1 00:00:00,660 --> 00:00:03,690 Hello. Good evening. It's very much coming along. 2 00:00:03,990 --> 00:00:08,430 It's absolutely my turn to invite my party, 3 00:00:08,730 --> 00:00:15,420 who has an enormously long title as a senior visiting fellow in the Primary Care Unit at the Institute for Public Health at University of Cambridge. 4 00:00:15,690 --> 00:00:18,780 But you can all go to his being allowed to write. 5 00:00:19,590 --> 00:00:25,860 So he's a sociologist by training. A distinguished academic has been to a number of institutions, including teaching here, 6 00:00:25,860 --> 00:00:28,650 because we just don't know what it is to teach it really as well. 7 00:00:28,950 --> 00:00:34,080 And published widely with sort of interest in sort of methods and philosophy of evidence based medicine, 8 00:00:34,090 --> 00:00:37,830 completely appropriate if you want a bit of that and that sort of prevention, 9 00:00:38,010 --> 00:00:43,200 health inequality, behavioural change, non-communicable diseases, end of life care and amongst many other things. 10 00:00:43,920 --> 00:00:47,700 Some of you may have seen on TV heard his dulcet tones on the Today programme. 11 00:00:48,210 --> 00:00:54,260 That was when he was between 2005 and 14. The director of the Centre for Public Health at Nice. 12 00:00:54,270 --> 00:01:00,450 You can go to his throat if you want to for that one working to to produce public health health guidance. 13 00:01:01,800 --> 00:01:06,350 And I think the public will be fairly confident that Michael Crichton is a seasoned hand, 14 00:01:06,350 --> 00:01:09,299 that speaking truth to power at various levels of government, 15 00:01:09,300 --> 00:01:16,530 at the families of various persuasions, 25 to 40 and a whole bunch of different types of governments. 16 00:01:17,220 --> 00:01:24,510 So he's chaired again countless committees and also advised the W.H.O. on things, for example, the social determinants of health. 17 00:01:24,780 --> 00:01:28,620 So he's the absolute perfect person for the topic tonight. 18 00:01:29,310 --> 00:01:34,380 I hope you will enjoy the talk. He's an excellent speaker, which is why I've invited him along. 19 00:01:34,650 --> 00:01:38,640 And please, can we extend the extremely warm welcome to my colleague? 20 00:01:41,700 --> 00:01:45,510 Right. Okay. Well, good evening, everyone. Great to be here. 21 00:01:45,900 --> 00:01:49,120 Back again. The title is A Play on Words. 22 00:01:49,350 --> 00:01:55,389 This was a song that came out during the war. Nice work if you can get it by the Andrews Sisters. 23 00:01:55,390 --> 00:01:59,550 And it's the signature Glenn Miller band. But nice work if you can do it. 24 00:02:00,750 --> 00:02:07,559 I chose as my subtitle and that would become clear as I proceed, because I'll be talking about the problem, 25 00:02:07,560 --> 00:02:14,760 I suppose, in essence, of trying to apply real estate principles to developing public health guidelines. 26 00:02:14,970 --> 00:02:16,800 In the work that I did at night. 27 00:02:16,950 --> 00:02:25,920 In particular, I'll use the example of the guideline we produced on alcohol misuse prevention and the furore that that produced. 28 00:02:26,280 --> 00:02:31,589 And when Jeff mentioned speaking truth to power, sometimes when you speak truth to power, 29 00:02:31,590 --> 00:02:35,970 you finish up very bruised and extremely bruised after all of that. 30 00:02:36,570 --> 00:02:41,190 Now nice, the National Institute for Health and Care Excellence has got two offices, 31 00:02:41,190 --> 00:02:46,140 one just on the top of a square by the arch in London and one in Manchester. 32 00:02:46,770 --> 00:02:54,300 And I worked in both offices, and it's job still, although I left it at the end of 2014 when I retired formally. 33 00:02:55,800 --> 00:03:01,830 Its job is to develop national guidance for the National Health Service and the wider public health community on, 34 00:03:02,100 --> 00:03:05,210 amongst other things, the promotion of good health and prevention. 35 00:03:05,220 --> 00:03:09,750 And it's that bit that I was responsible for health promotion and disease prevention, 36 00:03:10,110 --> 00:03:18,720 non-communicable diseases principally, but some infectious diseases like HIV or hepatitis, tuberculosis and so on. 37 00:03:18,900 --> 00:03:24,570 And that's what we did. Now Nice is an interesting, very interesting organisation to work for. 38 00:03:24,570 --> 00:03:29,580 It was I was there for ten years and it was probably the best ten years of my professional career. 39 00:03:29,580 --> 00:03:39,569 I really, really enjoyed it. We the what we did was based on a set of methodological guidelines and this was the one that was current. 40 00:03:39,570 --> 00:03:48,090 When I left the 2012 version, it updated at least twice since I left, and there's now a unified guideline manual on how you do it. 41 00:03:48,720 --> 00:03:58,020 If you look on the nice website, you'll be able to find it. But the basic principles enshrined in this guidance really originate with this man. 42 00:03:58,200 --> 00:04:04,560 So anyone learning that is a photograph of Archie Cochrane toward the end of his life. 43 00:04:05,280 --> 00:04:14,910 And in 1972, Archie Cochrane published a book called Effectiveness and Efficiency Random Reflections on Health Services, 44 00:04:15,210 --> 00:04:21,900 probably the most revolutionary book published in Medical Biomedical Sciences that decade. 45 00:04:21,930 --> 00:04:25,469 I would argue in it he asked a series of questions, 46 00:04:25,470 --> 00:04:32,280 and those questions became the basis not just of evidence based medicine as it has evolved and developed, 47 00:04:32,670 --> 00:04:36,510 but also the principles guiding the way Nice developed its guidelines. 48 00:04:36,780 --> 00:04:41,129 So first question do we know whether intervention X a problem? 49 00:04:41,130 --> 00:04:44,400 Why is effective? Is that drug effective? 50 00:04:44,700 --> 00:04:53,909 Does it work? 1974 I was a 1972 as a first year undergraduate, so the year I was went to university, 51 00:04:53,910 --> 00:04:59,670 someone wrote a book asking, Do we know whether this drug works for that condition? 52 00:05:00,510 --> 00:05:06,630 Second question is how do we know it's effective? On what basis do we make the judgement? 53 00:05:08,070 --> 00:05:11,790 Do we know whether it's more or less effective than doing something else? 54 00:05:12,870 --> 00:05:19,550 Is drug X better than drug Y for the same condition or a, B, C, D, any number of other? 55 00:05:19,560 --> 00:05:30,750 But on what basis do we make the judgement of effectiveness that Cochran's Archie Cochran's crime was with his medical professional colleagues? 56 00:05:31,080 --> 00:05:37,530 Because he said those judgements about effectiveness of drugs were being made on the basis of what people learned in medical school, 57 00:05:38,400 --> 00:05:43,260 what drug reps told them, what they've done ever since they'd been in medical practice. 58 00:05:44,100 --> 00:05:50,040 And his fundamental point was it wasn't based on scientific evidence, it was based on a whole lot of other things. 59 00:05:50,790 --> 00:05:56,910 In effect, the Cochrane's analysis of the medical profession, the way it is work is a sociological analysis, though it doesn't call it that. 60 00:05:57,480 --> 00:06:03,840 It's about the power struggle. He's particularly critical of the power of the London medical schools and the 61 00:06:04,230 --> 00:06:09,840 professoriate in those medical schools dominating the way practice was practised. 62 00:06:10,920 --> 00:06:15,300 And he has another really interesting question Does anyone know what anything costs? 63 00:06:16,650 --> 00:06:20,310 Answer In 1972, with nobody did, 64 00:06:21,510 --> 00:06:26,729 there was no systematic or even other systematic way of working out what the 65 00:06:26,730 --> 00:06:30,270 system was spending on treatments and whether it was good value for money. 66 00:06:32,370 --> 00:06:39,510 Is it cost effective? And actually, Cochrane worked out a very crude form of what economists would call. 67 00:06:39,660 --> 00:06:42,920 Cost benefit analysis. It costs so much for this. 68 00:06:42,930 --> 00:06:44,760 What's the benefit you get back from it? 69 00:06:45,750 --> 00:06:53,010 He was no economist for sure, but he made common cause with a professor of economics at the University of York called Alan Williams, 70 00:06:53,640 --> 00:07:00,780 who would develop what was developing a system for evaluating the cost effectiveness of medical interventions, 71 00:07:01,380 --> 00:07:05,250 which in the end came came to be called cost utility analysis. 72 00:07:05,530 --> 00:07:13,859 If you've ever heard anyone talk about the quality adjusted life here or the quality as a measure of cost effectiveness, that was Alan Williams. 