National Health Promotion in Hospitals Audit · PDF fileaudit was funded by the National Clinical Audit Programme, Department of Health1. The purpose ... Directors of Nursing and Directors

National Health Promotion in Hospitals Audit

Acute & Specialist TrustsFinal Report 2010

www.nhphaudit.org

2 National Health Promotion in Hospitals Audit

Report StructureThis report has been divided into three sections:

Section 1 Section 1 provides introductory information, an overview of the findings from the audit and organisational survey and recommendations on how acute trusts might improve health promotion practice.

Section 2 Section 2 presents the data for all participating sites, enabling benchmarking between organisations. This is followed by a detailed statistical analysis of the NHPHA data.

Section 3 Section 3 focuses on the findings from the organisational survey; and where possible relates these findings to the audit data.

National Health Promotion in Hospitals Audit 3

Section 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Development of the NHPHA . . . . . . . . . . . . . . . . . . . . . . . 7Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Main audit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Data collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Figure 1: Geographical Distribution of Acute/ Specialist Trusts Participating in the NHPHA. . . . . . . 8

Participating acute/specialist trusts . . . . . . . . . . . . . . . . . . . . 9Additional pilot acute sites . . . . . . . . . . . . . . . . . . . . . . . . 9

Main Findings - Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Overview of statistical analysis of NHPHA data: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Length of stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Treatment Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . 12Primary Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Type of Health Promotion . . . . . . . . . . . . . . . . . . . . . 13

Summary of findings from the Organisational Survey: . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Changes to the Audit Structure & Process. . . . . . . . . . . . . . . 16

Steering Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Section 2NHPHA Data Presentation & Analysis . . . . . . . . . . . . . . . . . . 17Case Mix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 1: Age distribution for whole NHPHA sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Table 1: Descriptive statistics for age . . . . . . . . . . . . 18

Length of stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Figure 2: Length of stay distribution for whole NHPHA sample . . . . . . . . . . . . . . . . . . . . . . . . 19Table 2: Descriptive statistics for length of stay . . . 19

Treatment Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Figure 3: Treatment Specialty distribution per participating site . . . . . . . . . . . . . . . . . . . . . . . . . 20

Primary diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Dementia/delirium diagnoses. . . . . . . . . . . . . . . . . . . . . 21Unconscious for whole spell, delirium, dementia. . . . . 21

Interpretation of summary main findings . . . . . . . . . . . . . . 22Figure 4: Relative percentages and standards for total audit sample . . . . . . . . . . . . . . . . . . . . . . . . 23Figure 5: Absolute percentages and standards based on total audit sample size . . . . . . . . . . . . . . . 23Table 3: Summary of standards met for each participating Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Interpretation of figures and tables on assessment and prevalence of risk factors and health promotion delivered 25

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Tables, Health Promotion. . . . . . . . . . . . . . . . . . . . . . . . . 25

Figures 6 to 9: Assessment of risk factors . . . . . . . . 26Figures 10 to 13: Prevalence of risk factors . . . . . . . 30

Contents


Integrated Care Pathways (ICPs) . . . . . . . . . . . . . . . . . . . 61Table 3: Ranking of risk factors for ICP elements . . 61Figure 2: Do care pathways have elements of assessment for…. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Figure 3: Do care pathways have health promotion/education for… . . . . . . . . . . . . . . . . . . . 63Figure 4: Do care pathways have referral to health promotion services for… . . . . . . . . . . . . . . . 63

Use of validated assessment tools. . . . . . . . . . . . . . . . . . 64Table 4: Identification of Trusts using validated alcohol assessment tools. . . . . . . . . . . . . . . . . . . . . . 64

Leaflets/written advice. . . . . . . . . . . . . . . . . . . . . . . . . . . 65Table 5: Number of Trusts with health promotion leaflets available . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Table 6: Combination of health promotion leaflets available within Trusts . . . . . . . . . . . . . . . . . 66Figure 5: How leaflets are accessed . . . . . . . . . . . . . 67

Specialists & specialist services . . . . . . . . . . . . . . . . . . . . 67Table 7: Healthcare professionals that prescribe NRT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Alcohol - Alcohol liaison nurses . . . . . . . . . . . . . . . . 68- Community alcohol teams . . . . . . . . . . . . . . . . . . . 68Table 8: Alcohol liaison nurses/workers and referral process to Community Alcohol Teams within Trusts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Nutrition/diet and physical activity . . . . . . . . . . . . . 70Health trainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Commissioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Concluding Recommendations . . . . . . . . . . . . . . . . . . . . 72

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Appendix 1 - Health Promotion for Malnourishment. . 78Appendix 2 – Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Appendix 3 - Inter-rater reliability . . . . . . . . . . . . . . . . . 87Appendix 4 – Health Promoting Hospitals Standards . 92Appendix 5 – Integrated Care Pathways . . . . . . . . . . . . 94Appendix 6 – Health Promotion Leaflets. . . . . . . . . . . . 97

Photography Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Health Promotion for risk factors: Figures and Tables . . . . . 34Figure 14: Health Promotion Delivered for Smoking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 4: Forms of health promotion delivered to smokers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Table 5: Percentage of total sample of smokers receiving different forms of heath promotion . . . . 36Figure 15: Health Promotion Delivered for Alcohol Misuse . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Table 6: Health promotion delivered to patients identified as misusing alcohol . . . . . . . . . . . . . . . . . 38Table 7: Percentage of total sample of patients misusing alcohol receiving heath promotion . . . . . 39Figure 16: Health Promotion Delivered for Obesity 40Table 8: Health promotion delivered to obese and morbidly obese patients . . . . . . . . . . . . . . . . . . 41Table 9: Percentage of total sample of obese & mor-bidly obese patients receiving heath promotion . . 42

Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43At risk of malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Table 10: Health promotion delivered to patients identified as physically inactive . . . . . . . . . . . . . . . . 46Table 11: Percentage of total sample of physically inactive patients receiving heath promotion . . . . . 47

Detailed Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Cluster analysis findings. . . . . . . . . . . . . . . . . . . . . . . . . . 49Reliability of Audit Data . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Section 3 - Organisational Survey . . . . . . . . . . . . . . . . . . . . . 55Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Health promotion policy and people . . . . . . . . . . . . . . . 57

Figure 1: Health Promotion Policy & People . . . . . . 57Table 1: Cross tabulation of Health Promotion Policy & People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Table 2: Number of Trusts reporting that staff have access to training on assessing and delivering health promotion to patients for risk factors . . . . . 60


Section 1 NHPHA Overview


Introduction

BackgroundThe National Health Promotion in Hospi-tals Audit (NHPHA) is a web-based audit designed to measure the delivery of health promotion to hospitalised patients within all English hospitals. The development of this audit was funded by the National Clinical Audit Programme, Department of Health1.

The purpose of the audit is to provide partici-pating hospital with details of the proportion of their adult hospitalised patients who were assessed for a risk factor (smoking, alcohol, obesity and physical inactivity), had a risk factor, and were delivered health promotion (form: verbal advice, written advice, referral to a specialist or service). Each hospital has already received a summary report of their data which they were able to download im-mediately following completion of the audit data collection.

In this final report we have presented the data from all hospitals in order to enable benchmarking across organisations; and fur-ther statistical analysis has been undertaken to explore whether differences between hospitals in assessment of risk factors and delivery of health promotion are related to differences in length of stay/age/gender/primary diagnosis/treatment specialty of patients. Participating Trusts were also asked to complete an organisational survey to provide baseline information on health promotion services within and available to them. Following on from the findings from the audit and organisational surveys several recommendations have been made on how to develop health promotion services within hospitals. The report is in three sections, this first section provides an introduction and overview of the main findings from the audit and organisational survey. The second section provides a detailed analysis and

presentation of the NHPHA data; and the final section discusses the findings from the organisational survey.

StandardsThe standards for 2009 were developed in reference to findings from a Greater Man-chester Health Promotion in Hospitals audit (which was the basis for the NHPHA) and the pilot results for the NHPHA. Standards represent what we found was realistically achievable for hospitals to deliver. Standards will be reviewed following the outcomes of the NHPHA and in line with emerging public health policy.

Development of the NHPHAThe NHPHA was developed by a team at Stockport NHS Foundation Trust and an IT company specialising in developing data-entry and reporting solutions for health-care: Advent IT2, was commissioned in April 2008 to develop a public website providing information about the project and a secure login area for NHPHA participants to enter audit data and access their summary reports (www.nhphaudit.org). The public side of the website was launched in summer 2008; and the securely accessed online audit tool was available in October 2008, at which point the pilot started. The main audit was rolled-out in spring 2009.

Risk Factor Assessment Health promotion delivered

Smoking 100% of patients

35% of smokers

Alcohol 95% of patients 50% of hazardous/ harmful drinkers

Obesity 45% of patients 45% of obese patients

Physical activity 35% of patients 45% of physically

inactive

1 http://www.dh.gov.uk/ab/NCAAG/DH_099788

2 http://www.advent-it.co.uk/


Figure 1: Geographical Distribution of Acute/ Specialist Trusts Participating in the NHPHA

86 trusts concerning participation in the pilot and/or main audit. We had confirma-tion of participating in the audit from fifty six acute/specialist hospitals and fifty three successfully completed the audit. Trusts that decided not to participate identified that this was either due to a lack of resources/capacity to undertake the audit work, that the timing meant it wasn’t possible to participate in 2009, but they were interested in participat-ing in the future, or that they were undertak-ing their own data collection and analysis for public health issues. Details of the geo-graphical distribution of participating Trusts are shown in figure 1.

Data collectionEach Trust collected data from a random sample of 100 hospitalised adult patients dis-

charged alive between January 5th and January 30th 2009 inclusive. On-line data

input was available from 1st June 2009 and the original deadline for

completing data input was 31st August, but this was extended

to 30th September. The organisational Survey was sent out in November with

a deadline of mid-December, which was extended to mid-January 2010.

ParticipationPilotSixteen acute/specialist hospitals and five mental health trusts participated in the pilot. Twelve of the acute/specialist pilot sites also participated in the main audit. Some of the pilot sites that did not participate in the main audit reported that the pilot had instigated changes to health promotion which would not be in practice in time for the audit, but that they were interested in participating in following years.

Main auditFollowing a first mail out to Chief Executives, Directors of Nursing and Directors of Public Health, we received positive responses from

Strategic Health Authority

1 North West (n = 16)

2 West Midlands (n = 6)

3 South West (n = 11)

4 South Central (n = 3)

5 South East Coast (n = 1)

6 London (n = 9)

7 East of England (n = 2)

8 East Midlands (n = 1)

9 Yorkshire and The Humber (n = 3)

10 North East (n = 1)


• Salford Royal NHS Foundation Trust• Salisbury NHS Foundation Trust*• Sandwell and West Birmingham Hospitals NHS Trust*

ū City Hospital ū Sandwell General Hospital

• Shrewsbury and Telford Hospitals NHS Trust ū Princess Royal Hospital ū Royal Shrewsbury Hospital

• South Devon Healthcare NHS Foundation Trust*• St George’s Healthcare NHS TrustP• Stockport NHS Foundation Trust*• Tameside Hospitals NHS Foundation Trust*• Taunton and Somerset NHS Foundation Trust• The North West London Hospitals NHS Trust*

ū Central Middlesex Hospital ū Northwick Park Hospital

• The Queen Elizabeth Hospital King’s Lynn NHS Trust• The Royal Marsden NHS Foundation TrustP• University Hospital of North Staffordshire NHS Trust*• University Hospitals Bristol NHS Foundation Trust• University Hospitals of Morecambe Bay*

ū Furness General Hospital ū Royal Lancaster Infirmary ū Westmorland General Hospital

• Walsall Hospitals NHS Trust*• Weston Area Health Trust, Weston General HospitalP• Wirral University Teaching Hospital

NHS Foundation TrustP• Wrightington, Wigan and Leigh NHS TrustP• Yeovil District Hospitals NHS Foundation Trust*

Additional pilot acute sites• East Kent Hospitals University

NHS Foundation Trust• Medway NHS Foundation Trust• The Newcastle upon Tyne Hospitals

NHS Foundation Trust • The Whittington Hospital NHS Trust

Participating acute/ specialist trusts

• Barts and The London NHS Trust*• Basildon and Thurrock NHS Foundation Trust• Basingstoke and North Hampshire NHS Foundation

TrustP• Blackpool, Fylde and Wyre Hospitals NHS Foundation

Trust• Bradford Teaching Hospital, St Luke’s*• Buckinghamshire Hospitals NHS Trust*P

ū Stoke Mandeville Hospital ū Wycombe Hospital

• County Durham and Darlington NHS Foundation TrustP

• Doncaster and Bassetlaw Hospitals NHS Foundation Trust

• East Lancashire Hospitals Trust*P• Epsom and St Helier University Hospitals Foundation

Trust,*• Gloucestershire Hospitals NHS Foundation Trust

ū Gloucestershire Royal Hospital ū Cheltenham General HospitalP

• Great Western Hospitals NHS Foundation Trust,*• The Hillingdon Hospital NHS Trust• Lancashire Teaching Hospitals NHS Foundation

Trust*• Liverpool Heart and Chest NHS Trust*P• Mid Cheshire Hospitals NHS Trust, Leighton Hospital• Mid Yorkshire Hospitals NHS Trust• Northamptonshire General Hospital NHS Trust*• Northamptonshire Healthcare NHS TrustP• Pennine Acute Hospitals NHS Trust*• Princess Alexandra Hospital• Royal Bolton Hospitals NHS Trust*• Royal Brompton and Harefield NHS Trust• Royal Devon and Exeter NHS Foundation Trust*• Royal Liverpool and Broadgreen University Hospitals

NHS Trust• Royal Surrey County Hospitals NHS Trust• Royal United Hospital Bath NHS Trust*

A * indicates that these Trusts responded to the service evaluation survey. P: also participated in the pilot. Some Trusts had more than one hospital site participating separately in the audit, these are indicated by “-“.


Alcohol4 Trusts met the standard that 95% of patients should be assessed for alcohol use. Overall 69% of patients in the NHPHA were assessed for alcohol use.

On average only 11% of those assessed for alcohol use were found to be hazardous/harmful/dependent drinkers. This is far lower than the expected prevalence of 20%, which was evident in 27 Trusts4. One reason for a low identification of alcohol misuse may be the lack of validated alcohol tools readily available for healthcare professionals to use – only half of the respondents to the organi-sational survey reported that their hospitals assessed patients for alcohol use with a validated alcohol tool. Of these 12 hospitals, 7 had the expected prevalence of alcohol misuse.

On average 45% of patients misusing alcohol received health promotion and 24 Trusts met the standard that 50% were delivered health promotion. The finding that 85% of patients who were clearly dependent drinkers (i.e. prescribed chlordiazepoxide) received at least one form of health promotion for alcohol was reassuring as one would hope that all such patients were provided with assistance to enable them to stop drinking. As with smoking, verbal advice was the most common form of health promotion delivered to all patients misusing alcohol.

Main Findings - Overview

Only 1 trust met all the standards for smok-ing, alcohol misuse, obesity, and physical in-activity; and there was considerable variation between trusts in meeting the standards. The lower standards for obesity and physical inactivity means that more trusts appear to do well in assessing and delivering health promotion for these risk factors in compari-son to smoking and alcohol, where in actual-ity hospitals need to make considerable im-provements in the assessment and delivery of health promotion for all risk factors.

A summary of the findings for each risk fac-tor in relation to the standards, supported by relevant findings from the organisational survey3 is provided below.

SmokingOnly 1 Trust met the standard that all patients should be assessed for smoking. On average 81% of patients were assessed for smoking. 25% of those assessed for smoking were found to be smokers; and on average 20% of identified smokers received health promotion. In total 21 Trusts met the standard that 35% of smokers were delivered health promotion. Verbal advice was by far the most common form of health promotion delivered to patients who smoke.

3 The organisational survey was completed by just over half of the participating Trusts.

4 For 4 Trusts this was on the basis of percentage of assessed patients identified as misusing alcohol, and in a further 23 Trusts on the basis of 95% upper confidence interval (CI) values.


It was clear from the organisational survey that hospitals are the least resourced/pre-pared for assessing physical activity in com-parison to the other risk factors. Prompts and tools for the assessment, health promotion/ education, and referral to health promotion services for physical activity were significant-ly less likely to be incorporated into integrat-ed care pathways in comparison to all other risk factors; and staff were less likely to be able to access training on physical activity as-sessment and health promotion for physical activity compared to other risk factors. How-ever over 80% of respondents to the survey reported that there were physical activity programmes that they could refer patients to within the community and/or hospital setting. This may explain the relatively good performance on delivering health promotion to physically active patients: On average 46% of patients who were identified as physically inactive did receive health promotion and 26 Trusts did meet the standard that 45% of physically inactive patients were delivered health promotion. However, given the strong likelihood that physical inactivity was not identified in many patients, one can not conclude that health promotion is being adequately delivered to those patients that require it. Verbal advice was the most com-

Obesity25 Trusts met the standard that 45% of patients should be assessed for obesity. 40% of the whole NHPHA sample was assessed for obesity and 21% of those assessed were identified as obese, which is in line with the prevalence of obesity in the general popula-tion. Overall 22% of obese patients received health promotion; and only 5 Trusts met the standard that 45% of obese patients were delivered health promotion. Verbal advice and referral to a specialist in nutrition/diet were the most common forms of health promotion delivered to patients, followed by the provision of written advice.

Physical activityThe standard that 35% of patients should be assessed for physical activity was met by 32 Trusts; and it was encouraging to see that 39% of the whole NHPHA sample was assessed for physical activity. However only 17% of those assessed were identified as physically inactive, which is far lower than the prevalence of physical activity in the general population, even when taking into account the number of patients who were not independently mobile; and given that physical activity declines with age and that the NHPHA sample predominantly consists of patients who are middle aged to elderly, one would expect a far higher percentage of physically inactive patients to be identified.


Hypothesis: Health promotion delivery is positively related to length of stay.

Delivery of health promotion for smoking, alcohol and obesity not clearly related to length of stay.

… but some indication from cluster analy-sis that obesity health promotion was not delivered to physically inactive obese patients who had short lengths of stay.

Delivery of health promotion was posi-tively related to length of stay for physical activity.

AgeHypothesis: There will be a normal distribu-tion for age and health promotion delivered - with the young and very old receiving relatively little health promotion.

no significant differences overall in age between patients who did and did not receive health promotion for smoking, alcohol and obesity; but, contrary to predictions, cluster analysis indicated that, overall, it was middle-aged patients that were least likely to receive health promo-tion for all risk factors.

Older inactive patients were most likely to receive health promotion for physical activity.

Indication that elderly patients with alco-hol problems were least likely to receive health promotion for alcohol misuse.

Treatment SpecialtyHypothesis: General surgery patients are more likely to be assessed for risk factors and delivered health promotion than general medicine patients.

There does not appear to be a clear cut relationship between treatment specialty and assessment or health promotion delivery for smoking, alcohol or physical activity;

mon form of health promotion delivered to physically inactive patients; and many were also referred to a physiotherapist.

DemographicsThere were slightly more female than male patients in the whole NHPHA sample; and females tended to have slightly longer lengths of stay. This may reflect the fact that females were significantly older than males and that there was a significant correlation between age and length of stay. The age of the NHPHA sample was skewed towards the older age group, with the median age being 65 years. 60% of patients were general sur-gery patients. Differences in age, length of stay, treatment specialty and diagnosis were taken into account in data analysis.

Overview of statistical analysis of NHPHA data:While some of the statistical analysis was ex-ploratory in nature, it was also undertaken to assess several hypotheses which are detailed below, followed by relevant findings (an indication of whether the findings supported the hypotheses is denoted by a “” and a “” indicates that the findings did not support the hypothesis):

Length of stayHypothesis: Risk factor assessment is NOT related to length of stay.

