Health and Community Care External Review Scotland of ASH
EXTERNAL REVIEW OF ASH SCOTLAND
The Saren Dixon Partnership Jo Armstrong, Diane Dixon & Jane Saren
Scottish Government Social Research 2008
This report is available on the Scottish Government Social Research website only www.scotland.gov.uk/socialresearch.
It should be noted that since this research was commissioned a new Scottish government has been formed, which means that the report reflects commitments and strategic objectives conceived under the previous administration. The policies, strategies, objectives and commitments referred to in this report should not therefore be treated as current Government policy.
© Crown Copyright 2008 Limited extracts from the text may be produced provided the source is acknowledged. For more extensive reproduction, please write to the Chief Researcher at Office of Chief Researcher, 4th Floor West Rear, St Andrew's House, Edinburgh EH1 3DG
ACKNOWLEDGEMENTS
The authors would like to thank the Review Steering Group, the staff of ASH Scotland and all those who took part in the stakeholder survey for their assistance in the conduct of the research and the production of this report.
3 CONTENTS
EXECUTIVE SUMMARY 7 Context Aims and objectives Methodology Main findings Main conclusions and recommendations
CHAPTER ONE INTRODUCTION 11
Commissioning of the external review Aims and objectives Period of scrutiny of the review Time period of the review Structure of the research CHAPTER TWO THE POLICY CONTEXT 13 Summary Introduction Key policy initiatives in the UK ASH Scotland contribution to policy developments and initiatives Conclusion CHAPTER THREE METHODOLOGY 19 Summary Introduction The elements of the methodology The Steering Group Analysis of key documentation Stakeholder survey CHAPTER FOUR RESEARCH FINDINGS: VALUE FOR MONEY 23 Summary Introduction The potential economic gains of the ban on smoking in public places The impact and effectiveness of specific projects and initiatives The effectiveness of ASH Scotland's external communications The added value gained through partnership working The internal effectiveness of ASH Scotland Conclusion CHAPTER FIVE RESEARCH FINDINGS: TOBACCO CONTROL POLICY 37 Summary Introduction ASH Scotland's contribution to "A Breath of Fresh Air for Scotland", the Scottish Tobacco Control Action Plan Achieving a shift in public opinion Case study – Smoking, Health and Social Care (Scotland) Act 2005 Cross Party Group Feedback from stakeholders regarding partnerships/alliances Training standards for smoking cessation training Conclusion
4 CHAPTER SIX RESEARCH FINDINGS: GOVERNANCE 46
Summary Introduction Governance issues Conclusion CHAPTER SEVEN RESEARCH FINDINGS: KEY STRENGTHS AND WEAKNESSES 53 Summary Introduction Internal organisational strengths and weaknesses The challenge of success Relationship between ASH Scotland and the Scottish Government External engagement: strengths and weaknesses Other relevant stakeholder views on general campaigning and lobbying External impact and effectiveness of ASH Scotland - impacting on the future ASH Scotland's own assessment of its performance Conclusion CHAPTER EIGHT CONCLUSIONS AND RECOMMENDATIONS 64 Summary Introduction Conclusions Recommendations
ANNEX 1 LIST OF DOCUMENTS USED IN THE RESEARCH 68 ANNEX 2 BREAKDOWN OF STAKEHOLDER INTERVIEWS 73 ANNEX 3 STAKEHOLDER SURVEY TOPIC GUIDE 77 ANNEX 4 COMMUNICATIONS STRATEGY : EVALUATION TOOL 78 ANNEX 5 ALLIANCES 80 ANNEX 6 ASH SCOTLAND ORGANISATIONAL CHART 83 ANNEX 7 TOBACCO CONTROL ACTION PLAN 2004 – 2007 KEY ACTION POINTS 84 ANNEX 8 PUBLIC OPINION BEFORE AND AFTER THE SMOKING, HEALTH AND SOCIAL CARE (SCOTLAND) ACT 2005 86 ANNEX 9 SDF AND ASH SCOTLAND INCOME AND EXPENDITURE 90
ANNEX 10 ASH SCOTLAND’S PERCEPTION OF ITS PERFORMANCE IN 2004-06 92
ANNEX 11 LIST OF ABBREVIATIONS AND ACRONYMS 93 REFERENCES 94
5 LIST OF TABLES AND FIGURES
Tables
Table 2.1 Smoking Targets for Scotland………………………………………………14
Table 5-1 ASH Scotland and the Tobacco Action Plan, ……………………………..39
Table 5-2 The contribution of ASH Scotland to the achievement of the Smoking, Health and Social Care (Scotland) Act 2005 – an analysis of views expressed by political stakeholders………………………………………… 42
Table 6-1 ASH Scotland Core - Annual Budgets, 2004-05 to 2006-07………………..48
Table 7-1 ASH Scotland and Scottish Drugs Forum Benchmark Information………...55
Figures
Figure 3-1 ASH Scotland Stakeholder Survey Participants by Field…………………...21
Figure 3-2 Project Flowchart……………………………………………………………22
6 EXECUTIVE SUMMARY
Context
1. In August 2007, the Scottish Governmenti commissioned The Saren Dixon Partnership to undertake an external review of ASH Scotland in the context of the funding it receives from the Scottish Government. The final draft report was produced in January 2008.
2. This stand-alone project was closely linked to the external review of Partnership Action on Tobacco and Health (PATH) which was commissioned separately.
3. The Public Health and Wellbeing Directorate funds ASH Scotland for the contribution it makes to the development and implementation of national policy designed to reduce smoking levels in Scotland.
4. The review focused in particular on the 3 year funding period 2004-07. However cognisance was taken of the significant advances in tobacco control policy and implementation which took place from 1998 onwards.
Aims and objectives
5. The overall aim of the work was to examine ASH Scotland's performance in providing value for money in relation to the funding provided by the Scottish Government, both to support its core activities and for specific projects it manages.
6. Specifically, the external review was to:
• examine ASH Scotland's performance in providing value for money in relation to the funding made available by the Scottish Government, both to support its core activities and specific projects/ initiatives it has been taking forward • assess ASH Scotland's short and long term strategic planning processes and the organisation's performance in, and contribution to, developing and delivering national tobacco control policy • assess the effectiveness of ASH Scotland's standing financial instructions and the internal and external audit, and • identify key strengths, which can be built upon, and propose solutions to any weaknesses which need to be addressed, value for money (VFM) and cost- effectiveness being a key feature
i The Scottish Executive was renamed The Scottish Government on 3 September 2007. For ease, the term Scottish Government has been used throughout the report even though in some cases it is referring to the period before the name change. Publications in the reference section and the list of documents in Annex 1 have retained the title of the original publisher.
7 Methodology
7. Data was compiled from desk research; semi-structured interviews with stakeholders, an initial meeting with the Board of ASH Scotland and attendance at its 2007 AGM; and from the selected benchmark organisation (the Scottish Drugs Forum). Following a preliminary value for money assessment and identification of issues, further data collection and analysis was undertaken to allow a more in depth analysis of some of these key issues.
Main findings
8. ASH Scotland has achieved much in respect of its external impact and effectiveness to date. It is praised by stakeholders for its partnership working, which provides added value; the Scottish Tobacco Control Alliance (STCA) and STCA bulletin were cited as particularly valuable by stakeholders. In addition to national alliances, ASH Scotland is active in the creation, building and support of local tobacco control alliances.
9. ASH Scotland’s strengths include its evidence base, ability to form and lead coalitions, working in partnership, consistency, single focus, courage, clarity and accessibility of its messages, and independence from government.
10. The Information Service and evidence base are regarded as central to ASH Scotland’s modus operandi and stakeholders hold these to be critical success factors for the organisation.
11. The organisation was involved in and made a contribution across all the key action point areas of the Tobacco Action Plan.
12. Some concerns existed about the suitability of the accredited smoking cessation training and ASH Scotland has put in place actions to tackle these.
13. There is a direct link between ASH Scotland’s budgets and its strategy and key priorities.
14. The close working partnership between ASH Scotland and the Scottish Government in advancing tobacco control during the period of the review was regarded as a strength by the majority of stakeholders surveyed.
15. Internally, ASH Scotland experienced a dip in morale in the immediate aftermath of the achievement of the smokefree public places legislation; and an untypically high staff turnover in 2006-07.
Main conclusions
16. The review found that Scottish Government funding did deliver ASH Scotland's objectives and priorities. Data limitations have meant a traditional VFM analysis has not been possible. However, the outcome from the review's interviews allowed the team to conclude that ASH Scotland provided VFM in respect of financial support from
8 the Scottish Government in the 3 year funding period 2004-07, in terms of delivery of the objectives and priorities set out in ASH Scotland’s strategic plan.
17. ASH Scotland appears to have robust business and strategic planning processes in place. It was already aware of the major issues facing it, and which have been identified by this review, including the need to diversify its funding base, the need to continue developing and implementing the organisation’s fundraising strategy as a priority and extend the membership of its Board to better reflect the skills match required.
18. ASH Scotland has made a significant contribution to a period of remarkable progress on tobacco control in Scotland. The organisation is now facing some challenges of success and maintaining momentum may be an issue.
19. Externally there could exist some perception that ASH Scotland’s work is substantially complete. Work with harder to reach groups where smoking remains prevalent, such as people living in areas of high deprivation, Black and Minority Ethnic (BME) communities, people with mental health problems, young people and young pregnant women, may require different approaches, strategies, partnerships and communications. This work is a continuing and high priority.
Recommendations
20. ASH Scotland’s partnership/alliance work is considered very beneficial by stakeholders and it should maintain this work as a priority, whilst continuing its assessment of its partnerships and alliances to ensure they best fit the current environment and needs of their membership.
21. ASH Scotland is aware of the imperative to diversify its income sources. In the light of the far tighter public sector financial climate, ASH Scotland should consider the adoption of a zero-based budgeting approach (i.e. where budgets are not assumed to be based on last year’s baseline figures but assumed to be zero and only increased as agreement to continuing activities is independently established). It is important that ASH Scotland ensures that the fundraising strategy is regarded as a “whole organisation” responsibility.
22. ASH Scotland should consider the tenure of a new Chief Executive in January 2008 as an opportunity to reflect, review and regroup in order to embark on the next phase of its mission of “liberating the people of Scotland from the harm caused by tobacco” (ASH Scotland, 2007)1.
23. ASH Scotland should continue to consider how tobacco control amongst harder to reach groups, in which smoking is more prevalent, can be most effectively delivered and its role in that delivery.
24. ASH Scotland should continue its work to adapt the accredited smoking cessation training to the needs of health boards.
9 25. There should be a more formal recording of ASH Scotland outputs against Scottish Government targets for its investment to aid on-going performance tracking against grant award requirements.
26. The next review of the risk register should involve a statement of the resources needed to manage the key risks identified and specify the timescale for any contingency arrangements to be put in place. In this way the Board can not only confirm it agrees with the organisational risks but it also sets targets for management and gives it the resources to manage them effectively.
10 CHAPTER ONE INTRODUCTION
Commissioning of the external review
1.1 In August 2007, the Health and Wellbeing Directorate of the Scottish Government commissioned The Saren Dixon Partnership to undertake an external review of ASH Scotland in the context of the funding it receives from the Scottish Government.
1.2 The review of ASH Scotland was part of the rolling programme of external reviews at 6 year intervals of agencies and organisations in receipt of major recurring grants of £100,000 or more. These are required under the Scottish Compact of Good Practice Guide "Advice on Scottish Executive relations with the voluntary sector"ii. This was the first such review of ASH Scotland.
1.3 This stand-alone project was closely linked to the external review of “Partnership Action on Tobacco and Health” (PATH) which was commissioned separately.
1.4 The Health and Wellbeing Directorate funds ASH Scotland for the contribution it makes to the development and implementation of national policy designed to reduce smoking levels in Scotland. ASH Scotland was established under the auspices of the Royal College of Physicians in Edinburgh and became a separate national organisation in 1993. ASH Scotland is a campaigning public health charity working to raise awareness about the harmful effects of tobacco use and contribute to effective public health policies aimed at helping reduce and eliminate the health problems caused by tobacco.
Aims and objectives
1.5 The overall aim of the work was to examine ASH Scotland's performance in providing value for money in relation to the funding provided by the Scottish Government, both to support its core activities and for specific projects it manages (i.e. Partnership Action on Tobacco and Health, the Tobacco and Inequalities Project, the Information Service and the Scottish Tobacco Control Alliance).
1.6 While the main focus of the ASH Scotland review was to be on the Section 16b of the National Health Service (Scotland) Act 1978 core grant, the research review team was also asked to address project grant funding made available towards the costs of specific initiatives: the ASH Scotland Information Service, the Local Tobacco Alliances Project and the Tobacco and Inequalities Project.
1.7 More specific objectives for this piece of work were:
• to examine ASH Scotland's performance in providing value for money in relation to the funding made available by the Scottish Government both to support its core activities and specific projects/ initiatives it has been taking forward
ii http://www.scotland.gov.uk/library2/doc16/cgpg-00.asp
11 • to assess ASH Scotland's short and long term strategic planning processes and the organisation's performance in and contribution to developing and delivering national tobacco control policy specifically the Tobacco Action Plan "A Breath of Fresh Air for Scotland" which was published in January 2004 • to assess the effectiveness of ASH Scotland's standing financial instructions and the internal and external audit, and • to identify key strengths, which can be built upon, and propose solutions to any weaknesses which need to be addressed, value for money (VFM) and cost- effectiveness being a key feature
Period of scrutiny for the review
1.8 This review focused in particular on 2004-07, that being the most recent period of Scottish Government 3 year funding. In looking at the policy context, the review team had regard to the period from 1998 onwards to reflect back to the publication of ASH Scotland and the Health Education Board for Scotland’s (HEBS)iii “A Smoking Cessation Policy for Scotland” (ASH Scotland and HEBS, 1998)2, the UK Government’s White Paper “Smoking Kills”(Department of Health, 1998)3, and ASH Scotland’s “Smoking in Public Places”(ASH Scotland, 1999)4, in which it called for legislation to be introduced to effectively restrict smoking in public places.
Time period of the research
1.9 The fieldwork was carried out between late August and mid November 2007. An interim report was submitted to the Scottish Government on 15 November and, after discussion with the Steering Group for the review (see below in Section 3.4 for details of the Group), the report was amended and a final draft version produced in January 2008.
Structure of the research report
1.10 Chapter 2 sets the policy context for the review. Chapter 3 of the report explains the methodology employed in the research. Chapters 4 - 7 set out the findings of the research, each chapter addressing one of the review’s objectives outlined above. Chapter 8 contains the review team’s conclusions and recommendations. There follows a series of appendices containing background information.
iii Now merged with the Public Health Institute of Scotland (PHIS) to become NHS Health Scotland.
12 CHAPTER TWO THE POLICY CONTEXT
Summary
This chapter looks at the policy context within which ASH Scotland’s effectiveness was assessed in this review. Key points to note are:
• significant moves on tobacco control followed the 1997 UK General Election and the establishment of the Scottish Parliament in 1999 • ASH Scotland undertook significant work and published important policy documents on tobacco control throughout the period 1998-2007 • by 2004 a shift in public opinion on legislating to restrict smoking in public places had taken place
Introduction
2.1 This chapter looks at the policy context within which ASH Scotland’s effectiveness was assessed in this review.
2.2 As has been noted in paragraph 1.8, the focus of this review is the period 2004-07 and, therefore, a key part of the policy context is the lead up to the Smoking, Health and Social Care (SHSC) (Scotland) Act 2005. Background UK and Scottish policy development since 1998 has been included here to set the wider external environment for ASH Scotland’s work.
Key policy initiatives: UK and Scotland
UK initiatives
Smoking Kills
2.3 One of the first significant breakthroughs in respect of tobacco control at UK level was the publication in 1998 of the first White Paper on Tobacco Control, “Smoking Kills” (Department of Health, 1998), by the UK Government. In it the Government set out three key objectives to be reached by 2010: • to reduce smoking among children and young people • to help adults - especially the most disadvantaged - to give up smoking • to offer particular help to pregnant women who smoke
2.4 The White Paper announced a Government investment of £110 million in England (£50 million public education campaign; £60 million smoking cessation services) and £8 million in Scotland (£5 million public education campaign; £3 million smoking cessation services). The Paper set down actions which it deemed to be required on a range of issues, including: • tobacco advertising, branding and marketing
13 • under age sales cigarette vending machines • Nicotine Replacement Therapy (NRT) • public education • anti-smuggling • research
Scottish initiatives
Towards a Healthier Scotland
2.5 In February 1999, the Scottish Office published its White Paper “Towards a Healthier Scotland” (The Scottish Office, 1999)5 in which it set targets on a range of health issues, including smoking. The specific targets are contained in Table 2.1 below
Table 2-1 Smoking Targets for Scotland Smoking issue Headline Targets for Scotland Smoking among young people (12-15 year olds) Reduce smoking among young people from 14% to 12% between 1995 and 2005 and to 11% by 2010. Proportion of women who smoke during Reduce the proportion of women who smoke pregnancy during pregnancy from 29% to 23% between 1995 and 2005 and to 20% by 2010. Second Rank Targets Rate of smoking among adults (aged 16-64) in all Reduce rate of smoking from an average of 35% social classes to 33% between 1995 and 2005 and to an average of 31% by 2010.
2.6 By July 1999, the new Scottish Parliament had assumed its full powers. The Scottish Government endorsed the UK White Paper and agreed it should be implemented in a Scottish context. In response to a Parliamentary Question, Susan Deacon, then Minister for Health and Community Care, explained the approach of the Scottish Government to “Smoking Kills”:
“The Scottish Executive will judge the impact of Smoking Kills in part by measuring Scotland's performance against the smoking targets set out in Annex A of the Public Health White Paper, Towards a Healthier Scotland, which was published in February 1999 (available in the Parliament's Reference Centre). The Executive will also be monitoring progress in a number of other areas to check how the measures are working. Health boards are expected to monitor and evaluate the success of their smoking cessation initiatives. An independent survey on smoking in public places is planned to monitor the impact of the Scottish Voluntary Charter on Smoking in Public Places.6”
2.7 The Scottish Government set up the Scottish Tobacco Control Strategy Group to guide the process.
14 The Smoking, Health and Social Care (Scotland) Act 2005
2.8 The Scottish Parliament’s Health Committee was first asked to consider legislation to restrict smoking in public places in August 1999. One newspaper report on this reflects the context of the time. The Scotsman’s report was headed “A controversial move to ban smoking in public places in Scotland is to be considered by MSPs, it emerged last night” (The Scotsman, 1999)7.
2.9 One member of the Committee, Hugh Henry publicly called for a ban. A fellow member of the Health Committee, Mary Scanlon, responded predicting there would be bitter opposition to the idea. She said:
"This is a touch of the nanny state. The government cannot control every moment of your life. They cannot dictate everything you do. It is up to the individual and individual choice. Individuals have to take responsibility for the effect that smoking has on their health and the health of those around them.”
2.10 A BBC Scotland survey of the Committee at the time showed 6 members backing the ban, four against and one member undecided8.
