Beyond Parody

As the dust settles on the general election result we can see that a period of great political uncertainty lies ahead. But in an uncertain world, the one thing you can rely on is that the public health racket will carry on regardless with their efforts to achieve world domination!

It has become a cliché to say that “alcohol has become the new tobacco” – that the methods used to damn tobacco smoking, and to control the advertising and availability of tobacco products – has provided a template for the same project in respect of beverage alcohol. But the ambitions of ‘public health’ don’t stop there. Whilst remorselessly campaigning for minimum unit pricing as a panacea for all alcohol-related problems, people variously described in the media as ‘doctors’ or ‘experts’ have called for a minimum price on sweets to cut obesity in children. It’s a magic formula you see. As Professor Sir Ian Gilmore of the Alcohol Health Alliance once put it “price changes culture”.

According to the Daily Mail:

•         Doctors have called for a minimum price on sweets to tackle the nation's obesity crisis 

•          The move would raise the price of the most sugar-laden snacks in a bid to deter children

•         Experts believe raising prices of sweets and chocolate is one of the best ways to tackle the problem

All this harks back to what ‘public health’ regards as a watering down of the obesity strategy of the Conservative Government, and represents a further attempt to build on the ‘sugar tax’ on fizzy drinks. It also fits into a wider ‘public health’ agenda to leverage government control on all the “industries of addiction”, which in their view drive ill-health globally, and to force the food industry into a mass reformulation of products. The fight to eliminate sugar and salt from our diet – essentially to render food tasteless – is well and truly on!

The notion of a minimum price for sweets seems to me beyond parody – not least because it is based on a false premise that the numbers of children who are overweight or obese is dramatically increasing, when essentially it has flat-lined. The headlines about rising childhood obesity have one fatal flaw: they aren’t true.

The official figures show that about one in five year 6 children are obese. This figure hasn’t changed significantly in five years: 2010/11: 19%; 2011/12: 19.2%; 2012/13: 18.9%; 2013/14: 19.1% and 2014/15: 19.1% (all official HSCIC figures). Now, it isn’t good that one in five kids are obese at year 6, but to frame it as a “growing crisis” is simply not true. Data from the Health Survey for England going back to 1995 show that rates of obesity among kids aged two to 10 peaked in 2005 and have fallen by a third in the last decade. Among 11 – 15 year-olds, the peak arrived in 2004 and rates have since fallen by a fifth (Diet & Fitness, C. Snowdon).

The number of adults overweight or obese has likewise flatlined at around 60% of the population. Nearly always ‘overweight’ and ‘obese’ get combined in order to make the number more scary, but paradoxically overweight people have greater longevity than people of a healthy weight or obese people; suggesting some problems with the definitions!

It shouldn’t surprise anyone that the proposal for a minimum price for sweets comes from Scottish doctors – Scotland is the home of minimum pricing and the SNP government is completely in thrall to temperance thinking and more generally to the world view of those who see the food and drink industries as conspiracies that have addicting the population to alcohol/sugar/salt at the heart of their commercial strategies. We’re back to one-dimensional capitalist bad guys.

The proposition for minimum pricing for sweets comes from the Lothian division of the BMA and is proposed as a motion to be heard at the BMA’s Representative Meeting to held later this month. It states:

“This meeting believes in line with rising obesity and increasing burden of type 2 diabetes on the NHS that the government tax sugar and bring in minimum pricing for all confectionary products and sweets.'

The BMA's Agenda Committee has also tabled a similar motion. Doctors will vote on the motions at the meeting, which takes place in Bournemouth, and if approved could become BMA policy.

Beyond parody? You couldn’t make it up.

THE ALCOHOL HARM PARADOX

A new study of drinking in Scotland published in the medical journal The Lancet Public Health takes a fresh look at an old subject. The so-called ‘alcohol harm paradox’ basically states that people living in socially deprived areas are more likely to suffer alcohol-related harms than those living in more affluent circumstances – even though the more affluent actually drink more alcohol. Why anyone with the smallest understanding of the complexities of health inequalities or drinking cultures should find this paradoxical I really don’t know, but apparently, some do.

