In a lather: do soap operas promote teen drinking?

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In a lather: do soap operas promote teen drinking?

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Girls also reported far higher viewing of soaps than teenage boys, 15% as opposed to 3% of boys who watched The Road to Tomorrow. Researchers conclude that, in particular for girls, the frequency of viewing The Road to Tomorrow is “significantly associated with juvenile alcohol use. ” No significant association was found between viewers of The Road to Tomorrow and, for example, aggression, delinquency, and self esteem, thus discounting the explanation that there is simply a specific group of young people who both frequently watch soaps and engage in a range of problem behaviours. In the soap Good Times Bad Times where the frequency of drinking is far less and has halved since a previous study two years ago, no relationship could be discerned. The researchers accept there is no proved causal relationship and that viewing soaps is just one of many factors, including availability of alcohol, advertising, and portrayal of drinking in films that result in a robust drinking culture in the Netherlands. But Professor Rutger Engels, who led the research, said that because a large number of adolescents have a prolonged exposure to such soaps it might be “wise to advise” television channels “not to let their actors consume alcohol.” Wim van Dalen, director of the Foundation for Alcohol Prevention, said the drinking scene among Dutch youth was a huge problem and that the media’s influence had been underestimated. “We wanted to clarify all possible influences, including TV soaps,” he said. He accepts script writers and actors don’t intentionally promote alcohol—it is just seen as normal. However, the foundation believes legal sanctions are required. “If a programme is popular with the under-18s then it is necessary to develop regulations about how alcohol is portrayed. You can’t expect TV companies and programme makers to follow their own rules—you need statutory regulations,” said Mr Van Dalen. A spokesperson for The Road to Tomorrow said the programme makers had absolutely no intention of propagating alcohol misuse but would look at the new research. They would make adjustments if necessary, the spokesperson said, but would not want the series to lose its realistic view of society. PHANIE/REX

ith the help of two experts, Vivian, 11 and Christine, 9, I take to the sofa and The Road to Tomorrow, the Netherlands’ popular television soap. Researchers claim that watching the show is “significantly associated with juvenile alcohol use.” Two of the show’s characters, Sherina and Daan, are uncorking wine for a romantic candlelit dinner—cut to celebratory opening of champagne with Ilyas, Elif, Iris, and Niels, back to more wine with Sherina and Dan, before Joost and Malü´ arrive and raid the fridge, for more wine. Is this just a realistic portrayal of modern society, as the programme makers claim, or does it lead to a promotion of unhealthy levels of drinking as normal? Certainly Dutch youth drink. They topped the 2003 European School Survey on Alcohol, ESPAD. Hospitals report up to 1000 youngsters are admitted annually due to alcohol poisoning. The proportion of 12 year old Dutch girls who had drunk alcohol increased from 38% to 68% between 1999 and 2003, and one in four 14 year old girls admit to getting drunk once a month—more than the boys. One explanation could be the portrayal of alcohol in soap operas as glamorous and social. Researchers believe that given the

great popularity of soaps, with up to 30% of teenagers watching them regularly, it seems likely that they could influence behaviour. Adolescents meanwhile, uncertain about their own identity and looking to adult role models to copy, are particularly vulnerable. The Foundation for Alcohol Prevention, responsible to the Ministry of Health for monitoring alcohol promotion to young people, has joined forces with Nijmegen University’s Behavioural Science Unit and come up with “preliminary evidence” of an association between viewing Holland’s most popular soaps, and subsequent drinking behaviour among young girls. Researchers studied The Road to Tomorrow and Good Times Bad Times, another of Holland’s most popular soaps, broadcast every weekday evening. They viewed about 30 episodes over six weeks and looked at the amount of alcohol drunk, the type of drink and the situations where drinking occurred. Researchers then investigated the viewing and drinking behaviour of a sample of 2190, 12 to 19 year olds. Questionnaires asked teenagers how much alcohol they had drunk over the past four weeks and how often they watched the two soap operas. On average there are 4.3 drinks per episode of The Road to Tomorrow, one every five minutes. Drinks are mostly social, or during meals, in cafes and restaurants. Drinking was never associated with any negative consequences. The most popular soap characters are also the heaviest drinkers, researchers found. There emerged a clear linear relationship between young girls’ alcohol use and their viewing of The Road to Tomorrow. The lowest levels of alcohol use were reported by those who never watch the soap, the highest among those who watched it four to five times a week.

