Examination of Witness (Questions 200-219)
Dr Matt Muijen
7 DECEMBER 2006
Q200 Lord Wade of Chorlton: We have received
evidence regarding the human rights aspect of mental health and
it has been suggested that an agreed basis of key principles for
human rights in the sphere of mental health might be a better
basis for making progress with Member States than one of setting
minimum standards for mental health. We would be grateful to know
how realistic you feel would be the aim of achieving minimum standards
for mental health across the European Union, and what do you think
of the alternative approach based on agreeing a set of key principles?
Dr Muijen: First of all, I do not think they
are mutually exclusive. One of the strengths of the national service
framework was that in effect it was based on principles which
then were reinforced by standards, not minimum standards but standards.
I think that principles or standards on their own can operate
somewhat in a vacuum—what do you do with principles that
are invariably well-meaning? They need to be followed through
with quite hard-hitting policies and legislation supported by
funding. Neither EC nor WHO, by the way, has a mandate to come
up with binding principles or standards, so it would be at best
advisory, which in itself might be worthwhile. Why I am always
slightly struggling with principles is that they nearly always
refer to wonderful ideals about human rights and other aspects
of care but can almost be seen as a substitute for the real thing.
The other danger of it is that, certainly across Europe, words
can mean so many different things in different countries. If one
talks about least restrictive care in some of our newer Member
States, it means something very different from what it means in
the UK, which already implies that in that case principles need
to be translated into very specific statements of what is required,
which then invariably leads to a common denominator which is adjusted
to the least developed Member States. What has been interesting
in the Helsinki Declaration exercise, however, was that the least
developed countries were least worried about the implications
because they often did not understand quite what the meaning was,
whereas the governments of England and other highly developed
countries were highly concerned because they understood very much
what was meant by some of the more complex statements. It does
not necessarily mean that countries will resist principles but
it might mean that they certainly will not follow them through.
The same could be said about minimum standards, not that minimum
standards imply that countries will not go beyond minimum standards,
but again how do you phrase them in such a way that they have
a clear meaning. And how do you inspect them afterwards across
Europe with no organisation having a mandate to both impose them
and reinforce them? I am not against principles. I think principles
are important, but on their own we would yet again get many of
these strategy documents which I receive on an almost daily basis.
It makes me exasperated because they include all these wonderful
standards and then none of them will be implemented.
Q201 Lord Wade of Chorlton: On that basis
you are suggesting that the minimum standard would be a more sensible
way, at least to start. Would you prefer to see a system in which
you could start with a minimum standard that might be accepted
over a broad area but you could then ratchet it up as time progressed,
because clearly, from what you are suggesting, some of the minimum
standards that might be accepted would not be terribly good?
Dr Muijen: If I had to choose I would go for
minimum standards. If I did not have to choose I would have both.
I think that principles are important as statements of intent
but they have to be followed by some quite clear explicit descriptions
of the care that is required in a more detailed manner. Besides,
these services need to be costed, and I mean service in its broadest
meaning here.
Q202 Baroness Greengross: Could we start
by looking at deinstitutionalisation? Do you think that the EU
has competence to look at care in the community and so on, and
what are the main issues that it might have competence to deal
with?
Dr Muijen: Let me answer the last question first.
The European Commission (and the European Union, of course) does
not have competence to deal with services, but it does have competence
to deal with issues that have impact on services, such as human
rights, and also public health and those can be translated in
ways which can bring it very close to, if not directly affecting
services by directives that could shape some of the foundations
of services. This can cause tension with Member States but Commissioner
Kyprianou is always very explicit in his statements, ie that there
is no mandate to impose any service directive. That is very clear.
Q203 Baroness Greengross: Taking that
a bit further into the issue of compulsory treatment and human
rights and so on, could you set out for us the key issues relating
to that, not just in institutions but also for compulsory treatment
in the community because that is very important to us at the moment
as a Bill is going through Parliament now on mental health?
