Local enhanced service (les)

Local enhanced service (LES)
Providing intensive smoking cessation support for patients
who want to stop smoking
Acceptance of Local Enhanced Service


__________________________________________________(name of GP Practice)
agrees to the above Local Enhanced Service.

Signed on behalf of the service provider:
Signature ________________________________ Date ______________
Name (print) ______________________________

Signed on behalf of Warwickshire PCT / Warwickshire Stop Smoking
Service:

Signature ________________________________ Date ______________
Paul Hooper, Smoking Cessation Commissioner A signed copy of this agreement will be kept by Warwickshire PCT / Warwickshire Stop Smoking Service. Revised Version – 21/12/11
Local Enhanced Service (LES)
Providing intensive smoking cessation support for patients
who want to stop smoking
2011-2013
Contents
5 Quality Standards Required to Fulfil Requirements of the LES
1. Introduction
Smoking cessation guidelines have been developed for Warwickshire PCT and include
guidance on intensive one-to-one support and drug therapy. This locally enhanced service
specification outlines the intensive smoking cessation services to be provided by GP Practices
in Warwickshire. The specification is designed to cover the enhanced aspects of clinical care of
the patient which are beyond the scope of essential services/QOF. This LES incorporates
Department of Health Guidance for NHS Stop Smoking Services, 2011-12 (1).
2. Aims
The intensive smoking cessation service is designed to offer:
• Intensive one-to-one support and follow up, including appropriate drug therapy, for patients
who express a wish to stop smoking and go on to set a quit date. 3. Background – See Appendix 1

___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR 4. Service Outline

Please note for the purposes of this document:
Service Provider = Worker(s) who provides intensive smoking cessation support within a
Practice as part of their role, e.g. Practice Nurse, Health Care Assistant, Health Visitor, etc who
has completed relevant training.
Specialist Smoking Cessation Advisor = Specialist role which supports the development of
services generally in a locality, including the provision of expert advice and support to service
providers in Practices.
Following on from the requirements of the essential service provision/QOF regarding routine
undertaking of brief interventions and recording of patients’ smoking status (see Appendix 2),
this locally enhanced service will fund:
Practices to provide in-house intensive smoking cessation services in line with the
minimum standards for smoking cessation services set out by the DH (4), and return
minimum data sets to stop smoking services as required by the PCT (see Appendix 3), in
time for inclusion in the quarterly report.

Full details on how to deliver quality intensive smoking cessation interventions and data
requirements are provided in Warwickshire Smoking Cessation Guidelines.

5. Quality Standards Required to Fulfil the Requirements of the LES

5.1 All staff involved in delivery of intensive smoking cessation support must have
received training to national standards for smoking cessation training.
This is achieved via the Stop Smoking Service 2 day training course, which operates to
national standards.

5.2 Competence to Practice
To ensure that trained staff continue to be competent to deliver the service they should:
a. Ideally attend refresher training every 2 years (1 day delivered by WSSS) b. And/or undertake measures to ensure skills and knowledge are kept up-to-date, eg. Networking sessions, meetings with Specialist Smoking Cessation Advisor NOTE: From April 2012 we may require that all that all trained staff who are delivering the
service aim to see at least 6 patients per year who set a date to stop smoking. Therefore, we
advise that Practices work towards achieving this during 2011-12.
Service providers must offer weekly support for at least the first four weeks of the
client’s quit attempt to ensure continued monitoring, client compliance and ongoing
access to medication.

___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Summary of Service Delivery (refer to WSSS Guidelines for further information): Contact 1 – 30 mins – plan strategy for quitting, including assessment for drug face-to face visit
Contact 2 – 10 -15 mins – possible quit date - face-to-face visit
Contact 3 – 10 -15 mins – support/progress - ideally face-to-face/can be by phone
Contact 4 – 10 -15 mins – 4-week follow-up - ideally face-to-face visit
Contact 6 – 10-15 mins - 12 week follow-up – ideally face-to-face visit (optional)
Contact 7 – 10 mins –
52 week follow-up (optional – no payment is made for this).

