Health: Public Health Responsibility Deal
(10 years, 10 months ago)
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Lord Clement-Jones
To ask Her Majesty’s Government what assessment they have made of the progress and impact of the Public Health Responsibility Deal.
Lord Clement-Jones
My Lords, it is now more than two years since the then Secretary of State for Health, my right honourable friend Andrew Lansley, local government and the leaders of a number of industries came together in March 2011 to agree the public health responsibility deal. There is no doubt that as a country we face significant public health challenges. Working-age ill health is estimated to cost the UK economy more than £100 billion a year. England has among the highest levels of adult obesity in Europe. We have more than 8,000 what might be described as premature deaths every year from too much salt in our food. Alcohol misuse costs the NHS £3.5 billion a year. Physical inactivity costs it £1 billion a year and the costs to the wider economy from sickness absence have been estimated at around £5.5 billion.
The essence of the PHRD, as the Secretary of State said in his introduction, was to agree voluntary action to ensure we,
“have more progress, more quickly”
with less cost than legislation. There are those who are sceptical about this kind of action. A recent paper in the Lancet by Professor Rob Moodie of the University of Melbourne concluded that the only way to achieve the UN’s goal of halving the mortality rate for diseases caused by tobacco, alcohol and poor diet was through greater regulation. Likewise, Which? is sceptical. Its executive director, Richard Lloyd, last year speaking about the responsibility deal, said:
“We have the worst obesity rates in Europe and diet-related diseases, like heart disease and stroke, are blighting the public’s health. Our audit of progress made under the Government’s Responsibility Deal has shown the current approach is overly reliant on vague voluntary promises by the food industry. This has so far failed to bring about change on anything like the scale needed”.
The BMA in its briefing for this debate said it believes that relying largely on voluntary agreements with the food and drinks industry is inadequate. It, of course, refused to sign up to the responsibility deal.
The question at the core of this is how far is nudging effective? The Health Select Committee in its report last year on the Government’s alcohol strategy said that,
“we do not oppose the exploration of innovative techniques such as ‘nudging’, where it can be shown, following proper evaluation, to be an effective way of delivering policy objectives. The Committee were, however, unconvinced that the new Responsibility Deal will be effective in resolving issues such as obesity and alcohol abuse and expect the Department of Health to set out clearly how progress will be monitored and tougher regulation applied if necessary”.
Clearly, issues of physical activity, alcohol misuse and obesity have to be tackled in a variety of ways but I know I am not alone in preferring to see voluntary action initially rather than increased regulation unless the former is shown to have failed. It is far too purist a line to say that industry should not be involved in public health initiatives. In the responsibility deal, different sectors made particular pledges for action, regarding food and diet, alcohol, physical activity and health at work. The essence of the deal was acceptance by signatories of the role they play in improving people’s health—encouraging them to adopt a healthier diet, fostering a culture of responsible drinking, encouraging and assisting them to become more physically active and actively supporting their workforce to lead healthier lives. The organisations involved made a series of collective pledges by sector, individual pledges by organisation, and what were called supporting pledges, regarding collaboration, monitoring and evaluation, information and development of further pledges.
Today, I regard all aspects of the deal as important but, given the time available, I want to focus on two limbs of the deal, relating to food and alcohol. The initial collective pledges by the food industry involved, for example, salt reduction, front-of-pack nutrition labelling, artificial trans fats removal and calorie reduction. One of the recent fruits of the responsibility deal has been the new voluntary UK traffic light scheme for front-of-pack nutrition labelling, which was launched on 19 June this year. This will introduce more consistent nutrition labelling across the UK by providing, on the front of food and drink products, clear information on energy and those nutrients of public health concern that the majority of us should be aiming to limit in our diets. Then of course there are the steps towards calorie reduction by the food and soft drink manufacturers, and the significant actual and planned reduction of salt in food, in supermarket products and catering.
For the alcohol industry, including manufacturers and the on and off-trades, the pledges involved: fostering a culture of responsible drinking; a reduction in alcohol units to remove 1 billion units from the market; a commitment to labels with clear unit content; awareness of alcohol units in the on and off-trades; tackling alcohol sales to those who are underage; action on advertising and marketing alcohol; community action to tackle alcohol harm, and support for Drinkaware. This partly depends on having clear, common understanding of the facts but these are not always straightforward. There are many conflicting statistics and it is not always easy to draw conclusions.
There are many different perspectives on current trends. It appears that national alcohol consumption trends are going in the right direction. Nationally, per capita consumption has fallen from 11.5 to 10 litres of alcohol per person per year, and is now below the European national average. More people drink within the guidelines. There is less drinking at harmful levels and binge drinking is down. There is less alcohol-related violent crime, and there has been a very significant drop in drink-driving fatalities over the past 20 years. All these statements are derived from official figures. However, hospital admissions are up, whether this is taken as those where alcohol is the primary diagnosis or those which are simply alcohol-related.
