Useless scientific advice

I lifted the box to the left from the Wall Street Journal, a newspaper that has to be clear, concise and to the point in its communications or its busy and clever readers buy the Financial Times instead. If only the European Commission could choose where it gets its scientific advice, and the scientists involved felt some pressure to be clear, concise and to the point. Alas, I came to read the preliminary report of the European Scientific Committee on Emerging and Newly Identified Health Risks on the subject of smokeless tobacco [PDF]. This will inform European public health policy, and if it was barely competent, it would lead to the lifting of the absurd policy of banning 'oral tobacco' (smokeless tobacco) in the EU outside Sweden. However, despite hundreds of citations and pages of data, the report doggedly conceals, obfuscates and evades the most obvious and important conclusions.

My response to the Committee: Suffice to say, I have been driven to pen a response. This required two components: an on-line response to constrained questions set by the Committee (see here), and a fuller response (see here) covering the broader failings of the work.

Not stating the obvious, focussing on the obscure. Because smokeless tobacco is many times less hazardous than smoking and can substitute for smoking, there are potential large public health gains to be had (or more likely lost, if the stuff continues to be banned). Sweden has the highest rates of smokeless tobacco use and lowest rates of tobacco-related cancer, respiratory and cardiovascular disease. Instead we ban the product and prevent other countries benefiting in this way. You would have expected these insights to form the core of the assessment. I really don't know why they are avoiding this: I can only assume someone involved thinks they are duty-bound to ensure these tobacco products stay banned on the ultra-naive basis that banning something harmful must be progress. But how does distortion and evasion help protect anyone? Apparently, several of the external experts are fed up, perhaps to the point of a walk-out, with the clear bias and manipulation in the drafting of the report's conclusions. The most important part of any scientific assessment is the framing of the issues - my initial memo to the Committee in January 2006 addressed this. As I had expected, it was roundly ignored but I think this now accounts for the problems.

The report actually does quite a good job of surveying the literature, but it is marred by misinterpretation and inappropriate conclusions drawn from the evidence. Glaring and important truths are ignored or sidelined (er, the very low levels of disease in Sweden hardly features) and great effort is expended on trivial detail - others more expert than me will no doubt tear its flawed inferences apart. But I'll highlight three major failings here that I think transcend the tobacco / public health issues:

1. Communicating risk. The report discusses at great length whether the use of smokeless tobacco is hazardous and addictive. It is. Everyone knows it is. But risk is only interesting if quantified in some way and set in context. Bacon is hazardous to health and coffee addictive. What is missing in this report is some sort of spectrum of risk - with common consumer risks at one end (eating meat), medicinal nicotine, smokeless tobacco - in all its various forms, smoking, drinking hemlock etc. That way, we would know how much to worry about a few extra people using smokeless tobacco that would otherwise have remained tobacco-free, compared to how much we might hope to gain if other people used smokeless tobacco instead of smoking. In fact, the risks of smokeless tobacco use vary markedly between products - but this range is compressed into one end of the spectrum that has combustible tobacco products clustered at the other end.

2. Communicating knowledge in conditions of uncertainty. Whether lazy or manipulative, scientists are often very poor at dealing with uncertainty - saying what is known, even if it is not known beyond reasonable doubt. There is a tendency to say 'no evidence' when what they really mean is that there are no randomised controlled trials showing significant results at greater than 95% confidence. But this is just an arbitrary, if widely used, convention in medical literature. In policy work, insights based on the balance of probabilities are often more important and a good scientific assessment will help policy makers through the difficulties of understanding knowledge where there is not high certainty. In trying to find a way of putting this to the Committee I came across the Intergovernmental Panel on Climate Change (IPCC) Guidance notes to lead authors on addressing uncertainties, which I think is an excellent guide and should be required reading for anyone working at the science-policy interface.

3. Burden of proof. Who should be doing the proving and what are the hypotheses? I think there is an in-built bias in so-called evidence-based policy making that favours the status quo. The problem is that high evidential hurdles are set as a pre-condition to justifying doing something new, but the case for carrying on with the current approach may not even be scrutinised and most probably questions never asked. The right way is to assess all the options including staying with the status quo taking a balance of probabilities approach. The ban on smokeless tobacco is an extreme case, but amazingly no-one seems to think it is important to justify the partial ban on smokeless tobacco in the EU - a bizarre intervention, and utterly without precedent, to ban a much less hazardous product variant than the market leader, in this case cigarettes.

