Hello. Good evening. It's very much coming along.
It's absolutely my turn to invite my party,
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.
But you can all go to his being allowed to write.
So he's a sociologist by training. A distinguished academic has been to a number of institutions, including teaching here,
because we just don't know what it is to teach it really as well.
And published widely with sort of interest in sort of methods and philosophy of evidence based medicine,
completely appropriate if you want a bit of that and that sort of prevention,
health inequality, behavioural change, non-communicable diseases, end of life care and amongst many other things.
Some of you may have seen on TV heard his dulcet tones on the Today programme.
That was when he was between 2005 and 14. The director of the Centre for Public Health at Nice.
You can go to his throat if you want to for that one working to to produce public health health guidance.
And I think the public will be fairly confident that Michael Crichton is a seasoned hand,
that speaking truth to power at various levels of government,
at the families of various persuasions, 25 to 40 and a whole bunch of different types of governments.
So he's chaired again countless committees and also advised the W.H.O. on things, for example, the social determinants of health.
So he's the absolute perfect person for the topic tonight.
I hope you will enjoy the talk. He's an excellent speaker, which is why I've invited him along.
And please, can we extend the extremely warm welcome to my colleague?
Right. Okay. Well, good evening, everyone. Great to be here.
Back again. The title is A Play on Words.
This was a song that came out during the war. Nice work if you can get it by the Andrews Sisters.
And it's the signature Glenn Miller band. But nice work if you can do it.
I chose as my subtitle and that would become clear as I proceed, because I'll be talking about the problem,
I suppose, in essence, of trying to apply real estate principles to developing public health guidelines.
In the work that I did at night.
In particular, I'll use the example of the guideline we produced on alcohol misuse prevention and the furore that that produced.
And when Jeff mentioned speaking truth to power, sometimes when you speak truth to power,
you finish up very bruised and extremely bruised after all of that.
Now nice, the National Institute for Health and Care Excellence has got two offices,
one just on the top of a square by the arch in London and one in Manchester.
And I worked in both offices, and it's job still, although I left it at the end of 2014 when I retired formally.
Its job is to develop national guidance for the National Health Service and the wider public health community on,
amongst other things, the promotion of good health and prevention.
And it's that bit that I was responsible for health promotion and disease prevention,
non-communicable diseases principally, but some infectious diseases like HIV or hepatitis, tuberculosis and so on.
And that's what we did. Now Nice is an interesting, very interesting organisation to work for.
It was I was there for ten years and it was probably the best ten years of my professional career.
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.
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.
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.
So anyone learning that is a photograph of Archie Cochrane toward the end of his life.
And in 1972, Archie Cochrane published a book called Effectiveness and Efficiency Random Reflections on Health Services,
probably the most revolutionary book published in Medical Biomedical Sciences that decade.
I would argue in it he asked a series of questions,
and those questions became the basis not just of evidence based medicine as it has evolved and developed,
but also the principles guiding the way Nice developed its guidelines.
So first question do we know whether intervention X a problem?
Why is effective? Is that drug effective?
Does it work? 1974 I was a 1972 as a first year undergraduate, so the year I was went to university,
someone wrote a book asking, Do we know whether this drug works for that condition?
Second question is how do we know it's effective? On what basis do we make the judgement?
Do we know whether it's more or less effective than doing something else?
Is drug X better than drug Y for the same condition or a, B, C, D, any number of other?
But on what basis do we make the judgement of effectiveness that Cochran's Archie Cochran's crime was with his medical professional colleagues?
Because he said those judgements about effectiveness of drugs were being made on the basis of what people learned in medical school,
what drug reps told them, what they've done ever since they'd been in medical practice.
And his fundamental point was it wasn't based on scientific evidence, it was based on a whole lot of other things.
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.
It's about the power struggle. He's particularly critical of the power of the London medical schools and the
professoriate in those medical schools dominating the way practice was practised.
And he has another really interesting question Does anyone know what anything costs?
Answer In 1972, with nobody did,
there was no systematic or even other systematic way of working out what the
system was spending on treatments and whether it was good value for money.
Is it cost effective? And actually, Cochrane worked out a very crude form of what economists would call.
