Liberal Vision

The Department of Health is watching you!

Last week a number of bloggers focussed on the dishonest, authoritarian nature of the DoH. This is not news to those who have researched the ethically dubious behaviour of a government department that is the only one that admits to paying third parties to lobby government. The department’s track record on public health interventions in particular is justifiable only in the eyes of those whose narrow focus allows them to take the extremist position that “the end justifies the means” and therefore excuses behaviours that are otherwise unacceptable.

I and many others have previously highlighted the lack of objectivity that is a feature of DoH “consultations” and the fundamentally flawed approach that has seen the DoH directly funding social “scientists” to provide “evidence” to support public health policies such as smoking bans and minimum alcohol pricing. To any objective observer the processes and people involved in producing this policy based evidence undermine the credibility of the policies and of the DoH itself.

I have no reason to have confidence in the DoH and ample reason to be concerned about its agenda so I was rather alarmed to find out just how much control it has over GP practices. I recently attended my practice for a routine appointment and was surprised to find out that I had to answer a question about my smoking habits in order to check in using the automated system.  I don’t smoke but as far as I am concerned, that together with my other lifestyle choices is information that I am prepared to share with my GP but do not necessarily wish to share with others.

The Orwellian and in my view unethical nature of this approach to information gathering prompted me to find out why a practice that has served my family well for decades has become increasingly impersonal and public health obsessed.  I was alarmed to discover that the DoH is effectively paying GPs to ascertain the smoking status of everyone over 15 and that this is not the only way in which the relationship between patients and doctors is being depersonalised and centrally controlled.

The mechanism underlying this policy is called the Quality and Outcomes Framework (QoF). The QoF financially incentivises doctors to not only to gather lifestyle information but to treat patients based not on what might be best for a specific patient in a specific GPs experience but on what DoH /NICE centralists deem best practice. This potentially undermines the important GP/patient relationship and represents a major bureaucratic overhead.

The QoF is supposed to be voluntary but is in the Leninist tradition of the DoH is “voluntary” only if GPs can afford to forgo the state funding associated with it. In reality 98-99 % of practices participate as according to one well-placed source it is “almost unsustainable” for practices to opt out of providing this service.

The QoF was introduced by the previous government in 2004. Despite claiming that it wants to empower GPs and reduce paperwork, the current government has done nothing to mitigate either its centralist nature or its bureaucratic content. Each revision seems to be more demanding than the last and some GPs are of the opinion that some of the latest additions make it “unworkable and impractical”

The lifestyle information gathering aspects of QoF are alarming from a liberal perspective and are also likely to have negative consequences for doctor patient relations thanks to the intrusive and repetitive nature of the questioning involved. The government cannot claim to be unaware of this and other issues relating to QoF as medical organisations including the BMA claim to have raised it on more than one occasion.

In 2013 the QoF section on smoking has been changed from being a semi-reasonable attempt to ascertain the smoking status and offer quit services to people with problems such as emphysema, to a blanket demand for practices to catalogue the smoking habits of everyone over 15 years of age.

Alcohol consumption is likely to follow the same path and NICE /DoH have already decided on QoF targets for screening a subset of patients. As the subset includes anyone with high blood pressure it will be quite large, so scaling it up to all patients won’t be a problem at some future review.

The manner in which this information is being gathered, the people who see it and the way in which it is used by the DoH are all further cause for concern. It is one thing to share information with a GP who is bound by doctor patient confidentiality but another thing entirely to supply that information in a format that might be viewed by many other people who are not. Data is supposed to be “anonymised” before practices forward it to the DoH but some professionals are concerned that this may not always be the case in light of increasing government demands for general access to health records.

It is not difficult to imagine a near future scenario in which the DoH thinks it knows the lifestyle choices of the majority of us at an individual level and really is watching us. It is already watching our GPs rather too closely for comfort.

It would appear that whatever government is nominally representing us, it is powerful entrenched bureaucrats with centralist inclinations who dictate the health agenda. Perhaps we might be better off diverting resources to front line services rather than ring fencing DoH funding?

