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BMJ: NHS smoking cessation analysis

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West et al published an analysis of the NHS SSS [1], the NHS smoking cessation programme, in the BMJ, in July.

It provides an interesting analysis of performance over the 10 years examined. The three notable factors are:
1. The paper does not mention that the costs quoted are only around 50% of the actual costs. The NHS routinely attempts to hide the drug costs associated with smoking treatments, for some reason; and since these are about equal to the NHS costs, the 'costs' published by them can be more or less doubled to get the real figure: what it costs the taxpayer.

2. These figures are for England only, so the real cost of smoking cessation efforts in the UK approaches (or exceeds) £200m a year.

3. West's estimate is that despite the millions treated in recent years, only around 20,000 per year are likely to have actually quit smoking. This is such an infinitessimally small percentage it is even worse than my previous lowest estimate of their efficiency [2].

This is something I have been trying to point out for a long time; essentially, the NHS SSS is taxpayer money flushed down the toilet accompanied by a near-fraudulent portrayal of the results and costs. The real beneficiaries are the pharmaceutical industry, who sell large quantities of virtually useless drugs to the NHS. The patients almost all revert to smoking; many will die as a result if they don't find some other much more successful way to quit.

Why do we accept such awful results?

The NHS Stop Smoking Services is notable for its high cost for abysmally poor results, not to mention its near-fraudulent cost presentations. West, however, is on record as describing the SSS as the jewel in the NHS' crown; I have described it as the turd on the NHS' face. It has the most abysmal performance of any part of the NHS, and that includes the notorious Stafford Care Pathway. Without a doubt it has killed many more people than Stafford Hospital.

In general the NHS performs exceptionally well, especially for a government-run service, and I am happy to place on record that my personal extensive use of its facilities scores a maximum 10 out of 10 in almost every possible regard. The only place I feel it falls down is the emphasis on treating disease instead of routinely putting patients through a triage system where nutrition and lifestyle would be addressed first, since GPs tell me that 75% of the patients they see are there because of diet and lifestyle choices. Nutritionists would be paid double their current rate if I ran the NHS, and it would be impossible to use NHS services without seeing one on a regular basis. But this is the most common failing in modern medical care, in any case. Treating the symptoms of ignorance doesn't seem an efficient way to run a healthcare system but that's the way it's done. Back to the West paper...

This study appears to be an attempt to dress up the very poor performance: 20,000 estimated successful quitters (per year?) versus a throughput of up to 800,000 smokers per year at a deliberately obfuscated cost of ~£84m per year for England alone (this figure omits the drug costs, which are about 50% of the total in any NHS area related to smoking). On the other hand, since the extremely poor performance is obvious from the figures, perhaps West is being rather subtle and actually giving us the reasons why we should demand this service is immediately halted.

The NHS traditionally hides its real costs in any smoking-related area: the drug costs are very likely to be 'optimistic' even if you can locate them, because it is very clear that the NHS are ashamed of this cost area and are very keen to downplay it or possibly present it in an optimal light, for reasons that are unclear at this time. Add to that, their 'success' rates are based on a 4-week successful quit rate. No, I'm not kidding - if someone is not smoking four weeks after the treatment finishes then they are marked up as a non-smoker. The 12-month mark more commonly used is far more honest (i.e., it is not fraudulent in both its intent and presentation, as the NHS version is perilously close to being).The truly honest and efficient use a 20-month mark for final determination of smoking status as that is the only realistic way to measure smoking cessation success, since the relapse rate has started to flatten out by that time - at 12 months it is still high.

(Many thanks to R Morrison for pointing out to me that relapse curves could be used to calculate the 'real' success; but that involves trusting DoH staff to correctly calculate and present the resulting figures - a task they are clearly institutionally incapable of doing honestly.)

How can anyone justify this situation?

In total, taking into account both the ridiculous time mark used, and the clear intent to hide costs, I would personally describe the NHS SSS and whoever is publishing their information as fraudulent. It is an attempt to defraud the taxpayer by promoting a service as a success when it obviously doesn't work, when the costs are ridiculously high, when the only people to benefit are the drug companies, and when the patients are at serious risk of disease and death (since almost all will return to smoking). In addition, they have published in the recent past a 'cost per successful quitter' figure that was blatantly fraudulent, pure and simple: somewhere around £320, when the true cost is in the thousands. There is no better example of deliberate fraud by the DoH, a Ministry that we already know has serious questions to answer concerning its competence and motives.

West's BMJ paper hints at the issues although we cannot really be sure what his intent is. He is a core tobacco control industry member, and has supported the NHS Stop Smoking Services strongly in the past; but he is also a supporter of e-cigarettes and has provided several useful (and accurate) quotes about their excellent safety and efficacy. In this BMJ paper, on the surface he appears to be supporting the SSS, but provides figures that reveal how utterly useless and possibly fraudulent this service is.



[1] The UK's National Health Service (NHS) Stop Smoking Services (SSS) is the smoking cessation treatment service provided by the national health system.

For non-UK residents: in Britain all healthcare is free and universal - everyone gets free medical treatment. It is paid for from deductions from pay, although people do not need to have contributed in order to receive free treatment. Although the perception is that the health service is the same across all regions of the UK, in fact much of the data is reported separately for England, Scotland, Wales and Northern Ireland (Ireland, or ROI/Southern Ireland, is an independent country). The data in the report discussed above is for England (the largest single region). So, if an annual cost is about £150m for England, it is likely that the total will be about £200m (as the England cost generally appears about 75% of totals).

Another useful factor is that some data is reported differently or in more detail for the other regions. So, although the 12-month smoking cessation figures are deliberately hidden for England (to disguise the scale of inefficiency, waste, profligacy and incompetence of this section of the NHS), the real figures are obtainable from Scotland, which allows us to see what the true results are (useless).

It is important to note that the NHS SSS standard of treatment is by far the worst of any section of the NHS, and results for other departments have absolutely no relation to the SSS results or cost per treatment success. The SSS is an appalling waste of life and money, and has no relation at all to other parts of the NHS.

[2] It has been suggested that this is a worst-case figure and perhaps over-honest. Even if it were quadrupled to 80,000 successes ex 800,000 per year (an impossibly high figure for the SSS), it is not a figure that anyone other than a Department of Health employee would consider anything other than a disgrace.

All figures in this area are routinely obfuscated, with all sorts of excuses given as to the reasons. The NHS SSS may be the world's most impressive centre of excuses - so at least they excel at something.



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