Location of Scheme: Community pharmacies within Cwm Taf Health Board locality

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1 Version SERVICE SPECIFICATION Cwm Taf Health Board And 1. Name of Scheme: Community Pharmacy Stop Smoking Service Location of Scheme: Community pharmacies within Cwm Taf Health Board locality Brief Outline: The Cwm Taf Tobacco Control Forum has a developed local strategy for tackling tobacco use. A key component of his strategy is to commission from Community Pharmacies a Smoking Cessation Service to support clients motivated to stop smoking. 2. Name of Person Responsible (commissioner) Cwm Taf Health Board Address: Ynysmeurig House Navigation Park Abercynon CF45 4SN Tel No: Name of Person Responsible (provider) Address: Tel No: 3. Client Group Any client requesting Nicotine Replacement Therapy and/or support to stop smoking 4. What are the specific objectives of the Services? To improve access to and choice of smoking cessation services, including access to nicotine replacement therapy. To assist in the delivery of local smoking cessation strategies To help service users access additional treatment by offering referral to specialist services where appropriate. To optimise the cost effectiveness of NRT prescribing and obtain data on quit rates Service description Any pharmacy entering into a contract with the LHB to provide this service must seek approval from the Health Board before delivering the service. The service offers three tiers of support: Level 1: The Promotion of Healthy Lifestyles is included as an Essential Service of the NHS Community Pharmacy Contract Community Pharmacists as part of their core health promotion activities are required to encourage smokers to quit, provide advice on quit strategies and signpost patients to the most appropriate smoking cessation service. This activity may be opportunistic or as part of local/national health promotion campaigns. Level 2: Pharmacists undertake a supply and support role for clients who are receiving smoking cessation advice form Stop Smoking Wales. Level 3: Pharmacists assess motivation and provide one to one assessment of client s needs; 1

2 initiate, supply and monitor the use of appropriate smoking cessation medicines; and provide brief intervention support each time NRT is supplied. The community pharmacies that take part in the LHBs enhanced pharmacy service work in partnership with Stop Smoking Wales to deliver level 2 and level 3 services. 6. How will the Service be provided? 6.1 General The consulting area used for the provision of the service should provide a sufficient level of privacy and safety. The pharmacist entering into the commissioning agreement has a duty to ensure that pharmacists and staff involved in the provision of the service have relevant knowledge and are appropriately trained in the operation of the service. The pharmacist entering into the commissioning agreement has a duty to ensure that pharmacists and staff involved in the provision of the service are aware of and act in accordance with local protocols and NICE guidance. The pharmacist entering into the commissioning agreement must nominate a named pharmacist accountable for the management of the service. The service should be conducted in accordance with any GPhC guidance. 6.2 Level 1: Smoking Cessation advice and Signposting as an Essential Service This service should be provided by every pharmacy as one of the Essential Services. Pharmacies should provide: Appropriate smoking cessation leaflets Ad hoc opportunistic advice to smokers to quit Information on how to access the Stop Smoking Wales (SSW) Service and the pharmacy scheme. Advice on other support for quitting, including GPs and the national Quitline number 6.3 Level 2: Supply of Nicotine Replacement Therapy to clients of Stop Smoking Wales (SSW) This is the provision of NRT in response to a referral for supply by SSW specialist. This arrangement does not include the supply of Bupropion/varenicline The supplying pharmacist is responsible for ensuring that all supplies are appropriate and within the product licence. If considered appropriate, the pharmacist should supply NRT and advise the client on its use. If the supply is considered to be inappropriate the patient must be referred to their GP for a prescription. The supply must be recorded on the client s record of supply of NRT (form SS1), The packs must be labelled in line with regulations and be marked indelibly NHS to reduce the potential for fraud. Subsequent supplies should be made in a similar manner at the request of the client. A maximum of 7 supplies may be made to the client. Supplies should be phased in the following manner: Week 1-1 weeks supply of NRT Week 2-1 weeks supply of NRT Week 3 2 weeks supply of NRT Week 5 2 weeks supply of NRT Week 7 2 weeks supply of NRT Week 9 2 weeks supply of NRT Week 11 2 weeks supply of NRT 2

