So You Think You Can Only Treat Illness?

Dr Aileen Keel CBE Deputy Chief Medical Officer for Scotland

“Every healthcare contact is a

health improvement opportunity”

Health Promoting Health Service

Health Promoting Health Service

Why?• Create a step change in health & wellbeing

• Tackle health inequalities

• Shift the focus of NHSScotland more towards prevention rather than simply treatment of illness.

Health Promoting Health Service

• Building on CEL14 (2008), further CEL setting out revised actions for NHS Boards imminent.

• All hospitals settings, including community hospitals and maternity units.

• Key issues:– Governance – Leadership – Workforce Development– Support

Key issues (1) - Governance

Chief Executives:• To delegate responsibility for implementation

to appropriate committee and governance structures;

• To provide a report to the Board on progress, at least annually;

• To ensure that the annual report is reflected in their self assessment for annual accountability reviews with Scottish Ministers.

Key Issues (2) - Leadership

• Chief Executives• Medical Directors & Directors of Public

Health• ACF & MCNs

- Provide professional leadership

- Champion HPHS approach

- Engage with key groups

- Monitor progress & support implementation of CEL

Key Issues (3) - Workforce Development

• Enormous opportunity available to NHSScotland to use its 150,000+ staff to promote health, and to improve the health of the staff.

• Build staff confidence and skills around health promotion, health inequalities and health behaviour change.

• Embed attainment of generic health improvement competences:- Knowledge Skills Framework (KSF)- Annual appraisal cycles

Key Issues (4) - Support

• National

– NHS Education for Scotland (NES)– HPHS Network– NHS Health Scotland– Quality Improvement Hub

• Local– ACFs and MCNs– PFPI & Better Together Groups– Public Health & Health Improvement Staff

Health Promoting Health Service

New CEL Actions

• Smoking• Alcohol• Breastfeeding• Food and Health• Healthy Working Lives• Sexual Health• Physical Activity• Active Travel

Health Promoting Health Service

•Key Issues for Next Steps

Governance

Leadership

Workforce Development Support

HEALTH IMPROVEMENT OPPORTUNITIES IN THE PRE-

OPERATIVE ASSESSMENT CLINIC – NHS TAYSIDE

Louise Bruce Senior Charge Nurse

Pre-operative Assessment

THE AIMS OF PRE-OPERATIVE ASSESSMENT

•IDENTIFY AND MANAGE RISK PRIOR TO ANAESTHESIA, SURGERY AND HOSPITAL ADMISSION

•IMPROVE OUTCOMES BY ENSURING SAFE, EFFECTIVE, PATIENT CENTRED CARE

ASSESSMENT TAKES PLACE 6-9 WEEKS PRIOR TO SURGERY – SOMETIMES LESS

THE RISKS AND SUBSEQUENT HEALTH ISSUES AS IDENTIFIED IN CEL 14 (2008) ARE SIMILAR TO THE RISK FACTORS BEING IDENTIFIED FOR SAFE ANAESTHESIA

•SMOKING•ALCOHOL•OBESITY – POOR DIETARY INTAKE•DRUG MISUSE

Able to therefore provide a rationale why a change in behaviour will assist them in their recovery from surgery

INCLUDED IN PRE-OPERATIVE ASSESSMENT

•Blood pressure (increased BP one of highest reasons for surgery postponement)•Height •Weight•BMI•Cardio-respiratory history•Smoking history•Alcohol intake•Drug use•Social history•Targeted tests e.g. blood tests, ECG•Exercise tolerance assessment (questions)

SMOKING – Why “Stop before your Op!”

Smokers have an increased risk of anaesthesia complications

•Need more anaesthesia to prevent spasms and coughing •Higher risk of post-operative chest infections•Need more oxygen in the post-operative period •Slower wound healing – reduced oxygen – particularly problematic in plastic, hand and back surgery

EXCESS ALCOHOL

•Abnormal liver function tests – processing of anaesthesia compromised•Clotting abnormalities – risk of bleeding•Post operative confusion/delirium•Poor pain control•Malnourishment – poor wound healing

DIETARY/WEIGHT ISSUES

•Surgery more difficult in obese patients•Difficulty intubating patients •Difficulty mobilising post operatively – greater risk thrombosis•Poor wound healing •Wound dehiscence (bursting open)

What have we done so far

•Health Improvement section in Anaesthetic Assessmentdocumentation – all patients asked – aim for approximately 25,000 patients per annum•Nursing staff brief intervention training for smoking and alcohol•Nursing staff training for electronic smoking cessation referrals•Commenced audit of number of smokers and number of successful interventions•3 year funded post to promote smoking interventions in pre-operative assessment from Public Health

Next steps•Obesity pathway being developed – patients with co-morbidities referred for dietary interventions •Exploring partnership working with external weight management company•Pre-assessment DVD being recorded. Patient Public Involvement.•Exploring “well being” pack to be given to all patients with healthy living information along with pre-op information leaflets•Commenced discussion with local Keep Well Project Manager to identify ways of strengthening links with Primary care particularly for patients from areas of high deprivation•Links with local pharmacies

CHALLENGES

•Short time to gain full assessment for anaesthesia and engage in health improvement activity

•Difficult to provide follow up and support from clinic

•Patients may be coping with life threatening illnesses e.g. surgery for cancer – not always the right time

•Resources in primary care to refer patients to

•Literacy in deprived areas – written information may not be useful

•Physical activity assessment/interventions

Health Promoting Hospitals

Quality in Action

Dr A Hendry National Clinical Lead

Quality and Efficiency

Promoting health Enabling self management

Improving Population Health

• People have the information, advice and support to live well with • their conditions and to manage their risk factors

• An increased number of people are quitting smoking, particularly • those from the most disadvantaged groups of society

