5 FINDINGS - THE VIEWS OF COMMUNITY PHARMACISTS AND NHS BOARD STAFF ON THE PHS SMOKING CESSATION SERVICE
5.1 This chapter of the report summarises the findings of the on line surveys of community pharmacists and NHS Board staff. The questions used in each survey can be found in Appendix A.
5.2 Community pharmacists were asked about how clients found out about the service; provision of the service; the therapies offered; facilities provided and the follow up of clients. They were also asked their views on the effectiveness of service; NHS Board support; links with other services; improvements they would like to see and data collection.
5.3 NHS Board staff were asked more specifically about the Scottish Government specification, training, governance and quality assurance.
5.4 A total of 120 community pharmacy staff (out of about 2,300 registered community pharmacists registered in Scotland) and 51 NHS Board staff responded to the two online questionnaires.
The Smoking Cessation Service
How clients find out about the smoking cessation service
5.5 Community pharmacists reported that most of their clients found out about the smoking cessation service they offered from pharmacy staff or material within the pharmacy promoting the service (Table 7). Health professionals were also an important source of referrals to the service. Clients also found out about the service from friends and family; TV, newspapers or radio; Smokeline; Facebook; local advertising; or NHS Board events.
Table 7- How clients found out about the smoking cessation service
|Health promotion material in pharmacy||73|
|Referred to service by other health professionals||71|
Staff involved in providing the service
5.6 Not surprisingly almost all pharmacists were involved in delivering the smoking cessation service (Table 8). Dispensing technicians and counter assistants were involved to a lesser extent. Others involved in delivering the service included pre-registration pharmacists, pharmacy students and dispensing assistants.
Table 8 - Staff involved in providing the smoking cessation service
What the consultations covered
5.7 There was considerable uniformity in what community pharmacists included in smoking cessation consultations (Table 9). Almost all community pharmacists (93%) also reported that they recorded data for the minimum dataset and/or HEAT target at the consultation.
Table 9 -Content of consultations
|Discussion of previous quit attempts||99|
|Discussion of current tobacco use||99|
|Current smoking status||99|
|Quit date agreed||97|
|Information on different types of NRT||96|
|Motivations to quit||94|
|Provision of information on different methods of quitting||89|
|Use of CO monitor||85|
|Advice/signposting to clients about other smoking cessation services in the area||67|
Nicotine therapy offered to clients
5.8 Eighty three per cent of all community pharmacy staff reported that clients were given a choice of which type of smoking cessation therapy they were given, 16% sometimes gave clients a choice of therapies and 1% never gave clients a choice.
5.9 A range of NRT and other products were offered to clients to help in their quit attempt. Ninety nine per cent of community pharmacists offered nicotine patches, 98% nicotine inhalers, 96% offered nicotine gum, and 89% offered nicotine lozenges. Only 62% offered nicotine nasal spray. A total of 15% of respondents reported that they offered other products including microtabs, mints and sublingual tablets. Several respondents were independent prescribers and reported that they prescribed varenicline 17.
Arrangements for consultations and follow up
5.10 The majority of community pharmacists said that they saw smoking cessation clients on demand (Table 10). Just under a third (32%) of respondents said they offered an on demand and appointment service. A small number of community pharmacists saw clients on an appointment only basis. This was the case for both the first and follow-up visits.
Table 10 - Pattern of consultation arrangements
|First visit||Follow-up visits|
|Clients seen on demand||60||69|
|Offered mixture of on demand and appointments||32||26|
|Clients seen by appointment only||8||5|
5.11 Few community pharmacists estimated that more than 75% of clients returned for their second or third visit. There was a further drop off in the numbers returning for a third visit (Table 11).
Table 11 - Estimate of clients returning for a second and third visit
|Estimate of clients returning for subsequent visits||Second Visit||Third visit|
|More than 75%||10||2|
|Less than 25%||14||40|
|Could not give an estimate||7||7|
5.12 Community pharmacists were asked to estimate what proportion of returning clients they thought had made a serious attempt to quit. Two thirds of community pharmacists estimated that more than 50% of clients had made a serious attempt by the time of their second visit (Table 12). In addition, 95% of those who responded saw clients who had made several quit attempts.
