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EXECUTIVE SUMMARY
Overview of Review
E.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.
E.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".
E.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.
E.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.
E.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
E.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.
E.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
E.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.
E.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.
E.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
E.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.
E.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
E.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.
E.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
E.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).
E.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.
E.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).
E.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.
E.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
E.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.
E.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.
Overall Conclusions
E.22 The overall conclusions of the review are that:
- 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.
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