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INTRODUCTION
This document is part of the outputs from the delivery of a Department of Health funded Public Health Inequalities Demonstration Project, one of 6 such programmes nationally. The project, in partnership with Tobacco Free Futures, identified data collection as a key theme. It will provide an update on the national local stop smoking services, service delivery and monitoring guidance (DH, 2011) and its application in the prison setting. This guidance applies to all intervention settings including prisons. The overall quit rate for prisons 2010/11 was 55% - higher than for any other setting apart from military bases (NHS IC, 2011).
It is clear from the project’s recent mapping work, carried out across the 16 North West Prisons, that there are a number of anomalies in the reporting of the prison data.
For example, one prison has relatively small numbers setting quit dates and subsequently successfully quitting, the result being an artificially high quit rate. This distorts the sub-regional figure for Cheshire and Merseyside. Similarly, another smoke free establishment has a very high quit rate as prisoners have to stop smoking on entry hence the prison scores a very high quit rate, again distorting the figure for Greater Manchester.
With a variety of models in the delivery of prison stop smoking services it is unclear if the national guidance on monitoring and data collection is being fully understood, correctly applied and adhered to consistently.
Context
The National Local Stop Smoking Services, Service Delivery and Monitoring Guidance 2011/12 (DH, 2011) identifies prisons as an important source of referrals, indicating that smoking status should be routinely checked as part of the prison induction process as well as via routine health checks during a prisoner’s stay.
The case for addressing smoking among offenders is well made and endorsed in both Healthy Lives Healthy People: A Tobacco Control Plan for England (DH, 2011) and the earlier ‘A Smokefree Future’ (DH, 2010). High levels of smoking are identified among prisoners (80%) and offenders are predominantly from disadvantaged backgrounds, often experiencing additional factors contributing to health inequalities including high levels of mental health conditions, substance misuse and educational limitations (Social Exclusion Unit, 2002). The ‘offender pathway’ incorporates police custody and movement within the prison estate and probation services, as well as other social care agencies. Thus there are many opportunities for joined-up working across the criminal justice system (CJS) to raise the issue of smoking and encourage access to specialist and/or generic services, together with appropriate provision.
The Choosing Health White Paper (DH, 2004) identified the need for greater focus on preventative services, fairer access to health information, resources and care, and greater emphasis on healthier lifestyles, particularly amongst disadvantaged groups. A Government review of health inequalities (DH, 2008) emphasised, “a fair society means helping people to make healthier choices in many different aspects of their lives,” going on to acknowledge that, “some people live in circumstances that make it much harder for them to choose healthy lifestyles.” The World Class Commissioning agenda and the work of Sir Michael Marmot (Marmot, 2010)) provided the context for the development of cost effective, quality services that are delivered in partnership. This includes two national objectives of: improving health promotion and health services to increase healthy life and to address inequality issues to reduce the Index of Multiple Deprivation (IMD).
By exploring the 7 factors that make up the IMD: income, employment, health and disability, education and skills, barriers to housing and services, living environment and crime, the relationship with the offender population is clear. The report estimates the cost of inequality as £5.5 billion to the NHS and £31-33 billion to the economy (Marmot, 2010). It is estimated that an estimated £2.7 billion a year is spent on treating smoking related illness, but less than £150 million on encouraging smoking cessation (DH, 2011).
