The National Referral System in England – a system to improve identification and referral of smokers in secondary care

“The National Referral System has made it easier for staff to make stop-smoking referrals, as a result referrals have significantly increased and the number of staff trained to offer very brief advice is the highest it has ever been in the Trust. The implementation of the National Referral System was made easier thanks to the knowledge and experience of the NCSCT delivery manager; with her guidance we communicated effectively with IT- which was crucial, and involved the right teams.”  – Cecilia Clarke, Health Improvement Programme Manager, Barts Health NHS Trust

Patients who remain smoke free during a stay in hospital will heal more quickly and are less likely to be readmitted. In addition, patients are more receptive to smoking cessation guidance while in hospital, and are often more motivated to stop.

The National Institute for Health and Care Excellence in the UK has published public health guidelines specifically for secondary care (NICE, 2013).  The guideline sets out how to support people using acute, maternity and mental health services to stop smoking, and recommends actions health professionals can take. This guideline gives specific recommendations on how to initiate and maintain cessation before planned hospital admissions, as well as having stop-smoking interventions immediately following admission .

It states that National Health Services (NHS) hospitals should help all patients who smoke to stop before or on admission, making this part of routine practice, and for clinical staff to feel this is part of their duty of care. Evidence suggests that patients already expect this care, with 95% of patients expecting to be asked if they smoke by a health professional (Slama et al, 1989).

The guideline aims to make it unacceptable to smoke anywhere on NHS hospital grounds, encouraging the health service to lead by example. It states that NHS hospitals should provide everyone with verbal and written information about the hospital’s smoke-free policy before their appointment, procedure or hospital stay, and that this should include the short- and long-term benefits of stopping smoking and details of the support available.

A clinical or medical director should be assigned as the lead on stop-smoking support and smoke-free policy for the organisation. This lead person should promote stop-smoking support for patients and staff and ban staff-facilitated patient smoking breaks and the sale of tobacco products in secondary care settings. They should also ensure smoke-free plans include removing shelters or other designated outdoor smoking areas, and ensuring staff, contractor or volunteer contracts do not allow smoking during working hours or when in uniform or on hospital business.

The guideline states that NHS hospitals should provide intensive stop-smoking support for people using secondary care services, and discussions about past and current smoking behaviour should be included in a personal stop-smoking plan. This should also include providing immediate access to licensed nicotine-containing products, such as nicotine replacement therapy patches or gum, or other pharmacotherapies.

The National Referral System (NRS) is a whole hospital approach to supporting patients to stop smoking, and is now fully implemented in 17 Hospital Trusts in England that has been developed and piloted and is now managed and implemented by the National Centre for Smoking Cessation and Training (NCSCT). It facilitates and encourages staff to ask and record smoking status for every patient, to deliver 30 second ‘very brief advice’ (VBA) and to generate electronic referrals on to local stop-smoking support services (tobacco dependence treatment services provided by the National Health Service/Public Health). The existing hospital system is used to make patient referrals, making it a straightforward and time-efficient activity, sorting patient details by postcode and referring them on to local stop smoking support.

Research has shown that implementation of the NRS significantly increases the identification and referral of smokers onto appropriate stop-smoking support. It engages staff by including a proven programme management approach that ensures the system is fully implemented and adopted by staff within an acute trust. One hospital, with a track record of referring a good proportion of smokers, more than doubled the annual numbers referred in 7 months (referring 2000 people in 7 months after implementation). In general Trusts have increased the numbers referred by between 600 and 4000% in year 1 compared to the year prior to implementation.

Fundamentally, it offers a standardised, robust and tested electronic referral system and it includes an evidence-based online training package and has been well received by the hospitals themselves.