Because assessments of risk factors are ex-pected to be undertaken on/near admission we do not expect length of stay to have a significant impact on assessments.

Significantly5 shorter length of stay in pa-tients assessed for smoking and alcohol.

Assessment of obesity was not related to length of stay.

Patients assessed for physical activity had significantly longer lengths of stay than patients not assessed.

5 P value < 0.0001 accepted as indicating significance.


Type of Health PromotionHypothesis: Health promotion is most likely to be provided as verbal advice.

It was evident that health promotion for all risk factors was most likely to be in the form of verbal advice. This is of some concern as medical information has been shown to be least likely to be recalled if it is delivered verbally; and most likely to be recalled if it is provided in written/picto-rial material alone or in combination with verbal information – yet written advice is provided to relatively few patients, with less than 20% of patients requiring health promotion receiving it in the form of writ-ten materials.

Summary of findings from the Organisational Survey:Policy & People: Half of responding Trusts had health promotion as part of their stated aims and mission, but this was rarely backed up with a health promotion strategy and personnel. Only 2 Trusts had a mission state-ment, written strategy and health promo-tion roles within job descriptions and an additional 5 Trusts had a board champion, health promotion group and coordinator. It therefore appears that the majority of trusts do not have in place a comprehensive man-agement policy and mechanisms that are supportive of health promotion.

While only 1 Trust had an identifiable budget for health promotion services and materials, 78% of respondents were in discussions with local commissioners on providing services within the hospital to encourage healthy behaviours. Only 3 Trusts had personnel di-rectly employed by the PCT to assist in deliv-ering health promotion to hospital patients.

Training: Over 70% of Trusts have training available to staff on the assessment and delivery of health promotion for smoking

however, general surgery patients were more likely to be assessed for obesity than general medicine patients.

Primary DiagnosisHypothesis: Patients with primary diagnosis ICD10 codes identified as related to risk fac-tors(6) will be more likely to be assessed for risk factors AND delivered health promotion.

Evidence that respiratory patients were highly likely to be assessed for smoking and delivered health promotion for smoking.

/ Patients with cancer diagnoses had relatively high levels of assessment for all risk factors and were highly likely to be delivered health promotion for smoking, obesity and physical inactivity, but not for alcohol. Except for a group of young cancer patients who smoked and received very little health promotion for smoking and all other risk factors. In addition, can-cer patients were most likely to be surgical patients, so we do not know whether high levels of assessment and health promotion are related to having a cancer diagnosis or being surgical patients.

In the cluster of patients with the highest level of alcohol related diagnoses nearly all received health promotion for alcohol.

Hypothesis: Predict that patients with diag-noses of dementia/delirium were less likely to be assessed risk factors AND delivered health promotion.

/ Cluster analysis indicated that patients with dementia were less likely to be as-sessed for smoking and alcohol, but highly likely to be assessed for obesity and physi-cal inactivity. When identified as having risk factors these patients actually received relatively high levels of health promotion for obesity and physical activity; and in line with average for the whole NHPHA sample for smoking and alcohol health promotion.


can prescribe NRT at only 6 of these Trusts. At the majority of Trusts it was doctors/medi-cal staff who were able to prescribe NRT (n = 13; 57%); and at 4 Trusts (17%) there were no policies in place for healthcare professionals to prescribe nicotine replacement therapy.

Specialist alcohol service: One of the best means of ensuring an optimal alcohol service is delivered is through the employment of al-cohol liaison nurses/workers. Alcohol liaison nurses/workers were employed at 14 Trusts (61%). While the majority of Trusts (21 Trusts: 91%) had a local community alcohol team (CAT), only 11 had a standardised system for referring hospital patients to their local CAT. Of concern is the finding that at least 4 Trusts had neither alcohol liaison nurses nor referral processes in place to CATs.

Specialist weight, diet, and/or physi-cal activity services: Nutrition specialists/ dietitians were employed in all but one of the Trusts; and in 16 Trusts patients could be referred directly to these specialists solely for the treatment of obesity (i.e. obese patients did not have to have nutrition related co-morbidities). 15 Trusts also reported that they have a system in place for referring patients to community weight loss pro-grammes. 19 Trusts reported that there were physical activity programmes that they could refer patients to within the community and/or hospital setting.

and (healthy) diet. Training for alcohol and weight is available to staff in approximately 65% of Trusts; but for physical activity train-ing is only available in half of the Trusts. When asked specifically about the availabil-ity of staff training on behaviour change, this was only available in 40% of the Trusts.

Integrated care pathways (ICPs): A picture emerged of hospital ICPs incorporating prompts or tools for the assessment of risk factors, but a lack of tools for the next step of delivering health promotion – the implica-tions of which are clearly seen in the audit re-sults. Physical activity assessment prompts/tools and health promotion guidance were far less likely to be incorporated into ICPs in comparison to smoking, alcohol and obesity assessment and health promotion tools.

Leaflets: Most Trusts had a good availability of leaflets, in particular for local services, yet we have seen from the audit results that written health promotion materials are infrequently provided to patients that would benefit from receiving them.

Smoking cessation: Hospital nurses trained in smoking cessation can help increase smoking cessation rates through the provi-sion of advice, behavioural therapy and/or nicotine replacement therapy (NRT). It was therefore good to observe that 17 Trusts (74%) reported having smoking cessation nurses. However smoking cessation nurses


• Trusts ensure that healthcare professionals are aware of the importance of ensuring verbal advice is supported by written health promotion materials given to patients (either leaflets or healthcare professional providing written tailored information).

• All Trusts should ensure that appropriate health promotion leaflets are always available in patient areas. A system of having individuals (e.g. health promotion coordinator, alcohol liaison worker, etc) and/or a department (e.g. occupational health) ordering leaflets and volunteers distributing the leaflets to patient areas has been shown to work well in several Trusts.

• All Trusts ensure that a commitment to delivering health promotion to patients, staff and visitors is explicitly incorporated into their stated aims and mission. Healthcare professionals can not be expected to deliver health promotion to patients if it is not part of the organisation’s vision.

• The strategic and operational development of health promotion should be informed by a specific group which has representatives from both the Acute and Primary Care Trusts and other partner organisations as appropriate.

More detailed recommendations are pro-vided within the body of this report in the review of the organisational survey findings.

Recommendations

We recommend that:• All Trusts have at least one nurse per ward

trained in smoking cessation techniques.

• All Trusts undertake the necessary measures to ensure that smoking cessation nurses can prescribe NRT.

• Mechanisms are put in place to enable patients to receive follow-up smoking cessation support for at least 1 month following discharge.

• All Trusts incorporate a validated alcohol assessment tool such as AUDIT or CAGE into their ICPs for in-patient care.

• All Trusts ensure that some basic training is available to ensure healthcare professionals feel confident in using alcohol assessment tools.

• All Trusts ensure that their staff are aware of community weight loss and physical activity programmes

• All Trusts establish referral processes to community weight loss and physical activity programmes for suitable patients.

• Further research is required to identify an appropriate tool for identifying physical inactivity in hospitalised patients. Once validated for use in hospitalised patients the tool should be incorporated into a health promotion ICP.

• All Trusts should review their ICPs and consider implementing a specific health promotion ICP which has appropriate assessment tools AND guidance on health promotion.


Steering GroupThe steering group contributed greatly to the development and running of the NHPHA. Members of this group are:

Angela Bartley, Public Health Lead, Royal Free Hampstead NHS Trust

Toni Doyle, Head of Nursing and Patient Experience, Salford PCT and Chair, Greater Manchester Essence of Care (resigned, post changed)

Dr Gary A Cook, Consultant in Public Health, Stockport NHS Foundation Trust

Dr Ann Hoskins, Deputy Regional Director of Public Health/Acting Director of Children and Young People, NHS North West (resigned, post changed)

Dr Melanie J Maxwell, Head of CPRU/Con-sultant in Public Health Medicine, Wirral University Teaching Hospital NHS Foundation Trust

Prof Mike Pearson, Professor of Clinical Evaluation, University of Liverpool

Alison Reavy, Clinical Audit Facilitator, Cheshire & Wirral Partnership NHS Founda-tion Trust (Mental Health Trust)

AcknowledgementsWe would like to thank the Department of Health for their financial support in the development of the NHPHA, Advent IT for their work on developing the on-line tools, Deborah Kenyon for her administrative sup-port and all of the individuals who collected and inputted data for the NHPHA in the first year of this audit.

Changes to the Audit Structure & Process

• In order to assist the interpretation of data from the NHPHA, in the future all participants will be asked to complete the organisational survey prior to the start of data collection for the NHPHA.

• Because the NHPHA health promotion questions for physical activity have only moderate inter-rater reliability the NHPHA team will investigate whether the wording of the audit pro forma questions need changing; and detailed clarification regarding physical activity data items will be provided in the user help notes.

• Unfortunately the postcode data (first half only) was insufficient to provide a single Index of Multiple Deprivation Score. We will investigate whether Trusts are willing to provide the first digit of the second half of the postcode to enable analysis into the provision of health promotion to patients from different socioeconomic backgrounds.

• The paper-based audit pro forma will be redesigned to reflect the logic that the IT system implements so that redundant data are not collected by data collectors.

• NHPHA standards will be reviewed.

• Due to funding constraints the audit will be repeated bi-annually, with the next audit data input period to start summer 2011 using data from patients discharged in January 2011. This will also have the benefit of providing hospitals with a good time period to make changes to health promotion practice and policy and for these changes to have a measurable impact.


Section 2NHPHA Data Presentation & Analysis


Case Mix

SexThere was a very similar distribution of females to males – with 2789 female patients in the whole audit sample (52.62%) and 2511 males (47.38%).

AgeFigure 1: Age distribution for whole NHPHA sample

FemaleMale

The age distribution is skewed towards the older population.

0%

5%

10%

15%

20%

25%

30%

35%

17-25 yrs 26-35 yrs 36-45 yrs 46-55 yrs 56-65 yrs 66-75 yrs 76-103 yrs

All data above are in years. There were significant differences in age between the sexes, with females significantly older than males (P < 0.0001).

Range Mean ± SE Median

Males 17 to 103 61.1 ± 0.4 64

Females 17 to 102 62.9 ± 0.4 66

Total 17 to 103 62.1 ± 0.3 65

Table 1: Descriptive statistics for age


All data above are in days. There was a small significant difference in length of stay between the sexes, with females having longer lengths of stay than males (P < 0.02).

Table 2: Descriptive statistics for length of stay

Range Mean ± SE Median

Males 1 to 241 7.5 ± 0.3 4

Females 1 to 365 8.3 ± 0.3 4

Total 1 to 365 7.9 ± 0.2 4

Length of stayFigure 2: Length of stay distribution for whole NHPHA sample

FemaleMale

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Up to 2 Weeks 2 to 4 Weeks 4 to 8 Weeks 8 Weeks or More


Figure 3: Treatment Specialty distribution per participating siteGeneral MedicineGeneral Surgery

Hos

pita

l

H53H40H44H42H50

H5H32H43H22H23H24

H4H49H15H29H12H16

H9H17H30H34

H8ALLH2

H31H33H48H10H11

H7H26H14H21H25H28H35H47H36H52H37

H6H18H45H46H13H20H38H41H39H19H51H27

H1H3

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Treatment SpecialtyAs can be seen from Figure 3 the distribution of general medicine and general surgery is not even within each site’s audit sample. 60% of the patients in the whole audit were from general medicine and 40% were from general surgery.

Primary diagnoses The variation in diagnosis codes is too wide to describe or present graphically. For the purposes of analyses investigating the rela-tionship between assessment and delivery of health promotion and evidence of risk factors, diagnoses have been categorised into codes representing conditions that may be related to

• risk factors6, • dementia and delirium codes (while

these patients should not be excluded from assessment and health promotion, patients’ condition may make it impractical to undertake these actions),

• and codes not obviously related to risk factors.

Dementia/delirium diagnosesA total of 74 patients (1.4%) in the audit had a primary diagnosis of dementia or delirium. Of these patients 33 (i.e. 44.6%) were not as-sessed for smoking, alcohol, and/or physical activity due7 to their dementia/delirium.

Unconscious for whole spell, delirium, dementiaA further 34 patients with delirium and 162 patients with dementia were identified as not being assessed for smoking/alcohol use/physical activity because of these conditions, and 12 patients were not assessed due to be-ing “unconscious for the whole spell”.

6 ICD10 codes for Alcohol, Cancer, Cardiovascular, Dementia, Gastrointestinal, Liver, Spontaneous abortion, Obesity, Pancreas, Respiratory, Vascular, and a grouping termed “smoking” which includes all ICD10 diagnosis codes identified by the Surgeon General as related to smoking; reference: “Diseases and Adverse Health Effects Related to Smoking: 2004 Surgeon General’s Report on the Health Consequences of Smoking and July 1, 2005 MMWR on Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses in the US, 1997—2001.” http://www.surgeongeneral.gov/library/smokingconsequences/

7 an option for not assessing obesity due to dementia or delirium was not provided in the audit as it does not require verbal communication to be determined


Interpretation of summary main findings

Figure 4 provides details of the overall per-centage ± 95% confidence intervals (CI8) of patients in the whole audit sample assessed and delivered health promotion for each risk factor, alongside the corresponding standard set for 2009.

Information for each risk factor is grouped together, starting with “assessed for …”, prevalence of risk factor (“evidence of ….”) and “health promotion delivered for ….”. Data in “assessed for…” is always out of the whole sample size of 5,300 patients, but the sample size becomes smaller depending on how many patients were assessed (the total assessed provides the sample size value for “evidence of ….”) and how many patients were found to have the risk factor that was being assessed (the total with evidence of a risk factor provides the sample size value for “health promotion delivered for ….”).

Each risk factor has its own colour through-out the figures in the report: smoking is represented by orange, alcohol by green, obesity by red and physical activity by blue. The standards are represented as grey columns.

In figure 5 data have been presented along the same lines as in figure 4 but the data is in absolute terms, with the denominator for

“assessed for …”, “evidence of ….” and “health promotion delivered for ….” always remain-ing at 5,300 patients, and the standards adjusted accordingly.

Finally, in Table 3 each participating audit site has been listed in chronological order of its code (staring from H1 to H539) with details of whether or not the audit standard was met for assessing and delivering health promo-tion for each risk factor.

A red tick () indicates that the standard was met on the basis of percentage, a black tick () indicates that the standard was met on the basis that the standard value fell within the 95% CI; and an “N” means that the stand-ard was not met. For example, if we look at the standard of 100% patients assessed for smoking, a would be given if all 100 of the patients assessed were asked about their smoking, but a would be given if, for in-stance, 99 of 100 patients had been assessed because the 95% CI would be between 94.6% and 100.0%.

The final row in Table 1 provides details of the total number of Trusts that met the standard on the basis of percentage assessed or delivered health promotion and in paren-thesis the number meeting the standard on the basis of their 95% CI value.

8 The 95% CI indicates the range of values within which one can be 95% confident that the true value for the whole adult in-patient population lies for each Trust.

9 Please contact [email protected] if you require the details of your Trust’s code


Figure 5: Absolute percentages and standards based on total audit sample size

Figure 4: Relative percentages and standards for total audit sample

Proportional Standard

NHPHA Standard


Assess smoking HP smoking Assess alcohol misuse

HP Alcohol misuse Assess obesity HP obesity Assess physical

activityHP physical inactivity

All N N N N N N H1 N N N N N N NH2 N N N N N NH3 N N N N N NH4 N N N N N H5 N N N N N NH6 N N N N N N H7 N N N H8 N N N N N N NH9 N N N N N N NH10 N N N N NH11 N N N N H12 N N N N N N NH13 N N N N N N N NH14 N N N N N NH15 N N N N N H16 N N N N N NH17 N N N N H18 N N N N N H19 N N N N N N NH20 N N N N N N N NH21 N N H22 N N H23 N N N N N H24 N N N N N N N NH25 N N N N N NH26 N N N H27 N N N N N N N NH28 N N N N N H29 N N N N N N H30 N N N H31 N N N N N NH32 N N N N N N NH33 N N N H34 N N N N N NH35 N N N N N N NH36 N N N N N N N NH37 N N N N N H38 N N N N N N H39 N N N N N N H40 N N N N N N NH41 N N N N NH42 N N N NH43 N N N N H44 N N H45 N N N N N N H46 N N N N N N NH47 N N N N N H48 N N N N N H49 N N N N N N NH50 N N N N N NH51 N N N N N H52 N N N N NH53 Total 1 12 (9) 1 (3) 24 21 (4) 4 (1) 26 (6) 24 (2)

Table 3: Summary of standards met for each participating Trust


In figures 16 and 19 the lower quartiles were 0% and as such the long dashed line has not been drawn as this would interfere with the legibility of the figure.

Tables, Health PromotionEach table depicts the percentage of patients identified as having a risk factor who were delivered each possible form of health promotion. Data are presented in order of hospital code. A traffic light system has been used to indicate those Trusts whose data were in the upper quartile: green, interquartile range: amber, and lower quartile: red for each type of health promo-tion delivered. Please note that each patient could receive more than one type of health promotion.

Tables detailing the descriptive statistics for each form of health promotion for all NHPH audit data combined are also provided.

FiguresData in all figures are presented in rank order from top to bottom indicating the highest to lowest performing Trusts respectively. All data shows the percentage (solid bar) and 95% CI (line dissecting the top of the bar).

Figures depicting the assessment (figures 6 to 9) and delivery of health promotion (fig ures 14 to 16, and19) for smoking, alcohol, obes-ity and physical activity all have a solid line illustrating the NHPHA standard.

For the purposes of benchmarking, informa-tion on the upper and lower quartiles for assessment and delivery of health promo-tion for each risk factor is represented by a dashed and long dashed line respectively. Those hospitals with data on or above the up-per quartile line are those with values in the highest 25% of data and those with data on or below the lower quartile line are within the lowest 25% of data.