2.11 The Tobacco Industry, the Scottish Licensed Trade Association (SLTA) and the Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST), the smokers’ rights group, were active in their opposition to anything bar a voluntary approach to a smoking ban in public places. FOREST claimed there was no real evidence on the risks of passive smoking and was quoted in an article published in the Daily Mail saying it was “the greatest myth of 20th Century”9; and wrote in a letter published in the Scotsman that “passive smoking is a hoax by the anti-smoking lobby”10.
Key additional influential publications in Scotland
2.12 Various additional publications (apart from those cited above) were influential in the external policy environment. These were: • “Improving Health in Scotland - the Challenge” (Scottish Executive, 2003) • “Reducing Smoking and Tobacco-Related Harm: a Key to Transforming Scotland’s Health” (ASH Scotland & NHS Health Scotland, 2004) • “A Breath of Fresh Air for Scotland” (Scottish Executive, 2004) • “Health in Scotland 2003” (Scottish Executive, 2004) • “Secondhand Smoke: Review of the Evidence since 1998. Update of Evidence on the Health Effects of Secondhand Smoke” (Department of Health, 2004)
2.13 All these publications pointed to the dangers of both smoking and passive smoking; and the benefits to public health of reducing smoking levels and preventing exposure to secondhand smoke.
15 The Scottish Tobacco Control Action Plan “A Breath of Fresh Air for Scotland” (Scottish Executive, 2004)
2.14 The action plan also upgraded the Scottish Tobacco Control Strategy Group to the Scottish Ministerial Working Group to progress the plan’s implementation and develop a future direction of tobacco control policy. The action plan had a number of key priorities, these being: • Prevention and education • Provision of smoking cessation services • Second-hand smoke (passive smoking) • Protection and controls • Measuring progress
2.15 It is in the context of that action plan that ASH Scotland’s contribution, effectiveness and impact is set for the purposes of the review.
ASH Scotland Contribution to policy development and initiatives
The Women, Low Income and Smoking Project
2.16 Prior to the publication of “Smoking Kills”, in 1996, ASH Scotland was already working on issues around inequalities and smoking and had established the Women, Low Income and Smoking Project.
2.17 An important aspect of the Project was the dissemination of findings to policy makers. This dissemination of findings to policy makers in turn informed the development of tobacco control policies in Scotland.
A Smoking Cessation Policy for Scotland
2.18 A Smoking Cessation Policy for Scotland on evidence-based smoking cessation interventions was jointly published in 1998 by ASH Scotland and HEBS (ASH Scotland & HEBS, 1998).
2.19 The policy was derived from the results of a seminar in November 1997, at which academics, policy makers and smoking cessation practitioners had met to discuss smoking cessation in Scotland. The participants considered evidence about nicotine addiction, the effectiveness and cost effectiveness of interventions, inequalities in tobacco use and the resource implications for Scotland11.
16 Clean Air
2.20 ASH Scotland had welcomed “Smoking Kills” stating that it perceived it as “providing an excellent framework for future action. Effective implementation of the paper in Scotland is crucial to its success”. In respect of clean air, however, it went on to say:
“ASH Scotland supports legislation to restrict smoking in public places. Studies have shown that workers on low income are most likely to have no protection from passive smoking in the workplace yet cannot afford to lose their jobs. At what stage will legislation be used if targets are not reached? ASH Scotland is disappointed with the emphasis on ventilation systems as they do not adequately protect against the health risks of passive smoking.” (ASH Scotland, 1998)12
2.21 In addition, it said, in relation to the Approved Code of Practice in the workplace proposed in the White Paper, that “ASH Scotland is concerned that the government has not gone far enough and that the new Code will lack 'teeth'”13.
Smoking in public places paper
2.22 In March of 1999, ASH Scotland had published a policy paper “Smoking in Public Places” (ASH Scotland, 1999) in which it outlined its position. This was:
“Since 1991 the voluntary code on smoking in public places has failed. A new voluntary approach - as outlined in the White Paper Smoking Kills - is unlikely to succeed. • Restrictions on smoking in public places will lead to a reduction in smoking prevalence. • Restrictions on smoking make a strong and symbolic statement about the government's stance on tobacco use. • Legislative action is the only way to ensure minimum levels of protection for public health. • The government should introduce legislation restricting smoking in public places.”
2.23 After extensive campaigning by ASH Scotland and its partners and collaborators, and widespread consultation by the Scottish Government, both prior to the legislative process and during it, the SCHC (Scotland) Act 2005 received Royal Assent in August 2005. The Act was implemented on 26 March 2006 and a ban in smoking in enclosed public places was instituted.
17 The formation of alliances and campaigning
2.24 In October 1999, the Scottish Cancer Coalition on Tobacco (SCCOT) was created by ASH Scotland as an alliance between itself and the leading Scottish Cancer Charities and Scottish branches of UK Charities.
2.25 In 2000, ASH Scotland received funds from the Scottish Government to undertake a consultation process to explore the need for a national tobacco control alliance and the role(s) that it might hold. It then went on to form the Scottish Tobacco Control Alliance (STCA) with Scottish Government funding, bringing together a multi-disciplinary, multi-sectoral body of over 120 organisations concerned with the impact of tobacco on Scotland and its people.
2.26 ASH Scotland set up Scotland CAN! (Cleaner Air Now) in May 2000. This brought together a wider group than SCCOT and began campaigning for legislation to restrict smoking in public places. In November 2004, it was agreed that SCCOT would no longer exist as a separate coalition, and that it would instead reform under the wider coalition of SCOT (the Scottish Coalition on Tobacco). Scotland CAN! also came under this umbrella.
Conclusion
2.27 The principal period for policy development on tobacco control was from 1998 onwards. ASH Scotland made a significant contribution to the development of such policies both through its own policy development and dissemination of best practice and in collaboration with HEBS and the Scottish Government.
18 CHAPTER THREE METHODOLOGY
Summary
This chapter sets out the review methodology, which includes:
• the establishment of the review Steering Group • collection of data from a range of sources • stakeholder survey • review of financial controls, audit and governance • evaluation of ASH Scotland’s communication strategy • benchmarking • identification of key issues
Introduction
3.1 The Saren Dixon Partnership’s overall approach to the review had as its starting point that ASH Scotland was a mature and established voluntary sector organisation with its own strategic plan and internal performance management systems. The review team did not wish to duplicate the existing internal business and performance management systems within ASH Scotland, nor the processes for external monitoring, evaluation, scrutiny and regulation which were already in place.
3.2 The review team set out to assess ASH Scotland’s activities covering the 3 E’s of economy, efficiency and effectiveness, including a value for money (VFM) assessment. The exercise included benchmarking components of ASH Scotland’s performance against that of the Scottish Drugs Forum (SDF) which was selected as a comparable organisation.
The elements of the methodology
3.3 The methodology involved a number of elements: • the establishment of a Steering Group to support the review and provide feedback on findings at 2 stages in the process, after the initial findings and after the interim report • the collection of data from a range of sources, including ASH Scotland, the Scottish Government, internet research and the SDF and the analysis of this • a stakeholder survey comprising 50 interviews of key external and internal stakeholders • review of financial controls, audit and governance • an evaluation of ASH Scotland’s communications strategy • benchmarking • identification of the key issues
19 • drilling down on the key issues, including the collection of further data and follow up with stakeholders • the production of an interim report for comment by the Scottish Government and the Steering Group • the production of a final report
The Steering Group
3.4 The review Steering Group comprised:
Mary Allison NHS Health Scotland Mary Cuthbert Scottish Government Gerard Hastings Institute of Social Marketing and Centre for Tobacco Control Research (CTCR) Emma McCallum Scottish Government Susan MacAskill Institute of Social Marketing and CTCR Kerry McKenzie NHS Health Scotland Maureen Moore ASH Scotland Jenny Niven ASH Scotland Brian Pringle ASH Scotland Joyce Whytock Scottish Government
Analysis of key documentation
3.5 A range of key documentation was examined. The majority of this related directly to ASH Scotland’s activities and included ASH Scotland’s most recent management accounts, annual accounts, business and work plans, current and draft future strategic plans, annual reports, publications and reports, staff policies and quality systems. Other documentation examined included research findings and publications external to ASH Scotland, other evaluations and reviews of aspects of their work, Scottish Government committee papers and Scottish Drug Forum reports. For the purposes of the evaluation of the communications strategy, ASH Scotland’s website was scrutinised. A list of the documents is available in Annex 1.
Stakeholder survey
3.6 Because of the difficulty of assessing ASH Scotland’s particular contribution to the advances in tobacco control in the period under review, as distinct from that of other organisations with which it worked, a significant part of the evidence for the evaluation of the external impact of ASH Scotland has been gathered through the stakeholder survey. A full table with a breakdown of participant stakeholders is contained in Annex 2. It was agreed with interviewees that they would be named but that their comments would not be individually attributed.
3.7 Fifty interviews were conducted with key stakeholders in a range of categories including the Scottish Government, public health and the voluntary sector. This was designed to reflect sectors and organisations with which ASH Scotland has worked in
20 partnership or had an important working relationship. 23 of these interviews were conducted face to face and the remaining 27 were conducted by telephone or by email. Annex 3 is the topic guide for the stakeholder interviews.
3.8 The profile of the interview sample is shown in Figure 3-1. Figure 3-2 illustrates the timeline and process of the research project.
Figure 3-1 ASH Scotland Stakeholder Survey Participants by Field
21 Figure 3-2 Project Flowchart
Collection of data
Supplement with: • Stakeholder survey • Evaluation of communications strategy • Review of financial controls, audit & governance • Benchmarking
Preliminary VFM assessment & Identification/analysis of issues
Progress report
Drill down on key issues Follow up with: • Stakeholders • Benchmark • Further data collection as required
Analysis
Interim report
Review & revise
Final report
22 CHAPTER FOUR RESEARCH FINDINGS: VALUE FOR MONEY
Summary
ASH Scotland’s performance in providing value for money in relation to the funding made available by the Scottish Government was examined by considering:
• the potential economic benefits of the Smoking, Health and Social Care (Scotland) Act 2005 • the impact and effectiveness of specific initiatives and projects • the effectiveness and value for money of ASH Scotland’s external communications • the added value gained through partnership working • the internal effectiveness of ASH Scotland
ASH Scotland’s specific role in contributing to the development and implementation of tobacco control policy in Scotland, and in particular the Tobacco Action Plan, is considered in Chapter 5. Since a number of organisations and individuals were involved in taking forward tobacco control policy, it is difficult to establish evidence which isolates ASH Scotland’s distinct contribution. The review team therefore made use of stakeholder views.
Notwithstanding these caveats, the outcome from the review's interviews allowed the team to conclude that ASH Scotland provided VFM in respect of financial support from the Scottish Government in the 3 year funding period 2004-07, in terms of delivery of the objectives and priorities set out in ASH Scotland’s strategic plan.
Introduction
4.1 The Scottish Government’s funding of ASH Scotland - both core funding and that for specific projects and initiatives - was not tied to detailed specific expected measurable outcomes. Rather, it was a contribution towards ASH Scotland’s work in areas which took forward the Scottish Government’s policy objectives. The core grant, which was the main focus of this review, is awarded under Section 16B of the NHS (Scotland) Act 1978, as amended, to national voluntary organisations engaged in health initiatives in Scotland, complementary to those required by statute. These grants can contribute towards the administrative costs of running organisations’ headquarters and, occasionally, fund specific innovative projects and capital needs. One of the main criteria by which applications for grants under Section 16B are assessed is the degree to which the applicant's aims and objectives relate to, and complement, current policies in the provision of health care, and in improving the overall health of the country.
4.2 Paragraphs 6.10 – 6.13 in Chapter 6 explain how the Scottish Government’s grant funding to ASH Scotland was linked to pre-agreed performance outputs and outcomes, and the systems for performance reporting which were in place.
23 4.3 ASH Scotland’s specific role in contributing to the development and implementation of tobacco control policy in Scotland, and in particular the Tobacco Action Plan, is considered in Chapter 5. Since a number of organisations and individuals were involved in taking forward tobacco control policy, it is difficult to establish evidence which isolates ASH Scotland’s distinct contribution. The review team therefore made use of stakeholder views, elicited through the stakeholder survey.
4.4 In order to assess ASH Scotland’s performance in providing value for money in relation to the funding made available by the Scottish Government, the review team has considered a number of factors. These inform a view on its contribution to improving the overall health of the country and how effectively it has operated: • potential economic benefits of the SHSC (Scotland) Act 2005 • impact and effectiveness of specific initiatives and projects • effectiveness and value for money of ASH Scotland’s external communications • added value gained through partnership working • internal effectiveness of ASH Scotland
The potential economic benefits of the ban on smoking in public places
4.5 Several stakeholders, in particular those from public health and the voluntary sectors, mentioned the potential economic gains, especially for the health service, of the ban on smoking in public places. Others mentioned the cost benefits to employers through the reduction in sickness absence from smoking-related illnesses. As one voluntary sector stakeholder put it, “in the long run, we are, after all, saving money to the NHS and we shouldn’t forget that”.
4.6 Another public health stakeholder said: “We don’t yet know what the real cost benefits to the health service will be, but there certainly will be savings”.
4.7 It has not been possible to be exact about the extent of ASH Scotland’s contribution to the passing of legislation to ban smoking in public places. However, the review team considered it valid to include some data on the predicted economic gains of the ban in order to reflect the potential savings to which ASH have undoubtedly contributed through their work. This data is derived from the report “International Review of the Health and Economic Impact of the Regulation of Smoking in Public Places” (Ludbrook et al, 2005)14.
4.8 The report estimates between £5,318,000 and £11,525,000 in NHS treatment cost savings (at 2003 prices) in Scotland in respect of lung cancer, coronary heart disease (CHD), stroke and respiratory disease. These figures have an inbuilt assumption that the gains may take 10 – 30 years to realise.
4.9 In relation to productivity losses due to sickness absence, the report gives estimated losses for asthma and CHD. For heart disease, the highest estimated loss is £4,126,000. The figure for asthma was estimated as £1,039,000, giving a total for the high estimate of £5,165,000. The report once again assumes that it may be between 10 and 30 years before the benefits are realised.
24 The impact and effectiveness of specific initiatives and projects
4.10 This section considers the ASH Scotland Information Service, the Scottish Tobacco Control Alliance (STCA), the Tobacco and Inequalities Project, Partnership Action on Tobacco and Health (PATH) and the Local Tobacco Alliances Project.
The ASH Scotland Information Service
4.11 The ASH Scotland Information Service exists to provide expert information and advice on all aspects of tobacco in Scotland. It provides: • an information database • a library collection, categorised according to ASH Scotland’s own specialist classification scheme • an enquiry service – which aims to provide an answer within 3 days and normally does so in one day • briefings • statistics • policy papers and reports • research articles • daily or weekly round-up ASH Scotland bulletins • monthly library update bulletin
4.12 The ASH Scotland Information Service is moving away from print copies and aims to provide most of its information online; however it will provide a single print copy of any of its web-based factsheets or briefing papers to anyone in Scotland, free of charge.
4.13 The ASH Scotland Information Service is regarded as being at the heart of ASH Scotland: it has built up and developed an evidence base and research to underpin policy. This view is validated by responses in the stakeholder survey, such as “a huge resource” and “the foundation of ASH Scotland”.
4.14 The case study on the SHSC (Scotland) Act (See Table 5-2) demonstrates the views of political stakeholders on the important role of the evidence base. Other stakeholders also commented on the way in which the evidence provided ballast to the campaign, for instance, one political stakeholder said:
“ASH Scotland provided the voice of reason behind the ban. To anyone who was posing the questions about why, the nanny state, damaging business etc – whether a supporter or a detractor – ASH Scotland was the authoritative voice on why we were doing it and sought to get that message across wherever possible.”
4.15 ASH Scotland’s evidence to the Scottish Parliament Health Committee during its examination of the Bill was quoted approvingly 3 times in the Committee’s report15.
4.16 In the run-up to implementation of the Act, ASH Scotland took the lead in producing joint sector-specific guidance for the NHS and local authorities; it also covered the non- statutory care sector.
25 4.17 The quality of the report “Reducing Smoking and Tobacco-related Harm” (NHS Health Scotland & ASH Scotland, 2004) produced jointly by ASH Scotland and NHS Health Scotland was cited by a number of stakeholders as a critical foundation in moving forward tobacco control in general and the campaign for smoke free public places in particular. A public health stakeholder commented that it was “a treasure trove of material for anyone saying anything on tobacco in Scotland”. The report was informed by literature searches and specific enquiries carried out by the ASH Scotland Information Service.
4.18 Examples of the use of the ASH Scotland Information Service by other stakeholders are given below, using comments given in the stakeholder survey.
4.19 One public health stakeholder commented of the ASH Scotland Information Service: “Anything specific, I would ask them directly and generally they’d be able to provide it”.
4.20 Another stakeholder in the academic/research community said:
“Yes, they provide me with the information that I need for my work. I take it for granted… if I need statistics or to answer a query, ASH Scotland is one of my first ports of call. They’re an excellent source and can come up with stuff in a hurry if it’s needed.”
4.21 A third stakeholder within a professional/trade union/umbrella body had used the ASH Scotland Information Service when writing briefings or speeches which touched on tobacco control issues: “They could always give me statistics to back up the argument, or point me in the right direction”.
4.22 Enquiries to the ASH Scotland Information Service are received from the Scottish Government: 15 enquiries were recorded in 2006 and 7 in the first 8 months of 2007; however this is thought to reflect significant under-recording since they can be routed via ASH Scotland staff outwith the ASH Scotland Information Service and thus recorded as internal enquiries. It would be useful for ASH Scotland to implement a system to capture the true extent of the use of the service by the Scottish Government and other statutory agencies.
4.23 Examples of the use of the ASH Scotland Information Service by the Scottish Government are: • an update on the economic impact of the Scottish legislation using reports from media and business sources • a short briefing detailing the differences between the Scottish and English legislation on smoke-free public places, produced at the suggestion of the Scottish Government stakeholders group on implementation; such briefings are typically 2- 4 pages in length and referenced
4.24 The ASH Scotland weekly bulletin is customised by the Alliances Manager to produce the STCA bulletin. This involves the addition of reports from STCA meetings, relevant planning documents etc, plus any updates submitted by STCA members.
4.25 The STCA bulletin appears to be a particularly valued product. Two public health stakeholders separately described the STCA bulletin as follows:
26 “The STCA Bulletin is brilliant and contains a mine of information. It makes you feel you are up to date – it must be an enormous piece of work but the content is great and it is invaluable.”
“The STCA Bulletin is brilliant. I always go through it when it arrives and it keeps me up to date generally as well as informing me of things I might want to do.”
4.26 Another said: “The STCA Bulletin is very useful and it’s impressive that it’s produced weekly; though I can’t always do it justice, because of time constraints”.
4.27 The ASH Scotland Information Service periodically surveys recipients of the ASH Scotland bulletin in order to ensure that it is meeting the needs of users.
4.28 The ASH Scotland Information Service is also responsible for the content of the ASH Scotland website. The “Resources for Young People” section of the website gathers links to interactive sites targeting this group.
