As CCGs consider their 5 year strategies to improve health outcomes and ensure maximum return on NHS funding, one of the questions that arises is whether we should incentivise individuals to be healthy.
In South Yorkshire and Derbyshire a pilot scheme offering mothers £200 in shopping vouchers to encourage breastfeeding has been set up. Breastfeeding has been shown to reduce cases of stomach problems, asthma and other respiratory conditions. The business case is relatively straightforward: the cost of the incentives will be more than outweighed by the benefits realised later on.
So is this, and other schemes like it, an approach that CCGs should be rushing to adopt? Does the business case stack up, both on outcomes and financially? Well there are other examples to learn from. In 2009 a weight-loss scheme, Pounds for Pounds, was set up in Kent which offered participants cash payments of up to £425. Less than half achieved significant weight loss and a high drop-out rate meant that evaluators were unable to recommend it as a way of tackling obesity.
However, a stop smoking scheme in Dundee had more success. The NHS there ran a two-year programme offering smokers £12.50 a week to quit smoking. By the end of three months, nearly a third of participants end up kicking the habit, more than twice as many as other smoking cessation projects achieved.
There are a number of arguments against this type of approach that I don’t intend to go into here, such as whether it creates perverse incentives, whether it is patronising, and whether it will simply result in paying people for something they were going to do anyway. But there is one point that I do think is particularly important, and this is best made by Harvard University political philosophy professor Michael Sandel.
Professor Sandel’s lecture ‘Why we shouldn’t trust markets with our civic life’ (you can find it here) tells the story of a Texas policy that awarded children two dollars for every book they read. He then asked the audience what they thought of the approach, and in discussion concerns were raised about the impact on the long term motivation of the children to read.
Sandel’s argument is that, when considering non-material goods, market mechanisms (e.g. putting a price on something, or using cash incentives) can actually change the nature of the goods. So if we pay children to read books, it can change their motivation to read and the types of books they read. A key outcome of the Texas study was that children read shorter books!
He says that economists assume markets are inert, that they do not change the products that undergo market exchanges. This is likely to be true for material objects. However, for non-material values like learning and education and health, this is not true. For us this means that the value of stopping smoking or breastfeeding or losing weight actually changes if we pay for it. We risk eroding the intrinsic value of these things by paying for them.
For health the unintended negative consequences could be serious. Will intermittent smokers start to smoke in order to receive the incentive to stop smoking again? Will obese people become morbidly obese to receive the incentive payments to lose weight? More importantly, will the value placed by individuals on their own health become a function of the return they receive for it, rather than something held as valuable in its own right?
Sandel himself says, ‘It is not about inequality and fairness but about the corrosive tendency of markets. Putting a price on the good things in life can corrupt them. That’s because markets don’t only allocate goods; they express and promote certain attitudes toward the goods being exchanged. Paying kids to read books might get them to read more, but might also teach them to regard reading as a chore rather than a source of intrinsic satisfaction.
‘Some of the good things in life are degraded if turned into commodities. So to decide where the market belongs, and where it should be kept at a distance, we have to decide how to value the goods in question—health, education, family life, nature, art, civic duties, and so on. These are moral and political questions, not merely economic ones. To resolve them, we have to debate, case by case, the moral meaning of these goods, and the proper way of valuing them.’
So for CCGs this approach is not something that can simply be adopted. As leaders with responsibility for population health we need to carefully think through all the decisions we make, and the consequences that these will have not just on the balance sheet but on society as a whole. Health and wellbeing boards are the perfect place to ensure these issues are fully debated on an individual basis, and it is our duty to ensure that this happens.