There are anomalies in respect of particular age groups and localities, even where the national picture shows improvement. Areas such as the north-west and the north-east have a disproportionate amount of binge drinking and hospital admissions, due to alcohol-related causes. Supporting Drinkaware, an independent organisation, is one of the key pledges given by the drinks industry. Drinkaware works with young adults to moderate drinking through the “Why let good times go bad?” campaign. It also helps parents tackle alcohol issues with their children. It has recently published an audit of effectiveness which demonstrates the progress it is making, and that its work is being increasingly recognised. Drinkaware says that binge drinking remains a social norm in many areas. We are, it seems, fighting a huge cultural battle so pledges are fine but translation into local action is key. There is clearly a need to target appropriate schemes at particular areas. The drinks industry tells me that it is working with local partners including local authorities, police and the third sector to do this.
There is in fact an impressive array of voluntary schemes. During the passage of the Police Reform and Social Responsibility Bill in July 2011, and in the debate initiated last year by the noble Baroness, Lady Coussins, I talked of the virtues of local voluntary actions designed to combat alcohol abuse. These are through schemes such as Purple Flag, Best Bar None, Pubwatch, business improvement districts and community alcohol partnerships, with central government working with the industry—both the on and off-trades and the manufacturers—and the advantage of those schemes over those imposed in a compulsory way, such as the early-morning restriction orders and the late-night levy. There is of course Challenge 21 and Challenge 25, a strategy that encourages anyone buying alcohol who looks under 25 to carry acceptable ID. There is also PASS, the nationally recognised Proof of Age Standards Scheme. It would be very interesting to know what evaluation has been done for these individual schemes, since each clearly has different objectives and outcomes. I am pleased that licensing authorities will have discretion to offer a discount from the late-night levy up to a maximum of 30% for premises that are part of—or members of—best practice schemes, subject to specific criteria.
A recent positive development is the revised version of the Portman Group’s Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks. The new version of the code now specifically states that there should be no linkage to sexual activity, no images of under 25s, and easier promotion of lower strength products. Furthermore, progress on alcohol unit reduction is well under way towards the goal of 1 billion fewer units consumed. The strength of well known brands has been reduced, and new lower-alcohol alternatives have been introduced.
Of course, at the back of all our minds is the question as to the future of minimum unit pricing, as originally proposed by the Government. I am an agnostic, currently, but the proponents of minimum unit pricing refer to the Canadian experience. What can my noble friend say on that subject?
So what is the future for PHRD? The scoping review undertaken on behalf of the Department of Health by the Policy Innovation Research Unit at the London School of Hygiene and Tropical Medicine concludes that, if properly implemented and monitored,
“voluntary agreements can be an effective policy approach, though there is little evidence on whether they are more effective than compulsory approaches”.
The key questions that the PIRU is being asked to consider are: does the responsibility deal as a mechanism work? Can voluntary pledges achieve the necessary change? Are the pledges themselves amenable to evaluation? In fact, can any cause and effect ever be evaluated? Yet the unit itself believes that the most useful questions at this stage of the development of the responsibility deal are about what it is; its objectives; how it is expected to work; how it can be assessed; and how will we know whether it works—in particular, what further steps are needed. I wonder what we can really expect from the PIRU study at the end of the day.
No doubt there is a considerable task ahead for my noble friend the Minister in replying today, but even more questions remain. Under new leadership, is the department still committed to this approach, and is the deal essentially worth it for all concerned? I look forward to my noble friend’s reply.
Lord Brooke of Alverthorpe
I thank the noble Lord, Lord Clement-Jones, for this debate. I see that a number of us who have debated these topics previously are present. My interests in this arena are declared in the Register of Lords’ Interests, although I might add that I am frequently sent messages by the All-Party Parliamentary Beer Group inviting me to various events—presumably, where I would get free beer. I assume that when we get the long-awaited review of the register of interests and of how we deal with people who lobby us, it may also have a look at what happens with some of those activities.
I also wait with great interest to hear how the noble Earl responds to this debate and to the questions posed by the noble Lord, Lord Clement-Jones. I, too, have a fair number of questions for him. Noble Lords will recall that, when the public health responsibility deal was launched by Andrew Lansley in 2011, he made much of its benefits accruing through public health, commercial and voluntary organisations working in partnership to agree practical actions to secure more progress more quickly and with less cost than would have been the case with legislation. He emphasised that the strength of the deal lay in the diversity of organisations that it brings together. In the event, those aspirations of bringing several groups together were not met, and fairly early on we saw some of the major players depart from the scene.
However, I would concede—and I would not be churlish enough to fail to say—that a number of developments have taken place since the scheme was introduced. Like the noble Lord, Lord Clement-Jones, I am very pleased to see the recently announced front-of-pack nutrition traffic lights labelling scheme coming in. That is good progress, but it has taken us years to get to that position. When it was left to the voluntary approach by industry, there were mainly two separate schemes, and they were unable to bring them together to work. We now have people coming together but, regrettably, it is anticipated that 20% will still not comply, even with the voluntary scheme. What will happen in those circumstances, given the consequences that we encounter when we come to deal with health issues, which I shall address later?
