NLN0030 - Evidence on NHS Long-term Plan: legislative proposals

NLN0030

Written evidence from Action on Smoking and Health (ASH)

Summary:

Action on Smoking and Health (ASH) is a public health charity set up by the Royal College of Physicians in 1971 to advocate for policy measures to reduce the harm caused by tobacco. ASH receives funding for its full programme of work from the British Heart Foundation and Cancer Research UK. ASH does not have any direct or indirect links to, or receive funding from, the tobacco industry or any other commercial interest.

Our submission to this inquiry focuses primarily on the impact mandating smoking cessation services could have in improving health outcomes and, importantly for this inquiry, supporting key commitments and ambitions made in the NHS Long Term Plan regarding prevention.

We conclude that mandating local authority commissioned smoking cessation services through legislation could (i) reduce demand on the NHS and help achieve the full potential of the Long Term Plan’s smoking commitments, (ii) help achieve the NHS Long Term Plan’s ambitions concerning prevention and health inequalities (iii) help deliver the Government’s ambition of a Smokefree Generation, where less than 5% of the population smokes.

Background:

Smoking remains the number one cause of death in England, killing more people each year than obesity, alcohol, drug misuse and HIV combined.[1] Smoking is also a significant cause of morbidity – for every death caused by smoking, approximately 20 more people are suffering from a smoking related disease.[2] In England in 2016 alone 77,900 deaths were attributable to smoking.[3]

The gap in life expectancy between the richest and poorest in society is estimated to be 9 years by Public Health England.[4] Smoking accounts for half of this gap.4,[5] This is primarily due to the disparity in smoking rates between socioeconomic groups. Whilst just 1 in 10 people in professional and managerial professions smoke, this increases to 1 in 4 people for those in routine and manual occupations.[6]

Smoking rates also remain very high amongst vulnerable groups, for example amongst people with a severe mental health condition, where smoking prevalence is estimated to be over 40%,[7] as high as 60% for those with probable-psychosis and up to 70% for those in psychiatric units.[8] Compared with the general population, life expectancy among those with mental health conditions is around 10-20 years shorter – the single biggest cause of this is a higher smoking rate.8

Whilst rates of smoking during pregnancy have been steadily reduced from 14.6% in 2009 to just under 11% today, the rate is no longer declining and has remained the same, at just under 11%, for the past 2 years.[9] On this trend, the Government’s target prevalence of 6% by 2022, as set out in the 2017 Tobacco Control Plan for England,4 will be missed.[10] Further, smoking rates in pregnancy differ dramatically across England, with the most recent data showing rates ranging from 2% in Richmond and West London to 27.2% in Blackpool.[11]

Smoking imposes an enormous financial burden on society and the NHS. In the Tobacco Control Plan for England, smoking was estimated to “cost our economy in excess of £11 billion per year.” £2.5 billion of this cost falls to the NHS, with parts of this expense accounted for by the 474,000 smoking attributable hospital admissions in 2015/16 and the fact that smokers see their GP 35% more than non-smokers.[12],4 In 2016/17, smoking attributable hospital admissions increased, with NHS Digital recording 484,700 such admissions.3

Given smoking’s significant impact on mortality, morbidity, health inequalities and the financial pressure it places on the NHS, along with the Long Term Plan’s ambitions to deliver across all of these areas, ensuring comprehensive approaches are taken to reduce rates of smoking is vital.[13]

Stop Smoking Services - Effective and cost-effective:

Commissioned by local authorities, Stop Smoking Services provide a combination of prescription medications and alternative nicotine products with behavioural support. When delivered in accordance with NICE guidance and quality standards,[14],[15] they can improve a person’s chances of quitting smoking by around 3 times (when compared to an unaided quit attempt) [16] and are recognised as the most effective intervention available for smoking cessation.16

Stop smoking services are also highly cost effective,[17] deemed to be “among the most cost-effective interventions available in the health care sector” with respect to their cost per quality adjusted life-year (QALY) gained.[18] An economic analysis conducted by NICE found that every £1 invested in smoking cessation would deliver £2.37 in future savings.[19]

The Public Health Grant:

Since 2013, when responsibility for many aspects of public health was transferred from the NHS to local government, local authorities have received a grant for public health work from the Department of Health and Social Care. From 2015 onwards, this grant has been progressively reduced:

In June 2015, a £200 million in-year cut to the Public Health Grant was announced
In November 2015, further cuts of 3.9% were announced for the following five years [20],[21]
The Health Foundation’s analysis found that these cuts will amount to a £900 million real terms reduction in funding between 2014/15 and 2019/20, coming at a time when life expectancy improvements are stalling and inequalities, including those which are smoking-related, are widening [22],6

After 2020/21, the Government intends to absorb the Public Health Grant into the proposed 75% Business Rates Retention scheme, a move which has the potential to widen health inequalities, erase accountability for public health spending, and deliver insufficient funding for public health initiatives.[23]

Stop Smoking Services - Provision and use:

In general, and quite understandably, local authorities privilege statutory services above discretionary services when setting budgets, particularly when budget reductions are required.