4.29 The Tobacco Information Service is a separate website that was designed in order to develop new audiences by providing the best possible gateway to smoking and tobacco- related information in Scotland. It is a partnership comprising ASH Scotland, Information Services Division (ISD) Scotland (part of NHS National Services Scotland), NHS Scotland e- library, NHS Health Scotland, The Centre for Tobacco Control Research at the Institute for Social Marketing and the British Medical Association (BMA) Tobacco Control Resource Centre. The BMA was a founding member of the partnership.
4.30 The funding for the ASH Scotland Information Service comes 50% from the British Heart Foundation and 50% from the Scottish Government. It is staffed by two Information Officers who both hold professional library & information science qualifications. This is reflected in the professionalism of the service which both underpins ASH Scotland’s work and also provides a beacon service of national tobacco information.
Synergy between Information and Communications
4.31 There is an important synergy between the work of the ASH Scotland Information Service and the organisation’s campaigning work; indeed there is a substantial overlap between communications and evidence in the task of seeking to influence the development of government policy (whether at Scottish, United Kingdom (UK) or European Union (EU) levels). Responding to consultations, for example, combines the provision of information with making the case for the efficacy of a particular policy approach or instrument. Two recent illustrations are the work of the Senior Policy and Research Officer on producing a detailed briefing and a draft consultation document for discussion in mid September, regarding a positive licensing scheme for tobacco; and the Research and Evaluation Officer has been currently working on compiling a response to the EU consultation on smokeless tobacco16.
27 Scottish Tobacco Control Alliance (STCA)
4.32 The STCA brings together representatives from most local authorities, health boards and universities, royal colleges and other professional bodies, government agencies, healthy living centres and health improvement projects, drug action teams, health charities and organisations tackling inequalities.
4.33 The STCA’s current strategic plan gives as its aims: • to engage in efforts to influence tobacco policies and the strategy for tobacco control in Scotland • to support and encourage the formation of local tobacco control alliances and provide encouragement and support to existing local tobacco control alliances • to provide ongoing opportunities for information exchange at a national level and provide educational events that help to skill the membership • to support a range of STCA topic groups to meet the needs of the membership • to increase awareness of STCA activity within the Scottish Tobacco Control Community, recruit, broaden the membership and involve new members in the STCA • to ensure that STCA members have ongoing opportunities to influence STCA structure, activities, policy priorities, and other organisational concerns • to evaluate the activities and functioning of the STCA
Feedback from stakeholders regarding STCA
4.34 Two senior public health sector stakeholders gave the following opinions on STCA. One reflecting on the major successes of ASH Scotland:
“The central role that they take in the coordination of tobacco related activity. It drives forward the activity. STCA as a structure has been incredibly successful – information sharing and networking.”
4.35 Another stated: “STCA is very important – its bulletin and communications maintain everyone informed [sic]”.
4.36 A further stakeholder highlighted the importance of the consultation exercise which was conducted prior to STCA being set up:
“An important factor was that relevant people were consulted about the need for an alliance and what it would look like. So, the alliance was built on what key players felt was needed and what they felt it should do.”
4.37 From the point of view of Scottish Government: “We needed to be able to say with evidence that this was the view of people in the tobacco field and hence the need for an alliance – the STCA”.
28 The Tobacco and Inequalities Project
4.38 Work on tobacco and inequalities has been an ongoing core activity for ASH Scotland dating back to the Women, Low Income and Smoking Project which began in 1996.
4.39 The more recent Tobacco and Inequalities (T&I) Project was a national community development project that aimed to develop capacity and sustainability, as well as challenging and changing practice and policy. The three initial target areas for the project were: • mental health and well-being • black and minority ethnic communities • older adults
4.40 The aims of the third phase of the T&I Project (2003-07) were: • to raise awareness of the issues and inequalities some communities across Scotland face in relation to tobacco and health • to establish good practice that can be disseminated and implemented across Scotland • to raise awareness, challenge preconceptions, and stimulate positive change in policy and practice • to form partnerships that will increase capacity, maximise sustainability and keep tobacco and inequalities issues high on local and national agendas
4.41 Specific recommendations and objectives, identified through previous inequalities work led by ASH Scotland and a needs assessment, were set for each of the 3 target areas.
4.42 The Tobacco and Inequalities Needs Assessment was undertaken between 2003 and 2004 and helped to inform the current phase of the Tobacco and Inequalities Initiative. The aim of the tobacco and inequalities needs assessment was to “investigate and facilitate service development and delivery appropriate to black and minority ethnic communities, older adults and people with mental health difficulties”iv.
4.43 To help build a profile of the 3 target areas information was gathered on existing evidence, research, service provision and resources as well as the beliefs, perceptions and attitudes to smoking and stopping smoking of the target groups and service providers.
4.44 The needs assessment identified a series of gaps, and recommendations were made for future work to target the three themes across areas such as: • service provision • training • resources • information • awareness raising • development of culturally attuned and sensitive services
4.45 The T&I Project was also responsible for the dissemination of a Small Grant Fund of around £220,000. The grant led to the allocation of 25 grants to 21 organisations with a wide geographical spread.
iv ASH Scotland Tobacco and Inequalities Project Needs Assessment Research Proposal, 2003.
29
4.46 External stakeholders whose organisations have been involved in the T&I projects reported successes (some relative) and pointed to some challenges. One commented:
“We felt that [our users] were one area of the population that had been traditionally ignored. Smoking was used as a reward or a punishment. Physical illnesses were high as a result, as were the financial costs. We needed the support mechanisms to be in place and we could provide these.”
4.47 Another, remarking on the successes of their T&I project said:
“The number of people who gave up. The number of people who cut down. The key factors were creating the right environment at the right time because of smoking in public places.”
4.48 A Scottish Prison Service stakeholder commented that the delivery of smoking cessation through trained peers in prisons “was a huge success and offered careers opportunities to prisoners”.
4.49 One stakeholder, on the subject of the T&I Small Grants funded projects, said:
“Giving small amounts of money to organisations doesn’t work. Only organisations which receive larger sums can achieve something.”
4.50 An internal stakeholder reported that the T&I pilot projects “in reality had just scratched the surface because they were one year projects” and that “mental health moved along but for BME communities, it was more difficult to engage with partners”.
4.51 On the other hand, an ASH Scotland stakeholder felt it important to recognise that, whilst “people probably wanted to see higher cessation rates [from the T&I projects], dependency is a complex issue”.
4.52 ASH Scotland recognises that there have been some issues around its T&I work, such as, for instance, the continuity and impact of its work in respect of young people, in part because of the turnover of staff who have occupied the Youth Development post in the organisation. However, the Youth Forum has met 3 times since the appointment of the current postholder and has a growing membership.
4.53 Although the third phase of the T&I Project has now ended, ASH Scotland has begun work to future plan its inequalities work. Such work is seen by both itself and external stakeholders as an important aspect of future development. They report that they already have plans to further develop work on mental health and explore opportunities with migrant workers and the Lesbian, Gay, Bisexual and Transgendered (LGBT) communities. The recent evaluation of the T&I Small Grants Funded Projects will also inform future developments.
30 Partnership Action on Tobacco and Health (PATH)
4.54 PATH is managed by ASH Scotland and has as its aim to reduce the number of people in Scotland who smoke.
4.55 As has been noted in the introduction, PATH is the subject of separate external review and, therefore, this review has not focussed on its performance. However, it was felt important to include here the most significant points emerging from this research, gathered from the stakeholder survey. These relate to the training standards for smoking cessation and the training modules arising from these. The detail of this is contained in Section 5 of the report, paragraphs 5.34 – 5.35.
4.56 The issues raised in respect of the accredited training modules do pose questions about value for money. Health Board stakeholders reported that: • training took too long to complete • they still sent staff outside Scotland to undertake what they considered to be a more cost-effective training, whereby a course to qualify to undertake group cessation work could be completed in one day • they still bought in (expensive) training from elsewhere to achieve staff training targets
4.57 Notwithstanding those criticisms, stakeholders’ feedback was that better coordination with Health Boards and a working group to look at future planning of training may well resolve these issues. This feedback was shared with the team undertaking the full evaluation of PATH.
4.58 The establishment of training standards, the accreditation of the training, the evidence base of PATH and the professional calibre of its staff were cited by stakeholders as strengths.
The Local Tobacco Control Alliances Project
4.59 The Local Tobacco Control Alliances Project has been developed by ASH Scotland to support the development and activities of local alliances working on or with a strong interest in tobacco control in Scotland. Its aim is to facilitate information sharing and good practice on communication and implementation of Scotland’s Tobacco Control Action Plan “A Breath of Fresh Air for Scotland” (Scottish Executive, 2004)17.
4.60 It was the view of stakeholders that the alliances clearly had the potential to bring added value to delivery at a local level by bringing together key players and avoiding duplication of resources and effort, as well as facilitating a focus on hard to reach groups, such as young people, through existing services that the communities already accessed. As one public health stakeholder put it:
“The alliances can give us the capacity to plan well at a local level, to make sure that we are working together and not all trying to do the same thing separately. They can help us learn from each other and from good practice and work out effective ways of targeting the most difficult groups to reach.”
31 4.61 In respect of young people, who were, throughout the research, consistently highlighted as a key target group, an internal stakeholder said:
“Every Local Tobacco Alliance Plan should have a young people’s section in it…We want to develop guidelines for developing services for young people.”
4.62 In October 2007, NHS Health Scotland and ASH Scotland produced a briefing paper “Designing and Delivering Smoking Cessation Services to Young People: Lessons from the Pilot Programme in Scotland” (NHS Scotland & ASH Scotland, 2007)18 on designing and delivering smoking cessation services to young people which summarises the key lessons from the Young People and Smoking Cessation Pilot Programme. This briefing will be available to assist local alliances in their work.
The effectiveness and value for money of ASH Scotland’s external communications
4.63 Notwithstanding the value of ASH Scotland’s evidence base, effective communications are an essential ingredient in achieving external impact. They also affect the sustainability and internal effectiveness of the organisation, for example its capacity to make a case for receiving and continuing to receive funding and support, its ability to develop a strong membership base, and its functioning as a corporate team.
Communications Evaluation Tool
4.64 The analysis of ASH Scotland’s communications function was facilitated by the Communications Evaluation Tool, compiled by The Saren Dixon Partnership for the purposes of this research, which is attached as Annex 4. In general it indicated that ASH Scotland is operating very effectively in relation to external communications; the majority of stakeholder opinion validated this conclusion.
4.65 Some particular points of interest which emerged from the use of the evaluation tool are:
Target audiences – the Tobacco Information Service website was designed specifically to develop new audiences and has demonstrated success in doing so. There is a continual need for any organisation to review its definition of target audiences and to ensure that it is “thinking out of the box” about who these are. Key messages – There is some tension between the precision of the traditional language of research/academia and the imperative of communications to derive a simplified, clear message. The detail and caveats which provide evidence of accuracy in the former can look like a muddying of the message in the latter. It is important for ASH Scotland to recognise this inherent tension and to continue to produce materials which are tailored for their specific audience and specific purpose. Evaluation measures – whilst there was a lack of baselines and measures to facilitate an evaluation of impact in ASH Scotland’s communications strategy, one should acknowledge that for a small organisation there is a balance to be struck between the effort required to put these in place and the value of the results. In respect of media monitoring, for example, a conscious decision had been taken to maintain an in-house database logging media coverage,
32 but not to go to the expense of commissioning external monitoring of impact measures (which are in themselves imperfect). This is entirely reasonable. Communications methods – ASH Scotland had recognised that it is not currently making best use of its website and this was under review. The strength of the ASH Scotland brand and profile means that the website may well attract users who believe that it is a direct service provider/adviser to smokers and the public. It therefore provides an important opportunity for signposting and links and its front page should be designed to avoid being off-putting to such potential users.
Communications Budget
4.66 There is no dedicated communications budget within ASH Scotland and the vast bulk of resource input is staff time. There is a publications budget within the Information Service - hence 50% funded by the British Heart Foundation (BHF) - which covers items such as publicity for conferences, leaflets etc. The supporters’ newsletter and bulletins are produced in-house, in both design and content terms. There are budget headings for the AGM and Annual Report which can carry external costs such as a photographer. Media monitoring is done in-house by the Information Service.
4.67 ASH Scotland argues convincingly that its work through coalitions and partnerships has enabled it to implement an effective communications strategy by attracting resources from elsewhere, and hence enhancing VFM. It is recommended that ASH Scotland considers the costs of the communications requirements of the fundraising strategy and makes any necessary budgetary provision.
Public and Media Relations
4.68 As stated in paragraph 4.65 above, target audiences is an area that needs to be under continual review. ASH Scotland will need to consider its range of audiences once the strategic priorities in the 2007-10 Strategic Plan are finalised. For example, it is recommended that ASH Scotland specifically review its target audiences to ensure that they fit with the fundraising strategy.
4.69 A database is maintained to collect the extent of media coverage. The decision not to attempt to measure or collect local media coverage is a reasonable decision on resource grounds (see section on evaluation measures in paragraph 4.65).
4.70 ASH Scotland is in the process of extending the distribution of Unfiltered News, making greater use of e-mail, and reviewing frequency. The publication has been redesigned for greater visual impact.
Corporate Image
4.71 In response to feedback gathered during the consultation on the 2004-09 Strategic Plan, ASH Scotland decided it required an updated branding which would: • give ASH Scotland a clear and recognisable corporate identity • clarify the relationship between ASH Scotland and the various projects/initiatives that are managed or co-ordinated through the organisation
33 4.72 This was one of the main development areas identified in the strategic review of the organisation. ASH Scotland brought in designers to assist with this task, which included the ASH Scotland logo, templates to enable combinations producing a consistent corporate image, the Annual Report, published Strategic Plan, website and stationery.
4.73 Since then, ASH Scotland has also simplified the relationship with partners by rebranding the Scottish Cancer Coalition on Tobacco (SCCOTv) as the Scottish Coalition on Tobacco (SCOT) in November 2004; and amalgamating it with Scotland CAN! into one umbrella coalition. This united body has the broader focus of raising public awareness of the links between smoking and a range of diseases, including for example heart disease as well as cancer. Scotland CAN! is a subsidiary structure, serving as a media arm and public profile for the smoke-free public places legislation and its implementation.
The added value gained through partnership working
4.74 ASH Scotland has a wide network of relationships with external organisations. It has also formed, promoted and serviced a number of alliances of different organisations, ranging from temporary alliances over specific issues, such as that with children’s charities over test purchasing arrangements, to permanent standing alliances such as the STCA and the Cross Party Group.
4.75 One of ASH Scotland’s stated objectives is partnership working:
“We cannot deliver our work in isolation. We believe that the most effective way to take forward the tobacco control agenda in Scotland is to work in partnership with key stakeholders, including: • Parliament and governments (local, Scottish, UK, EU and international levels) • Alliances and coalition partners • National Health Service Scotland • Trade unions • The media • Charities and voluntary sector organisations” (ASH Scotland, 2004) 19
4.76 Since 1999, ASH Scotland has established or been involved in establishing: • Scottish Cancer Coalition on Tobacco (SCCOT) • Scotland CAN! • SCOT (bringing together SCCOT and Scotland CAN!) • Cross Party Group on Tobacco Control • Scottish Tobacco Control Alliance (STCA)
4.77 Annex 5 contains more information about the above alliances, including their aims and objectives and their membership.
v SCOTT was established in October 1999 as an alliance of ASH Scotland and leading cancer charities as a means to raise awareness about the links between smoking and cancer. It was SCOTT which took forward the establishment of the Cross Party Group (CPG).
34 4.78 In addition to national alliances, ASH Scotland is active in the creation and building of local tobacco control alliances and has dedicated pages on its website which are designed to provide information and support for Local Tobacco Control Alliances across Scotland. They have a local alliances officer who works to develop and support them.
4.79 Stakeholders surveyed have resoundingly emphasised the importance of these alliances and groups at different stages in time. They have pointed to the lack of coordination before the groups came in to place and the benefits which they have derived from them. Importantly, they have highlighted as a strength that, not only did ASH Scotland identify the need for alliances and act on that, but also, in the case of the STCA, undertook a consultation that explored the need for a tobacco control alliance and the role(s) that it might have. Stakeholders reflected that this gave added strength to the STCA.
4.80 The STCA has some 120 members from a variety of fields and its members have access to the weekly STCA Bulletin, seminars, conferences, and other opportunities for information exchange. The STCA hosts a number of topic groups including: Researchers Group, Tobacco Control Issues Group, Cessation in Pregnancy and Youth and Tobacco Forum. The STCA was particularly highlighted by stakeholders in their comments.
The internal effectiveness of ASH Scotland
4.81 ASH Scotland currently has a staff team of 27 people. The organisation was established as an autonomous body in 1993 with 5 members of staff; since then it has expanded significantly both its number of employees and the range of activities it undertakes.
4.82 During the process of strategic review commenced in late 2003, ASH Scotland identified a number of organisational issues which needed to be addressed. Many of these related to the increased size and complexity of the organisation. There were also governance aspects, such as the need to expand the capacity and expertise of the Board of Directors, and the requirement to modernise the constitution to reflect best practice and changes in company and charity law.
4.83 The organisation was restructured in 2003, creating the existing three sections each headed by a member of the Senior Management Team. The Organisation Chart current at the time of the review research (November 2007) is attached as Annex 6.
4.84 Taking account of the growth in the size and complexity of ASH Scotland, and changes in the external environment, a number of other organisational policies were reviewed in 2004: • new financial and accounting structures and procedures were put in place • the Advisory, Conciliation and Arbitration Service was commissioned to undertake a job evaluation and a policies and procedures manual was developed • personnel policies were reviewed, including appraisal and support procedures, staff development and training
4.85 These changes were an appropriate response to the new internal and external environment.
35 Conclusion
4.86 ASH Scotland has achieved much in respect of its external impact and effectiveness to date. The overwhelming stakeholder view is that ASH Scotland contributed to the set of conditions which enabled the passage of the SHSC (Scotland) Act 2005. A summary of the data on the substantial anticipated health gain impact of this legislation in economic terms is included above. Notwithstanding the caveats expressed in this report about attribution of causation, the review team regarded it as reasonable to state that ASH Scotland had delivered value for money in respect of financial support received from the Scottish Government in the 3 year funding period 2004-07.
36 CHAPTER FIVE RESEARCH FINDINGS: TOBACCO CONTROL POLICY
Summary
ASH Scotland appears to have robust business and strategic planning processes in place. The organisation was involved and made a contribution across all the key action point areas of the Scottish Tobacco Action Plan “A Breath of Fresh Air for Scotland”. It continues to work and campaign using a number of bodies, partnership and alliances. The stakeholder survey revealed some reservations about the smoking cessation training which should be explored and resolved.
Introduction
5.1 This chapter summarises ASH Scotland’s approach to strategic planning and reviews ASH Scotland’s contribution to the development of “A Breath of Fresh Air for Scotland” (Scottish Executive, 2004), the Scottish Tobacco Action Plan, and its implementation. This includes an analysis of stakeholder views on ASH Scotland’s role in the passage of the SHSC (Scotland) Act, a focus on the shift in public opinion, the Scottish Parliament’s Cross Party Group on Tobacco Control, stakeholder feedback on partnerships and alliances and training standards for smoking cessation training.