Dr Muijen: And also since your Bill will have
major implications for the rest of Europe because England in particular
is seen as taking a leadership role. I have already been to meetings
where community treatment orders were perceived as a good idea
because there was a belief that they had already been introduced
in England, so any decision that is made in England will have
consequences for the rest of Europe, something England is not
always aware of. It is still seen as the model country in terms
of mental healthcare, and healthcare as a whole, I believe. What
one finds around Europe is a lot of diversity in legislation similar
to the diversity I referred to earlier on in services. Again,
it has been delegated in many countries to a lower level. There
is no German mental health law. There are laws in each of the
different Länder. The same is true in Spain and in Switzerland,
I believe, as well. There is considerable difference in the principles
of legislation around Europe. Some countries use a competence
principle at the point at which people are being admitted, and
I am talking, of course, here about legislation which takes away
freedom from a person with mental illness and enforces treatment.
I assume that that is the kind of legislation you refer to here.
There is, as I just said, a differentiation in many countries
between competence and risk. Some countries use the competence
principle and so someone can be admitted against their will if
they are deemed to be incompetent. In other countries, as in the
UK, it is based on the risk of an individual suffering from a
mental illness with very different definitions of what mental
illness is. The problem invariably encountered with competence
is the definition of competence. Competence has at least five
different meanings and in the end what it means is often that
a psychiatrist has to give a judgment on what they believe competence
is. What also differs is that in many countries magistrates will
make the final decision about whether someone should be admitted,
rather than, as in some countries such as the UK, psychiatrists
on their own, although often requiring approval by a third party
such as a social worker, being allowed to make this decision.
Another important distinction is that some countries, including
Holland, only allow people to be taken to a place of safety following
the imposition of an order rather than treatment being given against
their will, which is another specific step in addition to someone
being hospitalised. The direct link between people being placed
in a place of safety and then being given treatment is not automatic
in some countries, which can lead to very perverse situations
of people having to stay in hospital for weeks without treatment
being given because they meet the criteria for one but not the
other. At the moment there is no country I am aware of in Europe,
but again I have to be careful because there are so many different
legislations, which has a proper community treatment order in
the pure sense of the meaning, and what I mean by that is that
people can be treated against their will in the community. Countries
are very much looking to the UK. Recall is possible in some countries,
so that people are temporarily allowed conditional discharge into
the community, but there is as yet no example of the American
form of community treatment orders. One observation I always make
is that the whole issue of choice can be ignored in these debates.
To give myself as an example, if someone were to judge that I
needed treatment against my will I would prefer the option of
receiving that in a place of my own choice rather than immediately
and without alternative being taken to hospital, of course, with
due procedures in place.
Baroness Greengross: You have been talking
more about competence than risk and the big issue which is all
over the red tops at the moment here is, of course, risk.
Chairman: Risk to other people.
Q204 Baroness Greengross: It is the risk
to other people, not to the patient, and in that case it is probably
in relation to the taking of medication. Would that come under
this competence?
Dr Muijen: That is precisely the problem, and
that is why many countries in the end decide on risk, because
the risk may not be very easy to judge but it is easier; at least
you know what one refers to. There are many different dimensions
of competence and they are very rarely explicit. They have advantages
and disadvantages. The risk to others no doubt will weigh heavily
when determining competence because it is clearly related to competence
when judging whether behaviour is responsible. It could always
be formulate in terms of competence. On philosophical human right
grounds no doubt competence is the proper way to go. On the other
hand, if one looks at community protection, I can well see that
risk is a shortcut to decide what should happen. I also have to
say that when one looks at the evaluation of introductions of
mental health acts which create a different basis for admission,
there can be little change. When numbers were evaluated in Holland,
it was found that through one mechanism or the other on the whole
the same number of people are admitted against their will, although
it should be added that this is not a good argument not to develop
optimal legislation.
Q205 Earl of Dundee: What are your views
on preventative measures and the part that these can usefully
play in protecting against mental ill health?
Dr Muijen: It is, of course, a highly complex
question. Let me make one point that is relevant to every question,
which is the question of terminology. This is not unique to this
House, but already in these questions "mental health",
"mental ill health", "mental wellbeing", "mental
illness", "lack of mental wellbeing" are all being
used, and we all assume we are talking about the same group and
the same concepts. It is very dangerous. In the Helsinki Declaration
we consistently used either "mental wellbeing" to talk
about positive mental health, or "mental health problems"
to talk about negative mental health, and already this could lead
to debates about the meaning of those concepts. The importance
of it is that clearly prevention refers to very different groups
from those when we discuss community treatment order. The other
issue, and this will come back later in the debate about stigma,
is that there are different shades. We cluster together a whole
group of disorders and a whole group of people who actually have
nothing in common. It is a bit like talking about infectious diseases
as one group, and I do not mean this in any other way as a parallel.