Interpretation of figures and tables on assessment and prevalence of risk factors and health promotion delivered


Figure 6: Assessed for Smoking

Figures 6 to 9: Assessment of risk factors

Percent of patients in audit assessed for Smoking

Hos

pita

ls

Standard

Upper Quartile

Lower Quartile


Figure 7: Assessed for Alcohol Misuse

Percent of patients in audit assessed for Alcohol Misuse

Standard

Upper Quartile

Lower Quartile

Hos

pita

ls


Hos

pita

ls

Figure 8: Assessed for Obesity

Percent of patients in audit assessed for Obesity

Standard

Upper Quartile

Lower Quartile


Figure 9: Assessed for Physical Activity

Percent of patients in audit assessed for Physical Activity

Hos

pita

ls

Standard

Upper Quartile

Lower Quartile


Figures 10 to 13: Prevalence of risk factors

Figure 10: Evidence of Smoking

Percent based on sample assessed for Smoking

Hos

pita

ls

Expected Prevalence


Figure 11: Evidence of Alcohol Misuse

Percent based on sample assessed for Alcohol Misuse

Hos

pita

ls

Expected Prevalence


Figure 12: Evidence of Obesity

Percent based on sample assessed for Obesity

Hos

pita

ls

Expected Prevalence


Figure 13: Evidence of Physial Inactivity

Percent based on sample assessed for Physical Activity

Hos

pita

ls

Expected Prevalence


Health Promotion for risk factors: Figures and Tables

Figure 14: Health Promotion Delivered for Smoking

Percent based on sample with evidence of Smoking

Hos

pita

ls

Standard

Upper Quartile

Lower Quartile


Table 4: Forms of health promotion delivered to smokers

Hospital verbal advice written advice NRT prescribed Referred to smoking cessation nurse

Referred to specialist respiratory nurse

Advised to contact GP/practice nurse

H1 22.2 0.0 5.6 11.1 11.1 0.0H2 15.0 0.0 30.0 10.0 0.0 5.0H3 0.0 0.0 0.0 0.0 0.0 0.0H4 0.0 0.0 5.6 0.0 0.0 0.0H5 9.1 0.0 4.5 4.5 0.0 0.0H6 9.1 0.0 4.5 0.0 0.0 0.0H7 38.1 4.8 0.0 0.0 0.0 0.0H8 24.2 9.1 0.0 6.1 6.1 6.1H9 4.8 9.5 9.5 9.5 0.0 0.0H10 34.6 15.4 3.8 0.0 7.7 7.7H11 4.2 0.0 0.0 4.2 4.2 0.0H12 14.3 4.8 0.0 0.0 0.0 0.0H13 20.0 0.0 0.0 4.0 16.0 0.0H14 5.9 5.9 0.0 0.0 0.0 0.0H15 47.1 5.9 11.8 17.6 11.8 23.5H16 22.2 0.0 11.1 0.0 0.0 0.0H17 10.7 0.0 7.1 7.1 0.0 3.6H18 6.7 0.0 3.3 0.0 3.3 0.0H19 3.4 0.0 0.0 0.0 3.4 0.0H20 4.2 0.0 8.3 4.2 0.0 0.0H21 40.9 18.2 4.5 13.6 9.1 0.0H22 36.8 0.0 10.5 0.0 10.5 0.0H23 8.3 0.0 4.2 0.0 0.0 0.0H24 4.8 0.0 0.0 4.8 0.0 4.8H25 5.0 0.0 5.0 0.0 0.0 0.0H26 66.7 25.0 16.7 25.0 16.7 8.3H27 4.5 0.0 4.5 0.0 4.5 0.0H28 12.0 0.0 4.0 0.0 4.0 0.0H29 4.3 8.7 0.0 13.0 0.0 0.0H30 44.4 0.0 5.6 22.2 0.0 5.6H31 21.4 0.0 7.1 0.0 0.0 7.1H32 0.0 0.0 0.0 3.7 3.7 7.4H33 58.3 41.7 41.7 41.7 0.0 0.0H34 12.5 0.0 6.3 6.3 0.0 0.0H35 3.7 3.7 18.5 0.0 0.0 0.0H36 6.3 0.0 0.0 0.0 0.0 0.0H37 26.1 4.3 13.0 17.4 0.0 13.0H38 16.7 0.0 0.0 0.0 8.3 8.3H39 0.0 0.0 0.0 0.0 0.0 0.0H40 13.3 0.0 13.3 13.3 6.7 13.3H41 13.3 0.0 0.0 3.3 6.7 0.0H42 17.9 7.1 3.6 0.0 0.0 3.6H43 4.0 0.0 0.0 0.0 0.0 0.0H44 40.0 40.0 20.0 0.0 0.0 20.0H45 17.6 5.9 11.8 0.0 0.0 0.0H46 8.3 0.0 0.0 0.0 0.0 0.0H47 26.1 8.7 4.3 17.4 4.3 13.0H48 4.8 0.0 0.0 4.8 0.0 0.0H49 4.8 0.0 4.8 0.0 0.0 4.8H50 11.8 0.0 0.0 0.0 0.0 0.0H51 17.6 0.0 0.0 0.0 0.0 0.0H52 18.8 6.3 12.5 0.0 12.5 0.0H53 100.0 93.3 0.0 73.3 0.0 73.3


Health Promotion Mean ± SE 95% CI Lower quartile Upper quartile

Verbal advice 18.24 ± 2.63 12.97 to 23.52 4.76 22.22

Written advice 6.00 ± 2.08 1.83 to 10.18 0.00 5.88

NRT prescribed 5.98 ± 1.11 3.76 to 8.21 0.00 8.33

Referred to smoking cessation nurse 6.38 ± 1.72 2.94 to 9.82 0.00 7.14

Referred to specialist respiratory nurse 2.84 ± 0.63 1.59 to 4.10 0.00 4.35

Advised to contact GP 4.31 ± 1.52 1.27 to 7.35 0.00 5.00

Only one Trust: H26 is within the upper quartile for all forms of health promotion delivered to smokers.

A total of 1071 people were identified as smokers, of whom only 215 received health promotion. Verbal advice was the most com-mon form of health promotion delivered to patients who smoke. Review of the 95%CIs

indicates that there was no significant dif-ference in the use of any of the other forms of health promotion over another (written advice, NRT, referrals and advice to contact GP or practice nurse).

Table 5: Percentage of total sample of smokers receiving different forms of heath promotion

All values in the table above are in percentages


Figure 15: Health Promotion Delivered for Alcohol Misuse

Percent based on sample with evidence of Alcohol Misuse

Hos

pita

ls

Standard

Upper Quartile

Lower Quartile


Table 6: Health promotion delivered to patients identified as misusing alcohol

Hospital Verbal advice Written advice Advised contact GP

Advised contact alcohol service Given CAT Contact Referred to

alcohol service referred to HALW

H1 50.0 0.0 0.0 16.7 0.0 0.0 0.0H2 20.0 10.0 0.0 10.0 10.0 0.0 20.0H3 44.4 11.1 0.0 11.1 11.1 0.0 11.1H4 25.0 0.0 0.0 0.0 0.0 0.0 0.0H5 50.0 0.0 0.0 0.0 0.0 0.0 0.0H6 75.0 50.0 25.0 0.0 0.0 0.0 0.0H7 42.9 0.0 14.3 0.0 0.0 0.0 0.0H8 37.5 0.0 37.5 0.0 0.0 0.0 0.0H9 33.3 0.0 0.0 0.0 0.0 0.0 0.0H10 41.7 8.3 16.7 0.0 8.3 0.0 8.3H11 57.1 0.0 21.4 0.0 7.1 28.6 21.4H12 16.7 16.7 0.0 16.7 16.7 16.7 16.7H13 46.2 0.0 0.0 7.7 7.7 7.7 0.0H14 50.0 8.3 41.7 16.7 8.3 25.0 16.7H15 22.2 11.1 0.0 0.0 0.0 11.1 11.1H16 33.3 16.7 0.0 16.7 0.0 16.7 16.7H17 50.0 16.7 0.0 16.7 33.3 33.3 16.7H18 54.5 9.1 0.0 18.2 27.3 54.5 27.3H19 37.5 0.0 0.0 25.0 25.0 25.0 25.0H20 0.0 0.0 10.0 10.0 10.0 20.0 0.0H21 66.7 16.7 16.7 16.7 0.0 0.0 0.0H22 50.0 12.5 0.0 0.0 12.5 12.5 0.0H23 40.0 10.0 10.0 10.0 10.0 10.0 0.0H24 33.3 0.0 0.0 0.0 0.0 0.0 0.0H25 9.5 9.5 4.8 19.0 0.0 28.6 4.8H26 66.7 16.7 16.7 66.7 16.7 16.7 0.0H27 7.1 0.0 0.0 0.0 0.0 0.0 0.0H28 25.0 0.0 0.0 0.0 0.0 0.0 0.0H29 14.3 14.3 0.0 14.3 14.3 14.3 0.0H30 40.0 0.0 0.0 0.0 0.0 0.0 0.0H31 0.0 0.0 0.0 0.0 0.0 0.0 0.0H32 40.0 0.0 20.0 20.0 0.0 0.0 20.0H33 100.0 100.0 0.0 100.0 50.0 50.0 0.0H34 25.0 25.0 0.0 25.0 25.0 25.0 25.0H35 33.3 0.0 0.0 33.3 33.3 33.3 22.2H36 28.6 0.0 0.0 0.0 0.0 0.0 0.0H37 55.6 33.3 22.2 44.4 33.3 55.6 55.6H38 14.3 14.3 0.0 0.0 0.0 0.0 0.0H39 0.0 0.0 0.0 0.0 0.0 0.0 0.0H40 0.0 0.0 0.0 0.0 0.0 0.0 0.0H41 72.2 22.2 11.1 5.6 16.7 11.1 50.0H42 50.0 33.3 33.3 50.0 16.7 33.3 16.7H43 37.5 0.0 25.0 37.5 25.0 12.5 0.0H44 50.0 50.0 25.0 0.0 0.0 25.0 25.0H45 0.0 0.0 0.0 0.0 0.0 0.0 0.0H46 0.0 0.0 0.0 0.0 0.0 0.0 0.0H47 14.3 0.0 14.3 0.0 0.0 14.3 0.0H48 62.5 12.5 12.5 37.5 37.5 37.5 37.5H49 33.3 0.0 16.7 16.7 0.0 16.7 0.0H50 0.0 0.0 0.0 0.0 0.0 0.0 0.0H51 46.7 0.0 6.7 6.7 13.3 20.0 13.3H52 12.5 0.0 0.0 0.0 0.0 0.0 0.0H53 90.9 0.0 90.9 0.0 0.0 9.1 0.0


A total of 406 people were identified as hazardous or harmful drinkers, and of these, 116 (29%) were prescribed chlordiazepoxide, a clear indicator of alcohol dependency (al-though some of these patients were identi-fied as hazardous, which is very likely to be an underestimation of an individual’s alcohol intake). In total, 182 patients identified as misusing alcohol were delivered health pro-motion. As with smoking, verbal advice was the most common form of health promotion delivered to all patients identified as either hazardous or harmful drinkers (the latter category was also used to include depend-ent drinkers). Review of the 95% CIs indicates that there were no significant differences in

the choice of any of the other forms of health promotion over another.

It is reassuring to observe that dependent drinkers had relatively high levels of health promotion delivered, for example, between 60% and 77% were given verbal advice and between 34% and 53% were referred to an alcohol service. While a separate standard was not set for these drinkers, given the seriousness of alcohol dependency, all such patients (i.e. 100%) should receive referrals to a specialist alcohol service/worker; and a separate analysis revealed that 98 (i.e. 84%, 95% CI = 77% to 91%) did receive at least one form of health promotion for alcohol.


Verbal advice 35.97 ± 3.26 29.43 to 42.52 (59.71 to 77.23)a 16.67 50.00

Written advice 9.97 ± 2.41 5.14 to14.79 (14.46 to 30.15)a 0.00 14.29

Advised to contact GP/ practice nurse 9.29 ± 2.19 4.89 to13.69 (10.86 to 25.36)a 0.00 16.67

Advised to contact alcohol service 12.62 ± 2.66 7.28 to 17.95 (27.49 to 45.65)a 0.00 16.67

Given Community Alcohol Team (CAT) Contact 8.85 ± 1.71 5.43 to 12.28 (19.70 to 36.66)a 0.00 14.29

Referred to alcohol service 12.53 ± 2.11 8.30 to 16.76 (33.94 to 52.63)a 0.00 20.00

Referred to Hospital Alcohol Liaison Worker 8.70 ± 1.83 5.02 to 12.38 (18.94 to 35.74)a 0.00 16.67

Data for H33, H37, and H42 are within the upper quartile for all forms of health promo-tion delivered to smokers.

All values in the table above are in percentages. a: 95% CIs for percentage of patients delivered health promotion who were also prescribed chlordiazepoxide (i.e. dependent drinkers).

Table 7: Percentage of total sample of patients misusing alcohol receiving heath promotion


Figure 16: Health Promotion Delivered for Obesity

Percent based on sample with evidence of Obesity

Hos

pita

ls

Standard

Upper Quartile


Table 8: Health promotion delivered to obese and morbidly obese patients

Hospital Verbal advice

Written advice

Advised to contact GP

Advised to join weight loss programme

referred to GP

Referred to specialist in nutrition/diet

Referred to weight loss programme

Currently on weight loss programme

Referred to hospital gym

Referred to community organisation

H1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H3 50.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H4 9.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H5 10.0 0.0 0.0 0.0 0.0 10.0 0.0 0.0 0.0 0.0H6 11.1 11.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H7 37.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H8 42.9 0.0 0.0 0.0 0.0 0.0 0.0 14.3 0.0 0.0H9 18.2 9.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H10 12.5 37.5 0.0 12.5 0.0 25.0 12.5 12.5 0.0 0.0H11 20.0 0.0 0.0 0.0 0.0 20.0 0.0 0.0 0.0 0.0H12 4.5 4.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H13 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H14 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H15 33.3 33.3 0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0H16 8.3 8.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H17 16.7 8.3 8.3 0.0 0.0 16.7 0.0 8.3 0.0 0.0H18 33.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H19 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H20 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H21 57.1 14.3 0.0 14.3 0.0 7.1 0.0 14.3 0.0 0.0H22 25.0 16.7 0.0 16.7 0.0 16.7 16.7 8.3 0.0 0.0H23 16.7 8.3 0.0 8.3 8.3 16.7 8.3 8.3 0.0 0.0H24 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H25 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H26 - - - - - - - - - -H27 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H28 5.9 0.0 0.0 0.0 0.0 5.9 0.0 0.0 0.0 0.0H29 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H30 55.6 11.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H31 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H32 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H33 - - - - - - - - - -H34 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H35 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H36 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H37 - - - - - - - - - -H38 22.2 11.1 0.0 22.2 0.0 22.2 11.1 22.2 11.1 0.0H39 0.0 0.0 0.0 0.0 0.0 10.0 0.0 0.0 0.0 0.0H40 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H41 16.7 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 8.3H42 12.5 12.5 0.0 0.0 0.0 37.5 0.0 0.0 0.0 0.0H43 25.0 12.5 25.0 25.0 12.5 12.5 25.0 25.0 0.0 12.5H44 21.4 21.4 3.6 7.1 7.1 7.1 14.3 10.7 3.6 3.6H45 20.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H46 20.0 0.0 0.0 0.0 0.0 20.0 0.0 0.0 0.0 0.0H47 12.5 12.5 0.0 12.5 0.0 0.0 12.5 0.0 0.0 0.0H48 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0H49 0.0 0.0 0.0 0.0 0.0 33.3 0.0 0.0 0.0 0.0H50 0.0 0.0 0.0 0.0 0.0 8.3 0.0 0.0 0.0 0.0H51 30.8 23.1 15.4 7.7 0.0 30.8 0.0 15.4 0.0 0.0H52 0.0 0.0 0.0 0.0 0.0 16.7 0.0 0.0 0.0 0.0H53 91.7 33.3 79.2 0.0 16.7 16.7 0.0 0.0 0.0 4.2

Grey cells have been used as a visual aid to identify when patients have received some health promotion; given the very small percentage of patients receiving health promotion in these columns, both the upper and lower quartiles were at zero, and hence the traffic light system could not be used.


437 patients were identified as obese and 98 received health promotion. Yet again, verbal advice was the most common form of health promotion delivered to patients, provided to significantly more patients than any other form of health promotion except for referral

to a specialist in nutrition/diet, which was the second most delivered form of health promotion (the latter category is a com-bination of referral to a nutritionist, other nutritionist and/or dietitian), followed by the provision of written advice.


Verbal advice 14.81 ± 2.72 9.34 to 20.28 0.00 21.43


Advised to contact GP / practice nurse 2.63 ± 1.67 -0.73 to 5.99 0.00 0.00

Advised to join weight loss programme 2.53 ± 0.85 0.82 to 4.24 0.00 0.00

Referred to GP/ practice nurse 0.89 ± 0.46 -0.03 to 1.81 0.00 0.00

Referred to specialist in nutrition/diet 7.83 ± 1.57 4.68 to 10.98 0.00 16.66

Referred to weight loss programme 2.01 ± 0.76 0.48 to 3.53 0.00 0.00

Referred to hospital gym 0.29 ± 0.23 -0.17 to 0.76 0.00 0.00

Referred to community organisation 0.57 ± 0.31 -0.06 to 1.20 0.00 0.00

Table 9: Percentage of total sample of obese and morbidly obese patients receiving heath promotion



MalnutritionOut of a sample size of 5300, only 94 patients were identified as malnourished (1.8%); and 19 acute/specialist trusts had no patients with malnourishment in their samples.

In the 34 acute/specialist trusts that had malnourished patients within their audit samples, 64% received nutritional support, and 53% were referred to a dietician or nutrition specialist. Ideally we would hope all malnourished patients have contact with a dietitian/nutrition specialist; however, with an estimated 25% prevalence of malnutrition in hospital in-patient populations10, there may not be an appropriate number of dieti-tians/nutrition specialists within hospitals to be able to see all malnourished patients; and hospitals may have in place protocols/pathways that ensure other ward staff can appropriately address the needs of malnour-ished patients - NICE guidance stipulates that all hospitals should

“ensure that patients who are either at risk

of or have malnutrition should have access

to a dietitian if necessary. The relatively small

number of dietitians in most hospitals, means

that some of their roles must be delegated

to other ward staff. The dietitians therefore

need to develop hospital protocols and

care pathways on nutrition support, and to

participate in the nutritional education of

the entire clinical workforce. The aim should

be that all hospital healthcare professionals

should understand the importance of

nutrition in patient care and the means

available to provide it safely and effectively.”

http://www.nice.org.uk/nicemedia/pdf/

cg032fullguideline.pdf P.57, Section3.3.2

The organisational survey, requested details on the number of dietitians/nutrition special-ists available within each Trust. Given that

10 Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. British Journal of Nutrition 2004, 92(5):799-808.

11 While we would expect this to be part of normal medical care for malnourished patients, we have also included referral to dieticians or nutrition specialists as “health promotion” as patients may receive general dietary health promotion from these specialists.

the median value is 6.42 WTE for individual sites within Trusts, and the range is from zero to a maximum of 36, it would appear that the majority of Trusts would find it difficult to ensure that all malnourished patients are seen by a dietitian/nutritionist.

Figure 17 provides details of the number of patients with malnourishment who were provided with nutritional support and/or delivered dietary health promotion. Data are ordered from left to right in order of the highest number of malnourished patients receiving nutrition support and health promotion. A measure of “health promotion” is derived from data collected under the “weight and nutrition” section of the audit for verbal advice, written advice, referred to dietician/ nutrition specialist11, referred to GP, referred to community organisation, and/or advised to contact GP/Practice nurse. It is not necessarily always appropriate for patients with malnourishment to receive this “health promotion” and so data should not be used as an indicator of whether or not patients received appropriate health promotion care.

Table 1, Appendix 1 provides a breakdown of the number of malnourished patients provided with each potential form of health promotion.

At risk of malnutrition284 patients were identified as “at risk of malnourishment” (5.4% of the whole sample) within 41 of the 53 acute/specialist trusts (see Figure 18). 54% of these patients received nutritional support, and 39% were referred to a dietician or nutrition specialist. Health Promotion was delivered to 43% of patients. A breakdown of the different forms of health promotion is provided in Table 2, Appendix 1.


