Articles, Blog

Webinar: Smoking cessation and severe mental illness

February 26, 2020


Hello and welcome to this afternoon’s
digital event around smoking cessation and severe mental illness. My name’s Rose.
I’m part of a social enterprise called Kaleidoscope Health and Care and I’ll be
hosting today’s webinar alongside my panelists today. If you have any
technical difficulties, if you’d like to share the video with a colleague, or if you
enjoyed it so much that you’d like to watch it again, don’t worry because we
will be recording this event and you’ll be able to find it on YouTube later. So
today we’re going to be exploring the topic of smoking cessation. We’ll share
learnings from the research project so far and we’re going to explore how we
can put these findings into practice. So this webinar is part of a wider project
which is commissioned by the VCSE Health and Wellbeing Alliance, which is a
partnership between Department of Health, NHS England, Public Health England and 20
national voluntary sector organisations and consortiums. And so the Alliance aims
to bring a voice to the voluntary sector and people with lived experience,
international policy making, to promote equality and reduce health
inequalities. So the Association of Mental Health Providers, Centre for Mental Health and Rethink, as members of the Mental Health Consortium, are
leading on this project in particular alongside health and wellbeing partners.
So it’s involved extensive engagement with people with lived experience and the
VCSE sector and will culminate in the production of a suite of resources
including a report to outline the findings and case studies which Curtis
will talk about in a little bit. So I’m delighted to introduce my panel today.
We’ve got Curtis Sinclair from Centre for Mental Health who’s going to share his
research to date. We have Kevin James who’s a peer consultant, he’s going to
share his lived experience. And we have Paul Cilia La Corte from NHS England
who’s going to share the policy perspective. We’ve also got Peter on tech
and Chloe on Q&A, so please do start sending those through. So we’re
going to start with a quick poll to see who’s tuned in today so on screen you
should see a few options – if I had to pick I’d describe myself as?
So as you can see it’s clinician or practitioner, someone with lived experience,
someone working in policy or VCSE, researcher or something completely
different. Great, so we’re going to close the poll
there. Great! So it’s great to see we’ve got
quite a mix of people tuning in so especially in the sort of clinician/practitioner
and people working in policy and VCSE. Thank you, Peter.
Great, so there’s lots of different ways you can get involved in this webinar
today. As you can see from the slide which will be on your screen now, you can use
the ‘ask question’ feature on your screen. Just click the question button, type in
your question and we’ll come to your point in the discussion. You can email us
at [email protected] so please send through any suggestions,
comments, advice or questions and also please do tweet. We’re using #SMIsmokingcessation
and #HWAlliance and our twitter handle is @kscopehealth. Cool, so we’re going to go onto our second poll for
today. You’ll see on the screen we want to sort of get an idea of how much
do you know about this topic. So on the screen you’ll see different options including nothing at all, a little bit, quite a lot, I have personal experience,
or I could write a book on it. Great. Thanks Peter, we’ll close it there. Cool. So you’ll see the results on the
screen. So a mix of people tuning in, from people who know just a little bit
about it and to people who know quite a lot. No one’s written a book on it just yet but maybe at the end of this webinar
they might be able to. Brilliant. So next I’m going to introduce
Curtis Sinclair who’s going to talk about the research to date.
Thanks, Rose. Good afternoon to everyone joining us. I’ve got a very small window
to provide a brief update on the work that we’ve been doing on the smoking
cessation research project, including a bit of background to the project and
what work has been completed and also to touch on some initial findings. Can I
have my first slide please? And I’m sorry, the next one as well
please. So just to give a brief overview of the context and the
importance of this project. Certainly it’s rooted in the poorer
physical health outcomes faced by people with severe mental illness and smoking
contributes disproportionately towards issues such as reduced life expectancy
and several other health inequalities in comparison to the general population. In
addition, this group were more likely to smoke than the general population and to
smoke more heavily. Yet interestingly, motivation to quit is no less than that
of the general population. And it has been argued that what works for the
general population also works for people with severe mental illness but before
reaching this stage of offering support it makes sense that we must know who
needs support and how many people require access. Unfortunately, this is one
of several problems that are flagged up in the literature in the current
pathways that severely hinder the support being offered to people with
severe mental missing to quit smoking. Therefore, the aims of this project, broadly speaking, were to identify these
gaps but also to shine a lens on examples of good evidence-based practice. And on
the next slide you’ll see that we’ve taken a mixed method approach to achieve
the aims set out, drawing information from surveys workshops conducted by Rethink, interviews and case studies; much of which has been informed by a
comprehensive literature review which was undertaken by my colleague Joe
Wilton at the Centre for Mental Health. It was hoped that this approach
would help to draw out both lived experiences around access in smoking
cessation services, but also the views of professionals who might be asked to
support commissioned services. And after today with all the workshop and
interview data collected I will begin the process of thematically analysing
the data. You’ll see on the next slide a summary of the more pertinent,
emergent themes from the literature review. For me, one of the
central issues relates to the beliefs and norms held by either the person with
severe mental illness, significant others and/or healthcare professionals. For
instance, in the case of healthcare professionals, what came out in the
literature review and to some extent the survey data, is it’s not uncommon for
smoking cessation to be viewed as a difficult process that should be avoided.
