The government's NHS review is considering selling cheap nicotine patches through supermarkets and newsagents as part of a drive to prevent avoidable illness in poor areas. Among the ideas floated in draft reports from six modernisation action teams set up by Alan Milburn, the health secretary, is a plan to give priority to reclassifying nicotine replacement therapy "as general sales and not just a pharmacy only product".
A team on prevention of illness, chaired by Liam Donaldson, the chief medical officer, said the high prevalence of smoking in working class families was one of the main causes of health inequalities that shortened the lives of the poor. The high price and poor availability of nicotine replacement therapy acted as a barrier to poorer people kicking the habit.
The report recommended that bupropion, an anti-smoking treatment due to be launched commercially next week, should be made available on NHS prescription. And ministers should consider offering free therapy on the NHS to help poor smokers to quit.
The team called for every area to draw up targets for cutting smoking, increasing consumption of fruit and vegetables, encouraging physical activity and reducing obesity.
Parts of the report may be amended before the final draft to ministers next month. There was amusement in Whitehall last night about its proposal for "a national network of health walks", providing GPs with maps where patients might like to take gentle exercise.
But the team is expected to stick to its core recommendations for much more active intervention to reduce health inequality.
The prevention team recommended greater attention by the NHS to the wider interests of the community. Its procurement and employment policies should be made to benefit disadvantaged areas.
NHS staff should help to improve diet and nutrition among pregnant women and children.
It should help set up a network of women able to offer "peer support" to encourage breast feeding. The NHS should support local food co-operatives in disadvantaged areas and organise "fruit and vegetable schemes" to promote healthy eating in schools.
The report warned: "The supply of good quality food and vegetables in many disadvantaged areas is poor, and the price is too high."
Proposals for consideration in the longer term should include a GP contract with better incentives for doctors to work in disadvantaged communities. NHS regional offices could be merged with government offices of the regions to allow promotion of public health to be co-ordinated across all services.
The work of the prevention team was criticised last night by Stephen Thornton, chief executive of the NHS confederation.
"The NHS should focus on what it can do to prevent ill health. For example, we can make sure that people who have a heart attack take aspirin. Yet we know there is a significant minority of GPs who don't prescribe it."
• Recommendations of the other MAT teams included:
Patient Empowerment:
Smart cards allowing patients to access their personal health records were proposed as part of a set of recommendations to make more health information available. The NHS would have a full health care record of every individual, accessible to health professionals in GP surgeries, hospitals, ambulances and other medical facilities.
Patients could either carry this information on their own smart cards or access central records via adapters on phones or TV.
More general information about illness and possible treatments should be provided at touch-screen kiosks in public places. One option would be to adapt national lottery terminals which have spare capacity outside the peak times on Wednesdays and Saturdays.
Other ideas included access to cut-down versions of health websites via Wap phones, interactive digital TV and email question and answer facilities on NHS Direct.
Performance and productivity:
Ministers were advised to impose controls on private practice "to prevent exploitation of the arrangements by a small section of the profession, and to ensure that NHS work comes first". This might include "restricting access to opportunities within the NHS for individuals carrying out unacceptable levels of private practice."
The diagnosis
The problems
• Provision of primary care services outside office hours is limited, patchy and unrelated to patient needs. 20% of people in work put off going to their GP because of inconvenient hours, 29% have to wait 2-3 days for appointment.
• One third of health authorities report serious difficulty in finding dentists.
• Significant pockets of poor primary care infrastructure remain, largely in deprived areas.
• Out of hours access to pharmacies is patchy and information can be hard to find.
• During 1998/99 1.6m patients waited longer than 3 months for a first outpatient appointment while 1.3m waited longer than 3 months for inpatient admission.
• Conditions such as knee and hip replacements, coronary artery bypasses, and cataract extraction have average waiting times of up to 230 days.
• Every year over 1m patients fail to turn up for their outpatient appointment.
• Every year 60,000 operations are cancelled by the hospital on the day they are due to take place.
• Patients can wait for hours in A&E, simply to be seen. Many patients well enough to leave hospital are forced to stay because support services are not available.
Barriers to change
• Services based on historical patterns and institutions - they are not planned to meet the needs of patients.
•Rigid boundary between primary and secondary care.
• Lack of slack in the system. As a result, surges in demand for emergency care affect non-emergencies.
• No one takes overall responsibility for patients' care.
• Professional hierarchies create rigid boundaries.
• Staff feel overwhelmed by new initiatives.
• Insufficient importance given to leadership.
