Challenges and outcomes of implementing smoke-free grounds policy in a mental health setting

1. Challenges and outcomes of implementing smoke-free grounds policy in a mental health setting Fiona Kean NHS Lothian

2. Background • On April 1st 2015, NHS Lothian began implementation of the Smokefree grounds policy • Scottish Government’s 2013 Tobacco Control Strategy required that NHS grounds be Smokefree by March 2015 • It was decided by the Lothian Health Board that mental health settings would not be given exemption from this policy

3. Rationale • Reduce health inequalities • Reduce stigma • Change the culture in REH

4. What changed? • Patients, visitors, staff, contractors etc are no longer allowed to smoke anywhere on NHS grounds, including in vehicles • Staff no longer able to escort patients for the purposes of smoking • Smoking shelters removed • E-cigs permitted in the grounds • Cigarettes no longer sold in hospital shop

5. Smokefree Lothian’s Input Assistance offered to all sites that felt they would need additional support Royal Edinburgh Hospital (REH); with additional mental health wards within St John’s hospital (SJH) requested this additional support

6. Anticipated Fears Increase in Violence and Aggression Increase in smoking indoors Medication concerns Confronting someone smoking on the grounds Fire Risk Impact on local residents

7. Implementation • Steering group • Two dedicated Smokefree Facilitators • Communication plan • Countdown to Smokefree • Signage • T.V. and radio advertising • Local briefings for patients and staff

9. Challenges

10. “Smoking helps our patients relax and eases their symptoms” “This is their home, it is unethical to ask them not to smoke here” “Smoking is the smallest problem these people have to deal with” • “This is a mental health hospital, not a general hospital, allowances have to be made” “They always say they want to stop, but they never will” “Going for a cigarette is our number 1 de-escalation technique” “Challenging smoking means risking the therapeutic relationship”

11. Challenges - continued • Patients • Local Residents • REH site itself

12. entrance entrance George Watson’s College (Primary & Secondary School)

14. Where are we now? • Results of mapping exercise • 64% (11/17) felt the policy had improved smoking on the grounds • Around 29% (5/17) interviewed felt smoking indoors had become worse • Daily reports of staff continuing to smoke in uniform

15. Where are we now? • Just under half interviewed did not attend the Smokefree Lothian information sessions • All staff aware of the integrated care pathway into Smokefree Lothian Cessation service • Complaints from the public

16. The good news • 76% (13/17) of wards felt there was no increase in violence and aggression • 1 SCN felt his own staff were partly at fault for the increase his ward had seen • Reduction in anti-psychotic medication for a number of long term patients

17. The good news • Money spent on NRT in March 2016 at REH has increased by 146% when compared with same month last year • Had been estimated that in the year April 2015 - March 2016, REH would have spent £18,000 on NRT alone • Total was in fact £16, 877

18. NRT Expenditure Comparison

19. Moving Forward • Recording breaches of policy • More education for staff and patients • Induction of junior doctors • Compulsory for MH staff to attend brief intervention training?

20. Moving forward • PGD (Patient Group Directive) to be used to assist with gap in NRT provision. • Core packs of NRT to aide initial NRT prescription • Mandatory questions at admission about smoking status to be included in paperwork / electronic databases.

21. Moving Forward • Focus groups and listening events • Boredom busters. • Patients to have more ownership over grounds. • A place on all agendas in hospital meetings for “Smoke-free Grounds”.

22. Thank You