Smoking and mental health: working with the community Linda Bates Development Officer

About this presentation 1. Why we’re doing this work 2. What we’ve done so far 3. What we’re doing next (hopefully!) Who: Development Lead (2½ days per week) Development Officer (4 days per week)

1. Why are we doing this work? People with mental health issues: tend to smoke more than the general population, which leads to: very poor physical health outcomes that means they: experience a wide health inequalities gap and: have a reduced quality of life leading to: earlier death: 9-20 years shorter life expectancy for people with bipolar disorder 10-20 years shorter life expectancy for people with schizophrenia 7-11 years shorter life expectancy for people with recurrent depression Those who do manage to stop smoking improve their mental wellbeing as well as their physical health

2. What have we done so far? IMPACT Project (Improving Mental and Physical health – Achieving Cessation Targets) Royal Edinburgh Hospital consultation Scottish Government’s 10 year mental health strategy Smoking and mental health training pilot

IMPACT Project Two-year IMPACT project (funded by the Edinburgh & Lothians Health Foundation) aims to develop and deliver guidelines and implementation suggestions so that community-based mental health organisations in the Lothians can address smoking with the people they support. How will we do this? gather evidence on smoking & mental health and produce a report map existing community-based MH services across the region interview service providers about their practice/policy hold focus groups with people supported by services hold workshops with staff from community-based services distribute a survey which gauges staff knowledge/confidence produce guidelines and implementation plan (late ‘16-early ‘17) develop related website for ongoing use (early-mid ‘17)

NOT NHS SETTINGS!

IMPACT Project Focus groups (x4) held in Feb-March ’16: 24 people (15 women, 9 men), age range mid-20s to 55+ experiences varied widely (from recent acute hospital admission to never hospitalised) Knowledge Exchange workshops (x2) held in Feb-April ’16: 18 people from 12 different organisations (mainly community-based, but also four NHS: two stop-smoking services plus Breathing Space and Smokeline) Survey distributed to MH service staff Aug-Sept ‘16: - sent to 60 contacts; 39 responses from 15+ workplaces

IMPACT Project Themes from fieldwork - from the focus groups and knowledge exchange workshops: very little knowledge about links between smoking and mental health some didn’t believe there were links: “Smoking and mental health? It’s just another layer of bullshit.” most were unaware of how smoking can reduce the efficacy of MH medications (such as anti-depressants and anti-psychotics): “It should just become common knowledge… when you go to your doctor’s; [they should] mention that actually you’re not getting the benefit of your medication if you’re taking other chemicals such as nicotine.” electronic cigarettes are reportedly being widely used by this cohort, as with the general public - any guidance should provide the most up-to-date information about their safety/efficacy within a mental health context good ideas were generated for alternative coping mechanisms a person-centred, holistic approach was felt to be the best way of providing ongoing support, ideally provided by staff at mental health services. Such support would need to be intensive and ongoing To save time I’ve put the findings from the focus group and knowledge exchange workshops together. Acknowledge that the discussions in the focus group and knowledge exchange workshops were different, however did throw up some similarities: e.g. the little knowledge about links between smoking and health.

IMPACT Project Themes from fieldwork - from the MH services staff survey: knowledge and understanding of topics relating to smoking and mental health was generally good confidence in discussing these topics was lower some attitudes and assumptions still need to be addressed: “I work to build a safe trusting relationship with service users - lecturing them about smoking doesn't help build this relationship. Service users know that smoking is bad; they don't need it repeated by every mental health professional they come into contact with. And to think they do is condescending and patronising” Overall, practitioners welcomed the idea of better support and guidance on this issue

IMPACT Project Closing phase of funded Project: creating a Guidance document for community-based mental health organisations across the Lothians, to help their support workers talk about issues relating to smoking and mental health (launching March 2017). developing a website – www.impact.scot – which will host the Guidance, related evidence and a practice-sharing forum (launching spring/summer 2017) dissemination event 21st March 2017 repeat survey and compare to original results Mention the guidance focuses around the ‘AID’ acronym Ask, Inform, Discuss. Services need to be able to talk about smoking and it needs to be done in a supportive, enabling way. We need to change the perception that talking about smoking with people within group will result in tension or conflict. It’s not about meddling or telling people what to do, it’s actually about empowering and supporting them to make their own choices. By consciously deciding not to ask, you are actually already making a decision for them: that they’re not ready or don’t want to. Comparison with work around smoking and pregnancy and midwives.

