support to help patients to stop smoking and to minimise harmful alcohol consumption.
Access free online training to become confident in the delivery of IBA and VBA.
Ask who is leading delivery of the preventing ill health CQUIN in your trust, know what’s involved and become a champion.
Ensure that the preventing ill health CQUIN is included in the NHS Standard Contract.
Facilitate the successful delivery of the preventing ill health CQUIN by ensuring that there is strong leadership at all levels of the trust and that staff members feel supported to deliver these interventions as part of usual care.
Ensure there is a system in place to record the interventions in patient notes and report to the board on performance.
Mental health and community trusts
Use internal communications to continue to engage staff in the importance of the delivery of IBA and VBA.
Report to the board on how you performed in Quarters 1 and 2 and tell them how you plan to continue to enhance delivery.
Share what’s working well with other trusts to support successful national delivery.
Don’t wait for April 2018. Make necessary changes to information systems and prepare staff through communications and training now.
Identify who will lead delivery of the preventing ill health CQUIN and compose a multi-disciplinary project team (for example internal communications, governance, contracts, ICT, data management, clinicians, workforce development) to lead the way.