3 Provided that the pharmacy has established systems & SOP s, supplies may be made by any pharmacist including locums. Clients do not need to complete a consent form at the pharmacy as this will have been done by the SSW Service. The client should attend 6-7 group support sessions with the SSW specialist. Supplies may be made to the client s representative where pre-arranged. 6.4 Level 3: Provision of support and product directly to pharmacy clients This is pharmacy led provision of both the motivational support for quitting, and NRT. This arrangement does not include the supply of Bupropion/varenicline Eligibility for the service Exclusions Clients must be resident in or registered to a GP within Cwm Taf Health Board. Clients can either be referred to the service (e.g. by pharmacist, SSW specialist, GP, other health professional) or self refer. Clients must wait at least 6 months (unless exceptional circumstances contributed to the failed attempt) after a failed quit attempt before re-entering the service (NICE Guideline PH10 Clients must consent to their information being shared with the LHB. Consent to share information with clients GP and follow up and ongoing monitoring being made is at discretion of the client. The pharmacy is responsible for confirming the suitability of the client to access the service. The following patient groups are excluded from this service and should be referred to their GP for smoking cessation support. Clients who are aged 14 years or under or clients under 16 years who are not Fraser competent. Clients with severe cardiovascular disease (including severe arrhythmia or immediately post myocardial infarction period) or a recent cerebrovascular event (stroke or TIA) or with serious kidney or liver problems. Contraindication to NRT Refusal to provide consent for follow-up Service provision Initial contact The initial contact should be brief as there is no payment for this session The purpose of this contact is to: Give an explanation of how the service operates Provide the client with the induction pack including the Client Questionnaire and consent form The client should be asked to take the information home to read and, where possible complete it, returning to the pharmacy when they are ready to set a quit date. The initial consultation appointment must be made for the next few days or at the client s convenience. Clients should not be kept on a waiting list but signposted to another service provider if for some reason an appointment cannot be made in a reasonable time (maximum of 14 days). 3

4 All consultations must be carried out by a level 3 trained pharmacists or technician. Ideally the first three consultations should be carried out by the same person; all supplies of medication must be made under the supervision of a pharmacist. Initial consultation (Week 1) Make an assessment of the client s suitability and motivation to quit, (this will include a baseline carbon monoxide (CO) test). Suitability Clients can be accepted into the service at the pharmacists professional discretion if: The GP has started treatment and would like the pharmacy to continue it. The client has already quit and is seeking further help Check that NRT is not contra-indicated: Following advice from the MHRA, clients who are; pregnant, breastfeeding or have diabetes should receive advice specific to them (MHRA leaflet may support) Motivation Make an initial assessment of the client s motivation. Clients who are not sufficiently motivated (e.g. introduce problems) or who need extra support (e.g. have made several previous quit attempts or feel compelled to smoke) should be signposted to the Stop Smoking Wales Service. A programme of support should be agreed in consultation with the client It is possible that client may have already quit and have a negative CO reading (<10ppm), these clients are eligible for the service at the pharmacists professional discretion. Agree a quit date (i.e. the day they will attempt to stop) with the client. The quit date must occur within 2 weeks of the first session. Clients unwilling to set a quit date within this period should be advised to return when they are ready to stop. Ideally, the quit date should not occur on the day of the first support session to allow time for preparation before quitting. Only once the client has set a quit date may NRT be supplied. The following should be discussed with the client 1. Behavioural support strategies to help the person quit 2. Discuss preparation for quit attempt triggers, coping strategies, etc, 3. Explain the treatment programme, its aims, length, how it works and its benefits. 4. Treatment options - If the client is eligible for the service discuss the options for Nicotine Replacement Therapy (NRT). All products are allowed within their product licence. The supply must be recorded on the client s record of supply of NRT (form SS3). The packs must be labelled in line with regulations and be marked indelibly NHS to reduce the potential for fraud. Supply the client with appropriate support material. Advise client that information will be shared with NHS Wales and their GP (if the client has consented to the sharing of information) and that NHS Wales may contact them to determine 12 month quit status. Clients not yet ready to stop should be provided with brief advice and leaflets and advised to return when they are ready to set a quit date. Follow up consultations At the start of weeks 2, 3, and at the start of weeks 5, 7, 9 and 11 If the client needs further appropriate support and NRT the pharmacy may continue to supply this up to a total treatment length of 12 weeks. Each consultation should include: Smoking status validated using a CO test. Additional motivational support should be provided using motivational interviewing 4

5 techniques, as outlined in the training. If the client has quit a further supply of NRT can be made by the pharmacist at these consultations. Details of each session - the supply and the client s CO reading should be recorded on their Record of supply of NRT (form SS3) The next follow up consultation date or date range should be agreed and entered on the client s Record of Attendance and Carbon Monoxide verification card. Client Signatures All clients must sign the Record of supply form (for both Level 2 & 3 services) at each appointment, to confirm that they have attended and received treatment (where appropriate). Where a client attends a session but does not require NRT please annotate the NRT supplied column with no treatment before the client signs. 4 week quit status The smoking status of the clients at 4 weeks, with CO test validation, should be established and recorded on form 2. A client who has quit smoking would be expected to have a CO reading of less than 10ppm. The 4 week quit section on the record of supply form should be completed. 4 week quit should be assessed using the Russell Standard: Quit date definition: A client should be counted as having successfully quit smoking if he/she has not smoked at all since two weeks after the quit date. This date should be calculated, as 15 days e.g. if the quit date were a Wednesday, 2 week after the quit date would be Wednesday two weeks later. The reason for adopting the 2 weeks after definition is to allow a period of grace in recognition of the fact that some smokers initially struggle but then manage to quit. GP Feedback Where client consent to the sharing of information has been obtained, a GP feedback form (Form SS4) should be completed and sent to the clients practice at the end of the treatment period (12 weeks) or when the client leaves the service. A Client Evaluation Form should be given to each client accessing the service where required by the LHB. 6.5 Treatment Failure If at one of these consultations the client s CO test shows no reduction, they should be advised that the SSW Service is available for additional support and be issued with a one week supply of appropriate smoking cessation therapy. A review date should then be set for the next week. If there is no reduction in CO readings on 2 consecutive occasions the person should be removed from the service. This should be recorded on the form 2. Patients who fail to attend appointments 2 attempts should be made to contact the patient and details of each attempt should be recorded on form 2. Clients should then be removed from the service if they fail to attend. Where patient consent to the sharing of information has been obtained, a GP feedback form should be completed and sent to the clients practice. Clients not wishing to initially engage or those who choose not to complete the programme may be offered appropriate health literature or referral to an alternative stop smoking service. Clients who drop out of the service may not re-enter for a period of at least 6 months (unless special circumstances have hampered the person's initial attempt to stop smoking, when it may be reasonable to try again sooner NICE Guidance PH10). 6.6 Combination Therapy Pharmacists should consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of 5

