Smoking Cessation 2012/13 - Community Pharmacy West Yorkshire

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Community Pharmacy Local Enhanced Service Agreement

Smoking Cessation

2012/13 Version: Draft v1 Date Reviewed by LPC: March 2012 Responsible Clinician/Service Lead: Caroline Abbott Responsible Commissioning Manager: Diane Lee/ Rashesh Mehta/ Julie M Howard Review date: March 2013

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COMMUNITY PHARMACY LOCAL ENHANCED SERVICE AGREEMENT 2012/13

Smoking Cessation

Contents 1 Introduction 2 Background 3 Service Aims 4 Service Outline 5 Eligibility to provide the service 6 Quality & Clinical Governance Standards 7 Information & Data Collection Requirements 8 Performance Management 9 Service Review 10 Exit and Suspension Arrangements 11 Activity & Costs 12 References 13 Signatures

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1 Introduction

All Providers are expected to provide Essential and those Additional services that they are contracted to provide to all their patients. This Community Pharmacy Local Enhanced Service (CPLES) Agreement outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of Essential Services. No part of the specification by commission, omission or implication defines or redefines Essential or Additional Services.

2 Background

The prevalence of smoking in the adult population of Wakefield is estimated at 25.6%, which is about 5% higher than the national average (2010/11 IHS data).

Smoking is the single greatest cause of preventable illness and premature death in the UK. It causes more than 120,000 deaths each year. One in two smokers will die from a smoking related disease and 70% of smokers say they would like to stop. Wakefield consistently shows a higher rate of smoking related illness than the national average.

3 Service Aims

The purpose of this CPLES is:

a) To increase the number of smokers who successfully quit at the 4

week assessment stage. b) To provide a fully completed Minimum Data Set (MDS) for every

smoker who has a supported quit attempt. c) For practice staff to be competent in delivering the service to a high

standard. d) For accurate information on outcomes to be remitted to Wakefield

District PCT (hereafter referred to as ‘the PCT’). e) Help identify patients at risk of COPD and refer appropriately

4 Service Outline

The service provided by Providers under this CPLES should complement the service provided by the Wakefield Stop Smoking Service. Providers undertaking this CPLES should be willing and motivated to fully participate in the service provision and work together with the local specialist Stop Smoking team.

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In the delivery of this CPLES it is expected that providers will:

a) Deliver the service in accordance with the standards and training provided by the Wakefield Stop Smoking Service.

b) Only those Staff who are trained to level 2 can provide smoking

cessation service to clients. In the event that staff are on annual leave/absent or unable to provide support the client will be referred to the Wakefield Stop smoking service.

c) Offer a first appointment for a patient which is at least of twenty

minutes in duration. d) Perform a screening spirometry on all patients during their

first/initial consultation and record the result. e) Inform patients of any need to seek further advice from their GP

regarding screening spirometry results. f) Practice to be informed of abnormal spirometry using template

attached in Appendix 6 g) All patients will be given their lung age as part of screening

spirometry. h) Proactively make contact with the smoker ideally on a weekly basis

but at least fortnightly if the patient has difficulty attending more frequently.

i) Make themselves available to the patients on a weekly basis either

at a face-to-face consultation or by telephone. If a face-to-face consultation is carried out, Carbon Monoxide monitoring should be undertaken. A minimum of 85% should be Carbon Monoxide validated.

j) Ensure a timely pathway is in place for patients to obtain their

prescription (Champix, Buporpion or NRT) to coincide with a set quit date.

k) Complete an assessment 4 weeks after the agreed quit date. The

smoking status of the patient will be assessed and recorded at this point.

l) Validate the 4-week smoking status by the use of a Carbon

Monoxide monitor. m) If the situation arises where a waiting time of more than 4 weeks is

created, the Provider will make a referral to the Wakefield Stop Smoking Service.

