I was at an LGA event on Tuesday called ‘Changing behaviours in Public Health – to nudge or to shove?’ (See #LGAcwb on Twitter.) It certainly sparked my enthusiasm by showing how public health has been embraced by local authorities around the country, and how areas like Wigan and Hertfordshire seem to have successfully engaged wider partners, such as dentists and pharmacists, as well as getting councillors and council officers on board with the wider public health agenda. These are all things I feel we could do much better in Dorset.
However, as usually happens with me, I saw things very much in light of what I’ve been reading and thinking about recently.
Claire McDonald spoke persuasively and openly about mobilising private interests to advance public health causes – mentioning Unilever’s initiative to boost handwashing (and/or use of Lifebuoy soap?) and her own initiative to prompt women to tell their GP ASAP (As Soon As You’re Pregnant).
I could feel myself bristling, simply because I have a natural suspicion of the profit motive. However, given that we don’t have a nationalised food industry (although many public health professionals certainly aren’t comfortable with private food companies), I can’t help but accept that the market is perfectly capable of providing good things, and often efficiently. If we want to wash our hands more often, and this is a good thing, what’s wrong with a company finding a niche (and some money) in this?
The workshop discussion on alcohol policy also raised the same issues of whether industry has a legitimate role to play, featuring Emily Robinson from Alcohol Concern alongside Elaine Hindal from Drinkaware (funded by the industry) and (much more open about his industry links) Henry Ashworth from the Portman Group.*
This discussion didn’t quite lead to the clear argument I experienced at last year’s DrugScope conference (perhaps an indication that Henry and Elaine pitched their message better to the audience than Mark Baird did there), but there was certainly some scepticism from those in the room as to whether the industry could really foster a healthier drinking culture (a straw poll revealed almost unanimous support for ‘shoves’ over ‘nudges’).
Now here’s my hobby horse (for this week). I’ve been thinking about neoliberalism (resubmitting an academic article) – the point being that certain policy options around alcohol seem unthinkable because of the dominance of this ‘mentality of government’, when in fact they’ve been in place at various times and places in history. Reading Intoxication and Society I was struck by the example from James Brown of schemes that pre-date the Central Control Board or Gothenburg System by hundreds of years – where government took the profit motive away from those running drinking venues, so that they didn’t have a reason to sell people more alcohol.**
Given that very few councils have introduced Early Morning Restriction Orders (EMROs) or Late Night Levies, it’s no surprise municipal pubs aren’t on the agenda.
But this isn’t all about the need to abolish the profit motive surrounding something that is ‘no ordinary commodity’. Canada also had a comparable system of retail regulation, analysed in a new book by Dan Malleck: Try to Control Yourself. Unfortunately, I haven’t read it yet (but consider this me proposing myself as a reviewer to any journal that will have me). However, I have read the (free) review in Brewery History by Matthew Bellamy. The review questions Dan’s argument that the regulation was a key element in reshaping Canada’s drinking culture such that, in Bellamy’s words, ‘Controlling oneself and drinking moderately continues to define an important part of what it means to be Canadian’ – in contrast with the situation before Prohibition in 1916, when ‘It seemed as though there were only two types of Canadians . . . those who drank to excess and those who did not touch a drop’.
Let’s set aside for the moment the point that immediately occurs to me, which is that, unhelpfully, we often have a similar (but mistaken) understanding of alcohol consumption in the UK today.
Bellamy’s critique of Try to Control Yourself is that actually the culture change isn’t all about the regulation. It’s also about the brewers. (He’s writing in a journal called Brewery History, after all.) Having an (economic, profit-based) interest in temperance not winning the day, they found that they could embrace the model of the responsible ‘citizen-drinker’ the Liquor Control Board of Ontario envisaged.
You can see the same sort of motive operating in other times and places – Chris Routledge makes the point that the creation of the fantastic Philharmonic Dining Rooms (and other Cain’s pubs) in Liverpool was a deliberate move to generate a sense of respectability around drinking, enhancing its social, cultural – and therefore political and economic – capital.
And there are lessons in this commercial dynamic for us today. Not only is the industry a legitimate stakeholder in alcohol policy formulation, but it’s not a monolith. In the debate around MUP, some organisations were in favour, others opposed – the divisions weren’t always neatly predictable, and some companies shifted their positions.
In Bellamy’s interpretation, it’s the brewers who put the pressure on the hotel [pub] managers to run things smoothly. However, this needn’t be the dynamic today.
To bring us back to the LGA conference, in the alcohol workshop discussion, there was little mention of on-licensees. Where retailers were concerned, ASDA was mentioned, but most of the discussion was implicitly focused on the producers that fund the Portman Group – perhaps because this organisation is more open about its industry links, whereas Drinkaware is less directly the CSR arm of its myriad of funders (including plenty of organisations with on-trade interests, such as Admiral Taverns, JD Wetherspoon’s, Punch Taverns and Marston’s, for example).
