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Submission from CMF in response to the Department of Health on Choosing Health? A Consultation on Action to Improve People's Health

Published: 28th June 2004


Christian Medical Fellowship (CMF) is interdenominational and has over 4,500 members throughout the United Kingdom and Ireland who are Christians and who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. We have members in all branches of the profession, and through the International Christian Medical and Dental Association are linked with like-minded colleagues in more than 90 other countries.

Our ethical code is based on the Judeo-Christian ethic as revealed in the Bible; and is broadly in conformity with historical ethical codes such as the Hippocratic Oath, Declaration of Geneva (1948) and International Code of Medical Ethics (1949).

We are glad to have the opportunity to respond to this consultation and welcome the government's initiative to improve national health. We recognise the responsibility that this involves on the parts of individuals, professional bodies, and Parliament

Our expertise is primarily in the area of medical interventions, rather than the political and regulatory issues around implementation. In the first part of our response we shall address some of the general questions raised in Chapter 4 of the Choosing Health? document. In the second part of our response, we have addressed issues raised through the fact sheets that accompanied the Choosing Health? consultation document on the Department of Health website, and mentioned in paragraph 11 of Chapter 1:

1. Accidents
2. Alcohol Misuse
3. Diet
4. Drugs
5. Exercise
6. Inequalities
7. Mental Health
8. Obesity
9. Sexual Health
10. Smoking

Section 1 - 'The Questions' of Chapter 4

Question 1: What you eat and how you spend your time at home, school, work, leisure make a difference to your health.

- What would make most difference to the choices you make:
- do you want more, or different, information about what matters?
- where would you like to get information from, for example GP surgeries, telephone help lines such as NHS Direct, the internet, shopping centres, the workplace, leisure centres?

1. Most of us are influenced by what we see, hear or read in the media, including advertisements, but we are poorly equipped to make sound health choices based on advertising alone. In contemplating a national health awareness campaign there are sobering lessons to be learnt from the advertising industry, in that very large sums of money are spent by manufacturers to achieve just a small shift in purchasing. We should be realistic therefore about the extent to which any campaign using the much smaller resources commonly expended on health promotion will influence behaviour and choices.

2. Information in a standardised format on food packaging that indicates a few important nutritional parameters could be helpful - eg. how much the food contributes to the 'five portions of fruit and vegetables a day' message, or whether the food is low in salt.

3. Restaurants could do far more to offer healthy foods, and draw attention to the healthier options on the menu. Whilst it would be impractical for individual outlets to offer comprehensive nutritional information, there is scope for restaurants in large chains to do this - especially the major fast food outlets such as McDonalds. These popular chains are frequented by a relatively large proportion of the total population and are missing an opportunity to promote healthier foods by greater use of advertising of healthier options in the food outlets.

- are there choices you would like to be able to make which aren't available to you now?
- what would help you to make healthier choices, for example to engage in more physical activity?
- in your list of things to be done what should come first, and why?

4. Where there are choices people will tend to take the easiest option. A fundamental principle behind health promotion is to make the healthy choice the easy choice, or conversely to modify the environment to discourage unhealthy choices.

5. Many people claim that they would walk or cycle more if there were improvements in the frequency, reliability and safety of public transport and reductions in road traffic. In the absence of a sophisticated road pricing system that covers the entire country, fuel duty is the next most effective mechanism of imparting charges, especially for longer journeys and very short journeys. We are concerned that the cost of car journeys is actually falling in real terms compared to the cost of public transport, which for some decades has been rising in real terms. This difference increases the attractiveness of the car relative to other forms of transport. This also discriminates against the least affluent in society - the elderly, the disabled, the unemployed and parents with children - who may not have access to their own cars. In the same way that revenue from safety cameras is spent improving road safety, increased income from fuel duty should be directed towards improving alternative transport facilities.

6. In order to influence choices in health it is often necessary to influence other social factors. For example, fewer children are walking to school than ever before and more are being driven to school. This in part reflects the greater distances that children must travel to school, which in turn is a consequence of increased parental choice in where to send their children. Greater investment in schools currently perceived as 'failing' could reduce numbers of parents who feel that their children's education would suffer by going to a school within walking or cycling distance of their home.

7. By the same argument, if more children are being driven to school because parents believe their children are at greater risk of traffic accidents or assault, thought should be given to how these concerns can be allayed; such as improvements in road safety, street lighting, and enhancements to community policing. It may also be worth accentuating the factual reality about the risks - people may have an unrealistic perception of the dangers because of the bias in media reporting towards negative news and the few tragic cases that become excessively 'high profile'.

8. Physical activity could be promoted more as a social activity, for both families and friends. Socialising in the late teens to thirties frequently revolves around pubs, bars and clubs. Alternative venues, and their promotion through the media, could be encouraged. Teenagers looking for 'somewhere to go' in the evenings often find their only option is to loiter in the streets or go to pubs whilst still underage. Social venues for teenagers need to be considered, and local authorities or charities/voluntary organisations that provide these should be encouraged. It may also be necessary to think outside the 'youth club' box to consider cafes that stay open late, non-alcoholic 'bars' etc.

9. Making healthy choices should begin early in life - for example women should be offered more support to breastfeed, and to continue breastfeeding for longer. Such support may encourage them to think more about the health of their children and be better equipped to resist their children when confronted by demands for sweets and snacks. In an age where extended families are more distant and young parents have less support to turn to, simple measures like parenting support could potentially help parents learn how to help their children make healthy choices.

10. Unfortunately the healthy choice is often the most expensive. For example many companies will pay a generous mileage allowance for driving, and pay expenses incurred such as parking fees. Cycling allowance, if paid at all, is minimal, yet cycling costs companies less as the cost of car parking spaces far exceeds bicycle parking spaces. Companies should be able to offer much stronger incentives to make cycling financially attractive, and driving less so.

11. Similarly the least healthy foods - chips and burgers - are often the least expensive in the canteen whereas fresh fruit is the most expensive. Subsidising fruit and vegetables would make them more attractive, especially to those with limited resources. Guidance about how to feed a family on a tight budget would also be useful. This could be provided in leaflets through doctors. However, the best way would be through the supermarkets. For example, Waitrose currently has 'recipe cards' freely available, and the recipes and ingredients are inevitably lavish. Similar recipe cards with simple guidance aimed at everyday cooking with a budget in mind could be made available as well.

Question 2: Everyone should be able to make their own choices.

- What in particular would make a difference to choices that children, young people, pregnant women, people with disabilities and older people make? What would make most difference and why?

1. If people are to make their own choices they need to be presented with unbiased, impartial information from both sides of a debate. The huge disparity between the money spent on cigarette advertising historically and the amount spent on warning of the dangers of smoking emphasises this clearly. The advertising budget of food manufacturers vastly outstrips the resources the Department of Health would appear to have when advising us on the merits of crisps, chocolate bars and other 'junk foods'. Advertising of unhealthy foods must not be aimed at children - and that should include a ban on junk food advertising where children can see it. Schools should not be forced through financial demands to rely upon sponsorship by companies associated with harmful products, including junk food, alcohol and tobacco.

2. If sports personalities are considered so successful at promoting substances why can advertising companies not use sports personalities to promote healthier options instead?

3. The Government must not shy away from commenting on people's lifestyle choices by making recommendations about what is or is not healthy. It is the Government's responsibility to speak out for those who are unable to appraise the mixed messages coming from advertising and industry. The aim should be to equip people to make informed choices. The public appears to be susceptible to the messages coming from the advertising industry - otherwise the industry would not exist. These messages are inevitably biased in one direction to influence individuals' choices. Hence the provision of impartial information is essential.

4. The general question about choices in relation to alcohol, is covered in depth in the response of the Institute of Alcohol Studies to the Governments Alcohol Harm Reduction Strategy.[1]

5. We were interested to note that the example case study relates the benefits of involving the faith community in a smoking cessation programme. Association with and involvement in religious communities is known to reduce the risk of alcohol and other substance misuse. However, the government did not emphasise the role of faith communities in its Alcohol Harm Reduction Strategy. Research has also shown that religion and marriage both promote mental health. They also tend to have a positive effect on an individual's sexual health, by an inherent reduction in sexual partners. We would like to see the importance and value of faith communities to the health of society recognised, and increased support for the work of faith communities in ministering to those in difficult situations.

Question 3. People in some groups and areas experience health that is worse than the average including some people in black and minority ethnic groups and people living in disadvantaged areas.

- How are your circumstances affecting your health?
- What would support you or your community to be healthier?
- Who could help you?
- What should they do?
- What are the barriers that would need to be overcome?
- What could local services and organisations do to support healthier lifestyles? What would be better done by the community itself? In your list of things to be done what should come first, and why?

1. We are particularly concerned at the Government's attitudes to asylum seekers and refugees. Whilst acknowledging that not every application for asylum may be bona fide, many of those claiming asylum have fled oppressive regimes and if their initial application is denied they are currently forced to become destitute, with potential harm to their health and the health of others. On the one hand we deplore the sensationalism in parts of the media that suggests that asylum seekers are responsible for introducing or spreading infectious diseases such as tuberculosis. On the other hand the current policy of dispersal appears to make little allowance for follow-up treatment when an individual claiming asylum is discovered to have an infectious disease such as tuberculosis.

2. In disadvantaged areas it is more difficult to find shops selling fresh fruit and vegetables, and where sold the condition or price makes them less appealing than supermarkets, which are not accessible to the local population. Such 'food deserts' are not just characterised by a shortage of shops selling fruit and vegetables - they also have a shortage of restaurants promoting healthy foods and a relative excess of eating establishments selling junk foods. Planning legislation in some areas is currently able to encourage certain types of retailer - particularly charity shops - to trade at a reduced rent. Such incentives could also be used to encourage shops selling healthy food.

3. Please refer also to section 2.6 on Health Inequalities.

Question 4: One person's choice may spoil the chances of good health for others.

- Have we got the balance right when it comes to:
- smoking in enclosed public places and work places, eg. shops, factories, offices, hospitals, public transport, restaurants, clubs and pubs?
- recognising the difference between fun and anti-social behaviour?
- considering the consequences of unprotected sex?

1. In a culture that is obsessed with rights we seem to forget that every right must be balanced with a responsibility not to misuse that right. So with regard to smoking, whilst not denying people the right to harm themselves, we maintain that smokers do not have a right to harm others by smoking in the space of non-smokers.

2. A common reason people cite for not choosing to walk or cycle more frequently is fear of traffic accidents. The balance is far too much skewed in favour of driving, compared to other forms of transport. We welcome initiatives to enhance road safety, for example safety camera partnerships, and believe that more should be done to challenge the assertion by some motoring groups that safety cameras are an unjust tool that infringes drivers' rights to drive at whatever speed they choose. By driving at only a few miles per hour above the residential speed limit of 30 mph the risk of a pedestrian being killed rises greatly. It is dangerous and irresponsible for a relatively small minority to protest that attempts to limit their illegal driving are unjust. More widespread use of traffic calming measures, including home zones that reprioritise the road in favour of those without cars, should be promoted. The anomaly that driving at up to 30 mph in 20 mph limits cannot be enforced should be addressed.

3. It is too simplistic to treat sex merely as a recreational activity. Sex between two people by definition occurs in a relationship, however transient. More emphasis should be placed on encouraging stable relationships. In schools, sex education should emphasise the community aspects of sex; the benefits of stable, committed relationships, and the harms - ranging from emotional to pregnancy and infection - that come from trivialising sex to a recreational activity. Abstinence should be thought of as a key solution to teenage pregnancy rather than an irrelevant afterthought. The fatalism that we should teach the 'safe sex' message because 'children will have sex anyway' needs to be wrestled with and overcome.

4. There is a very complex and difficult balance to be achieved between the benefits and risks of alcohol consumption. Advice that is right for one person will be harmful for another. However, the Government have exploited this in their Alcohol Harm Reduction Strategy in order to obscure the fact that they are failing to do things that could help considerably overall.

5. Please refer also to sections 2.9 on Sexual Health and 2.10 on Smoking.

Question 5: The role of regulation.

- Should central and local government take more of a role in supporting people to make healthier choices by making it:
- easier to access the things that would improve people's health eg. fruit and vegetables, safe walking routes, safe cycling, better communal spaces, gyms, swimming pools, sun protection, access to contraception?
- easier to avoid temptation from things that can be harmful, eg. cigarettes, alcohol and foods high in salt, sugar and fat?
- If yes, then how?
- Should the rules be changed on:
- what gets advertised: on television, in newspapers and magazines, through promotions?
- availability of tobacco, alcohol, drugs to children and young people?
- how products such as sweets, snack foods and tobacco are promoted and displayed in shops?
- foods that industry produces?
- If yes, then how?

1. The Government has an obligation to help create a society in which healthy options are easier than unhealthy. Just as the Victorian sanitation engineers were responsible for much of the health gains of the nineteenth century (and prevailed despite at times unpopularity and derision), so national and local Government has the potential, through the environment we live in, to create housing, pathways and cycle tracks, open spaces and parks that promote physical activity and mental stimulation.

2. There is no reason why products that are demonstrably unhealthy should be on conspicuous display in shops. For example rather than displaying cigarettes prominently at the cash till of shops, they could be stored under the counter. If there was no point-of-sale advertising it need not be obvious that they were being sold at all. We cannot see why a product so uniquely harmful as tobacco should be so easily available and so easy to locate.

3. By the same argument confectionary should not be displayed at the checkout of supermarkets where it is too easy for parents to feel pressurised by their children into making purchases.

4. As far as alcohol availability is concerned, again this is touched on more fully in the response of the Institute of Alcohol Studies to the Governments Alcohol Harm Reduction Strategy document.[2]

5. Please refer also to sections 2.2 on Alcohol Misuse, 2.3 on Diet, 2.6 on Health Inequalities, 2.8 on Obesity and 2.10 on Smoking.

Question 6. Working together to support healthy choices.

- What opportunities are there to influence healthy choices through action by:
- parents?
- friends?
- schools and higher education?
- employers?
- faith communities?
- health and social care professionals?
- local government, including housing, education and the environment?
- voluntary and community organisations?
- retailers?
- manufacturers?
- industry?
- trades unions?
- the media?
- leisure organisations?
- national government?
- Are there examples of good or innovative practice that other organisations could or should adopt? What should be given priority? Where could more be achieved by working together?

1. Faith communities have a vital role in society. Many of the most successful schools are church schools, and these are frequently oversubscribed and receive requests for admission by parents from a wide variety of faith backgrounds. In deprived areas church groups have been instrumental in setting up 'after school' homework clubs to provide an environment in which children can focus on their homework before going back to a home where they might otherwise have little opportunity to study. Faith communities can provide a vital moral and social framework for people, giving them a sense of identity, supporting them at times of difficulty and offering an ethical framework that has been tried and tested over many centuries.

2. Manufacturers and employers can support healthy choices through for example offering smoking cessation services to their employees, prohibiting smoking at work or in company vehicles, offering healthy foods in the canteen, and providing adequate showers and secure cycle parking facilities. Employers could be encouraged to give incentives to employees who choose not to use the car (or should be discouraged from subsidising car use by paying excessively generous mileage allowances or parking expenses etc.). Workplace alcohol policies also have an important part to play.

3. In relation to faith communities, we would like to draw attention to the Live Life to the Full drug resource pack for Church Leaders produced by Hope UK (this covers all drugs).[3]

4. The importance of friends and socialising should not be underestimated, particularly with regard to excessive alcohol consumption and smoking. Pubs and bars are a deeply ingrained part of our culture, and often seen as the only meeting place for social occasions. The availability and promotion of alternative options should be considered.

Question 7. Organisations have an impact on health through their interactions with the public, employees and society.

- What action can industry, in voluntary and community organisations, the public sector take to improve health:
- in offering healthier choices in the products they provide?
- in influencing choices through advertising?
- as employers?
- improving access to services?

1. Examples for the food industry to consider include increased production and promotion of healthier products. This could include offering a wider and more attractive range of non-alcoholic beverages in pubs to increase the attractiveness of not drinking excess alcohol. The prices of non-alcoholic drinks should also be kept significantly lower than alcoholic beverages where appropriate. Often, the reverse seems to be true, where an orange juice or coke is still expensive, such that customers might be encouraged to drink alcohol instead. McDonalds has recently launched a 'healthier' range of products including salads and fresh fruit. There needs to be some standards to ensure that these are healthier than existing products, and if so the company could work much harder to promote them. Perhaps there should be a tax payable for advertising products considered harmful to health.

- How can we better enable and support everyone, taking account of differences in social and ethnic background, to lead healthy lives by:
- increasing knowledge of what makes a difference?
- encouraging a positive attitude to health?
- making healthy choices available?
- discouraging destructive choices in: diet, drugs, alcohol, tobacco, sex, exposure to the sun?

2. Perception of limited choices is sometimes cited as a reason that can explain why some people turn to drugs, alcohol or end up with unwanted pregnancy. Measures that increase self-esteem and the value society places on each person through creating opportunities for employment, attractive housing, a safe and desirable environment to live in etc. should be encouraged.

3. Rather than perceiving early sex as inevitable, schools and young people's counsellors should encourage young people to wait until they are completely ready for a sexual relationship, with the key aspiration being a committed faithful life-long married relationship. Whilst appreciating that it is important not to condemn people who fail to live up to this standard, marriage offers the greatest protection against sexually transmitted infections, avoids the emotional hurt of failed relationships, provides the most secure environment in which to raise children, and gives support to many people as they grow older. Studies consistently show that married people frequently outlive single and divorced people and are happier in themselves. Fear of upsetting or offending unmarried individuals does not justify failing to promote marriage as the best sexual relationship for adults to be in.

4. Please refer also to section 2.9 on Sexual Health.

- encouraging take up of screening programmes for early detection of diseases?
- improving access to and quality of NHS services, especially for people in disadvantaged groups and areas and people who are harder to reach?
- making sure people understand the risks and consequences of the choices they make?

5. In some parts of the country the NHS has struggled to meet the needs of people for whom English is not their first language. In order for everybody to receive the same opportunity to receive health information more consideration should be given to improving translation services in healthcare environments, both hospital and primary care.

- through better management of sickness absence and improving access and opportunities to people with long-term conditions or disabilities?
- what should be given priority and why? How should progress be measured?
- what might the barriers to progress be and how could they be tackled? Who should take the lead?

6. Barriers to some of these changes include misplaced fear of being accused of imposing a nanny state (in the context of industry, manufacturers, food retailers) and fear of being perceived as intolerant or politically incorrect when responding to the needs of ethnic minorities or advocating matters of personal morality such as the benefits of teenagers abstaining from sex or the advantages of marriage compared to other forms of partnership. The Government has a responsibility to protect the vulnerable in society, and that requires courage to admit and defend lifestyle choices that significantly benefit both the individual and society.

Question 8: Creating and Maintaining a healthy environment.

- What can be done to better identify, prevent and tackle inequalities to ensure that individuals, groups or communities are not unduly disadvantaged in their access to decent local environments (built and natural) and the environmentally related services and facilities needed for healthy lifestyles?
- What can be done to create and maintain an environment that enables and encourages healthy lifestyle choices: in nurseries, schools and higher education facilities?

1. In schools, encouraging team sports in which all can participate; preventing schools from selling off land presently used as sports grounds; improving the nutritional value of food eaten on premises, not being dependent on sponsorship by companies that promote junk foods (for example through vending machines).

2. In higher education, encouraging students' unions and welfare to take a responsible attitude to student health and lifestyle, including alcohol, drugs and sex.

3. Please refer also to section 2.6 on Health Inequalities.

- in places where health and social care are provided?
- in other public buildings and enclosed spaces?
- through improvements to public transport?
- in shops?

4. Consider local authorities having the power to offer lower rent to those shops that sell healthy foods (eg. greengrocers), in addition to existing legislation that allows councils to charge a lower rent for charity shops, which benefit charities and assist the least affluent.