Table 12 - Estimate of serious quit attempts
|Clients making serious attempt to quit||Second Visit|
|More than 50%||66|
|Less than 25%||9|
5.13 As part of the PHS clients should be followed up by:
- the pharmacist or support staff if they do not present for an appointment
- the NHS Board at 12 weeks and 12 months after the quit date to assess progress with their quit attempt (for those who have attended all appointments and to ascertain their smoking status). If agreed locally, the pharmacist may carry out the 12 week follow-up and the results are sent to the NHS Board.
5.14 Both community pharmacy and NHS Board respondents were asked if there was any follow-up of clients who did not keep subsequent appointments. The majority of respondents in both groups reported that non-returners were followed-up (Table 13). A greater proportion of NHS Board staff than community pharmacy staff were aware that clients were followed up.
Table 13 - Awareness of follow-up of smoking cessation clients who did not return
|Community Pharmacy Staff||Health Board Staff|
|Clients were followed-up||64||78|
|Clients were not followed-up||31||6|
|Did not know if clients were followed-up||5||16|
5.15 Follow-up could take the form of telephone calls, texts, questionnaires, letters and sending stop smoking literature. In some cases NHS Boards contract out the follow-up service. Follow-up was seen as patchy by a few of the health board respondents due to the fact that some clients do not give consent to be contacted. In addition, resources were not always made available by Health Boards to follow-up clients.
"The worst part is going through the paperwork! Many clients have not given consent therefore are lost. Many clients have not completed course. Many clients have been followed up before their 4 week quit! The paperwork is so late being sent in that we are contacting clients who have already gone through other quit attempts and we have no idea which one they are on. If we cannot follow up clients by telephone we send them a letter." HB 80
Effectiveness of the PHS Smoking Cessation Service
5.16 Both community pharmacy and NHS Board staff were asked how effective they thought the PHS service was in helping people to stop smoking. The majority of both groups felt the service was or ' very effective' or ' quite effective' (Table 14).
Table 14 - Effectiveness of PHS smoking cessation service
|Community pharmacy staff||NHS Board staff|
|Not very effective||10||12|
|Not at all effective||1||2|
5.17 There were a number of reasons as to why community pharmacy staff felt the service was effective. These are outlined below.
Ease of access
5.18 The ease of access to the service was the most frequent reason given for why community pharmacists felt the service was effective. A number of respondents mentioned that clients preferred the 'drop in' and 'on demand' nature of the service and that no appointment was needed.
5.19 The longer opening hours of pharmacies and pharmacies being open on Saturdays was also considered to be attractive to clients particularly those that worked or had other commitments and were unable to get to stop smoking clinics that were held at specific times.
5.20 Some respondents mentioned that clients were more likely to approach them for help to stop smoking than GPs as appointments were not necessary. Furthermore it was felt that some clients did not want to bother GPs but were happy to approach pharmacists for help.
"Personal and quick service which is adaptable to the patient's work and home life." [CP 38]
"They like the convenience of being able to come in at evenings and weekends." [CP 64]
"Very convenient for patient as a pharmacy easier to access than GP or specific stop smoking clinic." [CP 98]
5.21 Some community pharmacy respondents mentioned that they were able to give more regular and face-to-face support (for up to 12 weeks) to clients than GPs.
5.22 The additional support from other pharmacy staff was also considered an important factor in helping people quit successfully. Some community pharmacists felt that some clients preferred this weekly individual support to group sessions. In some cases clients were encouraged to call in whenever they wanted and staff would give them encouragement and support which was particularly important when clients were having a ' bad day'. The rapport built up between client and staff was felt to be important in supporting quit attempts.
"Using motivational support by staff who are ex-smokers along with CO monitoring helps." [CP 38]
5.23 Some community pharmacy respondents felt they also offered a friendlier and less judgemental service than GPs and several commented that they had an increasing number of clients who were referred to them by word of mouth and took this as evidence of a 'good/friendly/accessible' service.
5.24 It was also felt by some that quitting with a pharmacy enabled clients to have informal contact regarding progress with their quit attempt when they visited the pharmacy for other products or services:
"We encourage clients who have used the service to drop in to let us know, informally, how they are getting on. We get positive feedback from several people on a regular basis, and take the opportunity to reinforce how pleased we are with their success." [CP 113]
"Patients get regular individual support and are encouraged to return on a weekly basis. Previously they only saw the smoking cessation advisor once a month or received a prescription from the doctor for a month's supply." [CP 33]
5.25 Other features of the service offered by community pharmacists which respondents felt contributed to the effectiveness of the service were:
- the range of NRT products they were able to offer - one respondent felt that CPs had more up to date knowledge of the products available than GPs who tended to prescribe more traditional products.