To be fair, Henry mentioned schemes such as Best Bar None, and there’s plenty of work local authorities and public health teams have already done with such initiatives and more, working with the on-trade. However, I’d suggest that if we’re looking for innovative ways to change drinking cultures, there’s more that can be done.*** There is serious mileage in Henry’s proposal for encouraging the ‘nudge’ of house wines being weaker, for example. And in the context of Claire’s enthusiastic (or pragmatic?) embrace of Unilever and Merck/MSD as partners for public health change, the idea of having to shove the industry seemed dispiriting. (Of course, we could come back to the idea that, unlike Lifebuoy soap, alcohol is no ordinary commodity, but then neither are pharmaceuticals.)
Thinking about culture change locally, the alcohol policy options that have been pursued in the past, and the possibility of harnessing private enterprise to benefit public health, it’s not so much the producers who are worth targeting as the retailers – and, I would argue, the on trade specifically. This is particularly the case in the LGA context, when licensing (as opposed to MUP or taxation) is in the hands of local authorities.
The reason I think there’s more opportunity to engage the on-trade, if we’re interested in changing cultures around alcohol, is that the on-trade is no longer overwhelmingly reliant on the trade in alcohol. That is, to some extent the situation produced by state regulation in Carlisle or Gothenburg has come about organically. Although it’s an unusual case, I believe the majority of the turnover these days in student unions such as Bournemouth’s is on food and soft drinks including coffee and tea, rather than alcoholic drinks.
In the case of handwashing, Unilever have an interest in selling soap, but public health professionals want to encourage people to use soap, so working together seems plausible. In the case of the on-licensed trade, the mix today is such that the interest in profit doesn’t need to be an interest in selling (only) alcohol – and so there may be a potential overlap between the licensee’s interests and public health.
There are of course several issues with this claim. Most importantly, not all venues have the same model, and it’s those which are the most dominated by selling alcohol at the moment that are most likely to worry public health teams – and they’ll also be the least likely to have common ground. However, the converse point is to look at research like this (by Adrian Barton) and see that ‘pre-loading’ often happens in part because drinkers don’t like the option they’re being provided with by such venues, particularly early in the evening. And yet drinking at home isn’t always the best idea either from the perspective of government and public health, as an uncontrolled environment with little precision around units. Might one potentially beneficial outcome for both public health professionals and local licensees be to encourage people it’s better down the pub – or at least certain pubs?
There are also wider challenges in shaping the policymaking context. The argument that the brewers in Canada were in favour of the responsible ‘citizen drinker’ depends to some extent on the spectre of temperance and prohibition, when, as Brian Harrison put it, the world of temperance can seem a long way away, with ‘unfamiliar arguments and forgotten attitudes’. And yet for such a faraway movement it provided the policymaking context for the drinking laws that were in operation when Harrison was writing and, in slightly altered form, for the rest of the 20th century. One can trace the influence of such campaigning even if none of the key demands are met.
Similarly, organisations like Alcohol Concern can see themselves as providing a counterbalance to the drinks industry, and helping to shape the terms of the debate and possibilities seen by government, merely by being part of public discussions. Andrew Barr suggests that the formation of the Portman Group itself was a response to an emergent neo-temperance movement.
Thinking of Alcohol Concern as a counterbalance as a positive development sits somewhat at odds with my previous complaint of the zero-sum, realpolitik of the two apparently opposing sides in alcohol policy debates – though to be fair I did talk about the ideal dream world where different stakeholders come together for open and honest debate with their different perspectives...
But rather than this pessimism, I’d rather end in the same vein as I began: extolling another potential opportunity for innovative, helpful public health work. Now would seem as good a time as any to think about how the on-trade could be encouraging public health. Although there’s been good work so far, the opportunities for development are plentiful: as well as offering an alternative to pre-loading in city centres, the idea of the pub as the hub will resonate in more rural areas, enhancing social capital (and therefore health). In such a world, the industry doesn’t sound an amoral product of the profit motive. Maybe I am converted to public-private partnership… (Well, not quite yet.)
If you’re aware of interesting, effective work already going on please let me know. As far as I'm aware, the sort of development I'm proposing doesn't seem to have been a feature of Community Alcohol Partnerships, for example, but if things are happening that would keep the fire of my enthusiasm (and envy) burning a little longer...
*In a shameless act of self-promotion, here’s the link to my previous post on this issue – and here it is in a more public forum.
**For those who don’t know about these schemes, I can’t recommend highly enough reading about them in, for example, James Nicholls’ The Politics of Alcohol or Paul Jennings’ The Local.
***This raises the question of whether we actually want to change drinking cultures, and whether this is a legitimate aim of public policy. I’m not actually sure, but for this article it’s taken as read because it’s clearly a current public health aim. And, as I mention, there is something to be said for the industry representing its own interests and public health representing its own. They might sometimes overlap, but they won’t always and that’s why it’s useful and interesting to hear both perspectives.