Dame Sally Davies interview: the chief medical officer on e-cigarettes, antibiotic resistance – and stepping out of the comfort zone
As the government’s most senior medical adviser, it’s Dame Sally Davies’ job to stand up for hard evidence and grapple with some of the country’s biggest health challenges. Matt Foster meets her
Professor Dame Sally Davies may be a qualified haematologist, but it’s hard to come away from a chat with the UK government’s most senior medical adviser without thinking there’s also something of the seasoned diplomat about her. As chief medical officer – a kind of high representative for the use of sound medical evidence and protection of the public’s health – she must regularly navigate tricky terrain. What happens when, for example, research suggesting the health benefits of action on tobacco, alcohol, or sugar, comes up against the day-to-day reality of politics?
Her role, she explains, is to “present the best evidence” to ministers and debate with them about the other factors they have to take into account. “But at the end of the day, ministers make their decisions and take the rap for it,” she adds.
Sometimes, those decisions will be controversial. Take the coalition government’s move to rule out the introduction of minimum unit pricing for alcohol. Research suggests the option it backed – a more limited ban on extreme discounting of booze by supermarkets – would be far less effective in curbing premature deaths. Indeed, Davies pointed out as much in her first annual report after the decision, and critics including the Conservative MP Dr Sarah Wollaston accused ministers of caving in to lobbyists.
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Did the chief medical officer feel personally disappointed that minimum unit pricing was shelved? “I think governments can only move forward if they can take the country with them,” she says. “If you look at smoking legislation, it took 20 years to get us to a ban of smoking in public places, and then as the evidence accumulated about standardised packaging, to move that forwards.”
But Davies doesn’t appear to have given up hope that, ultimately, such a policy could win mainstream support. “I think we may end up with something like minimum unit pricing at some time. Clearly we have modelling evidence suggesting it would work – the public was not ready for it at that time. But the debate’s going on, and I think we’ll see something along those lines in the end.”
On e-cigarettes too, the chief medical officer remains cautious about overstating their benefits as a tool for quitting smoking until the evidence becomes more clear. She’s previously warned that the devices could end up normalising traditional cigarettes, acting as a gateway to the kind of behaviour she spends her working life trying to get a country with a seemingly insatiable appetite for self-destruction to move away from.
In August this year, however, Public Health England published a report suggesting that so-called vaping could be 95% less harmful than normal cigarettes. “There is no evidence that e-cigarettes (EC) are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it,” the PHE report states. “Despite some experimentation with EC among never smokers, EC are attracting very few people who have never smoked into regular EC use.”
In light of this, can the CMO foresee a time when the NHS prescribes e-cigarettes in order to help smokers kick the habit?
“Let me be clear,” she replies. “E-cigarettes are less harmful if you are addicted to nicotine than smoking cigarettes. But the best thing is to stop smoking. Smoking is one of the biggest causes of death in this country. We’re accumulating evidence that suggests they may help as a smoking cessation tool. But the evidence is not hard yet. Meanwhile, they’re not regulated. So when you buy them, you don’t know that you’re getting what it says on the packet.
“Can I see a day when we have hard evidence and they are regulated so they can be used [for smoking cessation]? Yes. But we haven’t got that information on the panoply of e-cigarettes that haven’t been regulated yet. I do – and will continue to – worry, because we don’t know what the effects are of long-term use, or about the effect on people who may be upping their nicotine addiction by using them as well as smoking, and the impact socially of normalisation. But, for nicotine addiction, they are less harmful.”
In an age where everyone claims to back “evidence-based policy” and “data-driven government”, does the chief medical officer feel that policymakers are now more receptive to scientific advice than may have been the case in the past?
