Bribery – the key to better public health

Survey reveals the scale of financial incentives offered by health services

Obese patients in Kent are being paid up to £425 to lose weight by the NHS in a trial to test whether financial incentives can be used to change unhealthy behaviour. In Essex, pregnant women who smoke are being offered up to £60 in food vouchers on the NHS if they give up. Payments are made after one week, one month and one year.

A review of the use of financial incentives in health, published today, says the approach has divided the health community. Some condemn it as bribery and coercion, which rewards people for unhealthy behaviour.

Others see it as the obverse of taxation, giving money back to people for healthy behaviour instead of making them pay (in tobacco and alcohol duty) for unhealthy behaviour.

Personal financial incentives are increasingly being used to persuade people to change unhealthy habits. But unlike tax they are targeted at individuals rather than populations. One of the highest rewards was offered by General Electric in the US to staff who stopped smoking. They were paid up to $750 (£500) with the major part ($400) payable only after 12 months of abstinence.

Theresa Marteau, professor of health psychology at Kings College, London, lead author of the review published in the online version of the British Medical Journal, said: "The theory is that much of our behaviour – 45 per cent – is habitual. The idea of incentives is to help break bad habits and once the new habit is established, the incentive can be removed. But unless you change the environment the chances of success are reduced."

She added: "This is about understanding human frailty. Most people don't want to be overweight or keep smoking but find it difficult to do anything about it. If we can kick start a change in their habits then that is good for them and for the rest of us."

Paying people to change their habits works because it offers immediate rewards for behaviour that will only provide a health benefit in years ahead. The approach was recommended last month in a report by Health England, a government advisory group chaired by a former No 10 health adviser, Julian Le Grand.

Professor Le Grand, a health policy expert at the London School of Economics, said: "One of the main problems facing both individuals and the Government is that we reap the costs of unhealthy activities in the future whereas we experience their pleasures and benefits today. The 18-year-old smoker does not think about dying of lung cancer at 60. Policies have to be developed that bring some of the costs of unhealthy activities – or the benefits of healthy ones – 'back from the future'."

The idea of paying patients to promote health originated in the developing world where it has been successfully used to encourage one-off responses, such as attendance at clinics or uptake of vaccinations.

But changing behaviour has proved harder. A review of 17 trials of the use of payments to help people give up smoking found the effects only lasted as long as the incentives were paid. Similarly nine weight loss trials showed no benefit from payments after 18 months.

Professor Marteau said the failure of incentives to change behaviour in the long term could be because the schemes were not sophisticated enough.

"Very few schemes tried to incentivise sustained behaviour change. If the incentives were more nuanced, it is possible they would be more effective. The General Electric scheme for giving up smoking offered large incentives – larger than anyone else – that were incremental the longer the smoker had given up. It is one of the largest schemes and it is clever, building on behavioural principles. The results are promising but they need replicating in other studies."

Cash for clean living: The incentives on offer

*Smoking

Pregnant women in Essex offered £20 food vouchers for giving up for one week; £40 after one month; £40 after one year.

*Obesity

Overweight patients in eastern and coastal Kent offered £70 to lose 15lbs, £160 to lose 30lbs and keep it off for six months, and £425 to lose 50lbs and keep it off for six months.

*Healthy eating

School pupils in Ayrshire earn points by eating healthy school meals which can be exchanged for items for Save the Children projects abroad, including farm animals, medical supplies and classroom equipment.

*Mental illness

Patients on anti-psychotic drugs in east London offered £5 to £15 per injection, to encourage them to take their medication regularly.

*HIV/Aids

Young people aged 15 to 30 in Tanzania offered $45 (£30), equivalent to one quarter of annual income for some, if they test negative for sexually transmitted diseases over three years in $1.8m trial sponsored by the World Bank.

*Child development

Payments are offered to poor families in Mexico for ensuring their children attend school regularly and have vaccinations under the Progresa programme.

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