So, what added value does yet another trot round this well-worn path give us? Well, temperance organisations the Institute for Alcohol Studies (IAS) and the UK Alcohol Health alliance (AHA) both like this piece of research because it concludes that targeting policies and intervention at heavy drinkers in low socio-economic groups with a view to reducing their consumption is unlikely to be as effective as whole population measures. Yes, you guessed it, minimum unit pricing, reductions in alcohol availability and advertising and marketing.

Study co-author Dr Elise Whitley said: “Heavier drinking is associated with greater alcohol-related harm in all individuals. However, our study suggests that the harm is greater in those living in poorer areas or who have a lower income, fewer qualifications or a manual occupation.”

Responding to the study, Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, said: “The findings in this study are worrying if not altogether surprising. It is clear that the way alcohol is being sold and promoted in Scotland and elsewhere in the UK is harming some of the most vulnerable people in society.”

Now conceding, as the study does, that the poor are likely to suffer more ill-health as a result of other factors associated with poverty – lifestyle, diet, and so forth, it is something of a stretch to reach the conclusion that the alcohol harm paradox is all the fault of how Big alcohol markets its products! In the introduction to this study, the authors make this, rather telling, observation:

“Efforts to target alcohol consumption by socio-economic status are unlikely to be successful in reducing health inequalities, unless drinking cultures in the most disadvantaged populations differ systematically from societal norms. Interventions seeking to reduce consumption across the whole population are more likely to result in greater reductions in absolute health inequalities than previously thought.”

The key assumption here is that targeting alcohol consumption by socio-economic group is unlikely to be successful “unless drinking cultures in the most disadvantaged populations differ systematically from societal norms.” Societal norms? The main societal norm is moderate drinking. But we don’t have one single drinking culture in the UK, or even in Scotland, and I for one believe that differing drinking cultures are the real drivers of alcohol-related harms.

I believe that once we understand the central importance of culture to drinking behaviour then we can begin to untangle the reasons why people drink at different levels, sometimes harmfully, in different ways and for different reasons. Let’s start off with a rough-and-ready definition of culture: “Culture is what me and you get up to round here.” Put more formally, sociologists refer to “cultures of intoxication” which is an understanding that places alcohol use into a modern context - one that recognises the plurality of drinking cultures and sub-cultures; that acknowledges that in addition to alcohol a whole generation of people now find it socially acceptable to take a range of other, illegal, intoxicants as part of a night-out. And that specific cultures of intoxication drive not only the quantity people drink, but the speed at which they drink it; whether they drink with food or on an empty stomach; what else they take; and whether they drink in safe places and social surroundings or dodgy bars and late-night party-pads.

When we look at the way in which alcohol health-harms are socially distributed we can clearly see the impact of the plurality of cultures of intoxication and the simplistic nature of the whole population approach. In 2010 the North West Public Health Observatory published a series of reports that break down drinking patterns and alcohol problems into different population segments.

By using the UK Government’s Index of Multiple Deprivation, the reports showed that people living in the poorest fifth of the population are five-and-a-half times more likely to find themselves in hospital with ‘alcohol-specific mental and behavioural disorders’ than those living in the richest fifth. People living in the poorest tenth are seven-and-a-half times more likely to end up in hospital because of alcohol than those in the richest tenth. People living in social housing are eight-and-a-half times more likely to have an alcohol-related disorder than a ‘career professional’; and those classified as ‘vulnerable disadvantaged’ register 13 times more alcohol-related hospital admissions than ‘affluent families’.

Social class, prosperity or the lack of it, and a range of other social circumstances determine what your drinking culture is likely to be, and the extent to which your life revolves around a culture of intoxication. But rather than calling for policies that tackle endemic poverty, ideologically motivated academics prefer to interpret data in a way that supports their preconceived whole population measures. All roads lead to minimum pricing!

ALCOHOL POLICY IN A ONE-PARTY STATE

It seems to me entirely possible that this general election will mark the demise of the Labour Party as a party of government. It could be reduced to the status of a left-wing protest group that is more concerned with its own ideological purity than with making the compromises necessary to widen its electoral appeal and actually win elections. This is a development which should concern all who believe that representative democracy requires a choice between two or more political parties that are at least electable, even if you don’t necessarily agree with their policy approach.