It is because of the response that we have had and because the health industry generally, and some of the NGOs, were so unhappy about the way in which they felt that the Government would be influenced by the drinks industry that they wanted to pull away from participating in the scheme overall. In reviewing where it should go in future, I believe that it will be fundamental to assess whether it really has validity if we cannot take the health industry with us. I should like to hear from the Minister what he intends to do about that when we come to the end of the review.
The Royal College of Surgeons and the BMA are the people who are dealing, on a daily basis, with the three major preventable killer diseases that confront us: smoking, alcohol and obesity. As recently as 5 March, their position has been supported by no less than Jeremy Hunt, the Secretary of State for Health, who advises us, following a major study, that Britain is now falling behind many western countries in progress on managing preventable disease. The Secretary of State went on to say that the UK needs a “call to action”, although he did not define precisely what that call to action would be. We all recognise that there is no simple silver bullet that will answer these problems, but there is a multitude of approaches that could be taken. I hope that today the noble Earl will give us an indication of where the Government stand on their approach to those three major topics and on trying to bring them together so that we can start to recover some of the ground which, according to the Secretary of State, we are now losing when compared with a fair number of other major European countries.
In this context, I know that the Policy Innovation Research Unit of the London School of Hygiene and Tropical Medicine has undertaken its scoping review. Will it be engaged to do further work and, if so, what terms of reference will it be given and to what extent will there be consultation among the wider health community, as well as the commercial side, on this further work? I also notice that Drinkaware has recently undertaken a review and audit of its work and that it has identified some quite significant deficiencies in its operations. Questions have been raised about the adequacy of the evidence base used for its campaigning work. Questions have also been asked about its independence. Again, it works too much in isolation and at too great a distance from the NGOs and the health profession. I know that consultations will be taking place over a wider front by Drinkaware, but I should like to know the noble Earl’s initial views on that, having read, as I am sure he has, the review that has taken place.
The Government’s strategy on alcohol has been predicated primarily on minimum unit pricing. Under my Government, the balance on alcohol licensing moved towards being in favour of the industry and recent legislation has shifted the fulcrum more to the centre, giving local democracy and local interests against commercialism a better stand. However, I was surprised to learn from the debate in the House of Commons last week that the Government have been contemplating abandoning the time-old tradition of requiring people applying for alcohol licences to publish their applications in local newspapers. There is strong opposition to this in the Commons and I hope that the Government will not proceed with it, as it flies in the face of localism and the chance to try to control what happens within your locality. Again, I should be grateful for the noble Earl’s comments on that.
Finally, I raise a little point that I have been campaigning on for years about including the number of calories in the labelling of alcohol products. We have been running this for about three years and we seem to be no further forward. Is there any chance of an indication that some headway is being made?
My last point does not relate directly to the responsibility deal, because much of the industry does not accept that it is responsible for the harm that alcohol causes. Will the Government give some thought to the concept that a new funding stream for the NHS could be drawn from the private sector to help to meet the cost of the harms which arise from alcohol and tobacco and particularly from the growth of obesity through fats, sugars and salt? We know the problems that the NHS will face in the future, although very little concern was expressed about its funding by the Chancellor yesterday. However, as all parties know, with the ageing population, changing lifestyles and the continuing growth in the cost of technology and drugs, the health service will be in real difficulties in the future. We need new funding streams and we might explore whether the private sector, which has responsibility for some of the harm, should be required to pay for it if it does not respond on a voluntary basis.
Baroness Masham of Ilton
My Lords, I thank the noble Lord, Lord Clement-Jones, for initiating this debate. There are more demands on the health systems than there are resources to deal with them adequately—hence the importance of the public health responsibility deal. If public health is to improve the nation’s health, it is important that all sectors work in communication and co-operation and build relationships: the Government, the health services, industry, academia, the voluntary sector and the public.
A growing problem is the increase in the number of people with diabetes. Prevention, if possible, is vital. Screening for bowel cancer and other conditions is also important so that diagnosis is made early. Health and well-being boards need to encourage integration, influencing strategy and reducing inequalities. There is much to do to improve the health and well-being of the population.
Over 20 years ago I chaired a committee which looked into the problems of alcohol, crime and young people. One of the problems seemed to be, and still is, the skilful and aggressive advertising of alcohol. What assessment have the Government made of the progress and impact of alcohol abuse within the public health responsibility deal?
There seems to be an increasing problem of people with alcohol disorders visiting over-pressed hospital A&E departments. They can cause disruption to staff and other ill patients by being aggressive and demanding. The increase in patients with liver disease, including very ill patients—many of them young—is putting more demands on hospital wards. Since I asked the noble Earl a question about the pressures of alcohol abuse on A&E departments, I have learnt that there are NICE guidelines, and I have heard that Liverpool has had some success. Will the Minister tell us what the guidelines say and how Liverpool has improved this difficult situation?
