HC 1048-III Health CommitteeWritten evidence from Action on Smoking and Health (PH 53)

About ASH

1. Founded 40 years ago by the Royal College of Physicians, Action on Smoking and Health (ASH) is a health charity, working to eliminate the harm caused by tobacco. ASH is funded by Cancer Research UK and the British Heart Foundation.

Executive Summary

2. This response reflects our concerns and priorities with respect to the proposed changes to the organisation of public health services in England, in the light of the impact these will have on tobacco policy.

3. Smoking is by far the largest cause of preventable premature death and disease and the cause of half the difference in life expectancy between richest and poorest in our society, and is therefore the prime public health challenge facing the UK today.

4. Public health has been defined by Sir Donald Acheson as “the science and art of preventing disease, prolonging life and promoting health through organised efforts of society”. The transfer of responsibility from the NHS to local authorities in England presents opportunities to improve the health of the people of England through better integration of society’s efforts. It also carries with it significant risks, particularly in diminishing the science of public health, which must be addressed.

5. Opportunities include integration with children’s services, education and adult social care as well as with services which ensure compliance with public health legislation such as trading standards and environmental health. In so doing, it offers a very strong opportunity to take a “life course” approach to smoking prevention and cessation and to provide greater accountability for public health policy.

6. On the health side, risks include the possible dislocation of preventative medicine from primary and secondary care. Furthermore, some councils may underestimate the effectiveness of many well established measures to reduce smoking prevalence and uptake, which are supported by a strong evidence base, and consequently may fail to provide the appropriate priority and resources to this area of work. At a time of transition there is a particularly acute need to maintain an authoritative, independent and well trained public health profession.

7. Summary of recommendations:

There should be a statutory responsibility on the face of the Bill for commissioning consortia and local authorities to take such steps as are necessary to improve the health of their populations.

Public Health England must be at arm’s length from the DH either as a Special Health Authority or alternatively by extending the existing structure and responsibilities of the HPA to encompass those of Public Health England.

There should be a statutory responsibility on local authorities to employ only suitably registered Directors of Public Health.

Directors of Public Health must be senior members of the management team reporting to the Chief Executive.

Any “health premium” incentives to reduce inequalities must focus on measureable behaviours such as smoking which most directly influence health inequalities.

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

Consortia commissioning plans should require the formal approval of Health and Wellbeing Boards.

Sufficient funds must be allocated to the ring-fenced public health budget to enable it to deliver public health gains – and provide protection to prevent it being raided to fund other services.

The Bill must include a statutory duty on public health agencies to make proper arrangements for co-operation with each other, a duty that would apply equally to county and district councils in two-tier local government areas.

The Government should clarify how it proposes to protect public health policy from the vested interests of the tobacco industry, specifically during the forthcoming consultation on plain packaging for tobacco products.

Our Response to the NHS and Public Health White Papers

8. In our response to the consultation on the Liberating the NHS and Healthy Lives, Healthy People, ASH made several detailed recommendations. We welcome developments in Government policy which have gone some way to addressing our concerns. However we continue to have reservations. Specifically:

Smoking is the primary cause of the gap in life expectancy between rich and poor. We are concerned that the proposals in the white paper may not reduce inequalities. We have particular concerns about the “Health Premium”. Health inequalities may be mitigated somewhat by local policy over time but are also influenced by economic and environmental factors and policy initiatives outside the control of local authorities.

We have two major concerns about the working of the Health Premium, first that any change in local health inequalities will be largely a product of external factors and second that the timescale required for calculating the health premium will be shorter than the time it will realistically take for policies to have an effect. Consequently the Health Premium may further disadvantage some of our poorest communities.

Current data sources do not afford the statistical power required to assess differences in local smoking prevalence by socio economic group and current proposals to gather these data are inadequate. If aspirations are going to focus on reducing smoking prevalence in areas the size of Local Authorities, the proposed method of collecting the data will not be adequate. To have an 80% chance (the usual criterion for statistical power) to detect a 1% drop in prevalence (which will represent good progress) compared with no change at all will require a sample size of 25,000 per wave. To be able to detect a difference between, for example, 0.2% (poor progress) and 0.8% (acceptable progress) would require substantially more. With a national sample size of perhaps 400,000, for all the surveys that make up the Integrated Household Survey the sample each year for each local area will be completely inadequate. Even data over several years will not be sufficient and in any event will not allow performance to be tracked in a manner that will be useful for policy development.

If the Health Premium is to work at all it will have to focus on our most disadvantaged populations and the measureable behaviours such as smoking, which most directly cause health inequalities.

We highlighted the need for high quality and accessible local information on public health needs and outcomes, offering the recently published Local Tobacco Profiles as an exemplar. We welcome proposals to produce an update of these profiles but note the continuing uncertainty about the funding for the Public Health Observatories which produced them.

