Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20-39)

23 FEBRUARY 2005


  Q20 Mr Jones: I do not object to that. Every now and again you have to have a punt and it may work. It may be one thing to do something when you do not have a lot of evidential basis but you think it may work, but even so you should be then measuring whether it is working after you set it up.

  Dr Reid: Yes, absolutely.

  Q21 Mr Jones: In the same way as the Health Action Zones may or may not have worked, will you be measuring this?

  Dr Reid: Yes, we will, and the process of evaluation on these—

  Q22 Mr Jones: Can the committee know how you are measuring it?

  Dr Reid: Yes. Fiona?

  Dr Adshead: There is evidence that community-based educational models work. There is also some evidence that psychologically-based behaviour change models around smoking work. There is evidence around our smoking cessation services. There is also some evidence around health eating and exercise that these approaches work. We are currently developing a health training model and as part of that we are working with a group of academics to build a valuation in and we are going to be building a valuation in throughout the programme so that we get real-time evaluation, because one of the problems with the Health Action Zones was that the evaluation came in some years after the programme had started. So this time we want to learn as we go along.

  Q23 Mr Jones: Sir Derek Wanless had something to say about how you establish evidence as well and he said that there had to be a body independent of the Department to analyse evidence, in his words "to develop the cost-effective evidence based on public health". The Health Paper rejected that recommendation.

  Dr Reid: No. We have already got the National Institute of Clinical Excellence, which now has a world-wide reputation for evaluating treatments and we intend to ask it to evaluate some of these things. Others will do internally as well, because we have got a Health Information and Intelligence task force, believe it or not, which is looking at both new ideas and the evaluation of the ideas.

  Q24 Dr Naysmith: Just before we leave this sort of philosophical area we are in at the moment, the philosophy underlying the White Paper and public health, we had some evidence given to us by the Association of Directors of Public Health (this was written evidence, we did not have a chance to question them on it) and they rather welcomed the White Paper on choosing health and its focus on lifestyles and individual choices, which we have just been talking about. They then went on to say that health improvement does need to also address the importance of the underlying determinants of health, things like poverty, educational attainment, housing, social networks and deprivations like that. They are obviously of the view that not enough attention was paid to that area, which goes back, as you know, because we have discussed it before, to things like the Black Report, and so on. Why can they make that criticism, and what do you say to it?

  Dr Reid: I find it bizarre, Dr Naysmith, and the reason why I am laughing is that since about 1844 some of us—I have not been around that long, but the traditions from which I come believe that a lot of people can make choices through their own free will but people do not make them in circumstances of their own choosing or circumstances equal to other people, and therefore some people in more deprived circumstances will find it difficult to change their lifestyle. When I pointed this out with reference to smoking, perhaps a young single mother with very little money, in debt, with four kids on a sink estate, and so on, and said that she might not find it as easy to change as someone else, I was attacked by any number of people from the public health field for stating precisely what you have just stated, that if you want to help people change, whether it is diet, lifestyle, or whatever, you have to help them change their social circumstances. Therefore, far from being the person who ignored that, I was the person who was championing it even in the most controversial of areas. The second thing is, that is precisely why—

  Q25 Dr Naysmith: I understand that. What they are saying is there is not enough about it in the White Paper.

  Dr Reid: I am just going on to tell you. This is precisely why we had the biggest exercise in cross-government collaboration—it may be that you think it should have been even bigger—with the Office of the Deputy Prime Minister on housing, the Secretary of State for Education in terms of the protection of children and foodstuffs, and so on, with Tessa Jowell on exercise, right across the spectrum and for the first time ever enshrined that in a Cabinet Sub-Committee chaired by me, MISC 27, which is still extant and will continue on putting through the delivery of public health. So we are trying to do that. It may well be that people feel we should have had more cooperation in changing social circumstances, and if so I welcome that because that is exactly where I am. I want to say that we must encourage people to choose healthily. We cannot dictate to them but one of the most important things we can do, as you said, is change the circumstances in which they live. To put it crudely, if you want to increase the chances of people giving up, say, smoking, make them middle-class and you will find that as horizons extend and opportunities and other things extend to them if you look at the statistics you will find that the smoking drops. So you do not just give them help directly on the question, you do not just give prohibitions but you change the social circumstances. That is the converse of that statement, for which I was castigated by many people.