By Chris Oakley. Chris’ previous posts on Liberal Vision include: Minimum pricing – policy based evidence ,  Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth ,  Lies, damn lies, statistics &…

Tags: Department of Healt, GPs, QoF, Quality and Outcomes Framework, smoking

Minimum pricing – policy based evidence

Based on the output of the English media, one could be forgiven for not having noticed that Scottish ministers appear to have shelved minimum alcohol pricing ostensibly due to legal challenges. It will be unfortunate if minimum pricing is shelved solely on the basis of illegality because the lessons to be learned from the attempts to justify it via policy based evidence will then once again go unheeded.

We hear much talk of evidence based public health policy these days but what we actually get is “evidence” concocted to suit policy. The public health industry seems utterly incapable of delivering honest, objective, scientific evidence and the media contributes to the problem through lazy uncritical reporting combined with establishment bias. This was typified by the BBCs response to being caught out making wild claims about the number of lives minimum pricing would “save” amongst pensioners.  Rather than investigate the obviously questionable reliability of its source, the BBC simply accepted a lower but no more credible number.

The BBCs source was The University of Sheffield, which has now received involuntary taxpayer funding from two governments and a public broadcaster. On each occasion the motive has been the gathering of policy based evidence and it appears that neither the politicians nor the media appear to care how dubious the quality of that evidence is provided that it suits their purpose.

Petr Skrabanek in his 1994 work The Death of Humane Medicine cited Nobel laureate Irving Langmuir from 1953 when making a case against the “science” that underpins public health. He wrote that it “accepts evidence not according to its quality but according to its conformity with a foregone conclusion”. It seems that his wise observations have been ignored because the ersatz science that provides the “evidence” for policy interventions is nowadays more prevalent than ever. The University of Sheffield study provides a classic  example of this anti-science in which every supportive scrap of data, however poor in quality  is treated as “conclusive” or adding to a “growing body of evidence” and every contradictory piece as “flawed”, “controversial” or “in need of further research”.  Evidence at odds with the authors’ predetermined conclusions is often simply ignored. Take for example evidence statement 13:

“There is consistent evidence to suggest that alcohol consumption is associated with substantially increased risks of all-cause mortality even in people drinking lower than recommended limits, and especially among younger people. High levels of alcohol consumption have detrimental effects. The evidence is more equivocal, however, where it relates to establishing cut-off points for lower risk versus harmful levels of consumption. There is an ongoing controversy as to whether or not there are beneficial (cardio-protective) effects at low levels of alcohol consumption.”

This statement is an extremely misleading interpretation of the available evidence. There is no excuse for this form of words appearing in a document paid for by public funds and intended to guide politicians who are not versed in the subtleties of public health disingenuity. Hiding behind theoretical and contestable risk factors, the authors peddle the scientifically improbable but politically powerful concept of “no safe level” whilst ignoring a large body of evidence showing teetotallers to have lower life expectancy than moderate drinkers.  I could write extensively about the “controversy” they refer to but Christopher Snowdon already covered it in some detail.

Unfortunately this is not an isolated example in a production that goes to extraordinary lengths to provide policy based evidence.  The other “evidence” statements display a similar lack of objectivity and, despite using the Household Survey data provided by the ONS as a basis for much of their modelling, the authors ignore it when considering consumption at the population level.  They open their section on areas for possible future research (and of course more taxpayer funding) with the typically convoluted sentence:

“Given the trends in consumption over the past ten years it is unlikely that a ‘do nothing’ policy would result in no change to the consumption of alcohol in the population.”

It is hard to tell, but I think that they are trying to say that consumption is trending up so government MUST act. This is a remarkably inept statement to make in the middle of a trend that, according to the ONS has seen household consumption decline by 20% in a decade without any significant government intervention.

I find it hard to understand why politicians continue to pay homage to what Skrabanek described as healthism despite the huge flaws in the “evidence” that underpins it being repeatedly exposed. Perhaps Skrabanek gives some insight into the reasons when he writes:

“Politicians find the facile rhetoric of healthism rewarding. It increases their popularity at no cost, and it enhances their power to control the population. It meets no resistance from the opposition, who promise to improve the ‘health of the nation’ even more.”

