I wrote a slightly different version of this paper recently for Massey. I am posting it here as a gateway to a second post I am writing, the left overs so to speak. What fascinates me about this is that the role of Jamie Oliver as policy pioneer creates some interesting issues around our politicians, our celebrities, what gap are Oliver and others filling ? and why one version of socialised neoliberal statist health in the UK is different to the nozickean neoliberal statist health in New Zealand ?…but that’s to follow.
Sugar Sweetened “Beveridges”
“A profound move that will ripple around the world.” – Television Chef Jamie Oliver on the introduction of a “Sugar Tax “in the UK (Horton, 2016)
“There is no simple answer otherwise people would have tried it “Jonathan Coleman, New Zealand Minister of Health on the same “Sugar Tax” (Plumb, 2016)
“ Human behaviour became …a problem to be analysed and resolved “Michael Foucault (Foucault, 1988)
“Until a law is passed to imprison fat people, gluttons of Britain are free to roam our streets and attend special diet classes like this one ..” – Television Comedy Little Britain (Little Britain, 2003)
In March 2016 the United Kingdom’s Conservative Government announced plans for a “Sugar Tax” (a levy raised on the production of soft drinks which contain above a certain level of sugar). This news caught many observers by surprise. How did a right leaning and anti-interventionist Government introduce a tax, which had not been mentioned in their manifesto some 10 months earlier? Within hours of the announcement the New Zealand Government, who share many ideological and organisational similarities with their United Kingdom (UK) counterparts were emphatically ruling it out. So how does this occur? Two Governments with similar worldviews on many policy issues, running health systems that operate within similar limits and constraints. One however has decided on a Sugar Tax, the other won’t even entertain it. What does it say of their comparative health systems? What does it say of their comparative views of regulation, individual choice and the role of the state? And has New Zealand really ruled it out forever?
Health systems the world over have been under increasing pressures from a number of factors. An ageing and growing population, the development of expensive technologies, increasing user expectations and access to knowledge and growing demand with a rise in a number of chronic disease states. How health systems respond to funding, delivering and governing these issues is a contentious and significant political issue. (Blank & Burau, 2014) As demand grows it becomes harder for Governments to fund existing services and operations, and the focus shifts to either raising additional revenue streams (private payment or taxation increases for example), improving service efficiency or rationing service delivery. In many countries combinations of all of these seem to be tried to varying degrees. And yet in many countries these prove challenging to deliver. (Gauld, 2009)There has been a significantly rise in Adult obesity and every region of the world has seen a doubling (at least) in obesity rates between 1980 and 2000. (Blank & Burau, 2014). This contributes to many other life threatening and costly disorders, Cardio-vascular disease rates and Diabetes type 2 for example. The UK and New Zealand have similar rates of adult obesity 23% in the UK compared to 20.9% in New Zealand. The desire to respond and reduce this growing social phenomena especially with the increases in youth obesity rates and the inequitable distribution of obesity amongst those of lower socio-economic status and lower educational achievement sits high on the list of most health systems. (Blank & Burau, 2014).
To the users of the UK and New Zealand health delivery system the systems may look and feel remarkably similar. Both would be defined as “Beveridge “health delivery systems. Beveridge systems are funded through the state and general taxation and result in universal delivery, free, or with minimal cost, at the point of service. The delivery model is often centralised and bureaucratic. (Van der zee & Kroneman, 2007) This is in contrast to so called “Bismarck” systems where the population are mandatory subscribed to an “insurance” premium model which allows them to fund care at a variety of competing providers with less central government control of care models. These systems result in a more pluralistic and devolved delivery of service and provision. The former are found in the UK, New Zealand and also Italy and the Nordic countries while the latter can be found in France, Germany and Japan. In addition to these two models is the third more market based private insurance model found in the USA where coverage is neither universal nor compulsory and care provision is not only competitive but at a cost to the end user. Both New Zealand and the UK have experienced some changes and challenges over the last 30 years which have seen more and more features of free market systems and incentives creep into the system. At heart though they remain Beveridge systems. (Gauld, 2009)As Beveridge systems New Zealand and the UK have similar health care outcomes as well.
Health systems focus much of their interaction with the population through the policy process. When applying policy, particularly in a centralised Beveridge system, there are three potential avenues open to them. Regulatory policies, distributive policies or redistributive policies. Regulatory policies limit people’s available actions and decisions. Distributive policies allocate provision of service to individuals or groups that are considered beneficial but may not materialise without state intervention. Redistributive policies allocate resource from one individual or groups and allocate it to others. (Blank & Burau, 2014)
In a health context regulatory policies might be the restriction or availability of certain pharmaceuticals or vaccine schedules. Distributive policies could include the provision of inpatient hospital services throughout the country even in sparsely populated areas. Redistributive policies may well include those targeted services, for example the free provision of dental care to under 18s is funded through taxation on those over 18.
