So You Think You Can Only Treat Illness?Dr Aileen Keel CBE Deputy Chief Medical Officer for Scotland
Health Promoting Health Service “Every healthcare contact is a health improvement opportunity”
Health Promoting Health Service Why? • Create a step change in health & wellbeing • Tackle health inequalities • Shift the focus of NHSScotland more towards prevention rather than simply treatment of illness.
Health Promoting Health Service • Building on CEL14 (2008), further CEL setting out revised actions for NHS Boards imminent. • All hospitals settings, including community hospitals and maternity units. • Key issues: • Governance • Leadership • Workforce Development • Support
Key issues (1) - Governance Chief Executives: • To delegate responsibility for implementation to appropriate committee and governance structures; • To provide a report to the Board on progress, at least annually; • To ensure that the annual report is reflected in their self assessment for annual accountability reviews with Scottish Ministers.
Key Issues (2) - Leadership • Chief Executives • Medical Directors & Directors of Public Health • ACF & MCNs - Provide professional leadership - Champion HPHS approach - Engage with key groups - Monitor progress & support implementation of CEL
Key Issues (3) - Workforce Development • Enormous opportunity available to NHSScotland to use its 150,000+ staff to promote health, and to improve the health of the staff. • Build staff confidence and skills around health promotion, health inequalities and health behaviour change. • Embed attainment of generic health improvement competences: - Knowledge Skills Framework (KSF) - Annual appraisal cycles
Key Issues (4) - Support • National • NHS Education for Scotland (NES) • HPHS Network • NHS Health Scotland • Quality Improvement Hub • Local • ACFs and MCNs • PFPI & Better Together Groups • Public Health & Health Improvement Staff
Health Promoting Health Service • New CEL Actions • Smoking • Alcohol • Breastfeeding • Food and Health • Healthy Working Lives • Sexual Health • Physical Activity • Active Travel
Health Promoting Health Service • Key Issues for Next StepsGovernanceLeadershipWorkforce Development Support
HEALTH IMPROVEMENT OPPORTUNITIES IN THE PRE-OPERATIVE ASSESSMENT CLINIC – NHS TAYSIDELouise Bruce Senior Charge Nurse Pre-operative Assessment
THE AIMS OF PRE-OPERATIVE ASSESSMENT • IDENTIFY AND MANAGE RISK PRIOR TO ANAESTHESIA, SURGERY AND HOSPITAL ADMISSION • IMPROVE OUTCOMES BY ENSURING SAFE, EFFECTIVE, PATIENT CENTRED CARE ASSESSMENT TAKES PLACE 6-9 WEEKS PRIOR TO SURGERY – SOMETIMES LESS
THE RISKS AND SUBSEQUENT HEALTH ISSUES AS IDENTIFIED IN CEL 14 (2008) ARE SIMILAR TO THE RISK FACTORS BEING IDENTIFIED FOR SAFE ANAESTHESIA • SMOKING • ALCOHOL • OBESITY – POOR DIETARY INTAKE • DRUG MISUSE • Able to therefore provide a rationale why a change in behaviour will assist them in their recovery from surgery
INCLUDED IN PRE-OPERATIVE ASSESSMENT • Blood pressure (increased BP one of highest reasons for surgery postponement) • Height • Weight • BMI • Cardio-respiratory history • Smoking history • Alcohol intake • Drug use • Social history • Targeted tests e.g. blood tests, ECG • Exercise tolerance assessment (questions)
SMOKING– Why “Stop before your Op!” • Smokers have an increased risk of anaesthesia • complications • Need more anaesthesia to prevent spasms and coughing • Higher risk of post-operative chest infections • Need more oxygen in the post-operative period • Slower wound healing – reduced oxygen – particularly • problematic in plastic, hand and back surgery
EXCESS ALCOHOL • Abnormal liver function tests – processing of anaesthesia compromised • Clotting abnormalities – risk of bleeding • Post operative confusion/delirium • Poor pain control • Malnourishment – poor wound healing
DIETARY/WEIGHT ISSUES • Surgery more difficult in obese patients • Difficulty intubating patients • Difficulty mobilising post operatively – greater risk • thrombosis • Poor wound healing • Wound dehiscence (bursting open)
What have we done so far • Health Improvement section in Anaesthetic Assessment • documentation – all patients asked – aim for approximately 25,000 patients per annum • Nursing staff brief intervention training for smoking and alcohol • Nursing staff training for electronic smoking cessation • referrals • Commenced audit of number of smokers and number of successful interventions • 3 year funded post to promote smoking interventions in pre-operative assessment from Public Health
Next steps • Obesity pathway being developed – patients with • co-morbidities referred for dietary interventions • Exploring partnership working with external weight management company • Pre-assessment DVD being recorded. Patient Public Involvement. • Exploring “well being” pack to be given to all patients with healthy living information along with pre-op information leaflets • Commenced discussion with local Keep Well Project Manager to identify ways of strengthening links with Primary care particularly for patients from areas of high deprivation • Links with local pharmacies
