Perspective – Cash for health

25 June 2010

by Joanne Curran, associate editor, MDDUS 

YEARS of government-led campaigns employing all manner of slogans and logos have urged the public to eat their five-a-day, strive towards a Smokefree Future, Know Your Limits when it comes to alcohol and make a Change4Life through increased exercise.

But after decades of clever TV adverts and snappy catchlines, the UK is still facing an epidemic of poor health. Obesity is rising, there are around 8.5million smokers in England alone while Scotland still struggles to shake off its image as the sick man of Europe.

So is it now time the government thought about paying people to improve their health? Will cold hard cash succeed where adverts have failed?

The issue of offering health incentives is controversial and one that has divided medical experts and commentators. So far the evidence surrounding incentives has been encouraging but far from conclusive.

Many questions remain over their long-term effectiveness, never mind whether the state should effectively bribe people to do something that is expected of all responsible citizens. And as the Government’s latest budget brings ever harsher spending cuts, health incentives may not be a feasible option.

The Citizens Council of the National Institute for Health and Clinical Excellence (NICE), which provides public input into the Institute’s work, discussed the pros and cons of health incentives at their latest meeting in London in May. The aim of such an approach, they say, is to cut down on the number of people who are overweight, smoke or drink to excess, and therefore save the NHS millions in the long-run.

Positive signs

It is true that the idea is already in operation in some parts of the UK. In the south, the obese in Kent have been paid to lose weight as part of the Pounds for Pounds programme. And in the north, pregnant women in Tayside in Scotland have been paid to stop smoking. For the last three years they have been offered £12.50 shopping vouchers (which can’t be spent on alcohol or cigarettes) if they could prove they are nicotine-free by having their carbon monoxide levels monitored. So far, 450 women have used the scheme and 20 per cent of those have successfully given up smoking – double the results of other anti-smoking schemes.

NICE’s head of public health Professor Mike Kelly said in a recent BBC news report: “We will want to see evidence that it provides value for money, there is a question over whether behaviour is sustained when incentives end. But the benefit of getting a child to become more active or a person to give up smoking at 25 is clear for the individual and for society."

He added: "We are storing up so many future problems and this is something within our grasp. There are no mysterious causes, it is about behaviour. Humans respond to incentives, we know that. What we now need to see is whether the economic behaviour can be repeated in terms of health behaviour. It is an idea whose time has come."

He admitted many questions remain about the use of health incentives, about whether they yield long-term results and if they are a proper use of public money.

One opponent is Patient Concern’s Roger Goss who said: “I can't see how it can be enforced. There is also the question about rewarding people for behaviour some people do voluntarily."

Is it right to reward people who have potentially spent their lives over-indulging in alcohol, food, cigarettes and other vices while ordinary people in good health get nothing?

These questions are what have driven NICE to hold a discussion amongst its Citizens Council on the issue and they will no doubt publish their findings in due course.

Evidence

What would be key to deciding the issue is something that is still not forthcoming: clear evidence.

Professor Kelly told the BMJ: “There is not much hard direct scientific evidence for incentives. We need to know whether they really work and in what circumstances and, secondly, whether they are cost effective. And it is important to see if the public would like to see public money spent in this way." He added: "If such schemes are to be extended they need to be backed by good scientific and economic evidence. Properly evaluated pilot schemes are the logical next step."

Incentives for health are more common in the US, but even there, evidence is not clear-cut. Dr Tammy Boyce, a research fellow with health think-tank The King’s Fund, said: “A lot of the research on incentives is done in the US where they operate a different type of healthcare system. Really the research base for the use of incentives is quite small. Sometimes they are effective, and they work for some people but the evidence is mixed. There is more research showing that incentives are less effective for weight loss than for quitting smoking.”

The King’s Fund produced a report in 2008, Kicking Bad Habits, which concluded that schemes offering cash incentives to encourage healthy behaviour need to be carefully designed and implemented. It found incentives are most effective when they are used as one element of a wider programme of long-term behavioural change.

One area where incentives appear to have proved successful is in getting children to eat more fruit and vegetables. The Food Dudes scheme developed by researchers at the University of Bangor in Wales is achieving impressive results by targeting children in schools and encouraging them to taste new types of food. When it launched in 22 schools in Wolverhampton, children increased their fruit consumption by 54 per cent and vegetables by 48 per cent.

And one point Professor Kelly was keen to tell the Citizens Council is that incentives need not be restricted to such rewards as cash or food vouchers. He raised the issue of how Weight Watchers rewards its members with a glass bead, which acts as a small but significant marker of achievement.

The Citizens Council face a challenge in reaching a decision on food incentives. It may well be that incentives for health are no more effective at improving overall health long-term than any other single scheme already in operation. What is needed is more research to take a thorough look at incentive programmes and all that they entail.