- in places people go for leisure activities?
- where people work?
- in homes and communities?
- in residential streets and public communal places?
- through improvements to the environment and environmental quality?
- What should be given priority and why?
- How should progress be measured? What might the barriers to progress be and how could they be tackled? Who should take the lead?

5. Promoting the place of 'alcohol free zones' in cities and towns.

Question 9: Helping people deal with the stresses of life.

- What can be done to help people in all social and ethnic groups to cope with the stresses of life by supporting them:
- in getting a good start to emotional development and developing and
- maintaining protective mechanisms such as:
- meaningful relationships: eg. at school, at home, if they are looked-after, when they leave home?

1. Support for parents: In an age where parents may be out at work and their own parents may not be in close proximity it can be difficult for new parents to know where to turn to for support about parenting. Simple measures such as encouraging people to eat together at set times rather than 'grazing' on food throughout the day and eating in front of the TV would help both to tackle obesity and enhance social cohesion and relationships. If the Government is not prepared to promote these sorts of messages they should enable and encourage others to carry the message instead.

- developing and maintaining meaningful social and occupational roles?
- achieving a work/life balance?
- in dealing with transitions: eg. leaving home for work or university, having children, when a partner or child dies, break-up of a partnership, losing a job, retiring?
- What should be given priority and why? Who should take the lead?

2. Faith communities have a vital role in establishing deep and lasting relationships and reminding people that there is a spiritual dimension to life. Faith communities can offer support with relationships such as marriage, encouraging families to stay together and resolving conflicts between couples and within families.

3. Alternatives to alcohol and drugs need to be made more readily available and acceptable as means of stress reduction. It should be made clear that smoking actually increases stress rather than helping to ease it.

4. The culture of debt that is growing in our society needs to be addressed. Money lending for profit encourages people to live beyond their means. Borrowing is necessary for certain large purchases (such as a house), but it seems to be expanding into everyday items, like washing machines, TVs, and cars. People are growing up in a culture where they expect to obtain immediately what they want and pay later, rather than saving up to purchase what they want/need. Debt is inevitably a cause of stress to people's lives, particularly if they have difficulty meeting the repayments. It also limits an individual's choice and freedom by tying them down until the debt is paid. Again, much of this is driven by advertising and the constant media message that people need to keep buying/consuming in order to be happy/successful etc. At the least, young people need good education on filtering the messages of the media, and learning to manage money and avoid debt as far as is possible.

5. Please refer also to section 2.7 on Mental Health.

Question 10: Working together to support healthy choices.

- What information does your organisation need to improve health and tackle health inequalities? What opportunities are there to influence healthy choices by:
- parents?
- friends?
- schools and higher education?
- employers?
- faith communities?
- health and social care professionals?
- local government, including housing, education and the environment?
- residents associations?
- voluntary and community organisations?
- retailers?
- industry?
- trades unions?
- the media?
- leisure organisations?
- national government?
- What should be given priority? Where could more be achieved by working together?

1. Our organisation is not directly involved in healthcare provision but is willing to participate in provision of information about healthy life choices.

Question 11: Evidence base

- Have we got the right evidence base to:
- assess the costs and benefits, including impact on inequalities, of current initiatives targeting lifestyle choices?
- understand how the pattern of wider environmental and social determinant can deliver both costs and benefits for public health?
- understand which interventions produce the greatest cost-benefits/reduction of inequalities?
- understand which interventions require joint action by several agencies and how can this best be achieved?
- Where are the gaps? How can they be tackled? How should they be prioritised?

1. Non-health sector agencies, including local authorities, transport planners, businesses etc. often have far greater influence on the wider determinants of health, including housing, the environment, education and employment than can be addressed through the NHS. Senior people in these organisations should be encouraged to have a greater awareness of population health and the extent to which their own position can influence health choices for better or worse.

- How can PCTs and Local Authorities improve the data they gather on local populations?

2. PCTs should ensure they invest in public health intelligence and information gathering. Working relationships with local authorities are greatly simplified when there are coterminous geographical boundaries.

3. We are concerned about the Government's selective use of the evidence base in its formation of the Alcohol Harm Reduction strategy.

Question 12: Disseminating information.

- What are the most effective ways of disseminating health information and good practice to the general public, the NHS, education, employers, other relevant organisations?

1. The most effective means of encouraging people to make healthy choices is through the influence of family, friends and relatives. These in turn can be influenced by the use of respected role models disseminating evidence based information in attractive and memorable ways in schools, churches, youth groups, and community groups, through the health service and through the visual and print media.

Question 13: Ensuring change happens.

- How can we ensure that examples of good and innovative practice are adopted more widely?
- How can we ensure that objectives, targets, performance assessment and management systems and incentives set the best context for local partners to work together for health?

1. Avoid the temptation to keep rearranging the National Health Service! People at all levels of a hospital or PCT should be able to devote their attention to working in an organisation without at the same time wondering what their organisation is becoming or looking out for the next job move since they do not expect their post to last beyond the end of the year.

Section 2 - Specific Medical Issues

2.1 - Accidents

No submission for this section.

2.2 - Alcohol Misuse [4]

The recently published Alcohol Harm Reduction Strategy outlines the government's proposed response to alcohol misuse and its strategy for dealing with alcohol problems. We are not clear what the impact of this consultation on that document will be. In response to both we would offer the following input:

a) The general principle is that, over time and between populations, alcohol related morbidity and mortality are directly related to quantity of alcohol consumed. The quantity of alcohol consumed is in turn directly related to availability and acceptability of alcohol in the population concerned. The real price (ie. price in relation to disposable income) is the major determinant here. Thus, taxation is one very effective preventive tool.

b) Much the same applies at the individual level; in general, the more the individual drinks the greater their risk of the alcohol related pathologies. This is the basis for the 'sensible drinking' message. However, the message is a generalisation and therefore will not be correct for every individual, is generally lacking in empirical evidence supporting its efficacy as a tool for prevention at the population level, and is a useful guide in the clinical consultation between doctor and patient rather than a prevention strategy per se.

c) Because of all of this, the general message that has emerged from the research is that you need to reduce the consumption of the population as a whole in order to reduce alcohol misuse. There are, again, exceptions. Clearly reduction of consumption, or prohibition, in certain contexts (eg. drinking and driving) has been extremely effective. However, in general, focussing on education would not appear to be a promising strategy.

d) Although it is moving more into the field of treatment than prevention, it is also worth mentioning that 'simple' or 'early' interventions have been shown to be effective and cost-effective. For example, a chat with a nurse or doctor generally has benefits for the person whose drinking is above recommended limits, or whose drinking has begun to affect blood tests adversely.

