Salford Council has worked hard to adapt the community stop smoking service, ensuring that local smokers experience an efficient and seamless service when leaving NHS care.
The challenge
Salford City Council is one of ten metropolitan borough councils in Greater Manchester and is a constituent council of the Greater Manchester Combined Authority. Greater Manchester was a pioneer of hospital-based tobacco dependence treatment services and experience in the region informed the national programme subsequently launched in the NHS Long Term Plan. Salford Council has worked hard to adapt the community stop smoking service to these changes, ensuring that local smokers experience an efficient and seamless service when leaving NHS care.
Smoking prevalence in the adult population in Salford is estimated to be 18.4 per cent based on QOF data. This is higher than the rate for Greater Manchester as a whole (15.2 per cent) and the national average of 16.5 per cent. Health inequalities within the city are strongly linked to tobacco use with smoking prevalence of 25.4 per cent in the most deprived communities compared to 9.8 per cent in the most affluent communities
The Salford health improvement service and the CURE Project
Salford's specialist Stop Smoking Service, part of the council's health improvement service, has been supporting people in Salford to quit or reduce smoking since 2004. The CURE Project, Greater Manchester’s programme for tobacco dependency treatment in acute care, was first piloted in 2018 then implemented across the region from 2019.
The CURE project is a comprehensive secondary care treatment programme for tobacco addiction. The programme aims to identify all smokers who are admitted to secondary care and immediately offer them nicotine replacement therapy and other medications, as well as specialist support for the duration of their admission and after discharge. The name of the project deliberately medicalises tobacco addiction, identifying smoking as a condition needing treatment rather than a lifestyle choice.
From the outset, the focus of the CURE programme was on changing the culture within acute settings to ensure that all smokers who were admitted were treated unless they opted out. The specification of the project included a robust discharge pathway but the available funding in Salford only covered the service within the Salford Royal Hospital with ongoing care funded through Public Health via the community Stop Smoking Service. This put pressure on the community service and its pharmacotherapy budget.
Early on, Salford Public Health recognised the need for leadership and a system-wide approach to enable long-term change. Consequently, council and NHS partners came together to gain an understanding of each other’s roles, identify where there was flexibility in the system, and map out discharge options and pathways. This created a solid foundation of trust which has been, and continues to be, essential to the local partnership.
Although other options were considered, the Salford community stop smoking service agreed at this stage to be the single point of referral in order to avoid confusion within the hospital at the time of patient discharge. As the tobacco dependence treatment pathway became more complex, it was vital to ensure that that smokers’ quit attempts were not inhibited as a result.
An important decision at the outset was to use PharmOutcomes, a web-based reporting tool, across the whole pathway. PharmOutcomes enables referrals, facilitates the provision of pharmacotherapy to patients and provides a collective view of performance data. Over the course of the collaboration the PharmOutcomes module has been amended and improved as the service has evolved.
An early change to the pathway followed intelligence from the community Stop Smoking Service that too great a resource was being spent on pursuing referrals for people who no longer had an interest in quitting. It became clear that the enthusiasm of smokers to quit when facing a health scare in a smokefree hospital could easily evaporate on discharge when they were feeling well again. Subsequently, smokers were asked at discharge about their willingness to quit, resulting in a lower referral rate but a higher conversion from hospital referral to engagement with the community service.
Additional investment in CURE from 2023/24 onwards will support greater person-centred approaches across Greater Manchester through expanded hospital teams that can provide continuity of care on discharge. The community Stop Smoking Service will however remain the first choice for many people leaving hospital in Salford.
For Salford City Council, future plans are framed by the priorities of the Salford Tackling Tobacco Alliance, a broad partnership that includes a Stop Smoking Providers Network, an Enforcement Operations Group, a Preventing Tobacco Uptake Action Group and a Smokefree Environments Action Group. Their respective goals are to:
- Encourage collaboration and sharing of good practice across stop smoking providers
- Reduce the availability of illicit tobacco/vapes and underage sales
- Prevent the uptake of smoking (cigarettes and cannabis)
- Create more smoke-free environments.
Outcomes
Improvements in the referral pathway pushed up the quit rate among patients discharged to the community Stop Smoking Service from 34 per cent to 44 cent in six months.
Between 2019/20 and 2021/22 the number of successful quitters seen by the community Stop Smoking Service increased by 87 per cent from 366 to 683 [1].
A strong partnership and closer working relationships have given local professionals the confidence to collaborate creatively and speedily when implementing new ideas and programmes, such as the Lung Health Check pathway.
How the work is sustained
- Commitment and support from members of Salford City Council
- Continuous service review and improvement.
- The Stop Smoking Service Providers’ Network facilitates collaboration, information-sharing and learning for new and emerging stop smoking pathways across the system.
- Public Health commitment to fund pharmacotherapy for all patients for up to 12 weeks.
Lessons learned
A major change in the configuration of services for smokers was successfully delivered thanks to strong system leadership, a whole-system view, and early commitment from all stakeholders to building relationships and trust.
The use of a common data collection system (PharmOutcomes) has been crucial to enabling the pathway and preventing double counting of quits.