NOTE: All patients should be offered all of the above, but no penalties will be incurred by the
Practice if the patient does not attend for interim support appointments.
5.3 Advertising and Promotion of Service

As a minimum appropriate posters and leaflets must be displayed to ensure clients are aware of
the stop smoking service provided by the Practice. These include general service posters and
at least one additional poster as supplied by WSSS.
The offer of referral to the in-house stop smoking service should be routinely made to identified
smokers. See Appendix 1 for referral pathway.
Other ideas for advertising and promoting the service can be found in the WSSS marketing
pack or via discussion with the Locality Specialist Smoking Cessation Advisor.
5.4 Drug Therapy
As per DH Guidance for NHS Stop Smoking Services, 2011-12, nicotine replacement therapy,
bupropion (Zyban®) and varenicline (Champix®) should be made available in combination with
intensive behavioural support as first-line treatments (where clinically appropriate). See WSSS
Guidelines for more information.
5.5 Monitoring
5.5.1 Four-week quit smoking rates are the local measure to reflect smoking prevalence as set out in Tier 2 vital Signs in the NHS Operating Framework. They are also a National Indicator (NI 123) in the Local Area Agreement (LAA) process. They also provide a useful performance measure for NHS Stop Smoking Services and a means of tracking service performance against local operating plans. 5.5.2 The use of the four-week point as a measure of clinical outcome (stop smoking success) has been questioned, but if the quality of smoking status data at four weeks is good (and is supported by high rates of CO validation) then longer-term success rates can be calculated with a high degree of accuracy. This is because relapse rates are predictable and well documented in the research literature. 5.5.3 The purpose of the monitoring system is to monitor and evaluate the effectiveness and reach of stop smoking services in Warwickshire. It also triggers payment for the service delivered. ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR 5.5.4 The monitoring criteria and procedures are taken from the “NHS Stop Smoking Services –
Service and Monitoring Guidance, 2011-12” and are adapted from the Russell Standard,
originally developed for use in clinical research. It is essential that all services adhere to these
definitions when recording the numbers of smokers entering treatment and the numbers
successfully quit at 4 weeks.
During 2011-12 it is expected that all Practices transfer from paper monitoring forms to the web-
based monitoring database (QuitManager). Training is available via the Locality Specialist
Smoking Cessation Advisors.
5.5.5 A WSSS monitoring form or record on QuitManager (database) should be completed for
each “treated smoker”. A “treated smoker” is a smoker who has received at least one session
of a structured, multi-session intervention (delivered by a Stop Smoking Advisor) on or prior to
the quit date, who consents to treatment and sets a quit date with a Stop Smoking Advisor.
Smokers who attend a first session but do not consent to treatment or do not set a quit date
should not be counted.
5.5.6 Monitoring forms or records on QuitManager should be completed fully and returned
within 6 weeks of the quit date for accurate reporting to Dept of Health.
5.5.7 Follow up at 4 weeks following the quit day should be attempted for all clients.
5.5.8 A CO Verified 4-week quitter is defined as:
a treated smoker whose CO reading is assessed 28 days from their quit date (-3 or +14 days)
and whose CO reading is less than 10ppm. The -3 or +14 day rule allows for cases where it is
impossible to carry out a face-to-face follow-up at the normal four-week point (although in most
cases it is expected that follow-up will be carried out at four weeks from the quit date). This
means that follow-up must occur 25 to 42 days from the quit date (Russell Standard).
CO verification should be conducted face-to-face and carried out for at least 85% of self-
reported four-week quitters.
5.5.9 A self-reported 4-week quitter is defined as:
a treated smoker whose quit status at four weeks from their quit date (or within 25 to 42 days of
the quit date) has been assessed either face-to-face or by telephone, text, email or postal
questionnaire.
5.5.10 Three attempts should be made to reach a client by phone/letter if they do not attend the
4 week follow-up appointment– if there is still no response the client is classed as “lost to follow-
up”.
5.5.11 A client is counted as having successfully stopped smoking if he/she has been
completely abstinent from smoking for a period of 2 weeks since 2 weeks after the quit
date. The rationale behind this definition is to allow a period of ‘grace’ in recognition of the fact
that some smokers initially struggle but then are successful in their quit attempt.
5.5.12 Spontaneous Quitters
Smokers who have already stopped smoking when they first come to the attention of the service
may be counted as having been “treated” only if they have quit within the 14 days prior to
coming to the attention of the service and have attended the first session of a structured, multi-
___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR session treatment plan within 14 days of their spontaneous quit date (which should be recorded
as the quit date).
5.5.13 Renewed Quit Attempts
 
Repeat service users

There is no longer a need to wait 6 months between quit dates.

Many smokers will need to make multiple attempts to quit before achieving long-term success; it
is important that those who are motivated receive repeat interventions following a relapse. As
the majority of successful quit attempts are unplanned or spontaneous, smokers should also be
enabled to stop whenever they want to.
Quit attempts should draw on experiences from previous attempts to stop, and should bear in
mind factors that contributed to previous relapses (e.g. high nicotine dependency). Groups with
higher rates of smoking, such as those with mental illness, are more likely to be repeat service
users, and specific provision should be made to encourage their re-engagement with stop
smoking services.