Cost benefit analysis. It costs so much for this.
What's the benefit you get back from it?
He was no economist for sure, but he made common cause with a professor of economics at the University of York called Alan Williams,
who would develop what was developing a system for evaluating the cost effectiveness of medical interventions,
which in the end came came to be called cost utility analysis.
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.
Well, Williams and Cochran like of course they became friends and colleagues and work together to set about answering that question.
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?
Another colleague in Cochrane asked another question What are the dangers posed to
the public of interventions and actions about which we are scientifically upset?
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?
All the interventions are dangerous. Now, remember, this question was posed around, of course, contemporaneous with the thalidomide scandal,
the biggest drug scandal probably of the late 20th century.
But, of course, it wasn't only solidified that this was dangerous.
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.
And if they're dangerous or worthless, why do we use them?
And Cochrane's answer to that was It's habit, it's practice, it's what we've always done.
And you might imagine, of course, this wasn't the most welcome book published, welcome book published that the medical profession received in 1972,
but has been profoundly influential and gives us at least two strands of follow through.
One being the development subsequently of evidence based medicine.
Because when David Sackett and his colleagues in the late eighties really posed the same questions about the effectiveness, undoing,
doing evidence in an evidence based way, they were able to say, actually,
nothing much has changed since Cochrane published his book nearly two decades earlier.
So that knowledge, the translation of those principles, very simple terms, turns on a number of key ideas.
So the original guiding principles for public health at Nice.
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.
1999 and when it started its remit was only new drugs.
Is this drug a cost effective way of doing X or Y treatment?
And it was one of the innovations of the incoming New Labour government of that period,
and they would they decided they put an ice in place to stop what they called the postcode lottery.
The fact that if drugs were available, it really depended on where you lived,
whether it was made available to in your local hospital where the local clinicians could prescribe it.
And of course, practice worldwide was highly, very effective.
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.
But it may seem rather odd that we've reached by now 1999.
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.
That was a significant advance and a significant change and of course one in a sense we take largely for granted now.
Now, in order to do that, we developed this methodology, as I said, based on Cochrane's that evidence based medicine principles.
But 1999, 2005, another revolution in the sense took place when the Department of Health published its research and development strategy,
published the research a couple of years before that, and argued that we should put public health on a similar evidence based footing.
So what was public health based on before then, if it wasn't on evidence?
Well, all sorts of things, some of which were evidential and there were cohort investigations,
but there wasn't much by way of systematic, evidence based public health data published in 2002, a manifesto saying it should be.
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.
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.
Now, in order to do that derived from Cochrane's ideas, we had a number of basic principles to start us up,
to use the best available evidence to answer a defined question.
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
smoking what is in their interests of sit downstairs a couple of hours I was waiting
to catch up with Che and there were a group of people arguing vehemently about how
important education was and how it succeeded in helping to people give up smoking.
I suppose in a general sense is true. Actually, that's not the evidence.
And I didn't interrupt and say sorry wrong, but I just listened with interest.
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?
The question is then formulated using the so-called eco framework.
So that means you identify p the population specify well who is you're interested in what's the intervention?
The I c stands for the comparator.
What you're what you're comparing it with. It's not in some you know, it has to be relative to something else.
And finally oh the outcome.
So using that framework which has become sort of ingrained in evidence based medicine, we try to apply that principle to public health interventions.
Then you engage in a process of searching sensitively and comprehensively for the evidence,
doing something which a decade before have been impossible.
We now had computer databases. We now could search the world literature.
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,
choosing evidence, choosing references to follow up, and hoping that you hadn't missed anything,
and hoping your supervisor had missed anything and hoping you had missed something the external examiner had written.
But it was guesswork. Now, of course, you could check it out in about 15 seconds online.
So we were able to search online sensitively and comprehensively for that evidence.
Then having found the evidence, you make an assessment,
and this is quite an important step in the process because just cos it's published doesn't mean it's brilliant evidence.
It means it's been published and it's been through a process that has deemed it to pass the threshold.
But one of the surprising things doing this job at Nice and previously when I was working
at a development agency is just how much bad research is actually published in high,
what we now call high impact jobs. You have to be deeply sceptical.
