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CHAPTER 8: PATH AND THE FUTURE

Summary

Stakeholder views on PATH as on organisation

8.1 Most stakeholders spoke very highly of PATH as an organisation, although some were not clear about how it differed from ASH Scotland. It was very apparent when conducting the face-to-face interviews at the ASH Scotland offices that there was no demarcation of PATH and ASH Scotland staff within the organisation. If PATH-funded staff ceased to work within ASH Scotland this would have an adverse impact on some of the current activities of ASH Scotland (e.g. it would be difficult for ASH Scotland alone to integrate the lessons from their short-term research projects with hard-to-reach groups into smoking cessation training).

8.2 PATH staff are generally seen as being very professional and approachable (though some people undertaking training courses did not share this view - see paragraph 4.29). People value its emphasis on evidence-based working (which is facilitated by its close association with ASH Scotland). The organisation is seen as providing a vital source of advice and help. It promotes networks and can signpost those with queries to others addressing similar issues. This function is particularly valued by those from the non-Central Belt Health Boards, who are less able to attend regular meetings of those working in tobacco control and smoking prevention and cessation (e.g. of the STCA) due to the distances involved and the associated time and travel costs.

8.3 Scotland is seen as leading other parts of the UK in terms of developing accredited courses for smoking cessation, largely due to the work of PATH. The national approval scheme, although still in its infancy, also has the potential to promote high and consistent standards for smoking cessation training across Scotland.

8.4 Even though many people voiced concerns about the MDS and the national database in practice, they all agree that these are necessary tools. Many praised PATH's ability to work with a wide variety of organisations to get these up and running. In a similar vein, although many comments were raised in relation to the supported projects, it was nevertheless widely acknowledged that such work is essential if hard-to-reach groups are going to be able to participate in smoking cessation services.

8.5 Stakeholders think that the organisation works flexibly and responds well to suggestions for improvement, new challenges and changed circumstances. For example, PATH regularly reviews its products and actively welcomes feedback, as illustrated by the current internal reviews of its accredited courses and of the MDS.

PATH as a partnership

8.6 PATH has generally built good working relationships with a wide variety of partners, including GCU (training courses), ISD Scotland ( MDS and national database), NHS Health Scotland and the Scottish Executive/Government. PATH staff are also in regular contact with co-ordinators and managers of smoking cessation services within the Health Boards. A strong working partnership has also been developed with the Scottish Prison Service, where staff have been involved in training and in one of the supported projects.

8.7 PATH also seems to have benefited greatly from its association with ASH Scotland as this has put it in regular contact with organisations such as the STCA and the Youth Forum.

8.8 However, there is also considerable potential to develop more partnerships with academic organisations if supported project programmes are to be managed more effectively in the future. Academic partnerships may also be encouraged if the academic community becomes more actively involved in research using the national dataset.

8.9 The only notable exception in terms of developing good partnership working has been COSLA. Although invited to send a representative to the PATH Advisory Group meetings, they have consistently failed to do so (possibly due to their own internal personnel changes and priorities).

Staff turnover within PATH

8.10 The interviews and PATH documentation suggest that PATH has experienced high staff turnover during its lifetime, and many of the current staff have been in post for 12 months or less. Whilst this has guaranteed a regular supply of new ideas, it does slow down progress and affect the continuity of relationships (e.g. with smoking cessation co-ordinators and service managers). The staff are of high calibre and are drawn from diverse backgrounds, which means that they provide PATH with a wide range of skills. However, internal training and induction inevitably take time, especially for staff who have not previously worked in tobacco-related services. Exit interviews within the organisation suggest that staff have usually left for positive reasons. Furthermore, it is widely recognised that staff turnover is often high when staff are relatively young and are seeking to develop their careers. Such staff may feel that it is time to move on after about two years in any job (e.g. an organisation employing 12 such staff should expect about six to leave each year). The fact that their contracts were only short-term did not seem to be of concern to the staff. It is important that funders recognise the realities of the local labour market for organisations such as PATH and ASH Scotland.

Possible future directions for the activities supported under PATH

8.11 It was generally acknowledged that PATH has achieved a great deal in the last six years and it is vital that this progress is not lost. Respondents felt that it is still early days for smoking cessation services and it is important that they do not share the experience of services for HIV/ AIDS, which suffered considerably when their earmarked funding ceased. Smoking cessation services are now in a position to start tackling the hard-to-reach groups. Although it can be argued that Health Boards have been allocated additional funds for such services, these have not necessarily been earmarked locally for these purposes. Several stakeholders felt that local resources for smoking cessation remain very tight, and they value any ways that they can access relevant support services without requiring access to local funds. This is a particular problem for training budgets, as these are often the first areas to be cut locally. Stakeholders felt that such funds still need "protecting" (e.g. through centralised provision and development of courses) if Scotland is to deliver consistent, high quality training to all staff providing smoking cessation advice and support.