Since the financial crisis of 2008 the central political question for Europe has been: Will the political centre hold? Or will we see populist or extremist parties gaining power because they have fooled their electorates into believing there can be simple solutions to complex problems. The election of Macron in France and defeat of Le Pen; the defeat of Geert Wilders in Holland and, I anticipate, the re-election of Angela Merkel in Germany does suggest that it will hold.

But in all these countries there are credible political parties of centre-right and centre-left to the parties that have actually won. Not so in the UK. The Liberal Democrats appear not to be making a breakthrough by attracting the votes of sensible Labour supporters that want to vote for a centre-left party as opposed to a bunch of Trots. So, what we could see after the election is not just a landslide Tory victory, but a Tory government whose only effective political opposition may come from within its own ranks.

Meanwhile, what does Labour have to say about pubs and alcohol? For starters, Diane Abbott, Labour’s shadow Home Secretary is a dedicated anti-alcohol zealot, but all of a sudden Labour seems to have woken up to the scale of pub closures by pledging “We will set up a National Review of Local Pubs to examine the causes for the large-scale demise of pubs.” They might start by looking at their own 2005 manifesto which promised to legislate to ensure that all enclosed public places and workplaces – other than licensed premises – would be smoke-free. The exception would be restaurants and food-led pubs that would be smoke-free, but wet-led pubs and members’ clubs would have a choice. Labour rebels conspired to ensure that those exemptions were not in the legislation and we ended-up with the smoking ban - which has done a huge amount to damage pubs and beer sales. Jeremy Corbyn voted for these measures and is not in any position to preside over an objective review of why over 11,000 pubs closed between 2007 and 2013 – even in the remotely unlikely event that Labour is elected.

So, what might alcohol policy look like after the election in what will effectively be an elective dictatorship? Historically, the Conservatives were generally much more sympathetic to the trade in beverage alcohol, and did much to defend its interests from the 1870s onwards; and it was thanks to the opposition of Conservative peers in the House of Lords that the attempt by the Liberal government of Herbert Asquith to close 30,000 of the nation’s 96,000 pubs over 14 years, and nationalise the rest was defeated.

The Conservative-led coalition government, formed after the 2010 general election, promised some radical supply-side changes to the way in which the sale of alcohol was regulated: a review of alcohol policy which led to the introduction of EMAROs and the Late Night Levy; banning below-cost sales of alcohol; and tackling underage drinking. In 2012 the Conservatives were minded to go further and to introduce minimum unit pricing – a policy that had long been championed by the health lobby and that had passed into law in Scotland, albeit not been implemented due to legal challenge.

However, attempts at introducing EMAROs have been thwarted by concerted and unified opposition from the trade and the late night levy has so far been introduced by only eight local authorities, and moreover, the policy has been panned by the recent House of Lords review of the Licensing Act 2003.

Then we saw what the health lobby regarded as a great betrayal: minimum pricing was abandoned by the Conservative-led coalition government, or at least kicked into the long grass for lack of evidence regarding its efficacy, and with the convenient excuse that we should in any event await the outcome of the legal challenge to minimum pricing in Scotland that will be resolved by our own Supreme Court at a hearing on July 24-25 this year. Minimum pricing was also contrary to the Conservative ideological opposition to anything that compromised free markets, and faced considerable opposition within Conservative ranks for that reason, as well as the more pragmatic opposition that arose out of the need to avoid measures that raised prices and gave ammunition to Labour charges of a “cost of living crisis.”

We can but hope that the traditional Conservative opposition to price fixing and market regulation, combined with the huge amount of work to implement Brexit, will mean that alcohol policy in the new one-party state is something they just won’t find time for.

LORDS AND COMMONERS

Last week saw the publication of the House of Lords Select Committee Review of the Licensing Act 2003 (LA2003). It also saw the CAMRA Members’ Weekend in Bournemouth on Saturday 8^th April, at which I was a speaker.

Having read the HoL Review I was struck by how most, if not all, of its proposals for change reflected the fact that the Committee had listened to a wide range of views and was thereby able to arrive at what were, for the most part, a balanced set of recommendations that avoided siding with some of the more swivel-eyed members of the ‘public health’ community, who of course wanted a public health licensing objective. In that regard it contrasts most sharply with the way in which the Chief Medical Officers’ of Health revised drinking guidelines were compiled – by a who’s who of the modern neo-temperance movement.

