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Archives for November 2010

Public health: Nanny or nudge?

Mark Easton | 17:42 UK time, Tuesday, 30 November 2010

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As Conservative health secretary and architect of England's public health strategy, Andrew Lansley treads warily along the tight-rope suspended between individual liberty and social responsibility.

Andrew Lansley

It is a divide that mirrors the ideological fault-line of British politics and has existed ever since Edwin Chadwick's 1842 Report on the Sanitary Conditions of the Labouring Population prompted Parliament to set up a General Board of Health.

Mr Lansley explains the "dilemma for government" in the foreword to today's Public Health White Paper: "it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live". (You don't have long to wait for the "but".) "But we cannot sit back while, in spite of all this, so many people are suffering such severe lifestyle-driven ill health and such acute health inequalities."

So there's plenty of "localism" and "big society" in the rhetoric of devolved power and personal responsibility. But...Mr Lansley knows that, historically, significant improvements to public health have required the catalyst of national state action and today's White Paper hedges its bets with taxes on alcohol, ring-fenced budgets, a new organisation to drive national strategies from the centre and the threat of regulation if change doesn't occur.

The health secretary draws a distinction between the "nanny state" and the "nudging state". Last summer he told doctors he is opposed to "lecturing people and telling them what to do" preferring to "harness behavioural science...nudging individuals in the right direction".

It is a contrast that's already drawn ridicule on some Conservative websites. Giving children shopping vouchers if they walk to school, one of the ideas in today's White Paper, is characterised as "more Socialist than the USSR ever was" by one right-wing blog.

Meanwhile, a left of centre site employs irony to suggest the "oppressive tyranny of colour-coded food packaging will be overthrown" by the champion of individual responsibility.

The "people power" ideology of his government might encourage Mr Lansley towards a light-touch public health strategy. But his report on England's Health and Well-Being [955.56KB PDF] today includes some big numbers which suggest an assertive preventative approach could save the tax-payer pots of money.

Here are a few of the estimated annual health costs which, it is argued, a public health strategy might help reduce:

• smoking-related illness - £2.7 billion
• alcohol-related illness - £2.7 billion
• drug-fuelled crime - £13.9 billion
• noise - £5-8 billion
• poor air quality - £9-19 billion
• working days lost to sickness absence - £13 billion (2007)
• hip fractures - £1.4 billion
• poor mental health - £77.4 billion (2003).

Nudge or nanny? Faced with the bills for all of this, one can imagine why Mr Lansley is reluctant to let go of the apron strings completely.

Will the mephedrone ban cause more drug deaths?

Mark Easton | 17:51 UK time, Tuesday, 23 November 2010

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Fascinating analysis on the Straight Statistics blog suggests that the now-banned drug mephedrone may have saved lives when it was legal.

Mephedrone

 

Professor Sheila Bird, a statistician with the Medical Research Council at Cambridge, has been trying to understand why, after steady rises, there was an unexpected but significant fall in cocaine-related deaths in the first half of 2009.

"One possible explanation," she writes, "might be that cocaine- and ecstasy- users were switching to a less dangerous drug, mephedrone, in and before this period":

"[T]he decision to make mephedrone illegal may have curtailed a notable decrease in deaths. And so closed off a pragmatic harm-reduction strategy - that of switching from illegal cocaine with its documented lethality to a legal high which avoided criminality and the criminals who deal drugs, and which might (or might not) have lower lethality than cocaine."

An article in the Lancet a couple of weeks ago also looked at the mephedrone ban and concluded that "classification of mephedrone has had a limited effect on controlling its availability and use":

"Before the introduction of the legislation, users generally obtained mephedrone via the internet. Now they buy it from street dealers, on average at double the price. We suspect that, in time, there are likely to be reductions in purity, and increases in health harms."

The findings echo warnings from the European Monitoring Centre for Drugs and Drug Addiction [190Kb PDF] over the summer.