Also, compliance by both the service user and the service provider are also pivotal in
creating the conditions for a successful quit attempt. For instance,
attendance at less than 75% in a particular study
was predictive of relapse. The emergent themes from the survey and
workshops on the next slide lend support to the wider findings outlined in the
literature review. Respondents were primarily heavy smokers who had made at
least one quit attempt in the past and reported willingness to try again in the
future. Typically participants were motivated to
quit but often lack confidence in maintaining abstinence and in some cases,
certainly in the workshops, some felt smoking was a good stress reliever.
Lack of access to support individual needs was apparent, such as feeling as
though options were limited to nicotine replacement therapy, rather than other
pharmacotherapy options. In terms of what helped people to quit in the past
and might help in the future included drawing on personal qualities, e-cigarettes, gums
and patches. But more importantly, there was a great range of individual
variation in what was reported to be useful and this lends support to the
finding from the literature for taking a much more tailored approach to smoking
cessation. Responses from commissioners and practitioners, who tended to be
working within the NHS, indicates the main challenges identified with low
success rates, high relapse rates, lack of uptake of services and lack of appropriately skilled workforce.
Typically, findings were again in line with themes from the literature review.
I want to finish with the next slide by highlighting several excellent
sources of research and guidance to draw from in helping to
better design effective services. In the case of SCIMITAR and Care2Quit,
these are great examples of adapting general population manualised approaches
specifically for working with people with severe mental illness. The ASK,
ADVISE and ACT guidance by Action on Smoking and Health
tackles one of the major issues already raised across surveys, workshops and
literature to tackle the capturing of who smokes but, more importantly,
providing some immediate follow-up actions regarding smoking cessation. And
the references to the other sources will be made available after
today’s session. Hopefully that gives you a flavour of what is to
come in the shape of the final report later in the year. Thanks. Brilliant. Thank you Curtis
for sharing the key findings from the research so far. We’re going to go on to
the slide again about how to get involved today. So if there’s any sort of key
reflections you have from Curtis’s session then please do send through
comments, reflections and questions to us. We’ll also have the slides available as
a handout which you’ll be able to see in the GoToWebinar function as well. Great. So next we’re going to talk to Kevin who is a
peer consultant and is going to share his lived experience of this topic. Kevin,
you’ve heard about the key findings from the literature review.
How does this resonate with you? What it identifies is that it’s a very complex area of
health care and certainly I think the findings identified that people who
need to be able to engage with smoking cessation services that there needs to
be more than just a one-size-fits-all approach to how we engage with people. So
I think how we can best help people to get the best out of services is
that I’m really interested in the aspect of patient flow and also making every
contact count. So wherever a person with lived experience, a service user, presents
themselves, whether it’s a GP surgery, whether it’s that they unfortunately need to
stay on an inpatient ward where it may be that there’s a consistent approach
and a consistent conversation with people about what options there are in
respect of helping them to achieve their goal, if their goal should be that they
want to give up smoking, help them to best access that. So the patient flow
bit I mean is that there needs to be smoking cessation
classes on inpatient wards, there needs to be conversations with people who need an
inpatient stay about how best to help them, if they have capacity that is. I
think the complexities start to creep in when it might be a short inpatient
stay for somebody and then they’re back out into the community and it’s about
that that lack of a joined-up approach. So once you then go back into the
community, if you are supported by a community mental health team, are there
smoking cessation advisors based in those teams? Are there classes? Are there
psychological interventions that people can access? And indeed, the same for
primary care. If you are discharged back to your GP, where is that consistent
joined-up conversation, that consistent conversation, because
with me, I definitely wanted to give up smoking,
knew the harmful effects of smoking. However, I was battling with
socio-economic challenges that meant that I wasn’t particularly at a stage
where I could give up smoking. So whilst people are trying to navigate the housing system and trying to get you
know stable affordable housing, whilst they’re trying to navigate the NHS or
the benefits system you know it doesn’t I guess the one focus, it needs to
be right for the individual and we need to accept and acknowledge and respect that
it needs to be right for the individual when they’re ready to make that choice
and always to be there to support them and be mindful that certainly for
myself it took many many many attempts to be able to quit smoking. I think it’s also
about changing the nature of the conversation as well so
everybody knows a bit like with your physical health, less input more
output. So eat less, exercise more. I think people need to be aware of the
the facts that can really give them the incentive to maybe want to give up
smoking. So, for example, if you do quit smoking successfully maybe you can
reduce your medication by 50%, for example. So 50% less mood-stabilising
medication, say less weight gain, less side effects
of craving sugary, starchy foods. But I think what the
report has identified is that we are a crossroads, we do want to enable,
empower, support people to make better lifestyle choices. But the reasons as to
why people continue to smoke are very relevant and very important.
So people would smoke because they perceived it may be
better for their mental health so having a cigarette calms the nerves, it soothes you.
