Steve Brine: Making the most of vaping to deliver a smoke-free Britain

10 Jul

Steve Brine is a former Public Health Minister, and is MP for Winchester.

Last year, the Government announced plans to make England smoke-free by 2030, building on previous initiatives such as the ban on smoking inside public places, and the introduction of plain packaging for cigarettes and hand rolling tobacco.

A year on, we have yet to see enough detail of how it intends to achieve its ambition, and there are real concerns that England could miss this target unless further clarity is provided.

The UK vaping industry, estimated to be worth more than £1 billion to the economy, can be a valuable partner in helping to deliver on the Government’s objectives and address the smoking cessation plateau.

Regulators and health experts in the UK have already acknowledged that vaping could play a crucial role in reducing smoking rates, providing smokers with an effective tool to quit altogether.

During my time as Public Health Minister, we laid out its plan for adopting a harm reduction strategy, aimed at maximising smoking cessation among adults and minimising uptake by young people.

This policy was driven by previous research conducted by Public Health England, which found vaping to be at least 95 per cent less harmful than smoking cigarettes. Since then, a clinical trial led by Queen Mary University of London found that vape products were almost twice as effective as patches and gum – known as nicotine replacement therapies – at helping smokers to quit.

With vaping, there’s no combustion, no smoke, no tar as found in traditional tobacco products. While vaping is not without risk, and we lack the long view afforded by decades of research science, we know it allows smokers to receive nicotine without the cancerous toxins produced by combustible tobacco.

However, to encourage smokers to try vaping, they need to have confidence that the products they choose are safe.

Recent negative media coverage means trust in the vape category has declined. For example, statements originating in the USA said that vapers could be at greater risk of contracting Covid-19, claims which are wholly unsubstantiated. This could deter smokers from transitioning to vaping, a significantly less harmful nicotine delivery method.

Such developments represent an opportunity for the Government to reappraise the regulatory landscape and improve product quality across the industry, thereby increasing consumer confidence in vape products as a mechanism for addressing public health concerns.

One of the simplest and most effective ways to achieve this would be to regulate non-nicotine products intended for vaping (specifically ‘shortfills’ – or ‘make your own’), which are not currently captured by the Tobacco and Related Product Regulations in the same way as nicotine-containing products are.

This would not only improve consumer confidence, but would ensure the UK retains its position as a global leader in the regulation of vape products and could support the Government’s public health objectives.

As the country moves through this unprecedented period of social upheaval, all efforts must be made to ensure that smoking rates do not rise again. The recent ban on menthol cigarettes will support this effort, provided regulators enforce it and challenge tobacco manufacturers who continue to flout the rules.

Greater efforts must also be made to inform the public about the benefits of vaping and how it has already helped thousands of people to reduce their tobacco use.

To be clear: if the question is ‘should non-smokers start vaping?’ the answer should and will remain no. But if we’re talking about smokers who are struggling to quit, then vaping is undoubtedly one of the better options in their toolkit.

Government and industry therefore need to recognise the opportunity they currently have, and that future regulation must evolve to reflect societal changes.

Rough sleeping has fallen sharply. The challenge is to stop it rising again.

9 Jul

Ending rough sleeping poses a particular challenge in a free society. That is because it is not only a matter of making help available, but of persuading those who need it, to accept it. Another complication is that the help required goes beyond accommodation. The lack of a bed to sleep in is invariably a symptom rather than the cause of an individual’s difficulties.

The coronavirus prompted greater urgency for the Government to take action. Ministers had already outlined in February a determination to find a long term solution – with the assistance of Dame Louise Casey.

Though this issue is a moral disgrace and source of national shame the numbers involved are relatively small. The latest snapshot survey for those sleeping rough on one particular night last autumn came up with a figure of 4,266. The BBC gave a figure of 28,000 (based on FOI requests to local authorities) of different people who had slept rough at one stage or another over 12 months.

How many have come off the streets during the coronavirus crisis? 15,000 have been provided emergency accommodation – though not all of those were rough sleepers. Some are from hostels and shelters which have had to close due to social distancing rules. Others will be those who would otherwise have got by as “sofa surfers”. There will also be those escaping domestic violence. However, there might also be around 5,000 who came straight from the streets.