‘Improving Health, Supporting Justice’: The National Delivery Plan of the Health and Criminal Justice Programme Board (DH, 2007) proposes a whole system approach, outlining that research has also shown that offenders generally do not access the health services they need outside of prison. The criminal justice system offers a range of settings and opportunities that, when properly used, would allow health services to engage better the perceived ‘hard-to-reach’ sections of the population. Prisoners do seem to engage more readily with healthcare in prisons (DH, 2007). The findings and best practice outlined in Stop Smoking Support in HM Prisons: The impact of Nicotine replacement therapy (MacAskill and Hayton, 2007) identifies that substantial quit rates can be achieved in the prison setting acknowledging that in addition there is prisoner interest in participation. Further, the National Offender Management Service’s (NOMS’s) National Reducing Reoffending Action Plan (NOMS, 2004) identifies improving health as one pathway out of reoffending. Health Trainer services in an offender setting can impact on four of NOMS’s resettlement pathways (NOMS, 2004):
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· Skills and employment
· Health
· Drugs and Alcohol
· Attitudes, thinking and behaviour
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Thus, the case for health and criminal justice services working in partnership is clear. Supporting offenders to choose and maintain a healthier lifestyle can have a significant, positive impact on the health service in areas such as mental well-being, stop smoking services and drug and alcohol. The green paper Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders (MOJ, 2010) clearly identifies the need for partners to work collaboratively to address the core challenges in breaking the cycle of reoffending outlining the role health has in achieving this.
COMPLEXITIES OF THE SETTING
The nuances and difficulties in delivering healthcare and health promotion across this setting are numerous. They include the public and professional perception of the criminal justice system with conflicting views of the purpose: notably, the punitive aspects of the system and on the other hand, the opportunities for reparation and rehabilitation (MOJ, 2010). Also, the public perceptions of investing in offender health care may well be one of the money is better spent elsewhere (MOJ, 2010). However, as indicated, the long term benefits of tackling an ‘at risk’ population by reducing inequalities and encouraging personal responsibility for health, may be a reduced risk of developing life threatening disease and contribute to preventing reoffending. The HM Prison Service priorities of safety, security and the reduction of reoffending, conflict with the provision of health care and addressing health inequalities (MOJ, 2010).
Client Group – Issues and Needs
‘Acquitted’: Best practice guidance for developing smoking cessation services in prisons (DH, 2003) outlines the basic principle underpinning health provision in prisons, that services should be based on need and offered to an equivalent standard to those delivered in the community. It is also essential that health promotion is integral to the delivery of prison healthcare (DH, 2002). ‘Acquitted’ also acknowledges the importance of understanding the role smoking has in the lives of prisoners, in particular relief from both boredom and stress. This is perhaps further compounded by increased stress points and the lack of variety in diversionary activities in prison. These are in most instances applicable to the wider probation setting and include the following:
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· Offenders as a high risk group.
· Both educational and health literacy[1] issues.
· Lifestyle experiences and risk taking behaviour.
· Isolation – lack of , or a need for, support from partners and family members.
· Boredom, including unemployment and limited access to diversionary activities and incentives for health changes.
· Culture and masculinity issues relating to men’s health and access to health services.
· Tobacco and its role as currency in prisons including issues of illicit trade.
· Mental health and well-being – depression, anxiety ; confidence self-worth ; emotional well-being, stress and appropriate coping mechanisms.
· Bullying – the social context, relationships and cultures of violence.
· Identity and the need to ‘fit in’.
· Control over the frequency, ability and affordability of smoking.
· Impact on offenders of staff smoking – in prison and probation.
DATA : INFORMATION AND INTELLIGENCE
It is essential, given the importance and complexities of delivering stop smoking services across the prison system, that robust data collection can be relied upon. Effective and efficient data systems need to be in place across the setting, providing up to date information that has integrity and meets the criteria outlined in national guidance (DH, 2011). This will provide a clear picture of the number of high risk service users accessing provision and provide information to inform and improve the commissioning and delivery of services.
Carbon Monoxide Monitoring
Regionally, during the period April to December 2010, 50% of successful quitters across all settings were CO validated. This is 1% up from the same period last year with only one service, one area in the North West having reached the nationally recommended CO validation target of 85%, achieving 90% CO validation. Prison data is recorded as a separate intervention setting acknowledging the high percentage of prisoners that smoke. Many prisoners will be from groups identified as being at higher risk, for example routine and manual workers. It should be feasible to achieve 85% validation across the prison system as the monitoring of individuals in the setting is easier as prisoners are captive, more accessible and access healthcare more readily in the prison setting. The use of regular and robust CO monitoring could also offer a control to the misuse of NRT as currency and also potentially reduce the pharmacy budgets at individual establishments. Given prisoners’ readiness to engage with health care and the anecdotal evidence to suggest that CO testing can be highly motivating for clients (DH, 2011) - the national guidance cites that readings decrease over a relatively short period if they quit successfully. Given links with the prison gyms and additional incentives, this may prove an additional benefit in prison.