Also the action of you know pulling out
tobacco and rolling a cigarette, if that is the way you smoke, and smoking it.
This is about finding other ways that people can
engage and how we can maybe detract people away from thinking
that smoking is a coping mechanism for them. And I’m sure it is, but we
need to present other options that work far more holistically for that
individual other than them choosing to smoke. And also, smoking poverty.
People will be smoking and not being able to afford to buy healthy food
or paying their bills and then you’ve got counterfeit tobacco. There’s all
sorts of real challenges that people find themselves in when they
continue to smoke and I think we’ve got to get better at how we consistently are
there to enable and support and empower people to make good lifestyle choices
in respect to smoking but understand that it’s really complex for that individual and we need
to come up with a range of different interventions and support mechanisms
that can enable that person to give up. And I think that reflects a lot in
terms of what Curtis was saying about the need for individual
support and some personalised support as well. Maybe you could talk a little bit
more about the need for tailored support and how that fits in as
well with different sorts of services. So tailored support, I think when I first started, I’m a reformed smoker so I’m
probably one of the worst people you’ll meet as a reformed smoker, because I’m very
critical of people who do smoke. I remember the whole kind of conversation
early on about becoming smoke-free in NHS hospitals and I thought that’s a
really good thing. What I’ve learned since then after speaking to many other
people with lived experience and also practitioners and nurses and other
people is that it can become a real conflict I guess in
respect of we’re kind of dictating to people that whilst you’re with us on an NHS site, which may be an acute
hospital or it might be an inpatient one, that you’re gonna stop smoking but we
don’t follow other or promote other healthy lifestyle options whilst people
are, you know, I have a visit in the hospital so you know some hospital
atriums have fast food outlets in it. What kind of message are we creating
there? When people come and stay on inpatient wards in mental health settings, we’re encouraging them to use
e-cigarettes or other nicotine replacement ways of helping
them to stop but yet we’re feeding them food that’s full of salt, sugar and fat
so it’s a very kind of contradictory message and I think that the people who
do smoke aren’t aware of different types of medications that can help them to quit
smoking. When you go and see a GP you’re lucky to get sort of
five to seven minutes with a GP and you’ve got to pick and choose which
aspects of your comorbid complex health condition that you’re gonna be speaking
about. So I don’t think GPS are probably in the strongest place to be able
to enable and support people. So I guess what I’m identifying really is that it’s a
really complicated process. It doesn’t really seem to be owned via either
primary care or secondary services and there may be smoking cessation clinics
and things but it’s got to be what works for that person
at that time. If people are on inpatient wards and in there for a
short stay, maybe two or three days, we’re saying you need to give up smoking and
here’s a different option but then they’ll go back out into the community
and then they’ll start smoking again so it really is about who picks up the
the opportunity to continuously work with that person, whichever area of health care
they pop up in really. Thank you, Kevin, and thanks for sharing your
perspective I think it seems to chime in with the key findings from the
literature review and it’s great to have that perspective in particular. Next
we’re going to move on to Paul who’s going to share the policy
perspective. Before that, we’ll just put up the slide again about how to get
involved. So if you’d like to ask Curtis or Kevin any questions or any comments on
or reflections on the sessions then please do add them into your question
box and also remember the hashtag is #SMIsmokingcessation and
#HWAlliance. Brilliant, thank you. Paul, over to you. Thank you and thank you
for inviting me to come and talk. I think trying to give the policy perspective
could be very dry so I’m just going to try to give a little bit at background
feels a little bit above what Curtis has says in terms of smoking and mental
health but also about the Long Term Plan and what we’re trying to do moving
forward with the Long Term Plan. So as per some of the previous documents published
by the NHS, the Long Term Plan does highlight prevention but this time we’re
trying to do something really different. We’re trying to really do something
proactive around prevention to actually help people move forward, which is why we’re
particularly focusing on tobacco addiction and the dependence that people
have and doing something proactive to actually start the ball rolling in
secondary care and also in primary care and community care but also in conjunction
with local authority services. So why smoking and mental health? Well there
are huge health inequalities. It was highlighted before in one of the earlier
slides. We know that people with common mental illness there’s 36%
prevalence compared to a national prevalence rate of about 14.4%
that rises with serious mental illness up to about 40%
and that again when you combine it with poverty can raise to 50% and then
in inpatient settings there are reports out there that say 70% of people
with an inpatient population do smoke. And there’s something there about
acknowledging that the NHS has a role to play. We know that some local authorities
deliver smoking cessation services. We know that the NHS in different areas
provides it. And we know that in some areas they just don’t have a huge amount of
services available to be able to access. So we need to do something bigger there.
We know that in mental health people die 10 to 20 years earlier than their peers
and we know that smoking is the biggest single cause for that mortality rate.
So we know we have to do something. We know this is driving health
inequalities. We know this is driving mortality. And there is an opportunity
for the NHS to turn around and say we’ve got patients in front of us, we’ve got
the opportunity to do something, to do something positive and to help people.