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n) Offer the patient a choice of receiving smoking cessation advice within group setting or a one to one intervention.

o) If patients prefer to receive advice within a group setting, the

Provider will make a referral to the Wakefield Stop Smoking Service.

p) If patients are still requiring support after 12 weeks, the Provider will

make a referral to the Wakefield Stop Smoking Service. q) The consultation should take place in an appropriate room to

maintain patient confidentiality. r) All pregnant women must be invited for 2 x 20 minute pure smoking

cessation advice appointments in the 1st trimester of their pregnancy run by a specialist advisor.

s) Patients identified as being at risk of lung disease will be asked to

see their GP for a full lung function test. t) Provide a minimum of 24 MDS forms per year There may be an opportunity for an annual Smoking Cessation in Pharmacy (SCIP) visit from a member of the Wakefield Stop Smoking Service to ensure maintenance of standards and discussion of any problems.

The Wakefield Stop Smoking Service will always be available for support and advice throughout the provision of this agreement.

A screening spirometer meeting national standards will be issued / provided by the PCT, via the Primary Care/Public Health team, free of charge, enabling pharmacist to perform the required spirometry screening during the consultation. The screening spirometer will be an asset for each individual pharmacy. NRT

For access to Nicotine Replacement Therapy (NRT) the advisor will redirect the patient to their GP by completing the standard GP prescription request letter.

NRT should be issued following the agreement to set a quit date.

For patients who prefer not to use NRT products and request other pharmaceutical products (e.g. Zyban, Champix) the advisor will redirect the patient to their GP. The GP will assess the patient and prescribe if appropriate

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Advisors should complete the standard Wakefield Stop Smoking Service prescription request letter for Zyban, Champix and NRT.

5 Eligibility to provide the service

A Provider may be accepted for the provision of this CPLES if it has a commitment to working with the PCT, GP Practices and other service providers to ensure a commonality of approach, where appropriate, across the PCT.

Participating pharmacies must notify the commissioner if there are

any changes in accreditation.

i) Education, Training & Support

The Provider should have a planned, regular programme of education, training and support in relation to the delivery of this service. This will include:

a) Ensuring all staff involved in providing this procedure are trained to

current standards and competent to undertake the service and maintain competence to do so.

b) Staff providing support must be trained to level two and approved

by the Wakefield NHS Stop Smoking Service.

c) Staff will deliver support to the standard contained in the Stop Smoking Services’ training package and written documentation.

d) Staff carrying out screening spirometry will have to undertake a

brief PCT commissioned training session to ensure competence.

e) Staff should attend an update/refresher Stop Smoking course on an annual basis and should retain evidence of attendance.

f) The PCT recommend all pharmacy counter staff undertake a Customer care/service course/training and be fully aware of all/any Enhanced Services provided by the pharmacy. g) Nice guidance recommends that all staff should be trained on very

brief advice. This can be done through an e-learning programme available for all pharmacies on http://www.nhshealth.org.uk/ . more information about the training package can be found on http://www.wakefielddistrict.nhs.uk/yourHealth/StayingHealthy/stopsmoking/briefadviceforsmokingcessation/

http://www.nhshealth.org.uk/

http://www.wakefielddistrict.nhs.uk/yourHealth/StayingHealthy/stopsmoking/briefadviceforsmokingcessation/

http://www.wakefielddistrict.nhs.uk/yourHealth/StayingHealthy/stopsmoking/briefadviceforsmokingcessation/

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Pharmacy Contractors

h) Pharmacists should also read:

“Helping smokers to stop: advice for pharmacists in England” (ISBN 1-84629-035-X) published by NICE, RPSGB and PharmacyHealthLink. A copy can be downloaded from www.nice.org.uk/download.aspx?o=517943. “Brief Interventions and Referral for Smoking Cessation in Primary Care and other Settings (Public Health Intervention Guidance No 1)” published by NICE. A copy can be downloaded from www.nice.org.uk/phi001.

i) All Providers should designate a senior pharmacist in the Pharmacy to have overall responsibility for the service.

j) All Providers should identify staff time (including responsibility and

accountability) to deliver the service. ii) Patient Experience & Engagement

a) Providers will be expected to:

i) Provide feedback to the PCT on all complaints and compliments received regarding the service and the lessons learned where necessary.

ii) The PCT requests you undertake an assessment of patient experience of the service through the current patient satisfaction survey.