We talk about people with, let us say, relatively minor anxiety
states and people with very major forms of schizophrenia as part
of the same group. It is unhelpful because they need very different
interventions leading to different outcomes. That is related to
prevention because there is already the challenge here of prevention
at the population level, which is particularly relevant to, let
us say, stress-related disorders, anxiety and depression, rather
than looking at prevention for very specific high-risk groups,
for example, children with two parents with schizophrenia. Everyone
is on the side of prevention but in practice it is very often
secondary to other forms of government action. Think about building
roads, building new housing, school development, all of which
have major implications for the mental wellbeing of the population
and potentially the development of stress and anxiety disorders.
There are some specifically targeted prevention strategies in
a country such as Finland which is very strong on that. Holland
has a very well developed prevention network, including specific
prevention workers. The evidence for very high level prevention
strategies is not very strong, for the obvious reason that they
cost a lot and they are quite non-specific. The evidence for more
targeted specific interventions is well beyond this discussion
because one then, of course, has to break it down into individual
groups. Just in passing I want to say a few words about the Commission
for Social Determinants, which has been started at the World Health
Organisation, chaired by Professor Marmot, who is probably well
known to you. It looks at the implications of different structures
of society for exposure to risk factors, which then leads to differential
disease burden and also to differences in access to care. Mental
health is very important in this cycle because mental ill health
is associated with a very high level of co-morbidity. The joint
prevalence of depression and cancer and the link with survival
rates is very important and as such I think mental health deserves
a far stronger and more explicit place in many policy-making areas.
Q206 Earl of Dundee: But do you consider
that we might be at risk of falling between two stools here, because,
as you point out, it may be very unhelpful to be too loose with
a definition of what mental health is or to extend it so much
to include wellbeing that we are not really, by including wellbeing
in preventative measures, achieving very much at all? On the other
hand, if we learn, which we do, that in a given year as many as
one in four people suffer a lack of mental wellbeing, then even
if we begin with a rather non-targeted collection of preventative
measures perhaps that will still serve a useful purpose. For if
European policy and deployment start like this in a rather loose
way then arguably proper methodology and targeting might develop
all the better later on. What do you think about that? Will this
approach fall between two stools? Or instead, will it yield the
best result?
Dr Muijen: I take the point that in an ideal
world where we prevent—and I do not quite know the right
term—poor wellbeing, we would have societal intervention
which means that everyone is going to be happy all the time, which
would prevent all forms of mental illness and which would be well
worth the investment. Sadly, I cannot think of any intervention
that would meet any of these kinds of aspirations, except maybe
in an absolutely equal society. It was attempted to create such
societies in some countries early in the last century, but we
do not support these forms of intervention and when they were
tried they failed. Efficiency is far higher when we target high
risk groups. It is even higher when we deal with people who already
have developed some early stages of these diseases. Again, I am
with you if you say that we need to combine these two approaches,
which is, of course, always a desirable compromise position, but
I would insist on some hard evidence from health economists, such
as Professor Knapp, who leads the world in this area, that it
will pay for itself because any pound spent on prevention is a
pound not spent on people suffering from very bad conditions.
One can add to this that sometimes the very best interventions
are non-specific mental health interventions, such as improving
conditions at work.
Q207 Chairman: That was what I was going
to ask you. What about working practices, for example? I am sorry
to interrupt you, and I do not know how technical the evidence
is but there seems to be quite a lot of evidence that there are
certain ways of working and atmosphere in the workplace now which
can be directly inimical to mental wellbeing and therefore lead
to things like depression and all the more minor things which
do cost the economy—and this is an interest of the European
Union, of course—a lot of money. I do not know whether you
have had any thoughts about how the European Union can somehow
get into that area because it might make a difference, not perhaps
to schizophrenia, that sort of illness, but to the ones which
are more general mental illness, the depressive diseases, in effect.
Dr Muijen: Exactly, and a lot of work has been
done in this country in some of these areas. If I am thinking
about stress at work, let me just say that the 28 per cent mentioned
in the Green Paper I find astonishingly low; that must be referring
to pathological stress because I am no doubt included in the people
who have some stress at work sometimes, as I suspect many of you
would agree with. Nor is that necessarily a bad thing, but I suspect
that issues like working environment, management styles, enforced
breaks, enforced holidays, would have a very beneficial effect.