Time between treatment episodes
When a client has not managed to stop smoking there is no definitive period of time required
between the end of a treatment episode and the start of another. The stop smoking advisor
should use discretion and professional judgement when considering whether a client is ready to
receive support to immediately attempt to stop again. If this is the case, the client must start a
new treatment episode, i.e. attend one session of a structured, multi-session intervention,
consent to treatment and set a quit date with a stop smoking advisor, in order to be counted as
a new quit attempt on a new monitoring form.

A quit attempt that takes place immediately following the end of one treatment episode.
A new treatment episode should be commenced in the database/service records. A new
monitoring form/database record should be completed.
5.5.14 In line with good practice, all service providers will attempt, wherever possible, to confirm
the smoking status of all clients self-reporting as having quit smoking at 4 weeks (mandatory),
at 12 weeks (optional) and then at 12 months (optional) by the use of a carbon monoxide
monitor.
5.5.15 The service provider must complete a record on QuitManager or the Warwickshire Stop
Smoking Service Monitoring Form (Appendix 3) fully and accurately and return following
agreement of quit date and completion of the 4-week follow-up. Data should be input/returned
within 6 weeks of the quit date to enable accurate monitoring.
5.5.16 In addition to the 4-week follow up, service providers may opt to extend their monitoring
to include 12 week and 52-week follow up. A client would be classed as successfully quit if
he/she has been totally abstinent from smoking for the time since the quit day validated through
CO monitoring. No payment is made for the 52 week follow-up.
___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR 5.5.17 Retention of Monitoring Forms
All paper monitoring forms should be retained the by service provider for a minimum of 2 years
to allow for possible auditing. Monitoring forms can be scanned into patient records.
5.5.18 Safeguarding against the possibility of fraudulent payment claims
All trained staff are required to have signed the following declaration (provided at training or
completed retrospectively):
“I claim payment for the stop smoking services that I have provided which are shown on this
form. I confirm that the information given on this form is true and complete. I understand that if
I provide false or misleading information I may be liable to prosecution or civil proceedings. I
understand that the information on this form may be provided to the Counter Fraud and Security
Management Service, a division of the NHS Business Services Authority for the purpose of
verification of this claim and the preventing, detecting and investigation of fraud.”
6. Performance Criteria
6.1 Quit Rate
National Service Guidance, 2011-12 states that 4-week quit rates (self-reported and CO verified) should fall between 35% and 70%. The benchmark is 50%, which is around the national average for stop smoking services. 6.2 Lost to Follow-up
This should be under 20% and ideally under 10%. 6.3 CO Validation
National Service Guidance, 2011-12 states that CO verification should be attempted in at least 85% of all treated smokers and any clients who cannot be contacted at 4 weeks (-3 day or +14 days) should be counted as lost to follow-up.
6.4 Return of Monitoring Forms
Records in QuitManager / monitoring forms should be completed within 6 weeks of the quit date. 6.5 Action for Non-Performance
If the individual practice data falls outside the above, WSSS will contact the practice for the following: a. Confirmation that all definitions have been followed with regard to the data submitted b. If the practice confirms that the approved definitions have been used, WSSS will carry out a minimum of 3 random checks of smokers treated by the practice, to establish that they met the criteria for self-reported or CO-verified 4 week quits at the 4 week follow-up point and that they have received an approved intervention of the required content and duration as described previously. If the random checks indicate that recorded quits are unreliable, all cases received from this provider will be checked using the approved definitions and the total number of 4 week quits will be re-entered onto the service database. c. If, after the required checks are carried out, the results are still outside the expected range, an assessment will be carried out of the most likely causes. WSSS will then support the Practice to make improvements to achieve results within the expected ranges. A written improvement plan will be agreed between the Practice and WSSS. ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR d. A period of 3 months will be given to make the required improvements. If the results are then still not within the expected range, 3 months notice will be given to withdraw the LES from the Practice, and alternative arrangements for the Practice’s patients who want to stop smoking will be made.
6.6 Advertising and Promotion
As a minimum appropriate posters and leaflets must be displayed to ensure clients are aware of
the stop smoking service provided by the Practice. These include general service posters and
at least one additional poster as supplied by WSSS.
6.7 Drug Therapy
As per DH Guidance for NHS Stop Smoking Services, 2011-12, nicotine replacement therapy,
bupropion (Zyban®) and varenicline (Champix®) should be made available in combination with
intensive behavioural support as first-line treatments (where clinically appropriate). See WSSS
Guidelines for more information.
6.8 Supporting Principles
To support the stop smoking service it is expected that the following principles are adhered to:
1. Practice do not promote/advertise non-NHS/NICE approved methods of stopping 2. Practice staff are not seen to smoke around the Practice building(s) or within an hour of 7. Funding
GP practices will receive payments ONLY on completion and submission of Warwickshire
Stop Smoking Service Monitoring data, via the QuitManager database (or paper
monitoring forms where access to QuitManager is not available or training has yet to
take place).
a. £10.65 per patient setting a quit date with agreed date for follow-up
b. £41.00 per patient still quit at 4-week follow-up. (assume 50% quit rate)
c. £10.65 per patient not quit at 4-week follow-up. No additional payment for those not