What is impressive is how high the acceptance rate has been from the rough sleepers offered a room. Many have been surprised it has been so high. Only a few hundred are thought to have spurned an offer. It could be the attraction of a hotel rather than a more humble shelter. It could be fear of the coronavirus. Then there is the tough choice that getting food – or the money to buy food – while staying on the streets would be harder. As noted, coercion is not available, but the tone of encouraging people to accept help has been emphatic rather than passive.

Amidst the statistical fog, a couple of points emerge. Firstly, that in proportion to the population, the number of rough sleepers was already tiny. The population of England is 56 million. It follows that accommodating them is a relatively modest claim on the public purse. Providing for others – children, pensioners, the unemployed, the disabled – are vastly more costly items. Secondly, that the already small number sleeping on the streets before the pandemic has fallen substantially.

Dame Louise says in an interview for The Big Issue:

“I was due to do a review into rough sleeping and homelessness but we have all been turned upside down by Covid-19. The primary motivation so far was led by Covid-19 to do an extraordinary thing in unprecedented times, which was to say, “Let’s just get everyone in.” We had everybody getting on the phone to hotels, getting [charities] St Mungo’s, Thames Reach and Look Ahead in London to stand up enough staff to literally in a couple of weeks add to the estate in London by 2,000 beds.

“We were chasing the virus just trying to stay ahead of it. When the inquiry eventually comes saying: “How did you do it? Why did you do it? And what choices did you make?” We just went for it, everybody went for it. We had to get everybody in, we cannot have people dying on the streets. And we cannot have people dying in communal night shelters and that is the prospect that we were facing. We need to be clear that right now we are dealing with this extraordinary situation where 15,000 people have been accommodated at this time.

“I’m not saying that we don’t want to work out how do we not return to the situation that we have seen in the last few years. But our primary purpose so far has been to keep people safe. That will remain our primary purpose, but at the same time we feel that we should see this as an opportunity to think that we can get something extraordinary out of this but that will take an extraordinary effort. The homelessness sector itself and the wider community also needs to think, at this horrific time in our nation’s history, what they can do to help as opposed to what they call on the government to do.”

Jeremy Swain, the Government’s adviser on homelessness, was also interviewed. He said:

“I was involved with Housing First in the 1990s and I’m a big fan, but the problem is there is a slight danger that we think that everybody in those hotels at the moment needs wraparound support and they need it for a long time. What we need to be doing, as well as getting people into housing, is to get people into work. And that is what they are wanting. That’s what they want – when I was at Thames Reach and you put out the questionnaires, 75 per cent of people wanted the services to help them get jobs. Consistently it is bottom of the list for the homelessness sector when for the people themselves it is top of the list.”

That is the tricky part. Amidst Government spending of £850 billion a year, funding an extra 5,000 hostel beds is a footling item. (That’s even before we consider the £10 billion a year we give to charity, often to help the homeless.) Getting those who have taken a wrong turn in life back on the path to proud, independent, and responsible existence is harder. Getting a job would be a pretty obvious ambition. Often that will mean overcoming such afflictions as drug addiction, alcoholism, and mental illness. When I was a councillor in Hammersmith and Fulham I found that very little specialist accommodation was provided – even though the Council had a very substantial Public Health budget which was largely wasted.

Many of those in emergency accommodation have been put up in hotels that would otherwise be empty. It is welcome that hotels are going back to normal business as the economy reopens. That does mean that alternative places to stay are needed – though some hotels are extended their contracts for emergency accommodation. Some universities have made rooms available in their halls of residence – after all college authorities need the money and these rooms would otherwise be empty at present. Some YMCA hostels have single rooms. Then councils have managed to find rooms for some in the private rented sector.

In the long term though, the Government plans new hostel places for 6,000. Much of this will be for specialist housing to cater for particular medical conditions. That will be crucial for these unfortunate souls to have their lives turned around.

“Never let a good crisis go to waste,” declared Winston Churchill. The signs are encouraging with respect to the impact of the pandemic on rough sleeping. A passive response from the authorities to those sleeping in shop doorways and along underpasses is no longer acceptable. Most of those people have already made some reconnection with society and there is every chance that it will not be broken.

