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Archive for the ‘Alcohol’ Category

By Dr Nadeem Hasan

The importance of effective advocacy to achieving public health goals cannot be overstated.
Every day policies and regulations that affect health outcomes for better or worse are put on the agenda and kept off the agenda; discussed and debated; approved and rejected.

Many, if not most of these relate primarily to non-health sectors, such as food and beverages, energy and infrastructure, and alcohol and tobacco. But their impact on health outcomes is very real: all the stop-smoking programmes in the world can’t match the impact of the ban on advertising and smoking in public places on smoking prevalence; and there’s no amount of spending on childhood obesity programmes that can make up for the regulatory vacuum in this area.

Looking more broadly, policy decisions that affect income inequality, carbon emissions, and military action all have serious consequences for health across the world.

If we’re serious about prevention, we need to be serious about advocacy.
Where profits can be affected (almost everywhere), industry lobbyists seek to influence the regulatory environment in their favour. And they are very good at it. In principle, this is quite right – those affected by policy and regulatory shifts should indeed be able to make representations and provide additional evidence to support the decision-making process – and this includes relevant industry actors.
Representing the interests of everybody else is where advocacy organisations come in – acting as sort of ‘civil society lobbyists’ to balance out the discussion – advocating on behalf of the health, wellbeing, and broader concerns of the general population. Notably, this isn’t always an ‘us vs. them’ relationship: health insurance companies are routinely allies on advocating for lower drug prices; and renewable energy companies are more than happy to work with advocacy organisations on climate change regulation.

Put this way, it might sound like a fair playing field, with decision-makers receiving submissions from a range of groups and making balanced decisions to maximise the benefits to all parties. The reality of course is quite different, and much, much messier.
In 2014, there were an estimated 30,000 industry lobbyists in Brussels alone, falling just short of the 31,000 employees for the whole European Commission.

Civil society pockets are not deep enough to come close to matching this (or the salaries of lobbyists), and civil society advocacy and pressure groups are few and far between. Transparency falls short of the ideal, and the revolving door between policy-making and industry remains alive and well. Most recently the former President of the European Commission José Manuel Barroso was appointed Chairman of Goldman Sachs International, a move that has been widely criticised.
Advocacy organisations, then, have a difficult task – but one where even small successes can have far-reaching benefits for public health.
The European Public Health Alliance (EPHA), based in Brussels, is one such advocacy organisation. They bring together a range of health-related NGOs to advocate for better public health in Europe, working across five campaign areas: antimicrobial resistance; food, drink and agriculture; healthy economic policy; universal access and affordable medicines; and trade for health (and specifically the EU-US free trade agreement – TTIP – and the EU-Canada free trade agreement – CETA). Earlier this year, they hosted myself and another registrar in a pilot placement to understand health advocacy at the European level and to develop skills in this area.
So how to sum up the placement?
Invaluable. EPHA track the policy process for each one of their campaign areas and engage at every possible point. They attend every meeting at the European Parliament and the European Commission on these areas and make oral contributions at every opportunity; they submit comprehensive written responses to every relevant consultation; they engage on a daily basis with journalists to publicise their positions and build public support; they engage like-minded actors in the public, private, and not-for-profit sectors on a case-by-case basis to coordinate action; and they do all of this with just a handful of relatively young staff and interns.

They were very welcoming in bringing us into the whole process, allowing me to engage in every one of these steps – from writing position papers and consultation responses to making oral contributions at the European Commission and Parliament on their behalf.
Notably, EPHA also position themselves as an advocacy agency that actors from across the spectrum can engage with – in contrast to, for example, much more vocal organisations such as Greenpeace.

By way of example, the area that I was working on was TTIP. Whilst there are a raft of advocacy organisations across Europe (and the USA) that reject TTIP outright, EPHA’s

approach is to work through the whole agreement and advocate for the protection of public health on a section-by-section basis without rejecting the whole deal. With the European Commission politically committed to getting a deal, this makes EPHA one of the few organisations they can meaningfully engage with on this issue (though recent developments have called into question the likelihood of getting a deal in the near future).