Now, why is that? What it, of course, is because if you're a scientist at the university,
the enormous pressure on you to publish and enormous pressure on you to publish findings that appear to be interesting and have impact.
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,
although actually in a scientific sense, has written it before.
But nonetheless, there's an enormous pressure on academics to publish.
There's an enormous pressure on them to the view their data to maximum effect,
which means that you have to treat any published finding with scepticism.
And we would often go back to original papers and sometimes additional data to check
out whether something was really as accurate as the paper might lead you to believe.
Now, I'm not saying everyone's a crook, arguing that for a moment.
There are a number of pressures on everyone to get stuff out and people do.
But that does mean that the review process is not what it is.
You know, one has to you can't second guess. Then there's another idea in all of this.
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,
the more likely it is to be accurate. And there are various statistical techniques, including better analysis and various other forms of synthesis.
So you accumulate evidence and try and be as broad as you can.
And it's very seldom that you would find or you would rely on one study and one study
only because since all these evidence based data stuff can go what we've learned.
Is that very often early trial data comes out as much more significant, both statistically and clinically,
than what happens when the drug has been in use for five years, ten years, 20 years.
You get to sort of the effect sizes tend to become more modest in routine practice than they often are in original trials.
And that's an interesting thing in itself, I guess.
Now the process is it was in two parts reviewing the evidence with our broad and inclusive searches in public health.
We were very keen to take a pluralistic approach to that, by which I think we were not going to find it.
So simply to randomised controlled trials we wanted. First of all in many areas in public health there were no randomised controlled trials anyway.
So had we restricted ourself to that we wouldn't have had to say very much at all.
There are some areas where there are good trial data. Smoking is one important area.
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.
But in stuff like what's the best way to do sex education for 12 year olds wasn't much at all.
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,
you clearly need a whole lot of other stuff to build into what you're doing.
A much public health is premised on the idea that you can change people's behaviour,
that you know, if I tell you something is good for you, you'll jolly well do it.
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.
I'll do something different. Well, the world just isn't like that.
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,
or, more importantly, to resist these kinds of interferences in their in their lives.
I was watching a repeat on my fire stick on Sunday evening,
I think it was of a programme by Jeremy Paxman on The Great War and amongst a very short little episode,
in a short little snippet in the middle of the programme,
he mentions the fact that one of the things that alarmed the government enormously by 1972, at the height of the war,
when the number of cases of venereal disease among the soldiers that were running at casualty levels,
not dissimilar to casualty levels in some parts of the battlefield.
So they clearly had to do something and they were trying to get soldiers to change their sexual behaviour,
as well as the many women who were servicing the needs of the soldiers in various kinds of ways.
And they were sort of patrols sent out to go and stop these women of ill repute affecting the army.
It was actually the forerunner organisation of what eventually became the Health Education Council,
and then the Health Education Authority began life in in the middle of the First World War.
But all of that is premised on the notion that if you could,
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.
But that's not the most compelling way to think so.
But the broader point in all of this is if you're interested in those sorts of things,
you need an evidence base that embraces psychology, sociology, economics, anthropology, marketing.
All of those sorts of things are part of your evidence base, not just the randomised controlled trials,
although if they're there they are very, very healthy up to a point.
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.
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.
First, in many arenas, there simply is no there is a dearth.
There aren't very many. In other words, good outcome studies answering the question What does what works or does it play?
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,
it's a very empty cupboard and there was still less answering the important question,
realist question what works for whom and under what circumstances.
That was an absolute rarity to find that kind of material.
It was a little bit of it, but, you know, it was a tiny, tiny.
Any fragment of what was available to us when we came to review the evidence as we found it.
Around about 2005, the start.
Third point, the evidence such as it is, is often too imprecise to determine the relationship between the intervention and the outcome.
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.
So you can do something about it. It's clearly very difficult.
One of the briefs we were given quite early on was with respect to sex education,
and it was based on the curious idea from the Department for Education,
Department of Health that something that happened in a classroom with a class of 11 year olds would have an impact on an event.