73 00:07:13,860 --> 00:07:22,380 Well, Williams and Cochran like of course they became friends and colleagues and work together to set about answering that question. 74 00:07:22,530 --> 00:07:32,430 And of course, at the heart of everything this does, is, is, is X or Y not just effective, but is it cost effective against a notional threshold? 75 00:07:32,670 --> 00:07:39,630 Another colleague in Cochrane asked another question What are the dangers posed to 76 00:07:39,640 --> 00:07:44,220 the public of interventions and actions about which we are scientifically upset? 77 00:07:45,180 --> 00:07:54,540 Why do we do treatments that we have no evidence, sound evidence that it is more or less effective than either doing nothing or doing something else? 78 00:07:55,710 --> 00:08:04,500 All the interventions are dangerous. Now, remember, this question was posed around, of course, contemporaneous with the thalidomide scandal, 79 00:08:05,430 --> 00:08:09,600 the biggest drug scandal probably of the late 20th century. 80 00:08:10,710 --> 00:08:13,560 But, of course, it wasn't only solidified that this was dangerous. 81 00:08:13,860 --> 00:08:23,850 The many other medications and the degree of danger was not systematically and in an evidence based kind of way, being put through, being analysed. 82 00:08:24,750 --> 00:08:27,780 And if they're dangerous or worthless, why do we use them? 83 00:08:28,530 --> 00:08:33,120 And Cochrane's answer to that was It's habit, it's practice, it's what we've always done. 84 00:08:33,930 --> 00:08:43,379 And you might imagine, of course, this wasn't the most welcome book published, welcome book published that the medical profession received in 1972, 85 00:08:43,380 --> 00:08:48,360 but has been profoundly influential and gives us at least two strands of follow through. 86 00:08:48,390 --> 00:08:51,510 One being the development subsequently of evidence based medicine. 87 00:08:51,780 --> 00:09:00,359 Because when David Sackett and his colleagues in the late eighties really posed the same questions about the effectiveness, undoing, 88 00:09:00,360 --> 00:09:04,259 doing evidence in an evidence based way, they were able to say, actually, 89 00:09:04,260 --> 00:09:09,210 nothing much has changed since Cochrane published his book nearly two decades earlier. 90 00:09:11,340 --> 00:09:19,220 So that knowledge, the translation of those principles, very simple terms, turns on a number of key ideas. 91 00:09:19,230 --> 00:09:22,020 So the original guiding principles for public health at Nice. 92 00:09:22,470 --> 00:09:34,680 Now I need to explain to you a nice began the year it started was 1919 9920 years old next year at a party hoping anyhow. 93 00:09:34,890 --> 00:09:39,630 1999 and when it started its remit was only new drugs. 94 00:09:40,680 --> 00:09:46,410 Is this drug a cost effective way of doing X or Y treatment? 95 00:09:47,280 --> 00:09:53,790 And it was one of the innovations of the incoming New Labour government of that period, 96 00:09:54,720 --> 00:09:59,610 and they would they decided they put an ice in place to stop what they called the postcode lottery. 97 00:10:00,030 --> 00:10:05,849 The fact that if drugs were available, it really depended on where you lived, 98 00:10:05,850 --> 00:10:10,290 whether it was made available to in your local hospital where the local clinicians could prescribe it. 99 00:10:10,290 --> 00:10:13,480 And of course, practice worldwide was highly, very effective. 100 00:10:15,000 --> 00:10:25,290 So nice it was put in place to look at drug interventions and to determine nationally what should be prescribed in the National Health Service. 101 00:10:25,950 --> 00:10:29,880 But it may seem rather odd that we've reached by now 1999. 102 00:10:30,210 --> 00:10:37,470 There's a national system is put in place for the first time to determine which drugs the NHS should prescribe and which they shouldn't. 103 00:10:37,950 --> 00:10:45,480 That was a significant advance and a significant change and of course one in a sense we take largely for granted now. 104 00:10:45,740 --> 00:10:51,900 Now, in order to do that, we developed this methodology, as I said, based on Cochrane's that evidence based medicine principles. 105 00:10:52,560 --> 00:11:02,730 But 1999, 2005, another revolution in the sense took place when the Department of Health published its research and development strategy, 106 00:11:02,730 --> 00:11:12,120 published the research a couple of years before that, and argued that we should put public health on a similar evidence based footing. 107 00:11:13,500 --> 00:11:17,110 So what was public health based on before then, if it wasn't on evidence? 108 00:11:17,130 --> 00:11:22,200 Well, all sorts of things, some of which were evidential and there were cohort investigations, 109 00:11:22,950 --> 00:11:30,720 but there wasn't much by way of systematic, evidence based public health data published in 2002, a manifesto saying it should be. 110 00:11:31,290 --> 00:11:39,450 And as a consequence of that, in 2005, Nice were given the task of developing evidence based public health and a whole team of people in. 111 00:11:39,640 --> 00:11:50,170 You myself were transferred from one part of the NHS into Nice in order to deliver the NHS public health on an evidence based footing. 112 00:11:51,280 --> 00:11:58,180 Now, in order to do that derived from Cochrane's ideas, we had a number of basic principles to start us up, 113 00:11:59,410 --> 00:12:03,370 to use the best available evidence to answer a defined question. 114 00:12:04,150 --> 00:12:13,450 So not just what is good evidence, but if we want to do X, say we want to provide doctors with the best evidence about helping patients to give up 115 00:12:13,450 --> 00:12:19,630 smoking what is in their interests of sit downstairs a couple of hours I was waiting 116 00:12:19,900 --> 00:12:25,510 to catch up with Che and there were a group of people arguing vehemently about how 117 00:12:25,510 --> 00:12:30,220 important education was and how it succeeded in helping to people give up smoking. 118 00:12:30,730 --> 00:12:33,720 I suppose in a general sense is true. Actually, that's not the evidence. 119 00:12:33,760 --> 00:12:40,390 And I didn't interrupt and say sorry wrong, but I just listened with interest. 120 00:12:40,660 --> 00:12:47,400 But anyway, what's the best available evidence to ask a defined question like what's the best way to help a patient get out of smoking or whatever? 121 00:12:48,970 --> 00:12:52,390 The question is then formulated using the so-called eco framework. 122 00:12:54,040 --> 00:13:01,659 So that means you identify p the population specify well who is you're interested in what's the intervention? 123 00:13:01,660 --> 00:13:05,410 The I c stands for the comparator. 124 00:13:05,410 --> 00:13:11,410 What you're what you're comparing it with. It's not in some you know, it has to be relative to something else. 125 00:13:11,890 --> 00:13:14,260 And finally oh the outcome. 126 00:13:15,520 --> 00:13:24,930 So using that framework which has become sort of ingrained in evidence based medicine, we try to apply that principle to public health interventions. 127 00:13:25,510 --> 00:13:31,000 Then you engage in a process of searching sensitively and comprehensively for the evidence, 128 00:13:32,050 --> 00:13:35,170 doing something which a decade before have been impossible. 129 00:13:35,440 --> 00:13:40,120 We now had computer databases. We now could search the world literature. 130 00:13:40,340 --> 00:13:48,310 You know, when I did my Ph.D., it was done on a kind of it wasn't entirely on the basis of looking in the references list, 131 00:13:48,490 --> 00:13:53,890 choosing evidence, choosing references to follow up, and hoping that you hadn't missed anything, 132 00:13:54,550 --> 00:14:00,070 and hoping your supervisor had missed anything and hoping you had missed something the external examiner had written. 133 00:14:01,780 --> 00:14:08,260 But it was guesswork. Now, of course, you could check it out in about 15 seconds online. 134 00:14:08,920 --> 00:14:14,470 So we were able to search online sensitively and comprehensively for that evidence. 135 00:14:15,700 --> 00:14:18,980 Then having found the evidence, you make an assessment, 136 00:14:19,990 --> 00:14:26,650 and this is quite an important step in the process because just cos it's published doesn't mean it's brilliant evidence. 137 00:14:26,770 --> 00:14:32,530 It means it's been published and it's been through a process that has deemed it to pass the threshold. 