The Minister for Health, Simon Harris, has signed into law the ability of physicians to prescribe cannabis-based drugs for a variety of conditions.
Neither he nor any of his department were involved in the process of analysing the existing clinical data on this topic. That scientific assessment was conducted by an independent expert committee of the Health Products Regulatory Authority (HPRA). The HPRA was set up as a statutory body through an Act of the Oireachtas. It is funded by Government, but completely independent of Government. This is similar to the Food Safety Authority of Ireland (FSAI) and the Environmental Protection Agency. In each case, the statutory agency is established by legislation, is independent of the State, and concerns itself solely with scientific assessment (risk assessment). On foot of that risk assessment, the agency may make recommendations to Government, who act as risk managers. The latter may implement some, all or none of the agency's recommendations, taking into account the politics of the issue.
Separating the risk assessor from the risk manager is like separating the roles of poacher and gamekeeper.
This internationally accepted model separating risk assessment from risk management does not apply to the Irish Government's advice on nutrition. Our Department of Health takes on both roles and is alone in Europe in not setting apart risk assessment in nutrition from risk management in nutrition.
Consider our near neighbours. The department of health in London relies on independent public health agencies such as Public Health England (PHE) to oversee the scientific evaluation of diet and health and, in that regard, PHE operates the Scientific Advisory Committee on Nutrition (SACN). This committee is convened from time to time to advise on key aspects of national nutrition policy.
Expressions of interest
Public calls are made for experts to submit expressions of interest in joining in a specific risk assessment initiative, the most recent of which has re-examined the evidence linking saturated fatty acids and heart disease. Selection of experts follows very strict principles to ensure that all aspect of a scientific debate are represented. Meeting agendas are made public as are the minutes of all the meetings of the selected experts and a draft report is circulated widely for an open consultation over a six-month period. Thus, the process of risk assessment is very much at arm’s length from the secretary of state for health in cabinet.
Nothing like that happens in our Department of Health.
The experts on obesity task forces of 1995 and 2016 were not chosen following an open competition and ultimately, their selection was very largely decided by the department itself. Neither of these obesity task forces included any of the dozen or so professors of nutrition on this island, despite the fact that several of them chair and participate in expert panels of international bodies such as the World Health Organisation or the European Food Safety Authority.
The department has pointed out to me that, in fact, it does farm out specific scientific risk assessment tasks to external agencies. But that is not independence. It still concentrates all the power in the Department of Health and allows the department to effectively cherry pick its advising body. In no other European country does this happen. All have bodies independent of government whose task is to give independent advice on nutrition to government, sometimes at the request of government and sometimes on the initiative of the agency itself.
When FSAI was established in 1999, the Act stated that the authority would be responsible for "nutrition in public health". Shortly afterwards, following the Good Friday agreement, the British-Ireland Act established several cross-border bodies, including the Food Safety Promotion Board (known as Safefood) and that Act removed from the statute book the responsibility of FSAI for any role in nutrition and public health. Moreover, it wasn't passed on to Safefood. It was brought back into the Department of Health, where it still resides, uniquely so among EU states.
Low on the agenda
The day-to-day agenda of the Department of Health is dominated by issues surrounding hospitals – from waiting lists, to budget over-runs to public concern over screening programmes. Public health nutrition would appear to be very low on the agenda and, where it is operational, it lacks any real transparency or any real momentum. For example, in the Government’s working paper on sugar tax, there are zero steps laid out to establish the efficacy of this tax in its ultimate objective, a reduction in obesity. A proper risk assessment strategy should always include transparency in the definition of outcome measures and the means to evaluate their success or failure.
If we accept the conventional wisdom that obesity costs the State €1.2 billion a year, if we accept the Irish Nutrition and Dietetics Institute statement that one in four older persons are malnourished and the Hiqa report on the poor delivery of malnutrition screening of hospital patients and if we accept that maternal nutrition in pregnancy plays a big role in adult onset disease, then we have a real problem, requiring a management system that is at least equal to all our European neighbours.
One option would be to return to the FSAI the responsibility for risk assessment across all public health nutrition issues, with a revision of the Act and with appropriate additional funding. Safefood should have the role of risk communication. The Department of Health and the HSE can retain the roles of risk management. All can be brought together in a coordinating committee, preferably not organised by Health.
As the OECD report on Best Practice Principles on the Governance of Regulators states: “Establishing the regulator with a degree of independence (both from those it regulates and from government) can provide greater confidence and trust that regulatory decisions are made with integrity.”
– Mike Gibney is emeritus professor of food and health at UCD