Social determinants of health (such as income, social status, educational level, and physical or social environments) are firmly in the mainstream of health policy, exemplified by their inclusion in the government’s “Prevention is better than cure” policy paper.
Yet it is less obvious from that paper that the government has fully taken on board how disease prevention cannot solely be the role of the health system, but instead requires engagement from all of government with Health in All Policies. This may be harder politically, but as the former Mayor of New York Michael Bloomberg reportedly said while enacting anti-tobacco legislation, healthcare may save lives retail, but public health has the potential to save lives wholesale.
That is why it makes sense that Public Health England (PHE) has “operational autonomy” from government, so that it can provide “…government, local government, the NHS, Parliament, industry and the public with evidence-based professional, scientific expertise and support.”
The announcement of a partnership between PHE and the industry-funded charity GambleAware on the “Bet Regret” campaign, has caused concern among researchers, who have been calling for more independent research into the role of the gambling industry in the UK. The announcement seemed particularly surprising, given the negative response to PHE’s recent partnership with the drinks-industry-funded DrinkAware (“Drink Free Days”). The “Bet Regret” campaign bears the hallmarks of a typical industry-funded campaign, focusing on individual behaviours and responsibility. It appeared against a background of targeted advertisements by gambling companies promoting their products, with the first airing of the Bet Regret advert being bookended by gambling adverts.
PHE’s involvement with both DrinkAware and GambleAware campaigns raises important questions about how such decisions to partner with, or otherwise support industry-funded responsibility campaigns, come to be made, and the extent to which the processes underpinning these decisions are transparent and evidence-based.
In health and healthcare, the need to address conflicts of interest is well documented, and while many challenges remain, structures have evolved in an attempt to manage them. For example, assessment and commissioning of new medicines via NICE necessitates the involvement of the pharmaceutical industry (which has a conflict of interest), but this is accompanied by impartial assessment of evidence of cost-effectiveness.
One may argue with individual decisions, but the principles underpinning the work of NICE, such as transparency, objective criteria for which evidence is considered and by whom, and where and how the pharmaceutical industry may input, all help to ensure NICE remains operationally autonomous and evidence-based. In fact, NICE processes to an extent even acknowledge that greater conflicts of interest require a greater degree of disclosure: For tobacco companies submitting to consultations (for example on e-cigarettes), NICE refuses to list them as “stakeholders”, and publishes all correspondence with these companies in full on the NICE website.
If the healthcare sector adheres to transparent processes and requires a firm evidence base for “downstream” interventions (once people are ill) such as medicines and new technologies, then surely an organisation such as PHE should adhere to them even more closely for “upstream” interventions that focus on prevention. These have the potential for much greater impact, especially when they involve the gambling and alcohol industries, who have a much clearer conflict of interest, and therefore partnership is associated with greater risks.
The fact that PHE has decided to partner with industry-funded bodies suggests that if indeed such processes exist, they aren’t transparent, and they aren’t effective.
The evidence to guide such decisions is clear. Industry-linked “responsibility” campaigns have a long history, but little evidence of effectiveness, other than, unsurprisingly, evidence that they increase positive perceptions of the sponsors of the message or the behaviours in question. Such campaigns typically place responsibility on the individual and not on the broader determinants of health, or indeed, the manufacturers themselves. This is why it benefits harmful product manufacturers to fund such initiatives, just as it benefits them to oppose evidence-based policy that might impact on sales. Indeed, forming partnerships with government agencies via corporate social responsibility initiatives can help enable greater soft influence in public agencies. It is therefore not surprising that the “Bet Regret” campaign can be funded by the same industry that so recently fiercely opposed reducing the stakes of fixed odds betting terminals.
The evidence showing the public health benefits of partnering with industry is lacking, and the risks of such endorsements are high. That is why the WHO has recently stated in an email to staff that it will not engage with the alcohol industry when developing policy or implementing public health measures. In order to assure their own independence and accountability—and the public perception of independence—PHE should be a model of transparency. This transparency could include communicating clearly how the campaign was instigated and how the content and final form was developed, which experts were consulted and their input, and the evidence underpinning its effectiveness. To mitigate risks of undue influence, it should be clear where and how industry participated, demonstrating that it was constrained to areas it has competence in. If such a process were already in place—it is doubtful that such partnerships on responsible drinking or gambling campaigns would pass muster.
Carl Sagan famously said: “Extraordinary claims require extraordinary evidence.” Recent examples from public health also suggest that beyond that, extraordinary partnerships require extraordinary transparency.
Nason Maani Hessari is a Research Fellow within the Department of Health Services Research and Policy, at the London School of Hygiene and Tropical Medicine.
Conflicts of interest: None to declare.