One more small reason to despair at the European Union - to me, a completely vital institution in a globalising world. But it does too much of the wrong things, does too many things incompetently that it should do well, and does not do enough of what it really needs to do. A subject I'll be returning to....! ... continues. Read full post.

Is this the worst policy announcement ever?

There seems to be a plan to give pregnant women £200 and training in nutrition - it will be a 'Health in Pregnancy Grant' [Pregnant women to get healthy food grant - Telegraph] [BBC]. Despite the recently announced end of spin, this was spun in the media several days before its real announcement, in a speech by the Health Secretary. By the time of the speech, the payment was less precise - it would be "substantial" and "sufficient to help every mother eat healthily during her pregnancy". Perhaps some sums have been done...

I don't doubt that it would be good to improve diet and nutrition - and we should be worried about the rise of the tubby tots see chart [data from Dept Health]. There are also marked social class differences in child nutrition and prevalence of low-birthweight babies - see ONS The Health of Children and Young People Survey - chapter 3 on nutrition.

But it is one thing to recognise a problem but quite another to find a policy that will actually address it. And I think this announcement is just about the worst policy I can think of.

Let's set out some of the doubts one might have...

1. Untargeted - there is a huge 'dead-weight loss' as payments are made to all women, including many that don't need the advice or don't need the money. Who are the target group? Why aren't they targeted? If there is less than 100% uptake, will those not taking it be disproportionately part of the target group?

2. Wasteful - a high likelihood the £200 will be spent on anything but the intended outcome thus wasting money - there is no evidence that apples, broccoli and oat bran are the marginal purchase for poor families. Frankly, if I was a pregnant women I'd be taking a well-earned lunch at Quirinale. Why do they think the money will have the desired effect?

3. Expensive - I'll guess about £130m assuming England and Wales (based on about 640,000 births per year) for the payments and provision of 'nutritional advice'. God knows how much for administrating it, preventing fraud etc. Even for the NHS, that's a substantial sum. About half the additional funding the government is making available for new flood protection by 2010-11 (£200m).

4. No evidence - I couldn't see anything links the intervention with the hoped-for outcome ... and to be honest it seems unlikely and hangs on the value of the nutritional advice. What's the evidence that nutritional advice interventions change diets? How intensive does the intervention need to be? Does it make a difference if the person opts in voluntarily or attends under semi-coercive conditions to receive a payment?

5. Untried - there's no sign that a pilot has been run - if there had it would have been part of the announcement. I've the evidence of my own eyes in seeing 'Healthy Start' vouchers exchanged for sweets and Coke in my local shop. Welcome to the graveyard of good intentions. Why can't they just try it and learn some lesson before they waste taxpayers' money?

6. Uncontested - There's no obvious consideration of opportunity costs or alternatives - what about strengthening supply side by improving the services available? Is pregnancy the best time for the intervention? Would a community-based intervention work better - eg. running an aerobics class with a wider focus on healthy living etc etc...

7. Unfocussed - What about bigger interventions aimed at fewer people? There's no recognition of the benefits of concentration - if, say, one-third are in the target group(the chav mums?), wouldn't a targeted £600 intervention work better that a £200 general intervention?

8. Implausible - I've yet to see what the training would amount to, but I'll be surprised if a lecture works - I suspect the problem is a skills deficit and confidence in cooking fresh food - linked with time poverty. Also, assuming one person can run 300 training session per year and there is a single training session per woman, that would require a workforce of about 2,000. Where are they?

9. Prudence - the old girl has had a quite torrid experience with this one. Where is the control and checks an balances on such poor policy-making? What is this government in a 'tight fiscal situation' doing? I hope the NAO and select committees are all over this.

Apart from that, it's a great idea. Nominations please, for a worse policy? Poll tax excepted.
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Saying stupid things with fake sophistication

If you want to say something absolutely jaw-dropping in its idiocy, then you need to cloak it in lots of fake sophistication. And this is what ASH Scotland has done with its new position paper on smokeless tobacco.

No less than 266 references are used to support the truly stupid idea that smokeless tobacco, which can substitute for cigarettes and is far less hazardous, should be banned. Smokeless tobacco is far less dangerous because there is no, er, smoke to draw into the lungs. The red hot particles, volatile gases and thousands or organic products of combustion ingested deep into the body do the harm.