I was once told by an A&E consultant from Leeds that one of the most upsetting incidents he had dealt with was when two young boys aged about 10 and 12 were brought in with alcohol poisoning. Both died. Many serious conditions are caused by the combination of drugs and alcohol. I remember as a child attending a Church of Scotland service: the minister was thumping the pulpit and shouting out the dangers of alcohol. Are our messages today strong enough? Should we not have more health education in schools, with clear messages about what alcohol can do to the pupils’ bodies and minds? Alcohol can be a contributory factor in the increase in sexually transmitted diseases, when inhibitions go out of the window and people forget to take precautions. With alcohol, people with a mental health problem can become a danger to themselves and society.
An effective alcohol policy must be based on the evidence of what works—in particular, increasing the price, restricting availability and tougher marketing restrictions. It must be a policy that therefore counters the pro-drinking messages communicated by an industry that spends £800 million in the UK each year marketing its products. Alcohol Concern shares the view of the World Health Organisation that, while the alcohol industry can and should play a role in implementing decisions on alcohol policy, it should not be allowed to influence the marketing of that policy.
It is welcome to see the progress made and the impact that the Food and Drink Federation has had on artificial trans fats removal, calorie reduction, consumer education, workplace well-being and front-of-pack labelling. This will help with the prevention of osteoporosis, obesity and diabetes. There should be healthy balanced eating and people should take healthy exercise.
I declare an interest as I have a small rural riding centre, which provides a healthy interest and occupation for people who want to enjoy the countryside. It gives them an interest away from sitting for hours and playing computer games.
I hope that the Minister will take this opportunity today to give assurances that independent monitoring and evaluation of the pledges and their impact on public health outcomes will be available to all.
Lord Addington
My Lords, I, too, congratulate my noble friend on bringing this subject before us today. Any initiative by people who take responsibility for public health should be applauded. Whether this is the right model or one for the future remains to be seen. However, trying to get several sectors to address the problem must be applauded for the simple reason that there is no one answer.
Behaviour, social change and the way we take in information and use it would seem to be the underlying message behind this. We have already heard that if you drink too much you put on weight and it affects your body in various ways; and that if you drink far too much at the wrong time you behave badly. Given the history of Gin Lane, Hogarth and so on, that is hardly news; it is nothing that we have not heard before.
Recently we have been dealing with the backlash of the social trend towards binge drinking. This has happened after the binge of taking pills to get oneself out of it. This habit seems to have died out in certain parts of the country but not in others, and people who have got into the habit of binge drinking seem to be carrying on doing so. People are suffering from liver damage earlier, getting stroppier earlier and losing control earlier. Given that our lifestyle today is one which has easy access to high fat, high salt and high sugar foods which can be consumed easily, and the fact that we do not take much exercise, we seems to be creating a world where it is quite easy to sit still for long periods of time, ingest huge numbers of calories and alcohol and damage ourselves.
How do we change that? There are two prongs to this which have worked in the past, of which smoking is a good example. First, you point out to people that it is damaging them; secondly, you take various supporting actions, through government, to encourage them to change. However, voluntary action is equally important. Every bit of information I have on this subject shows that we do not like being preached at. Talking to people may help them to change their minds over time, or preaching to people subtly and well may do so, but we are all politicians and we know how often we get that right and how often we get it wrong. We have got to strike a balance here.
I agree with the noble Lord, Lord Brooke, about the number of times we have heard about the labelling on food. I have had a number of bizarre meetings, particularly at party conferences, where people have tried to sell their form of labelling to me.
We also resist certain types of activity. I remember during a conference when the previous Government were in power—I think we were in Blackpool but I cannot remember which year—going to a dinner where people were trying to convince me that if we stopped selling what we now call full-fat Coke and other soft drinks in vending machines, children would die in huge numbers because they would cross the roads at lunchtime and, lemming-like, be flattened by cars. You could not make it up. You do not have to after a period of time. The rearguard action by the industries is usually very impressive and creative, but it is possibly one that missed. While we are talking about alcohol, by the third glass of wine I was prepared to say that they had missed on this occasion. Let us not knock everything all the time.
To address the issue of physical activity, the same ideas about what is involved in convincing people that exercise is pleasant must surely apply here. There is also the question of who we are addressing. I shall concentrate my remarks here on people taking low-level, casual exercise. Local government can make our parks and pavements, for instance, pleasant places to walk or take moderate exercise, as appropriate. People can encourage their children to have a game of football using two jumpers on the ground for goalposts while they use the swing. That is very appropriate. I look forward to hearing how we can encourage that.
Organised sports clubs can be only a limited aspect of this, because they are often dependent upon this type of activity. We talk a lot about school sport, but school sport can only do so much. A child must take part in physical education and become reasonably fit before they can be trained to take part in a sport and take it seriously. If a child who at the age of five has never moved, who has been plonked in front of the TV and who is carrying large amounts of fat around their waist and backside, is encouraged to go straight into some form of physical activity, the child will not do it. It will be painful and difficult.