138 00:14:33,400 --> 00:14:39,530 But one of the surprising things doing this job at Nice and previously when I was working 139 00:14:39,550 --> 00:14:47,140 at a development agency is just how much bad research is actually published in high, 140 00:14:47,140 --> 00:14:52,420 what we now call high impact jobs. You have to be deeply sceptical. 141 00:14:52,450 --> 00:14:57,550 Now, why is that? What it, of course, is because if you're a scientist at the university, 142 00:14:57,730 --> 00:15:05,130 the enormous pressure on you to publish and enormous pressure on you to publish findings that appear to be interesting and have impact. 143 00:15:05,380 --> 00:15:12,760 There's not much of a career to be filled out of finding out that nothing much worked or nothing much happens if an investigation is done, 144 00:15:13,180 --> 00:15:16,270 although actually in a scientific sense, has written it before. 145 00:15:16,720 --> 00:15:20,230 But nonetheless, there's an enormous pressure on academics to publish. 146 00:15:20,740 --> 00:15:29,140 There's an enormous pressure on them to the view their data to maximum effect, 147 00:15:30,280 --> 00:15:35,830 which means that you have to treat any published finding with scepticism. 148 00:15:36,250 --> 00:15:42,100 And we would often go back to original papers and sometimes additional data to check 149 00:15:42,100 --> 00:15:46,990 out whether something was really as accurate as the paper might lead you to believe. 150 00:15:47,450 --> 00:15:50,620 Now, I'm not saying everyone's a crook, arguing that for a moment. 151 00:15:50,860 --> 00:15:54,910 There are a number of pressures on everyone to get stuff out and people do. 152 00:15:55,360 --> 00:16:00,310 But that does mean that the review process is not what it is. 153 00:16:00,500 --> 00:16:06,150 You know, one has to you can't second guess. Then there's another idea in all of this. 154 00:16:06,160 --> 00:16:14,410 It's not just one study, but the principle of evidence based medicine is that the more studies you have with a similar kind of set of findings, 155 00:16:14,410 --> 00:16:23,560 the more likely it is to be accurate. And there are various statistical techniques, including better analysis and various other forms of synthesis. 156 00:16:23,800 --> 00:16:28,450 So you accumulate evidence and try and be as broad as you can. 157 00:16:29,140 --> 00:16:34,780 And it's very seldom that you would find or you would rely on one study and one study 158 00:16:34,780 --> 00:16:39,190 only because since all these evidence based data stuff can go what we've learned. 159 00:16:39,800 --> 00:16:47,810 Is that very often early trial data comes out as much more significant, both statistically and clinically, 160 00:16:48,530 --> 00:16:53,750 than what happens when the drug has been in use for five years, ten years, 20 years. 161 00:16:54,050 --> 00:17:03,950 You get to sort of the effect sizes tend to become more modest in routine practice than they often are in original trials. 162 00:17:05,090 --> 00:17:08,000 And that's an interesting thing in itself, I guess. 163 00:17:09,680 --> 00:17:16,930 Now the process is it was in two parts reviewing the evidence with our broad and inclusive searches in public health. 164 00:17:16,940 --> 00:17:23,170 We were very keen to take a pluralistic approach to that, by which I think we were not going to find it. 165 00:17:23,180 --> 00:17:32,540 So simply to randomised controlled trials we wanted. First of all in many areas in public health there were no randomised controlled trials anyway. 166 00:17:32,540 --> 00:17:36,500 So had we restricted ourself to that we wouldn't have had to say very much at all. 167 00:17:37,460 --> 00:17:42,020 There are some areas where there are good trial data. Smoking is one important area. 168 00:17:43,250 --> 00:17:51,200 Another one we had a lot of very good trials is on brief interventions in alcohol misuse, which is another good example where there's a trial basis. 169 00:17:51,440 --> 00:17:59,120 But in stuff like what's the best way to do sex education for 12 year olds wasn't much at all. 170 00:17:59,280 --> 00:18:11,000 Well, now in other areas, like if you're trying to look at the most the optimal way to increase people taking up physical activity, 171 00:18:11,750 --> 00:18:15,140 you clearly need a whole lot of other stuff to build into what you're doing. 172 00:18:15,500 --> 00:18:20,800 A much public health is premised on the idea that you can change people's behaviour, 173 00:18:21,530 --> 00:18:25,070 that you know, if I tell you something is good for you, you'll jolly well do it. 174 00:18:25,520 --> 00:18:34,580 Well, actually, no, that's not the way it works. Or if I educate you, if I get the message across, you will stop all the issues. 175 00:18:35,060 --> 00:18:38,510 I'll do something different. Well, the world just isn't like that. 176 00:18:39,350 --> 00:18:48,020 And so what you need is an evidence base that helps you understand the reality of both people's lives and their propensity to change, 177 00:18:48,020 --> 00:18:54,320 or, more importantly, to resist these kinds of interferences in their in their lives. 178 00:18:54,860 --> 00:19:00,379 I was watching a repeat on my fire stick on Sunday evening, 179 00:19:00,380 --> 00:19:07,430 I think it was of a programme by Jeremy Paxman on The Great War and amongst a very short little episode, 180 00:19:07,430 --> 00:19:12,080 in a short little snippet in the middle of the programme, 181 00:19:12,560 --> 00:19:19,280 he mentions the fact that one of the things that alarmed the government enormously by 1972, at the height of the war, 182 00:19:19,550 --> 00:19:25,640 when the number of cases of venereal disease among the soldiers that were running at casualty levels, 183 00:19:25,640 --> 00:19:29,420 not dissimilar to casualty levels in some parts of the battlefield. 184 00:19:29,690 --> 00:19:35,660 So they clearly had to do something and they were trying to get soldiers to change their sexual behaviour, 185 00:19:35,930 --> 00:19:41,600 as well as the many women who were servicing the needs of the soldiers in various kinds of ways. 186 00:19:42,260 --> 00:19:48,650 And they were sort of patrols sent out to go and stop these women of ill repute affecting the army. 187 00:19:49,100 --> 00:19:53,450 It was actually the forerunner organisation of what eventually became the Health Education Council, 188 00:19:53,930 --> 00:19:59,420 and then the Health Education Authority began life in in the middle of the First World War. 189 00:20:00,260 --> 00:20:02,510 But all of that is premised on the notion that if you could, 190 00:20:02,510 --> 00:20:10,280 you tell a soldier it's jolly bad idea to go and get venereal disease, especially the next day to be shot by the Germans. 191 00:20:10,550 --> 00:20:16,180 But that's not the most compelling way to think so. 192 00:20:16,670 --> 00:20:20,510 But the broader point in all of this is if you're interested in those sorts of things, 193 00:20:20,510 --> 00:20:27,500 you need an evidence base that embraces psychology, sociology, economics, anthropology, marketing. 194 00:20:28,820 --> 00:20:34,490 All of those sorts of things are part of your evidence base, not just the randomised controlled trials, 195 00:20:34,790 --> 00:20:39,050 although if they're there they are very, very healthy up to a point. 196 00:20:41,090 --> 00:20:49,010 But then we face the another issue which isn't just the nature of the subject matter and the nature of the evidence being brought about the evidence. 197 00:20:49,520 --> 00:20:57,650 But it's the problem within. Once you start to look for evidence beyond the evidence in clinical medicine, what you find is this series of things. 198 00:20:57,800 --> 00:21:02,570 First, in many arenas, there simply is no there is a dearth. 199 00:21:02,570 --> 00:21:10,400 There aren't very many. In other words, good outcome studies answering the question What does what works or does it play? 200 00:21:11,210 --> 00:21:20,360 It just wasn't much material there on this, but on on the kind of almost everything that we took on as a public health team at Nice, 201 00:21:20,930 --> 00:21:28,729 it's a very empty cupboard and there was still less answering the important question, 202 00:21:28,730 --> 00:21:32,720 realist question what works for whom and under what circumstances. 203 00:21:33,290 --> 00:21:36,650 That was an absolute rarity to find that kind of material. 204 00:21:36,800 --> 00:21:39,320 It was a little bit of it, but, you know, it was a tiny, tiny. 205 00:21:39,380 --> 00:21:44,990 Any fragment of what was available to us when we came to review the evidence as we found it. 206 00:21:45,320 --> 00:21:47,380 Around about 2005, the start. 207 00:21:50,000 --> 00:21:57,710 Third point, the evidence such as it is, is often too imprecise to determine the relationship between the intervention and the outcome. 