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Journal of Public Health Advance Access originally published online on May 11, 2007
Journal of Public Health 2007 29(2):118-122; doi:10.1093/pubmed/fdm011
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Developing the public health role of a front line clinical service: integrating stop smoking advice into routine podiatry services{dagger}



Jackie Gray, Consultant in Public Health Medicine1,

Gary Eden, Head of Podiatry Services1

Maria Williams, Head of Service2
1 Department of Public Health, Gateshead Primary Care Trust, Team View 5th Avenue Business Park, Team Valley Trading Estate, Gateshead NE11 0NB, UK
2 Gateshead and South Tyne Stop Smoking Service, Clarendon House, Windmill Way, Hebburn, Tyne & Wear, NE31 1AT, UK

Address correspondence to Dr Jackie Gray, E-mail: Jackie.gray{at}ghpct.nhs.uk

Background Although smoking is a major public health problem, many clinicians do not routinely provide evidence-based health improvement advice to smokers to help them to quit.

Methods Plan, Do, Study, Act (PDSA) cycle methodology was used to design and implement a service development so that health improvement advice for smokers featured in all podiatry consultations provided by a Primary Care Trust in North East England. IT systems were developed to record the number and proportion of patients for whom smoking status was assessed, and the number and proportion of smokers who were given advice to quit and referred for specialist support. A questionnaire to staff explored their perceptions of the development on their clinics and consultations.

Results During a 6-month period, smoking status was recorded for all 8831 (100%) patients attending podiatry clinics; 83% of smokers were given brief advice to quit; 7% of smokers were given help to access specialist stop smoking support services. Improvements were introduced within existing budgets and did not prolong clinics.

Conclusions It is straightforward and inexpensive to develop clinical services so that public health guidance is routinely implemented. More widespread implementation of similar service developments could lead to national improvements in public health.


   Background
TOP
 Background
Methods
 Results
 Conclusions
 Conflict of interest
 References
 
Smoking is the single, greatest cause of preventable illness and premature death in the UK.1 It is also the greatest identifiable factor that contributes to inequalities in healthy life expectancy within the country.2

Recently issued national public health guidance recommends that everyone who smokes should be advised to quit, unless there are exceptional circumstances, and that all smokers should be asked how interested they are in quitting.3 The guidance also recommends that all health professionals should refer people who smoke to an intensive support service, e.g. NHS Stop Smoking Services, and smoking cessation advice should be provided within community, primary and secondary care settings for everyone who smokes.

Despite the long established public health significance of smoking and health policies that call for more front line NHS staff to deliver health improvement advice,4 there is little evidence that front line NHS services have been systematically developed to routinely treat smoking prevention as a priority.5

During the period 1 October 2004 to 31 March 2005, we introduced service improvements within one of the allied health services provided by our primary care trust (PCT) with the aim of providing smoking health improvement advice during every contact.


   Methods
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 Background
 Methods
Results
 Conclusions
 Conflict of interest
 References
 
Local context
Our service improvement intervention was applied to podiatry services provided by Gateshead PCT, a spearhead PCT in North East England6 with a resident population of 191 151, which experiences some of the worst health outcomes in the UK. Standardised mortality ratios for adults under 75 years with coronary heart disease or cancer are 127 and 115 respectively, and there are large variations in smoking rates.7 In the most deprived ward, adult smoking rates are estimated to be as high as 50%.7

The PCT commissions intensively support for smokers wishing to quit, from the Gateshead and South Tyne NHS Stop Smoking service which helps around 1300 people to stop smoking each year and provides training to health professionals in primary, acute and community settings.8

Podiatry services are provided within the PCT by the Department of Podiatric Medicine, which delivers ~36 000 specialist contacts per year. When we initiated this service improvement, the department employed 23 specialists. The head of service estimates that the majority of patients are aged over 65 years.

We worked with the podiatry team to develop a PDSA cycle9 as a model to implement a service quality improvement whereby every podiatry contact would include help for smokers. We received no additional funding for this project.

Measures for improvement
Our service improvement aimed to increase the proportion of clients for whom smoking status was assessed and recorded and to provide more help for identified smokers in the form of advice or a referral to the South of Tyne NHS Stop Smoking Service.

The project was also designed to assess the financial costs of this service development and to qualitatively explore its impact on the podiatry staff and their consultations.

Strategies for change
At the outset we formed a project team to lead the PDSA. This team comprised leaders in public health, podiatry and smoking cessation (J.G., G.E., M.W.) and health information. The project team worked with all members of the podiatry team to develop and execute the cycle.