- The service was low or no cost to patients.
- The use of CO monitors was a useful motivational tool.
Other comments on the effectiveness of the service
5.26 One respondent felt that most clients did quit even if they occasionally relapsed and others who did not quit were able to make ' a significant reduction in their smoking'.
5.27 Several community pharmacist respondents commented that other health professionals did not seem aware of the service or that community pharmacists can prescribe the NRT products under the Patient Group Directive ( PGD).
Ineffectiveness of service
5.28 Lack of motivation by clients was the reason cited by many community pharmacy staff as the reason why they felt the service was not effective. They recognised that success in quitting smoking was almost entirely dependent on smokers' motivation to quit. There was a view held by some community pharmacy staff that some people did not want to use will power to stop smoking:
"A lot of people are not motivated enough they think that the medication is all they need to stop smoking" [CP121]
5.29 One respondent reported that the initial selection process focused on motivation to quit and they felt they had a 'good feel' as to whether an individual would be successful or not. If the motivation was questionable then the client was not enrolled in the service.
5.30 In the view of one respondent the provision of the service was 'very shaky' with large variations in the quality of provision between pharmacies. There was also concern expressed at the significant investment in the service despite the quit rates achieved.
Views of NHS Board staff on effectiveness of service
5.31 The reasons given by Board staff as to why they thought the service was effective were similar to those of community pharmacy staff i.e. the accessibility to clients and that it appealed to clients who did not want, or could not attend, stop smoking groups.
Strengths of the PHS Smoking Cessation Service
5.32 Many of the features of the service which community pharmacy staff and NHS Board staff felt worked well were very similar to the reasons given in the previous question as to why they felt the service was effective. These features included:
- Ease of access to the service
- Support from pharmacy staff
- One-to-one, flexible support
- Service free of charge to clients exempt from prescription charges and low cost to others and so avoiding high over the counter charges for products.
5.33 In addition to these strengths community pharmacy staff also reported that being able to supply more than one NRT product and being able to tailor these to people's needs was also a great advantage.
"Freedom to prescribe a wide variety of aids and the ability to combine if necessary more than one form of NRT." [ CP 45]
"Multiple therapy has made a big difference to our ability to better manage patient's cravings and thus positively influence the outcome of quit attempts. [CP 56]
5.34 Other strengths of the service mentioned by pharmacy staff included:
- The recognition that remuneration gave to pharmacists for their work.
- Improvement in the status of pharmacies within their communities and greater use of the abilities of pharmacists.
- Staff satisfaction in helping someone to stop smoking.
- Good training and good support from local Health Board.
- Less rigidity in the regulations than when the service was introduced initially.
- The weekly checklist to monitor progress or lack of progress.
- New, easy to follow MDS forms introduced (locally) in January 2011.
- Posters and cards advertising the service.
Areas where service works better
5.35 NHS Health Board staff were asked whether they thought the PHS smoking cessation service worked better in some areas rather than others for example in rural or urban areas. There was a mix of opinions. Many suggested that the motivation and skill of staff in providing the service was more important than the location.
"It works best where there are well trained and committed staff. Geography appears to have little to do with it."[HB 33]
5.36 Others suggested that in smaller rural communities, pharmacy staff may be less busy and will be able to spend more time on face to face contact with potential quitters. However, several respondents said that uptake was more to do with volume of prescriptions i.e. uptake was higher in pharmacies with low prescription volumes and lower in pharmacies with high prescription volumes regardless of the location of the pharmacy.
5.37 The service was thought to be more important by some, in rural pharmacies where there was likely to be fewer smoking cessation services within easy reach and more problems with transport to travel to other services.
5.38 Some respondents felt that quit rates were better in more socially advantaged areas, although there was huge potential in more deprived areas where smoking rates were higher.
Continuing to offer the service
5.39 The majority of community pharmacy staff (88%), who responded, said that, given a choice, they would like to continue to offer the smoking cessation service, 4% would like to stop providing it and 8% were undecided.