“I think we’ve moved a long way,” she says. “But what you have to remember is that evidence is a social construct. So there’s hard evidence, from randomised control trials and meta-analysis. But then there’s other evidence. And for a politician, what I want them to do is know the hard evidence and take it into account. But they have to use other forms of evidence as well. What I want is evidence-informed policy. Policy based just on hard evidence leaves out all sorts of things that haven’t been tested but which maybe should be tried…
“The other thing, which is always difficult to explain to the public and to non-scientists, is that science kind of flip flops a bit to get to a final answer. And that’s another reason policy shouldn’t be absolutely, down that channel – just ‘evidence-based’. It’s got to be evidence-informed, because we may not have the final evidence. You’re always looking for better evidence.”
Davies: antibiotic resistance battle "needed the whole of government"
It’s not just encouraging the public to rethink their bad habits that occupies Davies’ time, of course. Last year, she helped to coordinate the UK’s response to the Ebola virus outbreak in West Africa, and has earned plaudits both at home and abroad for her relentless drive to get governments, big pharmaceutical firms, and the wider public to sit up and take notice of what she sees as one of the biggest threats facing the world today: the increasing ineffectiveness of antibiotics.
Since the manufacture of penicillin in 1943, these onetime wonder drugs have helped to usher in a golden age of medicine. But, as Davies explains in The Drugs Don’t Work – a stark but highly readable Penguin volume on the problem – the era of knocking back antibiotics like sweets is rapidly coming to an end. “We have taken antibacterial and other antimicrobial drugs for granted for too long,” she writes. “We have misused them through overuse and false prescription, and as a result the bugs are growing in resistance and fighting back. We are also not developing new drugs fast enough. This is not a distant threat: already, resistant bugs are killing 25,000 people a year across Europe. That is almost the same number as die in road traffic accidents.”
The scale of that challenge – not to mention the fact that its solution will require commitments far outlasting a single political administration – could easily tempt those in power to casually slip it into the “too difficult” box. But Davies, who first gave serious thought to the issue in her 2012 annual report, has been determined to make progress – and quickly.
The result of her efforts has been the UK’s ambitious five-year Antimicrobial Resistance Strategy, published in 2013. As well as looking to boost understanding of the threat, the strategy aims to improve the way the NHS gathers data on how existing antibiotics are being handed out, with a view to bringing down prescription levels. As if that wasn’t enough to be getting on with, the AMR strategy also sets about tackling what Davies has called the massive “market failure” preventing big pharma from investing in the development of new treatments, and at the same time seeks to end the meat industry’s reliance on antibiotics as a cheap substitute for decent animal hygiene.
A glance at the sheer number of departments and agencies involved – the DH, Defra, NHS England, the Foreign Office, all three devolved administrations, to name but a few – is liable to send shivers down the spine of those grizzled Whitehall veterans burnt by previous attempts at “joined-up” government. How hard has it been to coordinate all of those disparate strands – and does Davies feel government has risen to the scale of the challenge?
“It would be lovely to take credit for all of it,” she jokes. “But actually, everyone’s joined in and everyone has helped. I think we have made a very good case for why this is a priority, not only in this country, but internationally, supported by the prime minister. And as a result, everyone has come together and wanted to work together. So we have a cross-government strategy group chaired by the Department for Health’s director general for public health, Felicity Harvey. We have an international strategy group chaired by our permanent representative to the UN in Geneva. These two groups bring everyone together. I get the reports and work with both of those groups, but they bring the machinery together.”
The chief medical officer acknowledges that she has played a big part as “a kind of ambassador” for the problem, including penning The Drugs Don’t Work and giving a lively TED Talk on AMR (worth a watch below, not least for her colourful berating of men’s patchy handwashing habits) to try and raise public awareness. But Davies is keen to stress that there’s support right across Whitehall for confronting the issue. “Everyone wants to do it, we have instructions to make it happen and I think it’s impressive where we as a nation have got to. When people say, ‘Oh, but government always works in silos’. I say ‘no – look at what we did! It can be done’.”
Davies’ second annual report on the strategy is due out later this year. It’s still early days, but what does she feel have been the biggest achievements of this mammoth cross-government endeavour?
