There’s a potentially effective medical intervention being wheeled out to all hospitals in England this year to help patients quit that big, old killer, smoking.
If you’re pregnant or in need or surgery, for instance, you’ll be asked on admission: would you like to quit? How about some help? Or something like that. It’s NHS 101 at its basic best.
Contact details of those who say ‘yes’ are supposed to be whizzed, with some simple IT, to their closest specialist quit-smoking service for the hands-on help that many addicts need. An administrative breeze, it should be.
But there’s a problem.
Many such services are being shut down, or downgraded, by the councils which inherited the role of funding and running them from PCTs (primary care trusts) in 2013, two years after austerity began.
So where will these automatic referrals of these patients, primed and willing to quit, now go? Why are the services shutting down? And what of the impact on smokers and the NHS?
To find out, BMA News has tracked the demise of a single service in Bromley, a south London borough which itself describes high levels of smoking for pregnant women, children and in pockets of its poorest quarters. Almost 10 per cent of its 15 year olds smoke compared with 8.2 per cent in England, according to its trading standards officers, and the percentage of pregnant residents who smoke is higher than the London average.
Its specialist service was axed last year, despite warnings from PHE (Public Health England), GPs, and Bromley Clinical Commissioning Group, the body which manages local NHS budgets and is run by a former director of public health of the defunct PCT.
Until it closed, it helped around 1,200 patients quit each year, most of whom had not smoked again, one year on. The average cost per quitter was £300, a modest sum given that a single 20-a-day smoker costs Bromley businesses, fire service and its NHS some £3,000 a year, according to the council’s own analysis.
But residents wanting to quit now have no such specialist support. Of its 43 GP practices, fewer than half even offer face-to-face advice. They get no funding to do so, and so have dropped in numbers, unsurprisingly. Just 8 per cent of pharmacies continued their support, the council found in an official update, published after it shut the service. Patients who want to quit have since been passed to the council’s public health department and are directed towards a ‘Stop Smoking London’ website and its telephone helpline.
Bromley says it has ‘merely changed the way we help smokers quit’. Its phone line is ‘more convenient and easier for many people and provides a value-for-money service,’ a spokesperson adds. ‘It better suits busy people in today’s world.’ She points to a PHE paper, which says phone lines can boost quit rates by 50 to 100 per cent ‘when done properly’. Specialist services, such as the one axed, boost them by 300 per cent, it also states.
But the loss of the specialist service is described as a ‘very difficult and regrettable situation’ for doctors and patients, by respiratory consultant Irem Patel at King's College Hospital NHS Foundation Trust, which runs the Princess Royal, the main hospital in Bromley.
Like other acute hospitals, the Princess Royal has ‘significant numbers’ of admissions for smoking-related conditions, such as cardiovascular disease, stroke, cancer, and chronic obstructive pulmonary disease, she adds.
‘It is absolutely right that when this [admission] happens we should identify those people, support them to be smoke free in hospital anad try to motivate them towards stopping smoking,’ Dr Patel says. ‘But if they agree to a referral for on-going support on discharge and that support is lacking or not effective, this could be very demotivating.’
Dr Patel is concerned for pregnant women who need services and treatment to ‘protect them so that we can protect the well-being of the next generation’.
‘We know that with the right pharmacotherapy and behavioural support from a skilled specialist the chances of a smoker quitting are vastly increased and this is a very high value treatment which should be offered at every opportunity.’
Bromley said it had ‘identified that pregnant women may need a slightly different approach’.
‘We are currently looking into the best way to help them to stop smoking,’ the spokesperson adds. ‘We will announce plans for this group in due course.’
Despite the value placed on quit-smoking services by the NHS, many others have been shrivelled or closed completely since control of their budgets passed to local authorities.
Specialist quit services were axed completely last year in Blackpool too, despite 22.5 per cent of its population being smokers. Havering and Harrow have already closed theirs, as BMA News has reported. Some services have been left relatively unscathed, including in authorities with low numbers of smokers, such as Buckinghamshire, where the incidence is 11.2 per cent.
The passing of public health budgets to councils was supposed to make service levels match local need better. But perversely, it has instead led to a mismatch in many areas, according to a comparison of budget cuts and prevalence rates for the BMA report, Feeling the squeeze.
Doctors in Bromley call the closure of the service a ‘disaster’, one told BMA News. ‘If they had taken out that service and put something else in that was newer or better, fine. But they simply stopped providing it,’ he added.