And we know that people want to quit. ASH has published survey results before that
shows that people are still worried about the health, they’re just not given the
opportunity. Again, that was highlighted in the slides. It’s something that we
have the opportunity to do something and just reflecting on what Kevin said, it’s
about making sure that we’re there when people are ready to do something. So we
know that people want to quit, we know that they’re worried about the health,
and we know they’re not necessarily given the opportunity. But we do know
that the medications do work, we do know that they’re effective and that they’re
tolerated. So why aren’t we doing it? And that’s what we’re trying to pull
together with a Long Term Plan. We’ve looked at tobacco dependence across the
board, we’re looking at doing work not just in mental health services but also
in acute trusts and in return services, really trying to drive change to NHS
perspectives to put this back onto the map and to actually turn around say
we’re going to stand up and do something for our patients. And so we’re putting
new money in and we’re focusing on secondary care because that’s where a
lot of the evidence about the interventions works but we know that
that’s just start of the journey. We know that we do need to branch out into
community services, into primary care, we just need to understand what works best
for people when we do that. I think what we want to do is be in a position in a
few years time that every person who comes into contact with an inpatient service, whether it be acute trusts, whether it be mental health, is given that
opportunity to beat their tobacco dependence. We know that part of it is an
addiction to nicotine, it is a medical condition and there are drugs – nicotine
replacement therapy – they can support that and what we can do is give people
access to that at a time in their lives where something is happening and they’re
more likely to take on that opportunity to change their behaviours. We don’t know
what model will exactly work within mental health, that’s why we’re doing
part of this work and that’s why we’re having these discussions. We need to know
what works and what works where and understand actually in different areas,
for different people, different things will be the right thing to do. So we’re
putting money into the system. We’re starting in secondary care. We’re going to put a
model in that will make sure that people have access the pharmacotherapy, they can
access that behavioural support. One of the key foundations of that is it can’t be
the NHS in isolation. It needs to be done in conjunction with local authority
partners, in conjunction with the third sector. People need to be
aware of that wider offer that’s available to them. So from next year
we’re working with a few sites to really test what we want to see happen over the
next three, four, five plus years. We’ll work with them to put money into
turn around and say alright we’re going to do this in inpatient settings but then we
need to understand what happens when that patient walks away from a forced
abstinence within an NHS trust because it’s smoke-free. What happens when they
go home and they’re right back where they started with all the social cues
that helped them smoke in the first place and then we need to take that
learning and just understand what we can do. We need to look at what’s already
happening in the system. Nothing that we’re planning on doing is rocket
science. Somewhere they’re already doing something and it’s working really well
for that local population so how do we find that, acknowledge that, and make sure
that everybody else can turn around say well we want a piece of that, we want to roll that
out. And it’s about acknowledging that it’s this about the pathway. You mentioned
patient procurement. It’s not just about looking at medicalising. What happens in
inpatients, chucking a load of nicotine replacement at people and saying there we
go we’ve helped you, off you go, start the rest of your life. We need to make sure
that it’s acknowledging that these people might need three, four, five, six, seven,
eight, nine, ten attempts to quit, but it’s about being there when
they’re ready and actually supporting them to do that. And it’s about making sure
that they don’t fall between the cracks. When they leave hospital or when they’re
in community services and they leave those services, it’s about making sure
that there’s a pathway for them to progress on to. And we just want to know
what works and we’re willing to learn over the next few years. Thank you very much. So we’re going to be moving on now to your
question and answer section and so we’ll add the slide again about where you can add
in questions. We’ve already had some great ones in so far so please do keep
them coming. Peter, do you mind adding that slide onto the screen? So again, please do email us, add
the question feature or tweet as well. Brilliant, so we’ve heard from all
the speakers. I think I’m going to start with one of the first questions around
where are we seeing particularly different trusts or different examples
where people have successively led smoking cessation change in their own
organisations and so Paul I don’t know if you have any particular reflections
on this from sort of your work NHS England that you’d like to start with? Say the question again? So are there any particular examples of where you’ve seen successful
change? – So I think there’s lots of isolated good examples of different bits
of practice. I don’t think I could turn around and say here’s one trust. They’re
doing it amazingly well, let’s photocopy exactly what they’re doing
across the whole of the NHS. It’s about actually recognising that a trust in
rural Cumbria might want a very different service to inner-city London.
So I don’t know there’s one trust. We do know that there’s areas, South London and
Moseley are ones that are held up to me. I don’t know exactly what they do there
and it would be fun to learn what they’re doing there but we’re gonna be working with
a couple of early implementer sites next year to really sort of test this out.
We’re going to work with sites across a large geographical footprint
that have different rural and urban areas and they will sort of test
different aspects of what we want to do and they will actually give us that
learning, and at the same time we’ll be able to promote what they’re doing, share
what they’re doing, and then hopefully promote other services to step up and say
actually we’ve done that, we’ve done it in this different way. And I think it’s
recognising that not one site will have the answer for everybody but what
hopefully we’ll be able to do is have a “menu” of interventions, something like
that, hide away from the tool box issue analogy but so making sure we highlight
where we know there’s good practice and go to but if people do know areas of good practice,
please do get in contact through the email address. Brilliant, thanks Paul. And so next we have a
question which I’m going to ask Kevin around how best we can support
and encourage people to take part in smoking cessation services? – How can we
best encourage people to… – So to take part in smoking cessation services.