• People are healthier and experience fewer risks as a result of alcohol

• Health Promoting Hospitals

Multiple Morbidity, Deprivation and Hospitalisation

Deprivation and MM

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Number of conditions

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SIMD=1

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SIMD=4

SIMD=5

Culture, Systems and Practice

Culture of Prevention and Early Intervention

•Help people live well

•Enabling interactions that promote health and wellbeing

•This is everyone’s responsibility

• Releasing Time to Care• Patient Safety • HAI • 18 weeks• Unscheduled Care• Falls, Nutrition and Tissue Viability CQI • MCNs work on pathway redesign

Systems Improvement

Confidence and Capability

Conversations that Matter

Clinical Champions Critical mass, momentum and pace

A National Survey of Smoking Cessation Provision in all Colposcopy Clinics in Scotland and a model for best practiceAlexis RumblesHospital Nurse Adviser Stop Smoking Services

Overview

• Integrating smoking cessation within colposcopy

• Effects of smoking on cervical cytology

• Outcomes of a national survey in Scotland

• Current practice within St John’s Hospital

• Summary

What is Colposcopy?

A diagnostic procedure in which a specialist examines a magnified view of the cervix using a colposcope

Why do women attend colposcopy clinics?

• The most common reason is an abnormal cervical smear suggesting precancerous changes within the cervix described as Cervical Intraepithelial Neoplasia (CIN)

• Low grade abnormal smears

• Moderate to high grade abnormal smears

What causes an abnormal smear?

• Persistent infection with HPV increases risk of abnormal smears • Smoking changes the ability of cervical cells to protect themselves so less able to fight off disease

Natural History of CIN

Treatment of CIN Within NHS Lothian

The most common formof treatment is loop excision. This removes the cells using a small heated wire loop. The removed cells go to the pathology laboratory for testing.

CIN 1

Szarewski et al (1996) demonstrated that stopping smoking lead to a reduction in size of the cervical lesion over a six month period.

CIN 3

Alcadious et al (2002) established that smoking is an independent risk factor for treatment failure of CIN.

There is clear evidence that stopping smoking reduces the risk of abnormal smears and decreases treatment failure

A literature review revealed there is no evidence that smoking cessation services are integrated into colposcopy clinics as part of treatment.

Aims of the national Scottish survey within Colposcopy Clinics

• Establish if smoking cessation advice and support is available in colposcopy clinics throughout Scotland• Review information given• Improve practice

Outcomes of the national survey

• 27/30 (90%) clinics returned questionnaires • 24/27 (88%) discuss cessation in some form

• 14/27 (52%) always ask smoking status

• 12/27 (37%) always discuss risks of continued smoking and benefits of cessation in relation to abnormal smears and colposcopy treatment

Who provides smoking cessation advice?

• 14/24 (58%) of colposcopy clinics – a mixture of doctors and nurses

• 7/24 (30%) - mostly doctors

• 3/24 (12%) - mostly nurses

What verbal advice is given?

• 13/24 (54%) of clinics advise either to cut down or stop smoking completely

• 11/24 (46%) advise on complete cessation

Providing written cessation advice

• 5/27 (18%) provide advice prior to colposcopy appointment

• 12/27 (44%) provide advice during colposcopy consultation

Nationally inconsistent information and advice given

Referral Pathways for smoking cessation support

• 5 colposcopy clinics have a referral pathway to specialist stop smoking services

• 2 refer to secondary care• 3 refer to primary & secondary care.

Current practice within the colposcopy clinic at St John’s Hospital

• Information leaflets sent out prior to colposcopy appointment include benefits of smoking cessation

• Smoking status always established and documented on NCCIAS form

• Referral forms collected daily from clinic

New leaflet developed outlining risks, benefits of stopping smoking and help available from specialist smoking cessation services.

Marteau et al (2002), Boardman et al (2004) and Bishop et al (2005)

New Leaflet Developed

Working in partnership with the consultants from the colposcopy clinic

Establishing effective practice

• Training health professionals to raise the issue of smoking

• Refer to Specialist Services

• Use motivational interviewing techniques

• Tailor support to meet the patients needs

Clinicians wanted to know, what type of smokers do we meet?

AddictiveHabitualPsychological

What smokers say, a barrier to referral?

• I’m not a heavy smoker• I don’t smoke much• I’ll cut down• I only smoke menthol cigarettes• I smoke lights• I’m too old to stop• I don’t inhale

Nicotine Replacement Therapy & Medication

• Patches• Oral Intermittent products• Combination therapy • Other medication

Nicotine Replacement

Medication

OutcomesAugust 2009 - August 2010

90 referrals44 of these set quit dates

• 1 month abstinence - 58%• 3 month abstinence - 40%• 1 year – current and expected outcome

Challenges of Obtaining CO Verification

• Real life implementation of a service

• 1:1 & telephone support

• Lose engagement of client

• Geographically challenging

Summary

• It is established that stopping smoking is beneficial in women with abnormal smears

• The provision of smoking cessation services in colposcopy clinics across Scotland is variable and the survey highlights scope for improvement

• St John’s service would indicate that integrating cessation services is effective

Where are we now?

• NHS Health Scotland, HPHS

• Other Health boards implementing NHS Lothian Model

• Submitted paper to Journal of Obstetrics and Gynaecology

• Survey within Primary Care completed

Acknowledgements

Dr Simon Nicholson, NHS LothianConsultant Gynaecologist

Dr Sarah Court, NHS LothianAssociate Specialist, Gynaecology

Helena Connelly, NHS LothianStop Smoking Services Manager

Contact details

Alexis RumblesHospital Nurse AdviserSt John’s HospitalLivingston

Tel: 01506 523871Email: Alexis.Rumbles@nhslothian.scot.nhs.uk