e) The specific question on the fact sheet: 'If you drink what would encourage you to drink more sensibly and moderately?' presumes that people make rational and objective decisions about their drinking without undue influence or constraint. The fact is that we live in a society that puts all kinds of pressures on people in respect of their drinking. That they are not well informed is only a part of the problem. Alcohol is promoted by the industry and by expectations of society and itself impairs people's ability to make rational decisions.

f) The fact sheet refers to the Government's advice on sensible drinking under the heading What works?. This is ironic, as education on sensible drinking is one of the few strategies for preventing alcohol problems for which there is little or no evidence that it actually does work. Yet the Government insists upon using this as a major tool in its endeavour to prevent alcohol related problems. The mass of evidence in support of effective strategies - notably taxation - should not be ignored or played down because of Government concerns about their relationship with the drinks industry or the drinking voter.

g) Economic incentive to drink less alcohol could also be given through ensuring that the non-alcoholic options in pubs and bars are kept at a low price.

h) The Alcohol Harm Reduction Strategy is a disappointing document, and we recommend the responses of the Institute for Alcohol Studies. We hope that the Department of Health will take this opportunity to address alcohol misuse in the wider context of national health, with consideration of the social problems caused by alcohol misuse.[5]

2.3 - Diet (incorporating the Department of Health's Choosing a better diet Consultation)

a) General Points

This section of the consultation has common ground with the section on obesity, however the health aspects of a poor diet go beyond obesity to include ischaemic heart disease risk, stroke, bowel health, cancer and osteoporosis.

The document refers to several key targets to achieve on a population level, with a view to improving the health of a nation.

There are key concerns about the definitions of these targets that may lead to missed opportunities. A requirement for a reduction in saturated fat as a percentage intake across the population may be achieved in a way that does little to address the current inequities within society. For instance, a programme of education may facilitate a reduction in people already on a low saturated fat intake (eg. perhaps health conscious professionals), whilst only frustrating other individuals who do not have the financial/personal means to make these changes.

In this context, mean saturated fat intake may fall, without a commensurate rise in benefit, particularly for the higher risk individuals.

Suggestion: Could the target be re-written to address this? Eg. to reduce proportion of individuals consuming in excess of 15% of energy as saturated fat? This target prompts focussing on individuals most at risk.

However, we are pleased that the government recognises the need to focus on the disadvantaged members of society.

A further concern is with regard to the targets themselves. Reduction in salt, saturated fat, increased fibre and increased fruit and vegetables has some evidence base; reduction of sugar and total fat is NOT evidenced-based.

b) Consumer choice:

People need evidence-based advice, and it is ethically unsound to ask for lifestyle change if there is no evidence that such change will improve their health.

Any education programme needs to be validated and shown to effect change. Messages should be simple. Furthermore the government should not shy away from challenging vested interests. For instance a message to reduce consumption of ready meals and processed food can reduce salt and saturated fat intake, but it is a message not appreciated by the food industry.

There is a potential for food suppliers to help in this education.

c) Improving food production and manufacture

With reference to the above section, perhaps there should be an encouragement to reduce consumption of processed food. Perhaps readily understood warning labels (high salt, high saturated fat, high calorie) could be used.

Improving portion size is not a problem in this sector, as suggested portion sizes on most packaging are appropriate for active individuals. People just don't stick to them!

d) Improving food supplied by retailers, caterers and the workplace

Organisations should be encouraged to provide meals that represent 25-30% of predicted daily energy intake for a typical UK adult. They could also provide meal options that are low in saturated fat and salt, and lower energy density (high energy density foods may present problems for appetite regulation.)

All caterers and retailers could be obliged to offer such choices.

e) Improving nutrition in pregnancy and the early years

The suggestion of financial assistance to buy healthy foods for disadvantaged families is a positive one, and would address some of the inequalities. Providing infant formulae is more controversial and should be assessed for its impact on breast-feeding rates.

Much is already being done to inform the public and expectant mothers on the benefits of breastfeeding - this should continue.

f) Improving nutrition in schools.

Providing healthy free meals to all irrespective of background is being trialed in one authority. If this can be shown to be effective in changing food intake - it would justify the cost nationwide.

Choices should be assessed for the quality of diet provided.

The place of vending machines should be reviewed.

Many school-leavers lack basic cooking skills and therefore rely on processed and pre-packaged meals in adult life - developing skills around healthy meal preparation and choosing a healthy diet on a budget would help many young adults.

g) Improving nutrition in the NHS

The NHS should have an obligation (which would be beneficial for all employers) to provide healthy food choices to staff, clearly labelled and promoted as such.

The major issue for inpatients is around under-nutrition - there are insufficient staff to monitor the poor intake of many elderly patients when help with eating and supervision is all that is required.

h) Improving nutrition in local communities

Many areas of deprivation do not have the same access to food choices. There are many pilots facilitating cheap healthy food, but a sustained national programme to address this in areas of deprivation is required.

Take the best of current pilots and implement them nationally.

i) Conclusions

As physicians and Christians we see any initiative that promotes the health of the nation as a positive one. Furthermore, addressing inequities in society and working towards equality of opportunity to health is particularly important and the widening gap between rich and poor must be reversed.

Education must reach all and be appropriate for all, and evidence-based.

Where resources are required to help facilitate change (eg. access to cheap food), they should be provided and sustained. Pilot projects that end without ongoing resource only frustrate, and it is immoral to ask for change without ensuring the means to do so.

Within the NHS, malnutrition is a problem, especially for elderly patients. Every hospital should be required to have a system to monitor and address this.

In summary, effecting change will only be equitable if resourced and means to change are accessible and affordable.

2.4 - Drug Misuse [6]

a) We recognise the important achievements of the Government's drug strategy in taking seriously the health and social consequences for individuals, families and society, of drug use and dependence. The recognition not only of the effectiveness of treatment, but also that addiction treatment saves money, has been a critical step in this process.

b) While the number of treatment places has expanded markedly, and there has been an increase in funding for treatment year on year, much more needs to be done:

  • This is one of the few areas of the NHS, where only about 1 in 4 individuals with illicit drug problems can access the type of treatment they need.
  • The expansion of services has been primarily in the criminal justice sector, where no doubt the greatest savings can be made. However the many patients with major drug problems who do not enter the criminal justice system should not be forgotten.
  • Prison drug treatment systems are typically overwhelmed by the vast numbers requiring assessment and treatment, meaning that services of adequate quality are often not being offered.
  • Monitoring of the performance of services is clearly critical to ensure resources are being used effectively, but organisations often feel quite overwhelmed by reporting requirements and there currently exists an over reliance on the quantity rather than the quality of treatment.