So are there any particular reflections from sort of your work that you’ve done in
the areas? What can we do to encourage people to take part? – I think it’s about creating the right conditions for change. So as I alluded to earlier it’s
addressing the reasons why people smoke or why people choose to
smoke. And when it’s seen as by the smoker a therapeutic intervention, i.e.
helps them to manage stress, it helps them to manage their mental health, then
we need to be looking at the reasons as to why that is. And as I said earlier,
some of it’s about you know chaotic lifestyles and not being, living
in stable environments and not getting a joined-up service. So I think it’s
looking at the person. It’s not a one-size response. So we need to
look at people individually and see what’s going on for them in their lives,
try and understand why they’re making that choice, if they feel it is a
choice, because it’s also an addiction for some people so they feel they may
not have a choice in that. It’s about giving people the
best opportunity to be able to make the choice to give up smoking and it comes
back a little bit to the to the patient for a bit. I think part of the answer to the question you had before was I’m sure
there is a perfect service out there because it exists in different bits all
over the country and if we could identify all of those bits that work well
in different areas of engagement and put it together. So I think it has to be
tailor-made for the individual, it needs to be something that benefits them. A lot of people will say that they smoke because they’re bored, they
like going through the process of making a cigarette and smoking it and some other
people will say that they find it soothing, it’s calming.
Whether there’s any scientific evidence to prove that I
don’t think there is but it’s about people’s perceptions isn’t it and if
that person perceives that smoking a cigarette is good for their mental
health then we need to be honest and acknowledge that but it’s also about
poly-use of substances as well. So if people are drinking and smoking,
those two substances complement each other really well in respect.
So it’s just, remind me of the question again? So it’s around how we can
encourage people to use stop smoking services? Okay so it’s about incentives
isn’t it and I think part of the incentive is giving people real life
information that can help them make an informed decision. I think about, you
know, I certainly know when I stopped smoking my taste improved, my sense of
smell improved, I was able to reduce my medication by 50% which meant
I carried less weight, there’s all sorts of health benefits but if
we’re not we’re not addressing the negative causalities of the
reasons why people are smoking, if we don’t deal with that bit then people are
never going to get to the point where they feel that they’re able to give up
smoking. – Brilliant. Thanks, Kevin. And
does that resonate with you in terms of the research to date and the
literature review that you’ve done? – Absolutely.
I think from the perspective of what is out there already in terms of the
workshops, people spoke very much about the timing being right and if the
timings not right then being asked about whether they’re ready to quit smoking
almost feels like they’re being nagged rather than it being a positive approach
and encouraging in that way. And that’s certainly something that comes out
of the the Care2Quit study, which was a preliminary small-scale study that
was focused on finding a support person which might be the person’s
partner or family member or friend and giving them the skills to encourage the person to seek out
smoking cessation information, not just necessarily the different services. And that
was very much around tackling some of the misconceptions and myths around
mental health and smoking and I think that again comes out in the literature
review, the workshops, the surveys, is that kind of misconceptions are held by
family and friends but also professionals working in mental health.
And so I think those are some of the areas that could be really useful to try and
focus on and tackle and those I think can be done now rather than later and maybe
don’t cost very much clear to implement as well. But equally, having a
collaborative approach where a person is given the opportunity to say what their
concerns are, what what they feel would work and having all the options
available to them is again something that not everybody is as experienced
where they may just be offered patches or gum but actually there’s better options out there in terms of pharmacotherapy and medications
that just aren’t prescribed to people. – Yeah, I think that reflects and one of the
questions that’s come through from Nora which is around whether we should
have smoking cessation drop-in clinics within mental health services
and within those clinics in particular. – I just wanted to support a little bit of what you said because I think adopting a culture
of non-blaming and non-judgemental of people who choose
to smoke is really important. And also it’s about not setting people up to fail. So
if you’re delivering smoking cessation classes or interventions to your service
user, if they’re going home, their family smoke, their partner smokes, they hang out
with their neighbours, their neighbours smoke it’s actually about what’s good
for everybody and not just that person with the severe mental
illness. It’s kind of like how we get society on board in respect of it’s kind of
everybody’s business I guess. When it comes to Nora’s question
about cessation drop-in clinics, absolutely we should have some form of clinic, or
intervention, or a smoking cessation champion, for want of a better
word. And also we should make those open to staff members as well huh? Because a
lot of people who work in mental health services who are staff members smoke
themselves and I think that adds another layer of complexity to the
conversation that you’ve got staff members encouraging service users to stop
smoking but yet you know during their break they’re nipping off site, maybe nipping off site unless they’ve got hidden place like most staff do and they’re
having a fag themselves and then they’re coming back onto the ward and
they’re smelling of smoke and you’re sat there and you think hold on a minute, you’ve been off for
a cigarette, I can’t have one. So again it’s about that joined-up message
isn’t it. But yeah absolutely we should have some kind of something on that’s ward-based
but again, there needs to be that same kind of presence in primary care or
