This is part of our guide to monitoring in the UK. This page explains the rules prohibiting promotion in the health care system.
You will find this information in printed form in our monitoring kit.
Restrictions on promotion
The Code makes it clear health workers are responsible for advising parents on infant feeding (Article 7).
Article 6.2 states:
No facility of a health care system should be used for the purpose of promoting infant formula or other products within the scope of this Code.
The UK law restriction on infant formula advertising applies. However, many health facilities adhere to the UNICEF Baby Friendly Initiative, which “requires that all public services seeking Baby Friendly accreditation adhere to the International Code of Marketing of Breastmilk Substitutes.”
The weaknesses with the UK law means that follow-on formulas and milks for older babies are advertised with posters and free samples in some health facilities, doctors surgeries and nurseries.
Examples have even included follow-on formula advertising on the default screens of individual television screens in maternity wards (right). As the service was provided by a subcontracted company, the hospital authorities did not even realise it was there until Baby Milk Action raised it.
Companies can provide scientific and factual information to health workers, but many health facilities ban company representatives from targeting staff directly on site. The UNICEF guidance for hospitals working for Baby Friendly accreditation states on company representatives:
Company representatives are typically employed to build relationships with health workers, suggesting that they provide important product information that health workers need for their work. There is no requirement to entertain company representatives, and information can always be obtained from companies directly rather than via sales representatives.
If access is given, company representatives should have only very restricted access to the service or staff. A number of models can be used:
- Representatives may only see the member of staff considered most expert in infant feeding, and she/ he then distributes any relevant scientific and factual information to other staff members in an appropriate manner.
A group meeting may be set up that all company representatives, as well as a range of independent experts, are invited to, to ensure that any information is reviewed based on its scientific merit.
Company representatives should always be asked to send relevant information before any meeting, so that staff have a chance to review any scientific evidence presented.
The Local Infant Feeding Information Board is an example of a multidisciplinary panel that began in Lancashire and is an approach that can be followed elsewhere.
The role of company representatives
When Nestlé entered the UK market with the takeover of the SMA brand in 2012, it recruited a network of well-paid Clinical Representatives (who also gain bonuses), with the stated responsibilities as follows:
As Clinical Network Representative, your role is to work on the designated territory, visiting hospitals, doctors, health visitors and community midwives to develop key clinical relationships within your local health Economies, leading to opportunities for the SMA brand and Nestlé Nutrition.
Working with the NHS at a territory level, you’ll be developing long-term, mutually beneficial relationships with key stakeholders and opinion leaders to support brand endorsement and strategically aligned education for Healthcare Professionals.
Tactics have included inviting key staff on a three-day trip to Switzerland for presentations – with plenty of free time and dinner following a vineyard tour.
Company training events
Companies also invite health workers to study days at nearby hotels. At these days there will be promotions and sometimes presentations on products by the Clinical Representatives.
To attend Nestlé health worker study days it is necessary to register via the company’s SMA branded website. The website promotes products with idealising claims. The example, below, states its SMA formula is closest to breastmilk (Baby Milk Action has won a case at the Advertising Standards Authority proving the claim that SMA is the best formula cannot be substantiated).
Health workers then receive promotional emails from the company. One such email launching SMA Pro claimed its NEW IMPROVED formula had protein profile closer to breastmilk and that existing formula gave “protein intakes in excess of requirements”. Nestlé expects people to forget the false claims it made about the previous formula.
First Steps Nutrition Trust has produced a report called Scientific and Factual that digs into the references that companies use in footnotes for their claims and found them to be of little scientific value. Available here.
Sometimes companies offer “unbranded” information materials. The UNICEF Baby Friendly Guidance states:
Companies may offer anything from unbranded diary covers, to teaching packs, to whole websites of information that appear to have no promotional element at all. Given their goal of increasing shareholder value, it is important to consider the true purpose of the distribution of such ‘gifts’. Gratitude and obligation are common reactions to being given a gift and such emotions can be a good basis for future contact and relationship building. Providing something useful is a good way of getting the all-important contact details of parents, or health workers who work with parents. These contact details are extremely valuable and can be used for more sophisticated and targeted marketing.
Websites and leaflets can also easily be changed. Initially, health professionals may scour these for inaccurate or promotional information before declaring them ‘clean’ and suitable for use. Changes can then be made that go undetected for long periods of time as the information continues to be distributed or recommended by health workers.
Unicef UK recommends that when any externally provided product is offered for use within public services or for use by parents, the source of this is established at the outset. If it is associated with any company within the scope of the Code it should be refused.
Such information is usually provided in breach of UK law. Regulation 24 relates to informational and educational materials dealing with the feeding of infants and states:
24 (4) No manufacturer or distributor of an infant formula shall make a donation of any informational or educational equipment or materials except in accordance with the following conditions—
(a) the donation shall be made following a request by the intended recipient;
(b) the donation shall be made with the written authority of the Secretary of State or in accordance with guidelines drawn up by the Secretary of State;
(c) the equipment and materials shall not be marked or labelled with the name of a proprietary brand of infant formula; and
(d) the equipment or materials shall be distributed only through the health care system.
Baby Milk Action is unaware of any materials being donated with the required written authority and their are no guidelines that negate the requirement for this.
Sponsorship and other inducements to health workers
World Health Assembly Resolution 58.32 from 2005 states to:
ensure that financial support and other incentives for programmes and health professionals working in infant and young-child health do not create conflicts of interest;
Health professional bodies that accept advertising from baby feeding companies generally include several pages of it in their journals and find it difficult to wean themselves of it – though an increasing number are doing so. The publication Practising Midwife has long made a point that it is free of formula advertising and amongst professional bodies, the Royal College of Midwives has shown the way in following suit.
The volume of advertising companies place suggests that is not only to promote products (usually with unsubstantiated claims), but provides a cover for channeling funds to the organisation, substantial enough to make it dependent on the income.
Similar concerns relate to such companies sponsoring health worker events and being present as exhibitors.
Baby Milk Action has produced a poster on Health workers, conflicts of interest and the baby feeding industry.
Please report any practices that concern you to firstname.lastname@example.org
Guide to UK formula rules: