Dear Editor,

We were interested to read the response to our recently published paper from the Principal Economist of OfCom during the time of the consultation, which is also available on the Institute of Economic Affairs website - https://iea.org.uk/does-ofcom-prioritise-commercial-interests-over-publi.... The additional context Mr. Gibson provides is welcome. On close reading we find that our original paper agrees with many of the points that Mr Gibson raises. We describe these, and provide more explanation on a number of other points below.

Mr Gibson points out that OfCom used much more than just the stakeholder responses analysed in our article to come to a decision on their final policy on TV food advertising to children. We recognise this in Figure 1 and in the discussion section of our paper where we describe the other ways in which interested parties could influence OfCom. A number of OfCom reports, in which much of the evidence noted by Mr Gibson was published, are also cited in our paper.

Mr Gibson appears concerned with our claim that the only independent evaluation of the regulations on TV food advertising to children found no change in the proportion of HFSS adverts seen by children between before and after implementation. As far as we are aware, the paper we cite (Adams et al, 2012) remains the only independent, peer-reviewed evaluation of the regulations. The finding of no difference is as reported in that paper. Whilst the results in Adams et al (2012) are at odds with evaluative data published by OfCom and quoted by Mr Gibson, reasons for these differences are discussed in that paper.

Mr Gibson proposes that the reason the original proposal for regulations to cover 4-9 year olds was extended to 4-15 year olds was unrelated to stakeholder responses to the consultation. Rather he notes that OfCom became convinced by other published research that “10-15 year old children also may not fully appreciate the long term consequences of their dietary choices”. This seems very similar to the argument set out in our paper that “all children needed protecting”.

Mr Gibson indicates that rather than, as suggested in our paper, the delay in implementation of the regulations reflected a concern about potential commercial impacts of the regulations, the delay was more related to practicalities of implementation and allowing broadcasters time to adjust. Again, these arguments seem similar and we struggle to see the point of disagreement – we propose that OfCom were concerned with reducing impacts on commercial organisations (such as broadcasters), Mr Gibson proposes that OfCom were concerned with avoiding a disproportionate impact on broadcasters.

Mr Gibson explains that in deciding the final nature of the regulations “There was no ‘precedence’ given to individual freedoms for adults over protecting children (as the article suggests), it was simply that Ofcom reached its decision on the appropriate balance to strike between competing objectives given the evidence that it had on the costs and benefits of each option.” Our paper reflects this difficult balancing that was required of OfCom. But OfCom did eventually make a final decision and their final statement does indicate that their preference was not for a 9pm watershed because of the costs of this to adult viewing times and commercial revenues. Thus is does seem that costs to these groups were considered to outweigh any potential benefit, such as to child health.

Mr Gibson notes the detailed impact assessment conducted by OfCom, including costs of obesity-related illnesses, and the role this played in their decision making. But does not disagree with our claim that wider societal costs were not mentioned in OfCom’s final report – which could be interpreted as an indication of how important these were considered to be.

We thank Mr Gibson for his detailed consideration of our paper and hope these responses clarify that we find few points of disagreement.