within community mental health teams that when that person leaves the ward
it’s about the next step. Who then is going to pick up the support for
the individual. So for me it’s about that, not
setting people up to fail. And I think by having interventions like that, ward-
based interventions are really good for people. Briefly just to kind of touch on what you’re saying about not setting
people up to fail, I think one of the elements that does come out in the
literature is around the use of harm reduction so, you know, cutting down
before quitting, or using cutting down NRT as a first step
whilst you’re kind of exploring how else you might take the smoking cessation
intervention and further. So I think that’s a useful tool to have available
and to provide people as an option. – Paul, I don’t know if you have any reflections of
how the smoking cessation and mental health services work together? – I think in a lot of places
they are currently disjointed. I think that is an absolutely
ideal way to make sure that we can draw upon the work that the
local authority smoking cessation services do really well at the moment, is
doing really well with the behavioural change support. There’s lots of services out
there that are incredibly helpful for people but people only access them when they’re
motivated to actually access them. It’s an opt-in service. Whilst people are an
inpatient, they can’t necessarily do that especially within the mental health
services. So actually having people to come in, sit down, maybe do some group therapy
with people that are sat there in that environment and being able sit down and
start to build those relationships and build that level of trust in a safe
environment for someone so that when they go home, when they’re back in front
of all those normal social cues, they can actually turn around and say I
know who I’m going to, I know where I can go to for additional support and that
might be in addition to support that’s put in by the NHS in primary care or in
community services and it gives the opportunity for people to start to
build the relationships, recognise that face. Sometimes that’s as big a
motivation, it’s that you’re going out and you know you’re going to be able to see,
you know you’re going to see them, you’re going to follow through on that
promise that you made a few weeks ago or a few days ago and you go out and you
meet them. And I think that’s an ideal opportunity. It’s also an ideal
opportunity for the cross-pollination. It will help staff to get involved. It will
help staff to see how they can just be supportive and those little bits of
motivation – on day three: you’re doing really really well, you’re nipping outside,
how about we come and make you a cup of tea. Let’s just distract
you from thinking about what you were thinking about to go out there and have
a cigarette. And they will learn from having those people there and having
those people there I think is invaluable for making sure that local
authorities and the NHS work together and build those relationships. – What I see on NHS trust sites are, you know, it’s really difficult
isn’t it when patients, service users have leave from the
inpatient ward and when they go on their leave they’re gonna go and smoke. You
know they might have some leave to go into the town or the nearest…
It’s really difficult and you know we’ve got staff groups who
nip out for a cigarette or you’ll see a cohort of people with lived experience with the
cleaning staff, which kind of comes onto the barriers and the
implementation of smoking cessation policies
and how they’re written and implemented. Again, I just see staff who don’t particularly want to implement policies around smoking cessation
because they’re trying to build a therapeutic relationship with that
service user and what they’re doing is being not adversarial but quite
challenging and saying there’s rules here and the rules are that you can’t smoke.
It’s that when people are really struggling with managing
their mental health problems then you know the last thing they want to be
thinking about is stopping smoking so I mean it’s kind of how you
have the conversation and when you have the conversation is the really important
part. If you are gonna have policies and develop policies it’s about
making sure the people who are gonna be benefiting from that are part of the design of those policies. It’s that whole kind of
co-production element of it rather than the kind of I’ve got something it was
written you know in a room by a few staff members and they just crack on
and implement that. Staff consistently feedback to me that they
don’t want to be implementing the policy because they’re trying to build
relationships. Then you’ve got smoking rules within community
settings. If you’re in your own home and you want to be visited
by a mental health nurse you know you’re not allowed to smoke in the house for up to
an hour before the visit. Staff feed back that they’re quite happy to go
in a patient’s home, service users home, irrespective of whether they’re smoking or not. So it’s really complicated. I don’t feel that a lot of policies have been designed
correctly and I think they’re quite muddled and difficult to
interpret and even more difficult to implement. – Thank you. So we have another question through from Samir who’s asked
about how we can address the wider determinants of smoking and poor
mental health. So I know we talked a bit about the impact of poverty on that as
well. I wonder whether Paul you’d like to start in terms of talking about the
intervention services to address these sort of wider determinants, whether you
have anything on that. It’s difficult because I think the wider determinants are different for
different people in different situations. So there has to be an element of
tailoring the interventions for that individual. I think there’s a key role
for people within the NHS to think about what are the wider determinants of mental health. You
mentioned poverty, housing is always a key one. We know that as part of the homeless population, there’s much more likely to be a smoker and have other substance misuse
problems as well. So we need to be holistic in what we do. Back at the ranch
where I work we’re looking at tobacco and alcohol together. How do we support
people to do that at a national level but in trusts there needs to be that
acknowledgement, Kevin mentioned it, we’ve got to tackle the reason why. Is it
because everybody at home smokes and it’s just the thing to do? What can we do
that’s novel? I mean the NHS we will treat the people that are in front of us.