Robin Fox, former editor of The Lancet describes Skrabanek as a “humorous man of immense culture and learning” in the Preface to The Death of Humane Medicine and despite not completely agreeing with Skrabanek’s pessimism, goes on to add that he “speaks many truths that we should heed”. I cannot help but feel that the world would be a better place if politicians, journalists and others did heed the words of this humorous, cultured medical man above the strident clamour of the health zealots. After all, without aggressive healthism there would be no need to insult our intelligence with pseudo-scientific policy based evidence and I sincerely doubt that the public would bemoan redundancies amongst the social “scientists”, non-practicing medics and psychologists who contribute to its socially divisive message. I doubt that these commenters on the BBC’s umpteenth plug for minimum pricing would mind at all:

For anyone who empathizes with Bauer and /or who is interested in a more liberal and less miserable future I recommend reading Skrabanek’s book which can be downloaded for free here.

By Chris Oakley. Chris’ previous posts on Liberal Vision include:  Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth ,  Lies, damn lies, statistics &…

Tags: BBC, minimum pricing alcohol, Sheffield University

Epidemiology – Splitting the atom with a breadknife?

“If your experiment needs statistics, you ought to have done a better experiment” – Ernest Rutherford

Statistics are so ingrained in so many aspects of our lives that it is sometimes hard to believe that the statistical approach is a relatively new phenomenon which is far from beyond criticism. It has dominated medical research and practice only since the mid-20^th century but is now the principle means by which new pharmaceuticals are judged and the basis for many public health claims.

One major problem with over reliance on the statistical approach is that it fails to adequately take into account our individuality and diversity. Human beings vary enormously in both nature and biology. Our individual biology dictates how we respond to drugs and our individual nature determines how we respond to public health initiatives.

Liberals question the statistical approach to public health because it often seems clumsy and heavy handed, offering poorly defined benefits to the few at the expense of the freedoms of the many.

Medics question the value of new drugs whose efficacy is judged by small statistical effects in large scale clinical trials because whilst these drugs may benefit some patients, the chances are that in many cases they will have no significant effect.    

In recent years, growing investment in personalized medicine has begun to challenge the dominance of the statistical approach. The idea is to treat patients as individuals based on their unique genetic make-up and thus offer “the right treatment to the right person at the right time”. As we move further down the personalized medicine path it is likely that medics will further challenge the value of the statistics based approach to their profession. One medic who certainly does is James Penston, author of stats.con

Penston believes that the statistical approach to medicine is flawed and uses both epidemiology and randomized control trials to illustrate his point.  His chapter on epidemiology subtitled The Study of Scare Stories is particularly damning. He concludes:

“People are right to be sceptical about medical research. Cohort and case-control studies, and those who promote them, deserve the scorn heaped upon them. A sensible approach to epidemiological studies would be to ignore the results altogether.”

A bit extreme perhaps but he does make a coherent case based on essential weaknesses in the approach and the tendency to place far too much emphasis on very small effects derived using imprecise methods.  The reality is that aside from establishing a link between smoking and lung cancer 60 years ago, epidemiology can claim very few successes but this has not deterred the media or the public health industry from bombarding us with statistics and exaggerated claims. It is difficult to take seriously risk factors calculated to x decimal places that are based on individuals responses to questionnaires. Do people really tell the truth about their lifestyles? Can they remember what they did 10 years before their illness began? Are these precise claims really justifiable?

The frequent misuse of the epidemiologist’s efforts by others contributes to epidemiology’s poor reputation as does its coverage in the media.  For example, this BBC article claims to report Tim Key’s study on lifestyle factors and circulating sex hormones in post-menopausal women. Key observed that elevated hormone levels, which are one risk factor for breast cancer, are more closely associated with obesity than other lifestyle factors such as smoking and alcohol. The BBC article is so poorly written that the reader is likely to be misled into believing that obesity is the major cause of breast cancer “shortly followed” by alcohol and smoking. That is not what Key studied but many more people will have read the BBC article than will have read the original paper. This is unfortunate because the contrast between Key’s carefully worded conclusions and the journalist’s interpretation is important.

Bearing in mind the large sums of research funding at stake, the constant meddling of politicians, the evangelical fervour of pressure groups and the ignorance of the media, it is perhaps not surprising that the importance of small epidemiological effects is often exaggerated for public consumption. 