5.40 Those who wanted to continue the service said this was because it was a valuable service appreciated by clients and easily accessible to them. Many respondents reported that they and the pharmacy staff involved found the work satisfying and professionally rewarding. However there was sometimes a downside to this when it was felt that clients did not attempt to quit. Several respondents also considered the service beneficial to the community and a good way to tackle a serious health issue. The service was also thought to be cost effective in comparison to other smoking cessation services.
"I enjoy offering the service and have had success with patients, who still come back to tell me how well they are doing which puts a smile on my face. One patient said I'd restored his faith in the NHS as the service was free (he was exempt from Rx charges)" [CP 20]
"Given the health implication for smokers and the prevalence of COPD in this area, smoking cessation is an essential service. I think the low quit rate is more to do with us having hard core smokers who have had a lifelong habit" [CP 120]
5.41 Workload was an issue for those who were undecided about continuing the service some felt there was little reward for all their hard work.
5.42 Those who said that did not want to continue to provide the service said this was because it did not seem to work, were uncertain if this was the best therapy and doubted whether people really did want to quit smoking. Others felt they were providing a service which GPs should be providing 'for no reward or thanks whatsoever'. One respondent wanted to end the service because:
"I feel that sometimes people need more support to help quit and maybe more interaction with other people attempting to quit." [CP 28]
Links with other Local Smoking Cessation Services
5.43 Community pharmacists were asked a series of questions about how they worked with other smoking cessation services in their area. Just under half of the respondents (47%) reported that they had links with other smoking cessation providers in the area (Table 15). These included:
- links with other services using the pharmacy to provide specialist services
- links with independent prescribers who can prescribe varenicline
- links between different health professionals and the pharmacy service such as GPs, stop smoking nurses, midwives and the service
- sharing clients between pharmacies. Several respondents mentioned the role of coordinators to initiate these links.
Table 15 - Links and referrals to other smoking cessation services
|Community pharmacists who||Yes||No||No other services in area||Not sure|
|Link with providers in area*||47||42||2||10|
|Refer to other smoking cessation services**||71||25||0||3|
Note: * N=120, **N=119
Referral to other smoking cessation services
5.44 The majority of community pharmacy respondents (71%) reported that they referred clients to other services (Table 15). The main reasons for referral were to provide group support for clients who needed this type of support, to provide additional prescribed medication not currently available via the service, to provide treatment past the 12 week period, to refer people who did not meet the PHS service criteria, and to provide specialist support for complex cases. The services people were referred to included:
- GP services.
- Group therapies.
- One to one counselling.
- Specialist services for people with complex issues.
- Self help groups.
NHS Board staff views on integration of smoking cessation services
5.45 NHS Board respondents were asked more generally how well integrated were the smoking cessation services in their area. A majority of these respondents (61%) agreed that the PHS smoking cessation service integrated very well, quite well or well with other services while 29% did not agree. Ten per cent did not have a view on integration.
5.46 The reasons why it was felt the service integrated well were mainly to do with the commitment of NHS Boards and other organisations locally. For example:
"We have a referral mechanism into Fresh Airshire, our specialist service, for those requiring more intensive 1:1 or group support. This information is available to all pharmacies. Pharmacists also dispensed the vouchers used by Fresh Airshire for their clients, thus building up the local relationship. We also have a service in place to prescribe Varenicline (Champix) through a number of independent and supplementary pharmacist prescribers based in areas outlined by Fresh Airshire, usually deprived areas. We have had major success in quit rates from this service. Again it links the pharmacist and the specialist service. "[HB33]
5.47 The lack of referrals to other smoking cessation services was the main reason why some NHS Board staff felt that services were not well integrated. There were also some comments that pharmacists were not well represented at information evenings and training.
"Not many people say they come to the specialist service as a direct referral from a community pharmacy" [HB 6]
5.48 Other respondents reported that some pharmacies viewed the service as an income stream and did not want to refer people on as they would lose income. Other services were often seen as competitors rather than as providing a specialist service:
"Each service is paid separately Looking to maximise own income stream No incentive for joined up working" [HB 16]
5.49 One respondent, a smoking cessation specialist, felt very strongly that community pharmacists were presenting themselves as specialists but did not have the training or knowledge required. They therefore did not know when it was appropriate to refer someone on to another service.