  Q26 Dr Naysmith: The second point which comes out of the Directors of Public Health Association is that they also say that not enough is made in the White Paper of preventative programmes such as immunisation and screening. I know your answer will be that there are other parts of the Department who are doing that and looking at it, but in order to tie together the whole of public health you have to sort of link it all together?

  Dr Reid: I will ask Melanie to come in on that, but just to say first of all that we had to decide at some stage the limits of the envelope and there were things like environment, toxicity, and so on, which were independent of people. We decided that the limits of the envelope should be basically on those issues which could be changed by people changing their own lifestyle rather than by changing external things in the main or having things done to people.

  Miss Johnson: I think my list of responsibilities, if you exclude the coronary heart disease and cancer, things which are not only public health but wider, is about some thirty-odd topics and obviously only about a dozen of them are represented here. They are all very much mainstream public health, including obviously things like vaccination and immunisation. But they are not things about the lifestyle choices generally that people are making, they are about the wider programmes of public health, and we decided to concentrate on really what in a sense is a most difficult area of public health, namely the areas in which the choices of a lot of individuals determine whether we are a healthy nation or not and the circumstances under which those choices are made. I think it is the most difficult areas that we have focused on. We of course recognise all the other areas which play a very crucial role in public health and which will continue to play that continuing role, in which regional directors and others still have very important roles to play.

  Q27 Dr Naysmith: Thank you. The final point on that is that keeping things like that outside of the White Paper, and people thinking this is the Public Health White Paper, may mean that there is not specific money for some of these things which are not in the White Paper and people will see what is in the White Paper as a high priority and things which are not in it may find themselves having to fight with other bits of the budget to get that?

  Miss Johnson: We have, for example, at additional extra cost, just introduced recently the five-in-one vaccination, an improve vaccination for children, so we are doing things that are still costing us extra money. We are still doing things to develop all of those programmes. We are looking at the pneumococcal side of things now as well. All of these things are developments. We have increased markedly the take-up of flu vaccines amongst the over sixty-fives and in the under sixty-fives at risk. All of those programmes continue to march forward at substantial extra cost as part of the general circumstances, the general environment in which lifestyle choices are being made and where we focus the White Paper on those particular issues.

  Q28 Dr Taylor: I think most of us will welcome the White Paper tremendously, particularly the recognition that prevention is better than the cure and it is cheaper than the cure, but because the health service is really by habit a sickness service there is a tremendous problem at PCT and Trust level making relatively small expenditures on prevention which in the long-term will save vast amounts of money elsewhere in the health service but not for them. Have you any comments on that? How can it be made easier to spend the money on prevention, which will not save money immediately but will save money for other departments, other parts of the health service later?

  Dr Reid: I think that if you see this in the context of the development of the National Health Service, Dr Taylor, you will see that there will be either pressures or determinants that are shaping people in this direction. The trend that I mentioned earlier, which is the encouragement of people to try and treat illnesses in the community at primary care level rather than at hospital, I think will be accentuated by people at the local PCT level recognising (and indeed GPs recognising) that if you send everyone to hospital then they are going to have very little money for anything else. The more you hand responsibility down to the local level, and that will happen year on year up to 2008—it is not uncontroversial; we have had discussions on this, on various forms of it—the more people take responsibility for that allocation of that money, their own priorities, and it will obviously make sense to treat people in the community rather than in hospital in many cases as much as you can. It is also obvious to us and to you, and I think will be increasingly obvious at the local level, that the saving of money by prevention rather than cure (as you put it) is a good medium and long-term benefit for the local area. Now, that is the first thing. The structures we are putting in place I think will encourage that. The second thing is that we intend throughout the National Health Service (for purposes which are not that but incidentally will assist in the question you asked) to try and encourage as part of the culture change of the NHS the 1.3 million staff rather than just to treat the sickness that they all treat in their own ways an early identification of preventative opportunities. I gave one specific example earlier on which was about drink but it could be in a whole range of areas, whether smoking, lifestyle or obesity, and so on. If we do that then I think that will have a rub-off effect as well at the local PCT level.

