Public health doctor

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What price public health services?

Dave McKenna
MCKENNA: the former pipe smoker was diagnosed with tongue cancer in 2008

Dave McKenna saw his GP’s face drop as he peered down his throat.

A former teacher and pipe smoker, he was found to have tongue cancer — a life-threatening diagnosis that would require years of gruelling treatment and radical neck surgery.

Discharged just three years ago, McKenna now considers himself ‘one of the lucky ones’, although deafened by multiple rounds of radiotherapy.

He abandoned his pipe overnight after the shock of his diagnosis in 2008 and is now a public face of Fresh, a body that coordinates quit-smoking campaigns in the north-east of England.

Fresh has an ‘amazing success story’ to tell about running effective public health campaigns on the cheap, according to Gateshead respiratory consultant Robert Allcock, who advises the organisation.

For the 27p per head of population that Fresh bills a dozen town halls, it has helped to cut smoking rates by 10 per cent across the region over a decade.

‘That adds up to an awful lot of lives saved,’ Dr Allcock says.


Under threat

But Fresh and many other quit-smoking services are under serious threat, BMA News has found.

After the chancellor took the axe — twice — to public health budgets in less than nine months, funding for many smoking cessation services across England are under pressure.

Several councils, which took over the public health purse strings from the NHS three years ago, are planning to make — or have already made — big cuts to smoking cessation budgets.

In one case, the London borough of Havering, which describes itself as a relatively healthy corner of east London, has axed the entire budget, resulting in the inevitable total closure of its quit-smoking service in May.

Bromley council, also in London, will follow suit with plans to abolish its service next year.

Smoking cessation budgets in Leicestershire, Gateshead, Darlington and North Somerset have been similarly targeted by their respective local authorities, much to the alarm of senior doctors.


Wider impact

And it’s not just quit-smoking services that are suffering potentially harmful reductions.

Cuts to Brighton and Hove’s sexual health service risk ‘increasing the prevalence of sexually transmitted diseases, including HIV’, the council says.

Meanwhile, cuts in Surrey are predicted to have an adverse effect on support for women suffering domestic abuse.

Older and vulnerable adults in Merton are likely to be lonelier and more isolated when its befriending service is cut, the council concedes in an official report outlining the impact of its cuts programme (see listings below).

BMA public medicine committee chair Iain Kennedy says the complete closure of services highlights the ‘desperate situation’ faced by public health.

Stop smoking services were among the ‘the most cost-effective interventions in healthcare’, he adds, saving the public purse £2 for every £1 spent.

They are the sort of intervention the NHS needs as it struggles to get out of the red, he says.


Health inequalities

Dr Kennedy also warns that even shrinking smoking-cessation budgets risks widening health inequalities.

He adds: ‘Smoking behaviour is now concentrated in less well-off populations.'

And his analysis is even backed by councils planning the cuts.

Havering’s 2016 public health review points to a reduced life expectancy of 6.5 years in its run-down areas — with smoking named as a chief cause of premature deaths.

While 18 per cent of its adults overall are smokers, almost four in 10 smoke in one of its most deprived neighbourhoods.

A similar pattern of higher smoking rates in deprived neighbourhoods is seen in Gateshead, another authority planning significant cuts to its stop-smoking service and one of the contributors to Fresh.

GPs, hospital doctors and anti-smoking campaign groups that are fighting the cuts are finding themselves on the back foot and discovering the extent of budget cuts only when it is too late to save vital services.


No dialogue

Meanwhile, town halls are not routinely consulting the NHS before trimming or closing services, it seems.

In one instance, the medical director of Barking, Havering and Redbridge University Hospitals NHS Trust was asked to flag up ‘serious concerns’ about Havering’s failure to consult on its ‘retrograde’ decision to close its service. So says its trust papers from 3 May.

The closure has been on the council’s cards since late last year, a spokesperson for Havering confirmed.

In another case of doctors caught off guard by public health cuts, Hinckley GP Darren Jackson expressed ‘surprise’ that ‘so little was known about the cuts to public health services’ in Leicestershire at a meeting of West Leicestershire CCG (clinical commissioning group) in April.

