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					County Durham Primary Care Trust Darlington Primary Care Trust

JOINT BOARD MEETING
03 April 2008 Item No JCD&DB08/04/09

Reducing health inequalities through effective tobacco control
1. Introduction The aim of this report is to provide assurance to both Boards on progress in relation to reducing the harm from tobacco in County Durham and Darlington. The report describes developments in the Stop Smoking Service, tobacco control issues and recent performance outcomes. 2. Implications and Risks Will there be a significant impact on patients or patient care? Yes, reducing smoking is the most important step in narrowing the gap between life expectancy in County Durham and Darlington and England as a whole.

Are there any financial implications to implementing this item? Will there be an impact on Equality, Diversity or Human Rights? Does this item form an essential part of quality or performance standards e.g. Healthcare Commission, NHS Litigation Authority? If yes, detail which standard.

Yes, specific LDP and LAA targets

*if “yes”, a brief summary of the implications is to be attached. 3. Recommendations County Durham PCT Board and Darlington PCT Board are asked to: • Note the progress and excellent performance achieved by the stop smoking service in: - Achieving/surpassing local delivery plan (LDP) targets and LAA targets. - Achieving some of the highest quit rates nationally per 100,000 population. • Note that the service will be under pressure over the next three years to achieve new targets and perform on all the core quality outcomes stipulated by the Department of Health.

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Be advocates for tobacco control by maintaining the high profile of tobacco control and encouraging and supporting the continuation of the effective delivery of tobacco control alliance work.

4. Submitted by Authors: Dianne Woodall, County Durham and Darlington Health Improvement Strategy Lead (Tobacco) Anna Lynch, Locality Director of Public Health, County Durham Primary Care Trust/Durham County Council

Sponsoring Director: Dr Tricia Cresswell Director of Public Health, County Durham and Darlington PCTs 17 March 2008 5. Purpose of the Paper Information sharing X Development/discussion Decision/action X

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County Durham Primary Care Trust Darlington Primary Care Trust

Reducing Health Inequalities through effective Tobacco Control
1. Background

Smoking remains the major cause of the lower life expectancy and higher cancer and heart disease rates in County Durham and Darlington compared to the national average. Reducing smoking is the most important step in narrowing the gap between life expectancy in County Durham and Darlington and England as a whole. To reduce inequalities in health, targeted investment in stop smoking services will be focussed on three key groups: routine and manual workers, pregnant women and vulnerable groups. County Durham PCT and Darlington PCT both have an excellent record in helping people to stop smoking. However, stop smoking services alone cannot reduce smoking prevalence. Concerted and effective activity on all strands of tobacco control by a range of partners must be implemented. The six strands of tobacco control are: • • • • • • Tobacco regulation; Reduced promotion and availability; Smuggled and counterfeit tobacco; Media and educational campaigns; Effective stop smoking services; Reduced exposure to second hand smoke.

All these strands must be delivered to ensure smoking is reduced. Darlington and each of the districts in County Durham have a local tobacco alliance working to deliver effective tobacco control activity to achieve national targets set for reducing smoking prevalence: • • Reduce smoking prevalence to 21% by 201 (currently 22%, 2006;) Reduce smoking prevalence in routine and manual workers from 31% to 26% by 2010 (currently 29%, 2006.)

2.
2.1

Stop smoking service
Performance

The Department of Health measures the success of stop smoking services using the number of people successfully quitting at four weeks per 100,000 of the population. The County Durham and Darlington stop smoking service continues to achieve and exceed targets for the local delivery plans (LDP) each year (figure 1).

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Over the last three years, the County Durham and Tees Valley services have continued to achieve the highest quit rates per 100,000 people in England (table 1). Figure 1: County Durham and Darlington LDP trajectories and actual quitters 2003/4 to 2006/7.
6000 5000

4 week quiter

4000 3000 2000 1000 0 April 2003 March 2004 April 2004 March 2005 April 2005 March 2006 April 2006 March 2007
Target
Actual

Year

Table1: Quit rate per 100,000 of population compared to England average Year County Durham Tees Valley Quit England average Quit Rate Rate per 100,000 of population per 100,000 of population 512 2003/04 934 744 2004/05 1212 818 2005/06 1214 783 2006/07 1216 For 2007/08 the stop smoking service’s LDP target is to achieve 5,454 quitters at four weeks. Table 2 shows the actual quitters so far this year. The service was 84% towards this year’s target by quarter 3. Table 2: Quitters achieved during the first three quarters of 2007/08 2007/08 Quarters Actual 4-week quitters Quarter 1 (April-June) Quarter 2 (July-Sept) Quarter 3 (Oct-Dec) Total so far 1,452 1,809 1,291 4,552

County Durham has a Local Area Agreement (LAA) stretch target. Table 3 shows the current performance against this target. The service exceeded year one target and by the end of quarter three of this year the service is already 99% towards achieving the target, with quarter four data still outstanding. Table 3: LAA performance to date Year Target Achieved 2006/07 3,768 4,519 2007/08 3,905 3,891 (quarter four data due May 2008) 2008/09 4,459