If you put that idea to any normal person they look at you as if you've lost your mind. Only in the insular world of 'tobacco control' do these ideas survive for longer than it takes to express them. In fact, there is a wealth of evidence that it is, as you would expect, a truly stupid thing to do - not least because the place where it is most widely used (Sweden - see chart) has much lower rates of smoking related deaths....

The chart shows male lung cancer mortality rates in some major countries [Source: IARC / WHO Cancer Mortality Database CANCERMondial]. One country stands out: Sweden. And Sweden also has lower rates of oral cancer and other smoking-related diseases. The difference between Sweden and the others is that a high proportion of its tobacco use in Sweden is in smokeless form [view]. One of Europe's especially ludicrous policies is to ban most forms of 'oral tobacco' [Directive 2001/37/EC Art 8], though not in Sweden.

So the main ASH Scotland policy idea is that other countries should be prevented by law from reaching a position where more of the tobacco use is through far less harmful forms of tobacco consumption and that addicted individuals should be prevented by law from having access to lower risk products. What next? A ban on anti-lock brakes? Cycle helmets? Ropes while rock climbing? Any risk reduction measures at all while engaging in inherently risky behaviour? There's the warped logic of the overweening health planner behind all this... if you make a risky activity much safer, then people might not stop doing it altogether.

Confused about burden of proof
Apart from the unsettling coerciveness of such positions, there are simplistic errors in the analysis - concerned with the handling of scientific uncertainty when making policy. Science can (and should) reserve judgement indefinitely or use 'beyond reasonable doubt' tests of evidence. But policy making requires decisions whatever the available evidence - and a decision includes "maintaining the status quo". This requires the policy-maker not to demand perfect knowledge but a 'balance of probabilities' assessment of available evidence. Throughout the document, the authors draw conclusions of the form: "there is not enough evidence [for doing something sensible]" and so decide to stick with doing something stupid, as if there is conclusive evidence to support the stupid ban. Which there isn't and they don't pretend there is, or even seem to recognise that there ought to be. All they've done is set a high or impossible evidential hurdle for the thing they don't like and not applied any evidential challenge whatsoever to maintaining the ban, which they do like. But what if the ban, by denying people less hazardous alternatives, is actually killing more people? It's at least plausible. And given the position in Sweden, where it isn't banned and many fewer people die, you might think that was a good starting point and expect some evidence to show that bans aren't just making everything worse. For me, the burden of proof is on those supporting the utterly insane idea of banning much less hazardous substitutes for very deadly products. Look through the ASH Scotland paper and you'll find no evidence to support a ban or give any confidence that it isn't doing more harm than good.

Confused about individual rights
But I think the thing I find most troubling about this sort of posturing is what it means at an individual level. In effect, these remote health planners are saying to a person who smokes cigarettes that they should not have access to a much less risky alternative. Where did the acquire the authority and the bare-faced arrogance to do that? How did they become so sure of themselves that they feel qualified to restrict the harm reduction options available to someone struggling with addiction? So on those estates in Glasgow, where smoking prevalence can be as high as 70%, ASH Scotland says 'no' to lower risk alternatives. You must quit. And if you don't quit - well, you might as well die.

Wrong questions
ASH Scotland solemnly poses questions like should smokeless tobacco be given a "legal designation as a harm reduction product in the UK? Eh? There's no such thing. It's a tobacco product - just much less dangerous than the norm. Or they state a preference for use of NRT for harm reduction or stopping smoking - but what if others find smokeless tobacco more effective or don't want or wont use a medicalised approach? What is the case for reducing the available options for quitting or reducing smoking? They prefer other interventions such as smoke-free places legislation and bans on advertising. All good ideas, but they don't explain explain why these are mutually exclusive with policies that reduce the harmfulness of the tobacco that is sold or why removing smoke would have a beneficial supportive 'denormalising' effect. Or why there wouldn't be additional benefits from reducing passive smoking exposure, role modelling and fire risk.

With top epidemiologists predicting 1 billion premature deaths from tobacco in the 21st Century, one might think that all options would be in play- especially as the smokeless products have done so much to keep the carnage down in the one place where they are widely used.

So for the next edition of this position statement:

1. please provide evidence that the ban you favour maintaining isn't doing more harm than good at population level by denying smokers access to much less hazardous products and opportunities to manage nicotine addiction, in the way it appears to work in Sweden. We know that even if a few extra people used it that were never going to be tobacco users or would have quit anyway, the extra harm would be small.