Strategic planning processes
5.2 ASH Scotland appears to have robust business and strategic planning processes. The development of the 2007-10 Strategic Plan involved a structured process with support from an external consultant. It included workshops with ASH Scotland staff and Board members. The Strategic Plans of ASH Scotland are wholly aligned to the mission of the organisation.
5.3 Measures of success are prepared by the Senior Management Team for each priority action and presented to the Board. The Board exercises scrutiny to ensure that these attempt to measure impact rather than activity20. The Board is periodically updated on progress according to these measures.
5.4 In anticipation of the outcome of the External Review of ASH Scotland commissioned by the Scottish Government, and because of the Chief Executive’s announcement of her departure from the organisation, ASH Scotland had not yet finalised its Strategic Plan for 2007-10 at the point when this review was completed. This was an update and roll forward of the current strategic plan and the delay did not impede ASH Scotland’s day to day operations.
37 ASH Scotland’s contribution to the Tobacco Control Action Plan “A Breath of Fresh Air for Scotland” (Scottish Executive, 2004)
5.5 The Scottish Government in its brief for this review asked the review team to pay particular attention to ASH Scotland’s contribution to the Tobacco Control Action Plan referred to above. It is important to note here, therefore, the key action points contained therein. These are taken directly from the plan and are contained in full in Annex 7.
5.6 In short, they cover the following areas: • The approach – introducing the Ministerial Working Group • Prevention and education – in particular in relation to young people • Provision of smoking cessation services – funding made available and PATH highlighted to develop the evidence base for effective cessation & development of baseline measures and outcome measures • Second-hand smoke (passive smoking) – introducing public debate in 2004, a national advertising campaign with partners, challenging employers, trade unions, voluntary groups etc to encourage and support the introduction of effective smoking policies by all employers; ASH Scotland to be involved in the development of guidance for NHS Boards and local authorities to review smoking policies • Protection and controls – work on test purchasing arrangements, illegal sales, tobacco advertising and promotion, point of sale, distribution, pack design etc, and liaison with UK Government on tobacco control • Measuring progress – NHS broad-based programme of tobacco control action, targets on smoking rate reduction and measurement of performance against these targets
38 5.7 The following table drawn up for the purposes of the review matches ASH Scotland activity against the Tobacco Action Plan’s key actions.
Table 5-1 ASH Scotland and the Tobacco Action Plan Tobacco Action Plan Key Action ASH Scotland Activity & Achievements Points The approach: • Provision of evidence base creation of Ministerial Working Group • Co-ordination of the Scotland CAN communications activity around 2005 Act • Active participation in expert Smoking Prevention Working Group Prevention and education: • ASH Scotland/NHS Health Scotland pilots aimed at young people in particular in relation to young people • Post of Youth Development Officer • Development of Youth Forum • External evaluation of young people and smoking cessation pilot programme and dissemination of results • Development with NHS Health Scotland of guidelines on work with young people Provision of smoking cessation • Management of PATH Support Fund and distribution of funds to services: funding made available and pilot groups, especially targeted at the hardest to reach PATH highlighted to develop the • PATH produced a Report of recommendations on data collection, evidence base for effective cessation & monitoring and evaluation development of baseline measures and • PATH developed a definition of services which should be included outcome measures in the National Monitoring • PATH assisted NHS Scotland's Information Services Division (ISD) to develop a national smoking cessation database • Training & development work • Development of National Standards on Smoking Cessation and National Training Strategy • Implementation of accredited training and a national training approval scheme • Tobacco & Inequalities Project • Buddy project pilot (till 2005) Second-hand smoke (passive • Significant campaigning and lobbying role in lead up to, during smoking): introducing public debate in consultation on and advising on implementation of The Smoking, 2004, a national advertising campaign Health and Social Care (Scotland) Act 2005 with partners, challenging employers, • Provision of evidence base trade unions, voluntary groups etc to • Involved in development of guidance for NHS Boards and local encourage and support the introduction authorities to review smoking policies of effective smoking policies by all employers; ASH Scotland to be involved in the development of guidance for NHS Boards and local authorities to review smoking policies
Protection and controls: • Contribution to the development of the test purchasing pilot work on test purchasing arrangements, schemes illegal sales, tobacco advertising and • Policy, campaigning and public education work on illegal sales, promotion, point of sale, distribution, tobacco advertising and promotion, point of sale, distribution, pack pack design etc, and liaison with UK design Government on tobacco control Measuring progress: • STCA NHS broad-based programme of • Local tobacco control alliances tobacco control action, targets on • Provision of information and advice to NHS Scotland health boards smoking rate reduction and • PATH’s smoking cessation minimum dataset measurement of performance against these targets ALL • ASH Scotland’s Strategic Plan and priorities
39 Achieving a shift in public opinion
5.8 ASH Scotland’s Strategic Plan 2004-09 sets as an objective the achievement of “widespread public support for a ban on smoking in public places” (ASH Scotland, 2004) 21.
5.9 To set a backdrop to this section, some of the facts in respect of public opinion are contained in Annex 8.
5.10 ASH Scotland’s contribution to a shift in opinion is examined in following section.
ASH Scotland’s contribution to shifting public opinion - findings from stakeholder survey
5.11 Whilst it is not possible to be definitive about the extent of ASH Scotland’s role in shifting public opinion in favour of a ban, stakeholders had much to say about its role. Those interviewed held a spectrum of views, but the majority felt that ASH Scotland had made a contribution to taking public opinion in the direction of the need for legislation and away from voluntary options. Some felt that this was ASH Scotland’s critical role, including stakeholders from Scottish Government, Public Health and the voluntary sector. ASH Scotland stakeholders themselves see this as one of the major contributions.
5.12 A public health stakeholder reflected “Their major success was maintaining themselves apart from Government but playing a significant role in changing public opinion”.
5.13 One Scottish Government stakeholder stated: “We would have got the legislation without ASH Scotland, but their crucial role was in shifting public opinion”.
5.14 Another, from the charitable sector, believed that: “[During the consultation period] ASH Scotland were a constant, providing … sensible information and advice when there was a lot of misinformation”.
5.15 A further stakeholder from the public health sector added:
“The message ASH Scotland put across was simple and consistent and, importantly ensured that the range of people who could influence opinion were transmitting the same message. With their co-ordination and leadership, we were all singing from the same song sheet.”
5.16 One stakeholder who had been in the public health sector for many years, highlighted ASH Scotland’s impact on public opinion on smoking by comparing the shift in respect of smoking and health to that in relation to obesity and health. They were of the view that ASH Scotland had had a significant impact on the level of public acceptance of the harm caused by smoking and secondary smoking, an acceptance which has not yet been achieved about obesity in Scotland.
5.17 The implementation of the legislation means it is unlikely that this kind of extensive work on shifting public opinion will be so central to the future work of ASH Scotland. Nevertheless, many stakeholders have pointed out that the public work on tobacco has not yet come to an end and ASH Scotland should endeavour to maintain its profile and presence with the public, even if this is with a change of direction to meet new circumstances, especially
40 addressing the hardest to reach groups. It was also noted by one stakeholder that figures for Ireland showed a drop in the numbers of people smoking in the early period after the ban but have started to rise again since. This clearly illustrates that there is work on tobacco control still to do after legislation.
Case Study – Smoking, Health and Social Care (Scotland) Act 2005
5.18 As a result of the significance of the potential health gain of the SHSC Act 2005 and the fact that Scotland was the first part of the UK to achieve a ban on smoking in enclosed public places, it was felt useful to analyse the views of stakeholders in the “political” category on the extent of ASH Scotland’s contribution to the legislation reaching the statute book as part of this review of ASH Scotland’s effectiveness. Elsewhere, the Review report considers the potential economic impact of the health gain impact of the legislation.
5.19 What we cannot do with any certainty is state what would have happened without ASH Scotland’s interventions. It seems likely that some form of ban on smoking in some public places would have been taken forward and it may be that the current position would have been achieved eventually. A strong case can be made for the influence of the Scottish legislation on the scope of the Westminster legislation and this was cited by several stakeholders.
5.20 The Scottish legislation was produced by a complex interaction of different factors, including UK and international drivers as well as the part played by a range of domestic players. Some stakeholders expressed a view on the root cause of the achievement of the SHSC Act 2005, often reflecting their own professional or geographical setting, or particular experience. These explanations of “the key” were not consistent and it is not possible to draw a definitive conclusion on the ultimate responsibility.
5.21 We can however state that all stakeholders acknowledged that ASH Scotland played a significant role. Some singled ASH Scotland out for particular mention; others added riders about other players, on occasion citing them as more important. The detail of the case study is contained in the table below (Table 5-2).
41
Table 5-2 The contribution of ASH Scotland to the achievement of the Smoking, Health and Social Care (Scotland) Act 2005 – an analysis of views expressed by political stakeholdersvi
Contribution No. Comments Played an important 12 Specific views on a spectrum from ASH Scotland as the key factor to one of a role number of contributors. Examples:- “Played a vital role.” “It would have been much more difficult to get the legislation in place without them.” “Very effective at persuading individual MSPs.” “It was evident that they got MSPs to act as advocates [when the Health Committee was considering the Bill].” “ASH was an important factor in achieving the ban.” “A necessary but not individually sufficient contribution.” “Among those who campaigned effectively.” “There was no one individual or organisation, but ASH Scotland was a very strong advocate and had some influence.” “ASH Scotland played a part, so did others.” Cited as particularly important:- Evidence base 8 “Enormous credibility of the ASH Scotland /Health Scotland report.” “The quality of their research material was very good.” “Value of the ASH evidence in bolstering the confidence of colleagues – an independent body strongly backing up the intentions of government.” Persistence at getting 6 “It was more about the courage to stand up and argue the line than the message across evidence.” Ability to lobby and 6 “We needed a reasonably funded independent organisation which could campaignvii establish sufficient presence to campaign for the legislation outside of the Parliament & Scottish Executive.” “They corralled third party opinion.”
Cross Party Group
5.22 One mechanism whereby ASH Scotland can engage with MSPs outwith normal parliamentary business is through the Cross Party Group (CPG).
5.23 The CPG on Tobacco Control was set up in December 1999 upon the initiative of the Scottish Cancer Coalition on Tobacco. Its purpose was “to take forward an effective tobacco control agenda and monitor the implementation of the UK White Paper on tobacco, ‘Smoking Kills’, in Scotland”22. It is the practice with the majority of CPGs that a voluntary organisation or charitable group provides the secretariat23 and ASH Scotland does this for the Tobacco Control CPG. It was very strongly praised by one political stakeholder for the standard of service it provides, which was described as “exemplary”.
5.24 Those political stakeholders who commented, regarded ASH Scotland as making good and appropriate use of the CPG. ASH Scotland acknowledges that it is for the MSPs to
vi Total number = 12 vii As opposed to the constraints on the Scottish Executive, civil servants and officials and professional bodies such as the BMA (“in a different niche”) with regard to their scope for lobbying and campaigning.
42 determine the direction of development of the CPG and its programme of activities and topics for discussion. The organisation regards it as a very useful route for highlighting issues to MSPs, or for MSPs to approach ASH Scotland for information e.g. to support the development of a Private Member’s Bill.viii
Feedback from stakeholders regarding other partnerships/alliances
5.25 Feedback on ASH Scotland’s partnership/alliance work was received from stakeholders interviewed as part of the stakeholder survey.
5.26 A stakeholder from the charity sector said the following of the Cross Party Group on Tobacco Control: “The intention to bring together a wide group of parties was very much based on the idea of creating consensus and drive and that we found very helpful”.
5.27 Another charity stakeholder, who had been a participant in SCCOT, was of the view that:
“One of the major successes in my view is pulling together the coalition. All four [charities] were saying the same thing individually, but it was easier for people to hear the message when we said it together.”
5.28 An academic stakeholder, with long experience of ASH Scotland’s work, commented generally on their role in partnership working: “They are key: they are hugely influential in bringing people together”.
5.29 One public health stakeholder was keen to highlight the importance of SCOT as an alliance.
“I belong to the SCOT – it brings together public health and the big charities, eg the British Heart Foundation and this is one group I hope would continue in ASH Scotland. It gets to a wider church. Every four years we produce a manifesto and the last one was just before the elections in 2007. It is clear and precise, especially for politicians and was very well received.”
5.30 The feedback would suggest that ASH Scotland should maintain its partnership/alliance work as a priority and that it should continue to address the areas of weakness reported in the STCA survey. The future of the organisation may require refocusing that work but it is, undoubtedly, greatly appreciated.
Training standards for smoking cessation training
5.31 The training and development function of ASH Scotland work lies with PATH. PATH's training and development objectives are: • to promote best practice through evidence-based training • to increase the quality and consistency of tobacco-related training in Scotland
viii Interview with internal stakeholder.
43 • to broaden the range and scope of tobacco-related training in order to increase the number of people trained in tobacco issues • to ensure that everyone who needs tobacco-related training has equal opportunity to access it • to enhance the professional standing of the smoking cessation specialism, through developing validation and accreditation systems
5.32 To deliver on those objectives PATH has: • developed standards for smoking cessation training in Scotland • developed a strategy for smoking cessation training in Scotland • set up an approval scheme for training that is in line with the standards • developed accredited training modules in smoking cessation in partnership with Glasgow Caledonian University
5.33 The stakeholders interviewed recognised the importance of the development of standards for smoking cessation training and gaining accreditation for that training, saying, for instance:
“There were no standards for training. Everyone was delivering cessation in a different way.”
“The delivery needed to be consistent. It shouldn’t matter where people are or what type of professional it is, you should get the same service.”
5.34 Some key stakeholders had strong views about the training and these included strong reservations. A reflection of these views is as follows: • it doesn’t currently meet the needs of all health boards, some of which have been doing their own training for a considerable time and it is too complicated to get accreditation for prior learning • it is too time-consuming – one stakeholder said it could take up to two years to complete the three modules • the health boards are still sending staff to London for training because they can do the same course in two days or they are bringing London-based trainers to Scotland which is very costly • communication between PATH trainers and the health boards has room for improvement
5.35 It was suggested by stakeholders that a short term training development group to look at the future could well resolve these issues in order that the training better meets the needs of all health boards and other deliverers of smoking cessation services. ASH Scotland reports that the above issues have been identified by the training team and actions are in place to resolve them.
Conclusion
5.36 The review team found evidence of ASH Scotland’s activity and achievement across all the key action point areas of the Tobacco Action Plan. All political stakeholders surveyed
44 credited ASH Scotland with an important role in the passing of the SHSC (Scotland) Act 2005.
5.37 There was considerable dissatisfaction voiced by some stakeholders about the smoking cessation training. ASH Scotland has remedial actions in place to deal with the issues which were raised.
45 CHAPTER SIX RESEARCH FINDINGS: GOVERNANCE
Summary
In this chapter the review team concentrated on top level financial control and risk issues rather than looking at detailed procedures.
There is a direct link between ASH Scotland’s budgets and its strategy and key priorities. The Board approves the overall strategic plan as well as ASH Scotland’s annual plan, which flows from the strategy. It may now be necessary to adopt more of a zero-based budgeting approach. (See paragraph 6.7 for an explanation of zero-based budgeting.)
The Board and management have developed a comprehensive risk register covering all the key risks facing ASH Scotland.
It is now acknowledged in the most recent strategic plan that the continuing development and implementation of the fundraising strategy is a priority.
Introduction
6.1 Taking account of the overall objectives of the research, the approach of the review team was designed to complement the existing internal business and performance management systems within ASH Scotland and the processes for external monitoring evaluation, scrutiny and regulation which are already in place.
6.2 ASH Scotland is a mature and established third sector organisation with its own strategic plan and internal performance management systems. It has been an autonomous national voluntary organisation since 1993. The Board of Directors is chaired by a University of Edinburgh Professor of Cardiology. It is a registered charity and therefore subject to the regulation of the Office of the Scottish Charity Regulator. The annual accounts of ASH Scotland are subject to independent audit and the organisation received an unqualified audit certificate in 2006. Consequently, in this chapter the review team concentrated on top level financial control and risk issues rather than looking at detailed procedures.
Governance issues
6.3 The areas focussed on by the review team were as follows: • do management and Directors review the budget position regularly and on the basis of good, up to date information? • is grant income spent on what it was given for? • are grant conditions fully complied with?
46 • do management and Directors understand the risks affecting the business and take steps to address them? • are there appropriate internal and external audit inputs and are their recommendations implemented?
The remainder of this section takes each of these questions in turn.
Review of budgets
6.4 Budgets are produced for each of ASH Scotland’s operating sections. The Finance Director first produces a draft budget, using the previous year’s as the baseline. This draft is then discussed in detail with each of the section directors and signed-off jointly with the Finance Director before being approved by the Chief Executive. This draft budget is then presented to the ASH Scotland Board for formal approval.
6.5 There is a direct link between ASH Scotland’s budgets and its strategy and key priorities. The Board approves both the overall strategic plan as well as ASH Scotland’s annual plan, which flows from the strategy. The strategy is developed through a process of consultation both internally and externally with ASH Scotland’s key stakeholders. ASH Scotland’s senior management then translate these high level plans into annual section or operational plans. Finally, these section plans form the basis of individual plans that are used in ASH Scotland for both staff performance management and annual appraisals.
6.6 Budgets are reviewed monthly by the Senior Management Team and then by the Board at each Board meeting. This review process limits the potential for unforeseen cost increases. Variances need to be approved in advance by the budget owner, the Finance Director and the Chief Executive. This approach is consistent with the Langlands Report’s (OPM and CIPFA, 2004)24 approach to good governance in public practice in that ASH Scotland very clearly states what it is aiming to achieve and communicates this to its wide stakeholder group.
6.7 Notwithstanding this good management practice, it may now be necessary and desirable for ASH Scotland to adapt its budgeting approach by considering more of a zero-based emphasis (i.e. where budgets are not assumed to be based on last year’s baseline figures but assumed to be zero and only increased as agreement to continuing activities is independently established). Forecast budgets are highly correlated to the actual expenditure for the previous year. Using last year’s budget as a starting point for determining what may be reasonable for next year works well when activities are relatively well known and where the risk of funding failing to materialise is limited. However, the Scottish Government is ASH Scotland’s major funder, providing between 75% and 80% of its income in the three years 2004-05 to 2006-07 (see Table 6-1). With a very tight funding settlement for the next three years, the Scottish Government’s ability to fund all that ASH Scotland may request would seem less likely than in previous years. However, as Table 6-1 also highlights, ASH Scotland’s expenditures are fairly fixed in nature, with almost 90% of its costs either wage or property related. Any measurable reduction in its core income will leave ASH Scotland severely exposed given a reducing contingency reserve; staff reductions may not be easy to implement quickly or be unachievable with a zero cost implication.