Figure 17: Number of malnourished patients receiving nutritional support and/or health promotion for nutrition

Yes HP - Yes NSYes HP - NS InappropriateYes HP - No NS

No HP - Yes NSNo HP - NS InappropriateNo HP - No NS

HP: Health Promotion, NS: Nutritional Support

Number

Hos

pita

l


Figure 18: Number of patients at risk of malnutrition who received nutritional support and/or health promotion for nutrition

Yes HP - Yes NSYes HP - NS InappropriateYes HP - No NS

No HP - Yes NSNo HP - NS InappropriateNo HP - No NS

HP: Health Promotion, NS: Nutritional Support

Hos

pita

l

Number


Table 10: Health promotion delivered to patients identified as physically inactive

Hospital Verbal advice Written advice Referred to Physiotherapist

Referred to rehabilitation Specialist

Referred to physical activity programme

H1 100.0 0.0 100.0 0.0 0.0H2 0.0 0.0 0.0 25.0 0.0H3 0.0 0.0 0.0 0.0 0.0H4 50.0 75.0 75.0 25.0 0.0H5 0.0 0.0 0.0 0.0 0.0H6 100.0 100.0 0.0 0.0 0.0H7 100.0 0.0 33.3 0.0 0.0H8 25.0 0.0 25.0 0.0 25.0H9H10 20.0 20.0 30.0 20.0 20.0H11 4.8 0.0 14.3 0.0 0.0H12 33.3 0.0 0.0 0.0 0.0H13 0.0 0.0 0.0 0.0 0.0H14 23.1 0.0 7.7 0.0 7.7H15 14.3 7.1 71.4 35.7 7.1H16H17 100.0 100.0 0.0 100.0 100.0H18 60.0 0.0 60.0 20.0 0.0H19 0.0 0.0 0.0 0.0 0.0H20 0.0 0.0 0.0 0.0 0.0H21 70.8 0.0 29.2 37.5 4.2H22 100.0 50.0 0.0 50.0 50.0H23 25.0 0.0 37.5 12.5 0.0H24 0.0 0.0 0.0 0.0 0.0H25H26 50.0 50.0 0.0 50.0 0.0H27 0.0 0.0 0.0 0.0 0.0H28 9.5 4.8 9.5 0.0 0.0H29 25.0 0.0 66.7 16.7 0.0H30 63.6 27.3 9.1 81.8 0.0H31 0.0 0.0 0.0 7.7 0.0H32 0.0 0.0 0.0 0.0 0.0H33 33.3 0.0 0.0 100.0 0.0H34H35H36 0.0 0.0 0.0 0.0 0.0H37 0.0 0.0 100.0 0.0 0.0H38 66.7 33.3 0.0 33.3 33.3H39 0.0 0.0 90.0 0.0 0.0H40 0.0 0.0 0.0 0.0 0.0H41 0.0 0.0 0.0 0.0 0.0H42 0.0 0.0 0.0 0.0 0.0H43 60.0 0.0 0.0 0.0 20.0H44 71.4 47.6 42.9 47.6 28.6H45 16.7 0.0 100.0 66.7 0.0H46 0.0 0.0 0.0 0.0 0.0H47 17.6 0.0 82.4 47.1 5.9H48 0.0 0.0 50.0 50.0 0.0H49 0.0 0.0 0.0 0.0 0.0H50 0.0 0.0 33.3 0.0 0.0H51 50.0 0.0 0.0 0.0 0.0H52 13.5 2.7 10.8 0.0 18.9H53 80.0 20.0 80.0 40.0 20.0

Blank rows in the table above indicate that there were no patients identified as physically inactive in these Trusts and as such no health promotion was expected to be delivered to patients.


350 patients were identified as physically inactive and 162 were delivered health promotion for physical activity. Verbal advice and referral to a physiotherapist were the most common forms of health promotion delivered to physically inactive patients. While referral to a physiotherapist has been included under health promotion, physi-otherapists may only provide treatment for the presenting physical condition, and not provide patients with additional informa-tion/support to enable them to lead physi-cally active lives. There were no significant differences in the provision of written advice, referral to a rehabilitation specialist or physi-cal activity programme to physically inactive patients.


Verbal advice 28.83 ± 4.98 18.81 to 38.85 0.00 55.00


Referred to physiotherapist 24.13 ± 4.85 14.37 to 33.88 0.00 40.18

Referred to rehabilitation specialist 18.05 ± 3.96 10.08 to 26.02 0.00 34.52

Referred to physical activity programme 7.10 ± 2.52 2.02 to 12.17 0.00 5.02

One Trust: (H53) is within the upper quartile for all forms of health promotion delivered to physically inactive patients.


Table 11: Percentage of total sample of physically inactive patients receiving health promotion


Figure 19: Health promotion delivered for Physical Activity

Percent based on sample with evidence of Physical Inactivity

Hos

pita

ls

Standard

Upper Quartile


Cluster 3Cluster 1

Cluster 2

Cluster 5

Detailed Analysis

Our initial plan was to undertake regression analysis in order to predict membership in the following groups: assessed, evidence, and health promotion delivered for each risk factor on the basis of patients’ length of stay, age, primary diagnosis and treatment specialty; however these variables were not sufficient enough to significantly and meaningfully predict membership in those groups. Instead, cluster analysis was undertaken as this is a powerful exploratory tool to examine differ-ences in populations by sorting data into associated groups (clusters) that use meaningful variables such as “assessed for smoking” or “length of stay” to describe variance within populations. Multiple analyses were undertaken and are described in Appendix 2.

Cluster analysis findingsThe main findings of interest from the cluster analysis are provided below and a detailed account of the findings from the main cluster analysis is provided in Appendix 2.

A cluster analysis utilising all the data from the audit resulted in six clusters. Some hospitals contributed more data (cases) to a specific cluster than others (see Table 2, Appendix 2 for details). A review of the variables which contribute to these clusters revealed that:

Elderly patients (mean 77 years) who also had long lengths of stay (mean 38 days) and high levels of dementia (cluster 5) had relatively12 low levels of as-sessment for smoking and alcohol, but high levels of assessment for obesity and physical activity. Of those that were assessed for risk factors, they all had rela-tively low levels of evidence of any of the risk factors; but of those that were identified as requiring health promotion, a relatively high proportion received health promotion for obesity and physical activity; and health promotion for smoking and alcohol was in line with the rest of the NHPHA population.

The hospitals that contributed the most data to cluster 5 were, in order of the most number of patients contribut-ing data H1, H46, H14, H18, H6, H35, H15, H51, H22, H34, H37, and H10.

Another cluster with elderly patients (mean 71 years) had lengths of stay on average just over a week, with a high prevalence of respiratory condi-tions and consisted almost exclusively of patients within general medicine. This cluster had relatively high levels of assessment for smoking, alcohol use and physical activity, but low levels of obesity as-sessment (cluster 3). These patients had a relatively low prevalence of smoking, alcohol misuse and obesity; and relatively high levels of health promo-tion for smoking, alcohol misuse and physical inac-tivity, but low levels of health promotion for obesity.

The hospitals that contributed the most data to cluster 3 were H45, H33, H39, H18, H26, H47, H52, H1, H7, H41, H3, and H36.

One of the clusters which consists of younger, middle-aged patients (mean age of 54 years) with short lengths of stay (mean 3 days) had very high levels of assessment for smoking and alcohol misuse (cluster 1); relatively high levels of evidence of smoking but low levels of health promotion for smoking; relatively high levels of alcohol misuse and obesity and high levels of health promotion for these two risk factors.

The hospitals that contributed the most data to cluster 1 were H26, H32, H50, H41, H21, H4, H33, H35, H8, H18, H5, H9, and H19.

Another cluster (cluster 2) has middle-aged patients (mean age of 55 years) with very short lengths of stay (mean 1 day). These patients have low levels of assessment for physical activity but relatively high levels of physical inactivity. Patients in this cluster also had high levels of smoking and obesity; but health promotion for all risk factors was delivered infrequently to these patients.


12 In reporting of the cluster analysis “relatively” is always in relationship to the values for the total audit data unless otherwise stated.


Cluster 6Cluster 4

Cluster 6 is mainly differentiated by the finding that patients in this cluster received no assessments for smoking and alcohol misuse and below-average assessments for obesity and physical inactivity. These patients were on the cusp of elderly (mean age of 65 years) and their mean length of stay was 6 days. Not surprisingly, this group had low levels of evidence for alcohol misuse (0%) and obesity (16%) but, relative to the whole audit population, average levels of physical inactivity (15%). Health promotion for obesity was very poor (5%) but relatively reason-able for physical activity (44%).

The hospitals that contributed the most data to cluster 6 were H40, H37, H46, H48, H12, H15, H36, H45, H50, H43, H5, H24, and H34.

Cluster 4 consisted of surgery patients with a high prevalence of cancer diagnosis (63%), unremark-able lengths of stay (mean 9 days) and mainly from the upper end of middle age (mean 64 years). This cluster was characterised as having relatively high levels of assessment for all risk factors, relatively low prevalence of smoking, alcohol issues and physical inactivity but 23% were obese (i.e. slightly higher than NHPHA population overall). Relatively high levels of health promotion were delivered for smok-ing, obesity and physical activity but not for alcohol misuse.


The cluster analysis for the whole NHPHA population indicates that

• Evidence of smoking, alcohol misuse, obesity, and physical inactivity was found more often in middle-aged than elderly patients.

• Despite middle-aged patients being more likely to need health promotion for all risk factors, they were less likely to receive it.

Cluster analysis of all patients identified as smokers indicates that:

• Smokers tended to be younger, with shorter lengths of stay than non-smokers (all those assessed for smoking and found to be non-smokers).

• Evidence of alcohol misuse in smokers was double that compared to the entire NHPHA population average (24.7% versus 11.2% respectively) and quadrupled compared to the population of non-smokers (6.1%).

• Smokers were less likely to be obese than non-smokers (16.0% versus 22.5% respectively).

• There were two groups of younger smokers – those with a relatively high level of cancer diagnosis but a very short average length of stay (1 day) who had far less health promotion for smoking, alcohol misuse, obesity and especially physical inactivity compared to other smokers; and those with an average length of stay of 10 days, who received health promotion for smoking in line with the average for all smokers, and very high levels of targeted health promotion for their alcohol misuse (92.5%) which was a particular issue within this cluster.

• Overall, smokers were more likely to receive health promotion for their alcohol misuse (51.0%) than non-smokers (32.1%), but this primarily reflects the successful identification of alcohol misuse in one particular cluster of male smokers.


Cluster analysis of all patients identified as misusing alcohol indicates that:

• Most patients with evidence of alcohol misuse are male (76%).

• Alcohol misusers were younger than non-misusers overall.

• Alcohol-related primary diagnoses were found solely in two Clusters, which also contained the youngest patients (mean age of 44 years and 42 years in clusters 1 and 5 respectively). Only 41% of patients in cluster 1 received health promotion for alcohol misuse but nearly all in cluster 5 received health promotion (97%)

• More alcohol misusers were found in general medicine than general surgery.

• Assessment of smoking in patients with alcohol misuse was slightly lower overall compared to non-misusers despite the finding that alcohol misusers were more likely to be smokers (56% compared to 20% in patients who do not misuse alcohol).

• Younger patients who misused alcohol also had a higher occurrence of physical inactivity (27-33% compared to 17% of non-misusers).

• Younger patients who misused alcohol were less likely to receive health promotion for physical inactivity and obesity than older patients who misuse alcohol.

• Clusters with the two oldest populations were least likely to receive health promotion for misusing alcohol - Hospitals need to improve the delivery of health promotion for alcohol misuse to older patients who misuse alcohol.

Cluster analysis of all patients identified as obese indicates that:

• Obese cardiovascular patients received fewer assessments for physical activity than cardiovascular patients who smoke; yet evidence of physical inactivity was higher within this cluster of obese cardiovascular patients than within most other obese patients and especially non-obese patients.

• Surprisingly, obese patients were slightly less likely to be assessed for physical inactivity (38%) than non-obese patients (44%); but (not surprisingly) obese patients were far more likely to be physically inactive than non-obese patients.

• Overall, evidence of obesity was found within surgery patients more than general medicine, which reflected the higher number of assessments of obesity in surgery patients.

• Obese patients had a lower prevalence of smoking and alcohol misuse in comparison to the population average.

• Obese patients who were assessed and identified as being physically inactive were more likely to receive health promotion for physical inactivity in all clusters than obese patients were likely to receive health promotion for obesity per se.

While health promotion for physical activity directly relates to weight and is therefore very appropriate for obese patients, the issue is the content and quality of


the health promotion – if obese physically inactive pa-tients are only receiving recommendations to undertake the minimum recommended levels of physical activity, this will have little impact on obesity as recommenda-tions for weight loss and obesity prevention in adults is daily participation in 45-60 minutes of at least moder-ate intensity physical activity13. Within the audit, user help notes identified that health promotion for obesity included advice on how to lose weight (which should include details on physical activity and/or diet). Further research is needed to understand whether the physical activity health promotion adequately addresses obes-ity issues; and to determine whether health promotion options for obesity and physical activity within the audit should (therefore) be combined into one group when looking at health promotion for obesity.

Cluster analysis of all patients identified as physically inactive indicates that:

• No gender differences were evident overall between physically inactive and physically active patients.

• There was an even distribution of specific diagnoses across the clusters in inactive patients except for one cluster (cluster 4) which was almost entirely composed of cardiovascular patients. Assessment of obesity was relatively high within this cluster; and health promotion for all risk factors was delivered to a high proportion of these patients.

• Physically inactive patients were more likely overall to receive assessments for obesity (52% assessed compared to 42% of physically inactive); but this was primarily due to high levels of assessment

within three clusters (clusters 1, 3 & 4) – the common factor between these clusters was relatively short lengths of stay in hospital.

• Overall, physically inactive patients had a higher occurrence of obesity compared to physically active patients.

The relationship between obesity and physical activ-ity assessments is complicated – if identified as obese, patients appear less likely to be assessed for physical activity; but if patients were identified as physically inac-tive assessments of weight status were made – clearly further investigation is required to understand why this is the case.

• The three clusters with the highest evidence of obesity (clusters 1, 3 and 5) had the lowest levels of health promotion delivered for obesity within the physically inactive clusters. These clusters were characterised by having the shortest lengths of stay (mean 1, 3 and 4 days respectively). Whether or not the short length of stay or some other reason(s) is an explanation for the lack of health promotion for obesity requires further research.

Reliability of Audit DataData for 10 cases at each audit site were double data col-lected for the purposes of assessing inter-rater reliability. This provides an indication of the precision of audit data, indicating how consistently data items are being collect-ed. Low levels of inter-rater reliability may be indicative of poor data collection by one or both of the data collec-tors and/or that question were not understood by data collectors (and may therefore require further clarification from the NHPHA team). A detailed analysis and interpre-tation of inter-rater reliability is provided in Appendix 3.

Inter-rater reliability was very good for all smoking and alcohol data items, good for most weight and nutrition data items and all physical activity assessment items.

13 Saris, W.H.M., Blair, S.N., Van Baak, M.A., et al. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st stock conference consensus statement. Obesity Reviews. 2003 ; 4:101-114.


Reliability was poor for some weight items: waist meas-urement taken, referred to nutritionist, and referred to other nutritionist specialist. When the latter two data items are collapsed into one category along with “referred to dietitian”, inter-rater reliability is much improved; accordingly data are presented for all 3 data items combined into a new category of “referral to specialist in diet/nutrition”; and in future there will be only one question relating to referral to specialists in diet/nutrition. There is little impact on the overall meaning of the audit results from a low inter-rater reli-ability on waist measurement taken, and should not be interpreted as casting doubt on the audit findings concerning weight.

For physical activity all health promotion data items showed only a moderate level of reliability (see Table 4, Appendix 3 for further details). A detailed exploration of where data differences between raters exist revealed that discrepancies occurred in only fourteen of the participating sites. This raises some concerns about the precision of the health promotion data and the iden-tification of individuals requiring health promotion in these sites, and in particular within one site (H51) which had differences in seven out of ten data items collected on physical activity health promotion. These fourteen audit sites should view their results on physical activity with some caution (see Appendix 3 for further details). The NHPHA team will investigate further why health promotion questions for physical activity have only moderate inter-rater reliability and, if appropriate, will make changes to the wording of the questions and/or help notes associated with each question to ensure a higher level of reliability.


Section 3Organisational Survey


Introduction

The purpose of the organisational survey was to provide a baseline measure of health promotion services within and available to acute/specialist Trusts (for ease of reading these will be referred to as “Trusts” from here on). This information can be used to inform guidance on developing health promotion services within individual Trusts. It is recom-mended that if you completed the organisa-tional survey that you read the report with reference to you own Trust’s survey data14.

Questions15 were asked on

• The population that each Trust served• Health promotion policy and people• Training for hospital staff on health

promotion• For each risk factor (smoking, alcohol,

weight, diet and nutrition, and physical activity) information was gathered on

ū Integrated care pathways for patient assessment & health promotion

ū Access to specialists/specialist services ū Availability and type of leaflets ū Additional questions specific to enabling the assessment or delivery of health promotion for each individual risk factor

• Commissioning arrangements

The organisational survey was distributed to all Trusts that participated in the NHPHA following completion of the audit. Because the survey was completed in some cases up to 12 months after the data period for dis-charged cases used in the audit (which was January 2009), direct comparison of survey findings with audit results is not appropri-ate as changes to health promotion policy, people and tools may well have occurred in the time between the audit data and com-pletion of the survey16. We would however hope that it is unlikely that health promotion

14 Please contact [email protected] if you do not have a copy of your survey and we will send you an electronic copy of the data file for your Trust.

15 Survey questions were based on face validity and informed by the Greater Manchester Acute Trusts Survey on Promoting Health and Tackling Health Inequalities http://www.nwph.net/AGMPCTS/Resources/Health%20Promoting%20Hospitals/Reports/Acute%20Trusts%20Baseline%20Survey%20Report%20July%202009.pdf and standards set by the International Health Promoting Hospitals project/network www.healthpromotinghospitals.org and http://www.who-cc.dk (see Appendix 4 for standards).

16 Several Trusts have reported that they made changes to health promotion policy/people/ tools following a review of their automated NHPHA summary results.

policy/people/tools have worsened since the NHPHA data period started; and so where there is a clear absence of health promotion policy/people/tools we will relate these find-ings to the audit data. In future the organi-sational survey will be sent to Trusts for completion at least 3 months prior to the start of data collection for the NHPHA4.

Twenty three acute/specialist Trusts (repre-senting twenty eight – 53% - of the partici-pating sites) responded to the organisational survey. Because the sample size is small inferences made from the data in the surveys may not be generalisable, but do provide an interesting insight into the responding Trusts’ health promotion policies, people, tools and services. In future, completion of the organisational survey will be a pre-requisite for participating in the NHPHA17. There follows a predominantly descriptive account of the data from the organisational survey. It is assumed that data provided by Trusts is correct, if you believe this not to be the case, please contact the NHPHA adminis-tration team.


Results

PopulationRespondents to the survey were from Trusts serving large, medium and small geographical areas. The populations served by the Trusts ranged from large (maximum: 2,800,000 population) to small population sizes (minimum: 180,000 people), with the av-erage population size approximately 510,000 ± 120,000 (SE).

Each trust was asked to provide details of the “number of in-patients treated between April 2008 and April 2009 (whole Trust)”. Because further additional information was not provided on how to answer this question, it appears to have resulted in different interpre-tations of the question, and so to ensure data collected are the same for each Trust we have used HES Data for admissions between 2008 and 200918. Admissions ranged from 12,337 to 210,573 with an average of 89,300 ± 8,145 (SE) and median of 87,175 admissions.

Health promotion policy and peopleIn order for hospitals to ensure that “health promotion is an integral part of the organi-

17 Case notes for review in the NHPHA are always from patients discharged at least 3 months prior to the start of the audit data collection period.

18 The NHS Information Centre, Hospital Episode Statistics for England. Inpatient statistics, 2008-09. www.hesonline.nhs.uk

19 http://www.euro.who.int/document/e82490.pdf

sation’s quality management system19” it is paramount that there is a health promotion policy that senior management endorse and which is supported by resources, staff training and awareness of the policy. Figure 1 provides details of the percentage and number of Trusts that have health promo-tion policies and people dedicated to de-livering health promotion within hospitals. Further details are provided in Table 1.