Reviewing how the mephedrone ban might play out, a report said "control measures could create an illegal market in mephedrone with the increased risk of associated criminal activity, including organised crime".

The paper accepted that prohibition could be expected to limit the availability of mephedrone but also suggested that the ban "could impact on both the quality/purity and price".

Drug harms

When it comes to drug prohibition, arguments are being increasingly made around the risks of unintended consequences which make matters worse.

Mephedrone was classified as a Class B drug last April, a move with broad political support in the House of Commons. The decision to prohibit its sale and possession followed a report from the Advisory Council for the Misuse of Drugs which said mephedrone has similar effects to amphetamines and can cause temperature changes, heart palpitations and paranoia.

Chair of the council Professor Les Iversen said at the time: "This is not a simple, harmless party drug. Just because it is legal doesn't mean it is safe."

However, an editorial in the Lancet following the decision said the ACMD "did not have sufficient evidence to judge the harms caused by this drug class", adding that "politics has been allowed to contaminate scientific processes and the advice that underpins policy".

Whitehall spending: Information overload

Mark Easton | 13:15 UK time, Friday, 19 November 2010

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"Come on. Unleash hell!" The foul-mouthed political schemer Malcolm Tucker from TV satire The Thick of It once responded to a crisis by demanding that officials release huge amounts of government data. "Stats. Percentages. International comparisons. Information. E-mail them... wads of information."

Too much information

When a helpful source in the Cabinet Office forwarded me the enormous files of data on Whitehall spending publicly released today, I stared at page after page of numbers and realised what is meant by the phrase "information overload".

How the solitary look-outs in David Cameron's "army of armchair auditors" are supposed to spot waste and to replace the professional quango scrutineers currently awaiting their P45s is a very real question.

Nearly 200,000 lines of data listing the details behind £80 billion of government expenditure is both intriguing and daunting. But to even begin to make any sense of it, I needed expert help.

With just a few days before today's publication, savvy colleagues worked day and night cleaning, sorting and crunching the data - the kind of effort unavailable to most households. Indeed, my rather outdated spreadsheet software was simply not powerful enough to open the Whitehall master file we built to get an overview of state spending.

Once the initial work had been done, I dived into the figures to see what pearls lay hidden in the dark mud of government spending.

I think it is interesting to note that Prince Charles received two payments from the government this summer - one for £667,000 covered the rent for Dartmoor prison and the other for £677,000 was from the Army, presumably so they can drive their tanks on his land in Cornwall.

Is that good value? Could a better deal be negotiated? Is it right that a Colonel-in-Chief and Royal Colonel of many Army regiments should expect such payment?

The data poses more questions than answers.

I can now tell you that the Treasury and the tax office between them paid £123,000 for copies of the Financial Times this summer. Sounds a lot of pink. But is it money well spent?

The Government Equalities Office spent £4,846 bringing a Swedish radical feminist over for a conference. The government car service received payments totalling £1.5m in the first five months of the coalition including £123,000 from the Department of energy and Climate Change for "Ministerial support". JobCentre Plus spends more than £200,000 a month on hotels. Should I be shocked?

Among the smaller items I spotted were:
  • £1,265.22 to diamond dealers De Beers
  • £650 to chic handbag designer Lulu Guinness
  • £1,500 to Estelle Earpiercing for "scheme management"
  • £1,000 to a company which makes jewel-encrusted dog collars

The last one seemed so bizarre I tracked the firm down to its headquarters in the Netherlands. The money apparently was from the Department for Business, a grant to help Diamond Dogs sell their wares in New York. If the trip drummed up lots of new orders for their Koh-i-noor pet accessories, it might have been a very sensible investment. The company pays tax in Britain, after all.

Not everything is transparent in the files. The Department for Business spent a total of £241,000 on dozens of items including hotels and air-fares but described only as "personal expense, name withheld".

