The Scottish Government

« Previous | Contents | Next »

Listen

CHAPTER 10: SUMMARY AND RECOMMENDATIONS

Summary

Overview of Review

10.1 The Scottish Government's Public Health and Wellbeing Directorate commissioned York Health Economics Consortium ( YHEC) to undertake an external review of Phase 2 of 'Partnership Action on Tobacco and Health' ( PATH) during the autumn of 2007.

10.2 PATH is funded by the Scottish Government and based within, and managed by, Action on Smoking and Health ( ASH) Scotland. It was set up in June 2002 with the central aim of reducing the number of people that smoke in Scotland. Most of its work therefore focuses on improving smoking cessation services. The specific high level outcome for Phase 2 (April 2005 - September 2008) is:

"To increase the existing cost-effectiveness of smoking cessation by providing centralised, co-ordinated, evidence-based support".

10.3 PATH's work falls into three broad areas:

• Training and development;
• Data collection and monitoring;
• Supporting research to explore new approaches to identifying and promoting best practice in smoking cessation and prevention work with identified priority groups.

10.4 The aims and objectives of the PATH review are to:

• Take stock of the key achievements made to date by PATH and the contribution made by the key partnership organisations represented on its Advisory Group, including with key stakeholders in the tobacco control and wider health improvement field;
• Assess PATH's performance in providing value for money in delivering the key outcomes agreed in June 2005;
• Make recommendations about the future direction of the activities supported under PATH, including exploring exit strategies; the scope for integration of key aspects within ASH Scotland or other appropriate agencies; and the issue of sustainability when Phase 2 comes to an end in 2008.

10.5 Three main methods were used to meet the study objectives:

• 'Desk-top' analysis of key documentation (internal and external);
• Semi-structured interviews (face-to-face and by telephone) with key stakeholders;
• A focus group/workshop with members of the Review Steering Group and other key stakeholders to consider future directions.

PATH's Achievements

Training and development

10.6 PATH has developed and launched three 15-week accredited courses with Glasgow Caledonian University ( GCU). These cover providing brief advice and delivering specialist smoking cessation support to individuals and to groups. Courses are delivered to geographical Health Boards and to the Scottish Prison Service. Between December 2005 and September 2007, 11 brief advice modules were delivered to 284 peoples, 151 students participated in the ten courses on providing specialist support to individuals, and 44 students have enrolled on four modules on specialist support in groups. PATH is currently conducting an internal evaluation of these courses. 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.

10.7 PATH also manages a national approval scheme for locally-developed smoking cessation courses. Eleven courses have been approved to date (from 15 submissions). Although still in its infancy, this scheme also has the potential to promote high and consistent standards for smoking cessation training across Scotland.

Minimum dataset ( MDS) and national database

10.8 The foundations for this work were laid prior to April 2005. Since then, PATH and the Information Services Division ( ISD) Scotland have further developed and implemented the MDS and the national database. This work has been highly complex and the MDS is currently being reviewed by a group of stakeholder representatives.

10.9 Almost all of the Health Boards are now contributing to the national database. ISD published its first national statistical report in March 2007 using the data for 2006. As stakeholders (especially those based in the Health Boards) become more familiar with the tools they are finding them increasing useful. This trend is expected to continue, given the Scottish Government's ongoing emphasis on targets for reducing smoking rates.

10.10 Although many stakeholders voiced concerns about the focus of the MDS, they all agreed that the MDS and the national dataset are essential tools for monitoring smoking cessation services. Many praised PATH's ability to work with a wide variety of organisations to get these up and running. Some stakeholders also stressed the need for better access to the national dataset for the academic community to ensure that research of national interest is undertaken using these tools.

Supported projects

10.11 PATH identified and funded 11 projects (seven service-based and four academic-based) during the first phase of its funding. These projects focused on working with groups of smokers who are traditionally hard-to-reach, such as those from deprived communities and pregnant smokers. Those projects that were still ongoing in the spring of 2005 have all completed their research and PATH is identifying the key themes and lessons from this work for widespread dissemination.

10.12 PATH is combining these lessons with those from a number of similar projects undertaken recently within ASH Scotland focusing on tobacco and inequalities and on young people and smoking cessation. In particular, the information will be used to develop training materials to promote working with hard-to-reach smokers, which is seen as essential if smoking rates are to continue to fall within Scotland.

PATH as an organisation

10.13 Most stakeholders spoke very highly of PATH as an organisation, although some were not clear about how it differed from ASH Scotland. Both organisations benefit greatly from their complementary skills and activities. PATH staff are generally seen as being very professional and approachable and their emphasis on evidence-based working is greatly valued. They are also flexible and respond well to suggestions for improvement, new challenges and changed circumstances. In addition, PATH is seen as providing a vital source of advice and help (e.g. by promoting networks and signposting those with queries to others addressing similar issues). This function is particularly valued by those from the non-Central Belt Health Boards, who can otherwise feel somewhat isolated from developments in tobacco control and smoking cessation.