The imposition of a “Sugar Tax” as advocated during current debates is clearly a regulatory policy. It cuts to the heart of a serious and contentious issue, that of an individual’s rights versus benefits they receive. Am I free to ingest high doses of Sugar, undertake minimal physical activity and then rely on the state to treat my health issues as a consequence of that? Or can the state regulate my behaviours or at least receive some compensatory transfer through taxation? Both New Zealand and the UK have historically had taxes on sugar but these have been pure customs and excise levies and often to provoke consumers not to utilise a healthier choice but to utilise a more economically favoured option (such as the sugar from a Jamaican plantation rather than a Louisiana slave trade supply). (Pinny, 2010) Sugar was first taxed in the UK in 1850 and British Sugars were taxed in New Zealand in the 1860’s, though presumable from British companies not grown in Britain.
Taxing as a way of reducing actions considered socially unacceptable is often referred to as a “Sin Tax”. The imposition of Sin Taxes are double edged, they look to break perceived bad behaviour but also to fund infrastructure to meet growing demand. (Blank & Burau, 2014). Some have even argued that these regulatory policies are nothing more than an additional way to “discipline” those citizens who are behaving unsatisfactorily in their lifestyle choices (Henderson, 2015)This even creates the risk of scapegoating a “fat” underclass being financially punished for their poor choices and requiring corrective action, often when they are the more vulnerable and least able to deal with the issues in hand. (Evans A, 2010)
In October 2015 the UK Government published as part of its childhood obesity programme a long awaited report into the effects of sugar. The report by Public Health England is titled simply “Sugar Reduction: the Evidence for Action” (Public Health England, 2015). The report followed on from an earlier report into the need for action on sugar reduction. It highlighted that 25% of adults, 10% of 4 to 5 year olds and 19% of 10 to 11 year olds were obese. The cost of obesity is claimed to be over 5 billion pounds for the NHS each year. While the report raises a number of concerns, including the role of media marketing to influence behaviour, the need for knowledge for consumers making decisions and the impact of price promotions on sugar intake (an estimated 6% increase in sugar intake was linked to price promotions) it was the sugar tax idea that caught the media attention. (Campbell, 2015). Tax can reduce the consumption of sugar sweets drinks and products. Of the 8 recommendations one was to introduce a price increase of 10 to 20% on high sugar products through a tax or levy. The report also notes that the food and drink industry has been an opponent of these changes in many of the countries they have been introduced, notably France, Finland, Hungary and Denmark. (Public Health England, 2015). Within a short space of time the Prime Minister ruled out such a levy whilst the British Medical Association and Royal Society for Public Health were amongst those favouring the idea. (Campbell, 2015). The perceived hero of the narrative of getting this policy on the agenda, Jamie Oliver, expressed concern that the financial might of the food and drink industry was hampering progress, while the Government insisted, despite raising the fears of campaigners, that they would not make any decisions on a tax until they agreed on a childhood obesity strategy. The timeframe for doing this was unclear. (Jones, 2016) (Griffiths, 2016). Oliver had used a TV documentary “Sugar Rush” to outline the effects of sugar on children, the advantages of a tax and of advertising changes. He even introduced a surcharge on certain drinks in his own restaurants. (Griffiths, 2016). Oliver had previously played the role of hero in another policy narrative, this was around the role of nutrition in school dinners. A similar tactic of documentary, individual action, political pressure and media attention had been used then though the outcome was less clear. (Naik, 2008). Whilst it’s unclear what changed for the Government in the few weeks following as the mid-March budget outlined the introduction of a Sugar Tax and the legislation to enforce it from 2018 has now been presented to Parliament, outlining two bands of levy depending on the rate of Sugar per 100ml, although there is still no sign of the Childhood Obesity Strategy previously thought so central to any tax decisions. (Elliot, 2016)
Whilst there was surprise in the UK, the New Zealand Government was quick to dampen any expectations of a tax or levy on sugared drinks. The Government has a childhood obesity strategy comprising over 20 issues and it did not wish to add a Sugar Tax to them. They were waiting for further research and the Health Minister felt there was no definitive evidence to support the change. The opposition were not clambering to advocate for the change either as they announced they would prefer sales regulations rather than tax. (New Zealand Herald, 2016). This position seems to have left them at odds with many health professionals and advocates. Professor Rod Jackson argued that waiting for definitive evidence would mean no action on most health interventions and that the question should be on balance will this reduce or increase harm? Jackson clearly falls into the reduce camp. (Jackson, 2016). Countering this view was the powerful Grocery lobby who saw the proposal as merely an excise tax and one with no impact on consumer behavior. They were advocating for “nudges” to behavioral health drinks initiatives. (Rich, 2016). Jackson and other academics had in 2014 produced a paper arguing for much of the same landscape as the Public Health England report. It noted that while some local initiatives had taken place encouraging Schools in some areas to replace high sugar drinks, and the lets beat diabetes initiative Counties Manukau ( which saw drink providers replace higher sugared drinks for lower sugared ones in their restaurants) there has been no coordinated approach from Government ( despite being a centralized Beveridge system) (Sunborn, Merriman, Thornley, Metcalf, & R, 2014) The authors recommended a national approach including a tax on Sugar Sweetened Beverages (SSB) and an end date for consumption of SSB in the same way that the smoke free 2025 target has been set for Tobacco eradication.
