Political priorities and public health services in English local authorities: the case of tobacco control and smoking cessation services

Abstract

Background

Since 2013, local authorities in England have been responsible for public health including smoking cessation services.

Methods

Online surveys of tobacco control leads in English local authorities were conducted in 2014 (76% response rate, n = 116), 2015 (82% response rate, n = 124) and 2016 (85% response rate, n = 129).

Results

A high priority for tobacco control was reported in 17% of local authorities in 2014, rising to 27% in 2016. A low priority for tobacco control was reported in 4% of local authorities in 2014, rising to 11% in 2016. Budgets for smoking cessation services were cut in 16% of local authorities in 2014, 39% in 2015 and 59% in 2016. In 2016, budgets were cut in all local authorities where the priority given to tobacco control was perceived to be low and in 40% of the local authorities where it was perceived to be high. Cuts in smoking cessation budgets were principally due to cuts to the public health grant and wider cuts to local authority budgets.

Conclusions

At a time of significant cost pressure, political support for tobacco control in English local authorities mitigates but does not remove the risk of cuts to budgets for smoking cessation services.

Background

In 2013 public health teams in England moved from the NHS to local authorities. This was not unfamiliar territory for the professionals involved; it was arguably a return ‘home’ as public health had historically emerged as a discipline within local government.¹ Moreover, prior to the 2013 reorganization, some directors of public health had been joint appointments with local authorities and many public health professionals had experience of working collaboratively with their local authority colleagues. Nonetheless, local authorities operate in markedly different ways to the NHS so the reorganization demanded that these professionals go beyond the comforts of partnership to engage fully with a new set of values, and adapt.

The NHS is a centralized bureaucracy in which most professional decision-making is independent from overtly political considerations. In contrast, local authorities are overseen by locally elected councillors who have great influence over both strategic and operational decisions. Evidence-based medicine, the gold standard for clinicians, can flourish in the former environment but may be marginalized in the latter where councillors’ local expertise may trump professional expertise² and local evidence may be more powerful in decision-making than academically robust evidence gained elsewhere.³

These different attitudes to evidence and decision-making are informed by different values, and as such are incommensurable. The challenge for public health professionals has been to bridge these values: working with diverse types of evidence to make their case, addressing economic as well as health impacts, framing evidence carefully to be accessible and persuasive, while also drawing on normative, political arguments.⁴ They have had to negotiate a plural understanding of ‘health and wellbeing’ in which greater emphasis is given to the broader determinants of health than in the NHS⁵ and the meaning of ‘wellbeing’ tends to be fluid and context-dependent.⁶

This process of adaptation and integration has been complicated by a series of funding challenges. When local authorities took over public health in 2013, they received a ring-fenced grant from the Department of Health to meet their new responsibilities. These responsibilities were broadly defined,⁷ so local authorities had considerable scope to decide for themselves how best to use the grant (local public health budgets were never ring-fenced). This flexibility was consistent with the rationale for the reorganization, which was to encourage action on the wider determinants of health,^8,9 but it generated some local tensions about how and where the new resources should be sent. Directors of public health have had to protect established public health services while also exploiting interest in the grant to engage with the wider interests of their local authorities.⁴

In June 2015, the government unexpectedly announced a £200 m (6.2%) cut in the annual public health grant, with further cuts to the grant planned year-on-year, amounting to a real terms reduction from £3.47 bn in 2015–16 to just under £3 bn in 2020–21.¹⁰ The effects of these cuts on public health have not been fully assessed though serious concerns have been expressed about their impact on public health services and the profession.¹¹

This study examines the post-2013 experience of public health teams in local government through the lens of tobacco control. This was an area of public health activity for which local authorities could boast significant expertise prior to 2013, particularly through the work of trading standards officers and environmental health officers in promoting compliance to smoking-related legislation. Many local authorities had also been partners with the NHS on local tobacco control alliances.

Smoking is the leading cause of preventable death in every local authority, contributing to 20% of deaths among men and 13% of deaths among women,¹² and the principal driver of health inequalities.¹³ Although smoking is a behaviour, and not one of the ‘wider determinants’ of ill health, smoking has a major impact on these determinants, above all by increasing household poverty.¹⁴ Smoking also costs local authorities in England £760 m every year in social care costs.¹⁵

We report key findings from annual surveys of tobacco control leads in local government conducted in the three years following the move of public health to local government. The analysis here focuses on political support for tobacco control within local authorities and changes to budgets for smoking cessation services and wider tobacco control work such as tackling the illicit trade, promoting smoke-free environments and media campaigns.

