Cash incentives could lead to healthy lives

Virtue, as Mark Twain asserted, “has never been as respectable as money”. This quote was brought back to me during a recent Radio 4 discussion on whether the pursuit of good health should be financially rewarded. The subject, which readily extends to social care as well as health, is both economically intriguing and ethically baffling.

Obesity – and its associated knock-on effects such as Type 2 diabetes, gallstone, strokes and heart disease – is estimated to cost the NHS £4bn a year, rising to £10bn by 2050. The burden on the individual and the Exchequer creates a powerful case for considering whether incentivising people to lose weight could not only benefit them, but also increase the coffers of the NHS. Some argue the approach could be extended to all of the “giants of excess” – overeating, smoking, alcohol, lack of exercise and the use of illegal drugs.

This whole issue has been the subject of considerable discussion. In the 2011 issue of the Harvard Men’s Health Watch, two studies were reported. The first related to smoking and the second to obesity. The smoking study looked at 878 employees of a large US multinational corporation. All were active cigarette smokers who had expressed the desire to quit. Half were randomly assigned to receive information to help them give up. The other half received the same information, plus a cash reward for kicking the habit in an agreed time period. The results – at least in the short term – supported the system of payments.

A similar result was found for a scheme to reduce obesity in a small programme of 57 volunteers. “Money talks” as the study concluded, and of course the hope is that over here this would eventually be reflected in reduced costs to the NHS.

In 2009, the British Medical Journal published an article on “using financial incentives to achieve healthy behaviour”. It, similarly, concluded that paying people to change their behaviour can work, at least in the short term. The BMJ article probed the pros and cons – that it can be seen as bribery or coercion, that it may be perceived as paternalistic or indeed unfair, in that you are paying people to do what they should be doing anyway. There is also the issue of public perception: how does paying those who have palpably failed to regulate their behaviour or modify their choices pass the “redistributive” test, re-allocating monies where they are most deserved? Against this are the arguments that it is not a bribe if voluntarily entered into; that it can promote fairness if addressed to the most socially deprived; and also efficiency with considerable health benefits from a modest increase in health expenditure. Whether you see this as key to reducing smoking, alcohol or obesity rates, for example, or simply little more than bribery will depend on your ethical perspective.

In a slightly different context, financial incentives have already been tested in the area of children’s social care. In the past, local authorities were collectively rewarded for improving their adoption rates and foster carers given higher allowances for taking more difficult children. Sometimes, this can create perverse incentives, with foster carers, for example, not wishing to accept that behaviour had improved if it meant that allowances were subsequently reduced. There is also some evidence in the US, where services are even more fragmented and privatised, that children would be stopped from moving on if it meant that the income was lost. 

The reality is that financial incentives could be extended in other and new directions: paying carers who manage to keep their children out of care; incentives for turning around troubled families; financially rewarding wider family members to pay for child care (as is sometimes done) to avoid state intervention; or rewarding young people who, for example, stay out of the youth justice system.

These raise immensely complex issues, both utilitarian and moral. What is certain is that the time has come for a more considered debate, across the health and social care divide, in order to explore more fully and resolve Cicero’s dictum that “nothing is so strongly fortified that it cannot be taken by money”.

Dr Chris Hanvey is chief executive of the Royal College of Paediatrics and Child Health