2. please outline your ethical basis for denying a person access to an alternative product that is much less dangerous than the one they may be addicted to. You might think it will save the lives of others (I don't, and you can't show it will), but what about that person's individual rights? Do they count for nothing in the face of your bossy prescription?

3. please explain why it would be good policy to provide legal protection to the cigarette makers in the market for tobacco and a barrier to entry to potential competitors offering much lower risk products. This is an especially stupid idea now being aggressively pioneered by health campaigners in the United States through their seedy and desperate deal with tobacco giant Philip Morris to support a Bill to pass regulation of tobacco to the FDA. Expect many dead.

Read this instead...
For a decent review of the evidence, don't spend too long watching ASH Scotland struggle with basic epistemology. See Brad Rodu and Bill Godshall in Harm Reduction Journal 2006, 3:37; and the collection of 50 best papers on the International Harm Reduction Association tobacco section. Even tobacco companies provide better and more balanced analysis than this effort by ASH Scotland: see this account of Experience from Sweden by Swedish Match - or this literature review by United States Smokeless Tobacco.
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Cap and trade for cigarettes?

If a country wanted to reduce tobacco use to a level that meant it was comparable with other public health risks, then why not simply reduce the amount that can be sold or number of customers they can have, by allocating quotas to manufacturers and allowing trade in quotas? This proposal has surfaced in the US as a legislative proposal: Help End Addiction to Lethal Tobacco Habits Act (geddit?) [full text] by Senator Enzi. This is partly in response to the pointless industry-sponsored Family Smoking Protection and Tobacco Control Act , which mystifyingly also attracts support form big US public health campaigns. I think have vested misplaced faith in regulation and regulatory bureaucracies. The Enzi approach is an alternative and the idea also has people talking in the public health world [article in New Zealand Herald and here]. But does it make sense? I'm not so sure... here are a few tentative thoughts (and I'd welcome responses from those promoting the idea)....

1. What does cap and trade add compared to increasing taxation on tobacco? Both systems tend to raise prices and bring supply and demand into line. Taxes, however, have the great benefit that the premium paid flows to the government, rather than the tobacco company (unless the quotas are auctioned, which I would recommend as an amendment to the Enzi Bill, in which case the premium flows to the government, but adds a lot of complexity).

2. The 'allocation programme' is cumbersome. Based on historic market share, Enzi's proposal grants important rights (effectively access to market) to incumbents. Again it could be improved by auctioning quotas, but adds nothing to cigarette taxes. The Enzi proposal actually makes the number of users the regulated quantity... but given the great heterogeneity in what makes a user and how much this changes over time, this is a really poor idea for a regulatory base.

3. Control of price volatility will dominate quota setting. This is a major problem with cap and trade systems (and we are suffering from this in the EU Emission Trading Scheme)... Whilst it is possible to set, quotas as Senator Enzi does, that give a desired outcome with certainty, in practice politicians are not indifferent to price hikes in widely used products. The result will be a fudge on quota setting that effectively guarantees that the price volatility is manageable. An economist's view is one thing, but these ideas have to be seen in terms of political economy.

4. Physiology. Smokers control their nicotine dose from smoking and, within limits, can get their fix from fewer cigarettes. This effect is already seen with poorer smokers, who will often smoke fewer cigarettes but achieve a higher blood-nicotine level by smoking more intensively. This is an issue for taxation of course, but proponents should remember that there isn't a linear relationship between a quota (whether number of sticks or number of users) and health impact.

5. Gaming. With complex regulation and definitions, there always comes the scope for innovative gaming. And you would surely expect that here. If the quota is users, can some new product be designed that takes them out of the user definition? Can users be encourage to lie to surveys? If the quota is measured in product terms, can longer cigarettes be introduced?

6. Scope of responsibility. It's generally a good principle of regulation to give organisations duties or targets only for things they have control over. Tobacco companies don't control the number of users, they are just one influence - health care support for quitting, taxation, public health advertising, smoke-free policies, marketing restrictions are all more important. They can control the quantity of product they sell and its price.

7. Legal constraints. The slightest sign that the allocation regime disadvantages importers or foreign brands, then a challenge at the WTO would be expected. In fact, it would happen just to get in the way. Anti-trust law or other consumer protection principles might be expected to be deployed by those disadvantaged in the market carve up. What would happen when people wished to bring in cigarettes they'd bough overseas?