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Tony Sheldon freelance journalist Utrecht, Netherlands [email protected]

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Redefining Health Care: Creating Value-Based Competition on Results Michael E Porter, Elizabeth Olmsted Teisberg Harvard Business School Press, $35, pp 528 ISBN 1 59139 7782 Rating: ★★★>

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his book “grew out of a puzzle: why is competition failing in health care?” This first sentence of the book is followed by a rationale, namely that “throughout the economy competition among private sector rivals is the most powerful force yet discovered for driving improvements in the quality and cost of products and services”—except in health care in the United States. The authors, who have studied competition in many industries, set out their hypothesis in this readable book. The book is an example of excellent value: at the time of writing the hardback, with its 506 pages of high quality paper, could be bought on www.amazon.com for only $23.10 (about £12). After analysing what has gone wrong in the US the authors propose that “valuebased competition” is needed: namely, com-

The End of Medicine: How Silicon Valley (and Naked Mice) will Reboot your Doctor Andy Kessler Collins (New York), $24.95, pp 354 ISBN 006113029X Rating: ★★>>

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ndy Kessler, who made millions of dollars in the Silicon Valley technology boom of the 1990s, focuses in this book on how that technology might be applied to health care to weed out disease in its earliest stages and significantly reduce costs. Kessler says that “doctors use ancient tools, memorize symptoms and solutions, and a halfway decent search engine can leave them in the dust.” 760

petition that is based on the value that patients attach to good outcomes of care; and competition not between conventional hospitals and insurance companies but between integrated practice units (IPUs), services that provide end to end care for patients with, for example, cystic fibrosis or heart disease. They are dismissive of the “whole process related approach” and say that “standardised process guidelines belie the complexity of individual patient circumstances and freeze care delivery processes rather than fostering innovation.” Their argument, though powerful, has weaknesses. Firstly, the evidence base for the book is unclear and selective. For example, they cite the elimination of inpatient costs by providing integrated practice units for cholecystectomy, which has led to and resulted from “increased demand for the lower risk, highly successful laparoscopic surgery that has improved the quality of life for many patients.” But they fail to cite another study that showed that, even though the operative mortality was lower, the total number of patients dying from cholecystectomy remained the same, because so many more people had the operation (New England Journal of Medicine 1994;330:403-8). Undoubtedly many outcome measures could be used that are not being used. Surely we should measure the outcome of cataract operations by functional assessment rather than by using a Snellen chart? But as a manager responsible for large scale screening projects I am dependent on process measures, because outcome measures would be too slow to show problems in quality, which can sometimes be explained away by arguing that “other factors such as case mix

are responsible for the poor outcome and not my competence as a manager.” Furthermore, when huge gaps exist between what we know and what we do—for example, a third of patients being considered for bypass surgery or angioplasty are not even receiving aspirin and statins (Lancet 2005;306: 1925-34)—then process based guidelines still have a part to play. The trick, as the authors point out, is to ensure that this does not stifle innovation. We have to be careful what is meant by innovation, when we consider how many innovations have killed people, and it would not be too much to argue that we should encourage innovation but only as part of research. The authors are not trying to change the world; they focus on health care in the US. However, their arguments are stimulating, and although the evidence in support of their hypothesis is relatively limited, their central message—that the “way to transform health care is to realign competition with the value for patients”—is a challenge that every society needs to face. We should not throw out the baby with the bath water. We need more guidelines and pathways based on best current practice, not fewer; but we could also measure the outcomes of value to patients more often and more accurately than we do now.