6 Quality & Clinical Governance Standards

The Provider will ensure that patients receive a quality service whilst in their charge and will ensure the following quality standards are in place:

a) Ensure adherence to best practice, and commitment to continually

improving the service. b) Meet all clinical standards, legislative guidance and local

procedures as required of the service.

c) All contractors (GPs, Pharmacies and Dentists) must ensure adherence to the current NHS Stop Smoking Service Delivery and Monitoring Guidance 2011/2012 and future iterations. The guidance can be found at

http://www.nice.org.uk/download.aspx?o=517943

http://www.nice.org.uk/phi001

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http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125939.pdf .

d) Meet all applicable statutory reporting requirements such as

compliance against the emerging Care Quality Commission Quality & safety regulations. The Provider should provide evidence of compliance to the PCT as/when requested to do so.

e) Providers should ensure that appropriate risk management and

health and safety procedures are in place.

f) Providers should ensure appropriate systems are in place to report Serious Untoward Incidents in line with the PCTs requirements for reporting Serious Untoward Incidents. If untoward events or near misses occur then a formal significant event analysis must be conducted. Lessons learnt and actions taken will be reported to the PCT.

Where clinical interventions are required:

g) Providers should adhere to the PCT Consent to Examination or

Treatment – Joint Decision Making Policy (Aug 07) which is based on current national DH policy.

7 Information & Data Collection Requirements

The Provider should ensure maintenance of accurate MDS records (Gold Standard Monitoring Forms), including informed consent, record of interventions, reviews, and outcomes for Screening Spirometry. The Provider will supply the patient with written advice / information issued by the PCT if identified as being at risk of lung disease.

For the Initial Consultation the Provider will fully complete the Minimum Data Set (MDS) provided by NHS Wakefield District. The MDS form also includes the necessary Department of Health recording of patient occupation and prescription status as recorded on their FP10. Where a MDS is not fully completed and signed, it will be returned to the provider for completion and resubmission, (this may incur a delay in reimbursement). The PCT to be informed of results of COPD6 Lung age check using template attached in Appendix 10.

For the successful quitters following the 4 week assessment the Provider must also have fully completed the Minimum Data Set (MDS) provided by NHS Wakefield District. Where an MDS is not fully completed and signed, it will be returned to the provider for completion and resubmission, (this may incur a delay in reimbursement).

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8 Performance Management

The Provider of this service will be subject to performance management arrangements put in place to review the provision of all commissioned primary care services. The PCT will select a random sample of Providers each year to visit and review provision of the service and to ensure it is in accordance with the service outline detailed above.

Pharmacies should ensure that all necessary information and key staff are available for the review visit.

The Provider will be expected to demonstrate: a) Appropriate health promotion material is available for the service

user and promotes its uptake.

b) That the staff involved in the provision of the service have undertaken CPD relevant to this service and attend the refresher sessions annually.

c) The Provider must work towards achieving an indicative target of

between 35% - 65% quitters at the 4 week assessment. The Provider participates when requested in an annual PCT organised audit of service provision

d) The Provider submits MDS (Gold Standard Monitoring forms) within

ten working days following the 4 week assessment.

e) Pharmacy contractors review their standard operating procedures and the referral pathways for the service on an annual basis

9 Service Review

This specification is for the financial year 2012/13. Commissioning of this service will be reviewed on an annual basis.

10 Exit and Suspension Arrangements

Termination Either party may terminate this agreement with immediate notice if the other party refuses or fails to carry out any of its obligations, provided that the matter complained of is incapable of rectification or it has not been rectified within 14 days to the reasonable satisfaction of the non-defaulting party.

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Suspension The scheme will be suspended if at any time the Provider is unable to provide services in line with the eligibility criteria.

Before any suspension the Provider and the Commissioner will discuss the reason for the suspension identifying any possible resolution. If the matter is not resolved the PCT will issue a suspension notice to the Provider within 7 days. If for any reason, service provision or patient safety is compromised in any way, the contract will be suspended pending the outcome of a full and transparent investigation, following which the agreement will either terminate or be reinstated. Exit Arrangements Either party can provide 6 weeks notice to exit the scheme. Before issuing an exit notice, the parties will meet to discuss the reason for termination. If after this meeting the reason for termination is not resolved then the relevant party will issue an exit notice. Variation The service may be varied if the Provider and the PCT agree this in writing.