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2.2

Capacity

This year has been a very busy year for the stop smoking service. With the implementation of Smokefree legislation on 1 July 2007, the service saw an increase of 72% in smokers accessing the service in quarter 2. This resulted in an additional 886 quitters in the quarter compared to the same quarter last year. In addition to smokefree legislation, a new stop smoking drug was licensed in England in December 2006 called Varenicline (Champix), a non nicotine replacement drug. The drug was endorsed by County Durham and Darlington Drug and Therapeutics Committee in June 2007. The drug has been very popular with smokers accessing the service. The service is experiencing quit rates from this drug that have exceeded quit rates from nicotine replacement therapy (NRT) and Zyban and, for the first time since its approval, its use was greater in quarter three 2007/08 than NRT (1025 smokers used NRT, 1235 smokers used Champix). The quit rate achieved with Champix was 61%; the quit rate with NRT was 42%. In 2007/08, both PCTs have invested to increase the capacity of specialist advisors. In January 2008, four new specialist advisors were appointed to work across Darlington and countywide in four identified gap areas; pregnancy; workplace; prisons; secondary care/mental health services. 2.3 Challenges

For 2008/09 new Operating Framework targets (previously called LDP targets) will be set locally. The Strategic Health Authority is expecting more challenging targets for County Durham and Darlington. The Department of Health is also implementing more rigorous monitoring guidelines which will focus on: • • • • improving the quality of stop smoking services; monitoring quit rates by socio-economic groups, types of intervention and intervention settings; services that do not achieve minimum set percentage quit rates will have to carry out exception reporting and greater focus on quitters from routine and manual workers.

From 1 April 2008, new Service Level Agreements (SLAs) will be implemented with all providers of stop smoking services in County Durham and Darlington to ensure performance and core quality standards are delivered. Since the reconfiguration of the PCTs, standardisation of service commissioning and access to stop smoking aids e.g. nicotine replacement therapy (NRT) is being implemented, to ensure equity of access across the County and Darlington for patients accessing stop smoking support. In County Durham and Darlington approximately 25% of pregnant women continue to smoke throughout pregnancy. Progress towards LDP targets for this group is not as successful as the generic service. This is the most challenging client group to work with. Many women smokers who are planning pregnancy, or on becoming pregnant, stop smoking. The 25% who do not quit are more likely to be younger, have no 5

partner, or live with partner and family members who smoke and be from a disadvantaged community. To address this, a steering group for smoking and pregnancy was developed in February. The group includes key staff representatives from maternity and midwifery services, contraception services, teenage pregnancy services, health visitor/school nursing, specialist pregnancy stop smoking advisors. An action plan has been developed which is based on the regional Ten High Impact Actions for reducing smoking at preconception, during pregnancy and post partum. The group will meet again in June 2008 to report progress on actions developed.

3.

Tobacco control

Implementation of smokefree legislation has led to an assumption that tobacco control work is complete. However, protecting people from secondhand smoke is only one element in the drive to reduce smoking prevalence. Ireland implemented smokefree legislation in 2004. As a result smoking prevalence dropped. However, no other tobacco control activity was undertaken and within two years the smoking prevalence has started to rise again (figure 2). Figure 2: smoking prevalence in Ireland pre and post legislation

To ensure this does not happen in England, actions on tobacco control are being continued. In the North East, ‘Fresh’, the dedicated office of tobacco control which is a joint funded initiative by all the North East PCTs, is a key strategic and operational element that plans and delivers on regional tobacco control activity for the North East. ‘Fresh’ leads on the development of all strands of tobacco control and provides evidence-based support to PCTs and alliances. The North East is the only region to have this approach. County Durham and Darlington have already established tobacco control alliances however, since smokefree legislation was implemented there has been a reduction in attendance at alliance meetings. In an effort to reinvigorate the alliances, in January 2008, a conference was held for key representatives from a range of organisations n County Durham and Darlington to hear progress on the six strands of tobacco control

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and find out what needs to be done in the future. The conference was attended by over sixty delegates who also participated in workshops to discuss how they can contribute. The feedback from these workshops has been shared with local tobacco alliances.

4.

Implications and Risks

Local tobacco alliances have been undertaking a process of reviewing functionality by assessing themselves against a set of criteria as to how they are performing in partnership work. A major outcome of these reviews is that all alliances need to increase partner organisation membership to enable all elements of tobacco control to continue effectively. Uncertainty in relation to structures post local government review in County Durham may be a barrier to engagement. There will be consequences for tobacco control work and reducing smoking prevalence if the alliances do not progress this work. The Department of Health has recommended that PCTs set new operating framework targets for stop smoking services based on the previous three year 4week quitters achieved. However, the Strategic Health Authority is concerned that this is not challenging enough. This will consequently put pressure on PCTs to set higher targets. Setting higher than the recommended targets for achieving quitters per 100,000 of population puts pressure on services to increase throughput at the risk of compromising on quality. Therefore quality and targets may be compromised. The new stop smoking service monitors performance and the SLAs will identify service providers who are not performing to standard. The outcome of this may affect providers’ contracts. The PCTs will need to put in place alternative arrangements to provide a stop smoking service in these areas, should this happen. This may have implication on the capacity of current stop smoking staff/workforce.

5.

Recommendations

County Durham PCT Board and Darlington PCT Board are asked to: • Note the progress and excellent performance achieved by the stop smoking service in: - Achieving/surpassing local delivery plan (LDP) targets and LAA targets. - Achieving some of the highest quit rates nationally per 100,000 population. • Note that the service will be under pressure over the next three years to achieve new targets and perform on all the core quality outcomes stipulated by the Department of Health. • Be advocates for tobacco control by maintaining the high profile of tobacco control and encouraging and supporting the continuation of the effective delivery of tobacco control alliance work. Sponsoring Director: Dr Tricia Cresswell, Director of Public Health, County Durham and Darlington PCTs 17 March 2008 7


				
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