The aim of the service will be to contribute to the three key public health tobacco outcomes:

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1 Stop Smoking service model questionnaire background Introduction The draft Tobacco Control Strategy, - drawing on findings from a tobacco control needs assessment and extensive local engagement work points to the need to review our smoking cessation services. The proposal is for North Yorkshire County Council to re-commission a countywide stop smoking service that is responsive to the changing needs of the smoking population of North Yorkshire. Background Smoking continues to be the biggest preventable cause of ill health and early death in North Yorkshire. It kills over 1000 people every year in North Yorkshire and the impact of tobacco is greatest on the poorest in the county; not just on the smokers but also on their children and their communities. However, reductions in smoking prevalence have been slower in these communities than other population groups. Reducing the prevalence of smoking amongst priority population groups will help reduce variations in health outcomes more than any other measure to improve the public's health. A high level of intervention is vital to deliver effective, cross-social group reach with evidence-based Stop Smoking services that remain highly effective in both cost and clinical terms. Proposal for the Stop Smoking service Smoking cessation services are currently delivered by a specialist provider supplemented by level 2 services delivered by GP practices and pharmacies. The needs assessment found that this arrangement did not allow effective targeting to priority groups and there is scope to improve the efficiency of services to increase the number of people who successfully quit. The Local Authority intends to commission a county-wide service overseen by a single organisation responsible for co-ordinating delivery across all service levels. The service will deliver high quality, evidenced-based, value for money Stop Smoking services which meet the needs of the North Yorkshire population. The aim of the service will be to contribute to the three key public health tobacco outcomes: To reduce smoking prevalence among adults To reduce smoking prevalence at 15 years To reduce smoking prevalence in pregnancy (measured at time of delivery)

2 The service will manage and lead delivery in a variety of settings which should include GP practices, pharmacies, dental practices, hospital settings, community, mental health services and workplaces. A wide range of service delivery settings are required to facilitate easy access and reach to the priority population groups as well as delivering the overarching outcomes of the service. This proposal would mean that the Council would no longer contract directly with individual GP s and individual pharmacies to deliver their existing level 2 Stop Smoking service. However, it is recognised that primary care clinicians play an important role in identifying and providing very brief advice and onward referral to Stop Smoking services. Therefore, the new provider would need to consider subcontracting certain elements of service delivery to both GPs and pharmacists (and possibly other providers) to ensure effective pathways of care. Priority groups The proposal is that any smoker aged 16+ can access the service but the service will be required to proactively identify and deliver their service to smokers in the following priority population groups: Residents in deprived areas of the county. Routine and manual workers. Pregnant smokers and their wider family network. Parents or carers who smoke with children under 16 years of age. People with a diagnosed mental health condition. People with a diagnosed substance misuse problem. People with long term conditions. Patients who smoke who have a planned admission to hospital. Main objectives The suggested main objectives of the service are: To ensure the service is targeted and promoted to the priority population groups to increase their access and uptake of services To provide evidence-based smoke free information, advice and interventions using a variety of methods (e.g. telephone support, online, groups, 1:1) to improve access, reduce lost to follow-ups and increase stop smoking quit rate success. To effectively promote the Stop Smoking service using a variety of media and undertake behavioural insight work as appropriate to support uptake and access to the service.

3 To ensure all stop smoking assessments are part of a broader holistic public health assessment with onward referral to other appropriate services such as NHS health checks, weight management etc. To collate data on all stop smoking quits and submit on behalf of the Local Authority to the Health and Social Care Information Centre. To evaluate the service through service user feedback, e.g. questionnaires, focus groups, telephone follow-ups, and develop a service improvement plan in response. To work to ensure that feedback is gathered from a cross section of service users those who have quit, not quit and lost to follow up. To ensure the service is continuously evaluated. To ensure advice on smoke free homes and cars is a component of every client interaction to support a reduction in exposure to second hand smoke especially amongst children. The proposed North Yorkshire Stop Smoking service model Level 1 (Very Brief Advice, Self help) Level 2 (text, telephone, online & pharmacotheraphy) Level 3 (text, telephone, online, face to face and pharmacotheraphy) North Yorkshire Stop Smoking Service (Single Point of Contact) The service will offer tiered support (level 1 level 3) according to level of individual need. The service should be tailored to their level of addiction, previous quitting and medical history, personal factors and socio-economic classification. The routes into the service and how support will be identified are set out below.

