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Barriers and Enablers to the use of NRT in primary care in the Hawke’s Bay

Barriers and Enablers to the use of NRT in primary care in the Hawke’s Bay. Catherine Marshall, Katherine Archer, Grant Carpenter, Roy Hoerara, Debbie Ryan. The Team. Ko te Tangata , He Taonga. Purpose.

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Barriers and Enablers to the use of NRT in primary care in the Hawke’s Bay

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  1. Barriers and Enablers to the use of NRT in primary care in the Hawke’s Bay Catherine Marshall, Katherine Archer, Grant Carpenter, Roy Hoerara, Debbie Ryan

  2. The Team

  3. KoteTangata, He Taonga

  4. Purpose • Identify the barriers faced by health practitioners prescribing or recommending nicotine replacement therapy • Gather ideas and suggestions about the range of support that would help them recommend NRT

  5. The focus groups 17 General practitioners, 29 nurses and 2 health assistants and 2 smoking cessation advisers.

  6. Barriers and enablers

  7. Findings - Awareness • High awareness of the NZ Smoking Cessation Guidelines, the ABC model and effectiveness of NRT • Increased interest from primary care patients/ clients about quitting • 64% GPs and nurses not trained in smoking cessation & don’t know NRT products • Nurses are nervous and uncertain about the appropriate doses - May lead to under-dosing • GPs and nurses not aware of support services for smoking cessation • Low use of Māori or Pacific focussed smoking cessation services

  8. Awareness… • Areas where best practice is uncertain, include: • treating people with multiple addictions • treating people with head injuries and/or mental health problems • combination NRT therapies and double and triple patching • whether reduction in the number of cigarettes is a valid goal, and • whether patients/ clients can use NRT while smoking. • Low community awareness that cigarette smoking is a drug, and that it is more harmful than NRT

  9. Findings – Motivation to Change • Practitioners know what “ABC” stands for, but don’t understand what brief is • GPs don’t have time to talk about smoking cessation and NRT and aren’t paid to do this • Practitioners feel awkward/ patronising • GPs refer their patient/ client to people with a special interest or training in smoking cessation • Nurses are highly motivated to get actively involved in smoking cessation

  10. Findings – Infrastructure barriers • Lack of onsite access to NRT supplies creates barriers to capturing the moment, problems of cost and access • Subsidised NRT is only available from pharmacies • Smoking cessation available at restricted times • Low public understanding of NRT, other meds and supports available • No clear feedback and follow up for referrrals • Family and whānau not seen as part of the team • Goal of being smokefree may be too hard

  11. Enablers • High awareness of the NZ Smoking Cessation Guidelines, the ABC model and effectiveness of NRT • High awareness of the ways to advise use of NRT with pregnant women • Increased interest from primary care patients/ clients about quitting • Primary care is routinely recording smoking status • Some practices have introduced excellent smoking cessation services eg Nurse led healthy lifestyle clinics

  12. Solutions identified through the research project

  13. Training and education • Training programmes for all practitioners be reviewed to ensure that they meet minimum competency •  Face to face training or education is required to assist busy, overworked health practitioners understand their roles • A menu of conversation starters • GPs and practice nurses should meet advisers in their local area • Nurses should be given wider opportunities to participate in training on smoking cessation

  14. Training and education… • Lunchtime workshops at clinics to introduce health practitioners to NRT products and to show them how to use tools such as the ‘heart forecast’ tool • All training courses should provide professional development points • Smokingcessationabc.org.nz online course updated to have more information about the practicalities of NRT • Extend the range of people who can provide access to subsidised NRT products eg pharmacists , community leaders and workplace cessation advisers.

  15. Reminders and EDS • Provide a standing order template for NRT for nurses • Electronic Quit Cards (redesigned) • Electronic follow-up systems between Quitline and other smoking cessation specialists • Reduce read codes • Promote yourheartforecast.org.nz tool

  16. Audit and Feedback • BPAC should conduct an audit of NRT use • GPs suggested that smoking cessation should be included in the PHO Performance Management System and funding should be linked to this

  17. Patient mediated interventions • Develop a wallet card that shows much is saved and the health benefits • Have a video of heroes/real people talking about NRT • Positive and encouraging posters • Promote greater awareness of the telephone and text support systems available to people giving up smoking • Redefine how NRT works and tastes • Identifying ways that the family/ whānau and workplaces can support people • Provide waiting room TV

  18. Mass media • Focus on positive messages that promote health and respect for the need to give up, the use of NRT and reinforce the value of the smoker • Create a campaign with a well known icon who can talk about giving up smoking using NRT • Highlight the specialist smoking cessation services – want them visible to both the primary care practitioners and community • Explain that smoking is a drug – and is more harmful than NRT

  19. Opinion leaders • Clinical opinion leaders to model ways to talk about smoking cessation as part of routine clinical care for chronic condition management • Create Smokefree heroes or ambassadors (this would help practitioners) • Create mentors for smoking cessation advisers to offer professional support to the nursing workforce

  20. Organisational issues • Teach GPs that their role is a very limited, brief - 1 minute responsibility • Swift and effective referral to either an onsite trained smoking cessation expert for immediate advice or Fast track referral system to Quitline or Aukati Kai Paipa (with electronic feedback) •  Reduce the time from discussion about smoking cessation to the point of getting NRT • Arrange services that are more convenient for smokers and their families to attend eg evenings and weekends

  21. National issues • Consider value of funding more GPs time to discuss smoking cessation • Access to samples and free demonstration packs of NRT available through MPSO needed • Extend range of subsidised NRT products eg inhaler • Widen the range of outlets for subsidised and free NRT • Develop a network of local community mentors and supporters

  22. New Directions – WhānauOra W Wairua Trained referral adviser Hinengaro GP – 1 minute message Mentors Family and whānau Heroes Whānau Tinana Champions Workplaces

  23. Next Steps

  24. Next steps • Promotion of NRT and pharmacotherapies to consumers • Production of an educational video about how to use pharmacotherapies • Development of: • a downloadable consumer brochure on patches • Goodfellow Unit Quizzes • BPAC Case Studies and Audit • Education sessions and launch of the new products in March 2011.

  25. Thanks • To the GPs and nurses of the Hawke’s Bay • James Curtis and Carolyn Murphy HBDHB • The Ministry of Health and PHARMAC • The people at Silver Fern Farms Waipukurau

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