Sometimes these simple general interventions are far more important
than mental health specific strategies in the workplace, which
I find, if anything, rather stigmatising.
Q208 Earl of Dundee: Earlier on you pointed
out that the newer applicants to the European Union are more receptive
than some other countries in these matters. Just now you mentioned
the beneficial effect of friendly working conditions, enforced
breaks and so on. Improved access to education, housing and transport
forms another example. There are countless other simple remedies
to reduce stress. All of them are fairly obvious. No great studies
are required. How strongly and frequently, therefore, do you and
your organisation advocate this common sense approach?
Dr Muijen: I would say that I do not need to
go to Lithuania to give advice about stress and transport. Taking
the train into work is very stressful. Certainly one of the lessons
I learned when I started working across Europe was how much many
of these newer countries are struggling economically. We are not
talking about wealthy countries that have the opportunity to fund
research. These are countries that are fighting for their economic
life and with very high levels of unemployment, high levels of
inequality, and they are struggling to spend every dollar in a
way that is directly linked to a better economy and growth and
wealth. I think many of these issues we are talking about here
are not quite on their agenda yet. Also, you would be surprised
how backward—and I use this word advisedly—many of
these countries are in their services. Most countries outside
western Europe, not just outside the EU, are still dominated by
institutions, so when we advise on first steps we look at issues
such as people sometimes sharing a bed, and if they are lucky
they have a blanket each to cover them. In some countries outside
the EU membership they are fortunate if they receive any medication
at all, not just new medication. There was one hospital I visited
where only 20 per cent of the patients were able to receive the
medication they needed.
Q209 Chairman: It is almost like the
developing world, in fact.
Dr Muijen: Some are, yes. Even countries which
are now members of the European Union are still very much struggling
even to provide basic facilities in mental hospitals, so to deal
with prevention at a societal level is hard. What does happen
in these countries is micro initiatives. We talked earlier about
civil society. There are some very fascinating small-scale initiatives
wherever you go, nearly always inspired by charismatic local leaders
who take an initiative and make it happen. Everywhere you go they
are there, and that is an area of real potential, in England as
much as anywhere in Europe.
Q210 Chairman: Thank you. We ought to
move on to stigma. You have had the question. I would like to
know how you think the stigma issue should be addressed in respect
of mental health. It is obviously a very severe problem, particularly
for those people who go in and out, let us say, of the workforce
or who are sometimes ill and sometimes well and are conscious
of the stigma, as it were, of it being held against them. What
examples have you seen across Europe where promotional activities
have helped with this problem?
Dr Muijen: I have seen promotional activities.
What I have not seen are well evaluated national activities. I
have been to countries where I saw posters on the bus, like, "Your
neighbour may suffer from mental illness". That was in France.
I am not sure whether it helps or not, by the way. There are quite
a few initiatives around Europe but evaluation is nearly always
rather soft. Of course, it is very hard because how do you measure
these kinds of national initiatives? I very much liked the activities
in Greece where famous singers were involved and other national
personalities. Finland has been very active. Holland has done
some good work and Scotland has been very active, amongst the
leaders in its level of activity, but good evaluation has not
taken place. I am always a bit concerned about stigma because
it has become so popular a theme that it is almost an excuse these
days. Whenever I talk to politicians they use the word "stigma",
and, rather than coming up with solutions, it tends to be a reason
why it is all so difficult. It has emerged as the key theme over
the last couple of years and not particularly in a helpful fashion.
There is also tremendous attention being given to addressing stigma
of mental illness, and sometimes it actually makes situations
worse. I remember once seeing a video that tried to de-stigmatise
mental illness, and if anything it probably would have increased
racism as well as stigma at the same time by constantly showing
the link between a very mean-looking big black man and schizophrenia,
which probably was not the intention. It is not always very professional
and well thought through, although always with the best intent.
What interests me much more is discrimination, the behavioural
level of stigma. That is where some more interesting activities
can take place. The other concern is promoting stigma as a solution.
It sometimes creates a kind of sense of mental illness being a
myth: if only we de-stigmatise it, it will disappear. Mental illness
can be a very serious conditions with people needing a lot of
support, and de-stigmatisation would not mean that support could
be taken away.