Your sincerely,

Dr. Ahmed Razavi
Dr. Jean Adams
Prof. Martin White

In December 2003 the Secretary of State for Health asked Ofcom to look into the regulation of television advertising of High Fat, Salt and Sugar (HFSS) food to children in order to address concerns about the rising levels of childhood obesity. How did Ofcom decide on an appropriate set of advertising regulations to address those concerns?
According to the authors of a paper in the BMJ Open , Ofcom consulted on the issue, considered the arguments advanced by the different stakeholder groups (advertising companies, food manufacturers, food retailers and broadcasters on one side, lobbying for more relaxed regulations, and civil society groups, politicians and public health stakeholders on the other, arguing for stricter rules to protect children), decided which arguments they liked and determined their final recommendations accordingly. They argue that because Ofcom moved towards the industry arguments between their original proposals and final recommendations on more issues than they moved towards the public health direction, that they favoured commercial interests over protecting children’s health. They even suggest that Ofcom might have been Machiavellian enough to cynically set some of their initial proposals in such a way that that they could concede ground to public health stakeholders on those issues and distract from more contentious issues.
In fact, the truth is somewhat different. Ofcom when moving forward with a complicated public policy question such as how far to restrict the advertising of unhealthy food on television developed their policy position by considering the evidence. They did not just rely on stakeholder responses as suggested in the BMJ article, Ofcom carried out a huge amount of additional evidence gathering and data analysis itself, assessing how effective different policy options might be at restricting children’s viewing of adverts for HFSS foods and working with the Food Standards Agency (FSA) to estimate the potential health benefits from the improved diets that might be gained. Ofcom then brought together all the evidence and analysis that it had into an Impact Assessment (a formal evidence-based process for assessing the costs, benefits and risks of alternative policy options). It used the Impact Assessment (IA) to assess the benefits and costs of different policy options – from doing nothing and sticking with the status quo, to a complete ban on all advertising up to the 9pm watershed. The evidence and analysis in the Ofcom IA was consulted on alongside the policy consultations and was highly influential in shaping its final policy decision.
As well as fundamentally misunderstanding the policy-making process, the authors are disingenuous about the success of Ofcom’s regulations. They suggest that there was no change in the proportion of HFSS adverts seen by children before or after implementation of the regulations. In fact, compared with 2005, children saw 37% less HFSS advertising by 2009 and 53% less by 2015 . That reduction has continued with children being exposed to 70% fewer adverts by 2017 (2.7 minutes per child per week on average compared to 9.1 minutes in 2005). Therefore Ofcom’s policy (combined with the general trend of children moving from watching television to other electronic platforms and social media) has been highly successful in achieving its objective of reducing children’s exposure to HFSS adverts on television .
Picking up some of the more egregious suggestions by the article’s authors, the reason that the policy was extended to cover 4 to 15 year old children rather than 4 to 9 years olds was not that ““arguments of public health groups held more weight over this issue”. The original rationale for protecting younger children from HFSS adverts was that they were not able to appreciate the consequences of an unhealthy diet and therefore there was a market failure that should be addressed through regulation. As part of its analysis, Ofcom became convinced by the evidence (in particular a literature review conducted by Professor Livingstone ) that 10-15 year old children also may not fully appreciate the long term consequences of their dietary choices; as a result Ofcom extended the regulations to cover the wider age range.
The article’s authors are incorrect to suggest that Ofcom ignored the possibility that both children and adults might watch television together. Of course Ofcom recognised that there are many programmes which both children and adults watch. They sought to balance the protection of children by reducing their exposure to HFSS adverts with avoiding intrusive regulation of advertising during adult airtime given that adults are able to make informed choices about advertising messages. That is why the final measures included restrictions on programmes of particular appeal to children (which might also have large adult audiences) as well as programmes specifically made for children. It is also obvious that the pre-9pm ban advocated by public health groups would also have been a balance - between allowing children to watch some HFSS adverts (after 9pm), and not restricting the broadcasting of HFSS adverts to a predominantly adult audience – Ofcom simply set the balancing point at a different position. There was no “precedence” given to individual freedoms for adults over protecting children (as the article suggests), it was simply that Ofcom reached its decision on the appropriate balance to strike between competing objectives given the evidence that it had on the costs and benefits of each option.
Similarly, the article suggests that the implementation timetable was an example of Ofcom being “more concerned about the potential commercial impacts of advertising restrictions [than minimising the exposure of children to HFSS adverts]” and that they “delayed enforcement of the restrictions as a result”. However there were practical considerations to take into account about how quickly the broadcasters could make the changes to their automated sales systems that would be required to implement the new measures. Ofcom also wanted to allow broadcasters time to adjust to the new arrangements by phasing in the new restrictions, this avoided a disproportionate impact on broadcasters while still reducing children’s exposure to HFSS adverts very significantly.
A particular misunderstanding in the article is the suggestion that Ofcom did not “consider the cost to the economy of poor health that could stem from a lack of appropriate restrictions … with no mention of societal costs” and that “future (external) costs of treating the potential health implications of HFSS food consumption did not appear to influence policy making”. Again this is incorrect. The Impact Assessment specifically analysed the (external) costs to society of a range of obesity-related illnesses using Department for Transport measures of the value people place on quality and quantity of life. Where these benefits occurred in the future, they were discounted to present values in line with HM Treasury guidance on policy appraisal and evaluation . This evaluation of the potential benefits of the different policy options was central to Ofcom’s IA and a key part of the decision making process.
It is a shame that a potentially interesting review of how stakeholder responses influence public policy decisions has been marred by a large number of significant factual errors and a failure to appreciate the basis on which public policy decision are made by economic regulators like Ofcom. As a result it comes to a conclusion that is both erroneous and misleading.
Stephen Gibson
Stephen Gibson is Director of SLG Economics and is on the Board of the Government’s Regulatory Policy Committee which scrutinises the quality of government departments’ and economic regulators’ impact assessments.
Stephen was Principal Economist at Ofcom between 2004 and 2007 when he was responsible for leading their Impact Assessment of Television Advertising Restrictions of Food and Drink Products to Children.

