Content

RESOLVED:
 
 
3.1  Agree the
commissioning of the City and Hackney Stop Smoking Service for a
period of up to five (5) years (3+1+1) beginning 01/07/2024 at a
maximum value of £4m (Option number 4 in section
6).  This will include within this
financial envelope, a budgeted amount of £80,000 per annum
for an insourced PO7 post to provide an enhanced community
engagement function and work with the provider to develop
partnerships with high prevalence and high risk
communities.
 
3.2  Such commissioning
shall include the option to award further funding to the successful
bidder of up to £500k (in total, over the lifespan of the
contract, depending on allocation from central government) for
optional additional work packages to deliver national initiatives.
The potential scope of these work packages is described in section
6.5.7 of the submitted report.
 
Reasons for Decision  
 
6.1  There are four options
relating to the future of the City and Hackney Stop Smoking Service
(SSS) that have been considered in this business case and are set
out below. It is essential to first understand the wider context in
which these options have been considered.
· 
Smoking is the primary
cause of preventable illness and premature death, accounting for
approximately 74,600 deaths a year in England, and the leading
cause of health inequalities, accounting for half the difference in
life expectancy between the richest and poorest areas.
· 
Evidence shows at
least one in two long term smokers will die from a smoking-related
disease, but that risk may now be as high as two in
three.
· 
The annual societal
costs of smoking in Hackney are estimated at over £100m each
year (equivalent data for the City are not available). These costs
are spread across health services, local authorities (accounting
for an estimated 8% of all paid home and residential care costs)
and the fire service - but the most significant costs are in lost
productivity due to smoking-related ill-health. In the context of
the current cost of living crisis, it is particularly important to
recognise and address the impacts of smoking in driving people into
poverty, estimated to affect almost 3,000 households locally each
year.
· 
Smoking interventions
are the most cost effective (often cost ‘saving’) of
all public health interventions and have the greatest impact on
reducing health inequalities (along with domestic violence
prevention).
· 
Smoking is highly
addictive, with two thirds of those who try smoking going on to
become daily smokers. Smokers who access an evidence-based stop
smoking service are three times more likely to quit than those who
go it alone.
· 
According to data from
the Annual Population Survey in 2021, smoking prevalence in Hackney
amongst adults (age 18+) was 14.2%, higher than our 15
‘statistical neighbours’.  Equivalent data are not available for the
City.
· 
Adult smoking
prevalence in Hackney has fallen since the existing service started
in 2018, from 14.8% to 14.2% in 2021. Applying 2021 estimated
prevalence to the local population equates to  approximately 30,000 adults (age 18+) still
smoking in Hackney.
· 
City and Hackney
currently has a single Stop Smoking service contract with
Whittington Health. This includes a subcontracting arrangement with
the GP Confederation, SLAs between Whittington Health and
individual community pharmacies and a directly delivered community
outreach service. The service also delivers training to partners
(very brief advice and specialist stop smoking advisor training).
This contract is currently due to finish at the end of June
2024.
 
6.2 Option 1 - End the service at the currently scheduled
end date of 30/06/2024 and do not commission a new Stop Smoking
Service
 
6.2.1 This option considers the implications of ceasing the
Stop Smoking Service in City and Hackney.
 
6.2.2 Whilst this provides a saving to the council, it does
not give full consideration to the context set out in 6.1 above and
the evidence of significant need related to tobacco-related harm
and associated health inequalities. This option will remove access
to a much needed evidence-based service for the tens of thousands
of people who still smoke in City and Hackney.
 
6.3 Option 2 - Reprocuring the
Stop Smoking service based on the current service model and
specification
This option considers reprocuring the Stop Smoking Service based on the
current model and specification that is already in
place.
 
6.3.2 The existing Stop Smoking Service performs well for
clients who attend the service; Hackney’s outcomes ranked 3rd
out of 16 in 2020 when compared to its statistical neighbours for
both “smokers setting a quit date” and for
“self-reported successful quits at 4 weeks”.,
Hackney’s performance against these national smoking
indicators is also consistently above the England
average.
 