We welcome the Government’s commitment to protecting health policy from the vested interests of the tobacco industry, in line with its obligations under Article 5.3 of the WHO Framework Convention on Tobacco Control. However, ASH continues to uncover evidence of the tobacco industry subverting these measures through the use of front groups purporting to represent smokers, retailers and the hospitality business. Greater clarity is required, particularly in relation to how government will fulfil its obligations to protect policy on illicit tobacco and the forthcoming consultation on tobacco packaging.

We have repeatedly expressed concerns about support for local authorities to encourage collaborative working over a larger geographic footprint where evidence supports need and effectiveness. Although the Department of Health (DH) has offered some encouragement for joint commissioning this remains a significant threat to public health and tobacco control in particular.

We continue to be concerned that Directors of Public Health will have sufficient authority and independence within the new structures to discharge their duties adequately.

Public Health, Tobacco Control and Local Government

9. Smoking is the largest cause of preventable death in England killing over 80,000 people every year. In England, deaths from smoking are more numerous than the next six most common causes of preventable death combined (ie obesity, drug use, road accidents, other accidents and falls, preventable diabetes, suicide and alcohol abuse).

10. The Coalition Government recognised the importance of tobacco control within its efforts to improve public health when on March 9, 2011 the Coalition Government published its Tobacco Control Plan for England. To be effective, this plan needs to be supported by a clear vision for public health among local authorities. Whilst we wait for the government response to the various “Healthy Lives, Healthy People” consultations we are concerned that some of the proposed revisions to the Health and Social Care Bill arising from the listening exercise risk undermining the strong vision of public health contained in the White Paper.

11. The Health and Social Care Bill 2011 does not include the requirement to provide “stop smoking services” on the face of the bill as it does other core public health activities such as weighing and measuring children. This could lead to post-code lotteries for smokers, who may be unable to access evidence-based help to quit in their own local area. It should be noted that NICE has concluded that stop smoking services are highly cost-effective and that they amongst the most cost-effective healthcare interventions available. The provision of stop smoking services needs to be a mandated part of public health provision at local level.

12. It is of great concern that responsibility for public health is being transferred to local government not just at a time when public spending is under unprecedented pressure but also at a time when previous structures supporting local delivery such as National Support Teams, Public Health Observatories and regional offices have been terminated or are under threat.

The Case for “Supra Local” Public Health Programmes

13. International evidence has concluded that investment at sub-national level on key components of national tobacco control programmes reaps significant benefits that are unlikely to be realised if local delivery evolves in isolation. These components include reducing smoking uptake, improving quit rates and protecting communities from the harm of secondhand smoke. For example, a highly active tobacco strategy in New York City has reduced smoking prevalence from 21% in 2002 to 15.8% in 2009. Similarly evaluations of California’s state-wide tobacco control programme have found that the comprehensive strategy put in place was highly effective, listing mass media among the particularly effective components.

14. Until April 2010 each of the regional Government Offices in England employed a Regional Tobacco Policy Manager supported by a small team. It was the function of these teams to coordinate communications for greater cost effectiveness, support local tobacco control and provide strategic guidance to local smoking cessation services.

15. In the North East, North West and South West of England, the functions were enhanced and further funded through a per capita contribution from PCTs. These three regional teams continue to lead collaborative and comprehensive tobacco control programmes with continued funding from local PCTs. However, the abolition of PCTs and the migration of public health funding and responsibilities to local authorities poses a risk to the future of these collaborative organisations

16. The first of these Regional Offices of Tobacco Control to be established was Fresh Smoke Free North East of England, which started work in 2005. In advance of the introduction of smokefree legislation Fresh coordinated a regional programme, including television advertising, to prepare local businesses for compliance. In the event, the North East saw some of the highest levels of compliance with the legislation requiring fewer enforcement actions and achieving the highest levels of popular support in England.

17. Most importantly, since the establishment of Fresh, smoking prevalence in the North East has fallen from the highest in England to England’s average.

18. Since April 2011 in areas without an Office of Tobacco Control communications on smoking and marketing of cessation services are delivered at PCT level. These tend to be substantially less efficient and effective. People’s work and social lives span wider distances than their own residential area. It makes little sense for a PCT or Local Authority to fund high impact marketing activity that will be seen across a much larger boundary on their own, but by jointly commissioning such marketing achieves great economies of scale while a single contact point allows the public to be directed to the service closest to them. One set of development costs and media buying co-ordinated by one small team communicating with local partners brings much better value to the taxpayer than a dozen sets by a dozen teams. Similarly, regional offices are much better placed to exploit “earned media”, that is to say unpaid editorial coverage from local and regional news outlets. They are very much seen by the media as the first point of contact for press, radio and TV journalists around tobacco issues. The combined purchasing power has permitted broadcast media campaigns helping parents in the North West and North East to reduce the harm of secondhand smoke and dispelling myths about the relative harmlessness of hand rolled tobacco in the South West.

19. A further example of the role of Offices of Tobacco Control is the North of England Tackling Illicit Tobacco for Better Health Programme. In this case the North West, North East and Yorkshire & Humber regions collaborated to coordinate local, regional and national agencies to improve intelligence, enforcement and marketing campaigns encompassing several regions on tobacco smuggling. This initiative would have been unachievable for local councils working alone.