Data in Figure 1 reveal that approximately half of all respondents have health promo-tion as part of their Trust’s stated aims and mission (“mission statement”), a quarter have a written health promotion strategy (“Written HP strategy”) and 30% of Trusts’ healthcare professionals with patient con-tact have a health promotion role written into their job descriptions/contract (“HP job role description”). The majority (70%) of Trusts have a champion for health promo-tion at board level, 40% have a group re-sponsible for health promotion within their Trust and 30% have specific personnel who co-ordinate health promotion.

Figure 1: Health Promotion Policy & People

HP: Health Promotion. Numbers in columns indicate the number or responses.

Missing DataNoYes

2

9

12

1

17

6

1

6

16

16

7

14

9

9

14

22

1

Description

Percentage


Only two Trusts (9% of respondents) had a mission statement, written strategy and health promotion roles in job descriptions (see Table 1). These two Trusts (H2 and H30) also had a board champion, health promo-tion group and coordinator (but no identifi-able budget for health promotion services/materials); and an additional five Trusts (representing seven hospitals: H3, H13, H20, H27, H37, H43, H46) had a board champion, health promotion group and coordinator.

While it is a positive sign that half of Trusts have health promotion as part of their stated aims and mission, this is rarely backed up with a health promotion strategy and personnel; i.e. it is clear that the majority of trusts do not have in place a comprehen-sive management policy and mechanisms that are supportive of health promotion.

While health promotion within hospital settings does not necessarily need to be a high cost activity, the finding that Only one Trust (H22) had an identifiable budget for health promotion services and materials is disappointing; yet not surprising given the current economic situation, with NHS Trusts required to make up to £20 billion in efficien-

cy savings by the end of 2013/2014, which translates into efficiency savings of millions of GBP for each hospital20. However several recent publications indicate that it is now more important than ever before to invest in health promotion –

“Health promotion is the only way of

ensuring a financially sustainable health

service … unless there is substantial

investment to support the public in active

pursuit of their own health and well-being,

the cost of treatment of chronic conditions by

the NHS will become unsupportable.”21

“Promoting good health and preventing ill

health saves money... Increased investment

in public health is key to increasing efficiency

in the health service. A small shift in resource

towards public health prevention activity

would offer significant short, medium and

long term savings to the service and to the

taxpayer.”22

- nevertheless evidence indicates that public health budgets are often raided to support other activities (prior to the “eco-nomic crisis”)23,24; and there appears to be reticence about recommending ring-fencing

PolicyNo Mission statement (n = 9) Yes, Mission statement (n =12)

Written HP strategy Written HP strategyHP role job description No (n = 8) Yes (n = 1) HP role job description No (n = 7) Yes (n = 5)No (n = 13) 5 1 No 4 3Yes (n = 7) 3 0 Yes 2 2Yes, some (n = 1) 0 0 Yes, some 1 0

PeopleNo Board Champion (n = 6) Yes, Board Champion (n =16)

HP Group HP GroupHP Coordinator No (n = 5) Yes (n = 1) HP Coordinator No (n = 8) Yes (n = 8)No (n = 8) 4 0 No 3 1Yes (n = 7) 1 1 Yes 5 7

Table 1: Cross tabulation of Health Promotion Policy & People

20 Nicholson, D. May 2009. The Year: NHS Chief Executive’s annual report 2008/09 http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_099700.pdf And for an overview see http://www.telegraph.co.uk/health/healthnews/5524693/NHS-chief-tells-trusts-to-make-20bn-savings.html

21 Royal Society for Public Health. 2009. Guide for World Class Commissioners. Promoting Health and well-Being: Reducing Inequalities. www.rsph.org.uk

22 NICE (2009) Using NICE guidance to cut costs in the down turn http://www.nice.org.uk/aboutnice/whatwedo/niceandthenhs/ UsingNICEGuidanceTo CutCostsInTheDownturn.jsp

23 Chief Medical Officer (2005) Annual Report. London: Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137367.pdf


24 Strategic Review of Health Inequalities. 2010. Fair Society, Healthy Lives - The Marmot Review Final Report. http://www.ucl.ac.uk/gheg/marmotreview/FairSocietyHealthyLives

25 Bernstein H, Cosford P, & Williams A. February 2010. Enabling Effective Delivery of Health and Wellbeing. An independent report. http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111693.pdf

funds supposedly allocated to public health activities, even from those supporting health promotion within the NHS - for example, an independent report focussing on improving the delivery of health and wellbeing services in England states

“We make no recommendations in this report

on ringfenced budgets. These can clearly be

helpful in protecting investment, but they

also tend to identify health and wellbeing as

separate from the mainstream function of the

NHS and other public sector bodies. Whether

or not budgets for health and wellbeing

programmes are ringfenced, we consider it

vital that the full corporate endeavours of the

NHS and the wider public sector are applied

to this purpose.”25

while the International Health Promoting Hospitals project/network highlights the im-portance that hospitals allocate “resources to the processes of implementation, evaluation and regular review of the [health promotion] policy … [and ensure] the availability of the necessary infrastructure including resources, space, equipment, etc in order to implement health promotion activities”19 (standard 1), it will clearly be a challenge for hospitals to achieve this, thus making it imperative that hospitals work in partnership with other health services, local authorities, voluntary organisations, etc; and this report ends with a discussion of the importance of working with local commissioners.


TrainingHealth promotion policy can only be support-ed by staff that have the tools, knowledge and confidence to deliver health promotion to patients. The importance of staff training has been highlighted by the International Health Promoting Hospitals project/network (standard 4): that hospital management should establish conditions for the develop-ment of the hospital as a healthy workplace, and in particular ensure there is a “resource strategy that includes the development and training of staff in health promotion skills”19.

In relation to staff’s training needs only one Trust has undertaken a health promotion training needs analysis (H37). Table 2 pro-vides details of the number of Trusts whose staff have access to training on assessing and

delivering health promotion for risk fac-tors. The majority of Trusts (77.3%) have training available to staff for smoking assessment/health promotion, and this is predominantly delivered by PCTs. The ma-jority (72.7%) also have access to training on diet, but this is mainly delivered within hospitals. Training for alcohol and weight is available to staff in approximately 65% of Trusts responding to the question and is usually delivered by the hospital rather than PCT. While there clearly appears to be the least amount of training available to staff for physical activity, with only 50% of Trusts’ staff having access to training, a Chi-Square analysis did not reveal any signifi-cant difference in the provision of training between the risk factors.

Table 2: Number of Trusts reporting that staff have access to training on assessing and delivering health promotion to patients for risk factors

Risk FactorDelivered by… Total with

access to training

No trainingHospital only PCT only

Hospital and PCT

Other Organisation

Smoking 4 12 1 17 5

Alcohol 7 3 2 1 13 7

Diet 10 5 1 16 6

Weight 9 4 1 14 8

Physical activity 5 3 1 1 10 10

Ideally health promotion training should include training on behaviour change in-terventions (for example brief advice, brief interventions, motivational interviewing and social marketing26); but staff at only nine Trusts have access to such training: staff at three Trusts are able to access behaviour

change training in-house and from external organisations (H1, H30, H36), at one Trust training is available in-house only (H37) and at five Trusts training is available from external organisations only (H5, H14, H17, H20, H22).

26 http://www.emphasisnetwork.org.uk/tphn/downloads/BIsummary161008.pdf

Chi-Square analysis comparing total with access to training and those with no training between the risk factors was χ2 = 4.036948, DF = 4, P = 0.401.


Table 3: Ranking of risk factors for ICP elements

Ranking Assessment HP from HCPs HP referral1 Weight Smoking Smoking2 Smoking and alcohol Diet Weight3 Alcohol and weight Diet4 Diet Alcohol5 Physical activity Physical activity Physical activity

HCP: healthcare Professional

The pairwise comparisons revealed that prompts and tools for the assessment, health promotion/education, and referral to health promotion services for physical activity are significantly less likely to be incorporated into ICPs in comparison to all other risk factors. There were no signifi-cant differences in the number of Trusts with ICPs having all, some, or no assessment and health promotion/referral elements between smoking, alcohol, weight and diet/nutrition.

Friedman analysis was also undertaken to determine whether there were differences in ICPs for assessment, health promotion by healthcare professionals and referrals for health promotion within each risk factor. Elements of assessment within ICPs are con-sistently and significantly higher ranked (i.e. more frequently reported as being in some or all ICPs) than both health promotion by healthcare professionals and referrals within each risk factor; and no significant difference in ranking between health promotion by healthcare professionals and health promo-tion referrals within each risk factor were evident. This reveals a picture of hospital ICPs incorporating prompts or tools for the assessment of risk factors but a lack of tools for the next step of delivering health promotion to patients for risk factors

Integrated Care Pathways (ICPs)Hospital healthcare professionals often report that a lack of time is a major obstacle in delivering health promotion to patients, so any mechanisms that can reduce the time it takes for staff to assess patients for risk fac-tors and that provide clear guidance on how to deliver health promotion (while maintain-ing an individualised approach to its deliv-ery) and/or whom to refer patients to should improve the delivery of health promotion. One such potential mechanism is the use of ICPs. Figures 2 to 4 show the percentage and number of Trusts who report that all, some or no care pathways have elements of

• Assessment of risk factors• Health promotion and education

delivered by Trust’s healthcare professionals

• Referral to (internal and/or external) health promotion services for each risk factor.

Analysis of whether there are differences between the degree to which ICPs have ele-ments of assessment, health promotion from hospital healthcare professionals and refer-ral pathways between the risk factors was undertaken through the use of a Friedman Test followed by all pairwise comparisons. This enables ranking of risk factors, which is shown in Table 3.


all or some ICPs have elements of assess-ment for weight status; and the presence of assessment of weight documentation in ICPs is more highly ranked than assessment docu-mentation for any other risk factors. Have assessment prompts/tools for identifying obesity been introduced since the audit was completed; or are there other reasons for why obesity is not being assessed in more patients?

Looking at the extent to which ICPs have health promotion and referral pathways in comparison to the audit findings on health promotion delivered, the relative proportion data does not appear to have any relation-ship to the profile of ICPs (see Figure 4, section 2): health promotion for physical activity and alcohol were delivered most of-ten, followed by obesity and smoking health promotion; but if we look at the absolute proportion of patients receiving health promotion (see Figure 5, section 2), the larg-est total number of patients received health promotion for smoking (4.1%), then alcohol (3.4%), physical activity (3.1%) and lastly for obesity (1.8%) – again it appears that ICPs for obesity health promotion are not translating into expected levels of health promotion for obese patients. Further exploration into whether health promo-tion documentation in ICPs is a relatively recent development within Trusts and/or whether healthcare professionals find obesity a particularly difficult issue to ad-dress, for example due to a lack of training and/or not feeling comfortable discussing obesity with patients (perhaps due to own observable issues with weight themselves27) is required.

(whether these are delivered directly by healthcare professionals within hospitals, or through referral mechanisms to health promotion services).

When we looked at the composition of ICPs on the basis of each risk factor (see Appendix 5 for further details) we found that only three Trusts (H31, H35, H38, H49) reported that all their ICPs incorporate assessment and health promotion (including referrals) for smoking; for weight and diet this was also evident in three Trusts (H1, H38, H43, H49 for both risk factors); for alcohol this was found in two Trusts (H22, H38, H49); and for physical ac-tivity no Trusts had all ICPs incorporating assessment and health promotion. One Trust had assessment and heath promotion within all ICPs for smoking, alcohol, weight and diet (H38, H49).

Given the small proportion of patients assessed in the audit for physical activity (38.8%) in comparison to smoking (81.0%) and alcohol assessment (68.5%), the finding that ICPs are significantly less likely to have elements of assessment for physical activ-ity is not surprising and may to some extent explain why these differences in assessment exist – if staff aren’t provided with explicit guidelines and prompts, it may be more difficult to undertake assessment, especially as physical activity is relatively harder than other risk factors to assess as a simple ques-tion or easily applied objective measure of activity does not exist. This reasoning does not however apply to obesity which is as-sessed in only 40.1% of patients in the au-dit and yet all Trusts that responded to the question on ICP assessment indicated that

27 This reason was reported by hospital nursing staff in interviews concerning attitudes towards health promotion for patients, unpublished report, Stockport NHS FT, 2007.


Figure 2: Do care pathways have elements of assessment for …..

Figure 3: Do care pathways have health promotion/education for .....

Figure 4: Do care pathways have referral to health promotion services for…..

Yes AllYes Some

NoMissing Data

Yes AllYes Some

NoMissing Data

Smoking

Alcohol

Weight

Diet

Physical activity

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

6 15 2

4 15 3 1

6 9 6 2

6 10 5 2

3 10 7 3

Smoking

Alcohol

Weight

Diet

Physical activity

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

5 14 2 2

3 13 6 1

3 12 6 2

5 10 6 2

10 10 3

6

Smoking

Alcohol

Weight

Diet

Physical activity

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

13 8

7

5

7

13

16

13

11

2

21

1

2

2

336


Use of validated assessment toolsThe assessment of smoking is relatively straight forward and can be achieved through simple questioning of a patient as to whether or not they currently smoke or have ever smoked. The assessment of all other risk factors is not as simple and is ideally achieved through the use of specific validated tools. For alcohol, many hospitals will have ICPs with question which merely prompt the healthcare professional to ask a patient how much alcohol they drink, rely-ing both on the healthcare professional to have a good understanding of alcohol units, and the truthfulness of the patient. This method has been shown to result in missing a significant number of patients with alcohol problems. It is far more appropriate to use a validated alcohol tool to understand how much someone drinks and their relationship with alcohol28. There are numerous validated tools available29, with the WHO recommend-ing the use of AUDIT (Alcohol Use Disorders Identification Test30) within primary care and the Royal College of Physicians recommend-ing its use within hospitals31. But studies assessing the use of alcohol tools within hos-pitals are equivocal with some favouring AU-DIT28 and others suggesting that alternatives such as CAGE32 may be more appropriate for use with hospital patients33. A recent pilot study has revealed that nurses do not feel

comfortable asking patients the questions in AUDIT34. This has had a negative impact on its practical application within the hospital. To address this issue alcohol liaison workers have provided training for nursing staff on how to ask the questions indirectly as part of a conversation rather than to ask the ques-tions as they are written. It is possible that all staff expected to use AUDIT with hospital patients will require such training to gain confidence in using the tool. Regardless of which validated alcohol tool is most appro-priate to use within hospital settings, they all show better sensitivity and specificity for identifying alcohol misuse than questions asking how much a patient drink.

The survey revealed that nearly half of all Trusts (n = 11; 48%) use one or more vali-dated alcohol tools (see Table 4 for details), with the most frequently used tool AUDIT (n = 6), followed by the Paddington Alcohol Test (n = 4; which was designed to be used within emergency departments) and GAGE (n = 4), FAST (n = 3), AUDIT-PC (n = 2), AUDIT-C (n = 1), MAST (n = 1), SADQ (n = 1) and FRAMES (n = 1). There is a clear preference for the use of AUDIT or one of its shorter versions (AU-DIT-PC or AUDIT-C) to assess alcohol use within hospital patients. We would recom-mend that those Trusts not already using a validated alcohol tool look into incorporating either AUDIT or CAGE into ICPs for in-patient care; and ensure that some basic training is available to ensure healthcare professionals feel confident in using the tools.

The classification of an individual as obese is not complex, but does require that a patient is weighed, their height measured and their body mass index (BMI) determined from these measures (usually through the use of pre-printed BMI charts). Clearly, weighing

Table 4: Identification of Trusts using validated alcohol assessment tools

Alcohol Assessment Tool Trust/Hospital codesAUDIT H2, H4, H9, H15, H23, H37, H45AUDIT-C H2AUDIT-PC H17CAGE H4, H15, H23, H35, H36FAST H2, H15, H20, FRAMES H15MAST H22PAT H2, H4, H15, H23, H45SADQ H45

28 Mackenzie DM, Langa A, Brown TM: Identifying hazardous or harmful alcohol use in medical admissions: a comparison of AUDIT, CAGE and brief MAST. Alcohol & Alcoholism 1996, 31: 591-599.

29 See http://www.drugslibrary.stir.ac.uk/documents/alccontools.pdf for information on various validated alcohol tools.

30 J.B. Saunders, O.G. Aasland, T.F. Babor, J.R. de la Fuente and M. Grant. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II, Addiction 88 (1993), pp. 791–804.

31 http://www.rcplondon.ac.uk/pubs/contents/ea90ff6a-fcd3-4112-b958-d98f0cc2246a.pdf

32 J.A. Ewing. Detecting Alcoholism. The CAGE Questionnaire. JAMA. 1984; 252(14): 1905-1907. http://jama.ama-assn.org/cgi/data/300/17/2054/DC1/1


scales are required to accurately calculate weight; and nineteen Trusts did respond that they had weighing scales on every ward. Of the three Trusts (H5, H15, H37) that report-ed they did not have weighing scales on all wards (nor any scales that automatically calculate BMI) none met the standard for assessing obesity. One Trust (H 37) assessed only 2% of its patients for obesity and the other two Trusts’ assessed less than a third of their patients for obesity. In the absence of weighing scales on all wards, health-care professionals can not be expected to assess all patients for weight – with the identification of both obesity and mal-nutrition in patients at risk. Scales which calculate BMI are an additional cost, but should ensure that patients have their BMIs calculated accurately and easily (hopefully assisting in the assessment and recording of patients’ BMI). One Trust reported having BMI scales on all its adult wards (H35), one had BMI scales on all patient areas (H30), four Trusts had BMI scales on some adult wards (H4, H9, H20, H23, H36) and one Trust had BMI scales in the gym and occupational health area (H31).

The audit also gathered data on whether patients were assessed for malnourishment. Twenty two Trusts report using a validated screening tool for malnutrition (one Trust did not respond to the question). Sixteen used the malnutrition universal screening tool (MUST35) and nine used another malnutrition tool, three of whom also used MUST. Trusts clearly have appropriate tools in place for the assessment of malnutrition.

Leaflets/written adviceWhile information alone will not lead to behaviour change36, the provision of infor-mation on the risks of unhealthy behaviours,

benefits of changing behaviour (on physical and mental health, finances, etc) and advice on how to change behaviour is one compo-nent of health promotion. It is vital that such information is provided in written form to patients as medical information is most likely to be recalled if it is provided in written/pic-torial material alone or in combination with verbal information37,38.

The responses in table 5 concerning the availability of leaflets with information on

• local health promotion services (“Local”), • national services (“National”), • risks of a risk factor and health benefits of

changing lifestyle (“health benefits/risks”) • and tips on how to change risk

behaviours (“Tips for change”) • indicate that most Trusts have a good

availability of leaflets, in particular for local services. It is a very positive finding that all Trusts report having leaflets available for smoking. Those Trusts that do not have leaflets available for the other risk factors – in particularly H30 which has no leaflets available for alcohol, obesity or physical activity - should look into identifying practical sustainable systems for ensuring health promotion leaflets are available to patients and visitors.

33 R. Hearne, A. Connolly, and J. Sheehan. Alcohol abuse: prevalence and detection in a general hospital. J R Soc Med. 2002 February; 95(2): 84–87.

34 “Developing a Lifestyle Service in Secondary Care” Stockport NHS Foundation Trust. Funding body: Public Health Leadership and Workforce, Department of Health. Report is due May 2010 and will be available to download from www.nhphaudit.org

35 http://www.bapen.org.uk/must_tool.html

36 The King’s Fund. 2008. Commissioning and Behaviour Change. Kicking Bad Habits final report. www.kingsfund.org.uk/document.rm?id=8146

37 Ley, P. (1979) Memory for Medical Information. British Journal of Social and Clinical Psychology, 18, 245–255.

38 Kessels RPC: Patients’ memory for medical information. Journal of the Royal Society of Medicine, 2003, 96:219-222.

Table 5: Number of Trusts with health promotion leaflets available

Local National Health benefits/risks

Tips for change

Number of Trusts with no leaflets

Smoking 22 22 22 22 0Alcohol 19 17 18 18 2 (H5, H30)

Obesity 11 7 15 17 4 (H19, H30, H31, H37)

Physical activity 14 NA 15 16 5 (H5, H15, H20,

H30, H31)

NA: not applicable, as there are no national schemes for physical activity Trusts were not asked whether they had leaflets for national services.