If parents do not have access to a pleasant environment, and are not encouraged to give their child the normal amount of time in which to run around, it will not happen. We must address this. If a child or an adult then thinks that it is terribly difficult to undertake activity, they will chose sedentary leisure activities, which often involve watching something. They will take that hit of sugar and salt from fast foods, as we probably call them now, or high-density foods. How do we balance this? How do we encourage people to get out?
I received a series of briefings from the Ramblers Association, saying that people are 72% more likely to walk and to carry on walking if their local area is pleasant, but they are 55% less likely to walk if their local area is unpleasant. If you get that balance right and make walking enjoyable, then people can get involved in it. What action and assessment are we taking to encourage individuals and groups to make sure that physical activity can be undertaken in a pleasant environment? Unless this casual organisation is encouraged, unless it takes into account the fact of this normal reaction, then it takes away from both the introductory levels of more serious exercise and that low-level maintenance which is so important to health. I could go on for much longer, but the clock has beaten me.
Baroness Coussins
My Lords, I would like to make one general point about the role of the private sector, and then some specific points about the alcohol element of the responsibility deal. First, I declare various interests. I am an independent adviser on corporate responsibility for two drinks producers, Heineken and Brown-Forman, and one food company, Mars. Details are in the register of interests. I emphasise that my advice to them is strictly non-parliamentary, and that I had no discussions with any of those companies about what I am going to say this afternoon.
On the general point, food and drink companies often get it in the neck for engaging in the public health arena. They are criticised by cynics who simply cannot believe that companies can possibly be sincere, and think they are really doing no more than watching out for their own commercial interests. The Government are also criticised for letting the industry off the hook with voluntary action.
However, I argue that this kind of partnership is no soft option for the industry. As long as outcomes are rigorously monitored and achieve the desired results, it can be extremely effective. The first reason for this is the very high level of public scrutiny. The companies openly sign up to detailed, challenging pledges, and they will look insincere and incompetent if they do not fulfil them. Secondly, the pledges are crafted in an inclusive way involving Government, health professionals and the industry, so the outcomes are much more sustainable because they are supported by industry from the beginning. Thirdly, of course the responsibility deal is in the commercial interests of the industry. There is a strong business case for companies to help minimise the harms associated with their products. The consequences of overconsumption damage brand image as well as body image. They give the company a bad reputation and undermine shareholder value. It is a good thing that the industry has recognised this. Its businesses would not be sustainable otherwise.
This deal puts the UK streets ahead of our EU partners by showing not just what can be achieved on a voluntary basis rather than through red tape but also how quickly. The pledge on alcohol labelling, for example, will see 80% of drinks labelled with a variety of health-related information and is well on target to be achieved by the end of this year. Mandatory labelling would almost certainly require EU legislation and take years. Another pledge, as we heard, is to take 1 billion units of alcohol out of the market by 2015 by reformulating existing brands to contain less alcohol and by innovating to bring new, lower-strength brands on to the market, helping more people to drink within the guidelines by providing a wider choice of lower-alcohol products. This has become a real growth area, with dozens of new products coming on to the market. Sales of lower-strength beer have grown by 59%, according to HMRC data.
A third pledge is to provide more support for local community schemes such as Best Bar None and community alcohol partnerships. That is vital because alcohol harms in the UK vary hugely across different regions. For example, we know that nationally the vast majority of adults drink within the government guidelines and that per capita consumption and binge drinking have fallen. But we also know that alcohol-specific mortality and liver disease in Blackpool is nearly three times the national average, hospital admissions in Liverpool nearly 2.5 times the national average and binge drinking in north Tyneside 1.5 times the national average. One reason these community schemes work is because they offer a win-win outcome. In Durham there has been a 75% increase in trade in pubs that support the Best Bar None scheme because it obviously makes the pubs safer and more attractive places to go. At the same time, figures suggest an 87% decrease in violent crime. There are now more than 50 community alcohol partnerships up and running and some have seen significant reductions in antisocial behaviour.
Producers have also committed continued support to Drinkaware by not only paying their dues but also using their brand marketing to promote the charity’s campaigns. During the 2012 FA Cup, for example, more than 50 million football fans saw Drinkaware branding through a beer sponsorship that featured Drinkaware on the stadium perimeter. During the semi-final matches, there was a 30% increase in direct traffic driven to the Drinkaware home page. In fact, the number of individuals who go to the Drinkaware website has grown massively, from 2.8 million in 2011 to more than 6 million in the past 12 months. Thanks to the funding it receives from the industry, Drinkaware has proved a tremendous asset to the public health effort to promote sensible drinking. Its progress was confirmed earlier this year, along with some welcome pointers for future improvement, by an independent review panel chaired by Sir Hugh Taylor, chairman of the Guy’s and St Thomas’ NHS Foundation Trust. The industry has pledged to review the codes on advertising and marketing and a revised Portman code came into effect at the end of May this year with several even stricter rules. A new, improved code on sponsorship is due to be launched in the next few weeks.