208 00:21:58,820 --> 00:22:06,950 You don't know if there is a relationship, might be an association, but what the nature of it might be and how it might work. 209 00:22:07,310 --> 00:22:11,810 So you can do something about it. It's clearly very difficult. 210 00:22:12,650 --> 00:22:17,120 One of the briefs we were given quite early on was with respect to sex education, 211 00:22:17,600 --> 00:22:22,370 and it was based on the curious idea from the Department for Education, 212 00:22:22,370 --> 00:22:33,240 Department of Health that something that happened in a classroom with a class of 11 year olds would have an impact on an event. 213 00:22:33,290 --> 00:22:39,730 Yet after the sexual debut of those children at the age of 15 or 16, whenever, 214 00:22:40,300 --> 00:22:44,510 but certainly not when they were just having the lesson at the age of 11, 215 00:22:45,440 --> 00:22:53,510 you think about the causal pathway and the mechanisms along that route from learning something in a classroom to your behaviour as an adult. 216 00:22:55,070 --> 00:22:59,600 The more prosaic aspect of it, you learn some geography when you're a school. 217 00:23:00,650 --> 00:23:04,730 Not just how helpful is that when you're trying to get around a city you've never been to before? 218 00:23:05,060 --> 00:23:12,650 The useless, isn't it? Well, I'm going to say the way a civil service thought about sex education was pretty much on the grounds. 219 00:23:12,650 --> 00:23:19,760 You know, we teach you this at 11. Everything's going to be fine at the age of 1815 or whatever it might be. 220 00:23:20,570 --> 00:23:27,049 But this isn't those two examples are part of a broader pattern of stuff. 221 00:23:27,050 --> 00:23:33,940 We do stuff, put out advertisements and device labels on things. 222 00:23:34,910 --> 00:23:38,270 Will that have an effect? Well, and if it does, how does it work? 223 00:23:38,660 --> 00:23:41,690 Remains unknown what the evidence is. 224 00:23:41,690 --> 00:23:42,620 And help us understand. 225 00:23:43,940 --> 00:23:52,220 Another important point is the logical study and the methodological quality of many of the studies as we found them then was actually very poor. 226 00:23:52,850 --> 00:24:01,130 You could spend all of your time picking faults in the world because, well, first of all, even the best, there's no such thing as a perfect study. 227 00:24:02,480 --> 00:24:09,140 But many studies fall well short of anywhere near perfection or even very, very good. 228 00:24:11,740 --> 00:24:19,120 Part of the problem is that the questions that scientists, academics and researchers turn their mind to are research questions. 229 00:24:19,510 --> 00:24:25,750 And if you're trying to develop a guideline on any of these factors, you've got rather different questions. 230 00:24:25,990 --> 00:24:29,980 Like, you want to know, does it work? But how does it work? 231 00:24:31,090 --> 00:24:34,660 And in the real sense, you want to know for which population will it work? 232 00:24:34,780 --> 00:24:38,440 For which people will it work, under what circumstances and way? 233 00:24:39,880 --> 00:24:47,200 Because unless you know those things try to develop a guideline with any form of precision, it's extremely difficult. 234 00:24:48,640 --> 00:24:55,330 So the evidence in the left, most of those things are not because the research questions turn their attention to something different. 235 00:24:56,380 --> 00:25:01,200 By and large, there are big gaps in it. So some areas we simply do not think about. 236 00:25:02,800 --> 00:25:07,510 When we came to look at accident prevention in children, it's another one we got. 237 00:25:08,950 --> 00:25:12,849 It proved to be very tricky. And that's an area you might have thought. 238 00:25:12,850 --> 00:25:21,850 There must be loads of evidence about how to design a playground, how to stop children, how to stop children hurting themselves, 239 00:25:21,850 --> 00:25:26,259 but also giving children enough freedom to learn to run and jump and play and climb 240 00:25:26,260 --> 00:25:30,700 trees and all those things that help with physical development and cognitive skills. 241 00:25:32,020 --> 00:25:35,430 Actually, it was a pretty bare environment. 242 00:25:37,040 --> 00:25:43,540 Then, of course, when you find the evidence, it often says something rather different to what most people think. 243 00:25:43,600 --> 00:25:51,549 It says most people think it saves. There's a there's a curious we put it you this way. 244 00:25:51,550 --> 00:25:56,220 I before I went to work in the National Service, I've been in academic for 27 years. 245 00:25:56,250 --> 00:26:00,220 I taught in medical schools and business schools in frightful places. 246 00:26:00,770 --> 00:26:06,520 There were some things I really thought I knew. And I've been teaching them to students for decades. 247 00:26:07,090 --> 00:26:14,350 And it was a very salutary experience to suddenly come across that it's actually what you thought was an absolute certainty. 248 00:26:14,980 --> 00:26:19,330 I used to be pretty on uncertain ground. 249 00:26:20,110 --> 00:26:28,840 One of the best certainties we used to always argue in public health about fluoridation as being a protector of from tooth decay. 250 00:26:30,340 --> 00:26:40,570 Well, it is. But the evidence on which we from which we know that turns out to be pretty poor in terms of scientific understanding, 251 00:26:40,840 --> 00:26:46,720 which is exploited by the anti fluoridated. But even some of the things that seem absolutely obvious. 252 00:26:47,740 --> 00:26:50,860 And of course. Well, I give some other examples as we go along. 253 00:26:51,640 --> 00:26:55,180 Well, how do you solve this problem? What are the conventional solutions? 254 00:26:55,210 --> 00:27:02,440 Well, one is the so-called evidence hierarchy, and this is what was pushed in evidence based medicine and in clinical medicine in particular. 255 00:27:02,830 --> 00:27:06,730 And you might have seen one of these sorts of diagrams or these sorts of tables, 256 00:27:07,600 --> 00:27:15,669 which is the so-called evidence hierarchy with high quality matter analysis of systematic reviews of randomised controlled trials, 257 00:27:15,670 --> 00:27:23,620 all randomised controlled, including cluster randomised controlled trials with very low risk of bottom at the very top and at the bottom. 258 00:27:24,400 --> 00:27:29,530 Expert opinion and formal consensus. No non analytic studies, for example, 259 00:27:29,530 --> 00:27:38,260 case reports and case series that actually means almost everything in the social sciences is down here and non asked and so on. 260 00:27:39,190 --> 00:27:43,780 By the way, it's called the hierarchy of evidence. It's actually a hierarchy of methods. 261 00:27:44,020 --> 00:27:50,800 If you look closely, not high ranking medical services, it's quite misnamed almost all the way through. 262 00:27:51,310 --> 00:27:59,139 But this has been a useful device. When you're thinking about areas where you've got rich data derived from trials, 263 00:27:59,140 --> 00:28:03,940 it does help you sort out the poor from the mediocre, from the good and so on. 264 00:28:04,480 --> 00:28:10,240 And it makes your task a lot easier because you can then focus on the stuff at the top rather than worrying about these other things. 265 00:28:10,690 --> 00:28:16,989 But if you're in an area like public health or social care or education or any other area outside of that, 266 00:28:16,990 --> 00:28:22,840 where there are three areas are very much at the top end, you have to come and work with this other material. 267 00:28:25,480 --> 00:28:29,020 Another part of the solution is we need more randomised controlled trials. 268 00:28:29,500 --> 00:28:32,050 Interestingly, when Cochrane published his book, 269 00:28:32,560 --> 00:28:39,430 he argued passionately that randomised controlled trials were the best way to make judgements about how good evidence was. 270 00:28:39,610 --> 00:28:43,900 And I think in that context he was right about the right side and it was a significant. 271 00:28:44,410 --> 00:28:54,220 What's interesting about 1972, the randomised controlled trial wasn't standard practice in clinical medicine or clinical or medical research. 272 00:28:54,520 --> 00:28:58,870 There were some famous ones going back to the 1940, but there wasn't. 273 00:28:59,290 --> 00:29:03,040 It wasn't uniform. Now it is. 274 00:29:03,300 --> 00:29:09,970 I think that's been a big revolution. But there are some areas in the social, social care field education, public health. 275 00:29:10,630 --> 00:29:13,540 You can't do randomised control so it doesn't help much. 276 00:29:14,940 --> 00:29:19,830 The conventional solution is all about trying to control the bias, because actually that that table, 277 00:29:20,340 --> 00:29:27,390 so-called hierarchy of evidence, the idea is the things that float to the top of it are less likely, least likely to be biased. 