Yet after the sexual debut of those children at the age of 15 or 16, whenever,
but certainly not when they were just having the lesson at the age of 11,
you think about the causal pathway and the mechanisms along that route from learning something in a classroom to your behaviour as an adult.
The more prosaic aspect of it, you learn some geography when you're a school.
Not just how helpful is that when you're trying to get around a city you've never been to before?
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.
You know, we teach you this at 11. Everything's going to be fine at the age of 1815 or whatever it might be.
But this isn't those two examples are part of a broader pattern of stuff.
We do stuff, put out advertisements and device labels on things.
Will that have an effect? Well, and if it does, how does it work?
Remains unknown what the evidence is.
And help us understand.
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.
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.
But many studies fall well short of anywhere near perfection or even very, very good.
Part of the problem is that the questions that scientists, academics and researchers turn their mind to are research questions.
And if you're trying to develop a guideline on any of these factors, you've got rather different questions.
Like, you want to know, does it work? But how does it work?
And in the real sense, you want to know for which population will it work?
For which people will it work, under what circumstances and way?
Because unless you know those things try to develop a guideline with any form of precision, it's extremely difficult.
So the evidence in the left, most of those things are not because the research questions turn their attention to something different.
By and large, there are big gaps in it. So some areas we simply do not think about.
When we came to look at accident prevention in children, it's another one we got.
It proved to be very tricky. And that's an area you might have thought.
There must be loads of evidence about how to design a playground, how to stop children, how to stop children hurting themselves,
but also giving children enough freedom to learn to run and jump and play and climb
trees and all those things that help with physical development and cognitive skills.
Actually, it was a pretty bare environment.
Then, of course, when you find the evidence, it often says something rather different to what most people think.
It says most people think it saves. There's a there's a curious we put it you this way.
I before I went to work in the National Service, I've been in academic for 27 years.
I taught in medical schools and business schools in frightful places.
There were some things I really thought I knew. And I've been teaching them to students for decades.
And it was a very salutary experience to suddenly come across that it's actually what you thought was an absolute certainty.
I used to be pretty on uncertain ground.
One of the best certainties we used to always argue in public health about fluoridation as being a protector of from tooth decay.
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,
which is exploited by the anti fluoridated. But even some of the things that seem absolutely obvious.
And of course. Well, I give some other examples as we go along.
Well, how do you solve this problem? What are the conventional solutions?
Well, one is the so-called evidence hierarchy, and this is what was pushed in evidence based medicine and in clinical medicine in particular.
And you might have seen one of these sorts of diagrams or these sorts of tables,
which is the so-called evidence hierarchy with high quality matter analysis of systematic reviews of randomised controlled trials,
all randomised controlled, including cluster randomised controlled trials with very low risk of bottom at the very top and at the bottom.
Expert opinion and formal consensus. No non analytic studies, for example,
case reports and case series that actually means almost everything in the social sciences is down here and non asked and so on.
By the way, it's called the hierarchy of evidence. It's actually a hierarchy of methods.
If you look closely, not high ranking medical services, it's quite misnamed almost all the way through.
But this has been a useful device. When you're thinking about areas where you've got rich data derived from trials,
it does help you sort out the poor from the mediocre, from the good and so on.
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.
But if you're in an area like public health or social care or education or any other area outside of that,
where there are three areas are very much at the top end, you have to come and work with this other material.
Another part of the solution is we need more randomised controlled trials.
Interestingly, when Cochrane published his book,
he argued passionately that randomised controlled trials were the best way to make judgements about how good evidence was.
And I think in that context he was right about the right side and it was a significant.
What's interesting about 1972, the randomised controlled trial wasn't standard practice in clinical medicine or clinical or medical research.
There were some famous ones going back to the 1940, but there wasn't.
It wasn't uniform. Now it is.
I think that's been a big revolution. But there are some areas in the social, social care field education, public health.
You can't do randomised control so it doesn't help much.
The conventional solution is all about trying to control the bias, because actually that that table,
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.
Those at the bottom are more likely to be biased.
And the idea is you can, if not eliminate bias, you can certainly limit the damages, the damage it can do.
And of course, evidence accumulation, synthesis, building of the evidence base,
more and more material about all these different things is also supposed to help.
