HC 1048-III Health CommitteeWritten evidence from Fresh – Smoke Free North East (PH 62)

About FRESH

1. Fresh – Smoke Free North East was set up in 2005 as the UK’s first dedicated regional tobacco control office and programme. It is based on international evidence base and implements a comprehensive programme to shift the social norms around tobacco use. Fresh is currently funded by all 12 Primary Care Organisations (PCOs) in the North East and hosted by County Durham and Darlington NHS Trust. It won the Gold Medal in the inaugural public health awards of the CMO in 2009.

Executive Summary

2. This response reflects our concerns and priorities with respect to tobacco issues. Tobacco is the single greatest contributor to health inequalities and half of all long term smokers will die prematurely from a smoking related illness.

3. In the North East, around one fifth of the adult population smokes – around 440,000 people. It is an addiction that starts in childhood. The average age for North East smokers starting is 15.

4. Every year, 5,000 people in our region die early from a smoking-related disease – 15 people a day and more than the next six most common causes of preventable death combined (drug misuse, road accidents, other accidents and falls, preventable diabetes, suicide and alcohol abuse). 84,000 children in the North East are exposed to smoke in the car and home each year, leading to 13,000 needing GP or hospital treatment.

5. 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 and also politicising public health which must be addressed.

6. 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.

7. On the health side, risks include the possible dislocation of preventative medicine from primary and secondary care. Also some council may underestimate the quality of evidence supporting many public health interventions and consequently may fail to give appropriate priority and resources.

8. There is also a risk that tobacco control could be subjected to a political “civil libertarian” ideology within come councils which would be very detrimental and ignoring the reality that smoking is not an “adult choice” behaviour but is actually a childhood addiction.

9. The North East approach to tobacco control has been successful through the unique approach taken whereby the PCOs and local councils have worked closely in partnership, and all of the 12 PCOs have commissioned and funded a regional programme based upon eight key strands of evidence based tobacco control delivery. This supra-local commissioning has achieved real economies of scale for essential areas such as media campaigns and also has worked effectively to address specific challenges such as illicit tobacco. This has been highlighted in both Her Majesty’s Government publications “A Smokefree Future” (2010) and “Healthy Lives, Healthy People: A Tobacco Plan for England” (2011).

10. The North East has achieved the biggest regional decline in adult smoking in England with a decline to 21% in 2009 from 29% in 2005. This has resulted from a strong regional programme, working in partnership with localities and with other key regional agencies such as the North East Association of North East Councils.

Summary of Recommendations:

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

12. Any “health premium” incentives to reduce inequalities must focus on measureable behaviours such as smoking which most directly influences health inequalities. There is a need for much better data sources.

13. The Government should give clearer encouragement for bodies to commission jointly on a larger geographic footprint where this provides better value. This has been clearly demonstrated in the North East.

14. A focus too much on “localism” could result in inefficiencies and could diminish the delivery of evidence based programmes, unless effectively planned, delivered and evaluated. The Government should encourage a “locally together” approach to tobacco control.

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

16. 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.

Data, Intelligence and the Public Health Observatories

17. Current data sources do not afford the significance 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 reductions in smoking prevalence in areas the size of Local Authorities, the proposed method of collecting the necessary data will not be adequate. 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 nothing like enough.

18. Even collecting data over several years will still not be sufficient and in any event will not allow performance to be tracked in a manner that will be useful for policy development. We also note the current lack of clarity over the future of this survey and this is of major concern to us. We need this survey to be able to track overall progress at the regional level.

19. 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.

20. 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.

Protecting From Tobacco Industry Interference

21. 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, FRESH is very concerned of the apparent confidence of the tobacco companies, particularly here in the North East when some industry representatives have been seeking meetings with local councils. In addition, new cigarette brands specifically designed to be attractive to young women are being promoted within the North East.