6.3.3 Whilst the service delivers a strong package of
support to the clients who attend, it has been less successful in
attracting referrals from some high risk groups/high prevalence
communities (including pregnant/postpartum women, smokers from the
Turkish/Kurdish community and those in routine and manual
occupations) (see appendix 1 for full list of priority
groups).
 
6.3.4 The main (Hackney) service began in July 2018 and
City of London joined to create an integrated service in April 2021
(following very poor performance under previous contractual
arrangements in the City). However, since the outset, the City
element of the service has continued to underperform and a recovery
plan has been put in place for the final year of the contract. It
is proposed that the successful elements of this recovery plan are
carried through into the new service.
 
6.3.5 In addition, since the start of the existing service
in 2018, new guidance has been published by National Institute for
Health and Care Excellence (NICE) on preventing smoking uptake,
promoting quitting and treating dependence. This guidance includes
several new recommendations including lowering the age threshold of
a Stop Smoking Service from 18 to 12 and incorporating
nicotine-containing e-cigarettes as a treatment option for over
18s.
 
6.3.6 Also, since the current service began, the NHS Long
Term Plan was published (in 2019), which provided NHS funding for
tobacco dependency treatment for inpatients within acute and mental
health trusts, as well as maternity services. These wider system
changes will have an (as yet unknown) impact on the community stop
smoking provision. The existing Stop Smoking Service, commissioners
and NHS providers are working closely together to ensure alignment
of local pathways and effective continuation of treatment following
discharge from hospital. This new NHS provision is not reflected in
the current service specification and therefore adjustments are
needed to ensure referral pathways remain transparent, effective
and safe for service users.
 
6.3.7 Local data and insight gathered as part of the
co-design process point to a number of improvements and
enhancements to the service model that would better meet the needs
of local people. These include:
· 
a strengthened
community outreach and engagement function to work in a more
targeted way with residents most at risk from the harms of
tobacco
· 
strengthening and
extending ongoing support for people to reduce relapse and remain
‘smokefree’
· 
increase access to
harm reduction approaches for those motivated to reduce their
tobacco use but not yet ready to quit in one go
Continuing with the existing model would not
provide the flexibility to improve the service in line with these
insights.
 
6.4 Option 3 - Recommission a
new Stop Smoking Service based on a redesigned service model and
specification
 
6.4.1 This option considers recommissioning a new Stop Smoking Service based on
a redesigned service model and specification.
 
6.4.2 As outlined in option 2, new NICE guidance (published
in 2021), analysis of the most recent data and new local insights,
as well as new funding for hospital-based tobacco dependency
treatment services, point to a number of improvements and
enhancements that will better meet the needs of local people.
Incorporating these elements (see 6.3.5 and 6.3.6 above) would
require a re-designed Stop Smoking Service to be
commissioned.
 
6.4.3 In addition, due to difficulties in estimating
service demand from the large transient City worker population
(approximately 587,000 workers are based in the City of London in
2023, with high estimated prevalence of smoking, but historically
low uptake of stop smoking services), a more flexible model is
required.
6.4.4 Whilst this option considers the latest evidence and
insight available for City and Hackney, this fully outsourced Stop
Smoking Service model does not give full regard and commitment to
the Hackney Labour Manifesto 2022-26 to review all outsourced
services, with a view to bringing them in-house. A fully outsourced
option would exclude some of the key advantages to insourcing
particular elements of this service, as detailed in option 4
below.
 
6.5 Option 4 - Recommission a
new Stop Smoking Service based on a redesigned service model and
specification including an insourced service element
 
6.5.1 This option considers recommissioning a new Stop Smoking Service based on
a redesigned service model and specification including an insourced
service element.
 