The return of the rave should put nightclubs on the Government’s radar

4 Jul

When I borrowed the interviewer’s chair for the Moggcast earlier this month, I took the opportunity to ask about the Government’s approach to the nightlife industry.

My concern was that as lockdown gradually eases, there was a danger that particular groups or sectors risked getting left behind, trapped in a system which is gradually getting less onerous for society as a whole.

Of course, clubs aren’t the only part of the cultural sector under threat: some theatres are already closing. And it isn’t difficult to see why the Government isn’t in a hurry to let nightspots re-open, as their high-footfall, low-margin business models are almost uniquely ill-suited to the era of social distancing.

But clubs pose a challenge which things like theatres don’t, namely that young people seem decidedly unwilling simply to wait for the Prime Minister’s say-so to go out.

Instead, frustrated clubbers are helping to fuel a dramatic resurgence in illegal raves. (Wildcat stagings of popular plays and musicals are not yet in evidence.)

This isn’t entirely a new phenomenon. The UK rave scene has endured, albeit with a much lower profile, since its Nineties heyday, sustained by a backbone of amateur enthusiasts and privately-owned soundsystems. These events occasionally get shut down by the police but are no scourge on society.

Yet there is a big difference between this semi-private fringe and a party scene which replaces shuttered clubs outright. Larger crowds of less-experienced party-goers means an increased likelihood of injury and crime, not to mention much greater disruption to nearby communities.

If this situation continues over the summer, it also becomes more and more likely that organised crime will start moving into this space. Such groups can clear huge sums off ticket sales, use their events to push drugs, and have the infrastructure to rebound from equipment seizures or other setbacks in ways the amateurs can’t.

Worse still, if dire industry predictions do come true and hundreds or thousands of nightlife venues shut their doors, the gangsters moving into the party scene could be well-positioned to buy up vacant clubs and move into the official scene when Covid restrictions are finally eased.

Speaking on LBC today, the Prime Minister was pressed on the timeline for opening various businesses, including gyms. But there is little sign that clubs, which probably lack much of a constituency at Westminster, are on the Government’s radar: Resident Advisor notes that the ‘Our Plan to Rebuild’ document mentions them only once. This needs to change.

There may not be a good answer. It is indeed difficult to imagine how such venues could operate with social distancing in place. But this must be weighed against not only the relatively low risk Covid-19 poses to the young, but the obvious fact that they appear ready and willing to take those risks with or without the Government’s permission. The question isn’t whether people will go out this summer; it’s who profits.

Chris Whitehouse: Faith leaders have a moral duty to be better prepared for the next pandemic

27 Jun

Chris Whitehouse leads the team at his public affairs agency, The Whitehouse Consultancy and is a papal Knight Commander of Saint Gregory.

Lockdown gave an unprecedented character this year to the major celebrations of the great Abrahamic faiths.

Those in the Jewish community endured Passover unable to join with family, friends and their wider community to celebrate the escape of the people of Israel from slavery in Egypt.

Those of Muslim beliefs found themselves daily breaking their Ramadan fast alone, not together; and approached the culmination of that celebration, Eid, at best in small household groups rather than with communal rejoicing.

]The Christian faiths marked the Last Supper on Maundy Thursday; the passion, crucifixion, and death of Jesus on Good Friday; and the resurrection of their Christ on Easter Sunday, without the usual community support in the dark hours or the joyous celebrations of the greatest day in the Christian calendar.

No amount of digital alternatives – Zoom meetings, live-streaming of services, on-line communal singing of religious songs – can really substitute for the mutual support in a time of crisis that comes from being together both physically and emotionally with those who share values and beliefs.

All those whose beliefs and cultural traditions involve them coming together to pray, to worship and to be in social communion have suffered as they endured separation from their wider communities; but for those, in particular, whose faith is nurtured through holy sacraments, their separation from what they believe to be the source of grace has been particularly painful.

Gathering in supportive worshipping communities and maintaining those horizontal relationships with other people is important.