Calculation for the % of CO verified clients from all quit dates set:
The number of treated smokers who self-report continuous abstinence from smoking from day 14 to the four-week follow-up point, and who have a CO reading of less than 10ppm:
Example: all treated smokers (N.B. Guidance applies to all settings)
Treated Smokers / Self –reported four week quitters / No. Of Self-reported four-week quitters CO verified / % of all treated smokers CO verified100 / 50 / 35 / 35/100=35%
Calculation for the % of self-reported four-week quitters who have been CO verified:
Number of treated smokers who self-report continuous abstinence from smoking from day 14 to the four- week follow-up point, and who have a CO reading of less than 10ppm:
Example: all self-reported 4week quitters (N.B. Guidance applies to all settings)
Treated Smokers / Self –reported four week quitters / No. Of Self-reported four-week quitters CO verified / % of all treated smokers CO verified100 / 50 / 35 / 35/50=70%
DEFINITIONS
Definition of a 4 Week Quit
It is essential to provide a clear picture of stop smoking activity across the prison system, therefore we must be clear on the definitions of a 4 week quit. The national guidance clearly outlines what constitutes a 4 week quit and outlines how the percentage of self-reported quitters should be calculated. ‘Successful quitters’ refers to those people who successfully quit at the four-week follow-up. A client is counted as a ‘self-reported 4-week quitter’ if when assessed 4 weeks after the designated quit date, they declare that they have not smoked, even a single puff on a cigarette, in the past two weeks (NHS IC, 2011).
Only by applying the data consistently across the system can a true picture of stop smoking activity be developed and understand why some prisons have high quit rates of over 60% and others struggle to achieve over 35%.
Lost to Follow-up
As in the community consideration should be given to the issue of ‘lost to follow up’. However, for prisoners completing a course in prison this is not usually an issue as systems are in place to ensure follow up contact. For people released from prison before completion, referral systems should be in place to link them into local stop smoking services and they should be provided on release with sufficient supplies of NRT to bridge any potential gap in service support. The national guidance makes it clear that for a treated smoker who cannot be contacted either face to face, or via telephone, email, letter or text following three attempts to contact at different times of the day, at four weeks from their quit date (or within 25-42 days of the quit date), the four-week outcome for this client is unknown and should therefore be recorded as lost to follow up (LTFU) on the monitoring form.
Prisoner Occupation Category
The national guidance outlines a key note point that services should be recording the occupation of prisoners: -
The ‘prisoner’ occupation category was added to the quarterly monitoring form submitted to the Information Centre (IC) in 2009/10 and subsequent years in an effort to reduce the number of clients recorded as ‘unable to code’. This change is reflected in the 2011/12 gold standard monitoring form. With the exception of prison staff, clients treated in prison should all be recorded as prisoners.
Definition of Quit Date
The date on which a smoker plans to stop smoking altogether with support from a stop smoking adviser as part of an NHS-assisted quit attempt.
Definition of a Renewed Quit Attempt
A quit attempt that takes place immediately following the end of one treatment episode. A new treatment episode should be commenced in the database/service records.
Definition of a Routine and Manual Worker
A smoker whose self-reported occupational grouping is of a routine and manual (R/M) worker, as defined by the National Statistics Socio-Economic Classification.
Definition of a Self-Reported Four-week Quitter
A treated smoker whose quit status at four weeks from their quit date (or within 25 to 42 days of the quit date) has been assessed (either face to face, by telephone, text, and email or postal questionnaire).