We’re not very good at treating the people that aren’t in front of us and
indeed you could argue that’s a public health function and that needs to be
picked up by local authorities but this is why it’s key that we all work
together, that we’ve gotten the new staff that’re coming into the NHS that
are going to work across the third sector and some of the social
prescribers. They can have an absolutely key role to understand what’s happening
locally that we can actually turn around and say actually we can do a bit as the NHS, we
can link you into the bit with the local authority and actually we can nip off
your housing issues, these other issues, but actually we know we’ve got a peer
support group in the community that this person can put you in touch with and
we can maybe link you into some talking therapies and other elements that might
be there for people but I couldn’t give you a list here and now to tick
them off. – I think you picked up a really interesting bit. One of the determinants might be that we’re quite good at discharging people from mental health services. We’re not very good
at inviting everybody into the conversation or the meeting around
about how we discharge people and that would be an opportunity to invite in a
smoking cessation practitioner maybe. But also we make it really difficult for
people to access mental health services in a timely fashion when they really
need it and that could be a determinant of why people continue to smoke
because if you’re saying, listen you got to wait 12, 18 months for psychological
interventions or you’ve got to wait three months for a care programme approach
meeting, or you’ve got to wait wait wait wait wait, we’re not giving people the best opportunity. We’re not conveying a message of
we care – of course we do – but we’re not we’re not giving that
person the best opportunity to do that. So I think it’s about getting the
discharge bit right I mean you’re always going to struggle to get a GP into a CPA
meeting but there’s other people involved in your care, where it’s health
and social care, it’s about giving that person the best opportunity to help them
to succeed, and I don’t think we do very well. Part of the work we’re doing, partly putting new
money into the system and driving people to say if you’re going to take this
money and we want you to take money you need to work together,
you need to identify the service, you need to identify this pathway, they
should be identifying that key person to put people in touch with. That might be very
different in Norfolk and Suffolk to Cornwall, but that named individual that people would hopefully be able to pick up the phone to them and say I’m having a bit of a wobble, can I just talk to someone and that they can get them in. I’m not
talking about everywhere having fast-track services. That would be ideal
but we’ve got to recognise that this puts constraints on the system but we
need to be able to figure out what works locally for people and give them the
opportunity to access that. – Okay Curtis do you have any reflections, particularly in terms
of how different services work together even beyond smoking
cessation and mental health services in the review or in the work? – Yeah I mean I
think many of the points have already been raised by Kevin and Paul but
certainly I think one of the things that needs to be coming out of the report is
about emphasising this need for embedding mental health
into smoking cessation services but vice-versa smoking cessation to be
embedded in mental health services and I think that will make it easier to combat
some of the issues that have been raised, specifically by Kevin. I
think that’s it from my perspective in relation to
the issues that are faced in terms of accessing services. – We are almost out of time for questions and in a moment we’re gonna go into closing
reflections panel so I’ll leave you to think about that but time for
one last question We’ve had two in from Eileen and
Richard which are kind of talking about particular stop smoking services or
interventions so around sort of things that can be put in place, like not
having smoking in particular areas or using vaping as a form of sort
of minimisation as well. I wonder if if any of the panel has any particular
reflection on those sort of policies that can be put in place or different
services? – I think it’s good that Eileen is saying that her local mental health
trust has relaxed the smoking policy. I think that having such a rigid set
policy again, policies for the most part haven’t been co-produced with the people they affect the most. And that’s
not just a service user, that’s a staff member that has to have the challenging
conversation or stop someone from going off to smoke, relaxing that. I think we do
need to revisit those policies and see if they are fit for purpose and as I say
for the most part I think they’ve been poorly written
and even more poorly implemented in a way that certainly when staff
members talk to me or indeed service users they find it quite contradictory and
confusing what’s in the policy so I’m not saying could we have one standard
policy for the whole NHS because that wouldn’t work but I think for me
it’s about maybe pushing the pause button and just revisiting the
conversation within your own areas of the country
and just having a joined-up conversation with other providers, public health,
because I agree with you, it isn’t just a business for the NHS and it can’t be. It
needs to be everybody’s business but yeah I certainly think that’s a good
idea. – The practicalities of it as well, there’s another report by ASH
where it talks about what providers do on a typical day versus for the best
practice and most people say that you know we won’t help someone to smoke on
the hospital grounds but 60% will say that that’s their best practice but
actually, sorry 25% will say that’s best practice but typically
60% of people will on any given day take someone for a
cigarette on the hospital grounds even when there’s a policy in place to
suggest that that shouldn’t be happening. So I think there needs to
be a common-sense approach like you’re saying. – I think one of the secure units
in Norfolk doesn’t own the land around the unit and the policy is you can’t
smoke on the NHS land but yet when people get leave from hospital they will
walk the perimeter of that hospital with a staff member and the staff member
saying you can’t smoke on NHS property and they’re going but you don’t own this
property and our company does. Again, those kind of
complexities and challenges come up all the time so I think this is a
good opportunity for us to kind of have a conversation about it. I don’t think a
one-size policy will fit everybody, of course it won’t, but I do think we need
to apply common sense to this because you know some inpatient will say you
know they’ve never got lockers in a kind of an airlock bit of access in an
inpatient ward where they hold on to your lighter and your cigarettes and
when you come out on leave or whatever they’ll give you that but I mean I just
think there’s so many practices that are being implemented and some aren’t that
it’s really confusing for both staff and service users and I think there needs to be
some national guidance on this really. – I said there is some national guidance.