According to an account of the meeting, Dr Jackson and three other members of the CCG warned that the ‘NHS would be responsible’ for plugging the gaps in the quit-smoking services left by the council’s cuts.

Dr Jackson told the BMA that practices across the region had ‘made good use’ of the ‘fantastic’ service that faced the axe.

He added: ‘Cuts to public health budgets are forcing the local authority to make cost savings, and the main funding cut is to smoking cessation counselling. As GPs, this is our biggest concern.’


Cheaper options

Leicestershire County Council plans to replace face-to-face counselling with cheaper online and telephone services. But Dr Jackson says this stripped down service may not meet all patients’ needs.

He adds: ‘Some people say that the approach is effective in different countries, but locally it will effectively be an experiment.

‘There is a group of patients that need the highly intensive face-to-face service.

‘Our CCG may have to find the money for some of these patients and we are struggling financially as well.’

West Leicestershire is not the only corner of the NHS hit by cuts to local authorities’ public health budgets.

GPs in Newcastle have also seen its quit-smoking service dramatically altered by funding reductions, according to Newcastle and Gateshead CCG assistant clinical chair Guy Pilkington.


New model

He adds: ‘The smoking cessation service in Newcastle has changed dramatically from a model in which a large amount of activity was delivered through GPs to much, much less activity delivered this way.

‘The public health department in Newcastle wanted a different, more bespoke model with a smaller budget.

‘That didn’t go down particularly well with some GPs — they decided to withdraw from the service and this directly impacted on the options that patients had.’

As a commissioner of health services himself, Dr Pilkington says he was ‘completely comfortable’ with Newcastle’s decision to slim its quit-smoking budget.

He adds: ‘As long as decisions are rooted in an evidence base, we have to be mature enough to accept those kinds of changes.

‘We can’t have a Rolls-Royce service in these times — but it is important to ensure that any budget cuts to services aren’t fatal to their function.’


‘Perfect storm’

Dr Pilkington is also concerned that cuts to council budgets – including public health – make it tricky to reshape health services, as demanded by the Five Year Forward View’s financial rescue plan for the NHS.

He says: ‘The public health and NHS squeeze creates a perfect storm. We are firefighting when we should be transforming public health.

‘If we don’t make essential changes in the NHS and get better at prevention, early intervention and supporting people to look after themselves, the demographic time bomb will blow us out of the water.’

Both Leicestershire and Havering justify cuts to quit-smoking programmes with claims that e-cigarettes and online services have reduced the need for the service.

Gateshead, another authority planning to cut its budget, says plans to force tobacco companies to sell cigarettes in plain packaging would also make a ‘real difference’.

Leicestershire Council’s cabinet member for health Ernie White points to a ‘significant decline’ in the use of its service — from 20 per cent to 5 per cent of smokers.


Rise of e-cigarettes

‘That is down to e-cigarettes and a continuing fall in smoking prevalence,’ he says, adding that cutting spending on smoking cessation by £1.1m would not ‘necessarily mean … a detrimental effect on the service’.

Havering Council says it will now rely on electronic services, such as mobile phone applications, to help smokers to stop sparking up.

‘We will signpost our residents to those services and maintain support for pregnant women who want to give up smoking,’ a spokesperson says.

But doctors and quit-smoking campaigners are not so convinced that the arrival of e-cigarettes will prevent all the 80,000 deaths from smoking-related illness in England each year.

Gateshead consultant chest physician Robert Allcock says the medical consensus recognises the use of e-cigarettes to reduce tobacco-related harm but that behavioural support services are the ‘gold standard’ for smoking cessation.

He adds: ‘To say you are not going to do both things — which are evidence-based and effective for reducing the biggest cause of death in the UK — just doesn’t seem rational.’


‘Red herring’

Campaign group Action on Smoking and Health says the idea that e-cigarettes can substitute quit-smoking services is a ‘red herring’.

ASH director of policy Hazel Cheeseman says councils appear to be ‘confusing’ the roles played by nicotine replacements and support services.

While products such as e-cigarettes could help to cut the number of smokers, face-to-face advice is essential for poorer smokers keen to kick the habit, she says.

She adds: ‘People who are disadvantaged are more likely to smoke and are no less motivated to quit. But they are less likely to be successful unless they have access to specialist services.’