Table 6 shows the different combination of leaflets available at all Trusts. The majority of Trusts have a wide variety of leaflets for smoking and alcohol, covering local and national services, tips for stopping smoking/reducing alcohol intake and information on the health benefits of stopping smoking/sensible drinking and risks of heavy drink-ing. And for physical activity, the majority of Trusts have leaflets providing details of local physical activity programmes, health ben-efits of physical activity and tips to increase activity. Types of leaflets available for weight are more varied, with six Trusts having no leaflets available for local weight loss pro-grammes although five of these Trusts have systems for referring patients to weight loss programmes in the community. It is however possible that the community programmes do not have promotional written materials available.

Availability of leaflets does not necessar-ily translate into the provision of these leaflets to patients – as we have seen from the audit results, relatively few patients receive written health promotion – the ease at which leaflets can be accessed by health-care professionals, in particular nursing staff, is one vital factor39. Trusts were asked whether leaflets could be downloaded from

the intranet/internet and/or provided by PCT public health units (see figure 5 for results). The majority of Trusts can access at least some leaflets through the intranet, inter-net and/or their PCT public health unit; but the finding that few of the Trusts can access all leaflets through these mecha-nisms implies that accessibility of ALL appropriate written information may be patchy. Trusts were also asked to “provide details of how hard copies of leaflets are distributed throughout wards”. The free text information provided in response to this question was subject to content analysis (see Appendix 6 for details). This revealed that leaflets are distributed by specialists such as nutrition link nurses, alcohol liaison nurses, etc (n = 6) and by volunteers (n = 5). De-tails also indicated that leaflets are ordered directly by ward staff (n = 4) and that leaflets are displayed on the wards, for example in racks, although the details of how they get there is not always clear (n = 6). A previ-ous hospital staff survey uncovered that the ready availability of health promotion leaflets is very important to nursing staff37. We would suggest that nurses’ time is not best spent ordering and arranging leaflets. The use of volunteers is perhaps the best method for ensuring regular distribution of leaflets.

Table 6: Combination of health promotion leaflets available within Trusts

Smoking Alcohol Weight Physical Activitylocal + national + health benefits + tips 20 14 6 NAlocal + national + health benefits - 1 - NAlocal + health benefits + tips 1 2 4 14local + national 1 1 NAlocal + tips - - 1local 1national + health benefits + tips 1 1 1 NAhealth benefits + tips - - 4 1tips - 1 1 1Total (hospitals) 23 20 17 16

39 Unpublished report in 2007 on health promotion services healthcare professionals at Stockport NSH Foundation Trust would value included the regular delivery of leaflets to wards. This has now been achieved through the use of hospital volunteers.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Intranet Internet PCT

through advice/behavioural therapy/provi-sion of NRT or bupropion/follow-up after discharge. A Cochrane review of interven-tions for smoking cessation in hospitalised patients found that counselling interventions significantly increased smoking cessation rates only if the counselling was intensive: intervention started in hospital followed by patient follow-up of at least 1 month follow-ing discharge. Less intensive interventions – those only delivered during hospitalisa-tion or with a follow-up of less than 1 month after discharge – were not effective; hence it is important that any patients provided with smoking cessation interventions within hospital are also provided with the option of follow-up after discharge40 from a smoking cessation nurse/service. The addition of NRT to Intensive counselling did not result in a statistically significant increase in quit rate but there is considerable evidence that all

Specialists & specialist servicesSmokingTwenty Trusts reported that they had special-ist respiratory nurses. The median number of full time specialist respiratory nurses across the Trusts was 3.0 WTE (whole time equivalent), average was 5.2 ± 1.1 (SE), and range was 1.0 to 23.1 WTE. Seventeen Trusts (74%) reported having smoking cessation nurses (those that have received accredited training to deliver smoking cessation to pa-tients). While the median number of full time smoking cessation nurses across the Trusts was 2.0 WTE, the average was 17.0 ± 12.3 (SE), indicating a large amount of variability in the number of smoking cessation nurses between different Trusts, which is also indi-cated by the wide range: 0.4 to 200.0 WTE. One Trust reported employing two smok-ing cessation advisors who were not nurses.

Smoking cessation nurses/advisors should be assisting patients to quit smoking

40 http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001837/frame.htmlRigotti N, Munafo’ MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001837. DOI:10.1002/14651858.CD001837.pub2.

Figure 5: How leaflets are accessed

MissingNANone

SomeAll4

1

4

13

1

15

11

6

2

16

2

2

3


Alcohol - Alcohol liaison nursesGiven the large increases in alcohol con-sumption within England over the past thirty years, the concomitant increases in hospital attendance and admission rates for alcohol-related health problems, and the finding that “most of the cost of treating alcohol-related acute and chronic conditions is spent in hos-pitals”42 it is vital that hospitals have appro-priate services to address the treatment and health promotion needs of those who mis-use alcohol and are dependent drinkers. One of the best means of ensuring an optimal alcohol service is delivered is through the employment of alcohol liaison nurses/workers - The Royal college of Physicians31 have highlighted the need for each trust to have one or more dedicated alcohol health workers employed by and answerable to the acute trust. The roles will include:

• implementation of screening strategies• detoxification of dependent drinkers• brief interventions in hazardous drinkers• referral of patients for on-going support

and with access/knowledge about locally available non-statutory and voluntary agencies

• provision of links with liaison/specialist alcohol psychiatry

• an educational resource and support focus for other health care workers in the Trust.” (Recommendation 7 of 12)

The Department of Health and National Treatment Agency for Substance Misuse have also stated that Alcohol liaison posts would help promote alcohol interventions and treatment within hospital settings.43

Alcohol liaison nurses/workers are em-ployed at fourteen Trusts (61%: H2, H4, H9, H14, H15, H17, H19, H20, H22, H23, H35, H36, H37, H45, H49, H38). One Trust (H45) did not

forms of nicotine replacement therapy (NRT) - transdermal patches, chewing gum, nasal spray, tablets and inhalers - significantly increase the likelihood that an attempt to quit smoking cigarettes will be successful in comparison to trying to quit without NRT/placebo41. Smoking cessation nurses can pre-scribe NRT at only six of the seventeen Trusts with smoking cessation nurses (see Table 7 for details of the Trusts/hospitals). At four of all responding Trusts (17%) there were no policies in place for healthcare professionals to prescribe nicotine replacement therapy. At the majority of Trusts it is doctors/medical staff who prescribe NRT (n = 13; 57%). Only one Trust reported that all nurses are able to prescribe NRT and at four Trusts some nurses are able to prescribe. Pharmacists can prescribe NRT at seven Trusts; and four other Trusts reported that other healthcare profes-sionals can prescribe NRT within their Trusts.

We recommend that • All Trusts should have nurses who

have been trained to deliver smoking cessation,

• All Trusts undertake the necessary measures to ensure that smoking cessation nurses can prescribe NRT,

• Mechanisms are put in place to enable patients to receive follow-up smoking cessation support for at least 1 month following discharge.

41 http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000146/frame.html Stead LF, Perera R, Bullen C,Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000146. DOI: 10.1002/14651858.CD000146.pub3.

42 The NHS confederation. January 2010.Too much of the hard stuff: what alcohol costs the NHS. http://www.nhsconfed.org/Publications/Documents/Briefing_193_Alcohol_costs_the_NHS.pdf

43 DH/National Treatment Agency for Substance Misuse. June 2006. Models of care for alcohol misusers (MoCAM). http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4136809.pdf


supply details of the number of alcohol liai-son nurses/workers employed at their Trust, but based on data from the thirteen that provided employment details, the median number of full time workers across the Trusts was 1.5 WTE, average was 2.6 ± 1.0 (SE), and the range was 0.24 to 14.0 WTE. Clearly those Trusts who do not have an alcohol liaison nurse/worker should look into either creat-ing the post or working in partnership with other organisations to ensure that hospital staff have direct access to such individuals to ensure that the needs of patients with alco-hol problems, especially dependent drinkers, can be appropriately met.

- Community alcohol teamsNearly all Trusts - Twenty one (91%) - re-ported that there was a community alco-hol team (CAT) in the geographical area that their patient population is from; but only eleven of these Trusts had a standardised system for referring patients to their local CAT (and one additional Trust reported that a “new simplified referral form has been devel-oped to enable effective referral”). Of concern is the finding that at least four Trusts (H3, H5, H11, H27, H30, H42, H46) have neither alcohol liaison nurses nor referral proc-esses in place to CATs (see Table 7).

Trusts were also asked what community and hospital based alcohol services were avail-able to their adult hospitalised patients. Twenty one Trusts reported that services were available to their patients – with eight-een providing details of community services and ten Trusts having hospital based services available to patients (eight Trusts had both community and hospital alcohol services). Space was provided for details of up to eight hospital and/or community alcohol services; an average of 3 community services and 1 hospital service was identified.

Table 8: Alcohol liaison nurses/workers and referral process to Community Alcohol Teams within Trusts

Referral Process to CAT?No Yes

Alcohol Liaison Nurses/Workers?

No 4 (2) 3Yes 3 (3) 8

Numbers in parentheses are those Trusts that did not respond to the question concerning whether they had a referral process to their local CAT.

Table 7: Healthcare professionals that prescribe NR

Healthcare Professional Hospital Code

Doctors/ medical staffH1, H2, H3, H4, H13, H14, H15, H23, H24, H27, H30, H35, H36, H43, H46, H49, H38

Smoking cessation nursesH1, H3, H13, H27, H31, H37, H43, H46

Some nurses H11, H24, H36, H37, H42All nurses prescribe H1

PharmacistsH1, H13, H17, H24, H31, H37, H38, H49

Other HCPs H1, H2, H5, H20, H30 No one able to prescribe H9, H19, H22, H45

HCP: healthcare professional

While there may be many more commu-nity alcohol services available to patients, of importance is whether acute Trusts are aware of these services and can signpost or refer patients to them. Of the five Trusts that potentially do not have community alcohol services their patients can access, one - H31 - also reports having no alcohol liaison nurses, does not use a validated alcohol tool and only has leaflets available with information on tips for reducing alcohol intake. This Trust was one of six Trusts that provided 0% of patients with health promotion for alcohol.


Previous research45 has found that adult hos-pitalised patients are keen to improve their levels of physical activity and have reported a desire to be able to access hospital gyms. Seven Trusts report that they have a gym within their hospital(s) that patients can use (H3, H4, H11, H17, H22, H23, H27, H30, H31, H42, H46).

Nineteen Trusts reported that there were physical activity programmes that they could refer patients to within the com-munity and/or hospital setting (the Trusts that did not provide details of community/hospital physical activity programmes they could to refer patients to: H3, H20, H24, H27, H38, H46, H49). Eighteen Trusts provided details of community services and six Trusts had hospital based services available to pa-tients (four Trusts had both community and hospital physical activity programmes). An average of 3 community programmes and 1 hospital programme was identified (median of 1 and 0 programmes respectively).

It is recommended that all Trusts ensure they are aware of community weight loss and physical activity programmes and that they establish referral processes to the programmes for suitable patients.

Health trainers“Health Trainers provide individual support and advice to help people to identify and achieve their own health goals and to make healthier lifestyle choices, most often in the areas of healthy eating, physical activity, smoking cessation and alcohol.”46

Health trainers’ clients are generally peo-ple living within areas of high deprivation. Health trainers are usually commissioned and managed by PCTs or local authorities and while they work in a wide range of settings

Nutrition/diet and physical activityTwenty two Trusts have nutrition special-ists/dietitians; and sixteen of these Trusts can refer patients directly to these special-ists solely for the treatment of obesity (i.e. the patient does not have to have co-mor-bidities associated with diet). Nineteen Trusts provided details of the number of nutrition specialists/dietitians they employed - the median number working across these Trusts is 11.0 WTE, average of 14.0 ± 2.5 (SE), and the range is 2 to 43.0 WTE.

Fifteen Trusts (65%) reported that they have a system in place for referring patients to community weight loss pro-grammes (H1, H2, H4, H11, H13, H14, H15, H17, H22, H23, H24, H30, H35, H37, H42, H43, H45). At ten of these Trusts only patients over a certain BMI can be referred to these pro-grammes, for the majority of Trusts the BMI cut-offs for referral are – in line with previous healthcare commission guidance44 - a BMI over 30 or over 27 with co-morbidities; for one Trust patients must have a BMI over 40 or over 35 with co-morbidities (H22). Three Trusts reported that all patients that perceive they have a weight problem and want to lose weight can be referred to community weight loss programmes (H13, H30, H37).

44 Healthcare Commission. 2006. Obesity: identification and management in secondary care. http://ratings2006.healthcarecommission.org.uk/Indicators_2006Nat/Trust/Indicator/indicatorDescriptionShort.asp?indicatorId=1214

45 Haynes, CL. 2008. Health promotion services for lifestyle development within a UK hospital - Patients’ experiences and views. BMC Public Health, 2008, 8:284 http://www.biomedcentral.com/1471-2458/8/284

46 http://www.dh.gov.uk/en/Publichealth/Healthinequalities/HealthTrainersusefullinks/DH_6590


“PCTs also need to see behaviour change interventions as integral to their full range of commissioning activities, including those in the acute sector. PCTs should ensure that patients in the hospital setting, as well as those accessing primary care, receive appro-priate advice and information on behaviour change. PCTs should use contracts and locally agreed care pathways to ensure that patients in the hospital setting are referred to appropriate local support services.”48

With the difficulties inherent in the funding of public health combined with the pressure on PCTs to be supportive of health promo-tion initiatives, it is crucial that hospitals are in communications with local commis-sioners in order to facilitate hospital-based health promotion services. The survey asked “Have there been discussions with the lo-cal commissioners on providing services within the hospital to encourage healthy behaviours?” Eighteen Trusts responded positively, while three said there had been no discussions (H9, H17, H31) and two Trusts did not provide a response (H13, H36).

Content analysis of the information pro-vided indicates that smoking is the main focus area for discussion with commis-sioners as this was reported by eight Trusts,

(often within the geographical areas that their clients come from), they are not usually found within hospital settings. However hospital admission rates are positively cor-related with measures of deprivation, with a higher proportion of adults from lower socio-economic groups47 admitted as emergen-cies compared with higher socio-economic groups; and hospitals may be the first point of contact with a health care professional for individuals from lower socio-economic backgrounds. Hence, having health trainers within hospitals may help narrow health inequalities if a system is established by which patients from more deprived background can be identified and given the option to access the services of a health trainer. This would also work if links are made with health trainers in the com-munity, and while this was not asked about in the survey, one Trust reported that they could access health trainers within the community (H22). Three of the responding Trusts do have health trainers within their hospitals - at one Trust (H37) they reported that they will have three mainstream health trainer services from March 2010, at another Trust (H45) they have three cardiac lifestyle trainers, one respiratory lifestyle trainer, one fitness trainer, and one psychologist and one Trust reported being able to access health trainers through their PCT (H5).

CommissioningAs we have seen earlier, hardly any Trusts have an identifiable budget for health promotion and while public health policy indicates that hospitals have an important role in preventing ill health, the lead for commissioning health promotion activities is expected to be taken by PCTs. The King’s Fund has recommended that PCTs work with hospitals to ensure hospital patients receive health promotion:

47 Reid, F. D. A., Cook, D. G. & Majeed, A. (1999) Explaining variation in hospital admission rates between general practices: cross sectional study. BMJ, 319, 98–103.

48 The King’s Fund. 2008. Commissioning and behaviour change. Kicking Bad Habits final report.


two of which make reference to smoking cessation provision being an agreed CQUIN (Commissioning for Quality and Innova-tion49) indicator with their PCT. Alcohol and obesity were specifically mentioned by three and four Trusts respectively; and secondary prevention of stroke was high-lighted by one Trust. At two Trusts the per-son coordinating health promotion within each Trust is funded by their respective PCT; and at one Trust the PCT employs individu-als who deliver interventions for smoking, alcohol and obesity to patients within the acute Trust and in the community. At two Trusts there is PCT representation on the hospital health promotion steering groups. One Trust reported having strategic discus-sions concerning health inequalities and ill health prevention in general; and two Trusts describe having good communications with their Directors of Public Health. One Trust describes having discussions “around public health and meeting Public Health domain seven objectives”50, thereby focussing broadly on ensuring the delivery of health promotion to hospital patients, staff and visitors.

Respondents were not given with very much space to provide details about the content of commissioner involvement in hospital health promotion services and some details may have been overlooked as there were no prompts for possible responses. In future there will be specific options for responses (e.g. PCT representation on hospital health promotion group) plus an extended free text box.

Concluding RecommendationsOn the basis of the findings from the organi-sational survey the key recommendations are that all Trusts

• Ensure that they have an explicit commitment to delivering health promotion to patients, staff and visitors in their stated aims & mission;

• Establish a health promotion group responsible for informing strategy and operations;

• Consider implementing a stand alone health promotion ICP which incorporates

ū assessment tools for all risk factors, and in particular the use of a validated alcohol assessment tool,

ū health promotion tools/prompts to support hospital healthcare professionals deliver personalised health promotion to patients for all risk factors,

ū and referral options to internal and external health promotion specialists and services for all risk factors;

• Promote to healthcare professionals the importance of following up verbal advice with written information to patients;

• Put in place necessary protocols/policies to ensure all wards have at least one smoking cessation nurse and that these specialists can prescribe NRT to patients;

• Improve training opportunities available to staff on behaviour change principles;

• Liaise with commissioners and ensure that the financial benefits (i.e. the business case) of having health promotion services within the hospital are presented.

49 http://www.dh.gov.uk/en/Publicationsand statistics/Publications/PublicationsPolicy And Guidance/DH_091443

50 Reference to Care Quality Commission Standards, see http://www.cqc.org.uk/_db/_documents/Criteria_for_assessing_core_standards_in_2009-10_-_Acute_Trusts.pdf


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Appendix


Numbers in brackets indicate those patients for whom it was deemed inappropriate to have nutritional support. * indicates that participating site responded to the service evaluation survey.

Appendix 1 - Health Promotion for Malnourishment

Table 1: Total number of patients identified as malnourished and details of those provided with health promotion and/or nutritional support

Hospital MalnourishedHealth promotion total

Verbal advice

written advice

Referred to specialist in diet/nutrition

Referred to GP


advised contact GP/ Practice nurse

Nutritional support

H7 1 1 1 1 1H9 1 0 H10 9 7 6 6 11 1 9H11* 3 0 1H12 2 0 2H13* 2 2 2 1 3 2H14* 10 (2) 8 5 6 1 2 8H15* 6 3 3 1 1 4H16 1 1 1 1 1 1H18 7 6 3 6 5H20* 2 1 0 1 1H21 1 1 1 1 1H22* 2 1 0 1 2H23* 1 1 0 1 1H27* 2 1 0 1 2H28 2(1) 2 2 1 3 2H29 8 1 1 1 H30* 1 1 0 1 1H32 5 3 0 3 2H34 2 1 0 1 2H36* 1 0 H38* 1 1 1 H39 3 2 0 2 3H40 2 0 H41 3 3 3 3 1 3H42* 1 1 1 1 1H43* 1 1 0 1 1H44 1 0 H45* 5 0 4H47 3 0 H48 1 0 H50 2 0 H51 1 1 0 2 H53 1 1 1 1 1 1 1 1Totals (columns) 94(3) 51 31 11 52 2 2 4 60


Numbers in brackets indicate those patients for whom it was deemed inappropriate to have nutritional sup-port. * indicates that participating site responded to the service evaluation survey. In addition, one patient at H15 was also referred to a weight loss programme.