6 dependence on nicotine or who have found single forms of NRT inadequate in the past. (NICE Guidance PH10) In cases other than previous failure with one product or urgency in quitting, patients may be prescribed one product and be advised to purchase the second product. Combination therapy of NRT plus either Bupropion or Varenicline is not recommended by NICE. 6.7 Follow up The LHB may make telephone follow up calls to all level 3 clients that have a recorded 4 week quit status and provided consent at 12 months. 7. How will performance be measured? The pharmacy will maintain appropriate records to ensure effective ongoing service delivery and audit. All staff providing this service will be expected to participate in appropriate Continuing Professional Development that complies with the criteria set by the GPhC. The Service should be provided in line with Welsh Government Standards for Smoking Cessation Services. 8. Training and Education Pharmacists providing this service will be expected to participate in appropriate Continuing Professional Development (CPD) that complies with the criteria set out by the GPhC. All Pharmacists and Technicians wishing to provide this service will have undertaken LHB approved training and completed the All Wales Enhanced Services accreditation procedure: Pharmacists and Technicians are responsible for informing LHB once they have completed the All Wales accreditation process. Relevant certificates and pharmacist listing forms should be submitted to SSP Swansea. Reaccreditation must be completed every 3 years, following the WCPPE All Wales procedure. 9. Reimbursement Fees are as follows: - Level 1 no additional fee Level per supply of NRT (maximum of 7 supplies) + cost NRT at Drug tariff price. Level 3 - Week 1 supply and support Week 2 & per supply Weeks per supply (4 supplies) Giving a total fee per successful quit of per patient + cost of NRT at Drug tariff price. Payment for NRT The cost of any NRT supplied under the Pharmacy Stop Smoking Service will be reimbursed at Drug Tariff price. Payments Guidance Contractors shall submit all claims using the NECAF Claims for payment should be made when the client completes the treatment period or leaves the service. 6

7 Fees and allowances shall be paid monthly in arrears Claims for payment shall be subject to Local Health Board arrangements for Post Payment Verification. Please note that it is the responsibility of the named pharmacist to ensure claims are accurate and that the correct payment has been made. 5.0 Record Keeping Level 2 Record of Supply (Form 1) must be completed each time a supply of NRT is made, and the client s signature obtained. All details on the form must be completed and the form signed by the responsible pharmacist at the end of the treatment period. Level 3 The Client Questionnaire and Consent Form must be completed by the patient prior to commencing the Level 3 service. Record of Supply (Form 2) must be completed each time a supply of NRT is made, and the client s signature obtained. All details on the form must be completed and the form signed by the responsible pharmacist at the end of the treatment period. Management of Paperwork When a client completes or leaves the scheme, Record Type Description NECAF Payment Claim Submit electronically at end of treatment Pharmacy Level 2 Service Record of Supply (Form SS1) Retain in pharmacy Or Level 3 service Client Questionnaire & Consent Form (Form SS2) Record of Supply (Form SS3) Records should be stored securely and for a length of time in line with guidance in Welsh Health Circular (2000) 71 Welsh Health Circular (2000) Resources When registration is complete the pharmacy will be issued with a toolkit of resources. The toolkit, including a carbon monoxide monitor, remains the property of Cwm Taf Health Board. A charge of VAT will be invoiced to the pharmacy for any carbon monoxide monitors, which are lost or not returned when requested, to cover the cost of a replacement. Further supplies of toolkit resources can be ordered from Emma Hinks, Cwm Taf Health Board via emma.hinks@wales.nhs.uk. Please note requests for resources will be processed within 14 days of request. No telephone requests will be accepted. 7

8 11.0 Service Volume The number of clients each pharmacy can report may be restricted due to constraints on funding and due to changes in management of paperwork associated with the Level 3 service following the publication of the national SLA 8