What should we do about “More”?

When Michael Young wrote the Labour party manifesto in 1945, the problems facing society were ones of deprivation. What people needed was more: more pay, more jobs, more housing, more education and more healthcare.

But as a philosopher once said, be careful what you wish for: you might just get it. In the world of healthcare at least, more has become the new enemy. Some of the biggest threats to public health are now the so-called “diseases of affluence” – coronary heart-disease, smoking-related cancers, stroke and type-2 diabetes – caused or exacerbated by modern diets and ways of life. Julian Le Grand’s 2007 Beveridge Memorial Lecture described these as the Giants of Excess, the reincarnation of the Five Giants of Sir William Beveridge’s 1942 report.

The challenge of “more” has become a major issue for our health system. And it is a particularly difficult challenge for statutory bodies to address, since tackling it requires not just providing more services, but encouraging people to change their behaviour. Coping with chronic illnesses requires us to spend more time monitoring and medicating ourselves, while avoiding them requires us to eat better, smoke less, and exercise more: in the jargon of healthcare, to demonstrate ‘self-management’ and ‘behavioural change’. Derek Wanless’s 2002 report on the future of the NHS made it clear that unless we become “engaged” in our own healthcare, NHS spending will rise to an alarming 12.5% of GDP by 2022/23. To put it another way, if we don’t improve our lifestyles, we’ll have a long unhappy old age to look forward to, and the NHS will go broke.

How then should the NHS respond to this challenge? Opening more hospitals and providing new drugs won’t do the trick. But the idea that it should encourage “behaviour change” is problematic: firstly, because behavioural change is controversial in itself, and secondly, because the NHS is not well equipped to achieve this sort of change on its own.

The reputational risks are many. One danger is it could be seen as the NHS abnegating responsibility: “patient, heal thyself”. Freedom of choice is also at stake: behavioural change evokes to some an Orwellian nightmare of mind control, with people being bullied into living lives of puritan joylessness designed by well-meaning officials. And inequality is a major concern: it’s a cruel irony that “diseases of affluence, especially ones linked to obesity and smoking, in fact hit the poor hardest, and coercive behaviour change programmes therefore risk reducing disadvantaged people’s freedom of choice disproportionately. The strongest critics of behavioural change argue that any form of encouragement or coercion is unethical, and that the only acceptable way of changing behaviour is to provide health information. This position is admirably pure, but seems naive in a world where we are continually subject to persuasion and coercion by the advertisers, peers, and other government bodies. Policy wonks at Demos, the Social Market Foundation, and the King’s Fund are currently thinking furiously about these questions, but it’s unlikely that they’ll stop being controversial any time soon.

The other problem the NHS faces is one of capability. It is more used to developing new clinical practices than to devising new ways to win hearts and minds. Only 0.5% of NHS research funding is currently spent on behavioural change: the vast majority goes on the traditional areas of drug discovery, device design and new clinical practice. Although many commissioners and providers are now striving to understand the needs of different groups of patients and tailor their services to them, this is often uncharted territory.

Our work suggests three important lessons that have a bearing on both the moral and the practical difficulties of behavioural change.

Firstly, NHS policy makers should learn from one of main precepts of medical innovation, namely the Hippocratic principle of “first, do no harm”. Experimenting with behavioural incentives that people can opt into, and that involve support and incentives rather than prohibitions or charges, seems a sensible course of action. At the Young Foundation’s Health Launchpad, we’ve looked at a number of programmes that provide rewards and build community support for exercise and self-management, and both their success and their popularity to date is very encouraging.

Secondly, Michael Young’s own methods should act as model for public bodies trying to encourage people how to change the way they live their life. The spirit of Family and Kinship in East London – a commitment to asking people what they actually think and want, and taking it seriously – is an essential part of supporting and encouraging change. NICE’s guidelines on behavioural change recognise this, but this does not always translate into implementation.

The third point flows from the second. Understanding what a large and diverse population wants is a hard thing for the NHS to do: but social enterprise can help. Incorporating community organisations, sports teams and walking groups into its behavioural change efforts is one way of understanding people’s goals and aspirations. The challenge for the NHS is to create a platform or a framework that allows it to work with communities to support and encourage people to fulfil their lifestyle goals.

We are developing a social enterprise to deliver just such a platform. We’re working in partnership with a leading PCT and with local communities to support and encourage healthy behaviour – so if this is an area you are interested in, please get in touch.