One very common method used to achieve impact far greater than the actual significance the data merit is to emphasize changes in relative rather than absolute risk. Using relative risk makes headlines but is often fairly meaningless at the individual level. For example, if a person’s  risk of contracting cancer A is 0.01% and a study shows that eating bacon increases that risk by 20%, then the bacon eater increases his actual risk of developing cancer A to 0.012%. The 20% headline is eye catching but most people would not give up bacon based on these odds.

Penston highlights cohort size as another factor misused by statistics adherents. It is an indication of just how dominant the statistical approach has become that we tend to be impressed by studies involving large numbers of people when the real benefit of such numbers is to achieve statistical significance for effects that are otherwise too small to be meaningful.

In a society that allegedly values individual freedoms should we really be basing policy on data that is all but meaningless to the individual and effects that require tens of thousands of subjects to achieve even the smallest significance?

Although I respect the work of some epidemiologists I have to ultimately agree with Dr Penston’s criticism of their collective output because the exaggerated, over-precise claims made by the media and public health industry contrast so sharply with the bluntness of the tools at the epidemiologist’s disposal that they can be reasonably equated to claiming to have split the atom with a breadknife.

By Chris Oakley. Chris has previously posted on Liberal Vision:  Smokers-State Aprroved hate and Intolerance is UK policy,   Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth , A Liberal Tolerant nation? ,  What hope is there for liberty if truth becomes the plaything of political lobbyists,  Public Health Success? and Could the increasing popularity of harm reduction products impact cigarette consumption?

Tags: Epidemiology, James Penston, stats.con

Is there a scandal brewing or just a big fat lie?

Serious questions are being asked today about Andrew Lansley’s stance on the consultation on the standardised (plain) packaging of tobacco.

Before the consultation was announced Health Secretary Andrew Lansley told the Times (13th Apri 2012l)  that the government did not work with tobacco companies as it wanted them to have “no business” in the UK. That set a few warning bells ringing.

Just a few days later, however, announcing the start of the consultation, his stance seemed to be more moderate. Andrew Lansley was insisting that his mind was “open” over proposals to strip cigarette packets of branding as a consultation on the plans was launched.

It is therefore surprising to find that the publicly funded pro-plain packs web site is claiming the Secretary of State is indeed, now at least, a supporter of plain packaging.

It is not clear when he became a supporter of plain packaging, but as this is a government funded body claiming it, I assume that is true? I am currently running the Hands of Our Packs campaign, opposing the introduction of plain packaging (no government money). I can’t imagine claiming that any Minister, health or otherwise, is against plain packaging, without checking with them first – no matter how many additional signatures it might draw into the campaign.

So I think that Andrew Lansley has some explaining to do? If he doesn’t then the campaign asserting that he has already made his mind up certainly does -particularly considering the source of its funding. It is all starting to look very curious indeed.

Angela Harbutt heads up the campaign Hands Off Our Packs. The campaign is funded by Forest – Freedom Organsiation for the Right to Enjoy Smoking Tobacco.

UPDATE:

A letter has now been sent to the Department of Health requesting a response to the following questions:

1. Is it appropriate for the Secretary of State for Health to be listed as a supporter of plain packs (by a campaign that receives public money) in the middle of a public consultation on the issue and before the DoH has published its report on the consultation?

2. What action will the DoH (or the Secretary of State) take on this matter?

Let’s see what the Department of Health has to say.

It is also interesting to note that two of the authors (including the lead investigator) of the Department of Health’s (emphasis own) “independent academic review of the existing evidence” relating to plain packaging are also listed on the plain packs protect web site as “supporters” of plain packs. The authors – Gerard Hastings and Linda Bauld are identified by the cmapign as being not quite so “independent” in their thinking as one might have hoped.

For more information and further updates go to the  “TAKING LIBERTIES” web site where the story is unfolding..

Tags: Andrew Lansley, consultation, health, open-minded, plain packaging, tobacco

Could the increasing popularity of harm reduction products impact cigarette consumption?

Not if the Public Health Industry has its way

One obvious failure of the 2006 Health Act is the fact that the much vaunted smoking ban has had no impact on smoking prevalence in the UK. Not that those people who rely on the mainstream media for news would necessarily be aware of this as the pampered public health industry has gone to some lengths to hide the negatives and is even now clinging to patently false claims of alleged benefits. Sadly the media seems quite happy to indulge this penchant for deceit and the DoH has gone out of its way to ensure the outcome of a “review” by paying a tobacco control activist to come up with the “right” conclusions.  Harsh words perhaps, but how else does one explain a scientific advisor with no science qualifications and a less than objective public profile?