During the planning stage, the project team worked with the podiatrists to develop a common understanding of the importance of smoking as a risk factor, the impact of smoking on demand for podiatry services, the evidence base for smoking cessation and services in Gateshead, which could help smokers to quit. The project team collated this information within a fact sheet for podiatry staff.10

The Stop Smoking Service then delivered training to the whole podiatry team. The training included instruction on how to assess smoking status, how to give basic advice to stop smoking and also motivational training. Brief advice was defined as raising the issue of smoking and the importance of quitting followed by simple advice on quitting. The motivational training component used professional actors and role play to show staff how their attitude to clients and to smoking could affect the impact of their advice to quit.

Following training, the podiatry staff developed their own clinical practice guidelines with reference to the fact sheet and in consultation with the local Stop Smoking Service.

Following production of the guidelines, the project team worked to develop the existing podiatry service electronic contact management system. At the start of the PDSA, it did not provide any opportunity for recording information about smoking status or smoking management for any contact. The updated system enabled podiatrists to record new information about each contact: smoking status (non-smokers, ex-smoker or current smoker); the type of smoking cessation advice given within the podiatry contact (none or brief advice) and the type of information the client received about the local NHS Stop Smoking Service (none, detailed information and leaflet, referral to the service).

The podiatry team worked through the guidelines and the enhanced information system to agree appropriate codes that would ensure consistent data entry throughout the service. The team annotated their clinical guidelines with the codes to ensure they were applied consistently.

The guidelines were first implemented on 1 October 2004 and the impact of this intervention was measured 6 months later, on 31 March 2005. The service continues to provide smoking health improvement advice.

After the first 3 months, the project team met to review progress and to identify and resolve any problems. At the end of the 6 months period, the project team collated and analysed the data about smoking that had been collected on the contact management system. At this stage, the service podiatry manager emailed all members of his team asking them to complete a questionnaire, which aimed to explore their experience of using the guidelines.


   Results
TOP
 Background
 Methods
 Results
Conclusions
 Conflict of interest
 References
 
During the 6-month trial period, smoking status was determined for all 8831 patients who consulted the service during that time. The results are summarized in Table 1, which shows that 1032 (12%) of the patients smoked.


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  		Table 1 Smoking status of all clients presenting to the Department of Podiatric Medicine during the 6-month period (1 October 2004 until 31 March 2005)

 
Information regarding the provision of stop smoking advice to smokers was collected for 957 of the 1032 smokers who had been identified (93%). The data in Table 2 show that 795 (83%) of those were advised to quit.


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  		Table 2 The number and proportion of current smokers who were given brief advice to quit during podiatry contacts in the 6-month period (1 October 2004 to 31 March 2005)

 
Data regarding referrals to, or information about, the specialist stop smoking service were complete for 823 (80%) of the current smokers attending the podiatry service and are presented in Table 3. These data show that 4% of the smokers were referred for more intensive support to quit, and a further 3% were given information about the available specialist stop smoking services. Fourteen of the 23 podiatrists (61%) completed and returned the emailed questionnaire sent by their manager.


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  		Table 3 The frequency with which podiatrists informed 823 current smokers about, or referred them to, the specialist stop smoking service during the 6-month period (1 October 2004 to 31 March 2005)

 
The staff's responses to two open questions exploring how the service development had affected clinics and consultations are presented in Boxes 1 and 2. Box 1 shows two main types of responses to the question ‘How did this project affect the normal running of your clinical sessions?’ The majority of responses indicated that it had usually been possible to integrate help for smokers into the consultation with minimal effects on clinic times. However, a few significantly reported that it was time consuming to include help for smokers in the consultation. The head of service reported that none of the clinics had been significantly prolonged.


Box 1A summary of the podiatrists' responses to the question: ‘How did this project affect the normal running of your clinical sessions?’

  • Depending on the patients—sometimes it caused the clinic to run late.
  • Sometimes impinged on time
  • I have found on odd occasions that a patient has really wanted to talk at length has caused my clinic to be running a bit late
  • Very little—can discuss during treatment
  • No real impact as only took a couple of minutes to ask patients.
  • Has not affected much. It's another conversation issue now.
  • Had no impact whatsoever, the paperwork was minimal and the advice was part of normal conversation
  • Didn't have any great impact other than some early confusion about codes.
  • In the beginning when everyone was being asked, it affected the normal running of clinics, but through time we may be asking four to five people a day which doesn't cause much of a problem.
  • Slight over-running on certain clinics but overall kept to a minimum.
  • The additional paperwork involved was negligible—no detrimental effect to clinical sessions in my opinion.
  • Clinics finished late.
  • Sessions were more stressful as time is always short. Patients loved to tell ‘their smoking tale’.
  • Generally, speaking about smoking was OK, but referral was just another form to fill in which we have no extra time for.
  • It was getting the question into the conversation. We review medication and history on every visit for changes, I would just add in ‘and may I ask do you smoke" and then "how do you feel about that’ if they did and then take it from there, talking about the effects on the lower limb. I am pleased that they didn't all smoke though, I would have sounded like a broken record in the end!