Methods

Online surveys of tobacco control leads in local authorities in England were conducted in 2014,¹⁶ 2015¹⁷ and 2016.¹⁸ There are 152 local authorities in England with responsibility for public health, the majority of which do not share public health resources with other local authorities. Most respondents therefore answered for the single authority they represented. In those local authorities where public health responsibilities are shared with neighbouring authorities, respondents were asked to answer key questions separately for each of the authorities they represented.

The surveys were conducted online using Survey Monkey. All respondents were emailed a link to the survey. Non-respondents were telephoned and encouraged to complete the survey online. The first survey was accessible between May and July 2014 and received 110 valid responses, representing 116 local authorities (76%). The second survey was accessible in June and July 2015 and received 116 valid responses, representing 124 local authorities (82%). The third survey was accessible in June and July 2016 and received 120 valid responses, representing 129 local authorities (85%).

Additionally, a subsample of 87 local authorities was identified for which responses had been received in all 3 years of the survey. This represents 60% of the local authorities for which data had been obtained in any year of the survey and 57% of all local authorities with a public health remit. The data for this subsample were combined in a unitary dataset to enable longitudinal analysis. There were no indications that this subsample differed from the larger single year samples: results for core questions did not differ significantly between the full sample and the subsample.

Quantitative analysis was undertaken using SPSS Version 24. Free-text answers to open questions were subject to simple content analysis. Free-text responses were reviewed and common themes identified, which were then applied systematically to the responses, revised where appropriate, then re-applied in a second pass though the data.

Results

Political support

Each year, respondents were asked how they perceived the level of political priority given to tobacco control in their local authority (Table 1). In all three years, a majority of respondents reported an above average or high priority given to tobacco control in their local authority. At the extremes, reports of low and high priority have both risen markedly while reports of average, below average and above average priority have all declined.

Table 1.

Level of priority given to tobacco control in local authorities, as perceived by respondents, 2014–16

Year	Level of perceived priority for tobacco control
	Low	Below average	Average	Above average	High
2016	13 (11%)	10 (8%)	31 (26%)	34 (28%)	32 (27%)
2015	10 (9%)	10 (9%)	32 (28%)	42 (38%)	19 (17%)
2014	4 (3%)	14 (12%)	38 (34%)	39 (35%)	18 (16%)

In the 2015 and 2016 surveys, respondents were asked to describe the level of support for, or opposition to, tobacco control expressed by the leader, lead member for health and wellbeing and chief executive in their local authority (Table 2). In both years, four in five respondents were confident of the support of the lead member for health and wellbeing. Active opposition from the lead member for health and wellbeing was reported by only 3% of respondents in both years.

Table 2.

Key stakeholders’ support for, or opposition to, tobacco control by local authority, 2015 and 2016

	Year	Support for, or opposition to, tobacco control
		Support	Neither support nor oppose	Oppose	Don’t know
Leader	2016	66 (54%)	20 (14%)	4 (3%)	32 (26%)
	2015	63 (55%)	17 (15%)	4 (3%)	30 (26%)
Lead for health and wellbeing	2016	98 (80%)	11 (9%)	4 (3%)	9 (7%)
	2015	95 (82%)	11 (9%)	3 (3%)	7 (6%)
Chief executive	2016	66 (54%)	24 (20%)	2 (2%)	29 (24%)
	2015	65 (57%)	15 (13%)	1 (1%)	32 (28%)

Budgets

Each year, respondents were asked if their budgets for smoking cessation services and wider tobacco control work had changed (Table 3). In the first year of the survey, budgets were relatively stable. In 2015 cuts to smoking cessation and tobacco control budgets were more prevalent than budget increases. In 2016, 59% of local authorities cut their smoking cessation service budgets and 45% cut their wider tobacco control budgets.

Table 3.

Changes to local authority tobacco budgets for smoking cessation services and wider tobacco control work, 2014–16

		Year-on-year change in budget
		Decreased	Stayed the same	Increased
Smoking cessation services (excluding medications)	2016	74 (59%)	44 (35%)	7 (6%)
	2015	45 (39%)	66 (56%)	6 (5%)
	2014	15 (16%)	63 (66%)	17 (18%)
Wider tobacco control work	2016	57 (45%)	58 (46%)	11 (9%)
	2015	30 (28%)	65 (61%)	11 (10%)
	2014	15 (16%)	52 (55%)	27 (29%)

Considering only the local authorities for which we have data for all 3 years of the survey, 11 (15%) had cut their budgets in 2014, 33 (41%) had cut their budgets in 2015, and 52 (61%) had cut their budgets in 2016. Within this longitudinal subsample, 21 (27%) had cut their budgets for smoking cessation services in both 2015 and 2016. Only 2 (3%) had cut their budgets for smoking cessation services in all three years of the survey.