20. The wider value of such interventions being commissioned and delivered at a higher level is recognised by the Coalition Government. The national tobacco control plan for England makes clear: “Tobacco control offices in the North West, North East and South West of England have demonstrated the value of such models of working for many years, particularly around marketing communications and tackling illicit tobacco. However, the public health reforms in general and the tobacco control plan in particular provide little encouragement for such cooperation. The likely consequence is a poorer use of health budgets and a greater and preventable burden of disease.

21. The Government should give clearer encouragement for bodies to commission jointly on a larger geographic footprint where this provides better value.

Public Health England

22. The Health Protection Agency (HPA) was established in 2003 by government as an independent organisation to tackle health threats and environmental hazards by providing information and advice to the general public and health professionals. It is proposed to absorb the HPA into Public Health England, which itself will be established within the DH. This is matter of concern, and we recommend that the Government reconsider the proposal, not only for the independence of Public Health England but also for the capacity of the HPA to generate income which, by achieving economies of scale, provides greater value for money to the public.

23. Alternative solutions exist including establishing Public Health England at arm’s length from the DH for example as a Special Health Authority or alternatively by extending the existing structure and responsibilities of the HPA to encompass those of Public Health England.

The Role of the DPH and the Public Health Workforce

24. Public health is a distinct and complex discipline with its own career path. Currently, a Director of Public Health (DPH) must be a qualified and registered public health specialist. Increasingly, suitably qualified non-medical DsPH have been appointed and this is to be welcomed. These non-medical DsPH often bring with them long experience in local councils, which will enable them to take full advantage of the transfer of responsibilities to local government. Despite this more inclusive approach adopted in recent years, the public health workforce continues to be under great pressure with insufficient qualified staff, particularly in our major cities.

25. It is all the more important, therefore, that the role of DPH be restricted to suitably qualified professionals, be they medical or non-medical, positioned at the most senior level of the councils, with the professional freedom to challenge publicly gaps in local delivery, and to manage the allocated ring-fenced public health budget to ensure it is used for public health gains. There should be a statutory responsibility on local authorities to employ only suitably registered Directors of Public Health. Directors of Public Health must be senior members of the management team reporting to the Chief Executive.

26. Teaching Public Health Networks were established across England to catalyse collaborative working between the public health workforce and further and higher education, to enhance public health knowledge in the wider workforce with a view to enhancing capacity to tackle inequalities and meeting public health targets. These networks developed innovative public health education and training. Funding for these Networks was withdrawn in 2010. The closure of these networks highlights the longstanding need for developing the public health workforce. This is a need which has been aggravated by the disruption and uncertainty for NHS based public health staff and becomes even more acute for the workforce of the future in the context of the proposed reforms.

Local Government and the Local NHS Working Together

27. Although GP Consortia are required to prepare a Joint Health and Wellbeing Strategy with the Local Authority, informed by the Joint Strategic Needs Assessment (JSNA), the GP Consortia Commissioning Plan itself need only have “due regard” to the Joint Health and Wellbeing Strategy. This restricts the opportunity to integrate priorities across public health, healthcare and social care. GP Consortia Commissioning Plans should require the formal approval of Health and Wellbeing Boards.

28. The drafting of JSNA should involve all relevant public health practitioners including environmental health officers and trading standards officers, to collect the evidence, assess local needs and attend to implementation.

29. Public health expertise must be embedded in all commissioning bodies, including not only Health and Wellbeing Boards but also GP commissioning consortia and the NHS Commissioning Board, to ensure the effective and efficient commissioning of health services for local communities.

30. We also have concerns about the clarity given to Local Authorities with regards to the funding of certain public health functions. Regulatory services have played an essential role in effective implementation of tobacco policies at local level, for example Environmental Health in smokefree legislation and trading standards in age of sale restrictions and will do so again in implementing the tobacco display ban. These services have been almost entirely funded through council budgets.

31. We welcome the ring-fence as a means of protecting the public health function as it becomes established in local authorities. The ring-fenced public health budget represents a transfer of resources to match the transfer of responsibilities to local government. Some authorities will see the new funding as a means of protecting important existing council services that make a clear contribution to public health. We do not object to the inclusion of these services within the public health budget. However, where functions currently funded by councils are to become funded from the ring-fenced budget, there should be a corresponding adjustment to the size of that budget.

32. Sufficient funds must be allocated to the ring-fenced public health budget to enable it to deliver public health gains – and provide protection to prevent it being raided to fund other services.

33. In some parts of England where there are two tiers of local authorities it is proposed that the public health function sit with the upper tier although the environmental health function sits with the lower tier.

34. The Bill must include a statutory duty on public health agencies to make proper arrangements for co-operation with each other, a duty that would apply equally to county and district councils in two-tier local government areas.

June 2011

Prepared 28th November 2011