5.50 Community pharmacy staff are asked to collect a range of data as part of the smoking cessation service. A quarter of respondents(25%) said it was easy to collect and over half (55%) said it was quite easy to collect. These respondents reported that the forms used locally had recently been improved including improved layout. A fifth (20%) said data collection was difficult or very difficult. Suggested improvements to data collection included:
- Simplifying paperwork, reducing the number of forms to be completed and not duplicating information within and between forms.
"Is there a need to enter same date several times as referral date, initial appointment date, quit date, signing date are often the same in our situation." [CP 76]
- Reducing the information required to be collected e.g. expiry dates of products, sensitive data such as social status and ethnicity.
- Collecting information electronically.
- Allowing pharmacists to keep the forms for 12 weeks so they can track patients rather than return them monthly.
5.51 Fifty six per cent of pharmacy staff who responded said the data collected was quite useful to them and 10% said it was very useful. A small number (14%) felt that the information could be made more useful to community pharmacies. Suggestions included:
- Providing feedback on our percentage quit rates and follow-up rates and comparing with regional and national averages.
- Adding more questions about lifestyle/health concerns/motivation.
The Scottish Government PHS Smoking Cessation Specification
5.52 Community pharmacy respondents were asked if they felt the smoking cessation specification was helpful. Of those who responded 29% felt it was very helpful, 56% said it was quite helpful and 4% had not read the specification.
5.53 Only 84% (42 respondents) of the NHS Board staff who responded to this question were familiar with the Scottish Government specification for the smoking cessation service.
5.54 Improvements to the specification included:
Data collection and payment
- Although a few community pharmacy respondents suggested linking pharmacy payment for providing the smoking cessation service to completion and return of minimum data set forms, this view was held more widely held amongst NHS Board staff.
- Respondents from both groups also suggested that electronic completion and return of forms would make the process easier and quicker.
The claims for payment and return of data need to be much more closely linked. This is vital for patient care and if Boards are to fully demonstrate their progress towards the HEAT target [ HB 61]
Link the return of paperwork at week 4 to payment directly, rather than pharmacy claiming to Scot Govt and the MDS forms going for local compilation and inputting. Electronic completion and transmission of MDS would be a great help. [HB 19]
- There were also suggestions from NHS Board staff that payment should be linked to results for example that payments should be made for providing the service, for the number of clients receiving the service and the number of clients who remain quit after a year. Others suggested that there should be incentives to keep people engaged with the service for the full 12 weeks.
- One community pharmacy respondent suggested that clients should pay a small charge for the service as an indicator of their motivation to quit.
Changes to the service provided
- One respondent suggested introducing a week zero in which patients were given time to think about their quit attempt and could return a week later to sign up to the service. The respondent felt that this approach worked well in their pharmacy and did not deter those who were serious about quitting.
- There were several suggestions about people making another quit attempt. One respondent wanted to reduce the length of time clients have to wait before they try again. Another suggested an additional attempt could not be made until a certain time had elapsed. There was no suggestion as to what this length of time should be.
- There were several suggestions by community pharmacy respondents on ways that they could reduce their time commitment to providing the service, these included: more emphasis on pharmacy staff providing the service rather than the pharmacist; ancillary staff completing the administration for the service and health boards being responsible for follow up rather than community pharmacies.
- One NHS Board respondent suggested that the service should be available during all contracted hours.
Quality of the service
- Quality of service and training of staff delivering the smoking cessation service were a concern for several NHS Board respondents. There were concerns that staff had not undertaken the necessary professional development e.g. the NHS National Education for Scotland ( NES) pharmacy training or PATH (ASHScotland) training. It was felt that the quality of the service should be specified with minimum quality standards incorporated into the specification, which should also include advice about training.
There also should be a quality element built in to the service. The variation in quit rates seems to suggest uneven service provision.
There should be a requirement to attend training if the quality of service ( i.e. quit rates) indicate such. HB 11
Make training for at least one member of a pharmacy team mandatory and ensure all people effectively signpost. Better still unless there is good evidence that it works- scrap the scheme- it would help local services and they are the experts in the field. HB 39
- A small number of NHS Board respondents felt that the PHS service was not a specialist Stop Smoking Service and should not be referred to as such. They also felt that unless PHS smoking cessation worked as well as other specialist services it should be scrapped and potential quitters referred to specialist services by pharmacies with a small referral fee as this would give them the best chance of quitting. Some suggested that referral criteria should be specified.
