Memorandum by the Royal College of Physicians
(WP 24)
The Royal College of Physicians is grateful
for the opportunity to comment on the terms of reference for the
above inquiry and attach our comments. For your information I
am also enclosing a copy of the College's original submission
to the Choosing Health? consultation.
The College has at its core aim the promotion
of the highest standards of medical practice in order to improve
health and healthcare. To this purpose it defines and monitors
programmes of education and training for physicians at all stages
of their careers as well as providing professional advice and
support for career grade physicians and those in training. The
College has approximately 11,000 Fellows worldwide—of whom
approximately 8,900 are in the United Kingdom—and nearly
7,300 Collegiate Members. The Fellows are senior members of the
medical profession, usually hospital consultants or physicians
working in university departments of medicine.
In formulating our comments we have received
advice from the Chairs of our Alcohol Committee, our Nutrition
Committee, our Tobacco Advisory Group and our Joint Specialty
Committee for Genito-Urinary Medicine. The College would be happy
to contribute to the oral evidence sessions if that would be helpful.
Yours sincerely
Professor Carol M Black CBE, PRCP
President
1.1 The Royal College of Physicians (RCP)
welcomes the Health Committee's Inquiry into the Government's
Public Health White Paper, as it did the White Paper itself and
the extensive consultation undertaken by the Government to collect
the views of a wide range of audiences.
1.2 The College has played a leading role
in addressing public health concerns for much of the past 50 years,
most notably in the area of tobacco control. Its work has, and
continues to be, informed by the experience and expertise of our
Fellows and Members who deal with the consequences of unhealthy
behaviour.
1.3 We broadly welcome the White Paper's
recommendations and proposals on addressing health inequalities,
sexual health and obesity that build on much of the work of the
College with its partners and we are committed to working with
the Government on implementing its proposals and improving the
health of the public. However we feel that the White Paper does
not go far enough in tackling the two biggest causes of premature
death in this country—smoking and alcohol misuse. We are
disappointed that it fails to put in place a total ban on smoking
in all public places and workplaces, or adequately address the
issue of problem drinking. In these areas we will continue to
press the case for the recommendations to be strengthened.
1.4 The White Paper does not meet our two
benchmark standards of tougher regulation and cross-government
co-operation at Cabinet level as set out in our response to the
Choosing Health? Consultation—this is likely to have an
adverse effect on implementation.
1.5 In addition, the pre-occupation with
intellectual arguments is in danger of distracting attention away
from proactive interventions that will help to, at the very least,
stem a public health problem that is in danger of spiralling out
of control.
WHETHER THE
PROPOSALS WILL
ENABLE THE
GOVERNMENT TO
ACHIEVE ITS
PUBLIC HEALTH
GOALS
Alcohol
2.1 We welcome plans to invest in improvements
to services to help the NHS tackle alcohol problems at an early
stage. However it is crucial that there is investment in research
and monitoring. No one yet knows or understands fully why we have
the binge culture, what to do about it, how to change it, or whether
education programmes work. Any initiatives will therefore have
to be carefully assessed in a rigorous and scientific way.
Obesity
2.2 The Government has avoided making targets
for the reduction of obesity in adulthood, which is disappointing,
and has merely indicated that for children the objective is to
halt the year on year increase in prevalence by 2010. We are uncertain
whether this more simplistic target will be achievable without
a stronger regulatory framework that engages the food and advertising
industries at an earlier stage. We completely support the proposal
for a close partnership with industry; however, we anticipate
that legislation will be necessary to bring about change. The
RCP believes that the proposed introduction of regulations in
2007 will be too late to achieve the childhood target and will
allow "drift" from the original good intentions.
2.3 We are unconvinced that the suggested
cross-Governmental approach is actually happening—the publication
of the White Paper does not appear to have changed the "silo"
approach by Government departments and there has been no public
pronouncements about the Cabinet sub-committee described in the
White Paper.
2.4 The achievement of the public health
goals is heavily dependent upon the delivery plans, which have
yet to be published.
Tobacco
2.5 The proposals to increase access and
uptake of smoking cessation services will help, and the more widely
their use can be encouraged, the greater this effect will be.
Provision of cessation services needs to become second nature
for all healthcare workers in order that support is delivered
as routine to all smokers who want to quit.