I spotted a number of payments from the Ministry of Justice to eight individuals who turned out to be the victims of miscarriages of justice. In total the payments came to £2.2m: no small change and, I would have thought, just the kind of detail required to hold the executive to account.

Among the recipients were Paul Henderson, former Managing Director of the arms supplier Matrix Churchill which was caught up in the arms-to-Iraq scandal of the mid-1990s that engulfed John Major's government. He received £583,810 in June this year.

Another of the eight was also linked to the arms-to-Iraq affair. Paul Grecian, former head of the military supplier Ordtec, received a payment of £627,734 in June this year.

I rang the MoJ for an explanation only to be told that they have withdrawn this section from the online data drop. But having been supplied with this information by the government, I can reveal the names of the other recipients of MoJ cash this summer.

Terence Pinfold, now 77 years old, is a convicted robber who subsequently spent years in prison for "procuring a murder". It later emerged he had been stitched up for that crime and this summer Justice Secretary Ken Clarke sent him a cheque for £328,327. Amanda Jenkinson, a former nurse from Nottinghamshire, was wrongly convicted of causing GBH with intent by interfering with a patient's ventilator in 1993. She has just received a cheque for £400,000. Joseph Kassar was wrongly convicted of smuggling hundreds of kilos of cocaine into Britain in 1992, drugs hidden inside lead ingots. He has now received compensation worth £100,000. In other miscarriage payments, Sean Hodgson received £100,000; Hussain Shah received £100,000; Christopher Finch received £25,000.

The fact that this detail has now been withdrawn from the online data illustrates the limits and complexity of the transparency idea.

The Ministry of Defence rang the BBC to say that within the pre-released files sent to journalists and developers was a line about payments relating to Libya that we should ignore. There will no doubt be many more howls of anguish from officials as people scour the numbers.

What will happen now? Francis Maude has admitted that "the data is not as good as it should or will be", hinting that we will get even more detail and context. Equally, there will be voices suggesting the whole idea is far too dangerous and should be scaled back.

The real danger, I think, is that people mistake transparency for accountability.

John Lewis model for government

Mark Easton | 11:39 UK time, Wednesday, 17 November 2010

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There is a long and hallowed tradition in the public sector for staff to complain that they could deliver services so much better if only those awful meddling managers would just let them get on with the job. Well, the government is now saying: "We believe you. Here are the keys. You drive."

Francis Maude

 

Ministerial zeal in looking to shrink the state and promote the Big Society has led them to consider a significant expansion of what might be called the John Lewis model for government business. Indeed, senior directors from the employee-owned department store have helped shape Whitehall thinking.

In a speech today, the minister in the Cabinet Office Francis Maude says he "plans to set public sector workers free, to let them take control of their organisations" with encouragement to set-up co-operatives or mutuals.

Echoing the right-to-buy model for council homes under Margaret Thatcher, state employees will be offered the "right-to-run" or the "right-to-provide" the services they currently deliver. Mr Maude believes that "employee ownership in public services has the potential to be transformative".

The government is determined to prove the cynics wrong, to demonstrate they are serious when they say they are giving up power and handing it to the people.

In this case, the recipients of people power will be public sector workers and, as a sign of commitment, Mr Maude says that Whitehall will lead by example with a new right "for civil servants directly employed by departments to form mutuals".

As the minister admits, this is "an incredibly complex area" and "the right would not be allowed to compromise the wider efficiency and policy objectives" of government.

It would be a mistake, though, if people shrugged and assumed the shift of control will never happen: Education Secretary Michael Gove is already looking at how staff co-operatives could run youth services in England; there are plans to let Sure Start centres "go mutual"; proposals that probation services and prisons be owned by the people who work in them. "This right will be as far reaching as possible," Mr Maude insists.

Ministers have been persuaded that co-operatives can reduce absenteeism, improve performance management, encourage innovation, and increase productivity.

"John Lewis's staff absence levels are half of the average in the retail sector. Staff turnover is lower when employees feel they can influence the way their organisation works, and productivity can be up to 19% higher in organisations where staff feel they have a stake in success."