10.14 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. COSLA (Convention of Scottish Local Authorities) is the only stakeholder organisation that has not accepted invitations to be actively involved in PATH's work.

Delivering Value for Money

10.15 Annual expenditure on PATH has varied from about £720,000 in 2005/06 (when several of the supported projects were still being funded) to a budget of about £565,000 for 2007/08 (when the accredited courses were becoming established).

10.16 Smoking rates have been falling steadily in Scotland in recent years. Nevertheless, about 25% of the population aged 16 and above smoked in 2005/06 (i.e. there were about 1.05 million adult smokers). Smoking rates vary considerably across Scotland and in very deprived areas over half of all adults smoke. This has considerable economic, societal and personal costs.

10.17 There are relatively few estimates of the economic impact of smoking on NHS expenditure in the UK, but a conservative estimate suggests that at least 10% of such expenditure could be smoking-related. In Scotland, an estimate of 10% would have equated to smoking-related hospital expenditure of £470 million in 2006/07 (or an average annual cost of about £450 per smoker for hospital services). Including expenditure on family health services and community services results in estimated smoking-related expenditure by the NHS in Scotland of about £780 million in 2006/07 (i.e. about £740 per smoker).

10.18 Although it is not possible to link expenditure on PATH directly to reductions in smoking rates in Scotland, the above data show that smokers generate considerable economic costs to the NHS (not to mention other societal costs, such as those associated with lost productivity and premature death). Smoking cessation services are widely recognised as being extremely cost-effective (e.g. in terms of their cost per life-year gained) and the above cost data show that PATH delivers excellent value for money.

10.19 This conclusion is reinforced when planned government expenditure on tobacco control of £13.8 million per annum for the next three years is compared with planned expenditure on alcohol misuse (£32.4 million in 2008/09, £42.4 million in 2009/10 and £47.4 million in 2010/11). Recent data (for 2003/04) show that £28.8 million of direct funding was provided to support drug treatment and rehabilitation services. Each year there are about 13,500 smoking-related deaths, compared with 2,372 deaths related to alcohol and 421 deaths due to drugs. However, it is also recognised that alcohol and drug misuse have significant societal impacts (e.g. on violence and crime).

Possible Future Directions for the Activities Supported under PATH

10.20 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 after September 2008. 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 effectively with and across a variety of statutory and non-statutory organisations.

10.21 Based on these criteria, the consensus view of the interviewed stakeholders was that PATH's current responsibilities should be transferred to ASH Scotland after September 2008, as this would streamline the work and simplify the organisation arrangements for its delivery.

Organisational recommendations

• Training and development:ASH Scotland should be 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;
• The MDS and national database:ISD Scotland should be funded to manage the day-to-day operational aspects of the MDS and national database, although some of the training should be provided by ASH Scotland's new training arm. ISD Scotland's work should be overseen and directed by a body similar to the current Project Board, which will be responsible for ensuring that the MDS and national database are fit for their local and national purposes. This body will comprise representatives from key stakeholders with national and local perspectives, and should be hosted by ASH Scotland (or another organisation outwith ISD Scotland);
• Supported projects:ASH Scotland should be funded to continue to develop the smoking cessation evidence base through managing supported projects focusing on social marketing and community development work with whole communities as well as with hard-to-reach groups of smokers. This should be done in partnership with the academic community to promote rigorous research. Findings from all of the research projects should be widely disseminated and incorporated into ASH Scotland's training and development work.

Specific recommendations for each element of PATH's work

Training and Development - Accredited Courses

• A training and development arm should be created within ASH Scotland. Funding should continue to be provided by the Scottish Government to enable this element of ASH Scotland to build on and extend PATH's current portfolio of training courses relating to smoking cessation, working closely with GCU to draw fully on their experience of developing training materials. This is important for several reasons:
• • There is an identified need for a wider range of courses, including courses for specific professional groups (e.g. pharmacists; dentists; social workers; youth workers) as well as courses for staff from a variety of professional backgrounds;
  • There is an identified need for courses of different durations (including some very short courses) carrying a range of accreditations (e.g. certificates of attendance; certificates of completion);
  • There is an identified need for courses that use a range of delivery media (e.g. distance learning);
  • Central development of such materials will ensure consistency across Scotland, with high quality courses that are regularly updated and based on recent evidence;
  • It is very time-consuming to develop such materials in-house (especially for the smaller Health Boards) and such central development will provide good value for money.
• The three current courses accredited by GCU should be updated/revised in light of the internal review undertaken by PATH and their delivery should be streamlined so that they are offered less frequently.
• Mechanisms should be devised to ensure that all previous course participants are 'formally' updated about relevant changes and developments in facilitating smoking cessation (e.g. those relating to nicotine replacement therapy).
• PATH staff (and subsequently ASH Scotland's training and development staff) should work closely with the NHS Health Boards to prioritise their needs for 'off the shelf' courses on smoking cessation that can be delivered by themselves and/or by local staff and then develop the materials for such courses.
• PATH staff (and subsequently ASH Scotland's training and development staff) should ensure that the key lessons on smoking cessation and prevention from the supported projects within PATH and ASH Scotland are incorporated into training materials to facilitate their dissemination across Scotland. Particular emphasis should be placed on working with traditional hard-to-reach groups (e.g. people living in socially deprived areas; young people; pregnant smokers; people from ethnic minority groups; people with mental health needs), and also with those living in rural and remote areas.
• PATH staff (and subsequently ASH Scotland's training and development staff) should work closely with the NHS Health Boards and relevant professional bodies to ensure that they are all actively involved in national discussions relating to the potential for developing a formal, national competency framework for smoking cessation (and to identify its resultant implications for training).
• PATH staff (and subsequently ASH Scotland's training and development staff) should explore the possibilities of building training-related alliances with others working within substance misuse services (especially regarding the use of cannabis).