“I think it’s probably been in raising global awareness and moving the debate on. We, along with Sweden, led a resolution at the World Health Organisation general assembly in May which committed 194 countries to preparing their global action plans over the next two years. Our own was already laid out in the AMR strategy and we’re beginning to really move forward on that, but all countries signed up will now do that.
“And in the Budget, the chancellor announced the Fleming Fund, which will provide overseas development aid of £195m over five years to support low-income countries in developing their own laboratory diagnostics and surveillance, so that they too can move forward. I think that’s a massive achievement in two years. Well, everyone says it is! But it needed the whole of government. It couldn’t have been done by one person.”
There’s a moment during Davies’ TED Talk where she matter-of-factly tells the audience that she’s the first woman to hold the post of chief medical officer. Before she can carry on speaking, the crowd breaks into spontaneous cheers and applause, clearly catching Davies off guard. It’s not the first praise the CMO has received since she took the reins in 2010. Radio 4’s Woman’s Hour has named her the sixth most powerful woman in Britain, while Health Service Journal has placed her as the highest-ranking woman – and third overall – in its most recent list of top clinical leaders.
Davies says her career path – which has taken in stints as a consultant haematologist, a professor at Imperial College, and director of research and development for NHS London – has been one of “serendipity and opportunity”, rather than some grand plan unfolding. “It’s the most wonderful career you can have to be a doctor, because there are so many opportunities, and you can shift around as I have done,” she says.
“But particularly for the women, you have to be prepared to go for it and take a chance. Take a risk and put yourself out of your comfort zone. The reason I’ve had this career is because I have pushed myself out of my comfort zone on a regular basis. I could have stayed as a consultant earning a perfectly civilised salary doing a good job. But I stepped out of my comfort zone. I kept pushing myself to do more and try different things. So, as I often describe it – hold your nose and jump! Though, I’ve always come up for air!”
Did she ever feel as though she faced barriers that a man of similar talents simply wouldn’t have had to overcome? “I became a consultant when there weren’t many women consultants, so it was quite tough,” she says. “I expected to have to be the best in every interview and show that I was better than the men.”
As well as smashing the glass ceiling underneath the chief medical office, Davies has tried to use the powers at her disposal to make things easier for the next generation of female leaders. While she says that both the NHS and civil service are good employers of women, she believes clinical academia is still too male-dominated. To this end, she made moves to ensure that the National Institute for Health Research – which she founded and still chairs – will in future only award major funding to clinical research institutions which have achieved the Athena SWAN Silver Award for female representation and support.
While Davies is clearly proud of her trailblazing appointment, and deeply immersed in some of the most complex public policy challenges facing government today, the things that get her out of bed in the morning remain refreshingly straightforward. “The opportunity to make a difference for people – it’s wonderful. And to work with some great colleagues. Una [O’Brien, department of health permanent secretary] supports me immensely, I’ve got a very good director general of public health, good relationships across government. It’s great working with people who are intelligent, who care, and who want to make a difference. I’m very lucky.”
...Why mental illness is no longer a party-political issue
“I think that everyone agrees we need to support people and help them. And I think that in the end we will have to get there. If you look at the World Health Organisation disease burden data, mental health is going up and up. And we know that it’s a big issue in the workplace, as people fall out of work because of mental health and if they don’t come back within four weeks it is very difficult for them to come back in. People need early support, intervention and treatment.”
...Whether she had a career plan
“Not at all. And actually that’s quite interesting because a number of people I’ve met along the way have had a plan, were very ambitious, and actually got knocked off it. I wanted the journey to be worthwhile. I wanted to enjoy everything as I did it, and I accepted the opportunities that came my way. So no grand plan, but being prepared to go out of my comfort zone, and accepting serendipity and opportunities, actually gave me a much more interesting time than the most ambitious of my colleagues.”
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