8. Distraction. This could tie up administrators in knots and expend valuable political capital to little purpose. I think there is only a limited role for supply-side interventions in reducing harm from tobacco. these are primarily by:

• raising the price through taxation that keeps pace with growth in incomes, and so reduces affordability of tobacco use over time;
• differentiating the tax rates according to the harm. I strongly support a much lower tax rate for smokeless tobacco products and no tax differentiation between smoked products (eg. by tar or nicotine yield) as there is no real health difference between smoking products, whatever you've been led to believe about 'lights' etc.
• giving meaningful information to tobacco users about relative risk of products - again, especially about the vast difference in risk between smoking and smokeless tobacco.

More important are the measures designed to act on the demand side - smoke-free policies, advertising bans, support for quitting, counter-advertising being the most effective.

9. Finally, an advantage. Where taxation is a dirty word and political non-starter cap and trade systems can have much the same economic effect (raising the price at the margin) but may be more easily implemented than a tax. Something similar happened with the US Master Settlement Agreement in which State Attorneys general sued the companies for health care costs, won $250 billion settlement, causing the companies to raise prices by 40-50 US cents to pay for it. Not far off taxation, but a lot of lawyers got rich too. I think lawyers would do well from a cap and trade system too... and that's never a good sign.

Of course... I very much doubt Senator Enzi's proposal will go anywhere, but always worth discussing innovative ideas.
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England goes smoke-free - wider lessons

Long awaited 1st of July arrives, and most enclosed workplaces (including pubs and restaurants) in England will go smoke-free today [BBC]. It's a triumph for all involved - both campaigners and government insiders - following a sustained struggle. It's also a vital next step in dragging down smoking rates - see chart based on ONS and Tobacco Advisory Council data care of Cancer Research UK, [XLS]. Still at about 25%, that's a huge number of people using an addictive product that kills one in two long term users - and does a lot of damage before death.

The ban on smoking in public places has always been justified around protecting non-smoking workers, for which there is the strongest civil liberties and legal basis, but its biggest public health benefit will come from 'denormalising' smoking - removing the societal support for smoking as a normal activity and role-modelling effects - and raising the cost of smoking in terms of time and hassle. The effect should be an acceleration in quitting and fewer starting.
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Mass killing machine making lots of money

Hopes that Big Tobacco might be in retreat are looking pretty forlorn. I came across BAT's share price data showing a huge gain over the last seven years, including a sharp and sustained rise following agreement of the WHO Framework Convention on Tobacco Control (FCTC) - an attempt by 146 governments (so far) to establish a common approach to regulating this industry and pushing a public health agenda. The FCTC text cover advertising, product labelling, smuggling, smoke-free environments, taxation and so on - much more useful information at the Framework Convention Alliance.

I remember having lunch with an analyst from one of the City of London investment banks in 2000, and asking why he had such a strong 'buy' recommendation on the BAT stock when there was so much litigation and regulation in the air. He replied "it's in the fundamentals: they sell so much of this stuff, it's really profitable, their customers are addicted, and worldwide the only way the pack price and customer base are heading is upwards".

The massive increase in BAT's stock price arises from gradual move to a valuation that reflects those fundamentals - the price was heavily discounted before. Investors now believe that the risks of damaging litigation are falling and that the FCTC wont slow the spread of tobacco use in developing countries - especially to women. Smoking kills about 5 million per year (and rising fast) worldwide, there are about 1.3 billion users, also increasing. On current trends about 1 billion will die early from tobacco use in the 21st Century - it is amongst the worst and most avoidable of public health problems.

I still find it incredible that many public health professionals can look at this situation and conclude there is no place for a market-based strategy aiming to switch as many tobacco users as possible from smoking cigarettes to using smokeless tobacco in its many forms (with much lower risk than smoking)... In fact, many in public health are determined to block attempts to make the market for smokeless tobacco products take off. Yet we know this has yielded large public health gains in at least one country, Sweden [research] and there is a strong case in consumer rights to be able to choose products that are vastly less hazardous, especially when you are addicted. Lynn Kozlowsky [here] invites us to imagine we were trying to help someone in our own family - would we really try to stop them trying something 100 times less hazardous? There's a compelling body of evidence supporting this strategy [eg. see International Harm Reduction Association library] and arguments have raged for years without the opponents of this approach ever once making a convincing case, or even any case. The truth is that they don't like the idea of tobacco companies making money or conceding there is any place for a tobacco product as part of the solution.