278 00:29:27,660 --> 00:29:30,000 Those at the bottom are more likely to be biased. 279 00:29:30,810 --> 00:29:37,890 And the idea is you can, if not eliminate bias, you can certainly limit the damages, the damage it can do. 280 00:29:38,730 --> 00:29:42,870 And of course, evidence accumulation, synthesis, building of the evidence base, 281 00:29:42,930 --> 00:29:46,860 more and more material about all these different things is also supposed to help. 282 00:29:47,760 --> 00:29:53,249 The core idea of which those conventional solutions are based is one of confidence that the relationship 283 00:29:53,250 --> 00:29:59,690 between the dependent and the independent variable is free or as free as you can make it from bias. 284 00:29:59,700 --> 00:30:07,589 The internal validity question refer to that question in turn is premised on the idea 285 00:30:07,590 --> 00:30:11,340 that the relationship between the dependent independent variable is a real one. 286 00:30:12,180 --> 00:30:17,910 In other words, it's not an artefact of the way the experiment was done or any other confounding factor. 287 00:30:18,310 --> 00:30:27,630 It's a real relationship. But that might be helpful if you're thinking about the relationship between two molecules and a molecule or 288 00:30:27,640 --> 00:30:33,810 two molecule into the interaction going on in the human body after the administration of a particular drug. 289 00:30:34,770 --> 00:30:44,969 However, in the areas that I was investigating to work, the variables such as they are exist with a complex web of relationships. 290 00:30:44,970 --> 00:30:53,700 Empirically, you're not dealing with two variables with lots of variables that interact with each other in all sorts of ways. 291 00:30:54,570 --> 00:31:04,020 That's the nature of the reality. And worrying about the limitation of bias between two variables doesn't help much 292 00:31:04,440 --> 00:31:09,180 when you're thinking about the arguments within these complex works of relationship. 293 00:31:10,110 --> 00:31:18,810 And of course, the notion of one variable acting on another is premised on a particular view of cold facts causes why derive from physics, 294 00:31:18,840 --> 00:31:27,720 not from human sciences. And if you do something that could argue works pretty well in physics, that, you know there's more to life than physics, 295 00:31:28,860 --> 00:31:35,670 but it's more the less conventional approach which we adopted in public health at night was to, 296 00:31:35,900 --> 00:31:43,380 but quite unequivocally borrow this notion of the program theory from possible. 297 00:31:43,980 --> 00:31:56,280 Now, I'd worked with the reports from around 92,000 as we began to think about these problems in evidence and the way that 298 00:31:56,580 --> 00:32:04,260 and this might not necessarily the way that all critical realists or realist thinkers think of the program theory. 299 00:32:04,260 --> 00:32:14,700 But my take on it was that what we used to lever our way into the problem was to say, What is it that people think makes an intervention work? 300 00:32:15,960 --> 00:32:21,540 What are policymakers? Why do policymakers believe, if they do this is going to have that outcome? 301 00:32:22,350 --> 00:32:30,300 And what are the stages along that pathway, which for the most part remain unstated that is supposed to lead to that happening? 302 00:32:30,900 --> 00:32:40,650 And that helped us to unravel all sorts of stuff that the trial based material looking at intervention and outcome simply didn't do. 303 00:32:41,040 --> 00:32:51,210 So our conduct and come overestimate or overstress just how important this idea was in helping us to rethink the nature of the problem. 304 00:32:52,380 --> 00:32:58,680 Because if we could work out why people thought things worked in a particular kind of way, we were then able to kind of get inside that, 305 00:32:58,950 --> 00:33:00,749 but not just like doesn't work like that, 306 00:33:00,750 --> 00:33:07,700 but what are your reasons for thinking that and what evidence would we need to fill in the logic models along the way? 307 00:33:08,490 --> 00:33:18,780 Really, really helpful. And of course, we used the standard CMO context mechanism, an outcome as a way of illuminating and getting to grips with it. 308 00:33:19,380 --> 00:33:24,960 And we even commissioned a number of realist reviews, and Jeff did one for us. 309 00:33:26,610 --> 00:33:34,200 We got the commission to look at how to prevent smoking in cars as a way of prevent protecting children 310 00:33:34,770 --> 00:33:39,509 and well obviously there's no evidence in randomised controlled trials or anything like that. 311 00:33:39,510 --> 00:33:47,500 So we commissioned the team working to try and Jeff to do exactly that and it took two wasn't it. 312 00:33:47,520 --> 00:33:50,700 Two very significant pieces of work I think came out of that. 313 00:33:51,780 --> 00:34:00,060 But the politics of it didn't work out at all because the Minister Brandis stopped us from doing the work. 314 00:34:00,650 --> 00:34:04,290 Andrew Lastly, the Secretary of State said, I don't want to know about smoking in cars. 315 00:34:04,290 --> 00:34:07,440 That's too much of an interference in ordinary people's lives. 316 00:34:07,740 --> 00:34:11,970 Now, this is just the part, the nanny state we don't want to set out. 317 00:34:12,930 --> 00:34:19,460 So we had to stop the program. The reviews are published and you can see them and read them and they're very interesting. 318 00:34:20,060 --> 00:34:25,280 Of course, politics is a funny thing because within about 18 months, Parliament, 319 00:34:25,490 --> 00:34:29,390 without any evidence, it's already decided to try and ban smoking in cars anyway. 320 00:34:30,200 --> 00:34:35,360 And even though they're right, it's still anyway. 321 00:34:35,400 --> 00:34:46,430 More on politics in a moment. The limits of the evidence, a lot of very important things that we came to realise by using this way of levering, 322 00:34:46,430 --> 00:34:49,489 open the evidence and what people thought was the evidence. 323 00:34:49,490 --> 00:34:53,900 Using a realist approach is of course the evidence doesn't speak for itself. 324 00:34:54,920 --> 00:35:00,650 There are a lot of people who, once you get good evidence, you've got the outside, but you don't. 325 00:35:01,070 --> 00:35:10,850 What you've got is good evidence. You then have to interpret that evidence in order to understand and apply it to whatever context you need to do so. 326 00:35:11,780 --> 00:35:14,479 So the amplification process is ever so important, 327 00:35:14,480 --> 00:35:23,830 but we go to a methodology textbook and try and find the chapter on interpreting evidence that's not about P 328 00:35:23,840 --> 00:35:31,460 values and significance tests and the mechanisms of interpreting evidence when you need other kinds of judgements. 329 00:35:31,910 --> 00:35:39,080 Terribly important. So there are well-defined scientific protocols and methods for scientific interpretation, 330 00:35:39,650 --> 00:35:46,370 many of them statistical, which help you determine whether you can trust statistical results. 331 00:35:47,570 --> 00:35:53,420 But the methods for understanding the processes of inference and judgement that scientists, people, 332 00:35:53,750 --> 00:36:02,120 particularly people trying to develop guidelines and using evidence or people using evidence to make policies or people 333 00:36:02,120 --> 00:36:10,700 using evidence to treat patients have to use inference and judgement that's much less well-defined in the literature. 334 00:36:11,840 --> 00:36:18,170 Is this obviously stuff of clinical judgement? And that's one very, very important part of this. 335 00:36:19,130 --> 00:36:28,520 But there's no equivalent of policy. Civil servants don't have to think about the nature of their clinical judgement and their policy. 336 00:36:28,700 --> 00:36:37,320 They just do it. And that's also true to some extent of guideline development, because really when you're doing a guideline, for instance, 337 00:36:38,180 --> 00:36:44,480 in the of question, not the internal political question or at least the extent of an innocent person is just as important. 338 00:36:44,960 --> 00:36:47,510 Does the empirical knowledge deal with the problem of issue? 339 00:36:49,070 --> 00:36:59,450 And as you have gathered from what I've said, the answer to that is usually partly or partially, but not in any sense of how we're applicable. 340 00:36:59,450 --> 00:37:03,490 Other data. You've got to hand the context and the circumstances. 