They are not confident the replacement phoneline will be as effective as face-to-face support. And while sympathetic to the financial pressures on the council from austerity, some see its targeting of the quit smoking service as the political choice of a long-standing Conservative-run authority, ideologically opposed to a large, ‘nanny’ state; that it’s not the state’s job to help people quit; it’s that of the smoker themselves.
This isn’t the argument advanced by the council. At a town hall meeting last year, Bromley’s then leader, Stephen Carr, ‘suggested that progress was being made in smoking cessation’ before the cut was voted through. Its director of public health said services had ‘to focus on significant issues and what is statutorily required and cost-effective’.
The few Labour councillors there tried to save the service with an alternative budget, using income from new housing to make up for shortfalls. It was easily quashed by the massive Conservative majority, which says the Labour proposal involved one-off ‘non-recurring’ funding.
Ian Dunn, a Labour member of Bromley’s HWB (health and well-being board) points to the council’s long-standing commitment, spelt out in official papers, of keeping its council tax ‘amongst the lowest in outer London’. Years and years of this policy had left little financial wriggle room when austerity hit.
But the council spokesperson says it has used a ‘logical way to prioritise services’ which ensured the ‘continuation of all statutory services’ and the ‘refocusing’ of others to ensure ‘continuation of most clinically and cost-effective’ services.
Some doctors in Bromley see a parallel between the council’s handling of children’s services and public health during the austerity years. Both are complex and involve risks which must be carefully balanced.
A damning report by Ofsted condemned ‘widespread and serious failures’ in Bromley’s ‘inadequate’ children’s service in 2016. According to Ofsted, its politicians’ proposals to address financial pressures lacked ‘sufficient analysis and understanding of the underlying complexities and impact on children’s services, including the risks’.
Could this same alleged failure to analyse, grasp and manage the risks of financial pressures apply to public health services?
Bromley declined to comment on this point. But there’s no doubt that it was told of the risk of axing the service. Bromley Healthcare, a major community care provider, warned in its response to a consultation that it would ‘widen inequalities’, as smokers were concentrated among ‘disadvantaged groups’. Public Health England said in its response that the cut went ‘against’ the council’s own priorities of its HWB strategy, a document now under review.
The CCG chief officer Angela Bahn told its councillors the decommissioning would ‘have an adverse effect on the health of many people’ at an HWB meeting in 2016.
Raise the alarm
These alerts failed to shift the council’s position, as other doctors have found to their frustration when flagging similar concerns across the country. Harrow closed its service despite a campaign by Northwick Park Hospital respiratory consultant Tara Sathyamoorthy and a petition signed by hundreds, for instance.
Such campaigns and concerns can only be raised when doctors have come across plans to cut public health services. It’s often by chance. Councils have no obligation to forewarn them, their hospital trusts or CCGs – whose budgets will take the pressure of rising acute admissions for smoking-related conditions.
Proposals are eventually published but can be opaque. Even then, to complicate matters, decisions on health services are bound up with others, on social care, bin collection, and council tax to name but a few.
How then are busy doctors and GPs to fight the cuts to public services?
Much of the weight for this seems to fall on CCGs, as it did in Bromley. ‘Unfortunately, I like many other GPs, am absolutely swamped by other issues in general practice,’ one GP in the borough tells the BMA.
Bromley CCG’s Dr Bahn says she hopes that the impact of losing the service will be ‘manageable for the moment’. ‘It is too early at this stage to understand what the longer-term impact will be,’ she adds.
‘Patients can still get support to help them quit which is essential because if we don’t help people to give up smoking now, then in five to 10 years’ time we’ll see respiratory diseases increasing which will have a greater impact on the health service. For some people, the impact will be much sooner.’
King's College Hospital’s Dr Patel is so concerned about the loss of services where its patients live that she’s looking at developing a replacement service in its hospitals.
‘This is also very challenging at a time of unprecedented financial and clinical pressure within our hospitals,’ she says. ‘But we know that smoking cessation started in hospital works and is likely to deliver significant savings in terms of future admissions, readmissions and length of stay.’
The cost of hospitals providing replacement services and the pressure of treating any rise in smoking-related illness will, of course, be borne by the NHS - not the councils which inherited the responsibility for running such services from it.
But what else is a doctor to do?
Read the BMA's latest recommendations for public health funding in its latest paper, Feeling the Squeeze
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