Councils may also be less inclined to fund cessation services because any long-term savings from having fewer smokers would be less ‘directly obvious’ than when the NHS ran public health, Ms Cheeseman says.

She adds: ‘There are certainly benefits to local authorities in terms of savings on social care, but as the NHS treats cardiovascular diseases the benefits are almost instantaneous.’


Tough decisions

Council leaders told the BMA they regret the cuts they were forced to make.

Leicestershire’s Mr White says ‘any reduction in public health funding is difficult to manage’.

Meanwhile, Havering says it is closing its service ‘with considerable regret’.

Gateshead’s director of public health Alice Wiseman described its decision to cuts its quit smoking budget as tough.

‘These were not decisions that [council] members would have made if other choices were available,’ she adds.

The council admits its planned cuts could have a ‘negative impact’ on its residents’ well-being.

All the doctors approached by BMA News are sympathetic to the difficulties faced by councils as they manage the chancellor’s cuts to public health budgets.


‘Grim time’

In Gateshead, Dr Allcock says he understands that councils are having a ‘very grim time’ but is worried by rumours that some of the dozen authorities that fund Fresh are considering pulling out.

He adds: ‘This would be particularly disappointing as the evidence is that the model can deliver remarkable value for money.’

Dr Kennedy says councils have to ‘do the best’ they can with ‘limited money’.

Town halls are further frustrated by Government demands to offer particular services.

While there is ‘little evidence’ that health checks mandated by ministers were effective, councils were forced to fund them ‘at the expense of more useful interventions’, such as quit-smoking services, Dr Kennedy says.

So what of the future for public health and its chances of reducing inequalities, as services such as quit smoking have previously managed so successfully?

The prospects are not looking good, according to Dr Kennedy.

Under the Government’s plan for public health funding, councils will soon pay for the service from taxes collected from business.

Dr Kennedy adds: ‘This will simply reward areas with already strong economies and penalise those local authorities with higher levels of deprivation.’

 

Planned cuts to public health services in England, 2016

Public health summary infographic 

 

Leicestershire

  • £1.1m cut from quit smoking service
  • Funding for substance misuse service reduced by £625k
  • £340k cut to sexual health services budget

Source: West Leicestershire CCG board papers, April 2016

 

Brighton and Hove

  • £338k cut from substance misuse budget Funding for in-patient detoxification slashed by 38 per cent.
  • £115k cut from sexual health service

Source: Brighton & Hove Council, impact assessment 2016-17

 

Bromley

  • Smoking cessation service axed in 2017
  • School nursing service decommissioned
  • Childhood obesity service closed
  • Public health staff roll halved from 32 to 16

Source: Bromley Council, impact assessment, February 2016

 

North Somerset

  • School smoking reduction programme cancelled
  • Diabetes prevention work put on hold
  • Primary care alcohol intervention contract axed

Source: North Somerset, Public Health Draft Equality Impact Assessment, January 2016

 

Merton

  • £600k switched from public health to social care
  • £540k cut from substance misuse
  • £200k cut from child public health
  • Befriending service axed
  • Quit smoking budget cut by £300k

Source: Merton Council, Public Health Budget proposals 2016/17

 

Leeds

  • £100k axed from addiction services budget
  • £375k cut from drug intervention and offender management
  • Staff budget cut by £423k

Source: Delivery of public health budget savings 2016/17, Leeds Council

 

Gateshead

  • £105k cut to child weight management programme
  • Smoking cessation service budget cut and capped.
  • Nicotine replacement therapy budget wiped out

Source: Gateshead Council budget proposal papers, February 2016

 

Havering

  • Stop smoking service axed
  • Chlamydia screening service for young people closed
  • Sexual health prevention for young people service decommissioned

Source: Havering Council briefing note, 10 March 2016

 

Darlington

  • Axing funding to Fresh, an organisation that co-ordinates quit smoking campaigns across the north-east
  • Quit smoking cut shrunk from ‘universal’ service to one focused on ‘priority, and vulnerable, groups including pregnant women and routine manual workers’
  • Disbanding of dedicated drug, alcohol and tobacco team

Source: Darlington Council budget proposal papers, February 2016

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