HC 1048-III Health CommitteeWritten evidence from Cancer Research UK (PH 116)

Background Information

1. Cancer Research UK is the world’s largest independent organisation dedicated to cancer research; in 2009–10 we spent £334 million on research. We receive no government funding for our research. Our vision is that “Together we will beat cancer”. We carry out world-class research to improve our understanding of cancer and to find out how to prevent, diagnose and treat different types of the disease. Around 300,000 people are diagnosed with cancer in the UK every year. And every year more than 150,000 people die from the disease.

Executive Summary

2. The determinants of public health are varied as are the necessary interventions to tackle ill health. Those directly responsible for delivering public health must be able to work with those in the NHS, social care and other relevant areas of government to effectively tackle public health problems and to promote cancer prevention and early diagnosis. The transfer of health improvement to local government has a number of merits:

More of the determinants of public health are in the control of local councils and many of the solutions need local adaptation.

It engages politicians in public health and this can be a driver for action in services while public health measures sometimes need political skills to be delivered.

It creates local focus. For example, most of the tools for reducing smoking levels will be delivered by the local authority with a stronger sense of ownership: NHS Stop Smoking Services, trading standards enforcement of smokefree legislation and age-limits and activity in schools.

3. However, Cancer Research UK is concerned that with the changes to the structure of the NHS and public health in England, partnership working could suffer. It is vital that the delivery of public health initiatives do not suffer whilst relationships between GPs and local authorities are being built. The NHS and Public Health England will need to work together to continue to improve awareness and early diagnosis of cancer. Whilst the outcomes framework acknowledges the importance of joint working and collaboration there is little detail in the document about how this will work in practice to support the prevention and diagnosis of cancer and how specifically it will be encouraged.

4. GPs will need to be made aware that they continue to play a role in improving the public health of England. This will include encouraging patients to take up screening and understanding the key role they play in raising awareness and the early diagnosis of cancer.

5. GPs will also have an important role to play as commissioners of preventative health in secondary care.

6. Directors of Public Health must have the necessary skills and experience for this demanding and important job and they must be in a senior enough position to enable them to enact change within their areas and not just act as advisors to local authorities. They should also have control of an adequate ring-fenced budget for health improvement to ensure that it is not squeezed by local authorities.

7. To improve public health, the government must put effective tobacco control measures at the heart of any public health strategy.

8. We are concerned that proposals for a health premium could lead to inequalities in some of the most deprived areas being reinforced. These areas may be penalised for failing to improve public health against the agreed set of public health outcomes.

9. We would also welcome further details about how best practice in public health will be evaluated and the structures which will be developed to share this information so that it won’t be duplicated in the future.

10. In the response below, we have focused our efforts where we feel our expertise is strongest.

The Role of GPs in Public Health

11. GPs play a key role in formulating local public health strategy. In particular, GPs should play a specific role in encouraging patients to participate in the bowel cancer screening programme. Early indications from the bowel cancer screening programme suggest that men and those in the most deprived groups are less likely to participate in bowel cancer screening than women and more affluent people. Efforts should be made to encourage greater participation and GPs should play a role in this.

12. GPs also play an important role with brief interventions to promote smoking cessation, which have been shown to be highly cost effective. Such interventions should be actively encouraged among GPs on issues with the strongest evidence base and extended to other areas of preventative health as the evidence base develops.

13. Cancer is a complex condition and a cancer patient will require the support of different aspects of the health service throughout their treatment and care. We are concerned that the reform to public health will risk fragmenting cancer services, at least in the short term and there is a risk that efforts to improve the early diagnosis of cancer will be fragmented.

14. Currently, GPs have working relationships with public health specialists at PCTs, giving them access to information about local initiatives in health promotion and prevention. The loss of PCTs and the delivery of these services by local authorities could potentially weaken this link, particularly in the short term. It takes time to build relationships across organisations and teams who often have very different professional backgrounds.