I end on a specific question or two for the Minister. A deal, by definition, involves more than one party. We know what the industry is doing. Have the Government or the health service committed to specific pledges? For example, will the Government take on one specific suggestion from me and do more to support the industry in its efforts to change EU legislation that currently prohibits winemakers from reducing the ABV of wine by more than 2%? Think how much more quickly we could achieve the pledge to take 1 billion alcohol units out of the market if wine companies could legally do what many beer brands already are doing and reduce the strength of their brands. I know that Defra has done a great deal to assist but this issue was put on the EU table by the industry at least three or four years ago and progress has been painfully slow—mainly, I understand, because there is very little support from other member states. Will the Minister agree to speak to his Defra counterparts and fire them up again to do more to encourage other member states to help change this legislation in the interests of public health?
In my opinion, the beauty of the responsibility deal is that it is a partnership. There is a place for legislation, but if it can be balanced with voluntary action, self-regulation and personal responsibility, behaviour change and benefits to society will follow more quickly and more sustainably.
Earl Attlee
My Lords, I am sure that the Committee would like to hear from the noble Lord, Lord Rea, but if he speaks past 2.41 pm, he will be doing so at the expense of the Front Bench.
Lord Rea
My Lords, I must apologise for not putting my name down in time last night; I forgot that that would have to be done early.
I will plunge straight in with my question to the noble Earl, Lord Howe. A recently published scoping review, which has been referred to by two other speakers this afternoon, states in its conclusion that,
“targets should be ambitious and a robust monitoring system should be in place … some of the most effective voluntary agreements are those with substantial disincentives for non participation and costly sanctions for non compliance”.
Does the noble Earl feel that the responsibility deal measures up to those requirements? How will non-compliance be measured and assessed?
It would be interesting if the noble Earl could name a few of the targets of the responsibility deal and describe the process of defining them. Are meetings where they are discussed open, or does the industry cite commercial confidentiality? Can he write to me giving the names of all the manufacturers and retailers who have signed up to the different sections of the responsibility deal and the pledges to which they have agreed? Were any suggestions for pledges made by the Department of Health but not agreed to by participating firms? For example, we know that the drinks industry was opposed to minimum pricing. Once the pledge is made, how legally binding is it and what penalties, if any, are there for breaching it?
In closing, I declare an interest as a trustee of Health Forum UK, which is a well known health policy group concerned with the prevention of non-communicable disease, which gives rise to the greatest cost to the NHS and social services and greatest suffering to the population.
Baroness Hayter of Kentish Town
My Lords, I should declare that I am a patron of a charity that picks up those with drink problems, the Blenheim Trust. We should all thank the noble Lord, Lord Clement-Jones, for bringing this subject to us today and introducing the voluntary partnership, which is part of the nudge campaign to help people to make healthier choices. However, our Science and Technology Committee expressed its major doubts about the effectiveness of agreements with commercial organisations, particularly where there are conflicts of interests. The Labour Party shares those concerns. We are sceptical whether a voluntary approach can address those barriers to a healthy diet and lifestyle, which are threatening a public health crisis.
The responsibility deal covers alcohol, food, health at work and physical activity. Success on each of those has been questioned. Handing over significant responsibility is part of the reason for that querying, especially where there is no parallel government action. In the case of alcohol, we have seen no reduction of the drink-drive level, zero funding for Alcohol Concern and, despite Mr Cameron’s pledge, no action on minimum pricing.
As has been mentioned, six health bodies, including the BMA, declined to participate in the alcohol deal because of its alcohol commitment, where the industry claimed that it would,
“foster a culture of responsible drinking, which will help people to drink within guidelines”—
without, of course, any evidence of that. Those health bodies were concerned that the project gave,
“inadequate recognition of the need to reduce alcohol-related harm”,
that there was no indication of alternative actions if the pledges did not reduce harm and that,
“the pledges were those of the alcohol industry rather than of health bodies”.
The BMA, as has been mentioned, considered that voluntary agreement with the industry was inadequate—perhaps I should go on and quote the rest of what it said—because the industry has, “conflicts of interest”. It said that,
“the state should put the health of citizens before commercial freedom”.
On food, the Government have made a welcome announcement on front-of-pack labelling. We welcome that but, within days, it was undermined. Only 60% of foods will be covered, according to our figures, because Coca-Cola, Cadbury, United Biscuits, Unilever and Heinz will not take part. How can food labelling work if key players refuse to sign up? Of course, there are things that the industry can do and has done. Heineken took one high-strength low-cost product off the market.
Central to the problem is that the responsibility deal agenda is that of the industry—that is, education, choice and labelling—rather than of the health bodies, which talk about price and availability. The lesson of cigarettes is that regulation makes the difference. Higher prices and banning smoking in public places are what reduced heart attacks. Professor Hunter, giving evidence to the committee in another place, said that he was,
“disturbed at the shift”,
by the Government,
“from being a nanny to being a nudger”.
He recalled that interventions “shoving people”, such as with the ban on smoking, were effective, whereas the effect of nudging was little supported by evidence.
