1. Delivery of the Risky Behaviour CQUIN
Don Lavoie

2. What I plan to cover Why smoking and alcohol?
What is the CQUIN indicator asking providers to do?
What evidence is there about effectiveness?
How is the CQUIN progressing so far?
What resources are available?
What the future might hold?
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

3. Why smoking? Nearly 1 in 6 adults smoke
11% (840k) of the smoking population are in hospital in any given year
The average patient spends 5 days in hospital
Currently, 28% of total hospital admissions are attributable to smoking, including:
43% of respiratory admissions
18% of circulatory admissions
48% of cancer admissions
28% of digestive disease admissions
Smoking costs the NHS £2bn annually through hospital admissions etc.
Smoking is the single largest cause of health inequalities and premature death, responsible for 17% of all deaths in people aged 35+
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

4. Why alcohol?
Alcohol misuse contributes (wholly or partially) to 200 health conditions, many leading to hospital admission
Conditions include:
Cardiovascular conditions
Liver disease
Cancers
Depression, and
Accidental injuries
Alcohol plays a role in over 1m NHS admissions per year of which 337,000 estimated admissions where directly alcohol-related (2016/17)
There were nearly 24,000 alcohol-attributable deaths in 2016
Alcohol is estimated to cost the public purse £21bn per annum, of which £3.5bn are costs to the NHS. Around three quarters of the £3.5bn cost to the NHS is incurred by people who are not alcohol dependent, but whose alcohol misuse causes ill health
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

5. CQUIN No. 9. Preventing ill health by risky behaviours
The preventing ill health by risky behaviours CQUIN focuses on identifying and influencing inpatients who are increasing or higher risk drinkers and who smoke by providing brief advice and appropriate referrals.
Eligibility
2017/2018
2018/2019
Mental Health Providers 
Community Providers
Acute Providers 
Adult inpatients (≥18 years of age)
Admissions to maternity wards
A&E patients that do not lead to admission
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

6. QUARTER 1 I PREPARING THE ORGANISATION FOR DELIVERY
April
May
June
July
August
September
October
November
December
January
February
March Q1
QUARTER 1 I PREPARING THE ORGANISATION FOR DELIVERY
Establish information systems
To record smoking status, alcohol consumption and the interventions.
Establish baseline performance
To allow for ongoing monitoring.
Train staff
To confidently deliver IBA and VBA to patients.
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

7. QUARTER 2 ONWARDS I DELIVERY
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
QUARTER 2 ONWARDS I DELIVERY
Deliver Very Brief Advice (VBA) and Identification and Brief Advice (IBA) to inpatients and record these activities
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

8. TOBACCO VERY BRIEF ADVICE
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
TOBACCO VERY BRIEF ADVICE
ASK (≥90%)
ASK AND RECORD SMOKING STATUS
Is the patient a smoker, ex-smoker or a non-smoker?
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

9. TOBACCO VERY BRIEF ADVICE
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
TOBACCO VERY BRIEF ADVICE
ASK (≥90%)
ADVISE (≥90%)
ASK AND RECORD SMOKING STATUS
Is the patient a smoker, ex-smoker or a non-smoker?
ADVISE ON THE BEST WAY TO STOP SMOKING
The best way of stopping smoking is with a combination of medication and specialist support.
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

10. TOBACCO VERY BRIEF ADVICE
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
TOBACCO VERY BRIEF ADVICE
ASK (≥90%)
ADVISE (≥90%)
ACT (≥30%)
ASK AND RECORD SMOKING STATUS
Is the patient a smoker, ex-smoker or a non-smoker?
ADVISE ON THE BEST WAY TO STOP SMOKING
The best way of stopping smoking is with a combination of medication and specialist support.
REFER THE PATIENT TO A SPECIALIST STOP SMOKING SERVICE AND OFFER STOP SMOKING MEDICATION
Build confidence, give information, refer, prescribe. They are up to four times more likely to quit successfully with support.
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

11. PATIENTS WHO DRINK AT ABOVE LOW-RISK
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
ALCOHOL IDENTIFICATION AND BRIEF ADVICE
IDENTIFY (≥50%)
PATIENTS WHO DRINK AT ABOVE LOW-RISK
Use AUDIT-C to identify the patients who are increasing or higher risk drinkers.
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

12. PATIENTS WHO DRINK AT ABOVE LOW-RISK
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
ALCOHOL IDENTIFICATION AND BRIEF ADVICE
IDENTIFY (≥50%)
ADVISE (≥80%)
PATIENTS WHO DRINK AT ABOVE LOW-RISK
Use AUDIT-C to identify the patients who are increasing or higher risk drinkers.
GIVE BRIEF ADVICE
Provide patients who are drinking at above low-risk (but, not dependent) with advice on what their score indicates about their health and information about the harm and benefit of cutting down.
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

13. ALCOHOL IDENTIFICATION AND BRIEF ADVICE
April
May
June
July
August
September
October
November
December
January
February
March Q2 Q3 Q4
ALCOHOL IDENTIFICATION AND BRIEF ADVICE
IDENTIFY (≥50%)
ADVISE (≥80%) or
REFER (≥80%)
PATIENTS WHO DRINK AT ABOVE LOW-RISK
Use AUDIT-C to identify the patients who are increasing or higher risk drinkers
GIVE BRIEF ADVICE
Provide patients who are drinking at above low-risk (but, not dependent) with advice on what their score indicates about their health and information about the harm and benefit of cutting down
REFER TO A SPECIALIST SERVICE
Refer dependent drinkers to local specialist services
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