The absence of smoking cessation from the list of mandatory public health functions has contributed, together with reductions in the public health grant, to reductions in stop smoking services across England. This has produced wide local variations in service availability and quality, which in turn is likely to be a major future driver of health inequalities and a barrier to the achievement of the Long Term Plan’s ambitions and commitments.

A recent analysis by the King’s Fund found that in 2017/18 local authority funding for wider tobacco control faces reductions of more than 30%. Stop smoking services are one of the top four services in absolute planned cuts (£16 million). In a growing number of authorities there is no longer a specialist stop smoking service accessible to all smokers. [24]

The latest findings from the annual survey of local authority tobacco control leads, conducted by ASH and commissioned by Cancer Research UK shows similar results.[25] In 2018 budgets for stop smoking services were reduced in 36% of local authorities, this followed cuts in 50% of local authorities in 2017 and cuts in 59% of local authorities in 2016.25,[26],[27]

The report also found that 44% of local authorities in England no longer have a specialist stop smoking service open to all smokers in their area and that over 100,000 smokers no longer have access to any local authority commissioned support to quit smoking.25

The top two reasons given by local authorities for cutting their smoking cessation and tobacco control budgets were ‘Reductions in the public health grant from central government’ (68%) and ‘Reductions in central government funding of the local authority as a whole’ (62%).25

This postcode lottery in stop smoking service availability is also being felt by the NHS. Whilst the Commissioning for Quality and Innovation (CQUIN) 9 has been renewed for the financial year 2019/20, a notable omission is the requirement to refer smokers to local stop smoking service. (This was present in CQUIN guidance for 2017/19).[28] This requirement was left out because, for some NHS providers where there are no local authority commissioned services, service referrals are simply not possible.

An absence of universally accessible stop smoking services across England pose a serious threat to the effective delivery of the Long Term Plan.

The Long Term Plan commits to rolling out Ottawa Model smoking cessation support in all hospitals by 2023/24. It also commits to adapt this model for expectant mothers and their partners and to implement a new universal smoking cessation offer for long-term users of mental health and learning disability services.[29]

Whilst these commitments are welcome, this support is only available to those who are already ill. If we are to make a serious commitment to prevention and inequalities reduction, as the Long Term Plan sets out to do,13 support needs to be available for smokers before they are become ill and admitted to hospital.

This is important both for people who smoke, and for an already stretched NHS. As noted above in paragraph 8, a significant number of hospital admissions are caused by smoking, and smoking prevalence among admitted patients is around 25%.[30],[31] This rate is substantially higher than the 14.9% rate for the general population, demonstrating the additional demand smoking places on the health service. It also makes a clear case for investing in prevention, rather than waiting for people to become seriously ill.

The National Audit Office has warned that without funding for public health services, the ambitions of the Long Term Plan risk being derailed, and the long term sustainability of the NHS undermined.[32]

It should not be assumed that wider support available for smokers who want to quit provide satisfactory alternatives to stop smoking services. In 2018, budgets for stop smoking medications were reduced in 31% of local authorities that paid some or all of the cost of these medications (following reductions in 34% of local authorities in 2017 and 44% in 2016).25 In response, some CCGs have informed GPs not to prescribe medications for stop smoking medications, as these costs will no longer be reimbursed by their respective local authority. As a result, the amount of nicotine replacement therapy (NRT) dispensed through primary care in England in 2016/17 has declined by 75% since 2005/6.[33]

Further, whilst the use of e-cigarettes has increased substantially in recent years – now the most popular aid to quit [34] - and recent research shows they are effective in improving quit success,[35] stop smoking services still offer smokers the best chances of quitting, further evidenced by ASH and Cancer Research UK’s report findings that local authorities which retained a specialist stop smoking service model had the highest rates of quitting.26

The latest annual statistics from NHS Digital on the use of stop smoking services (covering the period April 2017 to March 2018) shows that the number of people accessing these services has fallen for the sixth consecutive year. The number of people using these services fell from 816,444 in 2011/12 to 274,021 in 2017/18, a decline of almost two thirds (66%).[36]

This decline in service use is partly a consequence of reductions in available services and partly of falling demand. However, since stop smoking services provided to the NICE standard are known to give the best chance of successfully quitting smoking, the reduction in available services needs to be reversed, and this should be combined with further efforts to increase the number of smokers seeking to quit, for example through mass media campaigns.

Without provision of high-quality stop smoking services across the country (together with other tobacco control measures including mass media campaigns to encourage quit attempts):

the commitments to additional smoking cessation support made in the NHS Long Term Plan are unlikely to be fully delivered
the Long Term Plan’s ambitions for prevention and the reduction of health inequalities are unlikely to be achieved
the Government’s ‘Smokefree Generation’ target of a smoking prevalence rate of 5% or less is unlikely to be achieved by 2030

Therefore, legislation should be changed such that provision of stop smoking services which meet NICE Guidance (NG92)14 and Quality Standards (QS43)15 should be mandatory public health activity.

April 2019

For questions or further information, please contact robbie.titmarsh@ash.org.uk

References