  Q29 Dr Taylor: Can I take you back to alcohol specifically? Various Members were not very keen to take on the questions on alcohol!

  Dr Reid: There are no declarations of interest made!

  Q30 Dr Taylor: No, no declarations of interest. We have been told that alcohol consumption across Europe is falling but in this country it has doubled in post-War years and illnesses, particularly cirrhosis, have trebled between 1970 and 1998. These are figures from Sir Liam Donaldson. There is the worry that not only is alcohol linked with cancer of the liver but certain other cancers. We are not really quite clear what measures proposed in the White Paper will reverse this trend because this is really a preventative measure which should not cost much.

  Dr Reid: First of all, I think you are right in the emphasis that you place on this, Dr Taylor. I myself was interested that in the whole of the debate we had about the consultation out there we had a huge amount of controversy and discussion over smoking and hardly anybody in the press was interested in alcohol. I was trying to say that smoking was not the only issue that was facing people and I asked for some figures in the course of our discussions. There are at least one hundred and fifty thousand hospital admissions every year. I think it is probably true that 75% of people in prison are there as a result of violent offences, alcohol-related. There are at least fifteen to twenty-two thousand deaths a year caused through alcohol and the estimated cost to the NHS every year of alcohol-related illnesses is of the order of £1.7 billion, which coincidentally is the estimated amount, I think, for smoking-related illnesses as well. So it is a very serious subject indeed.

  Q31 Dr Taylor: So what are you doing about this?

  Dr Reid: One of the problems we had in taking as well defined measures on it—and you are entitled to ask that—would I have liked to have gone further and done more? The answer is, yes. Why did I not? The answer to that basically is related to what Mr Owen Jones asked us earlier, and that is that the evidence on how to identify and how to treat, and so on, and what treatments were available, was not as well developed as in many other areas. So one of the first things that we are doing—and you legitimately asked us what are we doing about it—first of all, this is the first time we have got a coordinated strategy for alcohol, the Alcohol Reduction Strategy, which I can go through if you want. Secondly, as a result of discovering the lack of information really that was available to us during a consultation, we have undertaken a national audit of the demand for and provision of alcohol treatment and this will provide, I hope, a comprehensive picture of the current availability of treatment and it will highlight the gaps in supply of treatment. I will receive that report later this month and I think that we will be able to send it soon thereafter to yourselves should you want that, Chairman. It will be followed up then by what in the management jargon is called "a local tool-kit" that will allow access to local need. The National Treatment Agency will be publishing models of care in alcohol guidance on the organisation of alcohol treatment in our review of treatment effectiveness and that piece of work and the results of the national audit will provide the foundation for the very programme that you are calling for. So yes, I would rather we had been able to do this earlier. Yes, you are right in the importance I believe is placed on it and sometimes is not outside where drugs and smoking get much more of the attention. It will also benefit partly from what we call the "pill treatment budget" which is distributed to drug action teams throughout the country and from May of this year the Department of Health will be piloting a programme of targeting, screening and brief interventions, giving short-focused advice and guidance to those identified as being at harm from alcohol abuse as it arises in the course of other treatment inside the NHS. I could go on and describe various other things. With the Portman Group we are engaging the industry—

  Q32 Dr Taylor: With respect, Secretary of State, I am trying to get at it earlier than alcohol problems that require treatment. The Health Development Agency says quite clearly that the only effective method of really tackling harm is to restrict the availability of alcohol and the first one would be a very unpopular measure but it would be to raise taxation and raise the price. That appears to be perhaps the only really effective method of reducing it. What is the Government's views on raising taxation on alcohol?