All well and good, but there are a host of practical challenges alongside some critics' ideological concerns. The traditional hierarchical structure runs parallel to the conventional system of accountability with the Minister sitting at the top of the pile. When "ownership" of state services has been handed over to hundreds of co-operatives, it becomes less obvious where responsibility for the quality of those services will rest.

Although Mr Maude insists there has been a wave of interest in setting up mutuals, it is hard to imagine millions of public sector workers wanting to take on the extra responsibilities. What is in it for them? There will be the Rooney/Garland thrill of asking "Why don't we do the show right here?" and pride and satisfaction in delivering high quality and efficient services.

However, any co-op-style business plan must save money and the employees are unlikely to see any significant improvement in pay or conditions as a result. In fact, they may find themselves landed with a whole range of legal obligations and facing a maze of bureaucratic obstacles. Mr Maude already recognises that climbing into the driving seat will be a struggle.

"I want to reassure public sector workers that their legitimate desire to run their own services will not be frustrated by those who attempt to stand in their way. I understand that some public sector organisations may have legitimate operational reasons for needing to block or slow requests. But we will not tolerate bureaucratic attitudes and processes intended to demoralise the entrepreneurial employees who wish to pursue this path."

We shall see.

PS I notice that the Institute of Government, advisors to Westminster politicians and Whitehall civil servants, has sounded a note of warning on mutuals. Have a gander at former Downing Street insider Adrian Brown’s blog on the subject.

Work, benefits and ethnicity

Mark Easton | 06:30 UK time, Friday, 12 November 2010

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As the government looks to squeeze the welfare bill, some interesting data published this week looks at the relationship between ethnicity and welfare.

While those of Indian origin, for instance, get 8% of their income from the state in the form of benefits, state pension and tax credits, those describing their ethnicity as Pakistani or Bangladeshi receive 29% of their income in various forms of state aid.

White citizens receive 15% of their income from social security, tax credits and the state pension. People of Chinese ethnicity get 10%. Those of mixed ethnicity get 13%, while those from black ethnic groups receive between 17% and 18%.

The variation partly reflects the fact that immigrant populations tend to be younger than the white population and are therefore less likely to receive a state pension or disability benefits.

Income

Turning the concept on its head, it is interesting to note that while white citizens receive 73% of their income from wages, salaries and self-employed income, the figure is higher among every other ethnic group with the exception of Pakistani/Bangladeshi.

People of mixed ethnicity and Asian British get 79% of their income from work. The figure for those of Indian ethnicity is 83%, black/black British 76%, black Caribbean 75%, black non-Caribbean 77% and Chinese 78%.

Again, the relative youth of immigrant communities is a factor here. A lower proportion of non-white citizens will be over the retirement age.

Is Britain looking for a fight?

Mark Easton | 12:59 UK time, Thursday, 11 November 2010

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Britain's reputation for dealing with the challenge of austerity is summed up by that now-ubiquitous poster echoing our legendary wartime spirit: Keep Calm and Carry On.

Keep Calm and Carry On poster

 

Yesterday's feisty protests made headlines around the world in part because the pictures of British bobbies holding the line against wild-eyed troublemakers are at odds with the accepted wisdom about the UK's response to the financial squeeze.

The Washington Post notes today how "many observers were surprised by the violence in central London because the British public had thus far been more tolerant of cuts than their counterparts in nations such as France and Greece".

A few weeks ago in the same newspaper, the columnist Anne Applebaum compared the response to spending cuts in Paris and London:

"In an age of supposed globalization, when we are all allegedly becoming more alike - listening to the same American music, buying the same Chinese products - it is astonishing how absolutely British the British remain and how thoroughly French are the French. Both countries need to change state spending patterns and cut budgets to cope with economic crisis. Faced with this challenge, the British have stiffened their upper lips - while the French have taken to the streets."