Royal Edinburgh Hospital consultation Context for consultation Inpatient mental health services: 10 wards providing acute admission, adult acute, intensive psychiatric care (IPCU), forensic psychiatry and psychiatric rehabilitation Each ward has approximately 30 members of staff (12 per shift) and beds available for 15-20 patients NHS Lothian wide Smokefree Policy Site specific Standard Operating Procedure (SOP): management of smoking within adult mental health inpatient areas Number of challenges and issues around compliance Moving to a new build early 2017 Very quick turnaround!! Initial approach in June, September before consultation agreed, consultation report anticipated March 2017

Royal Edinburgh Hospital consultation Consultation process Involving: patients, staff, family and carers Combination of questionnaires and focus groups Patient consultation (December 2016): 7 participants across 4 focus groups (acute, rehab and IPCU) In addition, 6 completed questionnaires 2 x staff focus groups, plus questionnaires (January/February 2017) 1 x family and carer focus group, plus questionnaires (January/February 2017) Draft report by end of March Meeting to discuss findings and agree what next in April (tbc) Pick up on numbers attending focus groups – closer to interviews/one to one discussions rather than focus groups.

Scottish Government’s 10 year mental health strategy (currently in draft – awaiting publication) A lot of lobbying!!! Scottish Government: Ministers, MSPs and civil servants Royal College of Psychiatrists Third-sector mental health organisations Mental Health Partnership in Scotland NHS Health Scotland COSLA (Convention of Scottish Local Authorities) Royal College of Physicians Edinburgh Blog pieces Learning from ASH in London “Stolen Years” report

Scottish Government’s 10 year mental health strategy (draft) Live Well – supporting people to look after themselves to stay mentally and physically healthy, to get help quickly when they need it, and to reduce inequalities for people living with mental health problems Priority 6: Improve the physical health of people with severe and enduring mental health problems to address premature mortality Ensure that prevention programmes e.g. smoking cessation are accessible to people with mental health problems Priority 7: Focus on ‘All of Me’. Ensure parity between mental health and physical health Develop more effective alignment with wider population health improvement (including smoking)

Mental Health Training Pilot Half-day training course, run in November ‘16 within NHS Borders as a pilot to gather feedback on content (specifically level of information contained within the course) Course aimed to challenge attitudes and perceptions, build confidence and knowledge levels of participants, and encourage participants to engage in the topic of smoking with the people they support who have existing and ongoing mental health issues Aimed at third-sector community based mental health services, however NHS also attended 12 participants attended the pilot and it evaluated well Currently undertaking a 3 month follow up survey to determine any lasting impacts/changes to practice Course covered: the evidence which proves the relationship between smoking and mental health the specific and direct effect smoking has on medications how smoking contributes to the wider inequalities faced by people with lived experience of mental health illness asking the question: reducing fears, increasing confidence, exploring attitudes and tackling the taboo, plus the role of the support worker in initiating the conversation nicotine containing products: pharmacotherapy (nicotine replacement therapy) and e-cigarettes, and non-nicotine containing products what stop-smoking support options are available (NHS and others) and what they can provide what to expect next: the role of the support worker in providing ongoing support and advice following a quit attempt

3. What we’re doing next (hopefully!) Supporting implementation of 10 year mental health strategy Roll out of IMPACT Project Encouraging practitioners within Edinburgh and the Lothians to engage with guidance Support for practitioners: IMPACT website and developing pilot training for roll out Identify other geographic areas Royal Edinburgh Consultation Develop project to address findings from consultation: working with REH colleagues, Advocacy Services and Family & Carers’ council

Linda Bates ASH Scotland 8 Frederick Street Edinburgh EH2 2HB lbates@ashscotland.org.uk Tel: 0131 225 4725