Q211 Chairman: Or gets any better, no.
Dr Muijen: Exactly. Stigma is everywhere. Let
us not belittle it. I have been to many countries where people
do not want to work in mental health because of stigma. Some of
our Member States have major problems recruiting staff. Trained
staff go to the UK because salaries are higher. I know of one
country where one per cent of medical students specialise in psychiatry
and then they often do not become psychiatrists because they go
for better paid jobs in the local economy. Stigma has a direct
role there. It is a theme well beyond just people at work.
Q212 Chairman: I quite like your idea
of concentrating on discrimination rather than on stigma. Discrimination
is something you can deal with. There is a legal framework for
dealing with it. In this country we are supposed not to discriminate
against people for various reasons. One might add other categories
to that, so that is helpful, thank you, the use of that word.
Dr Muijen: Can I add to that by anticipating
a question a bit later on, since we are now talking about discrimination?
The other important aspect is that it might be counter-productive
to specifically deal with mental illness as an isolated theme,
and that we should mainstream as much as we can. I think by singling
out legislation to protect people with mental illness we may create
a kind of gaming by employers to avoid employing people with mental
illness altogether.
Chairman: It has happened in other areas.
There was a reluctance to take on people with physical disabilities
because they had a responsibility towards them. I hope it is passing
over now but that would be the same sort of problem.
Q213 Baroness Uddin: Just before I come
to my question, which is about dealing with vulnerable groups,
particularly minority groups, I welcome what you said about de-stigmatisation,
particularly of groups who are suffering in that way. As a social
worker in this field many years ago, working particularly with
women, I think that the way it makes them out to be some kind
of demon in society when they have been through institutions is
a really valid point and I wish you every success in de-stigmatising
this and getting into that kind of arena of acceptability. I am
very interested in your reference to the demonisation of black
men and what that entails and now Muslims being demonised as terrorists.
Given that there is recognition that some groups in our society
are suffering more strenuously than the general population, triggered
by conflict or prejudice or discrimination, and an example is
children and very high suicide rates and self harm among Asian
women in this country, which could be because of discrimination
and conflict, lack of employment, all those points you mentioned,
as well as racism and Islamaphobia, what do you think are the
specific things that can be done to handle this issue at an European
Union mental health strategy level? I would be very interested
to hear from you about your experiences of good practice in Europe,
and if England is as good as you say, and I know it is, whether
you have sighted any good examples in England about this particular
issue.
Dr Muijen: Let me start with the second part
of the question which in some sense is easier. I was very impressed
with the report of the Social Exclusion Committee. It showed what
can be done when people from a more generalist perspective look
at a specialist area, because they look for mainstreaming—and
I have used that word earlier—rather than singling out and
providing very specific interventions, which always alarms me.
I think mainstreaming is very important in any form of discrimination.
You want to integrate people. You talked about specific sub-groups.
I think the danger is precisely that they can be marginalised
and as a consequence do not reach any of the support that is required.
Europe has very different challenges. I remember very well from
being in England, and also when I now talk to English friends,
that there is strong concern about first of all race and ethnicity
and, secondly, Islamophobia. What is interesting is that the former
is not so much of an issue elsewhere. Religion is often far more
important. There are very different sub-groups in countries, for
example juxtaposing Hungarians in Romania and Romanians in Bulgaria,
in Turkey Christians and Muslims. There are rather different challenges
in many different countries. I think there is a real danger for
organisations like WHO to plan this top-downwards. We believe
we can come up with a strategy for the whole of Europe, which
is impossible. I believe we need to think in countries at the
level of Blackburn and a sub-part of London rather than Europe
as a whole. It is too diverse. This is an area where England again
has been very active and I think that many other countries increasingly
realise that they also have to deal with these challenges. This
is however a question way beyond my remit. You are talking about
the whole of society rather than mental illness. The consequences
are directly affecting mental health, and, again, the social determinants
for health are relevant here but also the social stratification
with nearly always immigrant groups, and particularly ethnic immigrant
groups, at the very bottom living in unhealthy circumstances and
having poor access to care with all the predictable consequences.
Q214 Baroness Uddin: I understand that
that may be well beyond your remit but does that remit belong
to anyone?
Dr Muijen: That is a very good question. The
mental health remit belongs to me but I am talking about the social
determinants of health. There I feel an ownership, but where I
always get very nervous is when mental health specialists start
giving advice on the economic running of a country because I probably
do not know really what I am talking about.