6.5.2 This option would seek to incorporate the latest
evidence and best practice guidelines, as well as insights that
have been gathered from resident and stakeholder engagement and
data analysis (see option 2). For completeness the changes proposed
for the new service are repeated/collated below.
· 
Incorporate the latest
guidance from NICE including lowering the age threshold from 18 to
12, continuing to offer behavioural support plus medication (now
including nicotine-containing e-cigarettes for over 18s only) as
the most effective way to support smokers to quit, with support
tailored to the specific needs of individual smokers
· 
Integration/alignment
of community and hospital-based stop smoking and tobacco dependency
treatment service pathways.
· 
Strengthening and
extending ongoing support for people to reduce risk of relapse and
remain ‘smokefree’.
· 
Increase access to
harm reduction approaches for those motivated to reduce their
tobacco use but not yet ready to quit in one go.
· 
Specify a revised
model for the City element, including new activity targets (and
corresponding adjustment to the City contribution to the service
budget - see savings section 6.16), as well as additional capacity
provided through the virtual Stop Smoking London portal (available
through membership of the London Smoking Cessation and Tobacco
Control Programme, funded separately).
· 
Insourcing
of an enhanced community engagement function, through recruitment of a
dedicated officer to be hosted by Hackney Council. It is proposed
this would be a PO7 post and the budgeted amount for this is
£80,000 per annum, which is included within the
£800,000 financial envelope for this service. This community
engagement officer will work alongside the contracted provider and
develop close partnerships with key local high risk/high prevalence
communities, building on the successes of the Public Health
Community Champions programme. This partnership approach will aim
to ensure the service is flexible to the wider needs of priority
groups, helping to deliver on the new service's priority objective
to reduce inequalities in tobacco related harm. The full scope of
work for the insourced community engagement officer will evolve in
response to community and service needs, but is expected to
include:
o 
working with the
service provider to build capacity in community organisations to
deliver stop-smoking advice directly
o 
supporting the
co-development of tailored communications and targeted outreach to
promote the service
o 
building/strengthening
relationships between high risk/prevalence communities and the
service provider to maximise responsiveness and reach of the
service
o 
gathering insight from
people in these communities to support ongoing service improvement
and co-design to better meet the needs of smokers in City and
Hackney.
 
· 
Inclusion of a
ringfenced outreach and engagement
budget of £50k per year, to fund community partners to
support the work with priority groups described above. This fund is
part of the overall service budget and would be held and
distributed by the provider. The provider will be required to work
in close partnership with the insourced community
engagement  officer to co-design an
approach for allocating this funding that is proportionate, fair
and transparent.
 
6.5.3 This proposed new service would replace all existing
provision (including community outreach, GP and pharmacy based Stop
Smoking Services) and integrate with new NHS tobacco dependency
treatment pathways. The new service proposals will build on
learning from the coronavirus pandemic in seeking to work in
partnership with the voluntary and community sector; co-designing
and implementing a flexible service offer that meets the needs of
those who would benefit the most, within communities where tobacco
harms are high, but uptake of local Stop Smoking Services has
historically been low.
 
6.5.4 The evaluation and design work has considered options
for taking an holistic approach to supporting people to address
multiple health risks and address wider needs that affect
people’s smoking behaviour. It has considered the most
appropriate delivery model for achieving the priorities for the new
service (such as a single integrated service, lead provider network
or multiple contract lots and insourced provision - see section
9.4).
 
6.5.5 Following a detailed benchmarking exercise, (see
section 6.15), it is proposed that the budget for the new service,
whilst including the new/enhanced elements outlined above, can be
reduced (see savings proposals in section 6.16).
 
6.5.6 A recent announcement from the Department of Health
and Social Care has set out that “one million smokers will be
encouraged to swap cigarettes for vapes
under a pioneering new ‘Swap to Stop’ scheme designed
to improve the health of the nation and cut smoking rates. Pregnant
women will also be offered financial incentives to help them quit
as part of a sweeping package of measures to cut smoking rates in
England.”
 
6.5.7 At the time of writing, there has been no further
detail on when or how these national initiatives will be
implemented, nor how the funding for delivery will be disseminated
to local areas. However, it is expected that these initiatives will
be rolled out during the lifetime of the new Stop Smoking Service
and it is anticipated that up to £500k in total will be
received for local delivery across the life of the new contract.
These will be additional ‘work packages’ that the
provider would be expected to deliver as part of the Stop Smoking
Service contract, were the funding to become available.
 