But make money they will, and lots of it. I'm all for banning smoking in public places and stopping the advertising etc - that can only help. But one of the big public health questions of the 21st Century is whether Big Tobacco can be manoeuvred into making money by selling smokeless tobacco products instead of cigarettes, which are perhaps around 100 times as hazardous. One danger is that fussy, insular and instinctively authoritarian public health people will continue down the evidence-free path of blocking these developments and insist that for smokers it has to be 'quit or die'. On the other hand, and more positively, tobacco companies may see smokeless products as a way of doing business with less death and disease and persuade regulators that they needs some regulatory tweaks to make it work - for example it is still impossible to tell smokers the truth about relative risks, and much public effort go in to obscuring it. In Europe, the much safer products are banned, while cigarettes are on open sale. It would be a pity if public health people continued to get in the way - that's the real scandal.
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Women - cycle and live!

Mia culpa on the cycling and jumping red lights thing [see silly Cyclists obey the law and die post]. An excellent analysis by Marianne Promberger completely fillets the figures and trashes conclusions drawn in the media (and reported uncritically by me...) read her analysis here. For London, the proportion of cycle casualties (fatal, serious and slight) has been stable at around 79% male to 21% female since 2002 [source]. In 2001, the split of London cycle journeys was 73% male to 27% female [source] - which suggests that men have more casualties per journey. These figures are summarised here.

But a 2005 survey showed female cycling has now risen to 40% [cited here - ref 4] and this is backed by the evidence of one's own eyes... So this suggests although the female proportion cycling is rising, the female proportion of causalities is stable. It is lower than male as a proportion of trips made and it is getting lower over time.  More analysis follows...
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Cannabis - sorry about the apology

The Independent on Sunday reached a new peak of absurdity last weekend when it blazed over its front page: Cannabis - an apology and reversed its 1997 campaign for legalisation of the dope, apologising to its readers for leading them astray. The Indy frets that:

Record numbers of teenagers are requiring drug treatment as a result of smoking skunk, the highly potent cannabis strain that is 25 times stronger than resin sold a decade ago. More than 22,000 people were treated last year for cannabis addiction - and almost half of those affected were under 18.

It feels like a modern day Reefer Madness (view classic 1937 film) with 'skunk' playing the role of the evil marijuana. One struggles to know where to start with dismantling this rubbish! But lets try... ... continues. Read full post.

Next Big Idea - Labour to offer less of itself

The Chancellor wants an independent board to run the NHS (BBC: Brown plans independent NHS board) and leading Blairites want a Charter to regulate the role of ministers (Guardian: Labour unveils plans for BBC-style charter for NHS) All of which seems to be part of a move to greater devolution as the Next Big Idea for the New Labour project - see for example, Progress pamphlet: Empowerment should be the guiding principle for New Labour in the next decade by James Purnell, a junior minister, and heavy hints that this will be the big theme in Gordon Brown's bid for the top job (BBC: Brown in pledge to deveolve power).

Comparisons are being made to the independence granted to the Monetary Policy Committee of the Bank of England. But this is glib - the MPC has a technocratic role, albeit a difficult one, with a single target (currently 2% inflation) and a single policy lever (interest rate) in a simple monetary policy framework. The model of the BBC's charter is more complex, but there is not much in it that requires hard choices and it isn't really a satisfactory analogue.

I think the question is which activities should ministers and civil servants (never let them off the hook) be held acccountable for, and which are technocratic matters that should be down to implementation of settled policy by competent professionals or expert judgement. This is far from simple with a body like the NHS. All the places that cause the most controversy are those where politics will almost inevitably assert itself and draw ministers in... here are four areas of great importance where ministers will find it difficult to stand back from, rather than stand behind, tough decisions:

1. Rationing, allocation and prioritisation...
Even though the NHS has £84 billion in, critical decisions are made about where to spend and not spend - and these are not really pure technocratic decisions. A good example of the difficulty is the National Institute of Health and Clinical Excellence, which decides which drugs, devices and treatments are sufficiently cost effective to be supplied through the NHS, using criteria established as policy by ministers and civil servants (ie. it already fits the proposed 'devolution' model). The trouble is that NICE has had endless political pressure on its decisions, most notably over the anti-flu drug Relenza and Alzheimer's disease (article / BBC). Most notoriously, the licensing and cost-effectiveness appraisal system was over-run as ministers instructed Primary Care Trusts to make the unlicensed breast cancer drug Herceptin available and to fast track appraisals (see BBC news, account of campaign). The problem is that NICE is really there to ration health care spend and to be a gatekeeper to the NHS's potentially open-ended call on the taxpayer. Though it does much good work, where it comes to a 'no' decision - it enters tough political territory.