11 Activity & Costs

The PCT in agreeing to this enhanced service in no way commit themselves to the capital expenditure or revenue consequences of the equipment necessary for particular procedures covered by this enhanced service. For the purpose of this enhanced service, an episode of care has been defined as a completed 4–week assessment. However, it is expected that if patients require support after this point, that care will be provided.

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Providers will be reimbursed at the following rate/s:

ITEM PAYMENT

Initial Consultation fee - which includes completing an MDS form and performing a screening spirometry test and recording result. Maximum of 2 initial consultations per patient per year.

£10.00 per initial consultation

A payment by results (PBR) per smoke free patient as measured by a carbon monoxide monitor at week 4 assessment with a fully completed MDS.

£35.00 for a 4 week quitter.

An additional payment for those successful quitters who are eligible for free prescriptions as declared on MDS

£5.00

Please ensure you have completed all the requested information including occupation data and postcode. Payment for any Initial Consultation fee should be claimed on submission of a Smoking Cessation claim form, in conjunction with a completed the corresponding fully completed and signed MDS form(s) by the providers on a monthly basis. The PBR payment should be claimed for on submission of the same Smoking Cessation claim form, in conjunction with a completed PBR evidence form and the corresponding fully completed and signed MDS form(s) (within ten days of 4 week assessment). By ensuring you have fully completed the PBR evidence form correctly, it will automatically confirm on the Smoking Cessation claim form if you qualify to receive the additional payment of £5.00 per successful quitter(s) who are eligible for free prescriptions as declared on the MDS form.

Payment may be withheld/delayed should an MDS/Evidence/Claim forms not arrive within the allotted timescale, are not fully completed or have incorrect information. Incomplete MDS/Evidence/Claim forms will be returned to the Provider. Should this occur the fully completed MDS/Evidence/Claim forms must be returned to the PCT within 15 working days.

Providers will only be paid under PBR for patients who successfully complete the 4 week course and quit smoking. All fully completed MDS/Evidence/Claim forms must be returned no later than the 5th of the following month to: Lisa Allen, Stop Smoking Secretary, Pontefract Health Centre, Trinity Street, Pontefract, WF8 1EY.

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The PCT where able will reimburse these on a monthly basis and be identifiable as Local Scheme 3. All MDS form(s) along with the required evidence and claim form(s) will be provided by the PCT. Claims for previous quarters/financial years will not be paid unless concurrent with the end of the financial year/ CPLES agreement.

12 References

Government White Paper – Smoking Kills (Dec 1998) NSF Framework for CHD – (July 2000) Smoking Cessation Guidelines and their Cost Effectiveness Thorax (Dec 1998) ; 53: S1-S38 Dutch (Netherlands) SilagyC., Mant D. et al. Nicotine Replacement Therapy for Smoking Cessation (Cochrane review). In The Cochrane Library Issue 2. Oxford, Update Software, 1998. (updated quarterly) Nicotine replacement to aid smoking cessation. Drug Ther. Bulletin 1999; 37(7): S2-S4 Nicotine replacement therapy. MeReC 1999; 10, (3) 9-12 Division of Drugs and Toxicology. Drugs Evaluation Annual 1994. Chicago: American Medical Association (1994) Nathan A. Smoking Cessation Products. Pharmaceutical Journal 1998; 260: 340-343 McRobbie,H. & McEwen, A. Helping smokers to stop: advice for pharmacists in England. National Institute for Health and Clinical Excellence, Royal Pharmaceutical Society of Great Britain and PharmacyHealthLink 2005; 14-15. Report of the Committee on Safety of Medicines Working Group on Nicotine Replacement Therapy. Medicines and Healthcare products Regulatory Agency. Committee on Safety of Medicines. November 2005

Rashesh Mehta Public Health Commissioning Manager – Tobacco Control February 2012 Diane Lee Substance misuse programme manager

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February 2012

Julie M Howard Primary Care Commissioning Manager (Joint Pharmacy Lead) February 2012 Lisa Chandler Respiratory Programme Manager February 2012

13 Signatures Should the pharmacy wish to provide this Smoking Cessation Community Pharmacy Local Enhanced Service, please refer to the Enhanced Services Schedule 2012/2013 for signatures. Please be aware that in signing the enhanced service schedule 2012/2013 the pharmacy/pharmacist is agreeing to undertake all elements of this enhanced service as detailed in this specification.