Table 2: Total number of patients identified as at risk of malnourishment and details of those provided with health promotion and/or nutritional support

Hospital At risk of Malnourishment

Health promotion total

Verbal advice

written advice

Referred to specialist in diet/nutrition

Referred to GP


advised contact GP/ Practice nurse

Nutritional support

H1* 1 1 1 1 1 1H4* 6 5 2 2 4 5H5* 2 1 1 1 1 2H6 5 3 1 1 3 5H7 4 2 1 1 3 1H8 1 1H9* 2 1H10 7 4 3 3 5 3H11* 10 H12 6 1H13* 6 3 2 2 3 1H14* 4 H15* 9 6 6 6 5 1 1 4 6H17* 5 4 1 1 4 3H18 13 6 6 6 5 3H19* 16 1 1 1H20* 6 4 4 4 2 1 4H21 8 7 6 6 7 1 7H22* 19 14 6 6 10 1 2 12H23* 12 10 6 6 9 1 1 9H26 10 8 1 1 8 10H27* 1 1H28 4 1 1 3H29 2 1 1 1 1H31* 5 3H32 3H33 8 4 4 8H34 10 4 4 4H35* 7 3H38* 8 1 1 5H39 22 5 1 1 4 6H40 8 4 3 3 3 6H43* 6 2 1 1 3H45* 7 4 4 6H46* 2 2H47 9H49* 7 5 1 1 5 1 6H50 1 1 1 1H51 12 7 2 2 7 8H52 9 4 1 1 3 1 3H53 1 1 1 1 1Totals (columns) 284 123 57 57 110 4 5 8 144


Appendix 2 – Analysis

1. Simple frequency counts and basic de-scriptive statistics for variables: gender, age, length of stay, treatment specialty, diag-noses, assessment, evidence of, and health promotion for all risk factors.

2. Correlations between all variables above and the factors found in step 3.

3. Factor analysis based on correlation matrix of assessment, evidence of, and health pro-motion for all risk factors.

4. ANOVA to compare differences between groups for continuous variables (for exam-ple, difference in age and length of stay in patients assessed for smoking).

5. Regression analysis in order to predict membership in the following groups: as-sessed, evidence, and health promotion delivered for each risk factor. Variables

included n the regression analysis are ones that showed a significant correlation with each “group” described.

6. Cluster analysis: Following standard uni-variate statistics, cluster analyses is a power-ful exploratory tool to examine differences in populations. As the NHPHA data contains primarily binary data, latent class cluster analysis is preferred. Many analyses were run through Latent Gold software testing and comparing one through ten clusters, removing the least significant variables until a statistically optimal solution was found, maximizing the log-likelihood (LL) and minimizing the Bayesian information criterion (BIC). After the final optimal cluster solution was re-run to ensure repeatability, cases were then classified into clusters for cross-tabulations, chi-squares, and ANOVAs. In all analyses, ‘AGE’ and ‘GENDER’ were used as covariates to help classify cases.

Table 1a. Description of Variables used in final cluster analysis, sorted by R².

Indicators Description Type p-value R²

SMOKING_ASSESSED Assessed for Smoking Binary 0.000 0.563

Length of stay Days in hospital Continuous 0.000 0.485

ALCOHOL_ASSESSED Assessed for Alcohol Misuse Binary 0.000 0.290

GenMedicine 0: General Surgery, 1: General Medicine Binary 0.000 0.275

Cancer ICD-10 code related to Cancer Binary 0.000 0.162

Respiratory ICD-10 code related to Respiratory illness Binary 0.000 0.154

Dementia ICD-10 code related to Dementia Binary 0.000 0.050

OBESITY_ASSESSED Assessed for Obesity Binary 0.000 0.045

PA_ASSESSED Assessed for Physical Inactivity Binary 0.000 0.045

Cardiovascular ICD-10 code related to Cardiovascular illness Binary 0.000 0.014


Most hospitals have the majority of their patients within two clusters. Table 2 below provides details of the contribution (number of patients’ data) each hospital made to each cluster. Green indicates that the hospital’s

data was in the upper quartile of data for that cluster and red indicates that the hospi-tal’s data was in the lower quartile.

Table 1b. Description of Covariates used in final cluster analysis.

Covariates Description Type p-value

GENDER 0: Male, 1: Female Binary 0.000

AGE Age in Years Continuous 0.007

Table 2a. Contribution of hospitals to clusters (top 5)

Cluster 1 2 3 4 5 6

Sample 1375 1245 1112 506 512 550

Hospitals H26 51 H42 68 H45 43 H53 54 H1 37 H40 48

H32 48 H25 64 H33 40 H22 29 H46 27 H37 29

H50 44 H17 54 H39 38 H30 25 H14 21 H46 25

H41 43 H44 52 H26 34 H44 23 H18 19 H48 23

H21 41 H11 49 H18 34 H15 22 H6 18 H12 21

Statistics Max 51 Max 68 Max 43 Max 54 Max 37 Max 48

Min 10 Min 0 Min 0 Min 1 Min 1 Min 0

Average 26 Average 23 Average 21 Average 10 Average 10 Average 10

Median 26 Median 25 Median 22 Median 7 Median 8 Median 7

Quartile (top) 31 Quartile

(top) 31 Quartile (top) 29 Quartile

(top) 11 Quartile (top) 13 Quartile

(top) 15

Quartile (bottom) 17 Quartile

(bottom) 13 Quartile (bottom) 14 Quartile

(bottom) 5 Quartile (bottom) 5 Quartile

(bottom) 5

*Red = 6x greater than median or more. Orange = 4x greater than median or more. Yellow = 2x greater than median or more

CLUSTER ANALYSIS 1 – ALL PATIENTSUsing all data (5300 cases), we determined an optimal 6 cluster solution using the vari-ables described in Table 1a. Some variables will be more powerful than others in draw-

ing clusters apart. For example, there are stronger differences between clusters in the ‘SMOKING_ASSESSED’ variable than the ‘Cardiovascular’ variable.


Table 2b. Contribution of hospitals to clusters

Clusters (All data)H code 1 2 3 4 5 6ALL 1375 1245 1112 506 512 550 In Upper QuartileH1 15 13 31 1 37 3 Clusters 3 and 5 onlyH2 27 31 22 5 2 13 None in top quartileH3 16 34 30 1 8 11 Clusters 2 and 3 onlyH4 40 22 18 7 8 5 Cluster 1 onlyH5 35 13 14 11 11 16 Clusters 1 and 6 onlyH6 17 20 26 7 18 12 Cluster 5 onlyH7 31 21 31 6 7 4 Cluster 3 onlyH8 39 12 26 12 7 4 Clusters 1 and 4 onlyH9 33 34 19 6 3 5 Clusters 1 and 2 onlyH10 19 34 20 10 14 3 Clusters 2 and 5 onlyH11 28 49 13 4 1 5 Cluster 2 onlyH12 21 21 18 9 10 21 Cluster 6 onlyH13 24 34 24 4 7 7 Cluster 2 onlyH14 23 0 29 13 21 14 Clusters 4 and 5 onlyH15 11 10 21 22 16 20 Clusters 4, 5, and 6 onlyH16 17 26 13 21 9 14 Cluster 4 onlyH17 24 54 8 9 3 2 Cluster 2 onlyH18 36 0 34 8 19 3 Clusters 1, 3, and 5 onlyH19 33 43 14 2 4 4 Clusters 1 and 2 onlyH20 21 29 22 9 13 6 None in top quartileH21 41 22 18 3 10 6 Cluster 1 onlyH22 27 0 24 29 15 5 Clusters 4 and 5 onlyH23 28 28 22 6 11 5 None in top quartileH24 16 30 27 8 3 16 Cluster 6 onlyH25 16 64 5 2 6 7 Cluster 2 onlyH26 51 0 34 6 4 5 Clusters 1 and 3 onlyH27 25 31 24 3 5 12 None in top quartileH28 28 22 25 9 11 5 None in top quartileH29 25 26 23 11 8 7 None in top quartileH30 27 33 6 25 3 6 Clusters 2 and 4 onlyH31 15 23 27 9 13 13 None in top quartileH32 48 23 12 8 6 3 Cluster 1 onlyH33 40 0 40 13 2 5 Clusters 1, 3, and 4 onlyH34 16 25 21 7 15 16 Clusters 5 and 6 onlyH35 40 6 20 6 17 11 Clusters 1 and 5 onlyH36 17 25 30 3 5 20 Clusters 3 and 6 onlyH37 28 0 21 7 15 29 Clusters 5 and 6 onlyH38 26 28 29 3 9 5 None in top quartileH39 13 26 38 5 11 7 Cluster 3 onlyH40 27 11 0 11 3 48 Cluster 6 onlyH41 43 0 31 11 10 5 Clusters 1 and 3 onlyH42 15 68 3 7 2 5 Cluster 2 onlyH43 28 34 8 6 7 17 Clusters 2 and 6 onlyH44 14 52 0 23 5 6 Clusters 2 and 4 onlyH45 14 0 43 12 11 20 Clusters 3, 4, and 6 onlyH46 10 25 11 2 27 25 Clusters 5 and 6 onlyH47 26 17 32 12 5 8 Clusters 3 and 4 onlyH48 22 28 13 5 9 23 Cluster 6 onlyH49 29 20 18 5 13 15 None in top quartileH50 44 1 18 16 3 18 Clusters 1, 4, and 6 onlyH51 31 21 24 7 16 1 Cluster 5 onlyH52 20 31 32 5 8 4 Cluster 3 onlyH53 15 25 0 54 6 0 Cluster 4 only


Gender & Treatment Specialty (Table 3)As illustrated in Table 3, there are no major differences between clusters with regards to gender, although cluster 6 have a slight bias towards females.

The overall sample has more patients in General Medicine (60%) than General Surgery (40%). Cluster 3 is predominantly General Medicine while Cluster 4 is almost entirely General Surgery. Cluster 5 is mostly General Medicine, whereas the remaining clusters are nearly all 50:50.

Table 3. Cross-tabulation of Gender and Specialty by cluster.

Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 All

SAMPLE 1375 1245 1112 506 512 550 5300

SURGERY 687 603 3 480 105 245 2123

MEDICINE 688 642 1109 26 407 305 3177

Relative SURGERY 50.0% 48.4% 0.3% 94.9% 20.5% 44.5% 40%

Relative MEDICINE 50.0% 51.6% 99.7% 5.1% 79.5% 55.5% 60%

MALE 690 622 512 244 217 226 2511

FEMALE 685 623 600 262 295 324 2789

Relative MALE 50.2% 50.0% 46.0% 48.2% 42.4% 41.1% 47%

Relative FEMALE 49.8% 50.0% 54.0% 51.8% 57.6% 58.9% 53%

Age & Length of Stay (Table 4)Clusters 1 and 2 consist of relatively younger patients (approximately 55 years) with much shorter stays (1 – 3 days) than the other clusters, whose average ages range

between 65 years to 70 years with week long lengths of stays (6 – 9 days), except for cluster 5 which consists of patients who are exceptionally older (77 years) and stay in hospital for a month, on average.

Table 4. Means for ‘Length of stay’ and ‘Age’ by cluster.


SAMPLE 1375 1245 1112 506 512 550 5300

Length of stay (mean) 3.05 1.00 8.48 8.73 37.85 6.15 7.93

Age (mean) 54 55 71 64 77 65 62


Primary Diagnosis (Table 5)Certain ICD-10 codes were grouped to form new variables identifying diagnoses poten-tially related to differences in assessment, evidence, and health promotion given for smoking, alcohol misuse, obesity, and physi-cal inactivity. Because of the smaller samples, it is more relevant to present percentages out of the total number of patients with that diagnosis.

Cluster 4 contains 63% of the cancer diag-noses, specifically surgery patients (See Table 3). Cluster 3 contains 67% of the respiratory diagnoses, specifically medicine patients

(See Table 3). Cluster 5 contains 64% of the dementia diagnoses. The key diagnoses are fairly evenly spread throughout the rest of the clusters.

To summarise, Clusters 1 and 2 are younger patients with shorter stays in-hospital. Clus-ter 3 consists of medical patients, many with respiratory diagnoses. Cluster 4 are surgi-cal patients, many with cancer diagnoses. Cluster 5 are elderly patients with very long stays in-hospital, many with dementia (and other long-term illnesses). Cluster 6 is so far indistinctive, but has a slight bias towards females.

Assessment of risk factors (Table 6)Cluster 4 excels at assessment of all risk fac-tors, as shown in Table 6, even in comparison to cluster 3, who are above-average in as-sessing smoking, alcohol misuse, and physi-cal inactivity but below average in assessing obesity. These findings indicate that surgery patients are more likely to be assessed for obesity than patients in general medicine.

The older patients of cluster 5, despite their longer length of stay, are less likely to be assessed for smoking and alcohol than their younger counterparts in clus-ters 1 and 2; however they (cluster 5) are more likely to be assessed for obesity and physical inactivity. This may reflect hospi-tals’ efforts in preventing falls and frailty in elderly hospital in-patients.

Table 5. Cross-tabulation of diagnoses by cluster.


SAMPLE 1375 1245 1112 506 512 550 5300

Cancer 4 60 0 181 23 18 286

Cardiovascular 119 157 199 43 48 36 602

Gastrointestinal 54 24 27 6 10 27 148

Respiratory 25 57 417 0 62 58 619

Vascular 41 19 37 1 36 7 141

Dementia 0 1 18 0 47 8 74

Relative Cancer 1% 21% 0% 63% 8% 6% 100%

Relative Cardiovascular 20% 26% 33% 7% 8% 6% 100%

Relative Gastrointestinal 36% 16% 18% 4% 7% 18% 100%

Relative Respiratory 4% 9% 67% 0% 10% 9% 100%

Relative Vascular 29% 13% 26% 1% 26% 5% 100%

Relative Dementia 0% 1% 24% 0% 64% 11% 100%


The otherwise indistinctive cluster 6 be-comes well-differentiated as receiving no assessments for smoking and alcohol misuse and below-average assessments for obesity and physical inactivity. Given the ‘average’ nature of the demographics,

this cluster is a result of those few patients who are “missed” in most hospitals, as well as larger samples from five specific “poor-performing” hospitals (H12, H37, H40, H46, H48; Table 2).

Evidence of risk factors (Table 7)Despite the above-average number of as-sessments performed in cluster 4, the actual evidence found for smoking, alcohol misuse and physical inactivity is slightly less than average (though still in line with general population prevalence for smoking). As obese patients (especially morbidly obese)

are often easily visually identified, the higher evidence in clusters 1, 2, and 4 may be due to more targeted assessments. Evidence of obesity sharply declines in the older patients of clusters 3, 5, and 6. In fact, evidence of smoking, alcohol misuse, obesity, and physical inactivity is found more often in younger patients.

Table 6. Cross-tabulation of assessments by cluster.


SAMPLE 1375 1245 1112 506 512 550 5300

Assessed for Smoking 1339 987 1112 506 347 0 4291

Assessed for Alcohol Misuse 1168 860 858 451 292 3 3632

Assessed for Obesity 546 502 397 318 236 128 2127

Assessed for Physical Inactivity 485 345 573 268 237 150 2058

Assessed for Smoking 97.4% 79.3% 100.0% 100.0% 67.8% 0.0% 81.0%

Assessed for Alcohol Misuse 84.9% 69.1% 77.2% 89.1% 57.0% 0.5% 68.5%

Assessed for Obesity 39.7% 40.3% 35.7% 62.8% 46.1% 23.3% 40.1%

Assessed for Physical Inactivity 35.3% 27.7% 51.5% 53.0% 46.3% 27.3% 38.8%

Table 7. Cross-tabulation of evidence by cluster.


SAMPLE 1375 1245 1112 506 512 550 5300

Evidence of Smoking 393 271 229 108 70 - 1071

Evidence of Alcohol Misuse 160 96 78 44 28 0 406

Evidence of Obesity 135 121 62 74 25 20 437

Evidence of Physical Inactivity 81 77 100 35 34 23 350

Evidence of Smoking 29.4% 27.5% 20.6% 21.3% 20.2% 25.0%

Evidence of Alcohol Misuse 13.7% 11.2% 9.1% 9.8% 9.6% 0.0% 11.2%

Evidence of Obesity 24.7% 24.1% 15.6% 23.3% 10.6% 15.6% 20.5%

Evidence of Physical Inactivity 16.7% 22.3% 17.5% 13.1% 14.3% 15.3% 17.0%


Health Promotion (Table 8)Despite younger patients being more likely to need health promotion, they are less likely to receive it. The older patients in clusters 3, 4, 5, and 6 all receive higher levels of health promotion for physical inactivity, and clusters 3, 4, and 5 all receive higher levels of health promotion for smoking – double that for the younger patients in clus-ters 1 and 2. As age and length of stay are

correlated, it is not possible to identify what exactly is preventing these patients from being given health promotion as well as the older patients with longer stays. Either way, it is clear that more effort is needed to reach those younger patients who are only briefly in hospital. The delivery of health promotion is particularly poor in cluster 2; hospitals H11, H17, H25, H42, and H44 contribute a high number of cases to this cluster (see Table 2).

Table 8. Cross-tabulation of health promotion by cluster.


SAMPLE 1375 1245 1112 506 512 550 5300

Health Promotion given for Smoking 63 34 72 30 16 - 215

Health Promotion given for Alcohol Misuse 81 30 45 13 13 - 182

Health Promotion given for Obesity 40 17 7 23 10 1 98

Health Promotion given for Physical Inactivity 29 25 55 20 23 10 162

Health Promotion given for Smoking 16.0% 12.5% 31.4% 27.8% 22.9% 20.1%

Health Promotion given for Alcohol Misuse 50.6% 31.3% 57.7% 29.5% 46.4% 44.8%

Health Promotion given for Obesity 29.6% 14.0% 11.3% 31.1% 40.0% 5.0% 22.4%

Health Promotion given for Physical Inactivity 35.8% 32.5% 55.0% 57.1% 67.6% 43.5% 46.3%


Appendix 3 - Inter-rater reliability

Data for 10 cases at each audit site were dou-ble data collected. A total of 528 cases were double collected (at one site the double-data audit collector could not retrieve two of the 10 cases selected). Because we can not judge whether one data collector was more ac-curate than another, data from the first data collector has been taken as the data used in this audit. The purpose of double data collec-tion is to measure inter-rater reliability: this is analogous to precision, and indicates how consistently something is being measured. Low levels of inter-rater reliability may be indicative of poor data collection by one or two of the data collectors and/or that ques-tions were not understood.

Inter-rater reliability is measured by kappa statistic, which is reported for all data items.

A Kappa statistic below 0.20 is indicative of poor agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60 moderate agreement, 0.61 to 0.80 good agreement, 0.81 to 1.00 very good agreement.We have also provided the measure of ob-served agreement for each data item.

Key - HP: health promotion, CI: confidence interval, NRT: nicotine replacement therapy, CAT: community alcohol team, BMI: body mass index, PA: physical activity.

We can conclude that the audit questions were well understood. All items showed at very good agreement between data collec-tors, except “did patient want to quit smok-ing” which had good agreement.

Smoking Table 1: Inter-rater reliability for all smoking related audit questions

Item Is Smoking History Recorded

No Smoking History Reason

Patient’s Smoking Status

Was HP Required For Smoking

Ask If Want To Quit Smoking

Did patient want to quit smoking?