CHALLENGES • Short time to gain full assessment for anaesthesia and engage in health improvement activity • Difficult to provide follow up and support from clinic • Patients may be coping with life threatening illnesses e.g. surgery for cancer – not always the right time • Resources in primary care to refer patients to • Literacy in deprived areas – written information may not be useful • Physical activity assessment/interventions
Health Promoting Hospitals Quality in ActionDr A Hendry National Clinical Lead
Improving Population Health • People have the information, advice and support to live well with • their conditions and to manage their risk factors • An increased number of people are quitting smoking, particularly • those from the most disadvantaged groups of society • People are healthier and experience fewer risks as a result of alcohol • Health Promoting Hospitals
Help people live well Enabling interactions that promote health and wellbeing This is everyone’s responsibility Culture of Prevention and Early Intervention
Systems Improvement • Releasing Time to Care • Patient Safety • HAI • 18 weeks • Unscheduled Care • Falls, Nutrition and Tissue Viability CQI • MCNs work on pathway redesign
Confidence and Capability Conversations that Matter
A National Survey of Smoking Cessation Provision in all Colposcopy Clinics in Scotland and a model for best practiceAlexis RumblesHospital Nurse Adviser Stop Smoking Services
Overview • Integrating smoking cessation within • colposcopy • Effects of smoking on cervical cytology • Outcomes of a national survey in Scotland • Current practice within St John’s Hospital • Summary
What is Colposcopy? A diagnostic procedure in which a specialist examines a magnified view of the cervix using a colposcope
Why do women attend colposcopy clinics? • The most common reason is an abnormal cervical • smear suggesting precancerous changes within • the cervix described as Cervical Intraepithelial • Neoplasia (CIN) • Low grade abnormal smears • Moderate to high grade abnormal smears
What causes an abnormal smear? • Persistent infection with HPV increases • risk of abnormal smears • Smoking changes the ability of cervical • cells to protect themselves so less able to • fight off disease
Treatment of CIN Within NHS Lothian The most common form of treatment is loop excision. This removes the cells using a small heated wire loop. The removed cells go to the pathology laboratory for testing.
CIN 1 Szarewski et al (1996) demonstrated that stopping smoking lead to a reduction in size of the cervical lesion over a six month period.
CIN 3 Alcadious et al (2002) established that smoking is an independent risk factor for treatment failure of CIN.
There is clear evidence that stopping smoking reduces the risk of abnormal smears and decreases treatment failure
A literature review revealed there is no evidence that smoking cessation services are integrated into colposcopy clinics as part of treatment.
Aims of the national Scottish survey within Colposcopy Clinics • Establish if smoking cessation advice • and support is available in colposcopy • clinics throughout Scotland • Review information given • Improve practice
Outcomes of the national survey • 27/30 (90%) clinics returned questionnaires • 24/27 (88%) discuss cessation in some form • 14/27 (52%) always ask smoking status • 12/27 (37%) always discuss risks of continued • smoking and benefits of cessation in relation to • abnormal smears and colposcopy treatment
Who provides smoking cessation advice? • 14/24 (58%) of colposcopy clinics – a • mixture of doctors and nurses • 7/24 (30%) - mostly doctors • 3/24 (12%) - mostly nurses
What verbal advice is given? • 13/24 (54%) of clinics advise • either to cut down or stop smoking • completely • 11/24 (46%) advise on complete • cessation
Providing written cessation advice • 5/27 (18%) provide advice prior to • colposcopy appointment • 12/27 (44%) provide advice during • colposcopy consultation • Nationally inconsistent information and advice given
Referral Pathways for smoking cessation support • 5 colposcopy clinics have a • referral pathway to specialist • stop smoking services • 2 refer to secondary care • 3 refer to primary & secondary care.
Current practice within the colposcopy clinic at St John’s Hospital • Information leaflets sent out prior to colposcopy • appointment include benefits of smoking cessation • Smoking status always established and documented • on NCCIAS form • Referral forms collected daily from clinic
New Leaflet Developed New leaflet developed outlining risks, benefits of stopping smoking and help available from specialist smoking cessation services. Marteau et al (2002), Boardman et al (2004) and Bishop et al (2005)