47 Table 6-1 ASH Scotland Core - Annual Budgetsix, 2004-05 to 2006-07 2004-05 2005-06 2006-07 Income - Scottish Government 364,869 353,120 403,800 - British Heart Foundation 50,000 0 54,700 - Health Scotland 0 0 10,000 - Donations 2,000 1,000 0 - Supporters/ Patrons 1,500 1,500 2,000 - Publications 1,000 1,000 500 - Project Management 60,000 115,000 113,300 - Fundraising 20,000 0 0 - Bank Interest 12,000 17,000 20,000 - Deferredx 41,210 61,106 28,900 TOTAL INCOME 552,579 549,726 633,200 Expenditure - Staff 391,000 414,348 485,000 - Property 39,500 42,500 64,500 - Office consumables 96,500 64,500 63,650 - Governance 9,000 11,000 12,000 - Depreciation 12,000 14,000 8,000 - Contingency 4,000 3,000 0 TOTAL EXPENDITURE 552,000 549,348 633,150 Operating surplus / deficit 579 378 50
% Income - Staff costs 71% 75% 77% - Property costs 7% 8% 10% - All remaining costs 22% 17% 13% TOTAL 100% 100% 100% Source: ASH Scotland budget statements, various years
6.8 ASH Scotland does not have formally written guidelines for appraising any major new investments. Nonetheless, given the tight control the Finance Director, Chief Executive and Board have over the budgeting process, any such investment would not be undertaken without their prior approval.
Grant spent on objectives
6.9 As stated earlier, when making grant applications to the Scottish Government ASH Scotland links these directly to the strategic plan and to the underlying operational priorities contained within this key document. The Board is presented with a Measurements Matrix report which highlights how ASH Scotland has performed against these predetermined outputs. This would suggest all within ASH Scotland i.e. its management, staff and the Board, are clear about where income should be allocated to ensure it delivers against its targets and objectives.
ix For this analysis it has been necessary to rely on un-audited budget statements as the ASH Scotland Annual Accounts cover both the ASH Scotland Core activities as well as PATH. x Deferred income is the balance of income that has accrued in the previous year for use in the current year.
48 Fulfilment of grant conditions
6.10 The Scottish Government’s grant funding for ASH Scotland’s activities is linked to the delivery of pre-agreed outputs and outcomes. Each grant offer is made subject to the recipient meeting associated conditions covering, inter alia, the need to provide the Scottish Government with regular reports on performance.
6.11 Performance against objectives varies between the types of funding offered. In the case of grants allocated for the PATH and the Tobacco and Inequalities projects, assessment of performance is undertaken via discussions at Advisory Groups that the Scottish Government either chairs or of which it is a formal member. At these Advisory Groups ASH Scotland provides formal reports on performance.
6.12 Assessing performance of funding allocated to cover ASH Scotland’s core activities is less formal. Work plans drawn up in advance are reported on throughout the term of the grant. Critical in the development of these work plans is the ASH Scotland Strategic Plan. This outlines what ASH Scotland aims to achieve over the plan period and is what the Scottish Government seeks to have delivered in return for funding ASH Scotland’s core activities.
6.13 The grant conditions do require ASH Scotland to provide annual audited accounts as well as 6-monthly written reports of performance. The former reporting requirement has been fulfilled and whilst the latter has not, the Scottish Government ensures ASH Scotland has fully complied with its grant conditions via regular verbal briefings. Both ASH Scotland and the Scottish Government contest that these regular face-to-briefings provide a clear picture of the range of ASH Scotland activities and offer regular reassurances that ASH Scotland is delivering against work plans and the Strategic Plan.
6.14 Whilst it is reassuring that regular briefings occur and an analysis of ASH Scotland’s performance does take place, written reports to back up these regular discussions would seem essential to ensure full accountability and transparency of any grant funding allocated in the future. These reports would also assist in the determination of any future VFM analysis, as these should set out the outputs to be delivered by ASH Scotland and an indication of how well it is achieving its aims.
Risk management issues
6.15 The Board and management have developed a comprehensive risk register covering all the key risks facing ASH Scotland. This was developed following intervention from one of the Board who has significant knowledge of how such systems operate in the private sector.
6.16 Whilst the departure of the Chief Executive is a key risk to be managed, the risk register highlights two further risks facing ASH Scotland currently: skills gaps on the Board and the over reliance it has on the Scottish Government for its funding.
49 Board skills
6.17 The Board has considered a number of papers on both the make-up and constitution of the ASH Scotland Board to take account of changes to both company and charities law as well as to reflect the recommendations arising from the in-house Strategic Review undertaken in late 2003.
6.18 The following were identified as areas where additional Board members could help fill key skills gaps: • education / prevention • substance use • community development • legal • fundraising • public relations (PR)/lobbying • research • tobacco control • public health • cessation • evaluation
6.19 The review also identified a wide array of possible candidates. As with most charities, however, identifying gaps as well as possible candidates to fill them does not necessarily mean getting the right skills mix will be easy to accomplish. No fee can be paid for such services and individuals need to be willing and able to commit not inconsiderable time and effort to be of value to ASH Scotland’s management team.
Funding issues
6.20 As has already been highlighted, ASH Scotland relies significantly on the Scottish Government for most of its income. To attempt to change this, ASH Scotland undertook an assessment of how it might broaden its funding base. This assessment took longer than had originally been anticipated and, although the review did suggest ASH Scotland should seek to obtain funding for a dedicated fundraiser, it is not certain whether this post would be able to secure alternative funds in the time scale necessary. The proposal for such a post has not to date been approved by the Board.
6.21 The Scottish Government funding settlement from Whitehall for the period 2008-09 to 2010-11 is lower in real terms than it has secured in the last 2 spending rounds. Consequently, even if it wished to continue funding all of ASH Scotland’s current activities, it is likely that the real value of any Scottish Government award will be lower over the next 3 years. The 2007-08 experience may well be repeated where the cash value of the Scottish Government award was held flat thus reducing the real terms value, ie, taking into account underlying inflation.
6.22 Fundraising for charitable causes has become both highly competitive as well as more sophisticated. Asking someone not only to raise funds for their own post, but also to raise funds that substantially change ASH Scotland’s funding mix will not be an easy task in the
50 current climate. Indeed, to attract the most appropriate candidate may require the Board to approve a reward package that is at odds with the terms and conditions of employment of the rest of the organisation.
6.23 It is perhaps inevitable that in a period of intense and focussed external activity, which cumulatively secured substantial increases in funding - enabling ASH Scotland access to more resources via partnerships - diversifying its funding base received less attention within ASH Scotland than in hindsight might have been desirable. It is now acknowledged in the Strategic Plan that the continuing development and implementation of the organisation’s fundraising strategy is a priority. We would recommend that ASH Scotland ensures that any fundraising strategy is regarded as a “whole organisation” responsibility and that, regardless of the recruitment of a specific fundraising resource, it maps out an action plan for how this can be reflected across the organisation and at different levels within it. Also, we recommend that the senior management team considers in detail the key interactions required between the different sections in implementing and reviewing the fundraising strategy, the most effective method of achieving and co-ordinating these and how they will dovetail with the role of the new Board member who brings expertise in this area, and the role of the proposed dedicated post of fundraiser.
6.24 The interdependency of ASH Scotland’s fundraising strategy and its external communications and relationship building is acknowledged internally. The outline fundraising strategy reported to the Board in August 2007 makes mention of PR, relationship building, marketing, publicity materials, the website, supporters base, and pursuit of ASH Scotland’s selection as a nominated charity for corporate support – all activities with a key communications component.
6.25 The risk register goes to the Board on an annual basis. It would be sensible for the next review of the risk register to involve, inter alia, a statement of what resources are needed to manage the inherent funding risks and to specify the timescale for any contingency arrangements to be put in place. In this way the Board can not only confirm it agrees with the organisational risks but it also sets management targets and gives it the resources to manage them effectively.
Internal and external audit inputs
6.26 The external audit of ASH Scotland confirms its financial statements give a true and fair view of the state of the company. No adverse statements exist in relation to ASH Scotland’s compliance with its grant terms and conditions and the ASH Scotland Board receives reports on performance against the Strategic Plan.
6.27 Nonetheless, as the funding climate tightens, ASH Scotland may wish to consider implementing some element of 3rd party scrutiny of its achievements and its compliance with any grant terms and conditions.
Conclusion
6.28 ASH Scotland is aware of the imperative to diversify its income sources. In the light of the far tighter public sector financial climate, it may now be necessary to adopt a zero-based
51 budgeting approach. It is important that ASH Scotland ensures that the fundraising strategy is regarded as a “whole organisation” responsibility and that, regardless of the recruitment of a specific fundraising resource, it maps out an action plan for how this can be reflected across the organisation and at different levels within it. Finally, whilst it has systems in place that monitor performance against targets, ASH Scotland may now wish to formalise the external reporting of its achievements to ensure a clear and auditable trail against grant terms and conditions.
52 CHAPTER SEVEN RESEARCH FINDINGS: KEY STRENGTHS AND WEAKNESSES
Summary
ASH Scotland has made a significant contribution to a period of remarkable progress on tobacco control in Scotland.
It is clearly an organisation which enjoys considerable strengths. The close working partnership between ASH Scotland and the Scottish Government in advancing tobacco control during the period of the review was regarded as a strength by the majority of stakeholders surveyed.
The organisation is now facing some challenges of success and maintaining momentum may be an issue.
There exist some issues which require addressing around internal communications, staff turnover and diversification of ASH Scotland’s funding base.
Introduction
7.1 This chapter comments on strengths and weaknesses of ASH Scotland identified in the process of the review. These are examined under the headings: • internal organisational strengths and weaknesses • the challenges of success • relationship between ASH Scotland and the Scottish Government • external engagement: strengths & weaknesses • external impact and effectiveness of ASH Scotland – impacting on the future
Internal organisational strengths and weaknesses
Human Resources
7.2 ASH Scotland offers flexible working, with flexi-time and time off in lieu (TOIL) systems in place. A long hours working culture is not encouraged, indeed is said to be frowned upon.
7.3 As illustrated in Table 7-1, ASH Scotland experienced an atypically high rate of staff turnover in 2006-07. This was mentioned in a number of stakeholder interviews. One public health stakeholder commented:
“We are aware of and comment on the high turnover of staff. A concern is that contacts are made and then broken. I don’t know why … but people do comment
53 about it. It must have been incredibly difficult to refocus after the legislation. How do you refocus and energise? I do know that people left on maternity leave, or to go travelling etc but it is still an issue.”
7.4 Media stakeholders also mentioned the loss of established contacts due to staff turnover.
Internal communications
7.5 Internal communications were perceived by staff as an area that “didn’t go so well” in their half day workshop held to feed into the strategic planning process for 2007-1025. The issue was also mentioned by a couple of respondents in the stakeholder survey, in relation to the constraints imposed by the premises.
7.6 The Review Team is not in position to diagnose the nature of the issue – but would suggest that if is perceived as an issue by staff, then it does merit exploration.
7.7 Within the Senior Management Team, each Director has responsibility for communication about his or her own area of work, and communication within the organisation is also regarded as a responsibility of each and every staff member; however no Director has a lead role allocated for internal communications.
7.8 We recommend that the nature of the issue is scoped with the facilitation of an external consultant at a suitable opportunity; and a lead role on internal communications allocated to a member of the Senior Management Team.
Benchmark
7.9 Benchmarking is acknowledged as a useful tool in a range of areas including VFM, governance, Human Resources (HR), training, marketing and communications, finance procedures and evaluation. It helps to identify areas where an organisation’s costs are out of kilter with its peer group and enables attention to be focused on aspects where there is a significant variance from the norm. It can give new insights into best practice and how to achieve it, provide reassurance about what is working well, provide evidence to support change and help to determine priorities for action.
7.10 Since ASH Scotland is the only national voluntary organisation tackling tobacco control in Scotland, there is no immediately obvious peer organisation to use as a benchmark. Our criteria for selection were: • Scottish voluntary organisation • mission includes public education and the promotion of regulation/legislation in order to achieve individual and societal behaviour change • works at both community and national levels • probably health-related aim • major focus on campaigning, lobbying and communications • perceived as a well-run and effective organisation
7.11 Following discussion with the Review Steering Group, Scottish Drugs Forum was selected as a benchmark for the purposes of this review.
54 7.12 It proved to be impossible to carry out a comparative analysis of VFM in respect of outputs or external impact of the two organisations because of a) the lack of hard data; and b) the different policy contexts within which they are working.
7.13 The review team therefore decided to focus on three areas where data were available: • sources of income – please see Annex 9xi • membership profile • and a number of HR measures and indicators
Table 7-1 ASH Scotland and Scottish Drugs Forum Benchmark Informationxii
Measure/Indicator ASH Scotland Scottish Drugs Forum Number of employees 27 22 (Part time) (1) (2) Based in Headquarters (HQ) 26 16 Based in other office locations 0 5 Work from home 1 1 Typical background of staff Health/voluntary sector/politics Senior care sector workers who have & campaigns/research worked within specialist drug service or related fields Staff turnover %xiii: 2004/05 3.8% 16% 2005/06 7.1% 13.6% 2006/07 25.9% 7.6% No of staff employed @ 01/04/04 who were still employed @ 31/03/07 12 14 Sickness absence %xiv: 2004/05 1.15% 7% 2005/06 1.15% 4.5% 2006/07 1.85% 3% Formal supervision system Yes, monthly Yes, every 4 – 6 weeks HR Handbook Yes Yes Documented formal appraisal process Yes Yes Induction process and checklist Yes Yes Team meetings Every 6 weeks Every 2nd month; all staff expected to attend Membership: Individual 28 52 full; 5 associate Organisations 0 234
Commentary
7.14 The staff turnover figures are of interest because this is a feature that has been commented upon in relation to ASH Scotland by stakeholders within the survey. The figures bear out the view that turnover has increased markedly since the passing of the SHSC (Scotland) Act in November 2005.
xi The benchmark study looked at the whole organisations and did not disaggregate by projects/sources of funding. xii Information provided by ASH Scotland and Scottish Drugs Forum. xiii Based on average number of annual employees in each year, as published in annual accounts. xiv Based on actual attendances as percentage of total potential working days not including annual leave and public holidays.
55 7.15 Percentages for sickness absence can be skewed in small organisations by long term sickness absence. The Scottish Drugs Forum reported that it had 2 members of staff on long term sickness absence in 2004-05 and 2 in 2005-06; without these, the figures drop to 2.5% and 2% respectively. ASH Scotland’s rates of sickness absence are low: the average rate of employee absence in the non-profit sector was 3.6% of working time in 2006.xv.
7.16 The membership profile of the 2 organisations differs markedly in that ASH Scotland has 28 individual members and no organisations as members and SDF has 52 individual, 5 associate and 234 organisations affiliated.
7.17 This comparison leads to the following conclusions and recommendations: • ASH Scotland’s low rate of sickness absence is a strength and implies a high level of staff commitment • ASH Scotland’s atypically high level of staff turnover in 2006-07 may be a cause for concern; on the other hand it may be a natural response following a sustained period of achievement culminating in the implementation of the SHSC Act (Scotland) 2005. It could also be said that a high turnover at this stage could assist ASH Scotland to reposition itself for the new challenges ahead. It is recommended that ASH Scotland continues to monitor turnover on a quarterly basis; and continues to offer exit interviews to staff who leave the organisation and to analyse the feedback from these reviews. It may also be prudent to review opportunities for career progression within the organisation; and to be alert to any issues regarding staff morale • ASH Scotland may also want to consider whether increasing its membership base would be a means of strengthening the organisation and capitalising on its recent high profile. For example, it could develop a strategy for increasing individual membership and explore the pros and cons of creating other membership categories, such as associate and organisational. It would of course need to weigh up the potential benefits of an increased membership base against the costs of developing and servicing it
Culture
7.18 Organisational culture can appear to be a somewhat amorphous concept but is regarded as a useful tool to analyse determinants of organisational strategies and the capacity to adapt to changes in the external environment. A strong culture is also regarded as a means of ensuring that the knowledge embedded in separate teams with discrete technical knowledge – as could be said of ASH Scotland’s divisions – is shared “through substantial informal interaction among employees” with “...the idea of the strong culture as a pervasive, permeable essence that links people, both within and outside formal systems” (Jelinek and Schoonhoven, 1991)26 .
7.19 There were some interesting views expressed within the stakeholder surveys which related to different cultural paradigms. These took a number of forms. At one level, these related to the traditional clinical, evidence-based health approach, in contrast to the approaches of both social marketing and community development which seek more a more interactive process of engagement with their target group. Moves within the health service to
xv CIPD Annual Survey Report 2007.
56 a greater emphasis on co-production were also pointed out. Internally, 2 stakeholders mentioned the tension between the evidence-based approach to formulating messages in contrast to the communications approach.
7.20 These comments pointed to some potentially significant underlying shifts with a relevance to ASH Scotland’s future strategy, and which might be expected to be expressed within the culture of the organisation.
The challenges of success
7.21 ASH Scotland appears to be facing some of the challenges of success (the external perception that smoking is now “sorted”; a reported internal dip in morale; and high staff turnover in 2006-07). It also now finds itself in a less expansive public spending environment.
7.22 The issue of momentum seems to be a common feature of both internal and external challenges:
“The lesson for the leaders of non-profits is that one has to grow with success. But one also has to make sure that one doesn’t become unable to adjust. Sooner or later, growth slows down and the institution plateaus. Then it has to be able to maintain its momentum, its flexibility, its vitality and its vision. Otherwise, it becomes frozen.” (Drucker, 1992)27
Further legislation and regulation?
7.23 Of the 12 political stakeholders who were interviewed, 9 expressed a view on whether there was a need for further tobacco control legislation and regulation; whether the priority was now consolidation of the culture change embodied in the Smoking, Health and Social Care (Scotland) 2005 Act by continued prevention and education alongside monitoring and enforcement of existing statutory controls; or whether both approaches should be pursued equally.
7.24 Of the 9 who expressed a view, 4 stakeholders said they saw a need for further legislation and regulation. Two of these supported further regulation of point of sale advertising and display.
7.25 Three of the 4 supported legislation to ban smoking in cars: one stakeholder on safety grounds, akin to the ban on the use of mobile phones whilst driving. The other 2 wanted a ban on smoking in cars where children are present. However both said that this was not an immediate imperative, but rather should be tackled in due course.
“I would support a ban on smoking in cars with young children; but we need a bit more time to let the effects of the ban [on smoking in public places] be gathered and bed down.”
57 “The timing should be towards the end of the current Scottish Parliament session. That’ll be about 5 years on from the ban on smoking in public places, which is a reasonable interval.”
7.26 Taking into account these 2 last stakeholders, a total of 7 of the 9 political stakeholders who expressed a view did not favour further legislation/regulation in the short to medium term.
7.27 The 5 out of 9 political stakeholders who did not support further legislation and regulation tended to emphasise smoking prevention and cessation, plus the monitoring and enforcement of existing statutory controls. There was some nervousness about how seeking to go further might be perceived by the public: “it’s much harder to resist the accusation of the nanny state if you do more legislating”; “you could cross the line where you get a backlash”.
Relationship between ASH Scotland and the Scottish Government
7.28 ASH Scotland receives a large proportion (75-80%) of its funding from the Scottish Government and is one of three voluntary organisations which have received between £230k and £250kxvi under Section 16B of the National Health Service (Scotland) Act 1978. Given this situation, and the evidently very close working relationship which it has enjoyed with the Scottish Government at both a political and civil servant level, the question has been legitimately posed as to whether ASH Scotland can truly be regarded as an independent organisation.
