Table 2 Barrier and facilitators to implementation of the CURE model, with illustrative quotes

 Physical Opportunity

Environmental Context and Resources

Integration with the wider health care context

B

We kind of…mistakenly thought at the outset, was we get the CCG at the table then we’re kind of talking to everybody out in the community. But it’s really important to get out and see local GPs because they’re all little independent businesses. You know, they are joined by the CCG, but they’re independent practices. So it is, you can talk to a CCG and might have a view of the locality, but you do also have to get into individual GPs, and that’s quite hard to do. -P1, management.

Staffing Resources

M

…we’re only just catching up on [follow-up calls] now and we’ve had help from an admin person who screens the calls first, see if patients want to be followed up. So that’s working quite well at the moment. So, she follows them up. Anybody that wants to be seen by a specialist nurse she refers them on to us. Well, it’s taken lots of pressure off really as well. -P6, deliverer.

I think [the project manager] was the instrument behind all of that. She was just incredible. So, one incredible person kind of changed the whole thing around. – P10, management.

Secondary-care context

M

We were in a crowded office with two or three other teams. We had two chairs between five of us. Two computers between five of us. And not a lot of space and you couldn’t make phone calls and we were disturbing them, they were disturbing us, and it was just terrible. So, we’ve got this nice big office now which has now become full. - P6, deliverer.

There are situations where a patient might be in a busy bay of four patients, so it’s not always ideal in that sense, but you do the best that you can. – P5, deliverer.

Availability of CURE related knowledge and training.

M

…in the background there’s been training for different professionals in the hospital so that it becomes everybody’s responsibility to see smoking cessation as part and parcel of everyday conversations, everyday delivery. And so that has gradually improved and improved. As a team people become more and more aware of us, so there’s things out there on the intranet every so often reinforcing what the CURE project is about. So, 8, 9 months ago I might have gone on a ward and someone said, when I said who I am, why I’m there, oh we’d not heard of the CURE project. You wouldn’t expect that to happen now. – P5, deliverer.

CURE Branding

F

It starts at the basics, like a logo, and you start to realise the power just something of a simple logo. It started to build momentum behind it and started to get seen and started getting recognised. And so, what starts as something quite basic then really comes up and through that process becomes increasingly more complex and impactful - P1, management.

Flexibility of service

F

Even though we have set clinic times, like we do morning clinics and afternoon clinics, if a patient can’t make those, I can say right [when] can you get to the hospital? They say well I can get there for ten. So quite often we’ll make an appointment to see them in a Costa coffee or there’s a Subway whatever it is – P4, deliverer.

 Social Opportunity

Social Influences

Peer support

F

[The clinical and nurse leads] being a doctor and a nurse that worked in that hospital itself would go and present at every single training session that there was available. And obviously I would get [the clinical lead] to go to the doctor ones and I’d get [the nurse lead] to go the nurse ones, because I think having peer to peer explanation, I think, can be a lot stronger than sometimes. – P7, management.

I introduce certain things myself…within the team, of things that I’ve done before. So, we do share knowledge as well.… [I send] information over to other colleagues, less experienced colleagues who then get regular updates on that. – P5, deliverer.

Changing the culture of smoking cessation

B

One of the biggest roles [the clinical lead has] is then getting [CURE] out into all the places around the hospital, talking to as many clinicians as possible...whether it’s a junior doctor training session, whatever it is any session where we can discuss with clinicians about prescribing and changing how they…really changing their view of what they do with the smoker and moving away from the traditional view of smoking’s a lifestyle choice – P1, management.

 Reflective Motivation

Goals

M

It’s quite hard to keep that level [of promotion] up and not let it dwindle, because in a years’ time you’re going to have a whole new set of junior doctors. And so, you need to do the same thing again. […]. But that is a challenge, keeping the level of enthusiasm and message up over time. – P1, management.

Still [CURE has] never been modelled in a way to say that because a person’s stopped smoking and he hasn’t had any admissions, he hasn’t seen his GP or she hasn’t been having any long term problems. Does that make sense? So even though we know that they would stop, and just because they’ve stopped, well how can you say that it actually has an impact on our system? I think that was the hardest thing to sell. -P10, management.

Professional role and identity

M

The culture is still a problem, so again, whose job it is. ‘This is not my job’. So, the problem was always tobacco addiction treatment is not my job. ‘The skill that I have is not really suited for this’. - P10, management.

Beliefs about consequences

F

To me that is the most valuable thing, that you’re improving patients’ lives. - P2, management.

 Automatic Motivation

Reinforcement

M

I think the vast majority of people you speak to it is like ‘oh this is brilliant, my practice has changed just from a 30 min talk’, which makes it a really rewarding thing to do in the future. – P1, management.

Most [patients] do want to quit. You want to see the benefits of that and yeah, that keeps you going really. And also, when they do manage to quit, we become so pleased. I’ve had patients that say even whatever they spend buying cigarettes, tobacco, each week they put money in the jar and it’s that financial benefits as well. But I think it’s the main that their long-term health benefits’. – P4, deliverer.

 Psychological Capability

Skills

M

I suppose through my background and experience I have a way of working with people that’s worked for a long time – P5, deliverer.

Knowledge

F

I think the proof of concept was the main argument, I think. And because within that was a financial argument. About reducing readmission rates and things and that’s music to the ears of commissioners because most of…roughly two thirds of the CCG’s money disappears into secondary care. So, anything that improves patient lives but also reduces admissions, the readmission rate and things. – P2, management.