  Dr Reid: On the first one, which is how to tackle it—if I can divert just for a second, Chairman—you may not know, Dr Taylor, but when Kier Hardy published his first manifesto in 1894 the first demand he made was that there be home rule for Scotland, Wales and Northern Ireland, which has now been delivered. The second demand he made was that there be a minimum wage, which has now been delivered. The third demand he made was the end of hereditary power in the House of Lords, which is now delivered, and the forth was a ban on the production and sale of alcohol. We did consider putting that to a commission of the Scottish Labour Party to decide how much action we should take and how quickly on it, but we have no plans for that and I would not like anyone behind you with their pens to start running on it! On taxation, we leave that to the Chancellor. I note what you say on that, but matters of taxation are for the Chancellor. However, it is true that sensible drinking requires the engagement of the industry and the Portman Group, which operates with the industry. We are engaged with them on this. Do I think that we are all doing enough on this, including Government and industry? No, I do not. Do I think that the audit that we are carrying out in terms of treatment, which includes early identification as well, will tackle the problem? No, I do not. Do I think that the amount of persuasive marketing and advice to people to drink sensibly is in any way a counterbalance to the amount of general persuasion to drink out there? No, I do not. If you ask me, avoiding taxation, what I think is the solution, there are several levels of the problem. There are people who drink at home, perhaps silently, and that is an obvious problem. Then there are the people who are reasonably affluent, though maybe young, who are involved in binge drinking. Then there are not so much the people who binge drink in pubs, bars, and so on, but who drink the cheap fortified wine or other cheap drinks in areas that I am sure some of our colleagues here represent, which is a problem, on street corners, and so on. So we need a much more comprehensive strategy for dealing with those things and I hope that the audit we are carrying out will be the beginning and not the end of the action that we take on it, Dr Taylor.

  Dr Taylor: Thank you.

  Q33 Chairman: Could I just ask a question? Going back to the point about the limited amount of responses on alcohol on the consultation on the White Paper, I was very struck and I think the Committee was struck when we were looking at obesity at the very limited evidence that we received on the connection between alcohol consumption and obesity. I think this is an area of great interest. It seems fairly obvious to one or two of us that there may just be a connection there, but why is it in terms of a society we do not seem to be doing anything about it? We do not seem to have that response that you would have expected in putting out the proposals that you were considering.

  Dr Reid: You are asking me a question which I will immediately be challenged on by Mr Owen Jones as to my evidential base. I can give you my own view on this. I think that people do not think of the passive damage from alcohol the way they think of the passive damage from smoking, but the passive damage from alcohol is enormous: the number of people who are killed in drink-driving accidents, the number of people who are injured through drunken violent incidents, the number of people who are in jail and the cost to society of that through alcohol-related problems. It is sometimes on a Saturday night sixty to 70% of people in accident and emergencies being paid for by the state come there as a result of alcohol and yet it is an integral part of our lives for most people because they do not abuse it. Most people do not abuse it and also used in a sensible, entertaining, social fashion it is a fantastic addition to the social life of all good, healthy, sensible people. Whereas things like smoking one cigarette damages your health, one drink does not damage your health. So it is a much more difficult thing, Chairman, to classify as entirely detrimental to health because it is not. Drinking a few glasses of red wine is very good for you and from where you come from drinking a few glasses of beer is regarded as good socially as well as on the health side. So it is harder, I think. My own view is that if we are gong to tackle some of these problems, particularly with young people, the only real solution—and you mentioned tax—is to make it uncool because I do not believe that prohibition and curtailments, and so on, work on these things because sometimes for young people that has the disadvantage of making it appear cool rather than uncool.

  Q34 Chairman: Richard, it struck me that we have got your second election pledge that you are going to increase the tax on alcohol. Is that right? The first one was that old people should clean up graveyards! The second pledge. Over to you.

  Dr Reid: I did notice that. I think it is a contribution to the General Election campaign that the Liberals have now pledged, and David has now pledged, to introduce a tax on—what was it, a doubling of the price of beer?

  Chairman: Go on, Richard! Over to you.

  Q35 Dr Taylor: I am moving off that subject but going on with reducing the availability of alcohol, which really seems to be the only way of cutting the amount people drink. Another way would be restricting the hours and the days of sale. I should think most MPs have been approached by constituents with the worries about garages selling alcoholic drinks way on into the night. So at the moment it is incredibly easy to buy alcohol at any place. Have you any plans to reduce the availability by restricting the sale in any way?

