babyClear Implementing a regional approach to tackling smoking in pregnancy Martyn Willmore Performance Improvement Delivery Manager, Fresh Hilary Wareing Director, Tobacco Control Collaborating Centre

2010 RCP report on “Passive smoking and children” states that: “Each year in the UK, an estimated 3,000 to 5,000 miscarriages are caused by maternal smoking” The impact of maternal smoking

Smoking at time of delivery rates since 2006/07

How to stop smoking in pregnancy and following childbirth NICE public health guidance 26: Quitting smoking in pregnancy and following childbirth NICE Guidance

Key outcomes from research -Four main issues identified following regional survey of North East midwives: -Skills and training. How to make training standards consistent? Specific issues around using CO monitors -Resources. Prompts/triggers to help midwives raise issue in a more structured way. Access to resources -Carrying the message consistently. Ensure staff deliver same message every time -Managing relationships. Need to defuse any concerns about negative reactions to discussing smoking

Following procurement process, we commissioned the TCCC to deliver babyClear: Systematic approach to CO monitoring at first booking appointment Standardised referral process “Risk Perception” intervention by midwife at time of dating scan clinic Skills training for SSS (advisers and admin teams) Supply of all related materials Implementing a regional approach

Implementation Numerous meetings took place with a range of key partners: –Heads of Midwifery/Midwifery Supervisors –SSS commissioners and providers –Public Health staff –Clinical Innovations Team for Maternity & Newborn We committed to fund roll-out of babyClear and all associated materials in year one Letter sent out to FT Chief Executives, outlining the rationale for this approach, and seeking strategic support

Aim: To enable participants to systematically identify smokers at time of first booking appointment by means of a carbon monoxide reading. To raise “concern” and automatically refer all smokers into NHS Stop Smoking Services Standard midwifery booking intervention

Standard midwifery booking intervention Two-hour training for all staff who do booking appointments. Challenges include: o Identify everyone who needs to attend o Organise dates/venues for training o Ensure relevant staff register and attend o Provision of localised materials and CO monitors o Manage the on-going provision of resources o Ensure someone locally monitors/manages the compliance with this process o Future training needs to be picked up locally

Booking intervention training numbers Total number of midwives trained across all clusters 399 Total staff trained across all clusters 457 Total number of CO monitors issues across all clusters380

Aim: To enable a cohort of trained midwives to intervene (at time of 12-week dating scan) with smokers who have previously declined offers of help, and ensure they fully understand the risks of continued smoking in pregnancy Risk Perception Intervention

Risk Perception intervention All-day training for small cohort of nominated midwives. Challenges include: o We specified it must be a midwife delivering this….. o Organising dating scan clinics around smokers o Having to repeatedly make the case for this “new” intervention o Midwifery teams making appropriate staff available o Ensure equipment is made available o Monitoring the implementation/compliance

Risk Perception training TrustNumber trained County Durham & Darlington15 Gateshead5 South Tyneside1 Sunderland3 North Tees8 South Tees2 Northumbria8 Newcastle2

Stop Smoking Services Concerns that not all smokers being identified at booking Even majority of those referred opt out of support. Of those that did set a quit date, success rates were low We committed to ensuring that NE SSS pregnancy services deliver highest quality support: o One-day refresher training to existing advisors o Two-day full training to any new pregnancy advisors o One-day training for SSS admin teams on converting “leads” into appointments attended

Stop Smoking Services Challenges of SSS training: o Six NE SSS at time, all with different models of delivery, different data systems o Changes to models midway through implementation o Identifying preferred pregnancy advisors locally o Potential big rise in number of referrals, and impact o Significant role for SSS in helping to manage process and evaluate

SSS training Stop Smoking Advisors124 Healthy Living Pharmacies/pharmacist advisors 31 SSS Administrative staff28

Evaluation Newcastle University agreed to carry out an independent evaluation of the project`s quantitative outcomes Teesside University will be evaluating qualitative outcomes Universities secured funding from School of Public Health Research to undertake this work Not expecting report until Spring 2015 at earliest

Initial Results (SSS throughput) Quit dates set in April- September 2012/13 Quit dates set in April- September 2013/14 % change in quit dates set since last year County Durham & Darlington % Gateshead, South Tyneside & Sunderland % Newcastle & North Tyneside % Northumberland % North Tees % South Tees %

% change in quit dates set by pregnant women from Q /13 to 2013/14

Risk Perception County Durham and Darlington (12 th August – end of March) Numbers % of eligible cohort % of initial referrals Accepted referral following RP257 Engaged with the SSS24194% Set a Quit Date6627%26% Quit at 4-weeks3756%14% Promising early results from Cluster One…..

At 2013 County Durham and Darlington FT staff awards. babyClear approach won: Public Health/Health Improvement Award Chairman`s Quality Award Trust recognition of progress…

Key Lessons Learnt Importance of senior manager buy-in from the start But also crucial to work with those delivering, to understand local challenges/systems, and be flexible Make sure new processes are embedded and formally commissioned (e.g. CQUINs) to help sustain work Understand and address the consequences of upscaling efforts (more equipment, more admin work, etc) It`s not enough to just provide the training and resources….

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