The case for intervention
20 December 2012
A recent BMA report has attacked the coalition government’s cooperation with industry in tackling unhealthy lifestyles. Is more intervention an urgent necessity?
Obesity, alcohol misuse and smoking-related illness have reached epidemic proportions and it is time to get tough, the BMA argues in a new report.
Doctors leaders insist they are not being killjoys by calling for a stewardship approach and regulation to combat the biggest risk factors that kill and cripple: poor diet, lack of exercise, smoking and alcohol consumption.
In a new position statement Behaviour Change, Public Health and the Role of the State, the BMA says it has significant concerns about the coalition government’s public health policy for England.
The policy relies too heavily on voluntary partnerships with business, corporate social responsibility, and a drive to nudge individuals towards taking greater responsibility for their health, doctors leaders say.
It states: ‘For the government, as people are ultimately responsible for their own private decisions over what they eat, how much physical activity they do and whether they smoke or drink alcohol, centralised interventions and initiatives that restrict choice or lecture people in these areas are unjustified and ineffective.
‘Instead, the coalition favours a more localised and individual approach that respects the rights and freedoms of individuals and commercial organisations.’
Meanwhile, up to 40 per cent of the UK could be obese by 2025, causing heart disease, high-blood pressure, arthritis, type-2 diabetes and some cancers. Alcohol-related harm costs society £21bn a year, according to estimates cited in the government’s 2012 Alcohol Strategy.
BMA director of professional activities Vivienne Nathanson agrees the BMA has had some success in securing a number of regulatory measures that aim to create a healthier environment. These include minimum pricing for alcohol and limiting tobacco sales.
Dr Nathanson says the BMA worries that subtle attempts at behaviour change and nudge theory — as described by US behavioural economists Richard Thaler and Cass Sunstein in the book Nudge: Improving Decisions about Health, Wealth and Happiness — will continue to find favour at the expense of regulation and legislation.
Dr Nathanson adds that publishing the position statement at this time was partly to help policy makers by setting out the ethical arguments for curtailing some freedoms.
‘Even when governments are in favour of legislation and regulation, they face these accusations of nanny state, so having a paper out there is useful. It helps the government as well,’ she says.
The state ‘should put the well-being of its citizens before commercial freedoms’, the paper argues, adding that merely leaving people to their own devices risks further entrenching deep social inequalities.
Moreover, the statement adds: ‘If the state is serious about protecting and promoting individual autonomy, in enabling citizens to make use of genuine, substantive freedoms, then it has an obligation to address the underlying conditions in which autonomy can flourish. Critical among these conditions is our health.’
Pitching the debate as a simplistic fight between individual freedoms in one corner and the nanny state in the other does not do the issue justice, the BMA says.
The context of the environment in which we live is much more complex; rising alcohol misuse is linked to post-war social changes, greater affordability, the loosening of licensing laws, aggressive marketing and the pressures of modern living, for example.
Meanwhile, obesity is linked to increased sedentary working, changes in transport patterns, cheaper and more accessible energy-dense food and advertising and marketing.
The government bears a responsibility for creating a ‘reasonably healthy environment in which freedom can have meaning’, the statement argues.
Dr Nathanson explains this is why the BMA supports the stewardship approach, as put forward by the Nuffield Council on Bioethics. This suggests that health is a collective and an individual undertaking.
Duty of care
‘What we are trying to describe here is that governments have a responsibility to look after the health of the public, including the most vulnerable,’ Dr Nathanson says.
‘Stewardship, to me, is about [the] government looking at what it can do to help people make the most of their lives and their opportunities. And without being completely determinist, it recognises that our ability to make choices is often partly constrained by the environment in which we live. Health is such an important good that we have a collective responsibility and a collective role.’
So, for example, the public have accepted the need to wear seatbelts and not smoke cigarettes in public places for the sake of the health of the wider population.
‘That collectivism is what is behind the NHS. As a country, we have a strong sense of collectivism, so we think this approach fits in quite nicely,’ she says.
In early 2011, the coalition government set up five public health responsibility deal networks covering food, alcohol, physical activity, health at work and behaviour change. These included representatives from firms such as PepsiCo, Tesco, Mars and McDonald’s.
The idea was that by working with industry, change could be delivered more quickly. However, doctors leaders have insisted there is a fundamental conflict of interest in expecting businesses to take steps which could impact upon their profits.
In March 2011, Dr Nathanson and others withdrew from participating in the alcohol network, saying that pledges were not specific and the process had prioritised the views of industry.
Dr Nathanson says she is not convinced that the networks have delivered any tangible public health benefits. The food responsibility deal network has come up with putting calorie counts on signs at some fast-food restaurants, but this is not universal and it has taken years to get that far, she says.
Meanwhile, the statement also argues that health inequalities will widen if only education and nudging is used.
Last year, the Lords science and technology subcommittee inquiry into the evidence behind behavioural change initiatives concluded there was a lack of evidence surrounding the cost-effectiveness and long-term impact of such schemes. It called for further evaluation.
With time running out as large swathes of the public continue to damage their health, it remains to be seen how far the pendulum will swing between subtle methods and sharper shocks.
What does the BMA want to happen on public health priorities?
- Cut salt, sugar and hydrogenated fats added to pre-prepared foods
- Ban advertising of junk food and drink to children
- Mandatory traffic-light labelling on food packaging
- Appropriate physical education in schools
- Stop selling off school playing fields
- More cycle paths and networks.
- Standardised packaging for all tobacco products
- Strengthen nicotine regulation in UK
- Cut number of tobacco outlets
- Further reduce marketing
- Limit pro-smoking imagery in entertainment media
- Help smokers to quit with more smoking cessation services.
- Introduce minimum pricing
- Improve labelling to show alcohol content and daily guidelines
- Compulsory levy on industry to fund independent research
- Increase and ring-fence funding for specialist treatment services
- Increase and rationalise tax to ensure it is proportional to alcoholic content
- Cut licensing hours
- Ensure that licensing legislation is strictly enforced.