Dear Editor

We note the letter from Mr Declan McClements on September 9th 2019 and thank him for his interest in our work. As Mr McClements notes, the paper illustrates the significantly better outcomes achieved by children in Northern Ireland and the comprehensive school vision screening coverage that exists across the whole of Northern Ireland is acknowledged as a component of this success in our conclusions.

Mr McClements is concerned regarding “the omission in this article of any reference to Orthoptics or Orthoptists.” We recognise the work in Northern Ireland and Ireland carried out by orthoptists, school nurses, optometrists and ophthalmologists; reference to orthoptists is made in Table 1 of the paper.

The purpose of the study was to report and compare the prevalence and cause of persistent amblyopia in broadly similar population cohorts but different healthcare systems. Orthoptists, public health nurses, optometrists and ophthalmologists are comparable in Northern Ireland and Ireland with regard to training, qualifications and the functions they undertake, including their role in school-entry vision screening. The differences between the two jurisdictions, which were relevant to the disparity in outcomes on which we were reporting, relate to the less comprehensive nature of school-entry vision screening in Ireland and the differences in accessing treatment that exist between the two countries.

Yours sincerely,

Dr Siofra Harrington
Dr Karen Breslin
Dr Veronica O’Dwyer
Professor Kathryn Saunders

Dear Ferozkhan,
I read about your interesting plans to study the prevalence of common mental health disorders in adults who are high or costly users of healthcare services in BMJ Open.
Please allow me to share with you some thoughts about your plans produced by our own research.
- We studied the prevalence of (physical, mental and social) problems in the Netherlands (as defined by the GP on the Problem list; ICPC) in (persisting) frequent attenders 1 and whether we could predict, with these GP data, which frequent attender would persist in this behaviour.2
- We found that high users and costly users are two different groups. Frequent users of primary care3 have higher average/median costs (also and especially in sec care), but high costs are mostly generated in sec care.4
- We also found that costs are more substantial in persisting frequent users. Perhaps you can consider to differentiate between temporarily and persisting frequent users.
- Costs are very high in a few outliers. Do you exclude these patients from your research?? Median costs? Average costs?
- We also found that anxiety, and especially panic disorder, is associated with persistence of frequent attendance in primary care.5
Much success with your plans!

Kind regards,
Frans Smits, GP PhD

1 Smits FT, Brouwer HJ, Ter Riet G, Van Weert HCP. Epidemiology of frequent attenders: A 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders. BMC Public Health 2009; 9. DOI:10.1186/1471-2458-9-36.
2 Smits FTM, Brouwer HJ, van Weert HCP, Schene AH, ter Riet G. Predictability of persistent frequent attendance: A historic 3-year cohort study. Br J Gen Pract 2009; 59. DOI:10.3399/bigp09X395120.
3 Smits FTM, Mohrs JJ, Beem EE, Bindels PJE, Van Weert HCPM. Defining frequent attendance in general practice. BMC Fam Pract 2008; 9. DOI:10.1186/1471-2296-9-21.
4 Smits FT, Brouwer HJ, Zwinderman AH, et al. Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: A record linkage study between patient data and reimbursements data. DOI:10.1186/1471-2296-14-138.
5 Smits FT, Brouwer HJ, Zwinderman AH, et al. Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: A prospective cohort study. J Psychosom Res 2014; 77: 492–503.