As the changes to smoking cessation service budgets in 2016 were most pronounced, this year was taken as the focus for an exploration of the relationship between budgets, priorities and stakeholder support. Table 4 describes the relationship between the perceived priority of tobacco control within the local authority and changes to budgets for smoking cessation services in 2016. Where the priority for tobacco control was low, budgets were universally cut; where priority was high, 40% of budgets were cut. Between these extremes, among those reporting average, below average or above average priority, around third-fifths of budgets were cut.

Table 4.

Priority given to tobacco control in local authorities versus changes to budgets for smoking cessation services, 2016

Priority given to tobacco control in 2016	Change to smoking cessation services budget in 2016
	Decreased	Stayed the same	Increased	Total
Low	13 (100%)	0	0	13
Below average	6 (60%)	4 (40%)	0	10
Average	17 (59%)	9 (31%)	3 (10%)	29
Above average	21 (62%)	11 (32%)	2 (6%)	34
High	12 (40%)	16 (53%)	2 (7%)	30
Total	69 (59%)	40 (35%)	7 (6%)	116

The relationship between budget cuts and stakeholder support for tobacco control was explored by simplifying the variables and using bivariate tests (Table 5). The independent variable—perceived stakeholder support—was simplified to active support or lack of it (combining ‘neither support nor oppose’ and ‘oppose’). The dependent variable—changes to the 2016 smoking cessation service budget—was simplified by combining ‘stayed the same’ with ‘increased’.

Table 5.

Support for tobacco control from key stakeholders and changes to budgets for smoking cessation services, 2016

Support for tobacco control		Change to smoking cessation services budget in 2016		Total	Chi-square	P
		Decreased	Stayed the same/increased
Lead member for health and wellbeing
Active supporter?	Yes	51 (54%)	44 (46%)	95	5.132	0.023
	No	12 (86%)	2 (14%)	14
Leader
Active supporter?	Yes	35 (54%)	30 (46%)	65	1.178	0.278
	No	16 (67%)	8 (33%)	24
Chief executive
Active supporter?	Yes	35 (55%)	29 (45%)	64	0.353	0.552
	No	16 (61%)	10 (39%)	26

The results in Table 5 suggest that political support from the lead member for health and wellbeing is likely to be important in decisions about smoking cessation budgets. There is no evidence that support from the leader or chief executive makes such a difference.

In 2016, the 74 respondents who reported that their smoking cessation service budgets had been cut were asked why this had happened. This was an open question which respondents answered in their own words. The most commons responses were cuts to the public health grant (specifically cited by 27 respondents), local authority cuts (15 respondents) or simply pressure on budgets (13 respondents). Recommissioning was identified by 11 respondents, decommissioning by four and reduced demand and underspend by five respondents each.

Discussion

Main findings of this study

In the majority of English local authorities with a public health remit, tobacco control was perceived by those responsible for this area of work to enjoy an above average or high priority in each of the three years from 2014 to 2016. The proportion of local authorities where a high priority for tobacco control was reported has risen from 16% in 2014 to 27% in 2016. However, there has also been an increase in the proportion of local authorities where a low priority for tobacco control was reported, rising from 3% in 2014 to 11% in 2016.

In 2014, the first year following the relocation of public health to local government from the NHS, budgets were fairly stable. But in 2015 budgets for smoking cessation services were cut in 37% of local authorities, followed by cuts in 59% of local authorities in 2016. Similarly, budgets for wider tobacco control work were cut in 25% of local authorities in 2015 and in 45% of local authorities in 2016. Over a quarter (27%) of local authorities made cuts to their budgets for smoking cessation services in both 2015 and 2016. The main reasons for the cuts to smoking cessation service budgets in 2016 were the cut in the public health grant and wider cuts to local authority budgets.

The level of priority given to tobacco control within a local authority offers some protection for budgets at a time of financial constraint. In 2016, cuts had been made to smoking cessation service budgets in all of the local authorities where the priority of tobacco control was perceived to be low, and in 40% of local authorities where the priority was perceived to be high.