2. Facing down unions and producer interests...
The problem is writ large in getting reforms implemented. The NHS has strongly entrenched 'producer interests' (GPs, consultants, managers, nurses - even truck drivers) who are sometimes inclined to have the NHS run for their own convenience and enrichment with only a passing interest in patients. Much of the current reform effort is aimed at breaking down these groups and changing the NHS to be more patient-centric (see NHS Improvement Plan: Putting People at the Heart of Public Services). So patient choice, competition from independent sector providers, etc are really aimed at changing the attitude of the core NHS (whether they will work as intended is another question...). But much of this involves challenging producer interests within the NHS and is deeply political - in many ways the challenge is analogous to breaking down the power of unions that was faced in the private sector in the 1980s, and that cannot be done by a committee of the great and good.

3. Applying efficiency pressure...
In theory, a board could be tasked with with achieving some efficiency measure (QALY/£ or something) and be left to get on with it. But improving efficiency means taking tough and controversial action against the inefficient. In the end this may mean closing facilities like hospitals or single handed practices. An 'exit regime' for weak or failing providers is fundamental if the efficiency reforms are to work, but it is hard to see how ministers could hide behind a board when hospitals are required to close. When Kiddiminster hospital was up for closure the local MP lost his seat to an indpendent campaigning to save the hospital. Even on something as simple as out-sourcing logistics has caused a storm of controversy with strikes threatened (Guardian: Strike threat as private firm wins £1.6bn NHS deal), and it's hard to see how ministers could avoid engagement in that.

4. Securing the social contract underpinning the NHS
The NHS represents a huge social contract that transfers money through taxation to healthcare spending from young to old, rich to poor, fit to slothful, sane to insane and so on... it is a bargain struck between individuals as voters in return for a strengthening of the fabric of society and provision of safety nets. Keeping that contract adequately acceptable to all participants is the major political objective of the Secretary of State for Health, and there is little scope for out-sourcing inevitable controversy to a board of the great and good.

Still worth looking at though...
However, I think the idea of taking ministers out of technocratic decisions is a good one. where it can be made to work. The huge IT programme, Connecting for Health, is probably an example where it is working already. NICE technology appraisal decisions could be an area where a charter or independent board could restrain the involvement of ministers and give supposedly independent bodies more independence. With the NHS structured as a huge state-run monopoly provider, it will just be difficult to find areas that really are technocratic only and that aren't already at arms length from ministers.
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33 years to go

The recent hot weather remined me how annoying much of the 21st Century is likely to be, what with climate change and everything. So I wondered how much of it I might have to endure. You can look up how long you are expected to live at the Government Actuary Department's life tables. I've got 33.5 years to go from my last birthday - meaning I'm anticipating a statistical death on 21st August 2039. A party is planned. (Data for England) ... continues. Read full post.

Killing by the million - and that's just the health campaigners...

World cigarette production is about 5.53 trillion sticks per year. (about 2.4 per day for every single person in the world). This is stabilising as people in developed countries quit and growing populations in the developing world start puffing. According to WHO's tobacco group, death-toll from this is now about 5 million per year, heading for 10 million. With perhaps 1 billion potential premature deaths at stake in 21st Century on current trends. In other words it's huge.

What is absolutely amazing though is that there are forms of tobacco use about 10- 100+ times less hazardous than smoking (ie. chewing, sucking - anything non-combustible) - it's the smoke that really kills. Widespread use of these is why, for example, Sweden has the lowest rates of cancer and heart disease in the world. If the world tobacco market shifted to selling more of this and less cigarettes, millions of premature deaths could be avoided over the 21st Century. But true to form, the well paid and comfortably smug public health community refuses to accept this concept and adopts a counter-productive prohibitionist stance - hoping naively that if people have a choice between quitting and dying, they'll choose to quit. Inconveniently, tobacco is highly addictive, so many wont or can't choose to quit and will die. So instead of telling the truth about low risk options, there is a conspiracy to lie and mislead (for example, the US Surgeon General told a barefaced lie about it to Congress). In Europe, we even have a directive (2001/37/EC see article 8 and 2.4) that bans the much lower risk products than cigarettes. If there is a reason to be a Euro-sceptic, then this is one of the strongest - deliberate denial of access to products that are much lower risk to people that are addicted to nicotine.