Yesterday's violence will have blurred that distinction a bit, but the essential truth remains: Britain appears to be trying to stay calm and to carry on. Despite the mindless aggression of a small group of "protest junkies", the country does not seem to be in the mood to fight.

Demonstrators clash with police

 

Why is that? After all, the emotional drama of an old-fashioned student demo turning ugly provided pictures which shunted the story of a protest march against tuition fees from a few paragraphs on page 17 to the front page of every paper.

In that sense, violence works: questions in Parliament; media debate; water-cooler conversations. A few broken windows have prompted tens of thousands of words on the fairness of university funding proposals (as well as many more "why-oh-why?" pieces about angry young men).

Partly, I think it is because we are not a demonstrative people. Yes, there are groups of semi-professional trouble-makers: football hooligans, anti-capitalists, anarchists and racists among others up for a ruck. The British mainstream doesn't, by and large, "take to the streets".

Anne Applebaum, reflecting on the protests which greeted the spending review last month, noted how the protestors "looked suspiciously fringe" and "many waved signs advertising the Socialist Worker, a newspaper nobody reads".

There is real anger about the cuts, deep anxiety too. But there is, as yet, no obvious focus for that opposition. The influence of trade unions and political parties is diminishing; our society has become more individualistic than collective.

Opposition to the Iraq War cut across class, age and creed. The huge marches which snaked through London under "Stop the War Coalition" banners had a simple and clear aim. But the cuts to state services are by their nature more diffuse and public attitudes on the need to make savings seem to have become broadly accepting.

David Cameron will not have been surprised by yesterday's violence, though. He knows that as the state withdraws, pain and anger will be revealed. Some will try to exploit the moment looking for a punch-up. But his message to ministers and senior civil servants is clear: hold your nerve.

In a speech to Whitehall mandarins in July, the prime minister told them that he did not want them to try and protect the quality of public services after the cuts:

"Let me be very clear: I do not want you and your colleagues to think your role is to guarantee the outcomes we want to see in our public services - or to directly intervene in organisations to try and improve their performance."

Just imagine the reaction of public officials who had dedicated their lives to making state services more effective. The new boss had come in and told them that that wasn't the point anymore.

So, when the cuts really start to bite, people will respond the way they have for generations. They will demand the government "do something". They may march on Downing Street demanding change. A few hotheads may attach themselves to the demos in the hope of a fight.

But Whitehall is under instruction to be deaf to their pleas. It is no longer the job to step in with some scheme to protect people from the cuts, however cross they are.

As David Cameron told them:

"If you want to set targets, set new controls, impose new rules - don't bother, because you're likely to get the red light."

There will be lots of protests over the next few years. Some will get a bit fruity. But, at the moment, I struggle to see how opposition to the age of austerity can move from small-scale demos to the kind of national movement that brings millions onto the streets of France or Greece.

Mixed message on drugs and alcohol?

Mark Easton | 17:44 UK time, Monday, 1 November 2010

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It took the government some time to come up with a statement in response to today’s Lancet article on the relative harms from alcohol and illicit drugs. Reading it, one can see different departmental hands at work: the tensions that exist between Home Office and Department of Health seem to shout at me from between the lines. Have a look and see if you agree:

A government spokesperson said:
"The Government believes the drug classification system works, but we do not think it is a suitable mechanism for regulating legal substances such as alcohol and tobacco which are controlled through other means."
"More than half of people in England drink once a week or less, but almost 10 million adults drink too much, with potentially lethal health consequences, as well as costing the NHS around £2.7bn a year."
"That's why the Government will be bringing forward tough action to tackle problem drinking, including stopping supermarkets from selling alcohol below cost and introducing a tougher licensing regime, and will publish a drugs strategy in the coming months."
"In future, communities will also have the power and the budget to put in place services that work for them locally. The Government wants to see doctors working with local authorities to have a bigger impact on people's health."