6.6 From the options appraisal above, option 4
is recommended.
Benefits Realisation and Lessons
Learnt 
 
6.7.1 The current contract is managed by the tobacco
control lead and commissioning lead in the form of monthly and
quarterly meetings with the Stop Smoking Service provider. Monthly
meetings include general service updates and quarterly meetings
consist of benchmarking performance against the KPIs. Any issues
that arise in between meetings are addressed with the
provider.
 
6.7.2 Where consistent areas of underperformance have been
identified, most notably in the City element of the service, a
recovery plan was put in place and is reviewed on a monthly basis
by representatives of the provider, Public Health and the City of
London. The City KPIs (and budget) were reduced for the final year
of the current contract (2023/24) in line with ongoing
underperformance and assessment of lower than anticipated demand
(based on extensive engagement with a range of stakeholders). The
budget for City activity was reduced accordingly.
 
6.7.3 A full review of the current service model was
undertaken to inform the design of the new Stop Smoking Service. As
mentioned previously, for those who access the service, outcomes
are very positive - quit rates are well above the national standard
of 35% (commonly achieving or exceeding 60% over the life of the
contract) and the service consistently receives positive feedback
from service users. However, there are gaps in the reach of the
current service with certain high risk groups and high prevalence
communities (including Turkish/Kurdish smokers and those in routine
and manual occupations) under-represented. The new service aims to
address this through a strengthened focus on addressing
inequalities in uptake, through a fully flexible service model,
insight-informed tailored and targeted communications, plus a
dedicated outreach and engagement function (see 6.5.2).
 
6.8 Preferred Option
 
6.8.1 The preferred option for this service is Option 4:
Recommission a new Stop Smoking Service
based on a redesigned service model and specification including an
insourced service element.
 
6.8.2 This option:
· 
builds upon the good
performance of the existing service
· 
takes account of the
findings of recent data analysis, service and stakeholder
engagement and NICE recommendations.
· 
aligns with the
Hackney Labour Manifesto 2022-26 to review all outsourced services
with a view to bringing them in-house (Further details on the
benefits of a hybrid insourced/outsourced model can be found in
Appendix 2: Insourcing/Outsourcing Options Appraisal (Stop Smoking
Service)
· 
reduces the overall
budget following a detailed benchmarking exercise
· 
takes account of
future national government funding expected during the lifetime of
this contract.
 
6.8.2 Whilst this option provides savings when compared to
the existing budget, expenditure to deliver this service would
still be required (when compared to Option 1). 
 
6.9 Alternative Options (considered and
rejected)
 

Option
 

Advantages
 

Disadvantages
 

Option 1: End the service at the currently scheduled end
date of 30/06/2024 and do not commission a new Stop Smoking
Service
 

Provides an efficiency against the PH grant
 

Will remove an essential service from the already high
number of tobacco users locally, and will have a detrimental impact
on population health and further exacerbate health inequalities
across City and Hackney.
 
Fails to take account of local and national policy
commitments on smoking and inequalities
 

Option 2: Reprocure the Stop
Smoking service based on the current service model and
specification
 

Maintains the status quo of a service that is effective in
helping people stop smoking
 

Does not account for the findings of recent data analysis,
service and stakeholder engagement and NICE recommendations - in
particular actions needed to reduce inequalities in the harms from
smoking.
 

Option 3: Recommission a new
Stop Smoking Service based on a redesigned service model and
specification
 

Builds upon the good performance of the existing service
and takes account of the findings of recent data analysis, service
and stakeholder engagement and NICE recommendations.
 

Does not give full regard and commitment to the Hackney
Labour Manifesto 2022-26 to review all outsourced services, with a
view to bringing them in-house.
 
Fails to fully build on the learning from COVID-19,
including the Public Health Community Champions programme, about
working in closer partnership with communities to improve
population health.
 

 
.