  Dr Reid: I will ask Melanie to respond to you, but if I may just say something first of all, Dr Taylor, because it gives me the chance to counter the myth that the recent Licensing Act was only about extending the flexibility of hours. It was not. It brought in a local accountability element because local councillors rather than just those connected with the local judiciary have a power and responsibility and it brought in a range of restrictions which could be more effectively and more speedily implemented to premises where there were abuses of alcohol sales or use going on. So on your question, "Have you any plans to bring in some form of punitive or restrictive measures in law?" yes, we have brought them in actually. We brought them in through the Licensing Act brought in by the Secretary of State—I cannot remember who it was now. When they were brought in most of the coverage that was received in the press on this was on the flexibility of hours and missed out the fact that we were bringing in some fairly punitive and restrictive potential measures which could be applied at a local level.

  Miss Johnson: First of all, just on the cost of alcohol point, before you enter it into your election pledges and on the evidence-based question, looking at Continental comparisons you would not necessarily draw the conclusion that you seem to be coming to about the sensible use of alcohol and taxation levels. So I simply enter that as a caution into your thinking. Secondly, if I may go back to the behavioural points again a little bit more because when we think about drinking and driving or wearing a seatbelt, for example, a huge change has been brought about in general public acceptability, as the Secretary of State is saying, in terms of what people are prepared to do, what they think is right, by public campaigns to educate at the end of the day. The vast majority of people have bought into those campaigns. They have been hard-hitting, they have been long-term, they have been repeated and they have targeted the points that people are most sensitive on. I know from talking to the Portman Group, for example, they have run some advertisements, which you may or may not have seen but I am sure they can supply you with a video of them if you are interested, which are aimed at young drinkers. The picture of them is that they are out of control and they know from the research they have done that young people do not like the notion of being out of control.

  Dr Reid: It is uncool.

  Miss Johnson: That is not the picture that they want to see of themselves. So targeting things like those sorts of areas in terms of behaviour change I think is very important and we will be working more with them. But also on the point about the more punitive sort of restrictions, and so forth, there is an important place for those and that is why on cigarettes we have said we are clamping down on under-age sales. On alcohol, the Licensing Act already has a number of measures in it which does that. It makes it an offence to allow any person under sixteen to be present in licensed premises exclusively or primarily used for the sale of alcohol unless accompanied by an adult. Between the hours of midnight and 5.00 am it is an offence for somebody under sixteen to be present on those premises and for the first time it makes it an offence to sell alcohol to people under eighteen anywhere in England and Wales. I think we want better enforcement as well coupled with this, and certainly the Home Office and ourselves are very committed to seeing that better enforcement in place. I think these are part of the measures, coupled with a much better education, which are important in tackling the issues that we face. We are working on a new sensible drinking message which will be available later on this spring. I think spring in this case is a bit of an elastic season, as I have often found the civil service does have an elastic season for spring. It will produce a new sensible drinking message. It will be unit-based still because we know that there is still a degree of understanding of the unit-based analysis, as it were, of alcohol. But we need to think about how we get those messages across, how we reach the right audiences and really stepping up by a significant amount our efforts in getting those messages across to young people, particularly from mid-teens through to mid-twenties because that is probably the age group which is most affected by these issues.

  Q36 Dr Taylor: Do you think you will be able to have any effect on those slightly older drinkers who are drinking far more than they should and for whom the extended drinking hours will make that even easier?

  Miss Johnson: The extended drinking hours are a matter for the local authorities and I think the evidence is, if you are talking about the 2003 Licensing Act, that at the moment many places are not extending significantly their drinking hours. But it is a matter for local authorities. So if there is disruption, disorder or other consequences being seen in the locality, local councils now have the power to take not only short-term, immediate punitive steps by closing premises but also longer-term steps about the future of the licensing arrangements. So there is a considerable panoply of powers at a quite local level to reflect local behaviour, local need and a local view about what is necessary in dealing with the issues.

  Q37 Dr Taylor: So my local ambulance drivers, who have been approaching me with their alarm about the increased use of ambulances for drunks with the increased length of drinking hours should be approaching their local council?