2.6 The proposal to ban smoking in most
but not all workplaces will have an important effect on smoking
prevalence, but this effect will not be maximal and will be least
effective in the deprived communities that most need them. The
proposed timescale for introduction of smokefree policies is unnecessary
long.
2.7 The promises on spending on health promotion
are without substance in terms of budget or stated aims. High
profile, sustained and varied campaigns are effective but need
a substantial budget. We believe low-key activity will not achieve
much.
Sexual health
2.8 It is likely that through the high profile
public health advertising campaign there will be greater awareness
of STIs and HIV infection. A similar campaign in the 1980s in
retrospect seems to have been effective in reducing the transmission
of HIV and other sexually transmitted infections, this campaign
is therefore to be welcomed. This campaign will put increased
demands on already hard-pressed GU Medicine/HIV services; it is
going to be impossible for the Government to put in place effective
remedial action for these services before this campaign is launched.
2.9 There has been no co-ordinated organisation
of community services to make up for any shortfall and the current
system of commissioning for sexual health services through primary
care trusts (PCTs) is producing a very patchy and unsatisfactory
system throughout the country which will make it impossible for
an effective public health response to the current problems.
2.10 The introduction of a nationwide chlamydia
trachomatis screening for appropriate groups may be a major step
to cutting the transmission and the morbidity associated with
this serious public health problem and is to be applauded.
WHETHER THE
PROPOSALS ARE
APPROPRIATE, WILL
BE EFFECTIVE
AND WHETHER
THEY REPRESENT
VALUE FOR
MONEY
Alcohol
3.1 We are concerned that Ofcom does not
go nearly far enough in limitations on broadcast advertising of
alcohol. In France there is a complete ban on broadcast advertising
of alcohol and this has withstood legal challenge by the industry
3.2 We question the validity of running
an information campaign in partnership with the industry-funded
Portman Group rather than independent bodies such as Medical Royal
Colleges and Alcohol Concern.
Obesity
3.3 The Government concedes that the limited
evidence-base on population-wide strategies to prevent and treat
overweight and obesity and, quite rightly, calls for commissioned
research. Such research must draw on experiences from elsewhere,
most particularly USA and Australia and include a full economic
analysis. We cannot wait for the outcome of such research and
need action now.
3.4 The RCP is concerned that the desire
to devolve actions down to a local level reduces the opportunity
for a national health promotion campaign that could (and should
be) hard-hitting. The devolution of action largely to a local
level has the potential danger of widening rather than narrowing
social inequalities.
3.5 The White Paper includes no cost-benefit
analysis but merely refers to Sir Derek Wanless' report. Such
an analysis is essential to ensure that resources that are saved
for the longer term by effective preventive measures are clearly
identified and utilised at a national and local level. The Government
promises additional resource to PCTs from 2006 to strengthen primary
care capacity to prevent weight and tackle obesity—such
resource (financial and human) is needed now.
Tobacco
3.6 The tobacco control policies outlined
in the White Paper are appropriate, should be effective and represent
value for money if implemented with vigour. The likely effectiveness
of the White Paper policies is in approximate direct proportion
to the rigour with which they are implemented. The proposal to
make some but not all public places smokefree will be less effective
than early implementation of full smokefree policy; the effectiveness
of price rises is directly proportional to their magnitude; low
profile and dull health promotion campaigns are less effective
than interesting or challenging high profile ones.
3.7 The absence of a commitment to reform
nicotine regulation is a major missed opportunity.
Sexual health
3.8 STIs/HIV have now been recognised as
a major public health problem. For a public health campaign to
be successful it would require:
— public education on sexual health
leading to behaviour change;
— provision of wherewithal to provide
protection ie free access to barrier methods of contraception
and reduction of partner rate change;
— a substantial investment in new and
expanded premises especially in genito urinary medicine;
— 48 hour access to services in genito
urinary medicine;
— a community network of high quality
services made up of appropriately trained, supervised and co-ordinated
personnel; and
— a clear programme for implementation
of NAATS testing in all GU Medicine clinics and in the community.