Observed Agreement 96.21 % 95.45% 91.10% 92.80% 94.70% 93.37%

Kappa statistic 0.87(very good) 0.84 (very good) 0.88 (very good) 0.86 (very good) 0.83 (very good) 0.73 (good)

Item Given Smoking Verbal Advice

Given Smoking Written Advice NRT Prescribed Referred To Smoking

Cessation NurseReferred to specialist respiratory nurse

Advised To Contact GP Smoking

Observed Agreement 95.08% 95.64% 95.45% 95.45% 95.45% 95.27%

Kappa statistic 0.85 (very good) 0.86 (very good) 0.85 (very good) 0.85 (very good) 0.85(very good) 0.85 (very good)


We can conclude that the audit questions were well understood as all items showed very good agreement between data collectors.

Item Is Alcohol History Recorded

No Alcohol History Reason

Patient Drinks Alcohol

Alcohol Categorisa-tion

Given Alcohol Verbal Advice

Given Alcohol Writ-ten Advice


Kappa statistic 0.81 (very good) 0.80 (very good) 0.82 (very good) 0.82 (very good) 0.82 (very good) 0.84 (very good)

Item Advised To Contact GP / practice nurse

Advised to contact alcohol service Given CAT Contact Referred to alcohol

service

Referred to hospital alcohol liaison worker

Chlordiazepoxide Prescribed


Kappa statistic 0.84 (very good) 0.80 (very good) 0.85 (very good) 0.83 (very good) 0.84 (very good) 0.83 (very good)

Item Was Malnourished Was at risk of being malnourished

Weight recorded BMI Recorded Waist Measure-

ment TakenMid Arm Circum-ference Taken

Triceps Skinfold Thickness Taken

Observed Agreement 99.05% 96.4% 89.58% 91.29% 98.67% * *

Kappa statistic 0.70 (good) 0.73 (good) 0.79 (good) 0.80 (very good) -0.00 (poor)

Item Clinical Impression Weight Category Nutrition Support Provided

Given Verbal Advice

Given Written Advice

Advised To Contact GP

Advised To Join Weight Loss Programme

Observed Agreement 94.13% 87.88% 96.4% 89.02% 91.29% 91.67% 92.05%

Kappa statistic 0.71 (good) 0.79 (good) 0.73 (good) 0.71 (good) 0.76 (good) 0.77 (good) 0.77 (good)

Item Referred To Nutritionist Referred To GP Referred To

Dietician

Referred To Other Nutritionist Specialist

Referred To Weight Loss Programme

Currently on Weight Loss Programme

Referred To Hospital Gym

Observed Agreement 99.62% 100% 97.54% 99.24% 92.23% 92.23% 92.42%

Kappa statistic 0.00 (poor) 1.00 (very good) 0.64 (good) 0.33 (fair) 0.78 (good) 0.78 (good) 0.78 (good)

Item Referred To Commu-nity Organisation

*It was not possible to assess the inter-rater reliability for assessment of weight categorisation based on mid-arm circumference or triceps skinfold as all data items had a “no” response.

Observed Agreement 92.42%

Kappa statistic 0.78 (good)

Alcohol resultsTable 2: Inter-rater reliability for all alcohol related audit questions

Weight and nutrition resultsTable 3: Inter-rater reliability for all weight and nutrition related audit questions


We can conclude that while most of the au-dit questions for weight and nutrition were quite well understood and completed (items showing “good” or “very good” agreement between data collectors), waist measure-

ment and referred to nutritionist/other nutri-tionist specialist were not well understood/completed. Cross tabulation data for these questions are provided below:

Looking at the data, it is clear that the reason for such low agreement for “waist measure-ment taken” and “referred to nutritionist” is because there was absolutely no agreement between raters on the few occasions that a patient may have had their waist measure-ment taken or been referred to a nutritionist. For waist measurement taken the disagree-ments were found in H14 (n =1), H21 (n =1), H37 (n =1), H42 (n =1) and H50 (n = 3).

Because dietitian, nutritionist and “other nutritionist specialist” may be confused with one another (although this was not evident from the pilot), we checked the agree-ment between raters on the basis of any agreement between these categories. We found that “other nutritionist specialist” and “nutritionist” were coded as “dietitian” on one occasion each, changing the cross tabula-tions accordingly:

When all data were combined into a new cat-egory relating to referral to dietitians and/or nutritionists/other nutritionist specialists, the observed agreement is 97.54% and Kappa = 0.69 (good agreement).

Waist Measurement Taken Referred To Nutritionist Referred To Other Nutritionist Specialist

No Yes No Yes No Yes

No 521 6 No 526 1 No 523 1

Yes 1 0 Yes 1 0 Yes 3 1

Referred To Nutritionist Referred To Other Nutritionist Specialist

Category: dietitian and nutritionists combined

No Yes No Yes No Yes

No 526 1 No 523 0 No 500 4

Yes 0 1 Yes 3 2 Yes 9 15


We can conclude that the audit questions concerning the assessment of physical activ-ity were fairly well understood as all items showed “good” agreement between data collectors.

However, while observed agreement for the different types of health promotion is high, the kappa statistic values indicate that there was only moderate agreement between data collectors. Further analysis revealed that the raters disagreed significantly from one another in at least one response category on whether or not patients were referred to physiotherapists (significant Maxwell test statistic), but that the difference between raters for the other forms of health promo-tion was not significant.

Visual inspection of the cross tabulation data below reveals an area of concern (high-lighted in red): a considerable proportion of patients are being categorised by one rater as receiving health promotion (“Yes”), while the other rater either thinks it was not given (“No”) or not applicable (“N/A”; which indi-cates that the patient was categorised as not requiring health promotion) – for example, for verbal advice the second data collector

believed there to be 10 patients provided with verbal advice that the first data collec-tor thought were not applicable for verbal advice (because they did not require health promotion). The degree of discrepancies raises some concerns about the reliability of the data concerning 1) proportion of people requiring health promotion and 2) health promotion for physical activity. In particular, need for health promotion may be under-estimated because data from the first data collector has been accepted as “true” within this audit. However, without further explora-tion of the reasons for these discrepancies, it is not possible to know which data collectors are correct and which are not. It should also be noted that the same patient often has disagreements across several data item.

Disagreements in data items are apparent in the following hospitals:

H4 (n = 1), H8 (n = 2), H11 (n = 1), H14 (n = 2), H21 (n = 3), H22 (n = 1), H30 (n = 2), H37 (n = 3), H43 (n = 1), H44 (n = 2), H47 (n = 1), H50 (n = 1), H51 (n = 7), H52 (n = 1).

If these hospitals wish to look further into the discrepancies, NHPHA can provide them

Item Is PA History Recorded?

Reason for No PA History Mobility Not Enough PA Was HP Required For PA

Observed Agreement 88.64% 87.88% 86.93% 80.49% 84.85%

Kappa statistic 0.77 (good) 0.76 (good) 0.76 (good) 0.66 (Good) 0.72 (good)

Item Given PA Verbal Advice

Given PA Written Advice

Referred To Physiotherapist

Referred To Rehabilitation Specialist Service Referred To PA Program

Observed Agreement 90.34% 90.34% 90.53% 90.53% 90.53%

Kappa statistic 0.42 (moderate) 0.42 (moderate) 0.43 (moderate) 0.43 (moderate) 0.43 (moderate)

Physical activity Table 4: Inter-rater reliability for all physical activity related audit questions


with details in order to help identify the relevant cases – in particular, H51 may wish to investigate why there was a discrepancy in 7 of the 10 patients’ cases that were double data collected.

Verbal advice2nd data collector

N/A No Yes

1st data collectorN/A 456 23 10No 11 17 0Yes 5 2 4

Written advice2nd data collector

N/A No Yes


Referred to Physiotherapist2nd data collector

N/A No Yes


Referred To Rehabilitation Specialist Service

2nd data collector

N/A No Yes


Referred to PA programme2nd data collector

N/A No Yes



Management PolicyStandard 1. The organisation has a written policy for health promotion. The policy is implemented as part of the overall organisation quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff.

Objective:To describe the framework for the organisation’s activi-ties concerning health promotion as an integral part of the organisation’s quality management system.

Substandards:1.1 The organisation identifies responsibilities for the

process of implementation, evaluation and regular review of the policy.

1.2 The organisation allocates resources to the processes of implementation, evaluation and regular review of the policy.

1.3 Staff are aware of the health promotion policy and it is included in induction programmes for the new staff.

1.4 The organisation ensures the availability of proce-dures for collection and evaluation of data in order to monitor the quality of health promotion activities.

1.5 The organisation ensures that staff have relevant competences to perform health promotion activities and supports the acquisition of further competences as required.

1.6 The organisation ensures the availability of the necessary infrastructure, including resources, space, equipment, etc. in order to implement health promo-tion activities.

Patient AssessmentStandard 2. The organisation ensures that health professionals, in partnership with patients, system-atically assess needs for health promotion activities.

Objective:To support patient treatment, improve prognosis and to promote the health and well-being of patients.

Substandards:2.1 The organisation ensures the availability of proce-

dures for all patients to assess their need for health promotion.

2.2 The organisation ensures procedures to assess specific needs for health promotion for diagnosis-related patient groups.

2.3 The assessment of a patient’s need for health promo-tion is done at first contact with the hospital. This is kept under review and adjusted as necessary accord-ing to changes in the patient’s clinical condition or on request.

2.4 The patients’ needs assessment ensures awareness of and sensitivity to social and cultural background.

2.5 Information provided by other health service part-ners is used in the identification of patient needs.

Patient Information and InterventionStandard 3. The organisation provides patients with information on significant factors concerning their disease or health condition and health promotion interventions are established in all patient pathways.

Objective:To ensure that the patient is informed about planned activities, to empower the patient in an active partner-ship in planned activities and to facilitate integration of health promotion activities in all patient pathways.

Appendix 4 – Health Promoting Hospitals Standards

Standards for Health Promotion in HospitalsReference: http://www.euro.who.int/document/e82490.pdf


Substandards:3.1 Based on the health promotion needs assessment,

the patient is informed of factors impacting on their health and, in partnership with the patient, a plan for relevant activities for health promotion is agreed.

3.2 Patients are given clear, understandable and appro-priate information about their actual condition, treat-ment, care and factors influencing their health.

3.3 The organisation ensures that health promotion is systematically offered to all patients based on as-sessed needs.

3.4 The organisation ensures that information given to the patient, and health promoting activities are documented and evaluated, including whether ex-pected and planned results have been achieved.

3.5 The organisation ensures that all patients, staff and visitors have access to general information on factors influencing health.

Promoting a Healthy WorkplaceStandard 4. The management established conditions for the development of the hospital as a healthy workplace.

Objective:To support the establishment of a healthy and safe workplace, and to support health promotion activities for staff.

Substandards:4.1 The organisation ensures the establishment and im-

plementation of a comprehensive Human Resource Strategy that includes the development and training of staff in health promotion skills.

4.2 The organisation ensures the establishment and implementation of a policy for a healthy and safe workplace providing occupational health for staff.

4.3 The organisation ensures the involvement of staff in decisions impacting on the staff’s working envi-ronment.

4.4 The organisation ensures availability of procedures to develop and maintain staff awareness on health issues.

Continuity and CooperationStandard 5. The organisation has a planned ap-proach to collaboration with other health service levels and other institutions and sectors on an ongo-ing basis.

Objective:To ensure collaboration with relevant providers and to initiate partnerships to optimise the integration of health promotion activities in patient pathways.

Substandards:5.1 The organisation ensures that health promotion

services are coherent with current provisions and health plans.

5.2 The organisation identifies and cooperates with existing health and social care providers and related organisations and groups in the community.

5.3 The organisation ensures the availability and imple-mentation of activities and procedures after patient discharge during the post-hospitalisation period.

5.4 The organisation ensures that documentation and patient information is communicated to the relevant recipient/follow-up partners in patient care and rehabilitation.


Tables showing cross tabulations for as-sessment, health promotion/education and

referral to health promotion specialists in ICPs for each risk factor

Appendix 5 – Integrated Care Pathways

Smoking assessment: Yes, all

Health Promotion/ education

HP Yes, all Yes, some No Total (rows)

Referral pathway:

Yes, all 3 1 - 4

Yes, some 2 6 - 8

No - 1 - 1

Total (columns) 5 8 0 13

Smoking assessment: Yes, some



Referral pathway:

Yes, all 1 - - 1

Yes, some - 6 - 6

No - 1 - 1


Alcohol assessment: Yes, all



Referral pathway:

Yes, all 2 - - 2

Yes, some 2 6 - 8

No - 2 1 3


Alcohol assessment: Yes, some



Referral pathway:

Yes, all - - - 0

Yes, some - 4 1 5

No - 2 - 2


Alcohol assessment: No



Referral pathway:

Yes, all - - - 0

Yes, some - - - 0

No - - 1 1



Weight assessment: Yes, all


Yes, all Yes, some No Total (rows)

Referral pathway:

Yes, all 3 - - 3

Yes, some 3 6 - 9

No - 1 3 4


Weight assessment: Yes, some


Yes, all Yes, some No Total (rows)

Referral pathway:

Yes, all - - - 0

Yes, some - 2 1 3

No - - 2 2


Diet assessment: Yes, all



Referral pathway:

Yes, all 3 1 1 5

Yes, some 3 2 0 5

No - 1 2 3


Diet assessment: Yes, some



Referral pathway:

Yes, all - - - 0

Yes, some - 4 1 5

No - 1 1 2


Diet assessment: No



Referral pathway:

Yes, all - - - 0

Yes, some - - - 0

No - 1 - 1



Physical activity assessment: Yes, all



Referral pathway:

Yes, all - - - 0

Yes, some 1 2 - 3

No 1 - 2 3


Physical activity assessment: Yes, some



Referral pathway:

Yes, all - - - 0

Yes, some - 6 1 7

No 1 1 2 4


Physical activity assessment: No



Referral pathway:

Yes, all - - - 0

Yes, some - - - 0

No - 1 2 3



Details of how hard copies distributed Volunteers Specialists Ward staff order Leaflets on the ward e.g. racks

Trust has a ‘patient information service’ in collaboration with local authority library service. They provide information, leaflets etc ‘front of house’ whilst trained volunteers provide hard copies to each ward and other relevant areas.

Y

Nutrition link nurses, Resource file, Hard copies can be downloaded from intranet Y

The Alcohol Liaison Nurse delivers some Y

The ward order their own Y

Leaflets from PCT, DH and local stop smoking service. PCT health promotion resource department. Leaflets distributed by smoking cessation nurse and smoking cessation link nurses, by local stop smoking service, by alcohol liaison nurse.

Y

Appointment letters, available on wards, given out by specialist services i.e. respiratory nurses. Y Y

Volunteers, patient experience team, specialist staff, health exchange unit. Y Y

wards access leaflets directly, sometimes PALS are involved in distribution if needed. Y Y

Poorly! Currently trying to implement Stockport model [hospital volunteers] - but lots of problems.

Some are given in packs, some are placed in racks on the ward by ward staff, rehab nurse. Y Y

Volunteer services provide a regular leaflet distribution delivery to wards. Y

Leaflets provided as part of pilot project but soon to be printed in large quantities. Not many leaflets are distributed, most wards collect their own leaflets predominantly regarding their particular area of healthcare.

Y

Nursing staff identify need and order via hospital stationery ordering system. Leaflets displayed in racks within departments and distributed to patients by nursing staff if required.

Y Y

Racks in clinical areas and downloads in clinics. Y

Hospital staff, volunteers. Y

Ordered by wards, via cancer ????? Room. Y

Staff are expected to access leaflets in the wards which are usually attached to the wall mounted display bracket; ordering leaflets from intranet (communication dept) Y

Table of all the responses to Q.37 “Please provide details of how hard copies of leaflets are distributed throughout wards” and how they have been categorised

Appendix 6 – Health Promotion Leaflets


Photography CreditsThank you to the following photographers for use of their images throughout the National Health Promotion in Hospitals Audit project, courtesy of their ‘Creative Commons’ licenses.

vipez – http://www.flickr.com/photos/vipez/

jodigreen – http://www.flickr.com/photos/jodigreen/

DennisSylvesterHurd – http://www.flickr.com/photos/dennissylvesterhurd/

Sidereal – http://www.flickr.com/photos/sidereal/

RXAphotos – http://www.flickr.com/photos/more-cowbell/

catd_mitchell – http://www.flickr.com/photos/catdonmit/

nhanusek – http://www.flickr.com/photos/nhanusek/

mingaling – http://www.flickr.com/photos/mingaling/

edomingo – http://www.flickr.com/photos/edomingo/

Blujeeves – http://www.flickr.com/photos/braden71/

Adam Foster | Codefor – http://www.flickr.com/photos/paperpariah/

St Stev – http://www.flickr.com/photos/st-stev/

Tonymadrid Photography – http://www.flickr.com/photos/tonymadrid/

SiD – http://www.flickr.com/photos/_sid_/

HAMED MASOUMI – http://www.flickr.com/photos/hamedmasoumi/

georgia.g – http://www.flickr.com/photos/22372302@N04/

Xosé Castro – http://www.flickr.com/photos/cibergaita/

ajgelado – http://www.flickr.com/photos/ajgelado/

Breathtaking Photos – http://www.flickr.com/photos/seangloster/

Ferran. – http://www.flickr.com/photos/ferran-jorda/

simonlesleyphoto – http://www.flickr.com/photos/ simonlesleyphotography/

WjButt – http://www.flickr.com/photos/wjbutt/

sokr.at – http://www.flickr.com/photos/emilstefanov/

Burwash Calligrapher – http://www.flickr.com/ photos/burwash_calligrapher/

kharied – http://www.flickr.com/photos/kharied/

jamesjustin – http://www.flickr.com/photos/jamesjustin/

gio50000 – http://www.flickr.com/photos/pilatesorlando/

Dain Sandoval – http://www.flickr.com/photos/dainsandoval/

bryanpearson – http://www.flickr.com/photos/bryanpearson/

Pragmagraphr – http://www.flickr.com/photos/sveinhal/

shaletann – http://www.flickr.com/photos/peculiarmomma/

Christi Nielsen – whirledkid – http://www.flickr.com/photos/christinielsen/

roboppy – http://www.flickr.com/photos/whirledkid/

bookgrl – http://www.flickr.com/photos/bookgrl/

Jerry Cooke – http://www.flickr.com/photos/jerrycooke/

Sifu Renka – http://www.flickr.com/photos/sifu_renka/

Newyork808 – http://www.flickr.com/photos/newyork808/

su-lin – http://www.flickr.com/photos/su-lin/

babymellowdee – http://www.flickr.com/photos/babymellowdee/

jypsygen – http://www.flickr.com/photos/jypsygen/

Fuschia Foot – http://www.flickr.com/photos/fuschia_foot/

Laura Mary – http://www.flickr.com/photos/lauramary/

TowerGirl – http://www.flickr.com/photos/kitchen/

cokada – http://www.flickr.com/photos/cokada/

Mr Thomas Piskortz – http://www.flickr.com/photos/piskortz/

The Vault DFW – http://www.flickr.com/photos/thevaultdfw/

CoffeeGeek – http://www.flickr.com/photos/coffeegeek/

Anders Adermark – http://www.flickr.com/photos/cmbellman/

when i was a bird – http://www.flickr.com/photos/electrospray/

jeremy.wilburn – http://www.flickr.com/photos/jeremywilburn


The report was compiled and written by Dr. Charlotte L Haynes, NHPHA LeadMs. Katherine Lewis, NHPHA Administrator

Extracts from this publication may be reproduced provided the source is fully acknowledged.

For enquiries or comments about this publication please contact:

Charlotte HaynesRoom D3Clinical Effectiveness UnitWillow HouseStockport NHS Foundation TrustStepping Hill hospitalStockport SK2 7JE

0161 419 4220