Referring motivated smokers
A central theme that emerged from the interviews was that GPs believed that their role was primarily to identify smokers and advise them to stop smoking, but not to provide more intensive support for smoking cessation. Advice included pointing out the dangers of smoking as well as giving a clear recommendation to stop. However, GPs felt behavioural support should be provided by others and therefore referred smokers who were motivated to stop.
'... my job obviously is to ask people if they are smoking and I document how much they are smoking and advise them to stop and then I tell them about the systems that are in place to help them ... (GP3)'.
Beliefs underlying this decision included not having sufficient time to support smokers. Another belief was that GPs perceived other health professionals as better suited to provide intensive behavioural support because these were seen as having more expertise and experience in providing such support. GPs clearly appreciated the availability of services to which they could refer smokers for intensive support.
'I think it's a good use of my time to raise the issue and to give them [smokers] encouragement. I don't think it's the best use of my time because others do it better and I haven't got enough time to do the smoking cessation work as it were (GP15)'.
Preference for in-house support over PCTs' central services
GPs were aware of different options when deciding where to refer motivated smokers to intensive support. These included PCTs' central service, in-house support provided by a practice nurse, and local pharmacists offering smoking cessation support. Although GPs were aware of alternative services, they preferred to use the in-house support if this was available.
'I know that there is a PCT-based service that we can refer on to, but we do have our nurse here who does smoking cessation clinics, so anybody that I see that wants to stop smoking I tend to get to see our practice nurse (GP21)'.
When discussing the effectiveness of central service and in-house support, GPs agreed that both helped smokers to stop smoking even though many smokers who used either of the services would not succeed in stopping smoking. GPs presumed that smokers would receive intensive support and counselling at the central service and their staff were regarded as experts in the field possessing the most up to date evidence of smoking cessation methods. Contributing to this positive perception was the belief that a dedicated central service would have sufficient time to assist smokers.
'I think specialist clinics are a good idea. ... they're doing it full time and so they're aware of what's around (GP10)'.
GPs reported that practice nurses who provided in-house support often provided feedback to GPs that the service helped smokers. Contributing to a sense of effectiveness was GPs' perception that practice nurses had received the relevant training and hence possessed the necessary expertise. This included being able to support smokers in using pharmacological treatments for nicotine dependence and monitoring smokers' nicotine consumption levels by using carbon dioxide monitors.
'I will often refer them to the nursing staff who actually run clinics, and I think they've been to courses where I think it's Level B smoking advice they provide, and they'll sort of monitor the patient with the carbon monoxide monitors, and I think that is extremely useful for most of our patients (GP7)'.
Whilst both central services and in-house support were seen as offering expertise, two features of in-house support seemed to contribute to GPs' preference for this over the central services. One perceived difference between central services and in-house support was that the support practice nurses offered was more personalised than that provided by central services, which they believed made it more effective. The perception that the in-house support was more personalised was supported by the recognition that smokers and staff were familiar with each other and that smokers knew the setting.
'We're a very small practice, we take a lot of individual interest in our patients, and I think that has helped them to stop smoking more than sending them off in a rather nebulous way to a place where they learn en masse to stop smoking (GP5)'.
The other feature was that in-house support was seen as easier to access than central services. This was seen as having several implications, including a positive impact on the effectiveness of in-house support. One aspect about the ease of access GPs valued was that the in-house support was very responsive, capitalising on smokers' high levels of motivation. By contrast, some GPs expected that the central services would have a lengthy waiting-list, prohibiting smokers from receiving support at the time when they were ready to stop smoking.
'We occasionally refer to external smoking cessation clinics at other sites, but generally it's something that occurs within the practice. I think there's a huge benefit to people who look at stopping smoking. And I think it also works a little bit better if we make it, our time, available, because people often respond when they are ready to stop, and if they actually make a decision that they're ready to stop, if they can access something relatively promptly that tends to work a little bit better than having to wait some length of time before they access a service of that sort (GP20)'.
A second aspect about the ease of access was that GPs also believed that smokers could enrol with the in-house support with minimal effort. Smokers, GPs said, could simply make an appointment with the practice nurse when they were at the practice. A third aspect about the ease of access was convenience of locality. In comparison to in-house support, central services were seen as difficult to get to. This was seen as having a negative influence on the effectiveness of the central services because it was expected to lead to greater drop-out.
'I mean I suspect there's a higher risk of DNA [Do Not Attend], higher risk of people not turning up, higher risk of people falling out if they're having to travel further to access such services (GP9)'.
Apart from being poised for increased drop-out, inconvenience of location was also seen as decreasing the potential of the central services on smoking rates in the population because it would deter smokers from enrolling. GPs perceived this as a particular issue for the elderly and people without transport.
'I think it's very good [in-house support], because I think patients like to have services that are local to them, and I think they are much more likely to attend a service within their own GP surgery... (GP21)'.
GPs also valued the in-house support for promoting continued contact with patients and a comprehensive approach to patients' health.
'I think it is very important that the patient is having that aspect of their health looked after at the GP surgery, who is looking after a lot of other aspects of their health. And to me that is a strength, and maybe a disadvantage of the specialised centres... (GP14)'.
Supporting patient preference for familiar and personalized services was seen as another advantage of the in-house support. GPs believed that smokers preferred the in-house support because they were familiar with the practice and the staff, and because smokers preferred a more personal one-to-one approach.
'Well I think it's [in-house support] a very good service. It's well regarded by us as a practice, patients are attracted to it, we promote it, ... I think many patients value the one-to-one approach rather than a group approach (GP15)'.
When discussing whether in-house support and central services were effective enough to justify their costs it appeared that GPs believed that both were cost-effective. GPs based these evaluations on the effectiveness of the services at reducing the prevalence of smoking and the incurred future cost-savings that would result from the reduction of smoking related morbidity.
'I think even if you make just a few people give up smoking, you're still saving the NHS a massive amount of money from the morbidity and the mortality of what smoking does [in-house support] (GP12).' 'And what about NHS clinics [central services]?' (FV). 'The same thing, it must be saving money in the long term (GP12)'.
GPs also believed that offering support for smokers in groups, as practiced at the central services, would have a beneficial impact on their cost-effectiveness because it allows few health professionals to support many smokers, resulting in low salary costs per supported smoker. Factors perceived as limiting the cost-effectiveness of central services included, firstly, a perception that such services would see a high rate of drop out, and secondly, high maintenance costs. Maintenance costs incurred included salary for staff, who are specifically employed and trained to provide smoking cessation support, and costs associated with providing the premises at which the service would be offered.
'Well I wouldn't think they're that cost-effective [central services], because at the end of the day the Government's employing extra people, and also obviously added costs to that for rent of the place and whatever, the tools they use, when it's something that has been done in the surgeries, which had no extra costs to the PCTs, but maybe to the GPs because of the extra time the nurse had to put into it (GP8)'.
The high costs of paying the practice nurses for the additional service of providing smoking cessation support in-house was noted as a factor that reduced the cost-benefit of offering such a service in-house. In particular it was noted that the costs of such an in-house support provided at their practice would directly affect their budget, whereas the costs of the central services would be paid for by the PCT. On the other hand, the existence of sites in which the in-house support were provided by way of the GP surgeries was mentioned as a factor in support of the cost-effectiveness of the in-house support.
'How cost-effective do you think this service [in-house support] is (FV)?'. 'I would say moderately cost-effective, mainly because now the nurse time is quite expensive, mainly for that. But previously I think it would have been a cost-effective clinic to run. But now because her time is a lot more expensive and you have to reduce hours and it's not really making you any money, so again that's going to reflect (GP9)'.