Lessons Learnt

What happened?	Lesson(s) learnt	Action
Tobacco dependence team (TDT) members were present at post-implementation meetings and discussed several issues that were taking place related to the delivery of the service.	This allowed for the issues to be discussed and for solutions to be proposed with all members of Trust working group.	To communicate the importance of involving TDT members when discussing the setup of a post-implementation meeting.
Referrals being sent to community pharmacies prior to patients being discharged from hospital. Example: a referral was sent to a community pharmacy on the day of admission, and this resulted in the patient being contacted by the pharmacist while still in hospital.	The pharmacy was not kept up to date about the delay in the transfer of care and therefore was unable to provide the service to the patient. This caused frustration and distress to the patient.	Referrals should only be sent after the patient has left the hospital. To highlight to trusts using a dedicated electronic referral module that referrals can be ‘drafted’ and saved until there’s confirmation that the patient has been discharged.
Some Trusts can have a high turnover of staff in their TDT and/or difficulties recruiting staff.	This can affect the ability of the Trust to deliver the service, and subsequently reduce the availability of the service to patients. Some Trusts have adopted a multidisciplinary team (MDT) approach and designated respiratory and cardiac rehabilitation nurses to send referrals. Innovative approaches – Some trusts are utilising existing staff e.g. training pharmacy technicians as tobacco dependence advisors (TDAs) particularly in mental health (MH) trusts and project managers. Other trusts are upskilling phlebotomists, training them as TDAs.	To discuss a contingency plan during the implementation of the NHS England Smoking Cessation Service (SCS) with the TDT lead.
Trusts using a dedicated electronic referral module see all registered pharmacies as “live”.	Trusts may send referrals to a pharmacy without knowing that the pharmacy is no longer able to provide the service due to a change in circumstances. This will result in referral failure which may not be communicated to the Trust and disrupt the patients access to the service.	To explain to Trusts during the implementation stages that not all registered pharmacies will be able to provide the service. To recommend to Trusts who have recently gone live to contact pharmacies before sending a referral. A time scale for this should be discussed and agreed with the TDT lead during the implementation stages. This allows a pharmacy to get used to receiving referrals and for the service to become business as usual.
Trusts without Nicotine Replacement Therapy (NRT) on their formulary can’t deliver the service.	This needs to be determined early on in discussions as it can delay implementation and delivery of the service.	To establish NRT availability on a trust’s formulary with TDT/ pharmacy team during engagement discussions.
Having a more targeted approach to rolling out the service on wards with a greater volume of NRT prescribing e.g., respiratory, and cardiac wards.	Due to the patient demand for the service on the specified wards the Trusts had more success in delivering the service.	To find out from the Trusts which wards will be going live first with SCS and to recommend prioritising wards that see higher rates of NRT prescribing e.g., vascular surgery, respiratory and cardiac directorates.
Testing the referral route during the initial period of delivering the service.	Trust has more confidence in offering the service to patients due to reliability in delivering the service. Along with improved community pharmacy cooperation with the service reporting requirements.	To encourage Trusts to test the service to ensure that community pharmacies are responsive to referrals. To encourage Trust TDT leads to share learning with Local Pharmaceutical Committees (LPCs) to allow for improvement in community pharmacy performance across LPC.
The importance of trusts building a relationship with community pharmacies/LPC once actively sending referrals.	Better communication facilitates delivery of the service as well as Trust confidence in pharmacies. This is also important in the post-implementation phase to allow Trusts and community pharmacies to resolve issues together.	To involve LPCs at an early stage of the implementation whilst also sharing key contacts between Trusts and LPCs.
Community Pharmacy Clinical Leads/ Integrated Care Systems/ LPCs may request access to a Trust’s electronic referral module audit report(s).	This can be beneficial in developing a governance oversight process for referrals and an escalation process when all other options between a Trust and a pharmacy have been exhausted.	To encourage Trusts using an electronic referral module to give the relevant stakeholders access during the post-implementation stage.
Local authority teams perceived the community pharmacy service to be in competition with the locally commissioned smoking cessation service(s).	Need to explain to local authority teams that the community pharmacy advanced service increases service capacity and offers patients wider choice.	Include local authority representation in the local steering groups early so they can understand how the different services operate.
Some trusts wish to use an electronic referral module only and will delay implementing referrals until the module is in place as they are reluctant to use secure mail.	There can be significant delays in purchasing and implementing an electronic referral module. Delaying implementation in this instance, can negatively impact treating tobacco dependence (TTD) capacity in primary care (esp. if no locally commissioned service in place) It also reduces patient choice.	Work with local system partners and advise of the benefits to patients of using secure mail as an interim solution to prevent implementation delays. MCSU to urge trusts to engage with relevant stakeholders eg, pharmacy team, ICB or local prevention team(s) to source electronic referral module license funding.
Some trust Business Intelligence (BI) teams were found to not be submitting monthly SCS referral outcomes to the central prevention team due to being unaware of how to retrieve the data where trusts were using a dedicated referral platform.	This doesn't allow a trust to comply with national reporting requirements.	To ensure the process for retrieving follow-up data from dedicated referral platforms is included in any trust-related training.

What happened?	Lesson(s) learnt	Action
Pharmacies not acting on referrals sent to them.	Pharmacies that are registered, but not ready to provide the service can cause disruption to the service and loss of confidence in the SCS by the Trust and patients.	Pharmacies must de-register if they are no longer able to provide the service or notify the local system of a temporary delay in receiving referrals if they are in the process of working towards delivery. To ensure that the conditions and process for deregistering is explained to community pharmacies through LPCs at engagement events and communication sent out to the pharmacies. Discuss an escalation process with the LPC on how to deal with pharmacies not providing the service. Pharmacies are encouraged to better utilise staff within the pharmacy team to deliver SCS. For example, a member of the pharmacy team could be responsible for monitoring incoming referrals and contacting patients to make an appointment with the pharmacy stop smoking practitioner. This will help pharmacies to meet the 5 working day contact window target set out in the service specification.
Pharmacy technicians were involved in the service provision during the pilot which was a success.	Pharmacy technicians' involvement has the potential to increase capacity in pharmacies and therefore availability of the service to patients. Pharmacies also have more flexibility to deliver the service.	To communicate involvement of pharmacy technicians within the new service specification (published June 23) at discussions with LPCs and at pharmacy engagement events. Follow up with emails during seasonal holidays.
There is often a time lag between pharmacies registering to provide the service and a local Trust going live. This may cause pharmacies to no longer be service ready (due to staff turnover, change in business ownership or pharmacies disengaging with the service).	Communicating this risk with LPCs/Community Pharmacy Clinical Leads (CPCLs) during the initial stages of implementation can reduce frustration and allow LPCs/CPCLs to proactively update contractors on the implementation status of trusts.	To ensure that prior to a Trust going live with the service, LPCs sends regular communications targeting registered pharmacies to ensure that they are service ready. Also, to encourage pharmacies to attend engagement events organised by LPCs/ICBs.