4 Service users will access the service either via direct referral from a clinician or selfreferral in to the Stop Smoking service It is proposed that there is a single point of access for referrals and self-referrals. At this access point individuals should be provided with an initial triage assessment to establish what method of support they should receive. The assessment should be based on: Level of addiction using a recognised assessment tool. Previous quitting and medical history. Key priority groups. The stop smoking assessments should also incorporate a broader, holistic public health assessment (e.g. alcohol, drugs, mental health, weight management, Chronic Obstructive Pulmonary Disease). Where appropriate, referral to other services should be offered and documented. Every triage contact should be recorded. The assessment will determine the appropriate level of service for the service user. It is proposed that different levels of support are delivered as described below. All advice and treatment given to service users will be based on the current clinical evidence and delivered by qualified professionals. All face-to-face quit attempts should be validated using a CO monitor. All non-face to face quit attempts should be validated via verbal confirmation. Level 1 support could be delivered by the stop smoking service and other relevant organisations such as within primary care. Level 1 support includes the effective delivery of very brief advice with self-help, online signposting support or an onward referral into the Stop Smoking service where triage will take place. Level 2 support would be delivered by the Stop Smoking service and involves text, telephone and online support with pharmacotherapy. Level 3 support would be delivered by the Stop Smoking service and involves text, telephone, face to face, and pharmacotherapy.

5 Harm Reduction Approaches It is proposed that the service would be able to pilot a harm reduction approach in line with NICE guidance and locally determined guidelines. Nicotine inhaled from smoking tobacco is highly addictive. But it is primarily the toxins and carcinogens in tobacco smoke not the nicotine that cause illness and death. The best way to reduce these illnesses and deaths is to stop smoking ideally, stopping in one step (sometimes called abrupt quitting ). However, there are other ways of reducing the harm from smoking, even though this may involve continued use of nicotine. The recent NICE guidance (PH45) is about helping people, particularly those who are highly dependent on nicotine, who: May not be able (or do not want) to stop smoking in one step. May want to stop smoking, without necessarily giving up nicotine. May not be ready to stop smoking, but want to reduce the amount they smoke. It recommends harm-reduction approaches which may or may not include temporary or long-term use of licensed nicotine-containing products. Pathways of Care The service will be expected to develop strong, clear and operational care pathways across the system for identifying and treating smokers effectively and efficiently. Effective partnership working across the health and social care community will be essential. Ensuring good access to the Stop Smoking service The provider will need to address the range of factors which impact on access to local Stop Smoking services including the ability to deliver the services in the best location to effectively engage with the priority population groups and ensure rapid and easy access even in rural areas. Services should be accessible to service users including: Local rate telephone triage and support. Opening hours to accommodate working service users. Face-to-face support provided at locations across North Yorkshire that are convenient and appropriate for the priority client groups. Providers are expected to organise their own clinic venues, which should be in a range of settings including community and non-healthcare based.

6 Access for people who have a physical or mental impairment that affects their ability to do normal everyday activities Using a range of communication methods e.g. text, telephone, mobile apps Developing system-wide workforce competence The service will ensure all staff employed to deliver the Stop Smoking service are trained in line with National Centre for Smoking Cessation and Training (NCSCT) standards for delivering level 3 services. Training and continuing professional development should be available for all those involved in providing stop smoking advice and support. The service should consider employing staff to be able to prescribe pharmacotherapy and therefore hold the necessary prescribing qualifications. The service should also provide expert evidence-based training to the appropriate level which targets the staff working with priority population groups and supports system-wide competence in the provision of stop smoking advice and support. Provision of medication We are proposing that the commissioner retains the prescribing budget; however the provider would ensure evidenced based prescribing and active monitoring of prescribing practice. NYCC would develop guidance for the provider on smoking cessation prescribing in-line with NICE guidance and local prescribing activity reports, ensuring effectiveness and best value for the Local Authority. Nurse prescribers It is proposed that the service will have nurse prescribers who will be able to prescribe pharmacotherapy directly to clients without the need for a further appointment. Face-to-face intensive behavioural support and written prescriptions will be available from one source to improve the client journey. The nurse prescribers will hold the relevant qualifications to undertake this role. Performance outcomes The new service will be expected to meet a number of performance and monitoring requirements which will be set out in the detailed specification. However, it is proposed that whilst the main priority will be on quitting (which will be measured by the 4 week quit success indicator validated by the use of CO monitoring and following up a sample of clients at 6 and 12 months) there will be scope for the service to explore the harm reduction model in line with NICE guidance and other evidence.

7 Information management and technology The provider would be required to: Operate a robust IT system in place to record and produce reports on individual activity data and outcomes where applicable for all programmes and financial data including prescribing costs. Collate data on all stop smoking quits and submit data as per national gold standard requirements. Collate and report on data to fulfil performance and monitoring requirements defined by the commissioner. Communication and marketing It is proposed that the service provides dedicated resource to marketing and communicating messages using innovative approaches based on customer insights and user experience from priority population groups. Payment proposal We propose that the service provider will be paid through both a set block payment amount complimented by an incentive payment scheme. It is likely that the incentive payment scheme will be a significant proportion of the contract value. The incentives payments will be attached to getting quits that are CO monitored confirmed from priority groups. The provider will be therefore assured they have a set amount of funding to cover all the objectives of the service regardless of quit outcome. However, to secure further income the provider will have to demonstrate quit success especially among priority groups.

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