This isn’t to say that their approach is ‘superior’ – every actor plays a particular role, with the more intransigent organisations key in shifting public opinion and providing the space for actors such as EPHA to engage in more balanced discussions. This means that they are invited to closed-door sessions with only a handful of actors, and have much more influence on the process than they otherwise would.
One of the challenges from a ‘public health professional’ perspective was that effective advocacy sometimes involves taking – shall we say – a less balanced view than we would normally as technical experts. From an ethical perspective, this raises a number of questions around whether the ends justify the means. I witnessed first-hand industry lobbyists making quite outrageous claims, including a rather undignified moment where I coughed up half my glass of water in a large auditorium at the European Commission when it was submitted that ‘alcohol is in no way an unhealthy commodity’ .

In a world where climate change denial is alive and well despite the most overwhelming evidence to the contrary, the ‘best’ approach to making our points is perhaps not so easy to discern.
And what of the relevance to the UK, particularly as we now start closing our doors to the EU in a bid to be a more open, global-facing country?
Whether or not the UK is a member, the EU remains a powerful actor that can influence policies related to public health both for its own citizens (which will still number ~450m after the UK leaves), and globally. As a close neighbour, EU regulations will have a strong bearing on public health in the UK too, and so engaging in advocacy at this level will continue to be an effective approach to improving UK public health.

This is true for everything from environmental regulations and air pollution, to pharmaceutical regulations and drug pricing and safety.
Within the UK, whilst it’s true that our policy-making process is not as amenable to advocacy as at the EU level (or remotely as civilised), effective advocacy still has huge potential to improve public health. We have not done well recently, with a watered-down childhood obesity strategy, no resistance to an unfunded ‘7-day’ NHS (that differs from the 7-day NHS that has existed since 1948 in some undefined way), and year-on-year increases in the use of food banks without any policy response (to name just three areas).

At the local level, there are a cornucopia of opportunities for advocacy to improve health, from influencing urban planning (fast food outlets close to schools, street design, cycling lanes) to advocacy around shifting public perceptions e.g. from opposing to welcoming refugees into local communities.
In this context, strengthening the advocacy skills of the UK public health workforce through engaging with and learning from experienced actors such as EPHA should be pursued with vigour – we can ill afford the alternative.

Dr Nadeem Hasan is a Specialty Registrar in Public Health

 

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Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners.  Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost.  Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the   hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are.  Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base.  But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery.  This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

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By Alan Maryon-Davis

Health Secretary Andrew Lansley wants to encourage people to eat healthily, drink sensibly, stop smoking and get more active without lecturing or hectoring them. People don’t like being told what to do or not do – least of all by the Government – so Lansley says we should provide them with information and incentives and let them choose for themselves – nudging rather than nannying. Hence the Great Change4Life Swapathon with its supermarket discount vouchers for healthy options. Lots of carrots, no sticks.

There’s also much nudging behind Lansley’s Responsibility Deal with the food, drink and fitness industries. Double nudging – Lansley nudging them to nudge the public. Industry will “pledge” to provide information and incentives encouraging healthier choices.

So where’s the fudge? In return for industry cooperation (and cash) Lansley has said he’ll go easy on mandatory regulations around such things as marketing, labelling, availability and pricing. To be fair, he doesn’t rule these threats out completely. He talks about the Nuffield Ladder of Interventions, with the least intrusive (information, education and incentives) at the bottom and the most intrusive (regulation and legislation) at the top. But he’s made it clear he doesn’t want to climb that ladder unless he absolutely has to. It wouldn’t fit his political philosophy.

So there’s a big fudge around how he’ll monitor adherence to voluntary approaches, assess progress and judge when to bring in mandatory controls. The food and drink industries are notoriously slippery, evasive and foot-dragging – just look at labelling and marketing. Meanwhile the health lobby is going along with the Responsibility Deal in the hope that things might be different this time – well aware they risk being be-smudged as part of the fudge.

I’d like to see a solid pledge by the Government to regulate or legislate if voluntary approaches fail and to be crystal clear about how and when such judgements will be made. Without an explicit commitment to use force if necessary, the deal will be seen as no more than a charade letting Big Business off the hook.

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Campaigning does pay off — as we can see from the news that major supermarket chain Tesco is now backing the introduction of a mandatory minimum price for alcohol.

In the past six months the Faculty has taken a number of steps to raise awareness of the harm that alcohol is causing in Britain, and to make the case for the introduction of a minimum price for alcohol, and the benefits this would bring.