341 00:37:05,810 --> 00:37:09,360 Can you apply them to the problem you've got way. 342 00:37:12,530 --> 00:37:21,410 Whatever it is. Can the scientific intervention of the trial or the study be transferred to the context? 343 00:37:23,350 --> 00:37:30,010 So if the study was done in Glasgow, how applicable would it be in Oxford? 344 00:37:31,390 --> 00:37:38,629 Well, of course it is. It would be great, but it might not be be very specific things about the nature of the Glaswegian experience, 345 00:37:38,630 --> 00:37:42,100 but wouldn't make it applicable in Oxford or even Edinburgh. 346 00:37:43,540 --> 00:37:46,330 All reported associations and the evidence causal. 347 00:37:47,050 --> 00:37:54,580 The assumption is that they are very often, although everyone looks at a certain association with correlation, 348 00:37:55,300 --> 00:38:01,990 but actually they are often treated as they were, of course. It sort of ramps up along the discussion and policy makers. 349 00:38:01,990 --> 00:38:08,950 Seldom I've ever been to statistics one a 1 to 1 to learn the difference between cause and correlation. 350 00:38:13,440 --> 00:38:18,870 What are the empirical studies tell us about the mechanisms involved, how it actually works along the path? 351 00:38:18,960 --> 00:38:27,480 Often almost nothing. And of course, we were dealing with relational and dynamic stuff. 352 00:38:28,670 --> 00:38:37,140 Trust with the realism of what was going. Which is to say that individuals and populations interact differentially through interventions. 353 00:38:37,860 --> 00:38:42,990 So not everyone responds in the same way to whatever it might be. 354 00:38:43,120 --> 00:38:52,080 That's true, of course, of a drug as well. Everyone in this room, if you all Jeff, administered exactly the same dose of a drug to all of you. 355 00:38:52,470 --> 00:38:59,520 There would be biological variation, which would mean that if you all had the same disease, some of you would respond. 356 00:38:59,520 --> 00:39:02,790 Absolutely. On the other hand, there will be outliers. 357 00:39:02,790 --> 00:39:07,470 Some might get very, very ill and terrible side effects, and some might do no good at all. 358 00:39:08,430 --> 00:39:11,910 So we know that biological variation in drug treatments, 359 00:39:12,590 --> 00:39:20,640 but there's huge social variation in responses to policy interventions or public health interventions or any other kind of interventions. 360 00:39:21,990 --> 00:39:24,660 And of course, when you have a public health intervention, 361 00:39:24,780 --> 00:39:36,060 like a publicity campaign or like a provision of information about the dangers of X or Y, not only do people respond differently, 362 00:39:36,210 --> 00:39:42,390 the way those interventions are themselves delivered will vary all around the country huge amounts of 363 00:39:42,390 --> 00:39:49,070 variation which make a big difference when it comes to the perspectives we used to apply the w w w test, 364 00:39:49,460 --> 00:39:56,410 w w w test and ask the question of will it work on a wet Wednesday week when everyone's gone home? 365 00:39:56,560 --> 00:40:04,200 Individual investigation. And that's quite a good acid rain test anyway, 366 00:40:05,130 --> 00:40:12,450 because if it ain't going to work when the scientists have gone home and the enthusiasts have gone on to their next enthusiasm, 367 00:40:13,230 --> 00:40:21,210 it's not going to be much good to you. We also face a huge amount of opposition to all of this. 368 00:40:21,570 --> 00:40:32,010 Back in 2000, four five, when it was proposed that Nice would take home public health, there was a furore saying No you can't, you, you can't do this. 369 00:40:32,490 --> 00:40:36,510 Of course evidence based medicine should not be applied to public health at all. 370 00:40:36,590 --> 00:40:43,590 It's so different, you know, ever going to work. And I got a lot of flak because I was the head of the unit doing it. 371 00:40:44,070 --> 00:40:49,350 I was called all sorts of things. And one occasion was a meeting and I was called the Godfather of Positivism. 372 00:40:51,000 --> 00:40:55,010 So I sort of helped change. I thought that was so bad. 373 00:40:55,050 --> 00:40:59,400 But, you know, there was it was like it's all gone now. 374 00:41:00,090 --> 00:41:05,940 But there was a huge amount of opposition from all sorts of quarters, especially in the public health community at large, 375 00:41:06,510 --> 00:41:11,400 saying that what we were seeking to do was simply wrong and we shouldn't even bother. 376 00:41:11,910 --> 00:41:18,120 We should carry on with what we've always done. Public Health A Not the way many doctors respond to the original party conference book. 377 00:41:19,320 --> 00:41:21,480 But the other end of the spectrum is another objection. 378 00:41:22,620 --> 00:41:27,779 Because the minute we started changing, even said we need bigger evidence, like a more pluralistic approach. 379 00:41:27,780 --> 00:41:30,600 We need to look at sociology, psychology, economics, all of that. 380 00:41:31,890 --> 00:41:37,650 The even fundamentalists started attacking us because we weren't upholding the values of IBN. 381 00:41:38,220 --> 00:41:43,049 We used to call them the Taliban tendency because they gave us a really hard time. 382 00:41:43,050 --> 00:41:46,470 You know, we can't influence judgement. 383 00:41:46,590 --> 00:41:49,950 What's that got to do with evidence based medicine? Facts are facts are facts. 384 00:41:50,910 --> 00:41:57,810 Well, they're actually. But you know that that was so I was getting criticism on all sides. 385 00:41:58,230 --> 00:42:02,299 I'm. Television you talk about. 386 00:42:02,300 --> 00:42:10,490 It's great. Well, let's take a specific example of how this all plays out in the real world of politics. 387 00:42:11,180 --> 00:42:16,250 In 2010, we published this guideline for alcohol use disorders Preventing Harmful Drinking. 388 00:42:18,140 --> 00:42:20,840 And we published it in June 2010. 389 00:42:21,860 --> 00:42:30,200 So in other words, about three weeks, four weeks after the general election that brought the coalition into office, the civil servants. 390 00:42:30,200 --> 00:42:39,740 Interesting, it advised us to wait till after the election to release the guideline because Labour was lukewarm on taking on alcohol anyway. 391 00:42:40,640 --> 00:42:45,170 It taken from 1990, from 2005 right through. 392 00:42:45,530 --> 00:42:49,519 It took five years before we really got going on alcohol and that was because the 393 00:42:49,520 --> 00:42:56,089 Labour Government just wasn't really very interested in the simple of said wait, 394 00:42:56,090 --> 00:43:00,140 we did. And they said, well if there's a new government they might be enthusiastic about this. 395 00:43:00,920 --> 00:43:05,660 They were wrong. They reckon. Let's say that Labour had been. 396 00:43:07,130 --> 00:43:15,770 So there were a number of recommendations made which were based on some of the best available evidence that we had. 397 00:43:16,070 --> 00:43:21,980 So that came from economic modelling, that came from all sorts of powerful stuff. 398 00:43:23,120 --> 00:43:30,260 And this first one was the most contentious recommendation to consider introducing a minimum price per unit of alcohol. 399 00:43:30,980 --> 00:43:36,410 That would mean that you if you price the product. 400 00:43:38,410 --> 00:43:41,770 According to the power of the alcohol in. 401 00:43:41,770 --> 00:43:52,090 It's not any other criteria in fact that the levels we were looking at, if you went to a good restaurant and ordered a bottle of wine, 402 00:43:52,390 --> 00:43:57,340 it would have made no difference to the price of your wine because you're already paying well over anything like a minimum unit. 403 00:43:58,060 --> 00:44:05,560 If you go into a pub and pay £3.80 for a pint of bitter, that's well over the minimum price. 404 00:44:05,570 --> 00:44:15,370 What we were interested in was the fact that it was those cheap vodkas, cheap ciders, which were retailing at very, very low prices, 405 00:44:16,000 --> 00:44:24,550 were precisely the products which the heaviest drinkers migrate to and also the products that underage drinkers go for. 406 00:44:24,730 --> 00:44:31,180 That's the one children buy. That's the one underage drink. It's not so a minimum unit price. 407 00:44:31,180 --> 00:44:36,309 And the reason that you could get that stuff so cheaply is effectively because 408 00:44:36,310 --> 00:44:41,320 what's going on is the retailers don't charge the customer the excise duty, 409 00:44:41,320 --> 00:44:44,560 they pay it, and that's a loophole. 410 00:44:44,710 --> 00:44:49,750 So the solution to that is going to be a pricing recommendation, 411 00:44:49,900 --> 00:44:55,330 regularly review the minimum unit price and then also alcohol works saying get rid of alcohol duties. 