Where is the shoving? Where is the standardised cigarette packaging? Andrew Lansley said that packaging helped to recruit smokers and wanted to look at the idea of plain packaging. That, of course, was before the Conservatives hired Lynton Crosby, whose company has represented tobacco firms and has campaigned against standardised packaging in Australia.
On physical activity, the Government’s record is abysmal. There has been a drop in sports participation, an end of free swimming for the under-16s and over-60s, and reduced funding for the School Sport Partnerships. Where is Mr Cameron’s promise on minimum unit pricing? Has that disappeared because of lobbying by the drinks industry? It started in Scotland, first against the policy and then by a legal challenge; now in England it is at it again, with a campaign entitled, “Why should responsible drinkers pay more?”, even though it would cost moderate drinkers only 28p a week. Its website urges people to tweet the message to MPs.
The Opposition support anything that the industry does to reduce the cost of alcohol to the NHS and elsewhere. The noble Baroness, Lady Coussins, has mentioned some of the companies with lower alcohol strengths—Stella, Budweiser, Becks, John Smith’s, Carlsberg and Strongbow. There is a long list, and there are some new lower-strength drinks such as Carling Zest, Foster’s Radler, Carlsberg Citrus and Guinness Mid-Strength. These are to be welcomed and enjoyed—particularly, in my case, the Guinness Mid-Strength. But we need smaller glasses in pubs and restaurants and smaller containers, including 250 millilitre cans for beer. Is it really acceptable that a large wine glass with 14% wine contains more than the daily safe drinking level for a woman? How responsible is that?
Let us ask the industry to focus on what is in its remit—alcohol strength, measures and responsible advertising. However, along with the Independent and the WHO, we agree that we should not let the drinks industry set policy on alcohol. And where are the Government? The pledges are supposedly underwritten by the threat of legislation, but where is that? Could the Minister outline the Government’s responsibility for the targets that have been mentioned and for reducing alcohol-related harm? Could he tell noble Lords when David Cameron’s commitment to minimum unit pricing will be implemented?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank my noble friend for securing this debate and all speakers for their constructive and thoughtful contributions.
The responsibility deal is an ambitious and far-reaching challenge to business to lead the way in creating an environment that helps people to make healthier choices. It is a wide agenda; essentially, it taps into the potential for businesses to improve public health in areas where doing nothing is simply not an option. However, the something to be done is not necessarily best done by Government. Organisations signing up to the deal commit to take voluntary action to improve public health; there is no legally binding element to this. These actions are expressed as a series of pledges covering food, alcohol, physical activity and health at work. The deal has always had strong ministerial support. The Secretary of State chairs a plenary group of senior representatives which oversees the deal. Furthermore, each network is supported by a Minister, and both the Secretary of State and his ministerial team continue to hold meetings with both potential and existing responsibility deal partners.
In the two years since launch, the number of partners has tripled to over 500, with new partners joining every week. People are already benefiting from the deal. For example, the World Health Organization considers us to be a world leader on salt reduction; between 2001 and 2011, average daily salt intakes dropped from 9.6 grammes to 8.1 grammes. Through the responsibility deal all the major UK retailers, together with a number of key manufacturers and caterers, have committed to achieve further reductions. Every one gramme reduction in people’s average daily salt intake will prevent over 4,000 premature deaths and save the NHS £288 million every year.
Responsibility deal partners are also providing consumers with more information about their food through the out-of-home calorie labelling pledge. Over 70% of high street fast food and takeaway meals sold have calories clearly labelled. Partners signed up to this pledge provide one-third of all meals sold on the high street. As regards alcohol, we now have over 90 companies committed to putting labels on drinks by December 2013, with clear alcohol units, lower-risk drinking guidelines and warnings about drinking during pregnancy. This will help people to understand better how much they are drinking, and to drink within the lower-risk guidelines.
Following the success of the London 2012 Olympic and Paralympic Games, there has never been a better time for organisations to promote the benefits of being active. The physical activity pledges cover increasing participation by employees, for example by walking and cycling to work, and working with local communities. Over 300 organisations have signed up to the health at work pledges. These pledges include ensuring that employees with chronic conditions and mental health conditions can remain in work and are managed in the best way possible, and promoting stop-smoking services and staff health checks. Encouraging workplace health schemes which contribute to individual health and reducing absenteeism will also improve productivity.
In recent months we have concentrated on two pledges which, as mentioned by many noble Lords, could have a great impact: calorie and alcohol unit reduction. So far 34 leading food companies have signed up to a pledge to help the population reduce its calorie intake. They have committed to actions including product reformulation, reducing portion sizes, providing information and shifting their marketing mix towards lower calorie options.
The alcohol unit reduction pledge brings together over 30 producers and retailers. By December 2015 they will reduce the number of alcohol units in the annual UK market by one billion, a drop of around 2%. It is estimated that in a decade this will result in many hundreds fewer alcohol-related deaths and many thousands fewer hospital admissions.