But for those whose beliefs involve a sacramental tradition, that vertical relationship to God that comes through their access to his grace in the sacraments (for example, of holy communion and confession), to deny them that access is to starve them of the spiritual nurturing and sustenance their faith teaches them to crave.

For many of those Christians for whom the sacrament of communion, central to the mass, is the beating heart of their faith, to be able to be present in that sacrifice only remotely has not, for many, been to sense participation. On the contrary, it has exacerbated the sense of separation.

For a church founded on the blood of martyrs, persecuted, tortured, and executed for their subversive beliefs, it has been particularly uncomfortable to see the doors of our Christian churches locked when they could, and should, have remained open to allow private prayer and socially distanced participation in services.

That Westminster Cathedral and Westminster Abbey have remained closed, doors locked to keep out their faithful, whilst the local Sainsbury’s and Tesco have remained open, delivering socially-distanced access to physical food and drink, has been to exacerbate that pain of separation. Why a Warburton’s white medium sliced loaf, but not the bread of life itself?

That church leaders surrendered to this position at the outset of lock-down was perhaps understandable given the sense of crisis and uncertainty that prevailed at that time, but the closure could and should have been only temporary whilst practical precautions were introduced. It was not for our political masters to decide on the importance to the faithful of access to spiritual sustenance compared to other goods and services.

This plague has claimed many lives, including those of ministers of religion, and for their passing we mourn; but that they may have spent their final weeks denied the opportunity to share the sacraments with and to minister to the spiritual needs of their flocks must have been a cause of frustration and anguish to many. Not to hide behind locked doors did they tread the long and difficult path to religious ministry, but to share the love of God with his people and to be with them in their times of need.

Where was the priest to baptise my new grandchild? To marry my daughter whose wedding was postponed? To hear my confession and grant me absolution? To offer the sacrifice of mass and to let me take a personal, risk-assessed decision as to whether I should receive holy communion? To give the last rites to friends of faith who have died during the pandemic? To comfort my elderly and vulnerable mother, alone and fearful in her home?

For many people, these things are not just rituals, they are the building blocks of faith, the foundation upon which their lives, their families, their values, and their political views are based. Many are understandably frustrated, indeed angry, that these needs have been ignored.

Faith leaders will have had troubled consciences about these decisions; and there is no desire to exacerbate their doubts and fears; but their redemption can come only through them learning from these tragic few months, and by them making plans for the future so that when the next plague comes they are ready, their lamps are full of oil, and their wicks trimmed.

Church doors closed for a few hours for a deep clean and some social distancing sticky tape is acceptable; those doors being locked for 15 weeks is not. It must never happen again.

Maria Higson: The Coronavirus has already changed the NHS. Now it can be changed more for the better. Here’s how.

26 Jun

Cllr Maria Higson represents Hampstead Town ward in Camden. She works professionally as a strategist for a major London teaching hospital.

As the Covid-19 crisis moves to its next phase, the conversation is already turning to restarting elective care, and the lives taken indirectly in shutting these essential services. However, with ongoing pressures exacerbated by the impacts of the virus, now is a unique opportunity to innovate healthcare provision – not simply to go back to a system which was already struggling to cope.

Public goodwill towards the NHS has never been higher. If the weekly clapping (accompanied by cheering, pan-banging and bell-ringing) doesn’t show this, the speed at which 750,000 citizens volunteered is surely a strong indicator. The idea of awarding the NHS the George Cross is neither unwelcome nor surprising.

This goodwill is not misplaced; the NHS has stood up to the test of the Coronavirus with aplomb. To take just one example: by April 3rd, the necessary workforce, equipment, and space for over 2,500 additional adult critical care beds was found – an increase of over 50 per cent on pre-virus UK levels (and this excludes the Nightingale hospitals). This precious resource has provided headroom throughout the crisis, with over two thousand beds reported as available during the peak.

However, once the crisis is over and the media has moved on (following in the footsteps of Brexit coverage), what next for the NHS?

The pressures faced are as stark as ever, and the macro-trends are concerning. The UK population age 65 and over is due to grow 45 per cent by 2050; the average health spend of this additional 5.7 million people will be over four times as much as those aged 0-64. The potential impact on public health expenditure is enormous under any scenario, and that’s before considering the social care implications of our ageing population.