Despite the poisonous environment created by the media, the public health industry and the DoH, harm reduction alternatives seem increasingly popular and may therefore be more likely to impact on cigarette consumption than tobacco control inspired crack downs.  These alternatives will certainly not appeal to all smokers but the evidence from Sweden is that significant numbers of people choose safer forms of tobacco given the option. Sweden does not have especially low levels of tobacco consumption but the popularity of oral tobacco in the form of snus mean that it does have a low incidence of male cigarette consumption and also the lowest incidence of lung cancer in the EU

Although the Nordic tradition that contributes to the success of snus in Sweden does not exist in the UK where less harmful tobacco formats are in any case banned, legal smoking alternatives such as e-cigarettes do seem to be increasingly popular as evidenced by the fact that mainstream retail outlets like WH Smith are now promoting them. In a country where government is actively pursuing policies of denormalization and intolerance towards smokers it is perhaps unsurprising that a product that mimics some of the pleasure obtained from cigarettes but can be enjoyed in public is a potential winner. After all, as the marketing blurb says, e-cigs can be enjoyed legally anywhere. This is not strictly true as e-cigs are specifically banned on Virgin flights for example, but as water vapour shouldn’t trigger smoke alarms, vapers might risk a crafty one in the toilets.

Faced with the obvious benefits of harm reduction, we might expect the politicians, the media and the likes of CRUK to embrace snus and e-cigs as safer alternatives to smoking.

They don’t.

CRUKs otherwise often informative Web pages barely mention e-cigs and contain only a short ill-informed and misleading section on snus. This low key and dismissive attitude typifies tobacco control output and partially explains the EUs collectively miserable record on harm reduction which gives Clive Bates former head of ASH cause for concern. Bates criticises public health failure under 3 headings:

• Public health science ignored and abused
• Ethics and consumer rights violated
• EU legal principles disregarded

Jean King, CRUK’s director of tobacco control says:

“There has been little research into how safe e-cigarettes are. And there’s also very little regulation to control these products or their marketing. The only way to be sure of any risks or benefits is through rigorous testing.”

As a product lacking known carcinogens is likely to be relatively beneficial, one would expect the public health industry to have mobilised its vast resources to perform at least some testing as a matter of urgency.

It hasn’t.

The industry is apparently much more interested in its on-going war with “big” tobacco and smokers as evidenced by the vast amount of effort and (public) money it has put into vanity projects such as shop display bans and plain packaging campaigns.  If our divided, fear ridden society is genuinely concerned about exposure of children to the very sight of age restricted products why not consider selling such products in age restricted shops or sections within shops? That way, children don’t see displays or packaging, adults can choose their product without feeling like they are buying a class A drug and our money could be spent on something more useful.  I am not necessarily advocating this policy but I am suggesting that it has not been considered because it is insufficiently aggressive towards the tobacco industry and not as humiliating for smokers as the tobacco control preferred alternatives.

It is hard not to believe based on the available evidence, that the public health industry is motivated more by its hatred of certain other industries and its constant need to satisfy its own justifiably  fragile ego than it is by any genuine concern towards us as individuals. How else can one explain the myopic adherence to its “quit or die” dogma and the breath-taking arrogance of continuing this one-dimensional approach in the light of the historical evidence and human experience?

It is noteworthy that “big” industry in the form of tobacco companies and major retailers are popularizing harm reduction alternatives while the public health industry and UK government pointlessly pursue “plain” packaging apparently as part of a utopian project for a brave new smokefree world.  Utopian projects are, as they always have been, fundamentally and necessarily illiberal.

By Chris Oakley. Chris has previously posted on Liberal Vision:  Smokers-State Aprroved hate and Intolerance is UK policy,   Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth , A Liberal Tolerant nation? ,  What hope is there for liberty if truth becomes the plaything of political lobbyists and Public Health Success?

Tags: e-cigs, harm reduction, plain packaging, smoking, tobacco, vaping