d. £5.15 per patient for 12-week follow-up after quit date.

Max. available per patient = £56.80

8. Commencement / Duration
From 1st April 2011 to 31st March 2013
If new Dept of Health NHS Stop Smoking Service Guidance becomes available the LES will be
reviewed and any suggested changes negotiated with the LMC.
___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR To withdraw from the scheme three months’ written notice is required by the PCT / Warwickshire Stop Smoking Service. Warwickshire Stop Smoking Service will then collect materials previously supplied. Should the PCT / Warwickshire Stop Smoking Service wish to discontinue the service with a Practice three months’ written notice will be given. 9. Support

To support Practices to provide in-house intensive smoking cessation support, Warwickshire
Stop Smoking Service and locality based Specialist Smoking Cessation Advisors will provide
the following:
e.
Specialist advice and support. It is a requirement of this LES that a visit is made by the Specialist Cessation Advisor every 6 months. Free training for service providers is available via Warwickshire Stop Smoking Service (2-day workshop). Free refresher training is also available. All resources/materials required to support the practice based service provider to deliver intensive one-to-one smoking cessation support, including support with developing new materials if appropriate. Service guidelines – produced to enable evidence/best practice to be implemented efficiently and effectively. Free carbon monoxide monitors – plus free mouthpieces and free calibration by Specialist Smoking Cessation Advisor Free patient information leaflets and other materials – some of these have been developed in response to needs identified by Practice staff. Provision of monitoring forms and freepost envelopes. Additional funding for mailshot to patients – inviting patients to use stop smoking service / updating smoking status for QOF. Specialist advice and support from Locality Specialist Smoking Cessation Advisor/Manager, including advice on implementation of quality standards, service guidelines, performance issues; advice and support on “challenging” patients, medications, etc. Free practical support where there are short-term difficulties in an individual Practice, e.g. Loss of staff, support with a backlog of data. In some instances a sessional worker can be provided. Access to specialist smoking and pregnancy service – provide specialist support for this challenging target group (patients can be seen in Practices as part of the normal service if this best meets the patient’s needs/preferences). ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Information and resources for No Smoking Day and other tobacco campaigns. Promotion of smoking cessation generally within the population supports the achieving the QOF requirements/funding. Support on media work on smoking cessation, e.g. Practice Prizes, case studies, events, etc.
10. Audit

Practices will be required to provide an audit trail for a minimum of 2 patients per year to
demonstrate implementation of quality standards, including provision of support appointments,
appropriate prescribing, etc. This will include a report with recommendations on follow up
actions agreed with the practice.
___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Appendix 1 - Background

Evidence shows that:
a. 21% of the UK population currently smoke (1) (ONS 2007) b. Smoking kills over 80,000 people in England per year (2) and 1 in 2 smokers will die c. Smoking is associated with a wide range of health problems d. Treating smoking-related illness costs the NHS £2.7 billion annually (2), approximately e. Smoking is the single greatest cause of preventable illness and premature death in the f. Seven out of ten adult smokers in all social groups say they would like to give up, but due to the addictive nature of nicotine, most find it hard to quit (2) g. For smokers who give up, the chances of getting a serious or fatal disease are greatly h. Brief advice from a GP given to all smokers to encourage them to make an attempt to quit leads to 1-3 out of 100 to stop for at least 6 months (3) i. Helping smokers stop is extremely cost-effective. The cost per life year saved of a comprehensive treatment service is about £900. Many health economists rate a treatment that costs between £5,000 and £10,000 per life year saved as very good value for money. The median cost of a range of 300 medical interventions has been estimated at £17,000 per life year saved (Parrott et al). Therefore, evidence-based smoking cessation support is highly effective both in cost and clinical terms. It should therefore be seen in the same way as any other clinical service and offered to anyone who expresses an interest in stopping. j. The potential saving to the drugs bill if more smokers stop is considerable. Over 80% of patients prescribed statins would fall below the threshold for these drugs if they stopped smoking (Muir et al). Yet in 2000, the NHS spent about 12 times as much on statins as on smoking cessation, even though smoking cessation is about 17 times more cost-effective (Bates C et al) k. Helping smokers stop will reduce surgery visits from patients as they become less vulnerable to colds, flu and other illnesses (WHO, 2001). l. Effectiveness of pharmacotherapy and support options: ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Source: Cochrane Database of Systematic Reviews Reducing smoking is a key improvement area within the overarching health and well-being Public Service Agreement (PSA18) area, and this reflected in Strategic Health Authority (SHA) Local Delivery Plans, within the NHS Operating Framework and in Local Area Agreements (LAAs) ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Appendix 2 – Brief Interventions
Defining Brief Intervention: In line with the emphasis on initiating smoking cessation in
primary care, QOF included the recording smoking status of patients and offering advice to
smokers.

