The NHS 'should pay' patients to become healthy

smoking pregnant woman Pregnant women were offered cash to give up smoking in one NHS pilot

We all know what we should be doing to be healthy. But that doesn't meant that we actually do it. In this week's "Scrubbing Up" health researchers Becky Brown and Marianne Promberger say the NHS should pay people if it stops them pursuing unhealthy behaviour.

Schemes that offer financial reward for healthy behaviour are being tried out across the UK. Rewards have been seen to work well in drug treatment programmes and in helping pregnant women stop smoking. Even so, where the financial rewards work should we use them?

Fairness

The use of incentives is controversial. Should people be paid to do what they ought to do anyway?

The issue here is one of fairness, and to what extent we should hold people responsible for diseases they suffer as a result of what some consider to be a lifestyle choice.

Evidence however suggests that much of our behaviour is automatic and cued by the environment, and that socio-economic and genetic factors influence how well we can resist this influence. With this in mind, we must consider carefully how we apportion responsibility to people who smoke or are overweight. Where incentives prove to be cost-effective, are we willing to pay even more money - through later NHS treatment - because of our distaste for "unfair" rewards?

Start Quote

As taxpayers, we'll all be paying later to treat diseases that people contract through over-eating, smoking or not taking enough exercise.”

End Quote Becky Brown and Marianne Promberger
Effectiveness

Policy makers are showing an interest in the potential for incentives to help tackle difficult public health issues we are currently being faced with. One scheme outlined in the recent government White Paper on health, "Step2Get" proposed to encourage more school children to walk to school. Points are collected (and redeemed as rewards) by swiping a card against receivers placed along a safe walking route to school. Pilot studies indicate that such schemes could significantly reduce overcrowding on buses and associated anti social behaviour, as well as increasing physical activity.

Individual PCTs have also introduced incentive schemes. For example, in Birmingham pregnant women have been offered vouchers in exchange for quitting smoking. In Kent, participants in 'Pounds for Pounds' have been rewarded for losing weight with cash payments.

The evidence for the effectiveness of incentives is mixed. Rewards seem to work well in drug treatment programmes and in helping pregnant women stop smoking, but less so in programmes for general smoking cessation and weight loss. There is little evidence about whether they work long term, especially after the incentive has been removed.

Results driven

We need more systematic research based on established behavioural principles to understand the conditions under which incentives work best. However, we believe that policy in this area should be results driven. Concerns about fairness and encouraging responsible choices must be subject to scrutiny, and must be traded off against other outcomes such as money, and reduced pain and suffering.

Paying later

The burden of chronic disease brought about by smoking, unhealthy diet and physical inactivity continues to increase, in the UK and elsewhere. As taxpayers, we'll all be paying later to treat diseases that people contract through over-eating, smoking or not taking enough exercise. Where there are shown to be cost effective ways of improving health, there will need to be strong justification for turning our backs on them.

Your emails

I don't see why I as a taxpayer, or the NHS, should fund treatments for people who harm their own health. I eat well, don't smoke, don't drink much, work and raise my children with respect for their surroundings and friends and family. Why should I, who am doing all the right things on my own to live healthily and raise my family well, have to subsidise anyone else to do the same? I don't believe the NHS should do so either. Emma, Brighton

We all respond to incentives - for some, those incentives are different. For some, it's simply feeling and looking better. The reality is - different things, are different incentives, for different people. If the cost of 'rewarding' people is balanced against benefit - then it has to be a good thing. Often, that's just the kick start of the process. If you can use that to create larger scale behavioural change, others will follow and gradually those behaviours become the norm. The question is not - should we? The question has to be - does it work and do the benefits outweigh the costs? Claire Cater, London

With smokers, there are already clear health advantages in giving up at any age as well as a financial incentive (£2,500 approximately) per year for a 20 a day smoker, (£5,000 or a new car, new roof, two long distance holidays for a couple who quit smoking). What better financial incentive could the NHS offer? Its more difficult perhaps to put a financial value on losing weight, although the health advantages are still pretty clear. Maybe a contribution towards a new wardrobe for women would be an incentive. I'm sure there are good marketing people in the fashion industry, happy to work with the NHS to devise attractive incentive schemes. Subsidised gym subscriptions could also work. Jim Leary, Bathgate, Scotland

Daft - especially when the government believes we need to save money. Sorry, taxes are paid for the provision of services, not for promoting lifestyle choices however beneficial, especially when we have no actual links between behaviour and illness, just the 'risks' that pass for science within the medical profession! Megan, UK

Maybe we should have a health system that doesn't treat people as babies for their entire life! Are you in A and E because you got hammered? If do, pay for your treatment. Are you obese because you ate too much and couldn't be bothered to do anything about it? Bill some of the cost of the treatment in their NI contributions, even if they are on the dole take some money away from their benefit. That should encourage people to take charge of their health, finances and ultimately their lives. Then we won't have to pay for other people being irresponsible. Ana Burman, Slough

This is another example of the nanny state. If people wish to adopt an unhealthy lifestyle in full knowledge of the consequences, let them do so and accept the results. I do not see why I should have to pay for others' unwillingness to look after themselves. There are many cases of more deserving people of social handouts than people who abuse their own bodies. After all, we are in dire economic straits with little money to go round. Roger Adams, Bookham, Surrey

The first flaw in this proposal is that those who follow healthy lifestyles actually cost the most in health resources (and pension payments) because more of them live long enough to die of more expensive illnesses such as dementia, or receive long term nursing care. Jonathan Bagley, Manchester

I see there's no suggestion of rewarding those who have always had healthy habits. Paying people to quit smoking could encourage less-well-off non-smokers to start smoking just so they can get paid to quit. Also you must be extremely careful about assuming cause and effect - non-smokers get lung cancer too and slim people get type two diabetes, so how do you know the smoking caused someone's cancer or their excess weight caused their diabetes? Sue, England

This is a complete waste of NHS funds. It just accepts that people don't take responsibility for their own health. They expect to do as they please and then the NHS will sort them out. People should be penalised for self destructive behaviours by increased taxes on tobacco, alcohol and sugar. Education on lifestyle is the way to go and that starts within the family. We may well have already missed the boat for a couple of generations but we should be starting to educate the primary school aged children now. David, North Wales

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