Covid-19 adds long-term pressures both directly and indirectly. Of the thousands of intensive care survivors, up to 45 per cent may require rehabilitation support. In parallel, projections show up to two million people becoming unemployed following the crisis, with serious implications for physical and mental health. We will also need to contend with the backlog of elective care not provided during the pandemic.

Given existing, predicted and Coronavirus-related pressures, we cannot simply insist that the NHS goes back to its old practices; we need our non-virus healthcare services to resume, but in a different way. However, if we really want change in our healthcare services, we need to do more than talk about “transformation”; we need to truly shift the mindset of politicians, professionals, and the public to NHS services.

During Covid-19, service innovation suddenly became possible at break-neck speed. For years, the NHS has been calling for a greater prevalence of remote consultations, allowing patients to be seen quicker and without the risk of attending hospitals; where these had previously been resisted, they have now become commonplace. The NHS App – launched and rapidly expanded under the tech-loving leadership of Matt Hancock – saw a 111 per cent increase in registrations in March 2020. Patients have embraced new service models; this shift needs to stick long after the Coronavirus is over.

The causes of this recent rush towards remote care are clear: closed services, constricted travel, and concern of contracting the virus in healthcare environments. However, as these drivers subside, we need to consider what was stopping people from shifting to them pre-virus.

A core issue of remote GP consultations is that residents can still only register with one practice at a time – which means that signing up to an app-based service such as Babylon cuts you off from face-to-face GP care completely.

However, an app can’t measure blood pressure, take samples, or listen to your chest (at least not yet). Surely the most effective model for an individual’s care would be a hybrid one, in which remote appointments could be used where possible, with the back-up option of requesting a visit to a local surgery; this is not an option under the current restrictions. The one-registration rule was created to allow for a single location of health records, but now that technology allows people to hold their own records – readily accessible on their mobiles – it’s time we scrapped it.

Whereas remote GP services are readily available but not necessarily taken up by patients, remote hospital outpatient services are often not even available as an option. Many hospitals have started to implement new models such as telephone or video appointments and community clinics, but the pace of change pre-COVID was frustratingly slow.

In 2019, the Shelford Group of leading hospital trusts wrote that change should be driven, in part, at regional and national levels. Whilst many hospitals have created innovative solutions, it is prohibitively expensive to expect each organisation to invest individually in the development and implementation of these schemes. The national Outpatients Transformation Programme – still yet to be formally established – must be an NHS priority, either to provide much-needed support to existing partnerships or to lighten the load by sharing best practice and cost.

Funding and resources will need to both enable and follow these new structures. Critically, there will be a large infrastructure cost. The ‘NHS England Med Tech Funding Mandate’ makes organisations responsible for investing in innovation expected to deliver same-year savings, but central funding schemes must be increased and made more readily accessible for major investments.

Implementing new technologies will require a workforce with additional skills and an open conversation between professionals and politicians to tackle our existing workforce shortage.

It will also require a shift in where the workforce sits. The benefits of at-home consultations will only be maximised if follow-up care can also be done in the community or even better in the home as well. In February 2020 just 21.1 per cent of nurses and health visitors worked in the community – down from 24.2 per cent in February 2010. A lack of community nurses contributes to the centralisation of care into hospital settings. We must act to reverse this trend.

Finally, we cannot expect all models to work first time round – successful entrepreneurs often have failures amongst their successes, and we need to give the NHS room to take risks as it improves. One anaesthetist summed up much of the issue in describing the need for “permission” (and a common understanding of it) to try new ways of doing things, and the average tenure of an NHS Trust CEO is just three years – not enough time to implement a major transformation. Politicians need to provide professionals with the air-cover to innovate.

Of course, these are just some of the changes needed to help our NHS services to survive. To truly alleviate the pressure, we need to improve public health, and Boris Johnson is absolutely right to be launching a national anti-obesity drive. However, whilst we’re starting on that journey – which will surely be decades-long – we must continue to protect our NHS past Covid-19 by ensuring it is free to make the step-change towards sustainability it desperately needs.