The core idea of which those conventional solutions are based is one of confidence that the relationship
between the dependent and the independent variable is free or as free as you can make it from bias.
The internal validity question refer to that question in turn is premised on the idea
that the relationship between the dependent independent variable is a real one.
In other words, it's not an artefact of the way the experiment was done or any other confounding factor.
It's a real relationship. But that might be helpful if you're thinking about the relationship between two molecules and a molecule or
two molecule into the interaction going on in the human body after the administration of a particular drug.
However, in the areas that I was investigating to work, the variables such as they are exist with a complex web of relationships.
Empirically, you're not dealing with two variables with lots of variables that interact with each other in all sorts of ways.
That's the nature of the reality. And worrying about the limitation of bias between two variables doesn't help much
when you're thinking about the arguments within these complex works of relationship.
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,
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,
but it's more the less conventional approach which we adopted in public health at night was to,
but quite unequivocally borrow this notion of the program theory from possible.
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
and this might not necessarily the way that all critical realists or realist thinkers think of the program theory.
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?
What are policymakers? Why do policymakers believe, if they do this is going to have that outcome?
And what are the stages along that pathway, which for the most part remain unstated that is supposed to lead to that happening?
And that helped us to unravel all sorts of stuff that the trial based material looking at intervention and outcome simply didn't do.
So our conduct and come overestimate or overstress just how important this idea was in helping us to rethink the nature of the problem.
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,
but not just like doesn't work like that,
but what are your reasons for thinking that and what evidence would we need to fill in the logic models along the way?
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.
And we even commissioned a number of realist reviews, and Jeff did one for us.
We got the commission to look at how to prevent smoking in cars as a way of prevent protecting children
and well obviously there's no evidence in randomised controlled trials or anything like that.
So we commissioned the team working to try and Jeff to do exactly that and it took two wasn't it.
Two very significant pieces of work I think came out of that.
But the politics of it didn't work out at all because the Minister Brandis stopped us from doing the work.
Andrew Lastly, the Secretary of State said, I don't want to know about smoking in cars.
That's too much of an interference in ordinary people's lives.
Now, this is just the part, the nanny state we don't want to set out.
So we had to stop the program. The reviews are published and you can see them and read them and they're very interesting.
Of course, politics is a funny thing because within about 18 months, Parliament,
without any evidence, it's already decided to try and ban smoking in cars anyway.
And even though they're right, it's still anyway.
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,
open the evidence and what people thought was the evidence.
Using a realist approach is of course the evidence doesn't speak for itself.
There are a lot of people who, once you get good evidence, you've got the outside, but you don't.
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.
So the amplification process is ever so important,
but we go to a methodology textbook and try and find the chapter on interpreting evidence that's not about P
values and significance tests and the mechanisms of interpreting evidence when you need other kinds of judgements.
Terribly important. So there are well-defined scientific protocols and methods for scientific interpretation,
many of them statistical, which help you determine whether you can trust statistical results.
But the methods for understanding the processes of inference and judgement that scientists, people,
particularly people trying to develop guidelines and using evidence or people using evidence to make policies or people
using evidence to treat patients have to use inference and judgement that's much less well-defined in the literature.
Is this obviously stuff of clinical judgement? And that's one very, very important part of this.
But there's no equivalent of policy. Civil servants don't have to think about the nature of their clinical judgement and their policy.
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,
in the of question, not the internal political question or at least the extent of an innocent person is just as important.
Does the empirical knowledge deal with the problem of issue?
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.
Other data. You've got to hand the context and the circumstances.
Can you apply them to the problem you've got way.
Whatever it is. Can the scientific intervention of the trial or the study be transferred to the context?
So if the study was done in Glasgow, how applicable would it be in Oxford?
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,
but wouldn't make it applicable in Oxford or even Edinburgh.
All reported associations and the evidence causal.
The assumption is that they are very often, although everyone looks at a certain association with correlation,
but actually they are often treated as they were, of course. It sort of ramps up along the discussion and policy makers.
Seldom I've ever been to statistics one a 1 to 1 to learn the difference between cause and correlation.