7.29 Thirty-five of the stakeholders interviewed were from outside both ASH Scotland and the Scottish Government (including for the purposes of this analysis the Scottish Prison Service and Health Scotland as Scottish Government). Nineteen of these 35 stakeholders made comment on the relationship between ASH Scotland and the Scottish Government.
7.30 Eleven of those 19 stakeholders said that ASH Scotland was independent of the Scottish Government. 3 expressed views which were neutral on this specific point.
7.31 Five of those 19 stakeholders regarded ASH Scotland’s independence as to some extent compromised. For example one public health stakeholder commented:
“It’s really important that ASH has a degree of independence – that it’s able to speak out and not necessarily toe the party line. I don’t view ASH as totally independent, because it’s funded by the Scottish Executive.”
7.32 Some commentators have gone as far as to suggest that it has become an arm of the Government. A voluntary sector stakeholder said: “yes, it is an arm of the Scottish Government, but a positive arm”. One stakeholder in the academic/research category stated: "Given that much of its funding comes from the taxpayer, it is difficult not to believe that ASH is little more than the executive’s tobacco control agency”.
xvi Table 6.1 shows ASH Scotland as receiving £364,869 of Scottish Government funding. In addition to the funds that they receive under S16B of the National Health Service (Scotland) Act 1978, they receive other income from the Scottish Government under separate funding streams.
58 7.33 A very small minority of stakeholders felt that the level of funding and close relationship lends itself to unacceptable tensions, in particular in respect of ASH Scotland’s lobbying role. On the other hand, the Scottish Government has been clear that it does not fund ASH Scotland’s lobbying function and, although it has described ASH Scotland as its delivery arm xvii sees this in the context of the Tobacco Control Plan in which ASH Scotland and PATH are designated particular roles.
7.34 The majority of stakeholders felt ASH Scotland had managed to maintain its independence and that, for instance, it worked well across all political parties. It has been pointed out by stakeholders in various fields that ASH Scotland had the advantage of being able to do what Government could not do and that it has been equally willing to challenge Government as it has been to work with it. One Scottish Government stakeholder commented: “The other side of the coin is that Government can legislate and ASH Scotland cannot”.
7.35 One public health stakeholder put their view of the situation succinctly:
“We needed an organisation which was independent and which was able to take the debate away from the issue of the ban coming from the “nanny state”. At the same time, ASH’s independence has placed them in a position where they can argue for tobacco control whatever the political nature of the administration.”
7.36 For many stakeholders, that combination of a legislator with an outside but close working partner was a benefit, not a detriment, in the period that is the subject of this research. Having said that, the climate is somewhat different for the future, and the nature of that relationship may well change as policy issues emerge on which ASH Scotland and Government diverge more significantly. Future Scottish Government funding decisions and the ability of ASH Scotland to diversify its funding base may also impinge on the relationship.
External engagement: strengths & weaknesses
7.37 Comments from half of the media stakeholders interviewed suggested that they had found the changes in their main contact within ASH Scotland (the Communications Officer) somewhat disruptive because it takes time to build up a relationship.
7.38 ASH Scotland is seen as efficient and well-organised by its media contacts and was praised for its ability to react to stories with a tobacco angle: “I can almost guarantee that if there’s a story that relates to tobacco on any level, they’d comment – probably before you’ve even asked them”.
xvii Interview with Scottish Government stakeholder.
59 Other relevant stakeholder views on general campaigning & lobbying
7.39 ASH Scotland could have a more sophisticated interaction with the political process of policy formation by researching and planning according to the timescales of the various political parties. One political stakeholder commented that ASH Scotland:
“followed the classic strategy of sending a letter at election time. But most progressive NGOs [Non Governmental Organisations] have come to terms with the timetable for the rolling policy process. They did a Manifesto – that’s a publicity stunt rather than influencing policy.”
7.40 A more complimentary view was expressed by another political stakeholder:
”Unlike some voluntary organisations, ASH Scotland understands that briefings should not be sent on the day of the debate. It engages more broadly with politicians than just on the day-to-day parliamentary business.”
External impact and effectiveness of ASH Scotland – impacting on the future
An effective future direction for ASH Scotland
7.41 Stakeholders were very vocal indeed about the future direction of ASH Scotland and highlighted particularly the passing of the legislation on smoking in public places and the departure of the Chief Executive as setting a challenging scene, although not a negative one.
7.42 Stakeholders expressed concern that, with the legislation in place, the battle will be seen as having been won. This fear is not groundless; one political stakeholder, for example, said:
“The war is won in terms of what you can do with legislation. Therefore you’ve got to consider scaling back. As we take the big guns off the field, it’s time for the sharpshooter – the more forensic approach.”
7.43 Some stakeholders favoured the continuation of a whole population approach. One public health stakeholder commented:
“Only targeting inequalities is deeply conflictive. We still need a whole population approach. We need to keep our intervention going across all groups.”
Another stated that:
“The evidence from Ireland is that, although smoking rates fell in the first period after the legislation there, they have begun to rise again. So we mustn’t take our eye off the ball in relation to the whole population.”
7.44 A stakeholder from a professional/trade union group believed: “There is still a lot to be done about almost everything to do with smoking”.
60 7.45 The majority of stakeholders were much more inclined to favour investing funds to target the hardest to reach, even if they recognised that there remained issues to tackle in the whole population. The following were identified as the main inequalities groups to target: • people living in the most deprived areas • young people in general, and especially those in deprived areas where positive role models are less obvious and young women • BME communities, some thinking in particular migrant workers • people with mental health issues • older people • LGBT communities
These are largely in line with ASH Scotland’s priorities for its Tobacco & Inequalities work.
7.46 One suggestion from a Scottish Government stakeholder was that consideration be given by ASH Scotland as to how the Equality Impact Assessment tool, which has been developed by the Scottish Government, might assist them in taking their inequalities work forward.
7.47 Some stakeholders working in the field with people in the above target groups felt there needed to be a word of caution about the approach. As one put it:
“We need to understand the context in which smoking takes place and not have a one size fits all approach. We need to maintain an element of choice for particular sectors of society along with support to stop which is tailor made. Consultation with [harder to reach groups] may have an educative function as well, in that consultees hear arguments which help them decide to give up.”
“We need to focus on young people and look at different ways of getting the message across; we need a joined up approach of cutting off the supply (point of sale) and cessation with young people given that cessation rates amongst young people with a traditional cessation approach are so poor.”
7.48 Stakeholders made a range of other points on the future work of ASH Scotland. A Scottish Government stakeholder commented:
“On smoke free, all the evidence existed. On some of the other issues which ASH want to pursue, the evidence base is not there, but we sometimes need someone to be in the forefront.”
7.49 Stakeholders from the public health sector, the Scottish Government and the voluntary sector all mentioned the opportunity for ASH Scotland to become an international adviser on tobacco control issues and, thereby, possibly open up new funding opportunities.
7.50 A public health stakeholder said:
“The international agenda is now important – the tobacco companies have moved on. International sources of funding may be available for ASH Scotland to offer consultancy and expertise internationally.”
61 7.51 In short, other points made which merit mention are: • point of sale issues very important • younger end of 50+ age group is important to target • still have a huge issue of education to tackle • need to stretch the legislation to protect professional staff who go into places where smoking is not banned through agreements with Local Authorities • youth/community workers could be an ideal conduit for work with young people and deprived communities – need to think of new ways of getting the message across • need to target home smokers in relation to the damage they do to others around them • new measures need to be sensible and reasonable
Funding: the future
7.52 It has been noted in Chapter 6 that ASH Scotland is heavily reliant on the Scottish Government and to build an effective future direction, it will be necessary for it to secure funds from other sources both to generally diversify its funding base and to finance new initiatives. One suggestion has been for the organisation to seek international funding to support a potential role as an international adviser on tobacco control.
Corporate Profile
7.53 The evidence from the stakeholder survey is that the corporate profile of ASH Scotland is currently closely intertwined with the profile of the present Chief Executive (albeit that a number of stakeholders were at pains to say that they recognised that it was a team effortxviii).
7.54 The appointment of a new Chief Executive offers ASH Scotland an opportunity to consider whether this is the most effective way of maintaining and developing corporate profile, given the media, and perhaps general, preference for a figurehead; or whether it wants to consciously promote a number of ASH Scotland spokespeople and representatives, potentially including Board members and coalition partners as well as staff.
7.55 All in all, the stakeholder survey, the current external environment for ASH Scotland, the departure of a Chief Executive who was clearly widely respected and considered very effective, and the appointment of a new Chief Executive all point to a need for reconsideration about the organisation’s future direction, whilst maintaining the evident strengths of ASH Scotland.
ASH Scotland’s perception of its performance
7.56 ASH Scotland has undertaken an analysis of its recent performance in preparation for the development of its new strategic plan. It was felt appropriate to include some findings from this exercise and they are contained in Annex 10.
xviii “If they have a figurehead who is feisty but is seen to be arguing at a level people can understand, organisations are more effective at getting their message across…[but] it wasn’t all down to Maureen Moore, the staff are all effective communicators.”
62 Conclusion
7.57 ASH Scotland has made a significant contribution to a period of remarkable progress on tobacco control in Scotland. It is clearly an organisation which enjoys considerable strengths.
7.58 At the same time, there are some challenges of success which the organisation now faces. Its staff turnover has increased substantially following the introduction of comprehensive smokefree public places legislation. There are questions raised by stakeholders about how the strength of its signature evidence base fits with the approaches required to advance work with ASH Scotland’s priority target groups.
7.59 The review team has also highlighted some areas of possible weakness and sought to offer ways of addressing them. These include issues around internal communication, staff turnover and diversification of ASH Scotland’s funding base.
63 CHAPTER EIGHT CONCLUSIONS AND RECOMMENDATIONS
Summary
• ASH Scotland has enjoyed a remarkable period of internal growth and external achievement since 1997 • The contribution of ASH Scotland to advances in tobacco control is acknowledged by all stakeholders • ASH Scotland’s strengths include its evidence base, ability to form and lead coalitions, working in partnership, consistency, single focus, courage, clarity and accessibility of its messages, independence from government • An economic VFM exercise was not possible with the available data, but ASH Scotland clearly delivered a significant contribution to the development and implementation of tobacco control policy and the National Tobacco Action Plan • ASH Scotland needs to consider its future direction • ASH Scotland faces funding challenges in the current climate and with an external view that may see its work as complete, and needs to address a series of issues in its fundraising strategy • Some budgetary issues require addressing • More formal recording by the Scottish Government against grant award fulfilment requirements is recommended
Introduction
8.1 The overall aim of this external review was to examine ASH Scotland's performance in providing value for money in relation to the funding provided by the Scottish Government.
8.2 This section presents the review team’s overall conclusions and makes recommendations which can enable key strengths to be built upon and improvements made regarding some perceived areas of relative weakness.
Conclusions
8.3 ASH Scotland has enjoyed a remarkable period of internal growth and external achievement since 1997.
8.4 All stakeholders acknowledge the role of ASH Scotland (albeit with some differences in emphasis) in achieving legislation as comprehensive as the SHSC (Scotland) Act 2005, and introducing smoke free public places in advance of other parts of the UK, together with other advances in tobacco control. It has been influential within the UK and internationally.
8.5 Particular factors cited as contributing to ASH Scotland’s success include its: • evidence base
64 • ability to form and lead coalitions • working in partnership • consistency • single focus • courage • clarity and accessibility of its messages • independence from government
8.6 Although the data is not available on which to base an economic value of the value for money delivered to the Scottish Government in respect of its funding of ASH Scotland, there is clearly a significant contribution to the development and implementation of tobacco control policy and the National Tobacco Action Plan. There is already evidence of concomitant health gain and more will follow.
8.7 For ASH Scotland, there are some costs and some dangers alongside this success. Externally there could be some perception that ASH Scotland’s work is substantially complete. A continuing and high priority is to focus on specific groups, such as people living in areas of high deprivation, Black and Minority Ethnic (BME) communities, people with mental health problems, young people and young pregnant women, in which smoking is most prevalent and this may require different approaches, strategies, partnerships, and communications.
8.8 Public finances are now more constrained and we may be facing a general economic slowdown. Internally, ASH Scotland experienced a dip in morale in the immediate aftermath of the achievement of the smoke free public places legislation and an untypically high staff turnover in 2006-07.
8.9 A new Chief Executive will take charge at the start of January 2008 and this appears to be an appropriate time for ASH Scotland to reflect, review and regroup in order to embark on the next phase of its mission of “liberating the people of Scotland from the harm caused by tobacco (ASH Scotland, 2007)”28.
8.10 Any new direction of ASH Scotland should take cognisance of the need to effectively address tobacco control amongst harder to reach groups and the organisation should consider the role it has to play in developing work methods and approaches with these groups.
8.11 Some concerns existed about the suitability of the accredited smoking cessation training; ASH Scotland has actions in place to tackle these.
8.12 For the Scottish Government as funder, ASH Scotland remains an important partner. It will be able to have greater confidence that it continues to secure VFM from its funding if it can effect a holistic approach across all areas of Scottish Government to tobacco control.
8.13 Data from the Scottish Government was not made available on the grant application process. Interviews with both ASH Scotland and the Scottish Government indicate that there is no formal output statement produced by ASH Scotland showing the Scottish Government on an on-going basis what it is it has delivered for the Scottish Government funds. Verbal updates have nonetheless taken place and these have been viewed by the Scottish Government as adequate for tracking performance and fulfilling grant award requirements.
65 We would recommend that a more formal recording of such achievements be undertaken in the future to aid any follow-up evaluation exercise.
Recommendations
• ASH Scotland considers the tenure of a new Chief Executive as an opportunity to assess whether the most effective way of maintaining and developing corporate profile is to have a single figurehead or whether it wants to consciously promote a number of ASH Scotland spokespeople and representatives, potentially including Board members and coalition partners as well as staff.
• ASH Scotland reviews its range of audiences to fit Strategic Plan priorities, especially in respect of its fundraising strategy.
• ASH Scotland improves its potential for influencing policy by adopting a more sophisticated interaction with the political process; specifically tailoring its communications to the internal party timetables for policy development.
• ASH Scotland considers the costs of the communications requirements of the fundraising strategy and makes concomitant budgetary provision.
• ASH Scotland maintains its partnership/alliance work as a priority and that it should continue its assessment of its partnerships and alliances to ensure they best fit the current environment and needs of their membership.
• Some refocusing of ASH Scotland’s partnership/alliance work may be required to fit with the future priorities of the organisation but it is, undoubtedly, greatly appreciated.
• There should be a reconsideration about the organisation’s future direction, whilst maintaining the evident strengths of ASH Scotland. The stakeholder survey, the current external environment for ASH Scotland, the departure of a CEO who was clearly widely respected and considered very effective and the appointment of a new CEO all point to a need for this.
• ASH Scotland considers how tobacco control amongst harder to reach groups can be most effectively delivered and its role in this.
• ASH Scotland continues its work to adapt the accredited smoking cessation training to the needs of health boards.
• ASH Scotland considers adopting a zero-based budgeting approach to ensure objectives are still required and adequate funding is likely to be forthcoming for their implementation.
• ASH Scotland ensures that the fundraising strategy is regarded as a “whole organisation” responsibility and that, regardless of the recruitment of a specific fundraising resource, it maps out an action plan for how this can be reflected across the organisation and at different levels within it.
66 • The Senior Management Team (SMT) considers in detail the key interactions required between the different Sections in implementing and reviewing the fundraising strategy; the most effective method of achieving and co-ordinating these; and how they will dovetail with the role of the new Board member who brings expertise in this area, and the role of the proposed dedicated post.
• The next review of the risk register involves a statement of the resources that are needed to manage key risks and specifies the timescale for any contingency arrangements to be put in place, in order that the Board can not only confirm it agrees with the organisational risks but also set targets for management and give it the resources to manage the risks effectively.
• ASH Scotland scopes the nature of the perceived internal communications issue at a suitable opportunity with the assistance of an external consultant; allocate a lead role on internal communications to a member of the SMT.
• ASH Scotland implements a system to capture the true extent of the use of the Information Service by the Scottish Government and other statutory agencies.
• The Scottish Government institutes a more formal recording of ASH Scotland outputs against Scottish Government targets for its investment to aid on-going performance tracking against grant award requirements and any follow-up evaluation exercise.
67 ANNEX 1 DOCUMENTS USED IN RESEARCH
Akhtar P.C., Currie D.B., Currie C.E. and Haw S.J. (2007) Changes in child exposure to environmental tobacco smoke (CHETS) study after implementation of smoke-free legislation in Scotland: national cross sectional survey, British Medical Journal (2007) London: BMJ Publishing Group Ltd http://www.bmj.com/cgi/content/full/bmj.39311.550197.AEv1
ASH Scotland & HEBS (1998) A Smoking Cessation Policy for Scotland, Edinburgh: ASH Scotland & HEBS.
ASH Scotland (2003) Standards for Smoking Cessation Training in Scotland, Edinburgh: ASH Scotland.
ASH Scotland (2005) The Unwelcome Guest: How Scotland invited the tobacco industry to smoke outside, Edinburgh: ASH Scotland.
ASH Scotland (2007) Smoke-free success: Ash Scotland presents the Scottish experience, Edinburgh: ASH Scotland.
Bauld, L. et al. (2007) Evaluation of the ASH Scotland Tobacco and Inequalities Initiative Small Grants Funded Projects: Final Report, Scottish Centre for Research on Social Justice.
Clark, S. Letters. The Scotsman 20 August 1999.
Clearing the Air Scotland: National Consultation 2004. (2004): http://www.clearingtheairscotland.com/research/consultation-summary.html>
Department of Environment (1996) Smoking in public places: 2nd survey report, London: Her Majesty’s Stationery Office.
Department of Health (2004) Scientific Committee on Tobacco and Health, Secondhand Smoke: Review of the Evidence since 1998. Update of Evidence on the Health Effects of Secondhand Smoke, London: Department of Health.
Drucker, P. (1992) Managing the Non-Profit Organization: Practices and Principles. Oxford: Butterworth-Heinemann.