2.5 - Physical Activity

a) Though diet is still important, physical activity plays a key role in countering the current scourge of obesity - an independent risk factor for at least cardiovascular and skeletomuscular disease.

b) The form of exercise to be encouraged focuses on that involving 'fluid' movement - walking, cycling, climbing. Swimming affords an additional excellent opportunity for therapeutic exercise.

c) The Department of Health is right to give attention to providing opportunities for planned sessions of increased activity during leisure, work or education. The development of exercise and sporting facilities will clearly help, and we would endorse this for pre-primary, primary and secondary education. But 'special' exercise facilities and programmes can prove expensive for users (thus excluding those in lower socio-economic groups) and they separate exercise from 'ordinary' life.

d) The first bullet point under What next? on the factsheet is just as key as providing specialised facilities; promoting increased activity as part of our everyday lives is crucial. Exercise should be encouraged as a natural part of ordinary life. Firstly, it is inexpensive. It is certainly cheaper to walk or cycle somewhere local than it is to go by car. It will be substantially cheaper than using commercial sports centres the cost of which might send out the signal that exercise, though helpful, is unreachably expensive. Secondly, walking, climbing, running or cycling in the countryside (to which most have access) allows additional benefits: the use of distant vision (in contrast to our frequently staring at paperwork, computer screens or TVs - including those in sports centres!); it allows us to appreciate the delights of God's creation, the colours and beauty of which are often restorative beyond the effects of exercise; it allows fresh rather than air-conditioned/polluted air to be inhaled; and it often allows the enjoyment of social interaction whilst exercising (not always possible on the exercise bike, rowing machine or treadmill).

e) Team based sports or other exercise activities, while improving fitness levels, are likely also to aid motivation and to promote trust, communication, interdependence and social cohesion that published research shows to be healthy for both individuals and society.

f) Whilst supporting the physical exercise aspects of this document, we would put greater emphasis on activities that are inexpensive, can be incorporated easily into everyday life and engage both natural surroundings and other people.

2.6 - Health Inequalities

a) Overall Picture

In many of the disadvantaged groups and areas, there are compounding factors acting against health improvement:

  • High levels of chronic ill health within the family, increasing the need for carer support, and reducing the opportunities for employment.
  • Low income, leading to increased family stress and relationship breakdown.
  • Insecurities within the children, leading to poorer academic achievements and less ability to take control of difficult life-events.
  • Increased levels of crime and disorder amongst young people, and increased over-consumption of alcohol and misuse of drugs.
  • Health services in such areas tend to be patchy, and there are some areas where the primary care facilities are not fit for the purpose. This in turn can lead to problems in attracting high quality health care staff.

b) Regeneration

Regeneration of the more disadvantaged areas of the country is key to health improvement. There are some parts of the country that are 'food deserts', where for example there is very poor access to a selection of fresh fruit and vegetables.

c) Food

In some of the more disadvantaged areas of the country, cooking skills have been lost, and families are being raised on highly processed ready made foods, high in salt, fat and additives, thus storing up health problems for the future. National standards to reduce the salt and fat content of mass produced foods would be helpful, as would more understandable food labelling.

When Food Technology is being taught in schools, there should be an emphasis on the preparation of healthy foods, rather than teaching how to make foods rich in fats and/or sugars, such as pastries and cakes.

The provision of free fruit in schools is welcome. It should not be seen as an alternative to free school milk. In some disadvantaged areas, the calcium content of the diet is important to maintain if the children are to develop strong teeth and bones, and there is a strong case for having both free fruit and free milk in schools.

d) Physical Activity

School children of all ages should be given daily opportunity for physical activities. These opportunities should be varied, to meet the interests and needs of children with different skills, abilities and aptitudes, and both competitive and non-competitive activities should be encouraged.

For individuals, the high profile national publicity about physical activity is helpful, and frequent images on television and in newspapers and magazines showing the ways physical activity has made a positive difference to ordinary people's lives, do provide an incentive.

e) Smoking

There is a strong case for the Government to legislate for all workplaces to be smoke-free. This would enable public places such as pubs and restaurants to become smoke-free, and would provide added incentive for smokers to give up.

f) Alcohol

In the more disadvantaged areas, the social problems caused by excessive consumption of alcohol by young people are enormous. The national alcohol strategy does not go far enough in supporting local areas with tackling this problem. The binge-drinking culture has not been around for long, and it is having a very negative effect on both young people and their communities. More positive alternatives need to be encouraged for young people, so they are able to enjoy good nights out without the destructiveness of drunkenness, and its costs on society.

g) Chronic Disease Management

In the more disadvantaged areas of the country, the levels of chronic disease are much higher. This is a burden to the community, and means that more people need to be carers, and more are unable to work because of ill health. In such communities there is much more dependence on the health services, and there is great pressure on both hospital and primary care services.

There is a strong case for increased health care staffing per head of population in such communities. Some Primary Care Trusts in disadvantaged areas are still a large distance from their target funding; it would be helpful to the reduction of inequalities to bring them to that target funding more quickly, so that the health care staffing can be increased, and the chronic diseases within the population can be treated more effectively and efficiently.

h) Community Health Development

There is much untapped energy, skill and intelligence within communities, which could be used a lot more to improve health in disadvantaged areas. Health promotion teams in most areas are not skilled enough in community health development; more emphasis needs to be placed on developing these skills, to encourage local people to become involved in helping one another to lead more healthy lives.

i) The Role of the Arts

The role of the arts is increasingly being recognised as important for health improvement. Arts can be used as health promotion tools (eg. drama, visual images). Arts are also important therapeutically, to enable people to come to terms with their illness, such as for people with mental illness, or cancer. Alliances between health services and arts organisations should be encouraged, through awards, through funding mechanisms and through government policy.

j) The Role of Faith Groups

Faith groups have a very important role to play in local communities, and provide close-knit communities that are very supportive of people's physical, mental and spiritual health. There will be different skills and interests within each church, mosque, synagogue etc., but some will be very keen to become more involved in national strategies to improve health. Alliances between health services and faith groups should be encouraged.

2.7 - Mental Health [7]

a) The influences on a person's mental health are very varied. From a Christian point of view research has shown that religion and marriage both promote mental health. We would therefore urge the Government to make this evidence more widely known in a non-judgemental way.

b) The rates of childhood dysfunction are twice that of children in the intact nuclear family amongst single parent families; six times amongst step families and ten times that of the nuclear family amongst multiple reconstituted families.[8] Dysfunctional parenting is one of the causes of severe juvenile delinquency. Group parent training programmes using standardised videos have been shown to be both cost effective and clinically effective.[9,10] More help is needed in primary prevention of childhood dysfunction. The Sure Start Scheme gives intensive support to 'at risk' mothers and high quality play schooling for 'at risk' children.