412 00:44:55,330 --> 00:45:00,220 What U.S. think about them in a in a in a more in a different kind of way. 413 00:45:00,550 --> 00:45:03,160 Some of the data is a fragment of the data, 414 00:45:03,160 --> 00:45:10,149 but with a minimum unit price of $0.40 per unit of alcohol and the potential savings in millions we rent health will 415 00:45:10,150 --> 00:45:19,090 affect about 18.3 million crime about 6.8 absenteeism about 13.2 quite big numbers the economists came up with. 416 00:45:20,260 --> 00:45:25,900 And it's a bottle actually, the kind of the economists that worked on this with us, the group from Qaa, 417 00:45:26,260 --> 00:45:33,820 which is the School of Health and associate of research at University of Sheffield, particularly led by a colleague called Petra meyer. 418 00:45:34,300 --> 00:45:43,000 And the models they use their with a basis for this, the way the Scottish Government took this forward and did achieve minimum price in Scotland. 419 00:45:43,360 --> 00:45:47,290 So this wasn't some kind of back of the envelope stuff. This was as good as it gets. 420 00:45:47,290 --> 00:45:52,060 I think in terms of the scientific data, we also focussed on availability. 421 00:45:53,470 --> 00:45:58,209 Consider the revision to the licensing legislation to ensure there's a link between the 422 00:45:58,210 --> 00:46:04,600 availability of alcohol or taking account when licences are issued and alcohol related harm. 423 00:46:05,890 --> 00:46:11,560 Immediate sanctions on premises in breach of their licences, having two underage children, for example, 424 00:46:12,010 --> 00:46:18,969 and make the health body the responsible authority in England for licensing, as is the case in Scotland. 425 00:46:18,970 --> 00:46:23,530 That's marketing. This was a very interesting area. 426 00:46:23,860 --> 00:46:32,230 I consider a revision to the advertising codes to ensure that when the Advertising Standards Authority sets its rules, 427 00:46:34,390 --> 00:46:42,280 the proportion of the audience who are receiving the message is under 18, who aren't supposed to be buying drinks legally is considered. 428 00:46:43,390 --> 00:46:54,340 There was no duty for that to happen at all. Another one we looked at to see that children radically protected where alcohol advertising is permitted. 429 00:46:55,180 --> 00:47:00,430 And this was an interesting one, alcohol advertising to children via new media. 430 00:47:01,510 --> 00:47:08,880 There are all sorts of products on this one where you could join the brand that, you know, 431 00:47:08,890 --> 00:47:14,310 go online as a child and join the club in the way that you could join the Teddy Bear Club or something. 432 00:47:15,580 --> 00:47:18,860 There was no regulation in social media at all. I don't know. 433 00:47:18,930 --> 00:47:25,059 We pointed that out. Licensing needed to be done rather more systematically. 434 00:47:25,060 --> 00:47:28,210 We argued and ensure sanctions were fully applied. 435 00:47:29,680 --> 00:47:34,330 We also spent a lot of time talking about brief interventions for alcohol misuse, 436 00:47:34,690 --> 00:47:38,020 people who already got problem drinking or there's a teachable moment. 437 00:47:38,560 --> 00:47:45,780 Obviously they've been arrested or something like that where brief interventions have been shown to be very effective with trial placement. 438 00:47:46,780 --> 00:47:47,110 Well, 439 00:47:48,820 --> 00:47:57,150 2nd of June day after we published the guideline was the headline in the Independent Government Rejects Health Watchdog's Alcohol Alcohol Policies. 440 00:47:57,160 --> 00:48:10,690 That's not helpful we still have to an about bar and this was an extract from the piece government clashed with its medical advisers. 441 00:48:10,690 --> 00:48:11,589 Yes, they certainly did. 442 00:48:11,590 --> 00:48:18,450 The Department of Health put out a briefing the afternoon after we published the guidelines saying that Nice didn't understand the evidence. 443 00:48:20,230 --> 00:48:27,280 It was a pretty risky strategy. That's what we said. Nice called for the introduction minimum price per unit. 444 00:48:28,510 --> 00:48:33,190 And it said and I said our recommendations based by more study. 445 00:48:33,760 --> 00:48:37,000 But the Health Secretary rejected the analysis and said ministers have said. 446 00:48:37,300 --> 00:48:41,080 Banning supermarkets and off licences and selling alcohol below cost price. 447 00:48:42,400 --> 00:48:43,750 And then this was an interesting one. 448 00:48:43,990 --> 00:48:51,280 It's not clear, he said, that our research examined specifically the regressive effect on low income families at minimum price, 449 00:48:52,090 --> 00:48:58,510 or proves conclusively that it's the best way to impact price on demand through other 450 00:48:58,510 --> 00:49:03,130 policies that were regressive that I don't think they were quite so anxious about. 451 00:49:04,480 --> 00:49:14,920 You go, No. 18 months later, having rejected the nice guideline, although it's still alive, it's never been rescinded. 452 00:49:15,730 --> 00:49:17,290 It's still there on the nice website. 453 00:49:17,560 --> 00:49:24,130 And it still constitutes, I think, the most systematic account of dealing with alcohol based on the evidence as it was then. 454 00:49:24,340 --> 00:49:31,270 And if anything, my reading of the evidence since 2010 has accumulated in favour of minimum pricing, 455 00:49:31,270 --> 00:49:38,230 particularly the high risk populations, children and very, very heavy can have no effect, 456 00:49:38,350 --> 00:49:43,880 one has to say, on middle class drinkers and their expensive bottles of wine because they're already paying what I felt, 457 00:49:44,740 --> 00:49:48,020 although that got lost completely in the media furore. 458 00:49:48,020 --> 00:49:55,840 Right. But a year or so later, two years later, the Government led by the by the Home Office, 459 00:49:55,990 --> 00:50:01,120 now not by the Department of Health, introduced its strategy or published its strategy. 460 00:50:01,360 --> 00:50:06,850 And many of the things that were in our guideline were in that strategy, although they were not taken up. 461 00:50:08,110 --> 00:50:16,720 It lost its way amidst all sorts of controversies, not least the number ten switched from being pro intermediate policy as a unit, 462 00:50:17,290 --> 00:50:22,180 and it became a rather embarrassing topic insofar as that is concerned. 463 00:50:23,140 --> 00:50:30,520 But what we were being told all the time is that we were just part of those trying to interfere with ordinary men and women's lives, 464 00:50:30,910 --> 00:50:34,650 telling them what was good for them, and just generally being a right nuisance. 465 00:50:34,750 --> 00:50:43,350 Those who said Mary Poppins. Also for many of us, she was a famous nanny. 466 00:50:43,770 --> 00:50:50,610 Very nanny, by the way. That's much. I used to get called in the Daily Mail. 467 00:50:50,620 --> 00:50:56,860 The chief nanny was great until I retired and I think seven days got the mantle to Connecticut. 468 00:50:58,180 --> 00:51:13,300 I was thinking those, you know, children, I don't think that what we've done now, but I'd just show you this quotation, which comes from the Times. 469 00:51:14,890 --> 00:51:18,950 The date is 1854 August. 470 00:51:18,970 --> 00:51:22,960 I have before anyone else, anyone here know what happened? 471 00:51:24,280 --> 00:51:28,150 Late in August, 1854. After this episode was published. 472 00:51:29,620 --> 00:51:37,750 The most famous public health events in 19th century. So there's an outbreak of cholera in Soho. 473 00:51:39,010 --> 00:51:46,780 And John Snow, the anaesthetist, Queen Victoria, with also an interest in public health hypothesised. 474 00:51:46,780 --> 00:51:55,120 It was a waterborne infection and it was one of the worst outbreaks of cholera in the late 1850s, in the eighth century. 475 00:51:55,390 --> 00:52:02,020 But weeks before that outbreak, the Time Times published this leading article in which it said The Nation, 476 00:52:02,710 --> 00:52:07,060 which is about the aggregate of us all, is little disposed to endure a medical time. 477 00:52:07,840 --> 00:52:15,040 Mr. CHADWICK That's Edwin Chadwick, one of the most well-known health reformers of the 19th century, leader of the sanitation movement. 478 00:52:15,460 --> 00:52:22,780 And Dr. South and Smith, who was the medical chief medical officer essentially in the field of health at the time, had been deposed. 