The NHS needs to do more on smoking, but not at the cost of raiding Public Health budgets in Councils

Jim McManus is Vice-President of the UK Association of Directors of Public Health. This is his personal view. 

The RCP Launches today it’s report Hiding in plain sight: treating tobacco dependency in the NHS

This report does NOT call for smoking cessation services to go into the NHS, a welcome change of tone from their actual press release, which somehow, and reportedly contrary to the intentions of the report authors, did. 

It’s welcome that the authors have clarified that they did not intend to suggest or recommend that services are not transferred from local authorities to the NHS, but worrying how this got into their press release in the first place.

We know from experience that the NHS would be no better guardians of public health than councils who know their local populations best to help tackle the health and wellbeing inequalities that exist in their communities. The NHS had a history of raiding public health budgets for the acute sector – it is hypocritical now to claim that they would be better guardians of public health than they were until 2013, and it is very very welcome that the authors neither ask nor advocate for such a transfer.

So let’s leave that not intended line in the press release aside, and focus on their main points.

Some great value in this report

I support the RCP call for greater NHS involvement in Smoking Cessation, and welcome their acknowledgement that this should not be at the expense of council services. I particularly welcome their call that NHS premises should allow use of e-cigarettes/vaping .

While I also think they could and should have done more to engage Directors of Public Health in developing this report,  this report is very good in some parts.

Two Cheers

There is much we should welcome in this report. I would support the need for much greater NHS focus and contribution to reducing smoking rates, and it’s good that the report is arguing for the NHS to do its part.

If you want a system wide overview, the report could usefully be complemented by reading other reports such as those from the Local Government Association on the importance of the local authority role.

The opportunity here is a whole system approach with the local authority led Public Health role in tobacco control and reducing smoking prevalence complementing the opportunity in the NHS. This report does recognize that.

The NHS Prevention opportunity

Most of us I hope would agree that we need to be moving towards a position where the NHS takes on greater responsibility for supporting quitters properly including and especially as in-patients in acute and community provision – and especially in mental health providers. We also need decent systems that would allow us to monitor this and the report rightly identifies these as currently weak.

It is right that the NHS focuses more on helping smokers to quit – it will bring substantial economic and health benefits to the NHS, not least a reduction in treating the costs of smoking-attributable illnesses.

I would particularly welcome a focus on mental health service users, who remain disproportionately high in smoking tobacco and in smoking atttibutable ill-health and early death. I would also welcome NHS Clinical Commissioning Groups looking at how implementing this report could help them meet their statutory duty to reduce inequalities.  Inequalities in health outcomes and access remain stubbornly real for the poorest and most disadvantaged.  Implementing these recommendations could make a shift in that.

What councils and NHS do should complement each other

It’s good that the report recognises this is about doing more in the NHS and adding to our work. The report underplayed, for me, the role of local authorities. That may be entirely fairly because their focus is on the NHS. But a whole system approach is something which would give us a complementarity of approach across the NHS and local government.

Council-led schemes have had a major impact on helping people to quit smoking and responsibility for this work should rightly remain with local authorities. This report rightly recognises that what the NHS could do should be added to what’s going on.

To help more people quit smoking, overall tobacco control budgets need to increase – both in the NHS and Councils – to help the NHS play its part in this. Sadly councils are being cut by £600m and while the NHS has had a major increase in funding announced, we are still waiting on any detail on whether at least some of this recently announced extra long-term funding for the NHS will be focused on prevention. This would help implement the recommendations of this report.


 Smoking still kills

Prevention of disease and death from smoking needs to have multiple foci.

We must not forget the important contribution of vaping. That is underplayed in a coherent system wide view of tobacco control though the RCP has elsewhere been very welcoming of this. Vapers have shown leadership for their own health. We as a public health and health system have to do better.

Councils and the NHS both need to do prevention on smoking and reduce smoking prevalence. The report underplays the local authority led Public Health role in tobacco control and reducing smoking prevalence. That said, seizing the opportunity of this report could give us a system wide approach:

  • Councils have a focus on things such as licensing and other measures alongside targeting funding to greatest need which the NHS struggles to do.
  • Many of our most vulnerable smokers are where community based services have had some hard-won successes such as outreach in homeless hostels, drug & alcohol treatment centres and so on. They won’t hit the radar of hospitals or in many places general practice until they’re too far down the line.
  • Acute, Mental Health and Community NHS services taking these recommendations on board could get the right focus for the people they work with, reducing smoking prevalence in this population and saving treatment costs and avoidable costs. Smoking among people with mental health need is disproportionately causing avoidable disease and early death. This report presents a major opportunity to focus on improving the lives of people using mental health services especially
  •  Councils remain committed to working with the NHS to help smokers quit, however this is made all the more difficult by a £600 million reduction to the public health budget by central government between 2016/17 and 2020/21, which will only compound acute pressures for NHS services further down the line.


Some things we could do better

Although the report provides a very good synthesis of the evidence and a decent summary of the state of play around the structures and funding for smoking cessation and tobacco control, we still need greater examination of how the NHS and partners can use existing levers to push this on, measures like CQUINS (quality incentives) could be used to do this but aren’t because the NHS siphons these into A & E performance. There is also more to be said about a systems approach.

So the report isn’t the final word, but it is very welcome as one part of a system wide agenda that the NHS, Public Health in local authorities and others should get round a table to work together on.



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