What are the empirical studies tell us about the mechanisms involved, how it actually works along the path?
Often almost nothing. And of course, we were dealing with relational and dynamic stuff.
Trust with the realism of what was going. Which is to say that individuals and populations interact differentially through interventions.
So not everyone responds in the same way to whatever it might be.
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.
There would be biological variation, which would mean that if you all had the same disease, some of you would respond.
Absolutely. On the other hand, there will be outliers.
Some might get very, very ill and terrible side effects, and some might do no good at all.
So we know that biological variation in drug treatments,
but there's huge social variation in responses to policy interventions or public health interventions or any other kind of interventions.
And of course, when you have a public health intervention,
like a publicity campaign or like a provision of information about the dangers of X or Y, not only do people respond differently,
the way those interventions are themselves delivered will vary all around the country huge amounts of
variation which make a big difference when it comes to the perspectives we used to apply the w w w test,
w w w test and ask the question of will it work on a wet Wednesday week when everyone's gone home?
Individual investigation. And that's quite a good acid rain test anyway,
because if it ain't going to work when the scientists have gone home and the enthusiasts have gone on to their next enthusiasm,
it's not going to be much good to you. We also face a huge amount of opposition to all of this.
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.
Of course evidence based medicine should not be applied to public health at all.
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.
I was called all sorts of things. And one occasion was a meeting and I was called the Godfather of Positivism.
So I sort of helped change. I thought that was so bad.
But, you know, there was it was like it's all gone now.
But there was a huge amount of opposition from all sorts of quarters, especially in the public health community at large,
saying that what we were seeking to do was simply wrong and we shouldn't even bother.
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.
But the other end of the spectrum is another objection.
Because the minute we started changing, even said we need bigger evidence, like a more pluralistic approach.
We need to look at sociology, psychology, economics, all of that.
The even fundamentalists started attacking us because we weren't upholding the values of IBN.
We used to call them the Taliban tendency because they gave us a really hard time.
You know, we can't influence judgement.
What's that got to do with evidence based medicine? Facts are facts are facts.
Well, they're actually. But you know that that was so I was getting criticism on all sides.
I'm. Television you talk about.
It's great. Well, let's take a specific example of how this all plays out in the real world of politics.
In 2010, we published this guideline for alcohol use disorders Preventing Harmful Drinking.
And we published it in June 2010.
So in other words, about three weeks, four weeks after the general election that brought the coalition into office, the civil servants.
Interesting, it advised us to wait till after the election to release the guideline because Labour was lukewarm on taking on alcohol anyway.
It taken from 1990, from 2005 right through.
It took five years before we really got going on alcohol and that was because the
Labour Government just wasn't really very interested in the simple of said wait,
we did. And they said, well if there's a new government they might be enthusiastic about this.
They were wrong. They reckon. Let's say that Labour had been.
So there were a number of recommendations made which were based on some of the best available evidence that we had.
So that came from economic modelling, that came from all sorts of powerful stuff.
And this first one was the most contentious recommendation to consider introducing a minimum price per unit of alcohol.
That would mean that you if you price the product.
According to the power of the alcohol in.
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,
it would have made no difference to the price of your wine because you're already paying well over anything like a minimum unit.
If you go into a pub and pay £3.80 for a pint of bitter, that's well over the minimum price.
What we were interested in was the fact that it was those cheap vodkas, cheap ciders, which were retailing at very, very low prices,
were precisely the products which the heaviest drinkers migrate to and also the products that underage drinkers go for.
That's the one children buy. That's the one underage drink. It's not so a minimum unit price.
And the reason that you could get that stuff so cheaply is effectively because
what's going on is the retailers don't charge the customer the excise duty,
they pay it, and that's a loophole.
So the solution to that is going to be a pricing recommendation,
regularly review the minimum unit price and then also alcohol works saying get rid of alcohol duties.
What U.S. think about them in a in a in a more in a different kind of way.
Some of the data is a fragment of the data,
but with a minimum unit price of $0.40 per unit of alcohol and the potential savings in millions we rent health will
affect about 18.3 million crime about 6.8 absenteeism about 13.2 quite big numbers the economists came up with.