Fallis, R. (2004) Most Scots ‘are against ban’ on smoking in pubs [online]. [Accessed November 13 2007]. Available from World Wide Web:
Haw, S. and Gruer, L. (2007) Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey, British Medical Journal (2007) London: British Medical Journal Publishing Group. http://www.bmj.com/cgi/content/abstract/335/7619/549
Haw, S. et al. (2006) Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact? Journal of Public Health. 28 (1), pp 24-30. Oxford: Oxford University Press
68 Jelinek, M. and Schoonhoven, C. B. (1991) Strong culture and its consequences in Henry, J. and Walker, D. (eds) Managing Innovation, London: Sage
Jones, L., Hayes, F., McAskill, S., Angus, K., Stead M., and Amos, A. (2006) Evaluation of the Impact of the PATH Support Fund, Final Report, Edinburgh: ASH Scotland
Ludbrook, A. et al. (2005) Health Economics Research Unit and Department of Public Health, University of Aberdeen. International Review of the Health and Economic Impact of the Regulation of Smoking in Public Places, Health Scotland
Macdonnell, H. MSPs battle for total ban on smoking in public places. Daily Mail 18 August 1999
Macintyre, S. (2007) Inequalities in health in Scotland: what are they and what can we do about them? Glasgow: Medical Research Council, Social and Public Health Sciences Unit
Morris S. et al. (2004) The Robert Gordon University Centre for Public Policy and Management A Critical Review of the Cross Party Group System in the Scottish Parliament, Edinburgh: Scottish Executive
NHS Health Scotland & ASH Scotland (2004) Reducing Smoking and Tobacco-Related Harm: a Key to Transforming Scotland’s Health, Edinburgh: The Stationery Office
NHS Health Scotland & ASH Scotland (2007) Designing and delivering smoking cessation services to young people: Lessons from the Pilot Programme in Scotland, Edinburgh: NHS Health Scotland and ASH Scotland
NHS Health Scotland (2005) International review of the health and economic impact of the regulation of smoking in public places: Summary report 2005, Edinburgh: NHS Health Scotland
OPM and CIPFA (2004) The Independent Commission for Good Governance in Public Services: The Langlands Report. London: OPM and CIPFA
Philips, R. et al (2007) Smoking in the home after the smoke-free legislation in Scotland: Qualitative study, British Medical Journal (2007) London: British Medical Journal Publishing Group.http://www.bmj.com/cgi/content/abstract/335/7619/553?maxtoshow=&HITS=10&hits =10&RESULTFORMAT=&fulltext=Phillips+R%2C+Amos+A%2C+Ritchie+D%2C+Cunni ngham-Burley+S%2C+Martin+C&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
Scottish Drugs Forum (2007) Strategic Plan 2007-2012. Glasgow: Scottish Drugs Forum
Scottish Executive (2001) Funding Review of the Scottish Drugs Forum, Edinburgh: The Stationery Office
Scottish Executive (2003) Improving Health in Scotland - The Challenge, Edinburgh: The Stationery Office
Scottish Executive (2003) Reducing smoking and tobacco-related harm: A key to transforming Scotland’s Health, Edinburgh: The Stationery Office
69
Scottish Executive (2004) A Breath of Fresh Air for Scotland, Edinburgh: The Stationery Office
Scottish Executive (2004) Health Committee Report, Scottish Executive, Edinburgh: The Stationery Office
Scottish Executive (2004) Health in Scotland 2003, Edinburgh: The Stationery Office
Scottish Executive (2004) Smoking in public places: A consultation on reducing exposure to second hand smoke, Edinburgh: The Stationery Office
Scottish Executive (2005) The smoking, health and social care (Scotland) Act 2005, draft (prohibition of smoking in certain premises) regulations 205 and regulatory impact of assessment. Report of consultation responses, Scottish Executive, Edinburgh: The Stationery Office
Scottish Executive (2006) Towards a future without tobacco, Edinburgh: The Stationery Office
Wilkinson, C.A. Scottish Licensed Trade Association Submission to consultation on the Smoking, Health and Social Care (Scotland) Bill [online]. Available from World Wide Web:
SCOT documentation:
• SCOT Steering group meetings 2005 - 2007 • SCOT Steering group and communication group meeting 2007 • SCOT Coalition meeting 2005 - 2006 • SCOT Coalition building meeting 2006 • Meeting between SCOT, Scotland CAN! And the Chief Medical Officer for Scotland 2006 • Raising the Minimum Legal Age for Tobacco Sales Meeting between SCOT, Scotland CAN! and Duncan McNeil MSP 2006 • SCOT Q&A with Jeffrey Wigand 2005 • SCOT/Scotland CAN! Meeting with Minister of Health & Community Care 2005 • SCOT Steering Group & Scotland CAN! Communications meeting 2005 • SCOT Communications & Strategy Meeting 2005
Scotland CAN! documentation:
• CAN! Sub Committee Meeting 2004-05 • Scotland CAN! Communications group meetings 2005-07 • Scotland CAN! Communications strategy meeting 2005 • Scotland CAN! Minutes 2001-04 • Scotland CAN! Cleaner Air Now! Minutes • Scotland CAN! Public Places Small Working Group 2003
70
Scottish Tobacco Control Alliance documentation:
• STCA Annual Meetings 2004-07 • Evaluation of STCA Aims and Objectives for the period May 2003 to April 2006 • Work Plan 2003-2006 • Smoking, Mental Health and well-being: ‘Be happy, don’t worry and stop smoking’ March 2007 • Fags and HASH: a joint approach • Scottish Tobacco Control Alliance Seminar 2007 • Smoking Cessation in Secondary Care 2006 • STCA Fags and Hash Conference Report and Supporting Information. May 2006. • STCA Conference report from May 9th 2003 – Tobacco and young people: towards a smoke-free generation • STCA Reducing Tobacco Sales to Young People. 2006. • STCA Annual Meeting 2005 Report • STCA Group Meetings 2003-06 • STCA Group Meeting May 2006 – March 2009. • STCA Diary of Help in Kind • STCA Strategic Plan May 2006 - May 2009 • STCA Activity Tracker August 2007 Update • STCA Annual Meeting 2007 Newsletter • STCA Bulletin 2006 - 2007
Action on Smoking and Health (ASH) Scotland documentation:
• ASH Scotland Information and Communications Section report to Board. May 2005 • ASH Scotland Strategic Plan 2004-2009 • ASH Scotland Note of Staff Half Day Workshop 31 January 2007 • ASH Scotland Draft Strategy 2007-10. • ASH Scotland Annual Reports 2001-02 to 2006-2007 • ASH Scotland Information and Communications section workplan 2007 • ASH Scotland 2007: Populus poll results show huge support for smoking ban. Available from World Wide Web:
71 • Local Alliance Advisory Group Meetings minutes • Memorandum and Articles of Association of ASH Scotland • National Tobacco Information Service (Scotland): the ASH Scotland Information Service business plan • Annual accounts 2001-06 • Local Alliances Project documentation including Local Alliances Project Advisory Group Meeting minutes • ASH Scotland Performance management documentation • ASH Scotland Staff induction documentation • ASH Scotland Staff Handbook and contract • ASH Scotland Cross Party Group minutes 2001-06 • ASH Scotland 2008: Supporting Scotland’s Tobacco Control Action Plan: Partnership Action on Tobacco and Health
72 ANNEX 2 BREAKDOWN OF STAKEHOLDER INTERVIEWS
Key: Stakeholder Category Interview type PH Public Health T Telephone F Face to Face EM Email AC/RES Academic/research PRIS Prison service VOL Voluntary organisation MEDIA Media/communications PRO/TU Professional/trade union/umbrella body POL Politics ASHS ASH Scotland SG Scottish Government
Name Title Organisation Category Type of Interview Dr Paul Ballard Deputy Director of Public Tayside NHS Board PH F Health Dr Laurence Gruer Director of Public Health NHS Health Scotland PH T Science Bill Edwards Senior Health Promotion NHS Tayside & PH T Officer & Chair Coordinating Group STCA Fiona Dunlop Principal Health Promotion Greater Glasgow Health Board PH T Officer for Tobacco Lesley Hinds Chair NHS Health Scotland (and PH F formerly of HEBS) Mary Cuthbert (interviewed Head of Tobacco & Sexual Public Health and Substance SG F twice) Health Policy Misuse Division, The Scottish Government
73
Name Title Organisation Category Type of Interview Joyce Whytock Former Action Manager Scottish Executive Tobacco SG F Tobacco Control Policy Co-ordination Team The Scottish Government Mac Armstrong Former Chief Medical Officer The Scottish Government SG T Scotland Alastair Pringle Patient Focus Manager The Scottish Government SG T
Professor Gerard Hastings Director Institute for Social Marketing AC/RES F and the Cancer Research UK Centre for Tobacco Control Research Phil Hanlon Professor of Public Health Glasgow University AC/RES F
Andrew Harris Director Scottish Council Foundation AC/RES EM
Brian Monteith Research Director The Policy Institute AC/RES EM Linda Bauld Reader in Social Policy Department of Social and Policy AC/RES T Sciences, University of Bath Dr Andrew Fraser Director of Health & Social Scottish Prison Service PRIS T Care Wendy Sinclair Director Her Majesty’s Prison PRIS F Kilmarnock Lyndsay Moss Health Correspondent The Scotsman Newspaper MEDIA T
David Amers Planning Director The Leith Agency MEDIA F
Helen Puttick Health Correspondent The Herald Newspaper MEDIA T
Iain Brotchie Consultant, Public Affairs Fleishman Hillard MEDIA F
Dave Watson Scottish Organiser UNISON PRO/TU T
74 Name Title Organisation Category Type of Interview Peter Terry Chair BMA Scotland PRO/TU T Sylvia Murray Policy Officer, CoSLA CoSLA PRO/ TU F Secretariat Helen Eadie Member of the Scottish The Scottish Parliament POL T Parliament Irene Oldfather Member of the Scottish The Scottish Parliament POL EM Parliament Malcolm Chisholm Member of the Scottish The Scottish Parliament POL F Parliament Ted Brocklebank Member of the Scottish The Scottish Parliament POL F Parliament Richard Simpson Member of the Scottish The Scottish Parliament POL F Parliament Tom McCabe Member of the Scottish The Scottish Parliament POL F Parliament Brian Adam Member of the Scottish The Scottish Parliament POL T Parliament Bill Wilson Member of the Scottish The Scottish Parliament POL T Parliament Andy Kerr Member of the Scottish The Scottish Parliament POL T Parliament Douglas Campbell Former Special Adviser The Scottish Government POL T
Derek Munn Former Special Adviser The Scottish Government POL T
Peter Hastie Former Special Adviser The Scottish Government POL F
Helena Scott Head of Policy & Research Age Concern Scotland VOL T
Kate Seymour Communications Manager Macmillan Cancer Support VOL EM (Scotland & Northern Ireland)
75
Name Title Organisation Category Type of Interview
David Liddell Director Scottish Drugs Forum VOL F
Chris Owens Head of Tobacco Control The Roy Castle Lung VOL T Foundation Vicky Crichton Communications Manager Cancer Research UK VOL T
John Crawford Service Planner Scottish Action on Mental VOL T Health Roy Heath Area Manager Edinburgh & Penumbra VOL T Lothians Maureen Moore (interviewed Chief Executive ASH Scotland ASHS F twice) Brian Pringle Director Projects & Services ASH Scotland ASHS F Development Sheila Duffy Director Information & ASH Scotland ASHS F Communications Alyson Campbell (interviewed Director of Business ASH Scotland ASHS F twice) Jeanette Campbell Communications Officer ASH Scotland ASHS F
76 ANNEX 3 STAKEHOLDER SURVEY TOPIC GUIDE
Introduction
The stakeholder survey consisted of a combination of face-to-face, telephone and email semi- structured interviews. They were conducted on an individual basis with key internal and external stakeholders to gather views on ASH Scotland’s performance, in relation to the Tobacco Control Plan and in respect of ASH Scotland’s own plans and strategy; also covering organisational culture, communications, internal monitoring and evaluation, value for money issues and financial procedures, as appropriate.
There was an opportunity for stakeholders to volunteer general perceptions about ASH Scotland and its role in relation to national tobacco control policy, according to their individual perspective.
Each topic area was not necessarily covered with every stakeholder, in recognition of different roles and expertise.
Topic areas
General questions Name, job title, length and nature of relationship with ASH Scotland etc
Performance Strategic priorities, strengths and weaknesses, impact
Governance and risk management Clarity re functions, capacity of Board, risk management
Internal management Business planning, HR, performance management
Communications Range, quality and tailoring of communications methods to audiences
External perceptions of ASH Scotland Perceptions including re relationship with Scottish Government
The future Priorities and challenges
VFM and financial procedures Specialist section
77 ANNEX 4 COMMUNICATIONS STRATEGY: EVALUATION TOOL
Communications objectives
• Are they clear? Relevant and appropriate to the programme/project/campaign? • Are they intended: • to change behaviours and attitudes • to raise awareness • to help achieve a policy objective • to maximise compliance with legislation • to gain support and buy-in of stakeholders? • Realistic? • Measurable: have performance indicators & evaluation criteria been built in at this stage?
Target audiences
• Comprehensively identified – going beyond usual suspects? • Prioritised? • Are communications balanced across different stakeholder groups?
Key messages
• Concise • Framed from the perspective of recipient • Brief & in plain English [& other languages]; relevant to aim • Consistent • Tell a story – use of narrative, human interest, imagery • Strategic targeting & consistency are key
Evaluation measures and on-going amendment of strategy
• Is there a baseline (e.g. communications audit at start, preferably done by someone else) and post-campaign measurement built in? • What measures will be used? • Are target audiences consulted about how/when etc they want info, & how useful info they receive is? • Are timescales & milestones for achievement in place? • Who will conduct evaluation and how will it feed into amendment of on-going strategy? • Are resources allocated to evaluation - funds & people?
78 Budget
• Are sufficient resources allocated to communications?
Communications methods – tools & activities
• Is there a range, tailored to different audiences? • Have stakeholders been consulted about preferred methods of communication? • Is use of website maximised – range of audiences; and to achieve strategic aims?
Lobbying
• Using range of techniques appropriately • Do they have champions? • Aware of & acting within OSCAR guidelines • Innovative & timely • Use of partnerships (including less obvious ones)
The final element of the evaluation tool is to check whether the communications strategy is Specific, Measurable, Achievable, Realistic and Time-bound (SMART).
79 ANNEX 5 ALLIANCES
Scottish Cancer Coalition on Tobacco (SCCOT) formed in October 1999
1. SCCOT was an alliance of ASH Scotland and the leading national cancer charities dedicated to cancer research and education and to cancer patient care. Its membership comprised ASH Scotland, Cancer BACUP, Imperial Cancer Research Fund, Macmillan Cancer Relief, Marie Curie Cancer Care, Roy Castle Lung Cancer Foundation, and the Cancer Research Campaign
2. SCCOT provided a forum to jointly advise and inform the Scottish Parliament and raise awareness about the links between cancer and tobacco use. The coalition was committed to reducing the harm caused by tobacco use by promoting effective prevention and cessation strategies.
Scotland CAN! founded in May 2000
3. Scotland CAN! (Cleaner Air Now!) was founded by ASH Scotland in May 2000 to campaign for legislation to restrict smoking in Scotland’s public places. The launch of Scotland CAN! followed the public announcement of an initiative which relied on a voluntary approach to controlling second-hand smoke (the Voluntary Charter), promoted by government and the hospitality trade.
4. In November 2004 the Scotland CAN! group agreed to merge with SCCOT under the umbrella of the SCOT coalition. Scotland CAN! redefined its aims, to raise public awareness of the harmful health impacts of second-hand tobacco smoke (SHS), to lobby for legislation to increase protection from SHS and to work towards extending clean air environments in Scotland.
5. Scotland CAN! is the campaigning arm of SCOT, with a focus on issues relating to smoking in public places. The group supports comprehensive legislation to end smoking in enclosed public places in Scotland, and aims to work to publicise the harmful health impacts of tobacco smoke and to extend clean air environments.
SCOT (bringing together SCCOT and Scotland CAN!) formed in November 2004
6. SCCOT (the Scottish Cancer Coalition on Tobacco) was originally set up in October 1999 as an alliance of ASH Scotland and the leading cancer charities dedicated to cancer research and education and to cancer care. SCCOT provided a means to raise awareness specifically about the links between cancer and tobacco use. SCCOT also founded the Scottish Parliament Cross Party Group on Tobacco Control (CPGTC) to assist with this goal.
7. In November 2004, it was agreed that SCCOT would no longer exist as a separate coalition, and that it would instead reform under a wider coalition of SCOT (the Scottish Coalition on Tobacco).
80 8. In practice the Scottish Coalition on Tobacco carries forward the work of SCCOT, broadening it out to raise awareness of the links between tobacco use and a range of other diseases and conditions, such as heart disease. This broader focus is reflected in the areas of expertise of member organisations involved in the SCOT coalition. In accepting this broader umbrella coalition, SCOT has also recognised the importance of broad and wide ranging tobacco control measures to effectively combat the tobacco epidemic in Scotland.
Cross Party Group on Tobacco Control set up in December 1999
9. The purpose of the Cross Party group on Tobacco Control is to take forward an effective tobacco control agenda in Scotland.
Membership
10. MSPs: Brian Adam, Robert Brown, Jackson Carlaw, Kenneth Gibson, Irene Oldfather, Richard Simpson Non-MSP Individuals: Alan Lee MSYP Organisations: ASH Scotland (Jeanette Campbell, Dr Sheila Duffy, Rachel Harrison); Asthma UK Scotland (Gordon Brown); British Heart Foundation (Ben McKendrick); British Lung Foundation (Andrew Powrie-Smith); BMA (Gail Grant); Cancer Research UK (Vicky Crichton); Institute of Social Marketing (Prof. Gerard Hastings, Ingrid Holme, Susan MacAskill); Macmillan Cancer Support (Kate Seymour); Marie Curie Cancer Care (Lorena Brogan, Maggie White); Roy Castle Lung Cancer Foundation (Joyce Dunlop, Chris Owens); Royal College of Nursing (Geoff Earl, Shirley-Anne Sommerville); The Royal Environmental Health Institute of Scotland; The Stroke Association (Maddy Halliday, Angela MacLeod).
Scottish Tobacco Control Alliance (STCA) formed in 2000
11. The STCA is a multi-disciplinary, multi-sectoral body of over 120 organisations concerned with the impact of tobacco on Scotland and its people. It provides a forum for information exchange and a voice for those working in the tobacco field to influence policy development. The history of STCA development can be found in the STCA Foundations section of ASH Scotland’s website.
12. Members have access to the weekly STCA Bulletin, seminars, conferences, and other opportunities for information exchange. The STCA hosts a number of topic groups including: Researchers Group, Tobacco Control Issues Group, Cessation in Pregnancy and Youth and Tobacco Forum.
STCA Vision
13. A coordinated tobacco control strategy for Scotland that will progressively reduce the harm caused by tobacco.
81 STCA Goals
14. The Scottish Tobacco Control Alliance will provide the means by which organisations from across Scotland can exchange information and influence tobacco related policies at local, regional and national levels.
STCA Principles
• STCA membership will reflect the wide range of organisations and disciplines concerned with the impact of tobacco on Scotland and its people • the STCA will endeavour to address tobacco inequalities in all its activities • the STCA will be an inclusive, participatory body that encourages active engagement of its members • the STCA will be consultative of its members, transparent and accessible.
82 ANNEX 6 ASH SCOTLAND ORGANISATIONAL CHART
Please note that the organisation chart has been up-dated (January 2008) since the review (November 2007) and is available from the ASH Scotland website: http://www.ashscotland.org.uk/ash/3381.11.221.html. 83
ANNEX 7 TOBACCO CONTROL ACTION PLAN 2004 - 2007 KEY ACTION POINTS
The approach 1. In order to undertake or commission work on tobacco-related health issues of specific relevance to Scotland, the existing Tobacco Control Strategy Group will be strengthened and upgraded to a Ministerial Working Group chaired by the Deputy Minister for Health and Community Care. This Group will provide expert advice on the health impact of tobacco and provide a forum for the dissemination of best practice to health and other professionals throughout Scotland.