Widen the scope and flexibility in the service
- Three community pharmacy respondents wanted to be able to supply Champix or varenecline as part of the service and some NHS Board respondents suggested that pharmacotherapy beyond NRT should be included.
- Allowing leeway on the 12 week timeline for the supply of medication for those patients who had difficulties coming off treatment.
- Taking on patients who have already quit smoking at another service e.g. those who attended a group for 1 or 2 weeks but wish to continue their quit at a pharmacy.
Additional conditions of service such as:
- That the services will be available during all contracted hours.
- Making CO monitoring mandatory.
Training and Support
Support from NHS Boards
5.55 Community pharmacy staff was asked if they felt supported by their NHS Board in the delivery of the smoking cessation service. Of those who responded 86% felt supported while 14% did not. Support on offer from the NHS Boards included:
- Advising and helping with completion of forms
- Providing training, support materials and updates on changes to service.
- Service coordinators who were accessible and helpful.
- Setting up networks of support with specialist support.
- Visits to pharmacies to offer support.
5.56 A number of reasons were given as to why some community pharmacies did not feel supported by their NHS Board. For several respondents their complaints centred on a lack of communication, for example, local GP services being unaware of what pharmacies can offer while pharmacies are asked to publicise GP smoking cessation services.
5.57 Some felt there was poor understanding about pharmacists' workload and how the smoking cessation service fitted into their day.
5.58 It was also felt by some community pharmacists that the Health Board were only interested in the paper work and phoning the pharmacy if their success rate was not high enough.
5.59 Other issues raised were
- Lack of funds to maintain and support use of CO monitors.
- Problems with providing face-to-face training in remote and rural areas.
- Too many changes to forms.
5.60 Community pharmacy staff were asked about what training they had undertaken to help them deliver smoking cessation advice. Almost three quarters had undertaken 'brief intervention' training provided by their local NHS Board and over a half had undertaken in-depth training from the same source (Table 16). Distance learning packs provided by NHSNES were used by over two thirds of respondents. Few had made use of the ASH Partnership Action on Tobacco and Health ( PATH) training. One respondent having received the brief intervention training and none reported using the PATH/ ASH in-depth training.
Table 16 - Training in smoking cessation
|Local NHS Board training - brief intervention||73|
|NES distance learning pack||68|
|Local NHS Board training - in-depth advice training||53|
|NES local training course||31|
|Path/ ASH Scotland training - 'Raising the issue of smoking'||3|
|Path/ ASH Scotland training - brief intervention||2|
5.61 Other training mentioned included pharmacy champion/ smoking co-ordinator training, training on specific groups such as young people. Some had attended manufacturers' training events and others reported that they had read journals. One respondent had not received any training.
5.62 Fifty eight per cent found the training they had received very useful and a further 38% quite useful, the remainder, 4%, felt that the training they had received was not very useful.
5.63 Suggestions for revising or further training included:
- Adding more information on how to tailor support for different types of smoker and situations e.g. tips on dealing with difficult smoking cessation clients and ; chain smokers versus occasional smokers,
- Providing training on specific methods e.g. Neural Linguistic Programming, aversion therapy, motivational training (to be mandatory) and brief interventions.
- Training around the client journey and on patient experience.
- Providing training jointly with frontline pharmacists.
- NES training for pharmacy assistants and funding to allow staff to attend training.
- More information being provided about paper work and claim process.
- Providing training on new products and multiple therapy approaches.
- Shorter more concise training.
- Providing a national NHS Board helpline or contact person if there are any questions post training.
5.64 Board staff were asked what support they gave to community pharmacies to help them with training. Almost all provided training events and provided information on accessing specialist services (Table 17).
5.65 'Other" forms of support for training included posters, newspapers, toolkits, websites including NES18 online training, use of pharmacy champions and pharmacy facilitators, visits to pharmacies, direct contact with pharmacists, and support with CO monitors.
Table 17 - Support offered by NHS Boards for training
|Information on accessing specialised services||82|
|No support offered||6|
5.66 Other comments from NHS Board staff around training included the need to: train counter assistants; provide refresher training; have training budgets; provide locum cover for pharmacists so they can attend training; and making training compulsory. Ongoing issues around training included: the difficulties of providing training across large areas of the country; the fact pharmacy staff don't have much time to attend training; and the problems of high staff turn over in pharmacies making training difficult.