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COMMUNITY PHARMACY LOCAL ENHANCED SERVICE AGREEMENT 2012/13

Stop Smoking Cessation Service

Parties to the Agreement:

This agreement is made between: and

NHS Wakefield District …………………………………….

White Rose House …………………………………….

West Parade …………………………………….

Wakefield …………………………………….

WF1 1LT …………………………….………

Signed on behalf of WDPCT: _____________________________________ (Signed) _____________________________________ (Name) _____________________________________ (Position) _____________________________________ (Date) Signed on behalf of the Provider: _____________________________________ (Signed) _____________________________________ (Name) _____________________________________ (Position) _____________________________________ (Date) ________ (OCS Code)

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Appendix 1

Smoking Cessation

CPLES Accreditation Form – 2012/13

Provider Name:

Accreditation Name of Staff who have completed an approved Smoking Cessation training course and who have attended a local training event run by the Wakefield Stop Smoking Service.

Name Job Title Clinical /Professional Qualifications

Date Stop Smoking Training undertaken

Date Spirometry screening training undertaken

I certify that the above named people have undergone the appropriate training, a record of which is maintained in the Pharmacy for inspection by the PCT and that all aspects of the Service Agreement for this Community Pharmacy Local Enhanced Service will be adhered to. The practice should return the completed enhanced service accreditation form to the PCT. Please be aware that in signing the enhanced services schedule the practice is certifying that the above named individuals are competent to and will be carrying out this service. Please ensure that this accreditation form is returned to the PCT.

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Appendix 2 Why did I have this breathing test?

This simple test can help with the early detection of COPD (Chronic Obstructive Pulmonary Disease). COPD is an umbrella term for a number of lung conditions such as chronic bronchitis and emphysema. 1 in 5 smokers or ex smokers will develop COPD. Many do not know they are at risk as the condition can be undetected for many years as symptoms develop slowly. As a smoker or ex-smoker it is important you have this test if you are having some of the following symptoms:

Breathlessness

Coughing several times most days

Coughing up lots of phlegm

Getting out of breath more easily than others your age

If COPD is found early, steps can be taken to prevent further problems to your lungs and to help you feel better.

What do the results mean?

It is important to remember that this test is a screening test and cannot diagnose any lung conditions. The health professional doing the test will talk to you and give you advice about your test results. If your test results suggest that there may be some problems with your lungs, you will be asked to see your GP for a further breathing test. This test can give more information about your lung health. If you are still smoking you need to think about stopping smoking as it is starting to affect your lung health. If you do have any problems with your breathing or you have symptoms such as breathlessness, coughing or bringing up phlegm which you are worried about you need to see your GP to discuss them.

Where can I get more information and support?

Stop Smoking Service 01977 465 449 Local stop smoking advice and support

British Lung Foundation 08458 50 50 20 www.lunguk.org A helpline for people who are at risk from lung conditions

NHS Direct 0845 46 47 24 hour health advice and information

Patient Advice and Liaison Service 0845 602 4832 Provides information on a wide range of health and related matters

Information for Participants

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Appendix 3

Spirometry Check List

Please read the following and inform the

person carrying out your breathing test if

you answer YES to any of the questions.

o Have you had a heart attack in the past

6 weeks?

o Do you suffer from angina?

o Have you had an operation on either of

your eyes in the last 3 months?

o Are you seeing or have you been

referred to an eye specialist?

o Have you had an operation on your chest

or tummy in the last 3 months?

o Have you been in hospital in the last 3

months?

o Are you coughing up sputum?

(Are you ill at the moment e.g. chest

infection or cold?)

o Is your sputum blood stained?

Thank you for your help.