8.12 When considering the future, it is necessary to see PATH as a provider of a number of key functions rather than as an intrinsic organisation. The overarching view from stakeholders is that its work should continue to be funded, although " PATH" as an organisation could cease to exist. However, many stakeholders stressed the importance of keeping this type of work within an organisation that:

• Understands tobacco;
• Is located in the non-statutory sector (as this gives it more freedoms and fewer restrictions);
• Can work with and across a variety of statutory and non-statutory organisations.

8.13 The possibilities for each key function are discussed below.

Training and Development

8.14 PATH is keen to develop a portfolio of courses, which includes shorter courses for non-specialists (e.g. with certificates of attendance). PATH staff also want to develop materials for those working with specific target groups (e.g. pregnant women; young people), drawing on the lessons from the PATH/ ASH Scotland pilot projects with these client groups. Working with some of these hard-to-engage client groups will require service providers to develop new skills and approaches, such as social marketing. Some Health Board representatives also identified the need for training to develop skills in areas such as motivational interviewing.

8.15 PATH staff would like to work more closely with Health Board staff to help them fill any gaps in locally-available training (e.g. by providing off-the-shelf products that can be delivered by local smoking cessation staff or by ' PATH', including to staff from outwith the NHS, such as social workers, formal care staff and youth workers). In addition, current PATH staff recognise the need to develop formal ways to keep former course participants up-to-date with the latest developments in smoking cessation (i.e. with the new material that will be regularly incorporated into the main course materials). Such updates would include the findings of recent research studies and changes in available nicotine replacement therapy ( NRT) products. PATH would also like to deliver its accredited courses in a more structured way (e.g. less frequently and within specific academic semesters) and there is also interest in developing on-line learning packages (e.g. for dental staff). Such courses have the potential to generate some additional income for their provider. There is also considerable potential to build on current work by PATH to develop a portfolio of centrally approved courses.

8.16 Respondents suggested that this work could be taken forward in a number of ways, including:

• By funding and developing a Training and Development arm within ASH Scotland;
• From within NHS Health Scotland;
• Through integration with NHS Education Scotland ( NES);
• In partnership with one or more Scottish Universities.

8.17 The general consensus from the interviews, focus group/workshop and other discussions was that this work would be better undertaken from within an autonomous organisation specialising in tobacco-related issues (e.g. ASH Scotland) rather than from within NHS Health Scotland, where it could get overlooked and where there is arguably less tobacco-related expertise (although there is more training expertise). NES is not a suitable candidate as its remit only enables it to work with NHS staff. One or more Scottish universities will still need to be involved to deliver and develop accredited courses. Universities are also likely to be a good source of information and expertise about introducing new forms of course delivery.

8.18 It is therefore recommended that ASH Scotland is funded to develop a Training and Development arm which will build on the work and achievements of PATH from autumn 2008. Such work will require close partnership working with many stakeholders, including:

• Smoking cessation co-ordinators and service managers from the Health Boards;
• NHS Health Scotland;
• GCU (and possibly other Scottish universities);
• The research community;
• NES, the RCGPS and other bodies with an interest in endorsing approved courses;
• ISD to streamline national training relating to the MDS and national database.

The MDS and National Database

8.19 Although the main objectives of this workstream have been achieved, it is important to recognise that work and developments will continue in these areas. The general consensus was that the operational aspects of the MDS and national database should continue to be managed by ISD (with relevant funding), but that this work should be overseen by a body with appropriate expertise in tobacco and smoking cessation.

8.20 It is therefore recommended that ISD manage the day-to-day operational aspects of the MDS and national database. Their work should be overseen and directed by a body that includes representatives from a wide range of partners, including:

• The Scottish Government;
• ISD Scotland;
• ASH Scotland;
• The STCA;
• Smoking cessation co-ordinators and service managers;
• Public health and health promotion managers;
• The academic (research) community;
• NHS Health Scotland.

This body will be responsible for ensuring that the MDS and national database are fit for their local and national purposes and will perform similar functions to the current Project Board (and be able to convene ad hoc Expert Working Groups, where relevant, to address specific aspects of the MDS and national database). Such a body will need a 'host' organisation outwith ISD Scotland, and ASH Scotland is ideally placed to provide this function (although it could be located within another organisation if the partners feel this to be more appropriate). ISD and the new Training and Development arm within ASH Scotland will need to work together to determine the most appropriate way to provide the necessary training and support to those using the MDS and the national database.

Supported Projects

8.21 It was widely acknowledged by the stakeholders that there is an ongoing need for funded pilot projects to continue to develop the smoking cessation evidence base, especially with regard to working across deprived communities and with hard-to-reach groups. However, lessons need to be learned from the recent experiences of both PATH and ASH Scotland. In particular, much more academic input is needed when selecting and supporting projects to ensure they are methodologically sound, have realistic timescales and are appropriately managed by their host organisation. The findings from such project work need to be disseminated widely and incorporated into smoking cessation training and development.

8.22 Given its experience in these areas, it is therefore recommended that such work should be managed by ASH Scotland, working closely with the academic research community.

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