Unfortunately we’ve been on a journey for the last four or five years to move
to a smoke-free NHS and that is the national policy that there should be no smoking on
national grounds and that said I recognise that it’s very difficult to
enforce and I know there’s lots of areas and I suspect is what’s happening
Eileen’s instances that they’ve relaxed the rules locally to try accommodate the
patients that are there. But that said, it’s just why we have gone down that route. – Maybe the guidance could be to allow
local trusts to have a common-sense approach on how they apply
the principles of a no smoking policy because it does cause so much
tension between staff and service users and families and we are asking
people at the very most vulnerable moment to be thinking about
going smoke-free and of course we want people to live long,
fulfilled lives but I think there needs to be maybe
some evolving of responsibilities to say to trusts, obviously we want everyone
to be smoke-free but the who, the how, the where and the when can give a bit
more freedom to today’s trusts around how they go about that. – We’re quickly
running out of time but I’m gonna ask each of our panel to share a closing
reflection from the discussion today and different presentations as well. Paul would you like to go first? – I think something Kevin said really resonated with me. It’s that consistent approach I
think I repeated it a couple of times. So that’s why I’m reflecting on it.
We want to do what we want to do and relating into the smoke-free comment
it’s about making sure we get that support to people as quickly as we
possibly can do but it’s making sure that we can offer that support when it’s
the right time for the patient as well and making sure that if that support
works today yet they relapse and they start smoking again in a few weeks time
that we’re there again for them and making sure that we consistently make that
offer to people and do the best we can to help them and beat their tobacco dependence. – Kevin? – I think for me it comes back to the patient flow bit about
wherever I may present as a person with SMI who smokes, that every opportunity is
taken to engage with me and have a conversation, a recovery focused
conversation, not a blaming one, not a holding to account one, not a challenging one, and
making that every contact account for me. But as
we’ve identified there probably is a good service out there that exists in
different parts around the country but I need that support to follow
me in and out of services and I like the idea of having peer groups in
communities for people but there’s many people who will be suffering agoraphobia or social phobias who won’t be able to engage in find that useful. So it’s
a range of different interactions and interventions that are tailored to that
person and I think the bit about making it everybody’s business not just NHS
where voluntary and third sector organisations and others can look at
other ways of interacting with those people that give them the best
chance to be able to quit smoking should that be what they want to do I
think is your important bit because there will be some people smoking
and that is their choice and we need to respect that as well. – Curtis? – Yeah I think I was struck again by something that Kevin said about making every
contact count and I think within that one of the important elements is arming
staff with the skills to be able to support people better but also the
knowledge of what is available locally, what is available in terms of this kind
of smoking cessation interventions so that the person they’re
working with therapeutically I think is an issue that’s come up in terms of not
wanting to cause conflicts in terms of I guess approaching someone around smoking
cessation. So I think for me it’s going to be
important around emphasising those elements in the final reports and
hopefully those kind of recommendations that they’ll follow that
can be taken forward. – I think that’s a really interesting point that you’ve
raised there because it is not just about setting up the services to fail. If
we don’t invest in the staff and give the staff the training and the
opportunity to engage at every point then we’re setting ourselves up to fail
as well aren’t we. So that investment requires investment in staff to be able
to give that advice and in the right way at every opportunity. – We’ll be doing that through the next year. – Good, good. – I think for me my closing reflection would be it really highlights the
importance of co-production. I think a lot of the things that we think is right
or the things that we think it’s just the way things have been done, we really
just need to actually speak to the people who it affects. I think
particularly the reflection on how it will impact relationships is so important
and definitely something that’s made me really think about how policies are
implemented and we change practice. – Can I just come on to that because I think people
will lose community as a result of giving up smoking. I know that when I when
I gave up smoking when the smoking ban came in to pubs and I chose to not smoke
and I lost a huge amount of social contact so you know we need to think
about what we’re going to replace that with if people choose to not smoke and
all of their friends smoke. – Absolutely. Thank you very much. I want to thank all of my panel for joining us today and all of you for tuning in as well. On the slide on the
screen which will be on there now, this is where you can find more
information, so about the Health and Wellbeing Alliance, and more about this
work, some particular resources on Equally Well about smoking cessation and
severe mental illness and also if you’re affected by anything you’ve heard today
please do have a look at the resources and advice lines on Rethink Mental
Illness as well. All these slides will be available after
the webinar so please do download them as well. So after this webinar you will
be followed up by an evaluation form. Please do fill it out, share any
reflections, closing reflections or comments, or any sort of advice for us
on how we can do these better. Last thing to do is just say thank you and I
hope you all have a good rest of your afternoon. – Thank you. – Bye.

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