 

Box 2 shows responses to the question, ‘What impact do you feel the project had on your contact with each patient?’ These comments indicate that including stop smoking advice had often led to some more useful discussions between podiatrists and patients. They also highlight smokers' different responses to being given stop smoking advice. Although some smokers appreciated the advice, there were others who did not welcome it and responded negatively. Anecdotal feedback from the podiatrists indicated that some smokers were sick of being advised to stop smoking and were very resistant to advice about specialist help.


Box 2A summary of the podiatrists' responses to the question: ‘What impact do you feel the project had on your contact with each patient?’

  • For a lot, good but for others it's just another person ‘nagging’ them.
  • Helped to highlight concerns for their general health, i.e. that we are not just there to look after their feet
  • I feel that for smokers it has drawn attention to their habit and made them more aware of the impact it can have on their foot health and circulation, it has also made them aware that we can refer them for help if they want to try and stop.
  • Many patients didn't see the link between podiatry and smoking until it was pointed out. Gave me a chance to explain we're more than just ‘nail cutters’.
  • Added time but have used it to enable to talk revascular status and medical need and not just social talk.
  • In most cases, it was a positive opening to talk about all aspects of health and patient empowerment. The fact it was a new project gave a very good opening.
  • Usually fine, occasionally slightly reactive.
  • It has made some patients think about quitting and some patients get sick of being asked if they smoke or want to quit.
  • Some tensions, but some people have been receptive to advice.
  • Non-smoker—not a problem—OK/smokers—some were a bit defensive and felt under attack.
  • Having to ask every pt and give advice where necessary impacted on my clinical time—quite stressful for me.
  • When smoking was mentioned, patients sometimes felt like they were going to get told off. May affect contact but most of the time they did not mind to discuss the matter.
  • Using open questions and empathy with the social context of smoking and knowing when to see the signs that the patient may want to quit and guiding the person in the right direction has been the main benefit.
  • People are more aware of the help they can get now.
  • Has made no real difference, as most people are not interested.

 

There was no additional financial outlay for this service improvement. The main costs related to staff time out for planning and training, developing the information systems and analysing the data. Developing the information system and undertaking the analysis were the most time consuming elements.


   Conclusions
TOP
 Background
 Methods
 Results
 Conclusions
Conflict of interest
 References
 
Our quality improvement initiative showed that stop smoking health improvement advice could be introduced into the majority of podiatry consultations with minimal financial outlay and without comprehensive clinic delays.

Our data regarding the proportion of smokers (12%) attending the podiatry service are consistent with national estimates of smoking prevalence in people aged over 65 years.11

While our methods led to a high proportion (83%) of smokers receiving brief stop smoking advice, a much smaller proportion (7%) were made aware of, or were referred to, the specialist NHS stop smoking service. This may be because, as our qualitative feedback indicated, some smokers did not appreciate stop smoking advice and would not have welcomed further help such as a leaflet or a referral.

After we had analysed the results, we discussed them with the podiatry team and emphasised that they should refer more smokers to, or issue more information about, the specialist stop smoking service in order to give smokers the best chance of quitting.

Our intervention was successful in increasing the number of podiatry consultations in which the issue of smoking and the importance of smoking were raised, and simple advice on quitting was provided. However, we need to repeat our measurements to determine whether the improvements have been sustained and whether more smokers are being referred to the specialist NHS stop smoking service.

Our experience of using PDSA cycles has provided us with further evidence of their value as powerful tools for change management and workforce development. The PDSA cycle provided us with a straightforward and effective framework to initiate a service development and to identify how effective it had been. Small and frequent PDSAs are more effective than big and slow ones9 and it may have been more valuable to undertake a series of PDSAs addressing different elements of smoking prevention, rather than tackling everything at once.