And we have made a difference. Scottish CMO Harry Burns thinks we have really helped bring awareness of the issue to the mainstream, and by doing that we have managed to get politicians more interested in this issue.

There were barriers: first off there was an initial reaction that by pushing up prices we were trying to punish the poorest; then there was an argument that a law would force small breweries or distilleries to close.

But slowly, slowly some of the health facts and messages have started to make a difference, and politicians, the media and the public have started to understand more about why minimum pricing would work.

Interestingly the new Coalition programme for government has mentioned a number of policy plans relating to alcohol pricing, so we look forward to seeing how they manifest themselves.

It looks like times, and opinions, are a-changing.

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Very long faces in the West Country this week. Despite much pressure from the health lobby, Alistair Darling has chosen to ignore calls for minimum pricing of alcohol, and instead has imposed a hefty tax hike on cider. In Wednesday’s Budget statement, the Chancellor announced a duty increase of 10% above inflation for cider compared with 2% above inflation for other alcoholic drinks across the board.

In recent years cider has enjoyed something of a tax holiday, making it a firm favourite among young people with little money and big thirsts. Cider has been a cheap way to binge-drink, and the budget hike is intended to bring it back into line on duty and price.

But are above-inflation tax hikes the best fiscal strategy for tackling alcohol misuse – especially binge-drinking by young people? Why the aversion to minimum pricing as an additional measure?

The problem with hikes in duty is that they can be easily absorbed by the supermarkets, which continue to offer cheap drink as loss-leaders to draw people into their stores. Many deeply discounted drinks are currently being offered at less than the cost of VAT, and these tend to be the very lines, such as strong ciders, lagers and alcopops, that are especially popular with young people.

Minimum pricing, on the other hand, has to be passed on to the customer. By fixing a minimum price per unit of alcohol sold – in other words, banning ultra-cheap offers on booze – the government can ensure that no drink can be bought at less than, say, 50p per unit, the figure recommended by England’s Chief Medical Officer as an ‘immediate priority’ over a year ago. This would mean no less than £5.50 for a 2-litre bottle of normal-strength cider (compared with many current offers under £2), £6 for the average six-pack of lager and £4.50 for a typical bottle of wine – more for higher strength versions.

The impact on health could be considerable. Consumption is closely linked to price, and a team at Sheffield University have calculated that, with a minimum of 50p per unit, every year the UK could see: 3,393 fewer deaths, 97,900 fewer hospital admissions, 45,800 fewer crimes, 296,900 fewer sick days, and a total benefit of over £1 billion. The deterrent effect and health benefits would be greatest for the heavier drinkers, especially those with the least disposable income.

With an election in the offing, the tax versus minimum pricing issue has split the parties. The Lib Dems are likely to be for it, Labour against (after Gordon Brown’s flat refusal to accept the CMO’s recommendation last year) and the Tories somewhere in between (on selected types of drink favoured by young people). In Scotland the parties line up differently – perhaps distorted by the distilleries – and the SNP-led efforts to drive through legislation are having a rough ride.

But, after the election, there’ll be all to play for. My guess is that common sense will break out and minimum pricing will soon be on the statute book as a useful adjunct to increases in duty. It won’t be either/or, but both/and. There’s still a chance that, just as it did with smoke-free legislation, Scotland could lead the way.

Or perhaps a fresh lot of Westminster MPs will see the light, and a ban on deep discounting of booze could be one of the early benefits of a hung parliament.

Good news for the nation’s health – but maybe less so for the apple-growers and cider-makers of the West Country.

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Sir Liam Donaldson, the Chief Medical Officer has published his Annual Report 2009 this week. In the report the CMO highlights the key areas of public health requiring action and looks at progress made since previous annual reports.  One issue that he reflects on is the damage caused by “passive” drinking and the recommendation he made for a minimum price for alcohol in his last Annual Report.

FPH President Professor Alan Maryon-Davis  commented:

We’re strongly behind Sir Liam on this issue. The government should never have bottled out with minimum pricing. It makes total sense to ban ultra-cheap booze. We call on this government and future ones to reconsider all the evidence that is available.