The call for the government to abandon the Late Night Levy and Early Morning Alcohol Restriction Orders was also very welcome as was their Lordships acceptance of the value of local partnership working – particularly Business Improvement Districts. Council members sitting on local authority licensing committees should be trained, their Lordships said. Here! Here!

I did however find it a little curious that the release of the Review suggested that the committee members found the Licensing Act 2003 to be “fundamentally flawed”. I cannot agree – for the most part I think it works well and I think it is regrettable that modifications to it have rowed back from its original radicalism in order to accommodate those who were horrified at what was perceived back in 2003 as a liberalising Act. The crux of their Lordships’ concern is the view that it was a mistake to create new ‘licensing committees’ of council members when a system of planning committees already exists.

No one could argue with the idea that licensing and planning should work closely together – that is why the local planning department is a ‘responsible authority’ under the LA2003, and must be notified of any new licence application or application for a major variation of an existing licence. But to combine licensing and planning? In the 10 years since the LA2003 came in to force I have never heard that suggestion made. So, a little ‘left field’ it seems to me – not least because the sale of alcohol will continue to have its own laws and regulations and its own legal precedents. The Committee’s recommendation in this regard deserves to be studied carefully, but at first blush this seems a curious proposal.

So we know what the great and the good think of our licensing system, and perhaps by inference of our drinking culture. But what does the ordinary drinker think? Well, on Saturday 8^th April I had the privilege of addressing around a thousand CAMRA members at their annual shindig down in Bournemouth. Sometimes the alcohol and society debate seems be conducted between opposing groups consisting of industry players or health lobby fanatics; groups united only by their mutual loathing. The title of my talk ‘The Modern Anti-Alcohol Movement – Temperance Without the Hymns’ does indeed reflect this divide. So I was curious to hear the questions and comments from an audience of informed and influential consumers.

I argued that every society from the most ancient to the most modern has had at least one legally or socially accepted intoxicant – something that changes mood, social interaction or consciousness. Ours of course is beverage alcohol. But the widespread use of intoxicants throughout different societies and historical epochs suggests to me that the need to change your mood or consciousness is a fundamental human need. As such, in a society like ours, access to beverage alcohol within a legal framework becomes nothing less than a human right and must be defended.

Of course no one in the modern, ant-alcohol ‘public health’ community would openly call for the outright legal prohibition of alcohol, they know such suggestions would be ridiculed. But ‘public health’ harbours the same prohibitionist ambition as their clerical forbears, albeit prohibition by stealth. They call for a population-wide reduction in alcohol consumption, but will never tell you to what level. Thus the direction of travel is obvious, but the destination is never mentioned. A bit like Brexit!

I think the drinkers’ voice needs to be heard in this debate. I listened to that voice at CAMRA, down in Bournemouth, and what a passionate voice it was! I was able to announce a new, CAMRA-inspired initiative – the formation of the ‘Drinkers’ Voice’. This organisation, once set up, will articulate the voice of the consumer – the “ordinary drinker” – in the alcohol-society debate. It is time that voice was heard in the public square. Watch this space.

THE SHAPE OF THINGS TO COME

As I write we await the outcome of the House of Lords investigation into the workings of the Licensing Act 2003. One of the things they were considering was whether ‘protecting and promoting public health’ should be added as a fifth licensing objective. I don’t know what their Lordships will conclude on this issue, although rumour has it they will not recommend this, but that hasn’t stopped Public Health England (PHE) from publishing ‘Public Health and Licensing Guidance’, subtitled ‘A simple guide for responding to applications as a responsible authority.’ Directors of public health have been included as Responsible Authorities under the Licensing Act since 2013, so many in the ‘public health’ community may consider this guidance long overdue.

So, we have a guidance document consisting of some 27 sides of A4 which explains to local public health practitioners how to object to a licence application based on one or more of the four existing licensing objectives, notwithstanding that ‘public health’ isn’t one of them! As the document explains on page 7:

“Although the licensing objectives do not include a health objective, there is a health and wellbeing angle to each of them. It is also possible for a Director of Public Health to have an independent and supporting role as a responsible authority. The above provide some examples that do not cover the full range of opportunities for public health involvement, but outline some composite examples of actions that have been taken by responsible authorities that directly draw on the connection of health to the existing objectives.”