We believe that the principles of this simple service development could easily be transferred into other health care provider settings to promote widespread implementation of NICE public health guidance3 and a systematic approach to smoking cessation throughout the NHS.12 Similar service quality improvement interventions could be used to address other risk factors such as obesity or physical activity. Front line NHS staff are ideally placed to identify individuals with these risk factors and to provide them with appropriate advice or help to access more specialised support services.4

We presented this service improvement project to the PCT senior management team that commended our work and celebrated it as an example of good practice to be implemented more widely throughout its provider services. The PCT intends to develop similar PDSA cycles in other services addressing other health risk factors with the aim of making every contact a health improvement contact.

One of our greatest challenges was to develop the existing IT system so that clinical information regarding smoking could be recorded and analysed. This development is not readily transferable to other directly provided services in our PCT since they all use different IT systems and are not designed to record health risk factors. We believe that new NHS IT systems should be designed so that information about health risk factors and their management can be more easily and reliably recorded in all health care settings. Such a development would support a shift towards health services that focus on prevention and treatment.

Our qualitative results indicated that some smokers did not welcome stop smoking advice and this made some consultations difficult. In practice, this could mean that clinicians avoid giving health improvement advice in order to avoid conflict and maintain a positive relationship with their patients. Further work is required to explore how patient and clinician attitudes influence health improvement activity and how society can reconcile individual treatment preferences with the need to effectively manage preventable diseases like cancer and coronary heart disease.

Helping more smokers to quit will save lives and reduce the burden of preventable illness.1 Although there have been repeated calls to provide help for smokers in every consultation,3,5,12,13 this help is not routinely provided in all contacts.5,11

The economic simplicity and success of our service improvement intervention highlights the ease with which services could be developed to have more impact on public health. We encourage clinicians, senior managers and health improvement specialists to use our evidence when developing their personal practice, service modernisation or commissioning plans to fully maximize their public health role.


   Conflict of interest
TOP
 Background
 Methods
 Results
 Conclusions
 Conflict of interest
References
 
The authors cannot identify any competing interests. Jackie Gray and Gary Eden are employees of Gateshead Primary Care Trust. Gateshead PCT commissions Stop Smoking Services from the Gateshead and South of Tyne Stop Smoking Service which employs Maria Williams.


  
 
{dagger} This project was planned, conducted and reported by Jackie Gray, Gary Eden, and Maria Williams. Clare Beard, Guy Blackburn and Pat Elms were also involved in the early planning and conducting stages, but were not involved in reporting the project. All staff in the Department of Podiatric Medicine were instrumental in delivering the service improvement. Back


   References
TOP
 Background
 Methods
 Results
 Conclusions
 Conflict of interest
 References
 

  1. Department of Health. Smoking Kills: a White Paper on Tobacco (1998) London, HMSO.
  2. Acheson D. Independent Inquiry into Inequalities in Health (1997) London. The Stationery office report.
  3. National Institute for Health & Clinical excellence. Brief interventions and referral for smoking cessation in primary care and other settings (2006) Public Health Intervention Guidance. No 1. NICE, March.
  4. Department of Health. Choosing Health: Making Healthy Choices Easier (2004) London, HMSO.
  5. Britton J. Smoking cessation services: use them or lose them. Thorax (2004) 59:548–9.[Free Full Text]
  6. Department of Health. Tackling Health Inequalities: the Spearhead Group of Local Authorities and Primary Care Trusts (2004) London, HMSO.
  7. Gateshead Centre for Enabling Health Improvement. Gateshead Compendium of Health Related Statistics. http://www.cehi.org.uk/06_health_topics/statistics/ (11 October 2006, date last accessed).
  8. Billet A, Lambert M. Are Stop Smoking Services Reducing Inequalities in Gateshead – a Health Equity Audit (2006) August. Gateshead PCT.
  9. M Berwick. Improvement, Trust, and the Healthcare Workforce. Qual Saf Health Care (2003) 12:2–6.
  10. Gateshead Centre for Enabling Health Improvement. Smoking Fact Sheet. http://www.cehi.org.uk/documents/CEHI%20Smoking%20Factsheet.pdf (6 October 2006, date last accessed).
  11. Lader D, Meltzer H. Smoking related behaviour and attitudes, 2002 (2003) London. Office for National Statistics.
  12. Coleman T. Smoking cessation: integrating recent advances into clinical practice. Thorax (2001) 56:579–82.[Abstract/Free Full Text]
  13. 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) 53:1–18.[Web of Science][Medline]
  14. Britton J, Knox AJ. Helping people to stop smoking: the new smoking cessation guidelines. Thorax (1999) 54:1–2.[Free Full Text]

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