In fact, the CMO’s Report refers to FPH’s public health manifesto calling for minimum pricing earlier this year:

The Alcohol Health Alliance UK brings together the Royal College of Physicians, the Royal College of Surgeons, the Academy of Medical Royal Colleges, the Faculty of Public Health and 20 other such organisations. To see such a group of medical bodies speaking together with one voice is very powerful. They speak in particular of the passive harms of drinking. They, too, call for a minimum price per unit.

Other professionals have echoed this call. The Faculty of Public Health represents 3,000 public health specialists from the United Kingdom and elsewhere. The Royal Society for Public Health has 6,000 members from health-related professions. In January 2010, these two institutions joined forces to publish a public health manifesto. It listed 12 actions that government could, and should, take to tackle a range of public health concerns. The first action on the list was a minimum price per unit of alcohol. (p.16)

The major challenges the Annual Report discusses this year include climate change and health, the benefits of physical activity on health and risk of cold weather on health.

FPH has produced a booklet about climate change and health called Sustaining A Healthy Future – A Special Focus on the NHS .

There is plenty of evidence about alcohol minimum pricing being the best public health intervention to problem drinking, for instance an independent review by the School of Health and Related Research at Sheffield University.

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If home is an English(wo)man’s castle, it seems it’s now also his and her local. Until now homes have been uncharted territory for studies of where, why and how people drink. But at the Royal Geographical Society’s ‘Drinking Spaces and Places’ seminar on Britons’ drinking habits in town centres and rural communities, parks and pubs, London and the regions, it was the home that took centre stage.

One of the single biggest factors in how our drinking habits and tastes have changed in the last 100 years or so has been the creation and growth of supermarkets, according to Dr James Kneale from University College London. His presentation on the history of drinking patterns in Britain also showed that the rise of the now ubiquitous stores has been phenomenal in the modern times: the number of off-licences rose by 40% in five years (1996-2001). A lot faster than on-licences. And apparently one of the fastest growing groups of ‘home-drinkers’ is women – they choose to drink at home more and more often, perhaps because alcohol harm is less visible there.

What are the reasons for drinking at home? As well as being more affordable than going down to the pub, Professor Gill Valentine from Leeds University and Dr Sarah Holloway from University of Loughborough found that their study respondents drank to relax, to entertain friends, to lift their mood and even to treat depression. Some people were also ‘aspirational’ in their drinking: having a glass of wine with a meal every night was likened to cultures in the Mediterranean. Their study also found alarming ignorance of what constitutes harmful drinking. Many respondents thought, for instance, that if they took exercise and ate a healthy diet, drinking to harmful levels wouldn’t put them at any risk.

According to Elizabeth Fuller from the National Centre for Social Research families have a significant influence over the way in which young people drink. She looked at the drinking habits of 11 to 15 year olds – the age group when most young people try alcohol – and linked them to their home environment. Apparently, children of parents who were tolerant towards their drinking are more likely to drink than children whose parents weren’t. However, if the latter did drink, they were more likely to drink outdoors, to hide their drinking, and take part in other risk-taking behaviour such as drug-taking, smoking and truancy. It could be suggested then that drinking in the home environment might lead to a more balanced and healthier relationship with alcohol – assuming of course that the parents provide their children with a responsible role model.

There’s no question, however, that drinking is a huge problem. Eric Stark from the Government Office for London highlighted that drinking behind closed doors at home can exacerbate domestic violence, another significant public health issue.

There was a clear consensus at the event that a behaviour change is necessary and the most effective intervention would be to make alcohol less available. Emilia Crighton, the Faculty’s Scottish Convenor, presented strong evidence on how alcohol minimum pricing would help curb drinking in Scotland, a particular problem spot in the UK.  But it was also agreed that minimum pricing alone wouldn’t solve everything. What is needed is for public health campaigns to challenge the image of binge drinking. The issue is, as Professor Valentine and Dr Holloway pointed out, that drinking to a harmful level in a rural community in Cumbria doesn’t match the unruly and chaotic scenes in town centres all around the country on a Friday night. The majority of people do not relate to images like this and therefore do not realise that the way they drink might be putting them and people around them at risk.

Enjoying a drink at home in front of the telly or with friends at dinner doesn’t have to be a guilty pleasure. But the rise and rise of home drinking does pose a tricky challenge to policy makers and public health practitioners alike, and needs to be looked into more if we’re to understand the nature of Britain’s booze culture.

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