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Appendix 4

Screening Spirometry

Stop smoking consultation

Appropriate for

Screening spirometry

Abnormal result: Patient asked to see

GP written information and

reassurance

Discuss results with patient as

per script

Normal result: written information

and reassurance

Screening spirometry not

appropriate

‘Coughing Again’ information leaflet given advised to see GP if any respiratory

symptoms present

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Appendix 5 Testing procedure The testing area should be a private space. There must be a chair and a height chart for accurately measuring height prior to testing. The procedure for testing should be as follows:

1. Use the Spirometry Checklist to ensure that the patient does not have any reason why they should not have the test. Only proceed if there are no contraindications present. In patients where contra-indications exist please explain to the patient, provide a copy of the leaflet ‘Coughing Again’ and ask them to seek advice from their GP if they have any respiratory symptoms.

2. Measure the height of the patient in centimetres. 3. Demonstrate how to blow into the Screening spirometer using a

mouthpiece. 4. Ask the patient if they have any questions or concerns. 5. Enter patient details into the screening spirometer, place a new one

way flow mouthpiece into machine and ask the patient to blow as per user instruction manual. This process will be repeated 3 times leaving a short gap between blows.

6. If the ratio of FEV1 /FEV6 is less than 70% then the participant should be asked to see their GP.

Suggested Responses for those screened

(Green Sector Results) If FEV1 /FEV6 is less than 70%: “While it is important to remember that this is just a screening test, your results suggest that there may be some damage to your lungs that has probably been caused by your smoking. We would advise that you stop smoking and make an appointment with your GP in the next week or so to discuss the results. You may want to arrange a more accurate breathing test at the Practice.’’ If requested the following will give more information for the patient (Orange sector results) FEV1 > 50%

Smokers: The result is a little a bit lower than we would expect it to be for someone of your age and so we would recommend that you need to stop smoking. You should see your doctor for a full breathing test; they can also check whether some treatment like an inhaler might help you if you have any symptoms.

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(Red Sector Results) FEV1 < 50%

Smokers: The result is quite a bit lower than we would expect it to be for someone of your age and so we would recommend that you need to stop smoking. You should see your doctor for a full breathing test; they can also check whether some treatment like an inhaler might help you if you have any symptoms.

Lung Age Lung age is used to support a quit attempt in smokers. Lung Age ≤ actual age The test is showing that smoking has not yet had a big affect on your lung age and your lung age is equal to/less than your actual age. Now would be a very good time to stop smoking to protect your lungs from premature ageing. Lung Age > actual age The test is showing that smoking has had an affect on your lungs and your lung age is a little/much higher than your actual age. Now would be a very good time to stop smoking to slow down premature ageing of your lungs.

Provide the patient with written information re their test result including written information on any action required on their part. At the end of the test dispose of mouthpiece and clean between patients as per manufacturer’s instructions

FEV1 FEV1/FEV6

Normal Lung Function

≥ 80%

≥ 70%

Abnormal Lung Function

< 80%

< 70%

Brief guide to interpreting results

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Appendix 6

Date

Dear GP As part of their stop smoking assessment your patient…………………………

underwent screening spirometry using a COPD6 meter. The results were

FEV1………% and FEV1/FVC6 ………..%.

As this suggests further investigation should be undertaken, we have asked

them to contact you to make a formal appointment.

Yours sincerely Pharmacist

Pharmacy letter head

Breathe easily in Wakefield

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Appendix 7

Community Pharmacy Stop Smoking Service - Claim Form

FINANCIAL INVOICE MONTH I declare that the information given on this claim form is true and correct to the best of my knowledge.

I understand that action may be taken against me if I make an incorrect claim and consent to the disclosure of relevant information on this form for the purpose of fraud prevention, detection and investigation.

Pharmacy Trading Name:

OCS Code: Address:

Post Code:

Pharmacist Name:

Stop Smoking Service Total Number

Re-imbursement Costs

Amount Claimed (VAT included where appropriate @ 20%)

Initial Consultation fee - which includes completing the initial part of the MDS form and perform a screening spirometry test with result. Only 2 initial consultations per patient per year.

0 £10.00 £0.00

A payment by results (PBR) per smoke free patient as measured by a carbon monoxide monitor at week 4 assessment with a fully completed MDS.