NEWPIN in London sought to empower depressed victimised mothers by enlisting them in a self-help befriending scheme. Promoting childhood resilience factors leads to children being better able to survive adverse family life. Another example would be if children can find an alternative attachment figure (eg. a friend, teacher, neighbour, grandparent). Links with faith communities should be encouraged in this respect. Primary prevention by the provision of youth clubs has repeatedly been shown to be effective in reducing emotional and behavioural disorders in childhood (eg. Headstart Project in New York).[11]

More co-operation between statutory and voluntary sectors (such as faith communities) should be encouraged in the provision of these facilities. Older youth projects pioneered by Christian groups include the Greenhouse and Salmon Clubs in South East London.

c) There is some evidence that exercise helps depression in adults and there is a great need for improved leisure, sport and recreation facilities. These too will help prevent young people becoming bored and turning to anti-social behaviour, drug abuse and crime.

d) There is a need for more help for adults with mental health problems in getting back to work. The Christian charity PECAN in South East London offers this. The provision of sheltered work place opportunities for those who have mental health problems is important.

e) Co-operation between mental health services and the faith communities should be encouraged. This should increase opportunities for those with mental health problems to find roles, promote their sense of self-value and de-stigmatise mental health problems.

2.8 - Obesity

a) In considering a response to obesity we have to reflect on its causes. It is clear that obesity must result from an excess of energy intake over expenditure. Yet despite the common belief that we all eat more than we used to, energy intake in comparison with 40-50 years ago has actually declined. Therefore activity has declined to a greater extent. Nevertheless, there are factors that impair our ability to sensibly adjust calorie intake such as the increased energy density of processed and 'fast foods'.

As physicians we see the terrible consequences of excess weight in our daily practice - the relentless increase compounded by the individual's incapacity to achieve a significant weight loss, and their own failure compromising further their impaired self-esteem.

Worse still, it is the poorer sections of society who are seeing the brunt of this disease.

Yet as Christians we believe that individuals have responsibility for themselves and others and therefore obesity in a world that still suffers from hunger and scarce resources is wrong from a range of perspectives:

  • It damages the individual
  • It reflects a waste of food and money that could be used to address global inequities
  • The consumption of expensive, pre-processed food that requires a higher level of energy consumption (production and transport) implies a neglect of our responsibilities as stewards of the earth.

Though we do not believe it is our responsibility to judge, we would urge the Government to pay attention to the global impact of our consumption and consider our national responsibility to manage the resources we have in an honourable way.

b) What are the factors that limit an individual's capacity to control their weight?

The key factors are:

  • Personal responsibility
  • Avoidance of poverty
  • Safe, reliable, alternative transport
  • Knowledge of risks/benefits
  • Self-esteem
  • Self-care skills (ie. cooking, activities)
  • Cheap, healthy food

Knowledge is only one part. People do not know the scale of risk. The risk of type 2 diabetes starts before a person even reaches a BMI of 25 and translating this into real-life figures for height and weight shocks many. People need to know the facts that relate to them and their families. Focussing on the extremes leaves too many with a sense of false security.

Acceptance of individual responsibility is necessary. A person must accept that it is the food they eat and the exercise they do that determines their weight - NOT a slow metabolism. In fact obesity increases one's energy requirements.

Yet a tension exists - to labour this point without providing support can lead to feelings of guilt that further compromise a poor self-esteem. A government that seeks to prevent obesity must not support society's worship of beauty and physical perfection as a measurement of an individual's worth.

There are major obstacles to making the lifestyle changes necessary to control weight, particularly for the poorer members of society. Even taking a bus rather than the car improves activity, yet it is a viable option for few. Worse still, safe cycling is rare in this country.

Low-fat, lower calorie food choices are expensive except for those with cooking skills - both must be addressed.

c) So what are the solutions?

  • A programme of education for all stages of life about healthy living, from schools, HCPs and advertising that values the individual whatever their shape and makes the sense of risk personal, yet teaches a sense of responsibility for the self and others.
  • Resourced support for all those who need help to effect change.
  • Work with food providers especially supermarkets. Encourage non-processed food, with shorter transport distances, despite industry interests.
  • Safe commuting cycle routes around all centres.
  • Efficient public transport and increased options for those who choose not to use cars.
  • An equitably resourced health service to treat the extremes of obesity with effective measures.
  • A programme of ongoing monitoring to ensure that the disadvantaged members of society benefit equally from these approaches with independent public reporting of data.
  • A radical approach to poverty.

d) Conclusions

Christ calls us to live to higher standards yet He gives us the means to achieve them - a government who calls a nation to change has a God-given responsibility to provide the means to facilitate such change.

2.9 - Sexual Health [12]

a) Have we got the balance right when it comes to using condoms to prevent sexually transmitted infections (STIs)? (page four of summary document)

No! There is an assumption that condoms work for all STIs because they have been shown to reduce the risk of HIV by 85-90%. The risks of condom use are poorly understood by many doctors let alone the lay public who often believe they are '99-100% effective'.[13]

The risks are of:

  • User failure.
  • Risk displacement.
  • Not being more than 50-60% effective in most common STIs including chlamydia even with perfect use.[14]

An emphasis on changing primary behaviour is essential and was recently emphasised by three papers in the British Medical Journal.[15] The situation in Uganda and the success of the ABC initiative for addressing STIs has recently been highlighted by two papers.[16]

Even Douglas Kirby, a leading sex educator often quoted for saying the jury is still out on abstinence education also says 'the evidence is not conclusive' on making condoms available in schools either.[17]

An important approach is to encourage delayed sexual debut. Those who start having sex younger tend to have more partners over their lifespan, thus increasing their chances of an STI.[18] Many later regret this and wish they had delayed.[19] Adolescents should be empowered to resist harmful choices that they may later regret.

b) Are concerns about confidentiality stopping people accessing services? (last question of the sex health section summary)

Confidentiality in hiding abortions and provision of contraception to underage girls from their parents may actually be fuelling the sexual health crisis, as evidenced by the work of David Paton.[20]

We should be more concerned about encouraging parents to talk with their children about sex rather than keeping things from them in the name of confidentiality. 80% of teenage pregnancies result from failed contraception and this is where we should be focusing efforts rather than encouraging more adolescents to use it when it fails so often.

In short:-

  • Condoms are not the answer in themselves.
  • Easy provision of access to them fuels the sexual health crisis.
  • Parental involvement should be encouraged rather than parental exclusion under the cloak of the 'confidentiality' card.

2.10 - Smoking

a) The principles of protecting the disadvantaged and vulnerable are an over-riding principle in our response to smoking. The key problem is that once in the situation, tobacco is an extremely addictive drug. It is very well recognised that this is a lower socio-economic class issue and also that the tobacco industry is beginning to direct its advertising onto young females. In addition, globally there will be major problems for the developing nations as they are increasingly seen as the 'new market' for tobacco sales.

b) What can the government do to ensure that people don't start smoking and if they do to support them?