And it's a bottle actually, the kind of the economists that worked on this with us, the group from Qaa,
which is the School of Health and associate of research at University of Sheffield, particularly led by a colleague called Petra meyer.
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.
So this wasn't some kind of back of the envelope stuff. This was as good as it gets.
I think in terms of the scientific data, we also focussed on availability.
Consider the revision to the licensing legislation to ensure there's a link between the
availability of alcohol or taking account when licences are issued and alcohol related harm.
Immediate sanctions on premises in breach of their licences, having two underage children, for example,
and make the health body the responsible authority in England for licensing, as is the case in Scotland.
That's marketing. This was a very interesting area.
I consider a revision to the advertising codes to ensure that when the Advertising Standards Authority sets its rules,
the proportion of the audience who are receiving the message is under 18, who aren't supposed to be buying drinks legally is considered.
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.
And this was an interesting one, alcohol advertising to children via new media.
There are all sorts of products on this one where you could join the brand that, you know,
go online as a child and join the club in the way that you could join the Teddy Bear Club or something.
There was no regulation in social media at all. I don't know.
We pointed that out. Licensing needed to be done rather more systematically.
We argued and ensure sanctions were fully applied.
We also spent a lot of time talking about brief interventions for alcohol misuse,
people who already got problem drinking or there's a teachable moment.
Obviously they've been arrested or something like that where brief interventions have been shown to be very effective with trial placement.
Well,
2nd of June day after we published the guideline was the headline in the Independent Government Rejects Health Watchdog's Alcohol Alcohol Policies.
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.
Yes, they certainly did.
The Department of Health put out a briefing the afternoon after we published the guidelines saying that Nice didn't understand the evidence.
It was a pretty risky strategy. That's what we said. Nice called for the introduction minimum price per unit.
And it said and I said our recommendations based by more study.
But the Health Secretary rejected the analysis and said ministers have said.
Banning supermarkets and off licences and selling alcohol below cost price.
And then this was an interesting one.
It's not clear, he said, that our research examined specifically the regressive effect on low income families at minimum price,
or proves conclusively that it's the best way to impact price on demand through other
policies that were regressive that I don't think they were quite so anxious about.
You go, No. 18 months later, having rejected the nice guideline, although it's still alive, it's never been rescinded.
It's still there on the nice website.
And it still constitutes, I think, the most systematic account of dealing with alcohol based on the evidence as it was then.
And if anything, my reading of the evidence since 2010 has accumulated in favour of minimum pricing,
particularly the high risk populations, children and very, very heavy can have no effect,
one has to say, on middle class drinkers and their expensive bottles of wine because they're already paying what I felt,
although that got lost completely in the media furore.
Right. But a year or so later, two years later, the Government led by the by the Home Office,
now not by the Department of Health, introduced its strategy or published its strategy.
And many of the things that were in our guideline were in that strategy, although they were not taken up.
It lost its way amidst all sorts of controversies, not least the number ten switched from being pro intermediate policy as a unit,
and it became a rather embarrassing topic insofar as that is concerned.
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,
telling them what was good for them, and just generally being a right nuisance.
Those who said Mary Poppins. Also for many of us, she was a famous nanny.
Very nanny, by the way. That's much. I used to get called in the Daily Mail.
The chief nanny was great until I retired and I think seven days got the mantle to Connecticut.
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.
The date is 1854 August.
I have before anyone else, anyone here know what happened?
Late in August, 1854. After this episode was published.
The most famous public health events in 19th century. So there's an outbreak of cholera in Soho.
And John Snow, the anaesthetist, Queen Victoria, with also an interest in public health hypothesised.
It was a waterborne infection and it was one of the worst outbreaks of cholera in the late 1850s, in the eighth century.
But weeks before that outbreak, the Time Times published this leading article in which it said The Nation,
which is about the aggregate of us all, is little disposed to endure a medical time.
Mr. CHADWICK That's Edwin Chadwick, one of the most well-known health reformers of the 19th century, leader of the sanitation movement.
And Dr. South and Smith, who was the medical chief medical officer essentially in the field of health at the time, had been deposed.