The role of the state in dealing with the harms from, say, alcohol and ecstasy look different from the Home Secretary's office and the Health Secretary's Public Health Ministry. The question of whether drugs strategy should be a matter for the criminal justice system or the national health service remains unresolved.

Drugs debate hots up

Mark Easton | 00:00 UK time, Monday, 1 November 2010

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Today sees the publication of two pieces of scientific research that threaten to destabilise further the orthodoxy on drug policy in Britain.

One says our classification system of illicit substances is basically hopeless. The other says that decriminalising illicit drugs may be quite a good idea.

Tomorrow, of course, Californians vote on whether to legalise marijuana.

It is almost exactly a year since this blog revealed that Professor David Nutt had been sacked from his position as chair of the Advisory Council on the Misuse of Drugs (ACMD) by the then Home Secretary Alan Johnson.

His dismissal, for allegedly "campaigning" against government drugs policy, prompted a show-down between scientists and ministers which saw a further seven council members resign.

A number of those experts went on to found their own Independent Scientific Committee on Drugs, operating, as they put it, "free from the constraints of policy-making and politics".

Today an ISCD paper entitled Drug Harms in the UK: A Multicriteria Decision Analysis is published in the Lancet. Its title may not be overly exciting but its findings are bound to cause an almighty stir.

The headline is that, on the basis of new analysis assessing the relative harms of different legal and illegal drugs to the user and wider society, "alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack (54) in second and third places".

Graph showing drugs ordered by their overall harm scores

The professor helped produce an earlier version of what is called a "harm matrix" of drugs. As today's paper puts it, that "provoked major interest and public debate, although it raised concerns about the choice of the nine criteria and the absence of any differential weighting of them".

Graph showing drugs classification

So the ISCD has returned to the fray with what is called multi-criteria decision analysis.

This approach includes 16 criteria including a drug's affects on users' physical and mental health, social harms including crime, "family adversities" and environmental damage, economic costs and "international damage".

The scientists, based on their expert knowledge, score a substance on each category from zero to 100.

Graph showing overall weighted scores for each of the drugs

The problem remains, however, of how much weight to give each of these categories.

"The weighting process is necessarily based on judgement, so it is best done by a group of experts working to consensus," the report authors say.

"Extensive sensitivity analyses on the weights showed that this model is very stable; large changes, or combinations of modest changes, are needed to drive substantial shifts in the overall rankings of the drugs."

What emerges is a ranking of drugs at complete odds with the official Home Office classification system.

The fact that alcohol emerges as the most harmful drug leads the authors to conclude that "aggressively targeting alcohol harms is a valid and necessary public health strategy" but its place at the head of the table also suggests a legal status in stark contrast to the much less harmful effect of Class A drugs including ecstasy and LSD.

It is also notable that cocaine and tobacco emerge with very similar rankings in terms of harm.

"Our findings lend support to previous work in the UK and the Netherlands, confirming that the present drug classification systems have little relation to the evidence of harm," they say.

Also published today is another peer-reviewed paper assessing the effect of Portugal's decision to decriminalise all illicit drugs. You may recall I visited the country last year to report on a policy introduced in 2001.

Since then there has been a dispute as to how effective the new arrangements have been. I have seen all kinds of pretty half-baked analysis attempting to prove that the policy is either the silver bullet to drug abuse or that it has been a health and crime disaster.

Well, this new report looks at the arguments of both sides and attempts to provide a critical analysis of what has happened and concludes that "contrary to predictions, the Portuguese decriminalization did not lead to major increases in drug use. Indeed, evidence indicates reductions in problematic use, drug-related harms and criminal justice overcrowding."

The report goes on to point out that "such affects can be observed when decriminalising all illicit drugs. This is important, as decriminalisation is commonly restricted to cannabis alone".

The Home Office has not yet responded to the new study but drugs minister James Brokenshire recently told the House of Commons "[O]n the specific point about the Portuguese model, we are against that proposal."

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