479 00:52:23,110 --> 00:52:29,710 And it's this bit that I think is just astonishing. We prefer to take our chance of cholera than the rest. 480 00:52:30,160 --> 00:52:38,920 That'd be awfully good to have. And, you know, that's over 100 years ago, 160 odd years ago. 481 00:52:40,420 --> 00:52:43,750 And yet the debate still goes on between, you know, 482 00:52:44,020 --> 00:52:50,200 the state trying to protect the health of the population and the state interfering in the lives of the population. 483 00:52:50,380 --> 00:52:57,190 And actually, of course, if you do public health, it's always a trade off between the two because you know you're not going to please everybody. 484 00:52:57,550 --> 00:53:06,620 And clearly, certain public health forms of regulation are impositions on personal liberty and personal freedoms. 485 00:53:06,620 --> 00:53:12,250 There's no question about that. And it's a question, I suppose, that society itself has to agree. 486 00:53:12,640 --> 00:53:16,480 What's the point at which it will put up with these kinds of interferences? 487 00:53:17,170 --> 00:53:26,710 Like, smoking's a good example. So an interesting example is the first definitive study linking lung cancer to exposure to tobacco smoke. 488 00:53:27,130 --> 00:53:30,360 It's actually published in 1950 by Dolan. 489 00:53:30,370 --> 00:53:40,570 Here to let all of that stuff. 1952, there's a definitive paper offering a tentative causal account. 490 00:53:41,110 --> 00:53:45,399 Ten years later. 1962. The evidence is pretty well overwhelming. 491 00:53:45,400 --> 00:53:50,710 The Royal College of Physicians in the United Kingdom published its report on smoking and health, 492 00:53:51,280 --> 00:53:57,070 linking cigarette smoke not just to lung cancer, but to heart disease and severe bronchitis. 493 00:53:58,030 --> 00:53:59,850 Blood pressure and so on and so on. 494 00:53:59,890 --> 00:54:18,310 So the evidence in 1962, the smoking ban and the virtually normalisation of cigarette smoking comes about 67 years after the first paper. 495 00:54:19,480 --> 00:54:27,460 It took that long. The process and the process was exceedingly slow, but it's been extremely successful. 496 00:54:28,990 --> 00:54:35,290 But if you think about it, it's well, you know, imagine the cabinet. 497 00:54:35,590 --> 00:54:41,169 1962, Harold Macmillan, a lieutenant in the First World War. 498 00:54:41,170 --> 00:54:46,900 He's old school, old, old, old, old school. And the assembled politicians around the table. 499 00:54:48,550 --> 00:54:55,330 The Minister of Health, when the first paper was published of the 1952 papers How to Make Good Syrian McLeod. 500 00:54:55,780 --> 00:55:02,780 And at the press conference that Dalton Hill called to publicise that paper and invited the Minister of Health, 501 00:55:02,780 --> 00:55:07,059 he could have now the secretaries of the lung and McLeod's smoked through the 502 00:55:07,060 --> 00:55:11,050 entire press conference that was held at the Royal College of Physicians. 503 00:55:11,410 --> 00:55:16,900 Now you think, oh, hang on, it's the royal cottage. They even got ashtrays there for people to smoke school buses. 504 00:55:17,530 --> 00:55:24,970 When I went to university, 1971, it was routine for there to be ashtrays in lecture theatres, students smoked electric smoke. 505 00:55:25,330 --> 00:55:28,810 So the kind of fog of smoke. 1971. 506 00:55:29,410 --> 00:55:33,010 Now imagine again round. We're round with Macmillan round his cabinet table. 507 00:55:33,640 --> 00:55:39,350 Even if they had grass that said, actually, what we've got to do here is a virtual ban on smoking. 508 00:55:39,580 --> 00:55:43,000 We need to make it as invisible as possible in the public environment. 509 00:55:43,240 --> 00:55:46,930 We need to make it invisible in the retail environment. We need to educate people. 510 00:55:46,930 --> 00:55:53,530 We need to put the price up so high that it's it's virtually unaffordable and we need to normalise it. 511 00:55:54,220 --> 00:55:58,300 There would have been no appetite whatsoever politically to take that on. 512 00:55:59,020 --> 00:56:05,260 Not least because my guess would be three quarters of the men sitting around the table would be smoking. 513 00:56:07,900 --> 00:56:15,610 It's a bit like in the present day we've got a huge amount of evidence about environmental pollution and its damage on children's health. 514 00:56:16,330 --> 00:56:20,290 And I my guess is that in 50 years time someone might be standing around, recounted, 515 00:56:20,590 --> 00:56:25,840 how was it when they had all that evidence by the early part of the 21st century? 516 00:56:26,650 --> 00:56:30,340 Hardly anything was done to change that. 517 00:56:30,640 --> 00:56:39,490 Well, the answer is, of course, it's a slow process and smoking's a fairly easy one because it's one pathogen with one clear causal pathway. 518 00:56:40,630 --> 00:56:45,820 Thinking about the obesity epidemic and getting people to change the way they eat and drink, 519 00:56:45,820 --> 00:56:50,020 and it's a much bigger deal because we've all got to eat and we all have to drink. 520 00:56:51,100 --> 00:56:55,900 So we can't just say Let's ban it. Although I saw a spoof article in the Oxford University. 521 00:56:56,290 --> 00:57:01,030 A couple years ago, the student paper, which said they'd got the solution, it was to ban food. 522 00:57:04,980 --> 00:57:14,430 Anyway, it's my point is here is a problem, which is that not only does evidence not speak for itself, 523 00:57:15,210 --> 00:57:22,110 the fact is the evidence is part of a part of a political process, and it plays out in a political arena. 524 00:57:22,560 --> 00:57:32,100 And therefore, you need to be as clued up about the politics of evidence as you do about any P values you run on it or any other side. 525 00:57:34,300 --> 00:57:41,550 So my conclusion there clearly is an inter-relationship between policy and do 526 00:57:41,550 --> 00:57:46,800 bear in mind that policy making by civil servants is different to politics, 527 00:57:47,070 --> 00:57:49,110 which is what politicians engage in. 528 00:57:49,620 --> 00:57:57,360 They interact with each other, obviously, but they are different processes and evidence plays into both of them differently. 529 00:57:58,350 --> 00:58:01,770 Evidence is used. But, you know, 530 00:58:02,070 --> 00:58:12,510 I think we start with this evidence as we know evidence and go through all sorts of machinations and changes when it goes into that political process. 531 00:58:14,130 --> 00:58:23,220 I came to to realise, I suppose, all of how important it was to apply realist principles, the context, 532 00:58:23,220 --> 00:58:29,190 mechanism, outcome to the policy and politics and evidence interface as it was to any other. 533 00:58:30,290 --> 00:58:37,850 What's going on. You need to be as clued up about the process as what happens once the evidence is produced, once the evidence is out there, 534 00:58:38,180 --> 00:58:45,919 once the guideline has been made, and once the guideline is out, as you do to any of the other people, any of the other dimensions of that. 535 00:58:45,920 --> 00:58:49,910 So it's a kind of perhaps an extension of that broad idea. 536 00:58:51,510 --> 00:58:57,560 Even so, evidence based medicine has some fairly strong affinities, it seems to me, with realism, 537 00:58:59,210 --> 00:59:07,100 and in the sense that Sackett and his colleagues who pushed all this argued, believed, 538 00:59:07,100 --> 00:59:14,050 understood that things that happen in the human body don't happen for chance reasons. 539 00:59:14,060 --> 00:59:17,590 There are causes, but we don't always know what those causes are. 540 00:59:17,630 --> 00:59:26,290 And the job of IBM is to try to unravel. But as I've said at the end, it's not exactly the same thing as what we were doing at night. 541 00:59:26,300 --> 00:59:29,120 It was a derivative of and so on. 542 00:59:29,840 --> 00:59:38,360 Anyway, there's a series of things which I think that that's one of the factors going to put on for you to to see the series of references. 543 00:59:38,630 --> 00:59:46,880 So many of the things I've talked about here and beyond, some of the economics there, some of the problems of using different forms of evidence. 544 00:59:47,480 --> 00:59:54,709 And at the very end, this paper or this chapter in the book, 545 00:59:54,710 --> 01:00:00,290 edited by Nick Amil and colleagues called Doing Real Estate Research, which you come across. 546 01:00:01,010 --> 01:00:09,620 I've got a chapter in that and that describes and talks about in detail, particularly the alcohol controversy in in more detail. 547 01:00:09,620 --> 01:00:10,880 And I've spoken about it here. 548 01:00:11,120 --> 01:00:21,229 So lots of things you can read if you are might be so on the almost on the scope of sex I'll stop and as a chance if you want to ask questions, 549 01:00:21,230 --> 01:00:23,660 I guess. Great. Thank you very much, Michael.