5.67 Other advice and support offered by NHS Boards to community pharmacies on smoking cessation included:
- Funding sessional pharmacists or public health facilitators to mentor those pharmacies that did not have a particularly high throughput.
- Targeting pharmacies which were returning poor quality data or no data.
- Provision of training within pharmacies for support staff.
- Providing calibration or repair of CO monitors.
- Incentive schemes for additional payments if targets are exceeded.
- Offering access to training on the provision of varenicline to pharmacists as part of the PHS service.
Governance and Quality Assurance Arrangements
5.68 NHS Board staff were asked about what sort of governance arrangements were in place for the PHS smoking cessation service. Analysis of the minimum data set was the governance arrangement most likely to be in place followed by quality improvement programmes such as training and monitoring of the service (Table 18). Seven respondents did not know what governance arrangements there were and another 2 respondents thought governance arrangements should be in place at a national level, as it was a national programme. These respondents reported that they had not been aware that local governance was expected.
Table 18 - Governance of PHS smoking cessation
|Arrangements in place|
|Analysis of minimum data set||84|
|Development of quality improvement programmes for service||65|
|Procedures to identify and remedy poor performance||55|
|Clear lines of responsibility and accountability||45|
|Processes for managing risk||27|
|Unaware local governance was expected||4|
5.69 NHS Board staff listed the following local quality assurance activities:
- Regular visits to pharmacies.
- Employment of sessional pharmacy mentors and pharmacy practitioner champions.
- Providing annual update sessions, pharmacy specific smoking cessation packs and guidance and local toolkits.
- Monitoring levels of unallocated CPUS forms, completion of NES Smoking Cessation training, use of CO monitors, complaints and concerns.
- Providing feedback to pharmacies on performance compared to others in the CHP.
- Monitoring return of minimum data set forms against payment and highlighting discrepancies to relevant pharmacies and offering them support.
- Monitoring quit rates and conducting three month follow up of clients
5.70 Several NHS Board staff highlighted difficulties with providing local quality assurance as this is not explored adequately within the service specification. For example:
"No quality assurance in place, its not about quality its about getting paid for a service, quality is not part of that service." [HB 21]
"We try to ensure a quality service where possible by identifying poor performance but there is no potential course of action within the specification to allow serious action to be taken." [HB 33]"
"The arrangements suggested in the contract are weak and it's not clear who can hold pharmacies to account." [HB 12]
5.71 In terms of arrangements for dealing with problems or complaints many NHS Board staff reported that the NHS Complaints Procedure was used. Some had specialist routes for complaints through pharmacy leads or other pharmacy/ medicine teams or units. Some respondents mentioned that they were considering withholding payment to pharmacies who did not complete paperwork satisfactorily.
Improving the PHS Smoking Cessation Service
5.72 Both community pharmacy and NHS Board staff suggested a number of improvements which could be made to the smoking cessation service. Many of these have already been covered in previous sections on the specification and training. The main areas for improvement mentioned included:
Paperwork and administration
5.73 There was a widespread view amongst community pharmacists that there should be less and simpler paperwork associated with the service. Many also suggested that data should be collected electronically and that something similar to the electronic minor ailment prescription forms could be used.
5.74 Many NHS Board staff also felt there was too much paperwork associated with the service and that it was unnecessarily complicated - easier paperwork would allow more timely completion and better tracking of outcomes for individuals. However, many of this group also commented that the paperwork was poorly or not completed and would like to see payment linked to timely and better quality completion of the MDS form and in the view of a few, linked to success rates.
"Paperwork is time consuming, cumbersome and is either not completed at all or completed and not submitted. Pharmacy staff not checking patient status each month - in-pharmacy processes poor Confusion over Annex E claims leads to potential overpayments." [HB23]
"The submission to minimum dataset forms requires to be linked to payment somehow for this work." [HB 32]
5.75 There was a suggestion that more detail should be included in the service specification to allow NHS Boards to hold pharmacies to account. For example:
"Having payment claims detached from the return of patient information ( MDS) has caused Boards endless problems. The specification also allows little recourse to address this situation. It is too vague." [HB 33]
Changes to the service
5.76 Many community pharmacy respondents wanted to be able to provide a greater range of products as part of the service. Varenecline (Champix) in particular was mentioned and it was suggested this could be supplied through a PGD. There was also some support for this from Health Board staff with one suggesting this could be supplied to those who have failed to quit with NRT. One community pharmacy respondent wanted NRT products to be limited to patches.