Sticking to what he calls “the big three”— heart disease, stroke, and cancer—Kessler says that we spend huge amounts of money treating these diseases when what we should be doing is stopping people getting sick in the first place. In a tone that is a curious mix of lowbrow (“colonoscopies are a pain in the ass”) and scholarly, he conducts a series of interviews with scientists about how sophisticated technology can achieve this. One example is high resolution computed tomography that can quickly and cheaply provide “a decent entry-level image of your heart and arteries . . . enough to identify deadly plaque that can be rooted out.” Kessler gets very excited about the fact that half of the million heart procedures now done annually in the United States might no longer be necessary because some sign was detected early enough to treat the illness in other ways. “That’s a lot of hospital beds and cardiologists and nurses with nothing to do,” he declares. The naked mice of the book’s subtitle are the hapless hairless creatures on which experiments are conducted to test that approach, an effort that could teach us about prevention and cost savings, through cheap, mass screening by such means as

biomarkers that can accurately predict cancers and heart diseases. As far as the possible redundancy of doctors is concerned, Kessler notes that some radiologists are being replaced by computer aided detection and interpretation of images. Ophthalmologists are being shut out by laser eye surgery, and “physicalpeddling physicians will be replaced by multislice scanning machines.” Is all this science fiction? Alvin Toffler, author of the 1970s blockbuster Future Shock, said in a recent interview in the Financial Times, “[We] will be using new technologies from self diagnosis to . . . self administered therapies delivered by nanotechnology so patients can do for themselves what doctors used to do.” The end of medicine? Hardly. But it is perhaps the beginning of the end. For now, though, doctors should not give up their day jobs.

J A Muir Gray programmes director, UK National Screening Committee [email protected] Competing interest: JAMG is the author of a book to be published by Offox Press in October, How to get Better Value Healthcare.

David Woods president, Healthcare Media International, Philadelphia [email protected]

Items reviewed are rated on a 4 star scale (4=excellent)

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PERSONAL VIEW

SOUNDINGS

Lasting damage from the trastuzumab storm

Dominoes

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The bus was crowded and running late. An elderly man struggled on with shopping bags and made his way—red faced, panting, apologetic—to the back. Had I been his general practitioner, I would have targeted his smoking—first with the evidence based menu (goal setting, nicotine replacement therapy), and if that didn’t work, I would have milked our relationship. I’d know him unusually well, of course, because of the flare-ups of his chronic bronchitis. Continuity of care, “the doctor as the drug,” all that jazz. The bus was still stationary. The driver was accusing the old man of not showing his bus pass. We all watched as the poor chap struggled to the front, displayed his pass, and struggled back. It was a malicious move on the driver’s part, since the man was clearly of an age to get a free pass. He hung his head, humiliated at having held up the bus, and pretended to arrange his shopping while he got his breath back. A young black woman stumbled over one of the shopping bags. She was tall, attractive, and dressed in a fabulous kaftan. I might have seen her for contraceptive care or some minor skin blemish. She fell forwards, and was partially caught by the other passengers, but her foot was trapped in the shopping and she couldn’t free it. The old man, who was quite probably hypoxic, slapped the woman’s ankle and shouted, “Get off my shopping.” She struggled all the more, and the kaftan rode up to reveal an elegant, shining calf. The old man continued his slapping, and—it seemed to some—pushed the kaftan aside to expose more flesh, which he—perhaps—began to fondle. The woman screamed, but finally righted herself and took an offered seat. A middle aged woman in a baggy cardigan (a Hampstead feminist, by the look of her—perhaps we’d have discussed the dangers of hormone replacement therapy, and she’d have been right) turned on the man. Racist chauvinist git. Should be locked up. Fucking outrageous. A businessman leaped out from behind the Financial Times and asked her to watch her language. My stop was approaching. I gathered up my briefcase and made off to my committee, wondering how much more momentum this germ of malevolence would amass before the day was out. And I took a taxi home.