And it's this bit that I think is just astonishing. We prefer to take our chance of cholera than the rest.
That'd be awfully good to have. And, you know, that's over 100 years ago, 160 odd years ago.
And yet the debate still goes on between, you know,
the state trying to protect the health of the population and the state interfering in the lives of the population.
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.
And clearly, certain public health forms of regulation are impositions on personal liberty and personal freedoms.
There's no question about that. And it's a question, I suppose, that society itself has to agree.
What's the point at which it will put up with these kinds of interferences?
Like, smoking's a good example. So an interesting example is the first definitive study linking lung cancer to exposure to tobacco smoke.
It's actually published in 1950 by Dolan.
Here to let all of that stuff. 1952, there's a definitive paper offering a tentative causal account.
Ten years later. 1962. The evidence is pretty well overwhelming.
The Royal College of Physicians in the United Kingdom published its report on smoking and health,
linking cigarette smoke not just to lung cancer, but to heart disease and severe bronchitis.
Blood pressure and so on and so on.
So the evidence in 1962, the smoking ban and the virtually normalisation of cigarette smoking comes about 67 years after the first paper.
It took that long. The process and the process was exceedingly slow, but it's been extremely successful.
But if you think about it, it's well, you know, imagine the cabinet.
1962, Harold Macmillan, a lieutenant in the First World War.
He's old school, old, old, old, old school. And the assembled politicians around the table.
The Minister of Health, when the first paper was published of the 1952 papers How to Make Good Syrian McLeod.
And at the press conference that Dalton Hill called to publicise that paper and invited the Minister of Health,
he could have now the secretaries of the lung and McLeod's smoked through the
entire press conference that was held at the Royal College of Physicians.
Now you think, oh, hang on, it's the royal cottage. They even got ashtrays there for people to smoke school buses.
When I went to university, 1971, it was routine for there to be ashtrays in lecture theatres, students smoked electric smoke.
So the kind of fog of smoke. 1971.
Now imagine again round. We're round with Macmillan round his cabinet table.
Even if they had grass that said, actually, what we've got to do here is a virtual ban on smoking.
We need to make it as invisible as possible in the public environment.
We need to make it invisible in the retail environment. We need to educate people.
We need to put the price up so high that it's it's virtually unaffordable and we need to normalise it.
There would have been no appetite whatsoever politically to take that on.
Not least because my guess would be three quarters of the men sitting around the table would be smoking.
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.
And I my guess is that in 50 years time someone might be standing around, recounted,
how was it when they had all that evidence by the early part of the 21st century?
Hardly anything was done to change that.
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.
Thinking about the obesity epidemic and getting people to change the way they eat and drink,
and it's a much bigger deal because we've all got to eat and we all have to drink.
So we can't just say Let's ban it. Although I saw a spoof article in the Oxford University.
A couple years ago, the student paper, which said they'd got the solution, it was to ban food.
Anyway, it's my point is here is a problem, which is that not only does evidence not speak for itself,
the fact is the evidence is part of a part of a political process, and it plays out in a political arena.
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.
So my conclusion there clearly is an inter-relationship between policy and do
bear in mind that policy making by civil servants is different to politics,
which is what politicians engage in.
They interact with each other, obviously, but they are different processes and evidence plays into both of them differently.
Evidence is used. But, you know,
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.
I came to to realise, I suppose, all of how important it was to apply realist principles, the context,
mechanism, outcome to the policy and politics and evidence interface as it was to any other.
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,
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.
So it's a kind of perhaps an extension of that broad idea.
Even so, evidence based medicine has some fairly strong affinities, it seems to me, with realism,
and in the sense that Sackett and his colleagues who pushed all this argued, believed,
understood that things that happen in the human body don't happen for chance reasons.
There are causes, but we don't always know what those causes are.
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.
It was a derivative of and so on.
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.
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.
And at the very end, this paper or this chapter in the book,
edited by Nick Amil and colleagues called Doing Real Estate Research, which you come across.
I've got a chapter in that and that describes and talks about in detail, particularly the alcohol controversy in in more detail.
And I've spoken about it here.
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,
I guess. Great. Thank you very much, Michael.