Training and Development - Approved Courses

• The mechanism for approving locally-developed courses in smoking cessation should be retained within the remit of ASH Scotland's training and development work, but the approval process should be simplified and streamlined. This is especially important with respect to identifying the circumstances under which courses need to be resubmitted for approval (e.g. the extent of course changes; the time period since approval was granted).
• PATH staff (and subsequently ASH Scotland's training and development staff) should develop and launch a database of approved courses.
• PATH staff (and subsequently ASH Scotland's training and development staff) should explore the potential for working with all Health Boards delivering locally developed training courses in smoking cessation to help them to link these to competency frameworks, with the objective of promoting consistency across Scotland. If there is considerable interest in this, it is an important area for future collaborative work.

Data Collection and Monitoring

• The ongoing day-to-day management of the MDS and national database should continue to rest with ISD Scotland (with continued appropriate remuneration from the Scottish Government).
• Their work should be overseen and directed by a body that includes representatives from a wide range of partners and stakeholders. This body will be responsible for ensuring that the MDS and national database are fit for their local ('micro') and national ('macro') purposes, without being unnecessarily cumbersome for service providers to complete and submit.
• It 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). It should also oversee the choice of the specific topics for additional reports, analysis and research at local and national levels using the national database.
• Such a body will need a 'host' organisation outwith ISD Scotland, and ASH Scotland is ideally placed to provide this function. It is therefore suggested that ASH Scotland undertakes this role (although it could be located within another external organisation if the partners feel this to be more appropriate).
• Although the day-to-day support and some of the training should remain the responsibility of ISD Scotland, PATH staff (and subsequently ASH Scotland's training and development staff) should also continue to contribute to delivering the required training relating to the MDS and national database as part of ASH Scotland's training portfolio.
• Ways need to be found to provide academic researchers with easier access to the national database. For example, the new Project Board could act as a gatekeeper that reviews and approves proposals for access, thus enabling additional research to be undertaken by suitably qualified and experienced personnel/organisations.

Supported Projects

• Funding should continue to be made available (e.g. to ASH Scotland) for enabling and managing short-term service-based and research projects. This funding should generally be for a minimum period of three years. Many respondents stressed that work in this area is in its infancy and it is vital that the momentum achieved to date is not lost.
• A future round of supported projects should focus on undertaking community development work that not only engages with hard-to-reach groups but also explores ways of working across different groups of smokers. This work should include promoting techniques such as social marketing, and it should be extended to cover the delivery of smoking cessation services to those living in rural and remote areas. It should also include developing aspects such as motivational interviewing and relapse prevention and management.
• Voluntary sector organisations should be invited to bid for funds, as some hard-to-reach smokers may prefer to work with their staff rather than with those from statutory services.
• Before any further funds are allocated to projects, ASH Scotland should develop partnership working with one or more academic organisations to ensure that future funded projects are soundly structured (e.g. in terms of their methodologies and outcome measures), well managed and realistically resourced and funded.
• Lessons from all the PATH and ASH Scotland supported projects (past and future) should be synthesised and disseminated in a variety of ways (e.g. summary documents; ASH Scotland website; conference presentations) in a timely manner so as to deliver maximum impact.
• Lessons for service providers from all of the supported projects should also be incorporated into the portfolio of training courses that will be developed by PATH staff (and subsequently by ASH Scotland's training and development staff).

Overall Conclusions

• PATH is delivering its high level outcome for its Stage 2 funding;
• PATH has delivered most of the short-term outcomes due by mid-2006 and is on course to deliver the remainder of these and the longer-term outcomes by autumn 2008;
• All elements of PATH's work should continue with central funding beyond autumn 2008, but as partnership work with stakeholders such as GCU, ISD Scotland, NHS Health Scotland, managers and co-ordinators of Health Boards' smoking cessation services, and the academic research community. This work should be led from within ASH Scotland rather than by PATH in its current format (see Recommendations for further details);
• If central funding ceases, there is a serious risk that smoking rates will not be reduced in hard-to-reach communities and in key priority groups, thus exacerbating existing health inequalities and increasing the costs of health care both now and in the future.

« Previous | Contents | Next »