15. Public Health England and the NHS need to work very closely to drive improvements in the earlier diagnosis of cancer. Our concern is that this will not happen unless both parts of the service are jointly incentivised to promote early diagnosis. We would like assurances that this will be taken seriously and closely monitored.

16. Public health expertise must be embedded in GP-led commissioning consortia. The strategic input of public health professionals is essential to ensure that services are commissioned to meet the needs of the whole population.

Directors of Public Health

17. It will be very important that Directors of Public Health (DsPH) retain their independence and ability to advocate on the basis of their expertise as their role may sometimes be unpopular and may bring them into conflict with local politicians. It is important that they have the necessary skills and experience needed for this demanding and important job and are in a senior enough position to enable them to enact change within their areas and not just act as advisors to local authorities. They must have access to senior decision makers within local government, be able to influence commissioning decisions and be able to manage the ring-fenced public health budget.

18. Given the important role and wide range of responsibilities that the DPH has it is vital that they have support from public health specialists with appropriate skills and expertise. There is a risk that public health expertise which has been developed in Primary Care Trusts could be lost when they are abolished in 2013. Steps should be taken now to ensure that public health experts are retained during the transfer to local authorities to avoid a potential vacuum in knowledge.

A Ring-Fenced Budget

19. If DsPH and local authorities are to deliver public health gains it is vital that they have an adequate budget for health improvement. We welcome the decision to have a ring-fenced public health budget. This will be particularly important as in previous times of budget constraint public health budgets have been historically used to shore up acute services. However, it is important that local authorities do not use the public health budget to fund services and activities that were previously funded from existing council budgets. The DPH should have responsibility for the budget at a local level to ensure it is spent on public health priorities and not raided for short-term political demands.

Tobacco Control

20. To improve public health, the government must put effective tobacco control measures at the heart of any public health strategy. As the government’s tobacco control plan rightly acknowledged, tobacco use remains one of our most significant public health challenges, accounting for more than 80,000 deaths in England in 2009. To tackle this challenge, local authorities must ensure adequate resource for tobacco control and smoking cessation activities.

21. Smoking is also the single biggest cause of inequalities in death rates between the lowest and highest income groups—smoking-related death rates are two to three times higher in low-income groups than in wealthier social groups. Tobacco control measures are therefore essential to tackle health inequalities. Smoking prevalence and prevention should be key components within the public health outcomes framework.

22. The experience of tobacco control in recent years has also demonstrated the significant benefits of investment at a sub-national level rather than local areas working in isolation.

23. The Regional Tobacco Policy Managers which up until April 2010 were based in each of the regional Government Offices in England, and the Regional Offices of Tobacco control in the North East, North West and South West of England, which were established and continue to be run with PCT funding, have clearly demonstrated the value of coordinating communications and marketing of cessation services for greater impact and cost effectiveness.

24. However, the abolition of PCTs and the migration of public health funding and responsibilities to local authorities pose a risk to the future of these collaborative organisations. Despite acknowledging the value of such interventions being commissioned and delivered at a higher level in its national tobacco control plan for England, the public health reforms in general and the tobacco control plan in particular provide little encouragement for such cooperation.

25. The Government should give clearer encouragement for bodies to commission jointly on a larger geographical scale where this provides better value.

The Public Health Outcomes Framework

26. If the government is to achieve its aim of making England’s cancer outcomes among the best in Europe and saving an extra 5,000 lives by 2014–15—as set out in Improving Outcomes: A Strategy for Cancer—it is vital that early diagnosis including screening are prioritised by both those working in the NHS and public health. There must be a strong focus in both the public health outcomes framework and the NHS outcomes framework on early diagnosis of cancer. As patients diagnosed later are less likely to live to one year, one year survival trends can prove a good proxy measure for the later diagnosis of cancer. An indicator that measures the number of patients surviving cancer one year after diagnosis must be added to the outcomes framework.