  • Nicotine replacement and bupropion must be made cheaper and substantively less than the cost of smoking.
  • Ensure that people who supply and sell to the underage are more heavily penalised.
  • Although the government has poured resources into the smoking cessation services within Primary Care Trusts, there are still insufficient resources to deal with the harder cases of nicotine replacement. We also still need more level 2 counselling to be made widely available. These services must be permanently funded to ensure this strategy is not abandoned on a change in governmental policy.
  • Raise taxation further on cigarettes - we may be more expensive in terms of the cost of cigarettes than most other countries already but we also have one of the highest burdens in lung disease. This strategy is well recognised.
  • Consider a direct health tax to be levied onto the cost of cigarettes to allow the funds to be used for smoking cessation as well as dealing with the cost of smoking in the NHS.
  • Allow/encourage more explicit negative effects of smoking to be displayed in the media and on television programs. There should be more cases of lung cancer and cardiovascular death that make a distinctive link to smoking in our soaps so that the public consciousness is made aware of this important fact. Conversely the depiction of it being cool or just an adolescent 'thing' needs to be carefully examined in the media.

c) Who else in society should be involved in helping people not to start smoking and supporting those who want to stop?

  • Pharmacists should be given better induction and remit in terms of recommending NRT (nicotine replacement therapy).
  • Churches, youth groups and community groups should be encouraged and supported in their programs that could involve the education of young people about the effects of cigarettes as well the general theme of addiction given the other drugs that they may be exposed to.
  • Fund new drug studies to further increase the choice of agents that may help combat the addictive component of smoking.

d) Should alternative ways for smokers to get nicotine be more widely available?

Access to NRT is already widely available but the issue is that of cost. The largest socio-economic group that smoke are those that are least best placed to afford NRT. The price must be below that of cigarettes in real terms.

e) Should the government pass a law to make all enclosed workplaces/public places smoke-free? What about restaurants? What about pubs and bars? Would local authorities be better placed than Central Government to introduce laws?

There is accumulating evidence that passive smoking is a factor in developing smoking related disease. It is logical for this country to proceed to a complete ban of smoking in any public place including restaurants, pubs and bars. The implementation of this will probably be best managed locally but there must be a clear indication by the Government that this is a policy that they wish to pursue.

f) Apart from bans how else could local towns and cities respond to calls for more smoke-free public places?

Encourage more smoke free sections even within traditional 'smoke-filled' environments (eg. pubs and bars).

g) Who else apart from the government could be involved in media campaigns to help people stop smoking?

In addition to groups such as the British Heart Foundation and Cancer Research UK, involvement of other organ/disease specific 'smoking related' charity groups such as the British Lung Foundation should be encouraged. Broader health organisations can also get involved in publicising the negative effects of smoking and the positive health gains from cessation. The concept of our bodies being 'temples' that need careful stewardship is an extremely useful belief and that makes people less willing to 'abuse' this gift of life.


Dr Dominic Beer MA MB MRCP
Senior Lecturer in Psychiatric Medicine (Guys, Kings & St
Thomas' Institute of Psychiatry) and Honorary Consultant in
Challenging Behaviour and Intensive Psychiatric Care (Oxleas NHS Trust)

The Reverend Professor Chris Cook MB MRCP BSc
Emeritus Consultant Psychiatrist, Durham

Dr Mark Daly MB MRCP
Consultant Endocrinologist, Royal Devon and Exeter Hospital

Miss Jacky Engel BMedSci MPhil MA
CMF Research and Publications Assistant

Dr Diana Forrest MSc MB DOBSTRCOG
Public Health, Cheshire

Consultant Psychiatrist, Bristol

Dr Onn Min Kon MB MRCP
Consultant in Respiratory Medicine, St Mary's Hospital, London

Dr David Pitches DCH AKC MB BSc DFPH
Specialist Registrar in Public Health, Birmingham

Dr Peter Saunders MB FRACS
CMF General Secretary

Dr Trevor Stammers MB BSc MRCGP DRCOG
General Practitioner and GP Tutor, West London

Professor Richard Vincent LRCP MRCS MB MRCP
Consultant Cardiologist, Royal Sussex County Hospital


  1. See
  2. See
  3. See
  4. See articles at
  5. See
  6. See articles at
  7. See articles at
  8. Power, C. A Review of Child Health in the 1958 Birth Cohort: Natural Child Development Study. Paediatric and Perinatal Epidemiology 1992;6(1):81-110
  9. Scott, S. et al. Multicentre Controlled Trial of Parenting Groups for Childhood Anti-Social Behaviour in Clinical Practice. British Medical Journal 2001;323:194-198
  10. Scott, S. et al. Financial Cost of Social Exclusion: Follow-up Study of Anti-Social Children into Adulthood. British Medical Journal 2001;323:191
  11. McGuire, J. and Earls, F. Prevention of Child Psychiatric Disorders in Early Childhood. Journal of Child Psychology and Psychiatry 1991;32:129-154
  12. See articles at and
  13. Workshop Summary - Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease Prevention. Summary report prepared by National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, July 2001 (; Stammers T. The Condom Controversy: Safe Sex or Russian Roulette? (
  14. Warner L et al. Condom effectiveness for reducing the transmission of gonorrhoea and chlamydia. Am J Epidem 2004;159:242- 51. Paz-Bailey G et al. Condom protection against STD, at - National STD Prevention Conference 2002; presentation B9D
  15. Wilson D. Partner reduction and the prevention of HIV/AIDS. BMJ 2004 328:848-9; Shelton JD, Halperin DT, Nantulya Vinand et al. Partner reduction is crucial for balanced 'ABC' approach to HIV prevention. BMJ 2004 328:891-3; Genuis SJ and Genuis SK. Adolescent behaviour should be a priority. BMJ 2004 328:894.
  16. Low-Beer D and Stoneburner RL. Population level HIV declines and behavioural risk avoidance in Uganda. Science 2004 304:714-18; Low-Beer D and Stoneburner RL. Behaviour and communication changes in reducing HIV: is Uganda unique? African Journal of AIDS Research 2003 2(1):9-21 (
  17. Kirby D. Making condoms available in schools. West J Med 2000 172:149-151
  18. Santelli JS et al. Multiple sexual partners among US adolescents and young adults. Fam Plann Perspect 1998;30:271-5
  19. See for the National Survey of Sexual Attitudes and Lifestyles. Reported in Lancet 2001;358:9296
  20. Paton D. The economics of abortion, family planning and underage conceptions. J Health Econ 2002 21:27-41; Presentation - Random Behaviour or Rational Choice? Family Planning, Teenage Pregnancy and STIs (PDF File, 71KB). Presented at the Royal Economic Society Conference, Swansea, April 2004 by David Paton, Professor of Industrial Economics, Nottingham University Business School (

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