The reference in the second sentence of the paragraph quoted to “the above” refers to examples regarding how a director of public health might smuggle in a health objection as an objection based on, say, public nuisance:

“…a representation requesting noise related conditions or objecting to an extension of hours for an application using evidence on the health impacts that sleep deficit can have on the local residents.”

Or evidence from:

“last drinks survey data, A&E and ambulance data indicating a high number of alcohol poisoning cases coming from a particular premises, or from within its near vicinity.”

You can see right here the difficulty in relating general evidence to a particular application for a premises that hasn’t yet opened or had its hours extended. You can also see that the implicit assumption of PHE is that local directors of public health should be looking for reasons to object. In fact, the guidance document proposes a traffic light system based on ‘red’ and ‘green’ applications. A ‘red’ application – one that would need to be looked at with a view to making a representation – would include any application for:

·       Off licences

·       Any application for hours after midnight or before 8 am

·       Anything within a cumulative impact policy

·       Night clubs

·       Premises reviews by other responsible authorities

·       High volume or ‘vertical drinking’ establishments.

Whereas a ‘green’ application – one that would be of low concern to public health – might include applications for:

·       Restaurants before midnight

·       Food venue before midnight 

·       Theatre Bars before midnight 

·       Changes to the Designated Premises Supervisor

·       Temporary Event Notices (TENs) as the Director of Public Health does not have the remit to respond to these.

Clearly these benighted nannies don’t want the citizenry up and drinking after midnight – and even then only in posh eateries or theatre bars – but preferably not at all!

When your starting point is that it’s the availability of alcohol that makes people drink it, and that population levels of consumption drive alcohol harm, then it should come as no surprise that the starting point for directors of public health in relation to any application for a new licence is “how can we stop it?” the purpose of the traffic light system is merely to sift out applications where an objection would stand little chance of success.

I hope that the House of Lords and the government will not introduce a health licensing objective – much less a ‘health and wellbeing’ objective – and if you read the PHE guidance document you will see how often that word is insinuated into the text. The system we have works well as it is, and scarce resources need to be directed at those who really are drinking at unhealthy and damaging levels, not at making mischief through gratuitous objections to individual licence applications based on an objection to beverage alcohol as such, rather than any real local concerns.

Paul Chase

The shape of things to come by Paul Chase

As I write we await the outcome of the House of Lords investigation into the workings of the Licensing Act 2003. One of the things it was considering was whether “protecting and promoting public health” should be added as a fifth licensing objective. I don’t know what their Lordships will conclude on this issue, although rumour has it they will not recommend this. But that hasn’t stopped Public Health England (PHE) from publishing “Public Health and Licensing Guidance”, subtitled “A simple guide for responding to applications as a responsible authority”. Directors of public health have been included as responsible authorities under the Licensing Act since 2013, so many in the “public health” community may consider this guidance long overdue.

So, we have a guidance document consisting of some 27 sides of A4 that explains to local public health practitioners how to object to a licence application based on one or more of the four existing licensing objectives, notwithstanding that “public health” isn’t one of them! As the document explains on page seven: “Although the licensing objectives do not include a health objective, there is a health and well-being angle to each of them. It is also possible for a director of public health to have an independent and supporting role as a responsible authority. The above provide some examples that do not cover the full range of opportunities for public health involvement, but outline some composite examples of actions that have been taken by responsible authorities that directly draw on the connection of health to the existing objectives.”

The reference in the second sentence of the paragraph quoted to “the above” refers to examples regarding how a director of public health might smuggle in a health objection as an objection based on, say, public nuisance: “…a representation requesting noise-related conditions or objecting to an extension of hours for an application using evidence on the health impacts that sleep deficit can have on the local residents.” Or evidence from: “...last drinks survey data, A&E and ambulance data indicating a high number of alcohol poisoning cases coming from a particular premises, or from within its near vicinity.”

You can see right here the difficulty in relating general evidence to a particular application for a premises that hasn’t yet opened or had its hours extended. You can also see the implicit assumption of PHE is local directors of public health should be looking for reasons to object. In fact, the guidance document proposes a traffic light system based on “red” and “green” applications. A “red” application – one that would need to be looked at with a view to making a representation – would include any application for off-licences, any application for hours after midnight or before 8am, anything within a cumulative impact policy, nightclubs, premises reviews by other responsible authorities and high volume or “vertical drinking” establishments.