We will continue to increase the reach and impact of the deal by signing up new partners, making sure that there are appropriate pledges for all sectors and, where needed, developing new pledges. For example, a new front-of-pack nutrition labelling scheme was published last week, as noble Lords have mentioned. We welcome the support of the retailers and manufacturers that are pledged to adopt the scheme, which will help consumers to choose healthier, more balanced diets. The noble Lord, Lord Brooke, and the noble Baroness, Lady Hayter, were right to say that there is still a way to go before we sign up anything like enough, but we are confident that more organisations will agree to support the scheme over the coming months. Those who have signed up will want to make sure that they provide information which is helpful to their customers.
We also announced a pledge on domestic violence. This includes guidance to help organisations support colleagues experiencing harassment, stalking, violence or abuse. The Government are committed to evidence-based policy. In addition to the updates that partners submit each year, the Department of Health has commissioned an independent evaluation of the responsibility deal. The deal is a complex public health initiative and an assessment of its impact is challenging. Our strategy is therefore to evaluate the specific aims and objectives of the deal as a whole and a small number of pledges. The evaluation will be undertaken by researchers from the Policy Innovation Research Unit at the London School of Hygiene and Tropical Medicine.
A scoping study has been completed and included an international review of voluntary agreements between Governments and business, published in the journal Health Policy. The key message is that voluntary agreements, if properly implemented and monitored, can offer an effective policy approach. The main evaluation started this year and will run over three years. It is made up of a number of strands including examining the overall operation of the deal by engaging with its partners and key stakeholders; an in-depth analysis of a number of case studies; and measuring the public health impact of selected pledges. We will receive interim feedback wherever that is possible.
I have been asked a number of questions and I will cover as many as I can. I undertake to write to those noble Lords whose questions I have not covered. My noble friend Lord Clement-Jones spoke about the evaluation. I want to emphasise that the responsibility deal is only one stream of our policy activity. The evaluation of the deal looks at the mechanism as a whole plus a selection of case studies across the networks. The excellent schemes that my noble friend referred to have been operating for a number of years and are organised by other bodies, so they will not be evaluated as part of the responsibility deal evaluation.
A number of noble Lords, including my noble friend and the noble Baroness, Lady Hayter, have expressed scepticism on the concept of nudging. There is a difference between nudging and what we are trying to do with the responsibility deal, which is to bind companies into voluntary agreements. Nudges, such as providing information or advertising healthy products, form an effective part of a range of different public health interventions set out in the Nuffield ladder of intervention. Actions further up the ladder include enabling choice, guiding choice and restricting or even eliminating choice.
We adopt a range of approaches across our public health policy, depending on the level of harm caused and the target population. For example, we take actions higher up the ladder of intervention where children are at risk. The responsibility deal is, I emphasise, just part of this. Moreover, not all the actions taken within the deal are nudges. For example, the removal of trans fats from a wide range of companies’ products restricts choice and is not a nudge.
In answer to the noble Lord, Lord Rea, pledges are not proposed by the department but are proposed and developed by members of the respective networks. That is appropriate because we want meaningful pledges to which companies can put their names and undertake to abide by. The scoping review’s recommendation on voluntary agreements and robust targets was another issue raised by the noble Lord, who also asked whether targets were the same as pledges. The answer is no: some of the deal’s pledges, such as out-of-home calorie labelling, alcohol labelling, alcohol unit reduction and salt reduction, include milestones or targets in their wording. For other pledges, mainly those relating to health at work and physical activity, it would not be suitable to include a target. I will send the noble Lord a complete list of the organisations who have signed up.
The noble Lord, Lord Brooke, spoke about public health industry support for the deal and whether the deal was valid without it. A number of key public health organisations, including the Faculty of Public Health and the Association of Directors of Public Health, support the deal and are signed up as partners to it.
I agree with the noble Baroness, Lady Masham, that there is a need to educate young people on the risks of alcohol consumption. We are introducing an education and prevention pledge for schools which will secure investment to co-ordinate and initiate well evidenced alcohol prevention and education programmes for children and young people. We expect to launch that later this year. The noble Lord, Lord Brooke, asked what was being done on minimum unit pricing. The answer is that no decision has yet been made. We have received extensive submissions in response to the recent consultation and are considering all the views and all the evidence before making a decision in due course. Alcohol calorie labelling is a complex issue, which I know the noble Lord is aware of, but it is something that the Alcohol Network is looking into, and I will pass the noble Lord’s comments to the chairs of that network.
I apologise to other noble Lords that I have run out of time, but to tackle these challenges—obesity, harmful alcohol consumption, physical inactivity and reducing the prevalence of non-communicable diseases —we should not be scared to engage in and use the reach of business to achieve mutually beneficial aims. I thank the noble Baroness, Lady Coussins, for what she said in that context. Improving public health will always be the cumulative effect of sustained collective activity over time. There is no silver bullet. Public health is everyone’s responsibility and I hope that I have reassured my noble friend, in particular, that the responsibility deal is a fundamental part of an ongoing process to improve the health of the nation over the lifetime of this Parliament and beyond.