Chairman: I am sure you could have a
good stab at it but I think we appreciate your ability to pick
what you feel comfortable with in giving us your expert advice.
Q215 Lord Moser: If I may turn to discrimination
in the workplace, I find it very puzzling why the mental health
strategy of WHO, and therefore the EU, covers learning disabilities.
It is a field that I know a little bit about. I realise that people
with learning disabilities need help; I am not questioning that.
I also realise that mental health problems can cause learning
disabilities, et cetera, but mental health is a big enough and
confusing enough subject anyhow. Why throw in learning disabilities?
Dr Muijen: We did not. That is actually a question
which should be the other way round, and I will answer it in a
moment as if it were the other way round. Learning disability
is not included in the Helsinki Declaration and as far as I am
aware it is also not included in the Green Paper. There are references
to disability; I do not think there are references to learning
disability, unless I am very wrong. I can certainly talk authoritatively
about the Helsinki Declaration, which explicitly excluded learning
disability.
Q216 Lord Moser: When we asked last week's
witness he strongly defended its inclusion.
Dr Muijen: Who was this? In what? In Helsinki
or in the Green Paper?
Chairman: No, I think in the work that
we are doing.
Lord Moser: Perhaps Professor Knapp will
be able to tell us.
Q217 Chairman: In the Commission strategy.
Dr Muijen: The Commission strategy is not something
I am willing to take responsibility for, but based on this question,
I actually read it through and it is not mentioned. The word "disability"
is mentioned but it was mentioned as disability in the workplace.
Q218 Lord Moser: Sorry to interrupt,
but the Commission Green Paper does include it.
Dr Muijen: I am surprised because it has never
come up in any discussions, nor does it come up in the document
itself. Can I answer it? What deeply embarrasses me is our lack
of activity in relation to disability. That is probably a more
important question. I am very ashamed about having no discernible
activity in the area of learning disability when those are probably
the people who suffer most in institutions in many of our Member
States. Of course, the obvious follow-up question is why is there
no activity, which is my lack of resources. I am working with
three technical staff and two secretaries in 53 countries. I have
to assist with the implementation of the Helsinki Declaration
and two top priorities I cannot address, which are learning disability
and dementia.
Lord Moser: I am very happy with your
reply about that. Professor Knapp can sort this out for us. Something
is funny.
Chairman: Thank you very much indeed.
Discrimination in the workplace, Lady Gale.
Q219 Baroness Gale: I think you have
partly answered this in your earlier remarks about discrimination
in the workplace. Do you think there is a need for some new anti-discriminatory
legislation relating to mental health in the workplace? We know
that many employers would not employ someone if they knew they
had poor mental health. Do you think employers ought to have some
sort of code of practice that they follow and do you know any
examples of this good practice in Europe?
Dr Muijen: The second half is easier than the
first, but let me start with the first. To some extent I am always
very reluctant to recommend legislation because first of all it
needs to be enforced and secondly people look for ways of bypassing
it. We can hardly recommend affirmative action to make you employ
five per cent of your staff with mental illness because who is
going to determine what mental illness is? What is more important
is to offer support for people in the workplace, particularly
supporting people to get back to work and stay at work, but, of
course, prevention is highly relevant here. It is probably far
more effective at the workplace to prevent high levels of stress
rather than cure. I was asked a question not that long ago about
why we do not give special protection to people with mental illness
in the workplace, like giving them offices, to which my point
was, "I am in quite a stressful situation because I am in
an open space myself", and it is very difficult to come out
with guidance which specifies protection to a relatively undefined
group, like people suffering from stress. It seems to me that
this is an area where general good practice is probably more important
than specifically targeting a few people. With regard to people
with diagnosed mental health problems it is a question of who
to target. There are many examples of very good practice in several
countries, such as ongoing support after people go back to work,
job-seeking support, for example the clubhouse model but also
the social club, particularly in Italy, which gives tax advantages
if one employs a certain proportion of people with disabilities
including mental illness, which is much appreciated by the people
attending them. I have also seen excellent examples of modern
forms of industrial workshops in countries such as Israel and
France. At a national level legislation is more complex. It might
well be by carrots rather than sticks that action will be most
helpful, such as giving subsidies or tax breaks for good practice.
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