3.9 The proposals the Government make are
entirely appropriate in respect of the need for investment in
services. The question is will the response be adequate to address
the current shortfall? The Health Select Committee has itself
pointed out the woeful state of many genito urinary medicine departments
and the inadequate expansion of consultant numbers in genito urinary
medicine and there has been little progress in implementing the
2001 National Sexual Health and HIV Strategy for England.
3.10 It is hard to see the investment of
£130 million allocated to modernisation of genito urinary
medicine will have sufficient impact to meet the demands that
will be placed on services. It is essential that any new monies
are carefully allocated and monitored as to the appropriateness
of their use.
WHETHER THE
NECESSARY PUBLIC
HEALTH INFRASTRUCTURE
AND MECHANISMS
EXIST TO
ENSURE THAT
PROPOSALS WILL
BE IMPLEMENTED
AND GOALS
ACHIEVED
Alcohol
4.1 In our 2001 report, Alcohol: can
the NHS afford it? Recommendations for a coherent alcohol strategy
for hospitals, the RCP has already given strong arguments
for dedicated alcohol healthcare workers in all acute Trusts and
evidence exists for their cost-effectiveness, so we need to press
on. Also in the same report we called for a National Institute
for Alcohol Research akin to the National Institute on Alcohol
Abuse and Alcoholism (NIAAA) in the United States. We are concerned
that the Government has taken up neither proposal.
4.2 Relaxation of licensing laws runs contrary
to the spirit and intent of the White Paper. It highlights the
indecision within Government as to the underlying philosophy behind
its approach to public health.
4.3 Those of us working at the front door
of hospitals wonder how long must we wait for convincing evidence
of results from voluntary social responsibility scheme of the
industry before tougher statutory measures are taken. It represents
further delay during which the health crisis related to alcohol
misuse could get worse.
Obesity
4.4 There is very little expertise across
the NHS in the prevention and management of obesity. Most particularly,
this has not been regarded as a priority at a PCT level and there
is very limited public health and general practice experience
for applying effective measures. The situation in secondary care
is little different and the shortage of staff trained in obesity
management is extremely serious.
4.5 A priority must be the immediate establishment
of training programmes for all health professionals who work in
every location of the NHS. The White Paper's suggestion that this
will be picked up by the new NHS Competency Framework seriously
under-estimates the complexity of the task and the current paucity
of knowledge and skills—the White Paper makes no mention
about who will draw up and deliver this framework. There is a
danger that all of the opportunities for tackling obesity created
by the White Paper will founder unless there is an immediate and
substantial programme of education and training—this should
include not only health professionals but also the public.
Tobacco
4.6 For smoking cessation interventions
the rate-limiting step in many cases is the lack of priority given
to smoking prevention by many healthcare professionals. Resolving
this is a major undertaking that will require a great deal of
investment in training and the introduction of appropriate incentives.
When demand rises as a result, services will need to expand to
meet it.
4.7 The necessary regulatory system and
resources are not currently in place for nicotine regulation.
The UK needs to establish a nicotine regulation authority to oversee
all aspects of production, marketing, taxation, safety and monitoring
of all nicotine products, with the remit to minimise the use of
smoked tobacco as the primary source of nicotine in our society.
The pragmatic aim of the regulation authority should be to minimise
the harm caused by smoking.
4.8 Effective tobacco control policy requires
coordinated, cross-departmental activity; the White Paper does
not clearly state whether and how this will be achieved for tobacco.
4.9 There is a need for research and development
particularly in cessation service implementation, and this needs
funding support.
4.10 Monitoring of smoking trends in the
UK is piecemeal and slow. It is important to establish more regular
and quickly available monitoring systems so that the impact of
policy change can be assessed in a timely manner.
Sexual health
4.11 A serious problem is developing for
sexual health services for the successful implementation of the
White Paper proposals. As sexual health/HIV has not been identified
as a national priority for action, and the GP contract does not
give any priority to this area, the current contracting system
through PCTs and the devolution of care to inadequately trained
personnel in the community is of serious concern. Urgent consideration
needs to be given to both providing training and governance for
those who wish to provide sexual health services.
4.12 The infrastructure for implementing
the chlamydia trachomatis programme does not currently exist and
will need to be urgently addressed if even the goal of 2008 is
to be achieved.
4.13 There is an excellent case to be made
for treating STIs and HIV without the above contract system with
resources being put into a strategy that provides for a network
of sexual health/HIV services overseen on a national basis. This
would ensure a coordinated response to the public health crisis
and ensure fair provision of services.
January 2005
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