The lead member for health and wellbeing actively supported tobacco control work in 80% of local authorities in 2016. Where she or he did not, cuts to smoking cessation budgets were more common. Other key stakeholders—the leader and chief executive—did not appear to have this level of influence.

What is already known on this topic

Local government is recognized to be an overtly political environment in which priorities and strategy are negotiated between elected members, officers and the communities they serve. Public health professionals have had to adjust to this environment since their arrival from the NHS in 2013.⁴ Several studies have drawn attention to the challenges they have faced, including reconciling a commitment to evidence-based medicine with a local government approach to decision-making in which local evidence and political priorities may be more salient.^2,3

To date, there is little quantitative evidence about the effect of local politics and priorities on public health decision-making in local government. Concerns have, however, been raised about the use of the ring-fenced public health grant. In particular, there is a perceived risk that public health services funded by this grant may suffer if local authorities choose to use the money in different ways.¹⁹

What this study adds

This study provides a quantitative account of the relationship between political priorities and public health decision-making in local government using the case of tobacco control.

Tobacco control and smoking cessation services were a core part of all NHS public health teams prior to 2013. In the local government setting, this universality is under threat. Although tobacco control is perceived to be an above average or high priority in a majority of local authorities, there are many local authorities where this political support is not forthcoming. Tobacco control and smoking cessation services in local authorities where priority for tobacco control is perceived to be low are especially vulnerable to budget cuts and decommissioning. The support of the lead member for health and wellbeing was shown to be important in protecting budgets.

At a time of intense cost pressures, however, political support only mitigates the risk of budget cuts. The majority of local authorities in England cut their smoking cessation service budgets in 2016, including many local authorities where tobacco control was an above average or high priority. The primary reason for these cuts was the in-year cut in the public health grant for 2015–16, which all local authorities had to absorb.

This study also sheds light on local authorities’ use of their public health grant. The second-most common reason for a cut in the smoking cessation service budget in 2016 was local authority budget cuts. It is clear that public health budgets are not protected from these cuts, regardless of the ring-fence on the public health grant. However, we know nothing from this study about where else the public health grant is being spent within local authorities and whether the choices being made, at the cost of established public health services such as smoking cessation, are appropriate.

The increasing polarization of political attitudes to tobacco control over the 3 years of this study is noteworthy. We have no evidence about the cause of this polarization but it is possible that the cumulative effect of the cost pressures on local government has been to force local authority members to make more explicit where their priorities lie.

Limitations of this study

The data reported here are all drawn from self-completed surveys of tobacco control leads in English local authorities. The response rate was high in every year, so the results can be taken to be representative of all local authorities with a public health remit. However all data are personal views of the respondents. In particular, data on the priority of tobacco control within local authorities are the perceptions of tobacco control leads and do not necessarily reflect local authorities’ published priorities. Although perceived priority has been treated as the independent variable in the analysis of the relationship between priorities and budgets, changes to budgets may also have affected respondents’ perceptions of the priority given to tobacco control.

The surveys employed relatively simple measures to describe changes within tobacco control in local government. The analysis here focuses on changes to budgets without quantification of these changes. This is adequate to provide a broad view of the changes taking place but necessarily fails to capture the detail. The size of smoking cessation budgets and the scale of cuts to these budgets vary greatly between local authorities.

Conclusion

In the political environment of local government, some smoking cessation and tobacco control services have fared well but others have not. Experience has diverged and, to an extent, polarized since the transfer of public health teams from the NHS in 2013.

Many specialist smoking cessation services, well-established as the most effective way to quit,²⁰ have suffered budget cuts, principally because of the pressure on public health budgets from the cut in the public health grant and the wider cuts to local authority budgets. But it is local authorities’ staunchly-protected local decision-making powers that have shaped the diversity of response. In most areas, despite the cuts, smoking cessation services are still available to local smokers. In other areas, services are limited or gone. Although the reasons for these differences are necessarily complex, local political priorities play an important role. As smoking cessation services are not mandated, they may be vulnerable if local political support is weak. Wider tobacco control work has also suffered. The abolition of two regional offices for tobacco control in the northwest and southwest of England, which were supported by local authority funding, is one outcome of the downgrading of this work.

Directors of public health, lead members for health and wellbeing and tobacco control leads may have to find new ways of doing more with less in tobacco control but, given the size of the harm caused by tobacco, the case for protecting smoking cessation and tobacco control services at local level remains persuasive.

Conflicts of interest

None declared.

Funding

This work was supported by Cancer Research UK.