  Miss Johnson: Indeed. The local council has all the powers now to deal with that on a local basis, and much stronger powers than the magistrates would have had previously under the old arrangements.

  Q38 Siobhain McDonagh: If we can look at the kind of licensing rules, there are suggestions that while the local authorities do have more powers now, they are given a very strong set of guidance which is restricted and the alcohol industry will also be able to appeal to the courts if they do not get the decision they like from their local authority. Are local authorities in theory able to determine the number of pubs to give licences to, who to choose and who to close down, but in practice have their hands tied by Government guidance?

  Miss Johnson: I think the point about the licensing arrangement is to give local decision-making. If at the point at which decisions are being made there is not a good justification for it in some shape or form, the fact is that most councils, I think, will be trying to make their judgments on the basis of good evidence. I used to be a magistrate at one time and I have sat and made licensing decisions and I know limited information ever came to the magistrates generally and very little often was done at that level to change practice. There was certainly no overview of the community because it is a licensing by licensing decision. The councils can now take a much broader view than that, and I think for the first time they have the powers to affect things in a way which will be positive. But that is not the main thrust of what we are trying to do on public health. The main thrust of what we are trying to do on public health is to identify those who are at risk from alcohol. So, as the Secretary of State has already said in answer to an earlier question, those who turn up a couple of times at A&E who have clearly been drinking will be identified and the right ways, the sensitive ways of dealing with that and suggesting that they may want to get treatment or to see somebody to talk about sensible drinking will be put in place, and we are looking at how that can best be done through, for example, the initial contacts in A&E through to other services. Secondly, we are working on all of this area of sensible drinking and the binge-drinking culture, which I think is the thing that most concerns the public now, although I am sure, along with Members of the Committee, you will have all had contacts from a lot of the consultants who work with those who are affected by long-term drink and the effects of long-term drink on various aspects of health who are concerned about that. We share their concerns, but I think often that is where the treatment services and the audit that we have put in place is important because those people may need longer term support to give up their drinking. It is not just about the sensible drinking message. If you are a long-term, very serious drinker, you will in effect have an addiction of some kind and you need the sorts of supports for alcohol that we have been providing for drugs for some time, and that is being done on a much more systematic basis with the same sorts of standards being introduced and a much greater look at where the services are, what treatments are available, what works and how we develop that in the future, with some money behind it in the White Paper which we have put in here for that.

  Q39 Siobhain McDonagh: Thank you. Several submissions to the Committee have expressed surprise at the White Paper's identification of the Portman Group as the sole named non-statutory partner in the Government's response to alcohol problems, not least because its record has been severely criticised in the scientific press. Why do you involve the Portman Group but ignore reputable medical bodies which are free of drink industry connections?

  Miss Johnson: We are happy to see anybody who would like to meet with us and forward this agenda. Obviously in the case of the Portman Group they have money at their disposal as a result of the industry funding. We are certainly looking to them to make a bigger contribution on getting across the right messages about alcohol and drinking and playing a much more responsible role with us in encouraging the responsible use of alcohol in our society. I met a colleague of all of ours (I will not say who it was) who brought some consultant from her local hospital in to talk to me recently, to share experience and talk about the nature of the work that was going on and that she was aware of in relation to alcohol-related illness and demands on the health service. So we are always happy to receive input and to have a dialogue with any of those interested in tackling these problems.

  Dr Reid: I think the point to make in direct response to the point you make, Miss McDonagh, is that we want to work with anyone from the voluntary sector or anywhere else who wants to help us to combat irresponsible drinking which damages people's health and damages other people's lives, but we identify the Portman Group because they were related to industry, because we do believe that the industry has a responsibility here, a responsibility which will not be discharged only through the Portman Group but could be discharged through the Portman Group if it was more active and better funded. So we will be encouraging that in that direction. So ironically, we chose it. People may say, "Why are you only choosing this?" We are not only choosing this. We say, okay, if this is the vehicle through which the industry wishes to tackle some of the messages they want to put across then we will work with that and encourage it to be better funded and more active.

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