I feel very strongly about this, so last night I met with US Smokeless Tobacco to encourage its new chief executive to make his target market the erosion of the 5.5 trillion unit cigarette category. If he achieved that, I think they'd save more lives than most of their opponents in the public health community. he didn't need much convincing.
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Choice in the NHS will fail without exit strategy for the unchosen

Health Minister Andy Burnham disgraced himself this morning on the radio. Subject is 'patient choice' (BBC item), which is to be expanded. In my view, generally a good idea to put the patient and their adviser (usually the GP) in the driving seat - if money follows the patient then suddenly patients matter more to eveyone in the NHS. Whatever anyone says, the NHS is a bastion of producer interest and its staff quite capable of treating you as if you don't exist. There's lots that can go wrong of course, but patient choice is right should be doable. Burnham's disgrace was to fudge the critical question: what happens to places patients choose to abandon? He came up with some weasel words about support from the centre for hospitals that were struggling. But choice will only work if there is a credible exit strategy for places that aren't chosen. Vast sums of money and growing share of national income are at stake - see chart (click to open larger version). Ministers have to be much more careful than they have been about who gets to spend it and how that is decided. ... continues. Read full post.

Alternative medicine - you're on your own

Should the NHS fund complementary medicine? Some top medics say 'no'. Scientists are often too quick to dismiss treatments that work outside their own paradigm - and we need to stay open-minded about this stuff. But the question is, as always with the NHS, should someone else pay? The NHS is based on an implicit 'contract' between net beneficiaries (typically the old, sick and poor) and those that are net payers (young, healthy and rich). Those paying in are entitled to expect that NHS treatments have been shown to effective and cost-effective, and that they are not funding New Age fads. The NHS already has NIHCE to tell it what interventions are good value for money. I suspect that we will find that there are valuable therapeutic benefits from some of these treatments - but unless there is evidence, people wanting unproven alternative treatments should expect to go it alone. ... continues. Read full post.

Professor Sir Roy Meadow

It's hard to dislike anyone more than Professor Sir Roy Meadow - the 'expert' witness that consigned Angela Canning to gaol and her family to utter misery on the basis of completely incompetent statistical assertions designed to shore up his idiosyncratic theories about sudden infant death syndrome. And he has never even apologised.

So good news today to hear that the General Medical Council is to appeal against the High Court ruling denying its right to stike him off. And the GMC will be supported by the Attorney General. [BBC item]. The High Court's ruling was a disgrace, effectively protecting experts from the professional consequences of outrageous failure with extreme consequences for others.

The most famous claim with which Meadow mislead a jury was that there was a 73 million to one chance of two 'cot deaths' in an affluent family. There are two childish flaws in this statistical claim:

1. Widely reported: the events may not be independent - a common environmental or genetic factor may apply to the both the first and second deaths.

2. Less well appreciated: remember there are 1.5 million UK families that have 2 or more young children [data from ONS]. So if it was actually 73 million to one for a specific family, you'd be expect about a 1 in 50 chance that it would happen somewhere in that population. It's a bit like rounding up all previous lottery winners and accusing them of fraud because there's only a 1 in 14 million chance of winning and its very unlikely they would have won by chance. Add both these effects and it is hardly surprising these tragedies happen from time to time.

The best we can hope for is the Roy Meadow's reputation is utterly destroyed. personally, I think he should be behind bars - his negligence and incompetence caused far more agony than any assault or robbery could ever.
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EU judgement on hospital reimbursement goes way too far

The European Court of justice has just found that the NHS must fund treatment on the continent if the NHS waiting time is deemd too long. The ruling on case of Yvonne Watts (see BBC) effectively creates a single European health service with open ended obligations and removal of one of the very necessary approaches to rationing health care.

Where do these entitlements actually come from? Unspoken in this is that hospital treatment is a call on the taxpayer that funds the NHS, who has right to insist on limits to his or her liability in respect of other people's illnesses. This helps to make that liability open-ended. I don't think ECJ judges should be determining the social contract implicit in the NHS in this way.
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Climate change in Africa

Christian Aid says that 180 million people likely to die from climate change in Africa by the end of this century - see BBC story But the coverage focuses on mitigation (reducing greenhouse gases) rather than adaptation - which is what will matter most in Africa over the next 50 years. Here's a map showing where the deaths from climate change are already happening. And it isn't the USA...


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