14. What is reported? Indicators Data items
Screen 90% of inpatients for smoking and record this
Give brief advice on tobacco to 90% of inpatients who smoke
Provide referral and offer medications to 30% of inpatients who smoke
Screen 50% of inpatients for alcohol use and record this
Give brief advice or referral to 80% of inpatients who drink alcohol above low risk, as appropriate
Number of unique adult admissions
Number of unique admitted patients with a tobacco screen
Number of screened patients who smoke
Number of patients who smoke, given brief advice
Number of patients that smoke that are referred to a stop smoking service AND who have been offered stop smoking medication
Number of unique admitted patients screened for alcohol consumption
Number of screened patients drinking above low risk levels (but not dependent levels)
Number of patients drinking above low risk levels (but not dependent levels), given brief advice
Number of patients screened drinking at possible dependent levels
Number of patients that are drinking at possible dependent levels that are offered a referral for specialist assessment and treatment
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

15. Potential reach (estimated)
Service type
Estimated Number
Reach in Q1 2018/19
Mental Health Providers 62 54
Community Providers
103 65
Acute Providers
152 83
NOTE: Some Mental Health Trusts and Community Trusts are not eligible as they do not provide inpatient beds
≈ 3,000,000* inpatients in scope in 2017/2019 across all NHS mental health, community and acute providers
*note: preliminary estimate
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

16. The evidence - smoking Ottawa Model conclusions
“Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage”.
The study found reduced:
Mortality at 1 year and 2 years
All-case readmissions and smoking-related readmissions at 30 days, 1 year and 2 years
All-case emergency department visits
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

17. The evidence - alcohol NICE evidence statements
27 systematic reviews support the effectiveness of brief interventions to address alcohol misuse by adults.
Brief interventions found to reduce:
Alcohol consumption
Alcohol related mortality
Morbidity
Injuries
Social consequences
Use of healthcare resources
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

18. University Hospital Southampton NHS Foundation Trust
The trust provides services to some 1.9 million people living in Southampton and south Hampshire
It admits approximately 1,200 patients each month
In 2015, as part of the development of the Trusts Alcohol Strategy, it was noted that patients weren’t systematically being asked about a known health risk – alcohol use
A commitment was made to improve screening of inpatients across all wards
Medicine Management Technicians (MMT) were identified as being in an ideal position to ask all inpatients about their alcohol consumption
MMTs see all eligible patients within 48 hours of admission to carry out medicine reconciliation (the process of confirming what medications a patient is taking)
It was felt that alcohol screening could be incorporated into this process
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

19. Southampton results
A two week pilot was run to test acceptability and feasibility
The pilot covered all patients and all wards (excluding maternity and paediatric wards)
MMTs were trained to use AUDIT-C to screen all patients
Patients who were identified as increasing or higher risk drinkers were informed about the risk to their health and given an information leaflet
Patients who were identified as potentially alcohol dependent were offered a referral to the Trust Alcohol Care Team, who made an assessment and where appropriate referred on to community teams
Information on patients’ alcohol consumption, the advice given, and whether a referral was offered and made, was recorded to evaluate the pilot.
Results of the pilot were exceedingly positive
789 patients were assessed by 36 MMTs across 56 wards
25% of patients identified as drinking alcohol at above low risk levels and provided with an appropriate intervention
On average, the process took six minutes per patient to deliver
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

20. Tobacco indicators – average Q4
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

21. Alcohol indicators – average Q4
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

22. Support tools and resources
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

23. Support tools and resources

24. Blogs
Videos
Infographics
Case studies
Communication tools
FAQs

25. CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

26. New e-Learning programme
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

27. PHE YouTube video clips
Video Clip 1:  Introduction – making the case
Video Clip 2:  Very Brief Advice on Smoking
Video Clip 3:  Alcohol Identification and Brief Advice
Video Clip 4:  Patients who drink and smoke
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

30. Knowledge hub
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

31. Referral pathways
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

32. CQUIN mail box for queries
address for general queries concerning the CQUIN
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

33. Future of the CQUIN
NHS England has agreed a 2 year CQUIN programme for FY
Some (but not all) of the existing CQUIN indicators will be included
Final decision will not be known until November / December 2018
BUT, encouraging statements are being expressed by NHS England:
“Providers are showing strong commitment towards this CQUIN indicator and on average providers’ performance against all sub-indicators has continued to improve in Q3.”
“The high rates of risky behaviours being observed by providers, particularly smoking and possible alcohol dependence, echoes the importance of this CQUIN and the need for a sustained effort to deliver tobacco and alcohol brief interventions to patients in secondary care.“
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

34. “Listening” exercise Patient Groups Smoking Indicators
Alcohol Indicators
Data
QUESTION:  Expand CQUIN to include: Day patients in acute trusts Outpatients in mental health trusts
QUESTION:  SPLIT INDICATOR INTO: 9c:  Prescribed Nicotine Replacement Therapy 9d:  Patient accepted a referral to stop smoking behavioural support
QUESTION:  increase the threshold to 75% "Screen 50% of inpatients for alcohol use and record this"
QUESTION:  How do you collect data?
Highlights
Wide agreement
BUT
Not now!  There is a need to consolidate
If expansion does happen in the future, it should be a separate CQUIN
Wide support to split the indicator
A target for ‘prescribing’ rather than ‘offering’ NRT is not supported
They risk being penalised for things they cannot control – patient choice.
Fairly wide support to increase the threshold, BUT some exceptions
One acute trust’s baseline audit showed that only 9% of patients were screened for alcohol consumption levels.
Another stated “This is not realistic. We are still working hard to achieve the 50%...”.
Most are using Electronic Patient Records
A few still using paper systems
A few mentions that reviewing 500 patient records was  a burden
CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco

35. CQUIN No. 9. Preventing ill health by risky behaviours – alcohol and tobacco