5.77 There was a suggestion by a few community pharmacy respondents that clients should be charged for the service. It was felt that this would not be a deterrent to using the service if clients were motivated to quit.
5.78 One respondent wanted some flexibility in the period that patients could receive the service so that they could be 'weaned off' over a longer period if required while another respondent felt that patients should be weaned off the service by steadily reducing the frequency of visits. There was some support from Health Board staff for more flexibility in the service to ' facilitate the patient's journey' as clients would otherwise end up going back to GPs for continuation of supply of NRT for example community pharmacists wanted some discretion in not having to ask clients to leave the scheme if they admit they have smoked or provide a high CO reading when their progress has been good.
5.79 In contrast, some community pharmacy respondents wanted there to be a minimum period of time between one attempt and the next one - it was felt allowing quit attempts in quick succession reduced people's motivation to quit.
5.80 Some community pharmacists suggested that funding should be made available to allow them to employ a second pharmacist to allow them to undertake all the tasks they are being asked to do in addition to ' the efficient and professional running of our pharmacies'.
'Consultation time needs to be reimbursed at a better rate than the allowance given. Some follow-ups can be 20 minutes long'. [CP 35]
5.81 Some NHS Board respondents felt that there should be sufficient staff to effectively provide and deliver the smoking cessation service but they did not suggest additional payment for this. There was a suggestion by one NHS Board respondent that an appropriate payment should be given for the initial contact session which could take up to 45 minutes if explanations and motivational counselling were given.
Advertising and information
5.82 It was widely felt among community pharmacy respondents that continual advertising of the service at a national level and more information on what clients could expect from the service was required e.g. that clients sometimes can't be seen on demand if the pharmacy is busy.
Training, support and recognition for staff
5.83 Although some community pharmacy respondents felt more training was required e.g. motivational training, the view that more training was required was more prevalent amongst Board staff and much more strongly expressed:
There should be mandatory training to deliver smoking cessation support. [HB 57]
"Stop using staff with no stop smoking training" [HB 21]
5.84 Some respondents felt that there was a lack of knowledge of NRT, cessation support and little use of CO monitors by those providing the smoking cessation support. In addition, there was no requirement to take up Health Board offers of training and information.
Support for clients
5.85 There was a view that only those pharmacies that have the time and skills to provide the service should do so. Several NHS Board respondents felt that some pharmacies were too busy dispensing prescriptions to give the time needed to give a quality service to smoking cessation clients.
"Spend more time with clients. Clients often report that they just get their product and very little support within some pharmacies." [HB 38]]
Better signposting and referral
5.86 Greater integration with other smoking cessation services and signposting for clients to the most appropriate support, particularly if they have had several unsuccessful attempts with a pharmacy. One community pharmacist suggested giving pharmacists incentives for referring appropriate clients to specialist services. Another suggested providing the smoking cessation service in health centres.
5.87 However, there were mixed views amongst community pharmacists about the role of GPs and other health professionals. Some respondents felt GPs should be encouraged to refer patients to them but not, in the view of another respondent, before the clients were ready to quit. Another felt that clients should be referred to GP if they failed to quit after two attempts.
5.88 The views of the community pharmacy staff on the smoking cessation service were in the main positive. Many felt that that the smoking cessation service offered a valuable way for people to attempt to quit smoking and providing the PHS smoking cessation service led to real job satisfaction. However a small number of community pharmacy staff felt that the service would be better provided by others.
5.89 The main concerns about the service were the paper work, workload and support needed to provide the service. Many of community pharmacy staff felt that the scope of the service should be extended in terms of the products that are available, to offer support to help reduce smoking not just quit, and to provide support for longer than 12 weeks. Some also felt that there were issues with clients, who were not motivated to quit, accessing the service and that a small charge might avoid this problem.
5.90 Overall NHS Board staff had mixed opinions about the PHS smoking cessation service. Some staff felt that the smoking cessation service allowed more people to access NRT and that locally the service successfully complemented other more intensive smoking cessation services. Others felt that pharmacies did not have the time, training or skill to offer the support needed for supporting smoking cessation. Some commented that the paperwork for the service was onerous but many suggested that payment should be linked to the completion and return of paperwork. Several commented there was not enough evidence on successful quit rates for the service to be considered to be successful.