The Department of Health is encouraging all Healthcare Professionals to give clinically effective
stop smoking advice in as little as 30 seconds. Providing brief advice to stop smoking is the
single most cost-effective action a Healthcare Professional can undertake, and it doubles the
likelihood of a successful quit attempt.
Smokers may take several times to quit smoking successfully, so it’s important to keep giving
advice at every opportunity. Smokers are up to four times more likely to quit smoking
successfully with support from the NHS Stop Smoking Services.
Very Brief Advice (AAA) – 30 Seconds to Save a Life

1. ASK and record smoking status [QOF points]
Smoker – ex-smoker – non-smoker
“Are you smoking at all these days?” 2. ADVISE patient of health benefits
“Stopping smoking is the best thing you can do for your health”
3. ACT on patient’s response [QOF points]
Build confidence, give information, refer, prescribe
“Lots of my patients are succeeding with support from a Stop Smoking
Advisor and stop smoking medication. Would you like me to refer you to
them for more advice?”

Refer your patients to the trained Stop Smoking Advisor in
your Practice.

___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Appendix 3 - References

Dept of Health, NHS Stop Smoking Services – Service and Monitoring Guidance, 2011-12 Office of National Statistics 2008. Beyond Smoking Kills, ASH 2009 Secretary of State for Health. Smoking Kills: A white Paper on tobacco. The Stationary Office, 1998 West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987-999 Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Thorax 1998; 53 (Suppl. 5, Pt1): S1-S19 ___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR Appendix 4 – Monitoring Form
Warwickshire Stop Smoking Service – Monitoring Form
Client ID No. /

Note: All patient data will be kept securely and in accordance with Caldicott guidelines. Information can only be passed to
another healthcare professional if this contributes to the provision of effective care.
1. Client Details
Surnam e
2. Ethnic Group
a) White
b) Black or Black British
3. Socio-economic Classification (Definitions overleaf)
Never worked or unemployed for over 1 year Sick/disabled and unable to return to work 4. How Client Heard About Service
Other Health Professional … Advertising 5. Type of Intevention Delivered
6. Quit Date and Follow-up
Agreed Quit
Date
7. Type of Pharmacological Support Used (Please tick all relevant boxes. Use 1 or 2 to indicated consecutive use of
more than one medication, eg. Champix followed by NRT product)
8. Treatment Outcome
Date of last tobacco use
Quit (CO verified) …
Quit (self-report)
Lost to Follow-up
Quit = not smoked at all since 2 weeks after quit date. CO verified = with CO level less than 10 ppm Lost to follow-up = you should attempt to contact the person 3 times before submitting this form 9. Advisor Address
Client Signature (indicating consent to treatment and follow-up, and passing of outcome
data to GP/Stop Smoking Service)
Advisor Name
Advisor Signature
I claim payment f or the stop smoking services that I have provided which are shown above. I confirm that the information given on this form is true and
complete. I understand that if I provide false or misleading information I may be liable to prosecution or civil proceedings. I understand that the
information on this form may be provided to the Counter Fraud and Security Management Service, a division of the NHS Business Services Authority
for the purpose of verification of this claim and the preventing, detecting and investigation of fraud.
Please return top (green) copy immediately after 4 week follow-up to:
Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV32 5BR.
Bottom copy to be retained by service provider.
___________________________________________________________________________________________ Smoke Free Warwickshire, FREEPOST MID23827, Leamington Spa, CV23 5BR

Source: http://www.warwickshire.gov.uk/wp-content/uploads/2013/04/smokefree_gp_les_april_2011..pdf