Prevention and education 2. In consultation with the new Ministerial Working Group, we will commission a review of current national communication and education programmes and build any learning into the development of a coherent, integrated long-term communications strategy to guide future prevention activity at national and local levels.
3. In partnership with NHS Health Scotland, we will commission further research with young people to provide a clearer picture of the factors that lead them to start or resist smoking and track awareness of the dangers of smoking and passive smoking amongst key target groups.
Provision of smoking cessation services 4. We will allocate additional funding to smoking cessation services of £1 million in 2003/04, £1 million in 2004/05 and £5 million in 2005/06. Using the Revised Smoking Cessation Guidelines and the Smoking Atlas of Scotland, which are due to be published by the end of March 2004, NHS Boards should assess local needs, identify gaps and develop plans to fill these gaps.
5. We will take steps to further develop the evidence base for effective cessation services through increased investment in the Partnership Action on Tobacco and Health (PATH). The findings of the review report should be used to inform the priorities for this increased investment.
6. We will negotiate and agree cessation targets with each NHS Board by the end of July 2004. As part of this process we will work with NHS Boards, ISD and PATH to introduce reliable baseline measures and develop outcome based measures for future use.
Second-hand smoke (passive smoking) 7. In 2004, we will sponsor a major public debate on actions to minimise the impact of second-hand smoke. This will involve a range of conventional and innovative opportunities to contribute to the dialogue, including a major conference to provide acknowledged experts
84 with the opportunity to put their messages across to the people of Scotland.
8. We will work with partners including NHS Health Scotland to develop and deploy a national advertising and communications campaign about the dangers of second-hand smoke.
9. We will review our own current staff smoking policy, which permits smoking only in designated smoking areas, with staff representative bodies, with a view to introducing a complete smoking ban by the end of July 2004.
10. As part of efforts to facilitate ‘healthy working lives’, we will challenge employers, trade unions, voluntary groups and representative organisations to encourage and support the introduction of effective smoking polices by all Scottish employers.
11. NHS Boards and local authorities will be encouraged to review their smoking policies by the end of 2004 in the light of guidance available from Health Scotland, ASH Scotland and the Convention of Scottish Local Authorities.
Protection and controls 12. The results of the test purchasing pilot scheme will be carefully considered by the Lord Advocate in order to assess whether the test purchasing arrangements are sufficiently safe, effective and fair to allow the revised prosecution policy adopted for the pilot to remain in place or be extended.
13. In light of the decision on test purchasing, we will agree an enforcement protocol with our local authority partners to guide more effective enforcement of the Children and Young Persons (Protection from Tobacco) Act 1991. We will also look for ways to raise awareness about illegal sales and to encourage the public to report retailers who sell cigarettes to under- 16s.
14. We will continue to support the roll out across Scotland of the Dialogue Youth project and associated Young Scot card which provides amongst other things proof of age and to work with Young Scot, the Scottish Retail Consortium, CoSLA and the Society of Chief Officers of Trading Standards in Scotland to encourage support of the card, including by retailers.
15. We will make subordinate legislation in the Scottish Parliament to deploy the Tobacco Advertising and Promotion Act 2002.
16. We will establish, in partnership with the UK Government, appropriate arrangements to monitor the Tobacco Advertising and Promotion Act 2002 and act to close any loopholes which are identified. This will include monitoring of remaining marketing activity, including point-of-sale publicity, distribution strategies, pack design, new product development and corporate social responsibility campaigns.
17. We will continue to work closely with the UK Government to promote tobacco control policies at UK and international level.
85 ANNEX 8 PUBLIC OPINION BEFORE AND AFTER THE SMOKING, HEALTH AND SOCIAL CARE (SCOTLAND) ACT 2005
Public opinion - Period Pre Smoking Ban in Public Places – 2004 Data 1. On 7 June 2004, The Scottish Government Health Department published a consultation document "Smoking in Public Places - A Consultation". The aim of the consultation was to obtain people’s views on possible approaches to minimising the harm caused by second hand smoke. The consultation provided an open invitation to anyone who had an interest in this issue to give their views and the public consultation document was designed in a questionnaire format to enable the consultation to be as accessible as possible to a wide range of individuals who wished to make a response. A total of around 600,000 consultation questionnaires were distributed and 53,474 responses were submitted to the Scottish Government.
2. The consultation document set out the background to the consultation, highlighted the key topics for consideration and posed a series of questions to which respondents were invited to respond. The questions focused on 6 broad topic areas: • Whether further action needs to be taken to reduce people's exposure to second-hand smoke • Whether individuals would support a law that would make enclosed public places smoke-free • Whether there should be any exemptions if a law is introduced • What could be done to encourage individual businesses to take voluntary action to become smoke-free or to provide more smoke-free provision • What else could be done to reduce people's exposure to second-hand smoke • Details of any other views on smoking in public places
3. The results of the consultation showed that 80% of the consultation responses and 54% of opinion survey responses supported making all enclosed public places smoke-free. At that stage, despite this large scale support in the consultation responses for the ban, there was more reservation about exemptions:
" Majority (56%) of respondents did not think that there should be any exemptions if a law was introduced, 35% indicated that there should be, 5% didn't know and 4% did not reply. 24% of those who indicated that they would support a law were in favour of exemption” 29.
Period Post Smoking Ban in Public Places 4. Following on from the consultation in 2004, a series of MRUK omnibus surveys was conducted in May, August and November of 2005 and January, March, May and October 2006. This, in essence, tested opinion throughout a period during
86 which legislation was becoming, and then became a reality, rather than the 2004 consultation on the public’s views on tackling the effects of second hand smoking, with legislation being posed as an option.
5. The final wave of the research in October 2006 tracked public opinion across the period. 1,040 interviews were conducted on that occasion and the sample selected to be geographically representative of the Scottish population, was split evenly across male and female respondents and a took spread of ages, making it broadly in line with the population in Scotland and had a mix of respondents from different socio-economic groups. A third of the sample were current smokers (34%), 45% were non-smokers and 21% said they used to smoke but had now stopped.
Public attitudes to smoking in public places — MRUK omnibus survey — October 2006 main findings30.
Key findings
• Support for the smoking ban: Support for the smoke-free legislation increased to 70% in October 2006; between August 2005 and May 2006 support for the law was consistently between 58% and 61%. Non-smokers and ex-smokers were more likely to support the ban across the research. In October 2006, 91% of non-smokers and 80% of ex-smokers were in support of the legislation. However, increase in support was particularly marked amongst smokers, with 37% of smokers supporting the legislation in October 2006 (support among this group ranged between 19% and 33% in the previous 6 waves). • Awareness of smoking ban: Awareness of the ban has been high throughout the research, growing from 95% prior to the ban (March 2006) to virtually all respondents in October 2006 (99%). • Success of smoking ban: Between May and October 2006 there was an increase (from 73% to 77%) in the proportion of respondents who thought the legislation had been successful in making enclosed public places smoke free. Non-smokers and ex-smokers were more likely to consider the ban successful compared to smokers (80% and 71% respectively). However, the proportion of respondents who thought the legislation was unsuccessful dropped from 10% to 5% between May and October 2006.
Summary of main findings
Support for the smoking ban • Support for the ban was attributed to a variety of factors including the cleaner air / environment (18%) and a dislike of smoking (16%). Health reasons were also considered a factor influencing respondents’ support of the ban, although this reason became less prominent over more recent waves (12% in October 2006, 31% in August 2005 and 33% in May 2005). • In October 2006, 23% of respondents (predominantly smokers) did not support the legislation. The main reasons identified for not supporting the ban were that they enjoyed smoking (23%) or because they/their partner
87 smoked (16%). These reasons have been reiterated throughout the research findings. However, a notable difference across the research was the reduction in the proportion of respondents stating that smokers have the right to smoke in public places (39% in May 2005; 3% in October 2006).
Perceived impact of the legislation • In each wave of research, respondents anticipated that the new legislation would impact on them in a variety of ways and would generally have a positive impact on their lives. For instance, 18% said the smoking ban would be better for people’s health, while 12% said socialising would be more enjoyable as a result of the ban and 11% thought the ban would make environments safer and cleaner. • Similarly to previous waves, non-smokers and ex-smokers were more inclined to perceive the ban on smoking to be better for health (23% and 24% respectively), compared to smokers (7%).
Perceived success of the legislation • Success of the ban was largely ascribed to the following: cleaner environment in pubs, clubs and restaurants (15%); most people were seen to be abiding by the legislation (13%); and all public places being smoke free (20%). • A higher proportion of those who considered the ban unsuccessful perceived there to be a detrimental impact on employment and revenue as a result of the ban (33% in October 2006, compared to 19% in May 2006). There was also an increase in the proportion who objected to smoking outside in October (20%) compared to May 2006 (2%), perhaps reflecting seasonal factors. Among this group, a less prominent perception was that the ban stopped people going out (4% in October 2006; 20% in May 2006).
Perceived impact on smoking behaviour: smokers only • Across the waves of research, the majority of respondents who smoked thought the legislation would have no effect on the amount they smoke (69% in October 2006). In October 2006, 29% said the ban had helped them reduce the amount they smoke; this proportion had decreased slightly since May 2006 (35%). The figure for anticipated smoking reduction had varied throughout the research from 27% in November 2005 to 40% in March 2006. • The majority of ex-smokers said the ban had not influenced them to give up smoking (93% in October 2006), with only 5% saying that the ban had some degree of influence on them. It is important to note that some ex- smokers may have stopped smoking prior to the ban.
Attitudes to the risks of passive smoking • Throughout the seven waves of research, the majority of respondents have consistently agreed that action should be taken to reduce people’s exposure to passive smoking/second hand smoke (73% in October 2006).
88 Household smoking policy • Broadly consistent with recent waves of research, half of respondents said smoking was not permitted anywhere in the home. Across the surveys, the findings highlight that those in socio-economic group AB (57%) are significantly more likely to not allow smoking in the home compared to those from group E (29%). • A quarter of respondents (26%) said smoking was permitted throughout their home. This figure has varied across the waves, ranging between 24% (March 2006) and 33% (November 2005). In October 2006, 23% of respondents said smoking was allowed in certain rooms; this figure is broadly consistent with previous survey findings.
Workplace smoking policy • 46% of those respondents in employment reported that smoking was not permitted anywhere on their work premises, lower than in May 2006 (67%). However, a higher proportion reported that there were designated areas outside the premises (49% in October 2006 compared to 30% in May 2006).
89 ANNEX 9 SDF AND ASH SCOTLAND INCOME AND EXPENDITURE
SDF Budgets 2004-05 2005-06 2006-07 2004-05 2005-06 2006-07 Income Expenditures
Grants & donations 1,062,407 1,066,796 1,022,260 Staff 853,705 834,235 721,838
Conferences & seminars 44,000 60,100 35,100 Property costs 46,402 67,025 77,100 Members' subs 18,000 19,000 20,000 Publication & Ad sales 6,000 3,000 1,800 Consultancy & training fees 11,000 500 10,000 Bank interest 5,000 3,500 1,600 Other income 0 31,400 18,850 Total incoming 1,146,407 1,184,296 1,109,610 % Turnover Grants & donations 92.7% 90.1% 92.1% Staff 74.5% 70.4% 65.1% Conferences & seminars 3.8% 5.1% 3.2% Property costs 4.0% 5.7% 6.9% Members' subs 1.6% 1.6% 1.8% Publication & Ad sales 0.5% 0.3% 0.2% Consultancy & training fees 1.0% 0.0% 0.9% Bank interest 0.4% 0.3% 0.1% Other income 0.0% 2.7% 1.7% 100.0% 100.0% 100.0% 78.5% 76.1% 72.0%
90
ASH Scotland Budgets 2004-05 2005-06 2006-07 2004-05 2005-06 2006-07 Income Expenditures
Grants & donations 414,869 353,120 468,500 Salaries / Pensions / Insurance 355,000 376,848 440,000
- Scottish Government 364,869 353,120 403,800 Property costs 39,500 42,500 64,500 - British Heart Foundation 50,000 0 54,700 - Health Scotland 0 0 10,000 Members' subs 1,500 1,500 2,000 Publication & Ad sales 1,000 1,000 500 Project management 80,000 115,000 113,300 Bank interest 12,000 17,000 20,000 Other income 41,210 61,106 28,900 Total incoming 550,579 548,726 633,200 % Turnover Grants & donations 75.4% 64.4% 74.0% Salaries / Pensions / Insurance 64.5% 68.7% 69.5% Members' subs 0.3% 0.3% 0.3% Property costs 7.2% 7.7% 10.2% Publication & Ad sales 0.2% 0.2% 0.1% Project management 14.5% 21.0% 17.9% Bank interest 2.2% 3.1% 3.2% Other income 7.5% 11.1% 4.6% 100.0% 100.0% 100.0% 71.7% 76.4% 79.7%
91 ANNEX 10 ASH SCOTLAND’S PERCEPTION OF ITS PERFORMANCE IN 2004-06
1. As part of the process of production of the Strategic Plan for 2007-10, in January 2007 ASH Scotland conducted separate half day workshops for Board members and staff. Part of this included an assessment of what went well and what didn’t go so well in 2004-06.
2. A subsequent event in March 2007 pulled together the outputs from the previous events and, inter alia, discussed Strengths, Weaknesses, Opportunities and Threats. This table shows the key items identified by the Board members and staff19.
What Went What Didn’t Go Strengths Weaknesses Well So Well Smoke free Lack of diversity Credibility with Lack of diversity of funding – legislation of funding Scottish Government only one main funder Expansion of Rapid growth; lack & key organisations Limited capacity to gather ASH Scotland’s of support; change – evident in our evidence and so research – work management work at all levels always using external orgs – Our profile, Misconceptions Partnership working not doing it reach and about the breadth (eg STCA, SCOT) – Capturing knowledge / reputation of our work and close working continuity of roles; information Information what we do partnerships lost when people leave/ lack of service Slippage in (steering groups understanding of people’s roles Partnership timescales have partners within the org working, Engagement with present) alliances and local authorities Policy development coalitions Education and and lobbying – Training prevention work legislation through Involving hard to earlier than reach groups anticipated
19 These are taken from the notes of the Board and Staff Workshop 7 March 2007. The workshop identified the “big issues” from longer lists and it is these big issues that are reproduced here. 92 ANNEX 11 LIST OF ABBREVIATIONS AND ACRONYMS
ACAS Advisory Conciliation and Arbitration Service AGM Annual General Meeting ASH Scotland Action on Smoking and Health Scotland BHF British Heart Foundation BMA British Medical Association BME Black and minority ethnic CEO Chief Executive Officer CHD Coronary heart disease CoSLA Convention of Scottish Local Authorities. CPG Cross Party Group CTCR Centre for Tobacco Control Research ETS Environmental Tobacco Smoke EU European Union FOREST Freedom Organisation for the Right to Enjoy Smoking Tobacco GP General Practitioner HEBS Health Education Board for Scotland HQ Headquarters HR Human resources ISD Information Services Division Scotland LGBT Lesbian, gay, bisexual and transgendered MSP Member of Scottish Parliament NGO Non governmental organisation NHS National Health Service NRT Nicotine Replacement Therapy PATH Partnership Action on Tobacco and Health PR Public relations SCCOT Scottish Cancer Coalition on Tobacco SCOT Scottish Coalition on Tobacco Scotland CAN! Scotland Cleaner Air Now! SDF Scottish Drugs Forum SHSC 2005 Smoking, Health and Social Care (Scotland) Act 2005 SLTA Scottish Licensed Trade Association SMART Specific Measurable Achievable Realistic Time-bound SMT Senior Management Team STCA Scottish Tobacco Control Alliance T&I Tobacco and Inequalities Project TIS Tobacco Information Service TOIL Time off in lieu UK United Kingdom VFM Value for Money
93 REFERENCES
1 ASH Scotland (2007) Draft Strategy 2007-10, Edinburgh: ASH Scotland 2 ASH Scotland and the Health Education Board for Scotland (1998) A Smoking Cessation Policy for Scotland, Edinburgh: ASH Scotland & HEBS 3 Department of Health (1998) Smoking Kills, A White Paper on Tobacco, London: The Stationery Office 4 ASH Scotland (1999) Smoking in Public Places, Edinburgh: ASH Scotland 5 The Scottish Office (1999) Towards a Healthier Scotland, Edinburgh, The Stationery Office 6 Parliamentary Question put by Bill Aitken MSP to Susan Deacon, Minister for Health and Community Care, 1 December 2000 7 The Scotsman (1999) 18 August 1999 8 http://news.bbc.co.uk/1/hi/scotland/422757.stm 9 Macdonnell, H. MSPs battle for total ban on smoking in public places, Daily Mail 18 August 1999 10. Clark, S. Letters, The Scotsman 20 August 1999 11 http://www.ashscotland.org.uk/ash/3391.html 12 ASH Scotland (1998) Briefing on Smoking Kills - the White Paper on Tobacco, Edinburgh: ASH Scotland, p8 13 http://ashscotland.org.uk/ash/3710.html 14 Ludbrook, A. et al. (2005) International Review of the Health and Economic Impact of the Regulation of Smoking in Public Places, Health Economics Research Unit and Department of Public Health, University of Aberdeen, Edinburgh: Health Scotland 15 Information and Communications Section report to ASH Scotland Board May 2005 16 ASH Scotland Board minute August 2007 17 Scottish Executive (2004) A Breath of Fresh Air for Scotland, Edinburgh: The Stationery Office 18 NHS Health Scotland and ASH Scotland (2007) Designing and Delivering Smoking Cessation Services to Young People: Lessons from the Pilot Programme in Scotland, Edinburgh: Health Scotland 19 ASH Scotland (2004) Strategic Plan 2004-09, Edinburgh: ASH Scotland, p4 20 Minutes of ASH Scotland Board Meeting 29 August 2007 Item 2 21 ASH Scotland (2004) Strategic Plan 2004-09, Edinburgh: ASH Scotland, p7 22 http://www.archive.official-documents.co.uk/document/cm41/4177/4177.htm 23 The Robert Gordon University Centre for Public Policy and Management (2004) A Critical Review of the CPG System in the Scottish Parliament, http://www.festivalofpolitics.co.uk/business/committees/standards/papers-04/stp04-08.pdf 24 OPM and CIPFA (2004) The Independent Commission for Good Governance in Public Services (The Langlands Report), London: OPM and CIPFA 25 Note of Staff Half Day Workshop 31 January 2007 26 Jelinek, M. and Schoonhoven, C. B. (1991) Strong Culture and its Consequences in Henry, J. and Walker, D. (eds) Managing Innovation, London: Sage, p82 27 Drucker, P. (1992) Managing the Non-Profit Organization: Practices and Principles, Oxford: Butterworth-Heinemann, p8 28 ASH Scotland (2007) Draft Strategy 2007-10, Edinburgh: ASH Scotland 29 http://www.clearingtheairscotland.com/research/consultation-summary.html 30 http://www.clearingtheairscotland.com/research/opinion-survey.html
94 ISSN 0950 2254 ISBN 978 0 7559 7222 7 (Web only publication) www.scotland.gov.uk/socialresearch
RR Donnelley B57541 08-08