Whereas a “green” application – one that would be of low concern to public health – might include applications for restaurants before midnight, food venues before midnight, theatre bars before midnight, changes to the designated premises supervisor and Temporary Event Notices as the director of public health does not have the remit to respond to these.

Clearly these benighted nannies don’t want the citizenry up and drinking after midnight – and even then only in posh eateries or theatre bars – but preferably not at all! When your starting point is it’s the availability of alcohol that makes people drink it, and that population levels of consumption drive alcohol harm, then it should come as no surprise the starting point for directors of public health in relation to any application for a new licence is “how can we stop it”? The purpose of the traffic light system is merely to sift out applications where an objection would stand little chance of success.

I hope the House of Lords and the government will not introduce a health licensing objective – much less a “health and well-being” objective – and if you read the PHE guidance document you will see how often that word is insinuated into the text. The system we have works well as it is, and scarce resources need to be directed at those who really are drinking at unhealthy and damaging levels, not at making mischief through gratuitous objections to individual licence applications based on an objection to beverage alcohol as such, rather than any real local concerns.

The hydra-headed monster by Paul Chase

I thought I would return to the fray with a new twist on an old theme – minimum unit pricing (MUP). Readers of my articles may recall the legality of a minimum unit price for alcohol is an issue that has been batted back and forth between the Scottish government and the Scotch Whisky Association (SWA) since 2012. The Scottish courts had their say (legal); it was referred to the European Court of Justice (not legal). But the ECJ left the final decision to the Scottish courts, which needed to be convinced there was no other, less trade-restrictive way of achieving the Scottish government’s health objectives in respect of alcohol if they were to conclude it was, after all, “legal” to impose a minimum price on a unit of alcohol.

They promptly did so when the Scottish government provided them with the latest research findings from the boys and girls at Sheffield University, whose modelling forms the basis of all the claims made for this measure. So, game, set and match? Well, not quite. The SWA has appealed the Scottish court’s decision to the Supreme Court in London. They have been rather busy of late considering whether the UK government has to get parliamentary approval before triggering Article 50 of the EU treaty to take us out of the European Union. But the little matter of MUP is likely to be ruled on around June this year.

Meanwhile, the authors of the Sheffield model haven’t been sitting around twiddling their thumbs. Oh no! They’ve been modelling the effect of an MUP of 50p on alcohol-related hospital admissions and deaths in Northern Ireland. A charity called Northern Ireland Chest Heart and Stroke said raising the minimum price paid for booze would save lives, lower hospital admissions and cut the costs of crime by £20m a year. Neil Johnston from the charity said: “Alcohol sold for less than 50p a unit makes up the majority of alcohol purchased by high-risk drinkers. Work by Sheffield University shows that pushing up the price of very cheap alcohol will reduce consumption of it by high-risk drinkers and bring considerable benefits. Introducing a minimum unit price of 50p is estimated to save 63 lives a year and result in almost 2,500 fewer hospital admissions.” Very impressive, but do the figures stack up? It is informative to compare Sheffield University’s predictions for Northern Ireland with its predictions for Scotland:

• How can it be that a 50p MUP saves three fewer lives each year in Scotland than in Northern Ireland, despite the fact Scotland has 3.6 million more people than Northern Ireland? And, in terms of alcohol-related hospital admissions, nearly twice as many of these are saved in Northern Ireland despite the fact Northern Ireland’s population is only a third of Scotland’s!

• It is interesting to note that MUP as a policy has been enthusiastically and uncritically supported by Scotland, Wales and Northern Ireland, whereas in England the UK government’s view has been much more sceptical. The “healthiest” agenda tends to receive much more support by governments that are relatively new, struggling for legitimacy or relevance, and for whom embracing policies that claim to improve the “health of the nation” gives them an opportunity to promote themselves as standing up for the interests of “the people” and against those of big business – in this case Big Alcohol.

It remains to be seen whether the UK Supreme Court will risk being labelled “enemies of the people” by yet again standing up for rationality and finding against MUP. In this “fake fact” world, where an appeal to prejudice is seemingly all that is needed to identify a large constituency of support that will rise up vociferously, it seems to me we need some unelected judges who aren’t afraid to tell us the truth.