Thursday, 20 May 2010

Paying people to be healthy

From the BBC, NHS explores paying people to become healthier.

The NHS is exploring the possibility of using financial incentives to encourage healthier lifestyles.


NICE, which advises the NHS in England and Wales, believes they may help tackle obesity, smoking and drinking.


And in Kent cash payments have been given to people who lose weight.

There are several major problems with this plan. Leaving aside the practical difficulties of implementation, and the likelihood of generating a perverse incentive (say, to take up smoking so that you can get paid more than the cigarettes cost to give it up), the proposed schemes take health care in a worrying direction and reinforce existing prejudices.

Firstly, the whole point of a universal health care system like the NHS is that it helps everyone. Obviously, the healthier the population in general, and the less frequently they require its services, the more money and staff time it has left to help the rest. Public health and prevention of disease are areas it should be spending time on.

However, if the system is allowed to mark certain people as "more deserving" of health care, then the consequences will be very severe indeed. The system is of course - in practice, possibly also in theory - allowed to do this, as in the case of Daisy's "death by indifference" [trigger warning], so further extensions into the realm of officially-condoned actions are extremely unwelcome.

Giving direct incentives like this does that. There's not a lot of difference in practice between giving someone money to "behave in a more healthy fashion" and charging them extra if they don't.

There's no moral requirement to be "healthy". The disablism that says that there is, is very closely related to the disablism used to justify killing Daisy and many others. It's an attitude that needs to be removed from health care entirely, not encouraged.

Secondly, there's the hugely oversimplistic and incredibly commonplace use of "losing weight"1 as a proxy for "getting healthier". That the two are conflated is a big enough problem already, both for the NHS and health care specifically, and for society and fat people in society more generally.

Paying people to lose weight seems a pretty sure way to encourage disorded eating, including in people who you aren't actually paying. What worries me is that this particular likely consequence is very unlikely to be picked up in any trials of this scheme. Let's think about the format the trial would take, in the probable best case:

  • Find a sample of X people who want to lose weight. X is small relative to the local population, but large enough to be statistically valid
  • Pay half of them based on whether they do or not, don't give the other half anything. Well-designed controlled experiment etc. etc.
  • Look at the differences in the average weight loss of the two samples after six months. Let's assume for the rest of this that there will be a difference, and the paid group will have on average lost more weight by a statistically significant amount.
  • Approve the bribery scheme for wider use, forgetting that:
    1. Weight loss does not equal health gain.
    2. Just about anything will show weight loss over a six month period compared with the control. Nothing, yet, has been shown to do so over a longer follow-up period of five years.
    3. The trial didn't consider side-effects on people outside the sample.

When released to the public, of course, it will add to all the social pressure to be thin, but it might be years before the NHS actually starts getting the bill for the disordered eating that results, by which time the process will be too embedded to easily stop.

Thirdly, it largely ignores the social factors that cause these particular public health problems. Bribing people might work temporarily, but perhaps the money would be better spent on subsidising the provision of healthy, cheap and convenient food (and it has to be all three), or on providing more accessible spaces for exercise. The whole thing is based on the assumption that people just don't care "enough" about being healthy (which may, because it's not a moral requirement, be true and not a problem for some people), rather than not actually having the resources to reach their preferred level of health.

Yes, a bit of extra cash might well help them with this aim, but in that case, why not just give them the extra cash for whatever purpose they choose and let them get on with it! (The likely study above will probably also forget this other control group)

1 As measured, this being the NHS, either by the uselessly two-dimensional BMI measure, or by the even sillier one-dimensional "waist circumference" measure.