22. The tobacco industry continues to 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.

Public Health, Tobacco Control and Local Government

23. Smoking is the largest cause of preventable death in the North East killing over 5,000 people every year. In England, deaths from smoking are more numerous than the next six most common causes of preventable death combined (ie drug use, road accidents, other accidents and falls, preventable diabetes, suicide and alcohol abuse).

24. 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.

25. We note that the Health and Social Care Bill (2010-11) does not refer to “stop smoking services” in the same way 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. The provision of Stop Smoking Services needs to be a mandated part of public health provision at local level. It is highly cost effective.

26. 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, Strategic Health Authorities and regional offices have been terminated or are under threat.

The Case for Regional Tobacco Control Programmes

27. 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.

28. 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, deliver programmes focussed on reducing health inequalities from smoking, support local tobacco control and provide strategic guidance for effective local stop smoking services.

29. In the North East, a concerted effort has been in place since 2005 to focus efforts to reduce smoking rates, involving a range of partners through the FRESH programme. This programme delivers around eight key strands of activity based upon the World Bank evidence base for tobacco control and has been commissioned by all the PCOs who have been providing funding to FRESH on a per capita basis of between 0.27 and 0.33 pence. This pooled funding has achieved great efficiencies particularly around the development and implementation of world class media and communications activities.

30. The FRESH programme has united a number of partners including the NHS, local councils through the Association of North East Councils, North East Trading Standards Association, Regional Environmental Health Forum, TUC, HMRC, North East Chamber of Commerce, Voluntary Organisation Network for the North East, and galvanised action across a wide range of priorities including: reducing tobacco promotion and marketing, motivating and supporting smokers to stop, protection from secondhand smoke, reducing the availability and supply of illegal tobacco and also all tobacco to children, media and communications and research, monitoring and evaluation.

31. Two other regions have also established similar programmes with the North West launching in 2008 and the South West in 2009 – these were based upon the model from the North East. The three regions have worked closely on a number of different programmes achieving even greater economies. However, the abolition of PCOs and the migration of public health funding and responsibilities to local authorities poses a risk to the future of these collaborative organisations if “localism” results in fragmentation and duplication of practice.

32. The North East has delivered the largest shift in social norms around tobacco use, the highest per capita media coverage on tobacco issues, the highest throughput of smokers through NHS stop smoking services and the largest decline in smoking of any region in England.

The Case for Pan-Regional Working

33. 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 to reduce the demand and supply of illicit tobacco. This initiative would have been unachievable for local councils working alone. It has been highlighted as best practice within the recently published joint HMRC and UK Border Agency “Tackling Tobacco Smuggling- building on success” Strategy quoting:

“4.38 Trading and consumption of illicit tobacco happens throughout the UK. Joining-up marketing and multi-agency enforcement will be essential to tackle this problem.4.39 The ‘North of England Tackling Illicit Tobacco for Better Health Programme’ is an example of how this can work. The programme combines the use of marketing and enforcement across several agencies to tackle the illicit tobacco market, including the Police, Trading Standards, Licensing Officers and HMRC.”

The Value of Supra-Local Commissioning

34. 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.”

35. 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.

36. Whilst we are fairly confident that the twelve local councils in the North East will work closely together on tobacco control and recognise the benefits of commissioning the regional specialised programme an explicit recommendation around this should be given by the Government. It is not the case that all public health activity within a region such as the North east needs to be undertaken twelve times, but some areas such as media campaigns, training delivery, dedicated programmes around smokefree families and illicit tobacco are better delivered once across the region. We are concerned what the impact of the loss of a regional tier of public health will be for other localities in England.

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

Local Government and the Local NHS Working Together

38. 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. We recommend that this arrangement becomes more stringent and that the GP Consortia Commissioning Plans require the formal approval of Health and Wellbeing Boards.

39. 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.

40. 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.

41. We also have concerns about the clarity given to Local Authorities with regards 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.

42. 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.

43. 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.

June 2011

Prepared 28th November 2011