This emphasis was again followed up by a group of over 70 leading academics and specialists, after the UK announcement, urged the Government to introduce a Sugar Tax as a quicker way of gaining action on childhood obesity. (Plumb, 2016).
But will it work?
The New Zealand Government is reluctant to assess the proposal other than with a long bow. The report published by the Ministry of Health reflects only on the Mexican example and finds that there is insufficient evidence of its impact and that while sugar taxes have a role there are “difficult and detailed design issues” to overcome. (Ministry of Health, 2015). In some ways this also shows a reluctance to be seen as a Government that will increase costs on users of recreational goods. The New Zealand Treasury and Government took a similar view for a number of years on taxation increases on tobacco users. The Treasury were unconvinced that the effects of reducing smoking rates outweighed the economic hardship that would be added to existing users, particularly those who had lower rates of disposable income. (Thomson & Wilson, 2001) Public Health England however had taken a wider view on the evidence and pointed to reduced SSB intake in a variety of Countries that had introduced taxes of some description, including Norway, Finland and Hungary. (Public Health England, 2015) Whilst New Zealand may want to wait for definitive evidence, there are many research studies that show that an increase in the price of SSB will result in lower intake of sugar, improvements in obesity related diseases and cost savings to the state. (Lennert Veerman, Sacks, Antonopoulus, & Martin, 2016). Or as Professor Jackson commented “don’t wait for the unobtainable definitive evidence, act on the best available evidence.” (Jackson, 2016)
Even having taken the bold decision to introduce the tax though the UK Government may still find resistance. Although the Sugary Drinks Portion Cap Rule introduced in New York City in 2012 was not a tax but a regulation its aim was similar, to reduce the negative impacts of sugary drinks, and its resistance was forcefully led by the retail grocery lobby. New York had tried and failed to introduce a Sugar Tax in 2009 and in 2012 the Mayor of New York introduced a ban on large servings of sugary drinks (defined as 25 calories per 8 ounces). The ban also reduced the size of cups in restaurant self-service establishments. (Min, 2014)The ban known as the “Soda Ban” was never fully enacted due to extensive lobbying that led to several legal challenges. The leading Industries in the UK have already signaled a strong intent to pursue legal challenges to the Sugar Tax claiming it is discriminatory. (Evans & Smith, 2016)
The UK health sector is moving into new territory. The Sugar Tax that will start in 2018 will create a number of new challenges and opportunities. It is above all though a clear signal that the Government will respond to childhood obesity in new policy ways which may make a difference. The research study undertaken in Mexico suggested a 12 % decline in SSB and a 17% decline amongst lower socio-economic groups. At the same time non SSB drinks have increased 4%. There is no reason that this kind of impact can’t be made in the UK or New Zealand. (Colchero, Popkin, Rivera, & Ng, 2016). What however does this tell us about the health systems? As Beveridge systems national priorities remain firmly centralized and dictated by Government. In the UK it is of note that the change has come when the Chancellor (Finance Minister) has led the charge and it is not driven purely by the Health Minister. This perhaps reflects the fact that it is a Tax, but also reflects that key [policy in a Beveridge system needs to be owned by the Treasury. This was certainly the case with the Tobacco control policy in New Zealand. (Thomson & Wilson, 2001). There is also a reality that Beveridge systems although similar in outline have some remarkable differences. In the case of New Zealand and the UK this might include provision of service such as dentistry. It also though recognizes the political reality within these two countries. Although the Governments are remarkably similar, the NHS is now reflective of what one commentator observed as “Socialized Neoliberalism” (Gauld, 2009, p. 152). This confirms others views of the agenda pursued by Jamie Oliver, within a neoliberal or capitalist framework there is a well intentioned corrective action agenda- making smarter consumers. (Evans A. , 2010). By framing the debate in terms of the product and production rather than the outcome (Sugar Taxes over Fat Taxes) there is a softening of public perception and acceptability. (Min, 2014) Enabling people to live independently. (Gauld, 2009). Perhaps this is the reason why New Zealand is set against looking at the merits of the Sugar Tax? The National Government came to office campaigning against the “Nanny State” those policies and regulations that it felt were encroaching on people’s freedoms. They have been hyper-sensitive since 2008 to reflect any policy support that was or could be seen as nanny state and it is a criticism thrown, often with little evidence but able to halt action. (Rudman, 2016) . Or maybe it is the reality that Sugar allows the masses an escape from reality? Sugar has been seen as one of the first consumer goods that’s use allowed people to create different versions of themselves (Mintz, 1985)
What we do know though is that the centralized Beveridge system, once the will and momentum becomes apparent, possibly with a more charismatic leadership outside of the political arena, direction and implementation will be forth write and forthcoming.
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