0 £35.00 £0.00

An additional payment for those successful quitters who are eligible for free prescriptions as declared on MDS

0 £5.00 £0.00

TOTAL £0.00

OFFICIAL USE ONLY

Payment Authorised By: ____________________________________

Return completed form to: Lisa Allen Stop Smoking Service, Pontefract Health Centre, Trinity Street, Pontefract, WF8 1EY by the 5th of the following month

Payments will be shown as local scheme 3 on your monthly statements

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Community Pharmacy Smoking Cessation Service Data Return Form

MDS Consultation Record

FINANCIAL INVOICE MONTH

Date of consultations

Patient Name NHS ID no. Post Code Eligible for free prescriptions

Agreed Quit date

4 week quit date Achieved – CO verified

Yes (1) No(0)

Total:

0

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Appendix 8 WAKEFIELD DISTRICT STOP SMOKING SERVICE – GOLD STANDARD MONITORING FORM Note: All patient data will be kept securely and in accordance with Caldicott guidelines. Information can only be passed to another

healthcare professional if this contributes to the provision of effective care.

Please return this form to:

Wakefield District Stop Smoking Service, Pontefract Health Centre, Trinity Street, Pontefract, WF8 1EY.

ADVISER DETAILS:

Department/Ward Location/setting

Name / Reference No.

Venue

Contact Tel. No.

Quit Shop/Central

Service/Medical Centre

NRT Voucher

number if applicable

CLIENT DETAILS:

Surname First Name Mr/Mrs/Ms/Other

Address

Postcode NHS ID. no.

Daytime tel no. Mobile no.

Alternative contact

number (friend/relative)

Next of kin

Name & Address of Clients GP

Practice

Date of Birth Age (in years) Gender Male / Female

Exempt from prescription charge Y / N Pregnant Y / N Breast feeding Y / N

Occupation code

(see reverse for

further information)

Full-time student Never worked/long term unemployed Retired

Home carer Sick/disabled and unable to work Managerial/professional

Intermediate Prisoner Routine & manual Unable to code

ETHNIC GROUP: (please tick relevant group)

a] White b] Mixed c] Asian or Asian British

British White and Black Caribbean Indian

Irish White and Black African Pakistani

Other white background White and Asian Bangladeshi

Other mixed groups Other Asian background

d] Black or Black British e] Other ethnic groups f] Other

Caribbean Chinese Not stated

African Other ethnic group

Other black background

HOW CLIENT HEARD ABOUT THE SERVICE: (please tick relevant box)

GP Friend/relative Pharmacy

Other health professional Advertising Other (please specify)

Agreed quit

date

Date of last

tobacco use

Date of 4 wk

follow-up

TYPE OF INTERVENTION DELIVERED: (please tick all relevant boxes)

Closed group

Open (rolling) group

One to one support

Telephone support

Couple/family

Drop-in clinic

Quit Shop

Other (please specify)

__________________

TYPE OF PHARMACOLOGICAL SUPPORT USED: (please tick all relevant boxes. Use 1 or 2 to indicate

consecutive use of more than one medication – e.g. Champix followed by NRT product)

None

NRT – Lozenge

NRT – Microtab

Zyban

NRT – Inhalator

NRT – Spray

NRT – Gum

NRT – Patch

Champix

TREATMENT OUTCOME:

Quit CO verified

Quit self report

Not Quit

Lost to follow up

Adviser signature

Date _________________________

Client signature (indicating consent to treatment, follow-

up, quality assurance purposes and to pass on of outcome

data to GP)

_______________________________________

Date ______________________

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Notes:

1. Location/setting should be one of the following: stop smoking services, pharmacy, prison, primary

care, hospital ward, dental practice, military base setting or other.

2. A client is classified as long term unemployed if they have currently been unemployed for one year or

more. If unemployed for less than a year, last known occupation should be used for classification.

3. Home carer – i.e. looking after children, family or home.

4. If a client is self-employed please use the flowchart below to determine classification.

5. Supervisor or Foreman is responsible for overseeing the work of other employees on a day-to-day

basis.

6. Managerial and professional occupations include: accountant, artist, civil/mechanical engineer,

medical practitioner, musician, nurse, police officer (sergeant or above), physiotherapist, scientist, social

worker, software engineer, solicitor, teacher, welfare officer; those usually responsible for planning,

organising and co-ordinating work or finance.

