In the Greater Glasgow NHS Board area, 33 per cent of the adult population smokes, rising to 37 per cent in Glasgow City alone. In some of the most disadvantaged communities, adult smoking rates are greater than 50 per cent.
On average, each community pharmacy in Glasgow serves the needs of 1,500–2,000 smokers. Over 400 community pharmacists and counter staff have been trained as smoking cessation pharmacy advisers through a recognised training programme. This involves attending a one-day training course that covers the art of brief negotiation interviewing together with providing information on the range and suitability of nicotine replacement therapy (NRT). The local public health pharmacy facilitator then visits to discuss the paperwork. Once these two elements are complete, the pharmacist is able to prescribe and dispense NRT to suitable patients and the assistant can give the support and NRT from week one onwards.
Starting Fresh is the largest pharmacy smoking cessation service in the UK, with more than 35,000 smokers accessing it since June 2003. In Greater Glasgow 207 (92 per cent) of community pharmacies now prescribe NRT together with brief support. The pharmacies are easily accessible, some with extended opening hours both at evenings and weekends.
Clients can access the service either directly or by referral from another healthcare professional. No appointment is necessary to speak to the trained staff about the service. If clients seek help to stop smoking they are individually assessed for their readiness to stop. The service offers weekly support and the supply of NRT in accordance with prescribing guidelines for up to 12 weeks. Carbon monoxide monitoring is used to motivate clients. NRT is free to people who are exempt from NHS prescription charges.
Starting Fresh is a key element in smoking cessation provision in Greater Glasgow as a whole. It also provides NRT and continued support to clients from other specialist services set up by Smoking Concerns, NHS Greater Glasgow and Clyde’s specialist tobacco project.
Effect of smoking ban
The Starting Fresh programme has grown to a high level of activity in a relatively short timescale. In January 2006, almost 2,000 clients signed up to receive support to stop smoking and weekly prescribing of NRT; 94 per cent of these clients were prescribed NRT directly from their community pharmacist. The increase in client numbers in the first quarter of 2006 was due in part to the introduction of the smoking ban in public places on 26 March. Twelve-monthly follow-ups will give an indication of the reason for the client accessing the service and whether or not the ban played a part on their choice of quit date. Typically clients self-refer but can be directed to the service by other healthcare professionals.
Funding
The community pharmacists are funded by the Primary Care Division of NHS Greater Glasgow and Clyde. Pharmacists are paid in instalments up to a maximum of £30 per client recruited. The scheme is funded by discounts secured from the drug company involved. The level of discount is determined by the volume of sales in the Glasgow and Clyde areas. Sales include all over-the-counter purchases of that brand of NRT and prescriptions written by the GP, pharmacist or nurse prescriber.
The service’s unique role is three-fold and covers the main elements that make it attractive to NHS Greater Glasgow and Clyde:
- Pharmacies are easily accessible with extended and often weekend opening hours, allowing clients more access to the service outside standard surgery hours.
- Pharmacy assistants are trained to provide the service to clients after the initiation of NRT i.e. from week two onwards. In that way, pharmacists’ time is freed up to carry out other duties. Anecdotal feedback suggests that the assistants delight in this increased level of responsibility and they therefore become more valued members of the pharmacy healthcare team.
- There has been a downturn in GP prescribing costs of NRT as well as freeing up GP time and resources.
Outcomes
Research recently completed by Glasgow University provides clear evidence that users are being drawn to the service from the most disadvantaged parts of Glasgow, with 57 per cent residing in the two quintiles that are associated with the higher areas of social deprivation. There are clear indicators in success rates between levels of deprivation.
New policy
Starting Fresh has a recent change in policy for prescribing and dispensing NRT. On entering the service, clients have around one week to prepare for their quit attempt. This first session is an information and assessment session. The intention is to motivate clients to make a serious attempt at stopping smoking. They are given an appointment to return between five and seven days later if they are fully committed to stopping smoking, when they will start their course of NRT for up to 12 weeks.
Evidence has shown that 20 per cent of clients do not return following the information and assessment session. This will inevitably have a positive effect on the quit smoking outcome data and cost-effectiveness of the model.