difficult discussions. Some approved all n May 2005 the annual conference of the patients who applied as exceptions. Some American Society for Clinical Oncology studied the evidence once it was published included a powerful speech by a US and concluded that cost effectiveness was patients’ advocate that highlighted the damuncertain and therefore that the decision to age from “access advocacy,” whereby drug fund should await NICE appraisal. North companies undermine research, licensing, Stoke Primary Care Trust was in this third and appraisal (PLoS Medicine 2005;2:e358). group, but in November its decision was Also presented were fast tracked abstracts of reversed after direct government intervenpreliminary results for trials of trastuzumab tion, mediated through the trust’s strategic (Herceptin) for localised breast cancer. Pubhealth authority. licity for the society’s annual conference is On 21 December a legally aided patient stage managed by its drug company sponfrom Swindon was granted judicial review. sors, and the trastuzumab story buzzed Arguments about the conflict between what through news wires worldwide. the health secretary advised and what was Unlicensed, expensive new drugs withlawful and rational, and about exceptionality out peer reviewed published data do not and human rights, were examined exhausjump the queue over other priorities. If tively. The initial judgment dismissed the patients want drugs for cancer that are unliclaimant’s arguments and upheld the lawfulcensed or not approved by the National ness of Swindon’s policy. But the subsequent Institute for Health and Clinical Excellence appeal judgment conceded that there had (NICE), and hence not funded by the local been irrationality purely primary care trust, they because Swindon, when generally pay for them The Swindon trust issued with a “letter before themselves. This, though action,” had followed health regrettable, does not nor- fell foul of the department advice and had mally attract media com- judges precisely examined the claimant’s ment. When trastuzumab case to see whether excephit the headlines some because it tional circumstances patients funded the treat- followed the existed. The judges conment themselves and some cluded that Swindon’s ran fundraising campaigns health secretary’s policy, which was to refuse or remortgaged their guidance the drug because it was houses to raise the cash. On 3 October 2005 unlicensed and unapBarbara Clark was granted NHS funding praised, would have been lawful if it had for trastuzumab for her localised breast refused to even hear any exception requests. cancer, on the grounds of individual excepAlternatively, if Swindon had said no to all tionality. eligible patients on the grounds of cost and On 5 October the department issued a competing priorities, that would have been press release saying, “Patricia Hewitt, Secrelawful, and hearing exceptions would have tary of State for Health, has announced that been rational. So the reason that the women who are diagnosed from this week Swindon trust fell foul of the High Court onwards with early stage breast cancer will judges was precisely because it bent over have the opportunity to be treated with the backwards to follow the health secretary’s drug Herceptin.” The expectation created by guidance not to refuse on grounds of cost the news release meant many patients alone and not to ignore individual circumbelieved that the NHS would now adopt the stances. Undoubtedly, if Swindon had not drug for routine use. Careful reading of the examined individual circumstances then the announcement showed that it was old news claimant’s lawyers would have argued from months earlier—that NICE would be unlawfulness for failing to follow health asked to fast track trastuzumab for appraisal department guidance. as soon as the manufacturer had applied for, Without sound principles and estaband been granted, a licence. Subsequent lished case law the issue of exceptionality is a clarification in the Department of Health’s complete mess. Whatever a trust now does, Chief executive bulletin (issue 294, 4 Nov 2005) there is scope for a skilled lawyer to argue stated: “PCTs should not refuse to fund Herthat some aspect of legal, ethical, or statutory ceptin solely on the grounds of its cost” and advice is being contravened. Do we really “PCTs should not rule out treatments on want the NHS to sink under this weight of principle but consider individual circumadministrative and legal complexity, purely stances.” Many clinicians understandably because our leaders will not stand up to responded by referring all eligible cases as drug companies that contravene their own exceptions. At this point any hope of a concode of conduct? sistent approach evaporated. Some trusts decided immediately to fund trastuzumab Angela Raffle consultant in public health, Bristol for all eligible patients, not because the case North Primary Care Trust was made but to avoid long, costly, and [email protected]

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Trisha Greenhalgh professor of primary health care, University College London

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