Tackling Inequalities and the Health Premium

27. In recent years, policies to reduce health inequalities have focused predominantly on encouraging people to change their behaviour. Whilst we agree that it is important for people to take responsibility for their health, the government also has a responsibility to address the wider social problems that are linked to this behaviour. We know that people face many complex difficulties and challenges in their lives that make it difficult for them to change their behaviours. In order to narrow health inequalities the government must address the wider determinants of health inequalities such as unemployment, stressful work conditions, and poor quality housing.

28. Because of the complex nature in which people’s choices are structured, the acceptance and uptake of healthier behaviours as a result of public health initiatives is likely to be more difficult in more deprived areas. Focusing the health premium on health improvement rather than need may have the perverse effect of penalising the communities where need is greatest. The government should carefully consider how to design the health premium to protect against this. One way would be to link the health premium to tackling the wider determinants of health (domain 2) rather than healthy behaviours (domain 3). The Marmot review recommended that interventions should have a health equity impact assessment rather than a focus on individual behaviours and lifestyle.

29. It is also important to bear in mind that the Marmot review was based on a principle of proportionate universalism—to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. Whilst it is tempting to focus limited resources on those most in need, this will only tackle a small part of the problem.

30. As the Marmot review highlighted, tobacco control should be central to any strategy to tackle health inequalities. Smoking accounts for approximately half of the difference in life expectancy between the lowest and highest income groups and smoking-related death rates are two to three times higher in low-income groups than in wealthier social groups. Smoking prevalence and prevention should be key components within the health premium. The “national ambitions” in the recently published tobacco control plan should be incorporated into the outcomes framework, including the ambition on youth smoking rates.

31. Tackling obesity and alcohol misuse are also necessary to reducing health inequalities. Individuals from lower socio-economic groups are more likely to be overweight or obese than those who are more affluent and whilst those in lower socio-economic groups drink less than their better off counterparts, harm from alcohol consumption disproportionately affects the poorest in society. Prevalence of healthy weight in adults and children and indicators that account for alcohol-related harm should also be included in the health premium.

Sharing Information and Best Practice

32. We welcome the role Public Health England will have in drawing together information into a more coherent form so that it will be easily available for those who will use it and more likely to be used. The most important principle for this function will be transparency as this will help reduce duplication in public health research and provide information about current research.

33. It will be particularly important for Public Health England to develop systems and networks to encourage the greater dissemination, sharing and cascading of research. We also recommend that there should be key leads in each local authority with responsibility for disseminating good practice.

34. Public Health England should identify and map current gaps in public health research and develop a strategy to commission and carry out this work. This could include:

Identifying gaps in behavioural economics research.

Evidence and research for when greater levels of intervention should take place, in line with the Nuffield Council on Bioethics intervention ladder.

Developing criteria for how the health premium will be shared between local authorities.

Guidance on local incentive schemes to encourage smoking cessation.

Models for maximising the impact of social networks promoting healthy behaviours.

Guidance on the local promotion of social norms that foster healthy behaviours.

A report on the scope of applying highly effective strategies for changing youth attitudes such as the Truth Campaign.

An evidence base on the role of media representations of unhealthy behaviours.

35. Public involvement in the design and implementation of behaviour change policy interventions is vital as these are measures which require public support to be effective and cost-effective to implement. Voluntary and community organisations can be supported in using high quality research to articulate the needs of users.

36. Local partners can engage in local qualitative research to understand the needs and attitudes of the population. For example, a screening programme for oral cancer was carried out in the Bangladeshi community in East London between 2006 and 2008. The research set out guidance on the development and promotion of oral cancer screening activity among the Bangladeshi community and the development of accompanying oral cancer awareness literature as well as criteria for screening, the development of referral pathways and determination of inclusion criteria. The project demonstrated the feasibility and acceptability of oral cancer screening using a mobile dental unit among the Bangladeshi community of Tower Hamlets.

June 2011

Prepared 28th November 2011