7. Intermediate occupations include: call centre agent, clerical worker, nursing auxiliary, nursery nurse,

office clerk, secretary.

8. Routine and manual occupations include: electrician, fitter, gardener, inspector, plumber, printer, train

driver, tool maker, bar staff, caretaker, catering assistant, cleaner, farm worker, HGV driver, labourer,

machine operative, mechanic, messenger, packer, porter, postal worker, receptionist, sales assistant,

security guard, sewing machinist, van driver, waiter/waitress.

9. The ‘prisoner’ occupation category has been introduced for collections from 2009/10 onwards in an

effort to reduce the number of clients recorded under ‘unable to code’. With the exception of prison staff,

clients treated in prisons should all be recorded as prisoners.

For further assistance in determining socio-economic classifications please see the flowchart below. If

you are still unable to establish this, please record as unable to code.

For further assistance in determining socio-economic classifications please see the flowchart below. If

you are still unable to establish this, please record as unable to code.

No Yes

Yes

Yes

No

No

Yes

No

Yes

No

Yes

Yes No

No

Yes

No

Start

Self-

employed?

More than 25

employees?

Professional

occupation?

Manager?Managerial/

professional

Supervisor?

Professional

occupation?

Technical,

manual or

routine

occupation?

Managerial/

professional

Managerial/

professional

Intermediate

Managerial/

professional

Routine &

manual

Professional

occupation?Managerial/

professional

Routine &

manual

Intermediate

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Appendix 9

Screening Spirometer Agreement This document constitutes an agreement for the provision of screening spirometers. It concerns asset ownership, maintenance and disposal. Asset Ownership The screening spirometer will be an asset of each individual community pharmacy participating in the Smoking Cessation, Community Pharmacy Local Enhanced Service (CPLES). They will not be an asset of NHS Wakefield District Primary Care Trust (WDPCT). They will not be placed on the WDPCT asset register, not subject to the WDPCT ‘Medical Devices Management Policy’ (Reviewed 2009). Maintenance It will be the responsibility of each individual Community Pharmacy to ensure that the device is correctly maintained as per the manufactures instructions and that Health Care Professionals are suitably trained in its operation. WDPCT Guidelines have been produced for the use screening spirometers. These should be read in conjunction with the contents of this letter. WDPCT will accept no liability of risk for the clinical use of the screening spirometers. Disposal It will be the responsibility of the individual Community Pharmacy to dispose of the spirometer in a safe manner. WDPCT will not accept any responsibility for a spirometer being given to an external or internal third party. WDPCT holds no obligation for replacement should the screening spirometers detailed in this agreement become irreparable. The Donation and Liability for the Equipment Upon your signature and return of this form, WDPCT via Pfizer will donate to you the Equipment, and all rights in and title to such Equipment shall pass to you. WDPCT via Pfizer will take reasonable care in providing the Equipment to you but, as the Equipment is provided free of charge; Pfizer excludes responsibility for any loss, liability or cost in connection with it (whether under contract or tort) to the full extent permitted by law.

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Signature on behalf of the Pharmacy Contractor On behalf of the pharmacy, I confirm I have read and accept under these terms and conditions the Screening Spirometer Agreement. Signed ………………………………… Printed ………………………………….

Position ………………………………………………………………………………..

Pharmacy Trading Name ……………………………………………………………

Address ………………………………………………………………………………..

…………………………………………………………………………………………..

Post Code ……………………..…… OCS Code ……………………………

Please sign both copies as acceptance of the terms and conditions. Your copy will be returned along with the counter signed formal agreement of the Smoking Cessation CPLES. Please retain a copy for your records.

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Appendix 10

COPD 6 Claim Form Patient Name………………………………….. ….. DOB………………..

GP Practice …………………………………………………………………………….

COPD6 Screening completed: Yes No Date ……………..

If No please explain: ……………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

Test Result: Normal Abnormal

GP letter given: Yes No

If No please explain: ……………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

Breathe easily in Wakefield

Smoking Cessation 2012/13 - Community Pharmacy West Yorkshire

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