The Long Term Costs of Lifestyle Risks. Pathways to Change: A Case Study in the UK

4. A Cold Climate

Increased poor health will occur in a climate where less money is available for public services. The vast increases in spending that the NHS has seen in recent years are set to come to an end. The NHS has already been asked to make an efficiency saving of three% this year and it is likely to have to make further savings as budgets tighten across government32.In short, an end to the “flash flood” of funding is coinciding with an increasing demand for services.

National policy on the promotion of good health remains focused on the role of government, despite the evidence presented above of the benefits to individuals and employers from the use of personal incentives. But there are welcome signs that policy makers are now open to a new set of ideas based on personal incentives. This would see the idea of healthiness change from one of ‘public health’ — with the idea of creating a ‘healthier nation’, through national communication and exhortation — to ‘personal health’ — with the idea of making individuals responsible for their own health, with employer support. As the biggest employer in Europe, the National Health Service itself has a leading role to play.

In the most recent speech on public health, by the British Minister of Health Alan Johnson he made clear that government retains the key responsibility for improving public health33. He praised the Government for increasing the amount it spent on prevention and public health from l.8% of total health expenditure to 3.6%. He argued that government had a moral responsibility to intervene “as the waistline of the nation expands, lives get shorter and deprivation intensifies”. He described the launch of a new government-sponsored national advertising campaign, Change4Life. Similarly, the recommendations in Dame Carol Black’s report on workplace health (and the UK Government’s response to it) look almost exclusively to government for progress.

A key instrument in the current approach to public health issues is the use of publicity campaigns. Recent campaigns have focused on subjects such as alcohol (‘Know your Limits’), smoking (‘Worried’) and obesity (‘Change4Life’). These campaigns have focused heavily on disseminating information through advertising and billboards. The ‘Know your Limits’ campaign has relied on imagery to inform people how many units of alcohol they are consuming, while the ‘Worried’ campaign is aimed at encouraging parents to stop smoking by highlighting the distress it causes their children. The aim of Change4Life is to develop a brand that can be used by other agencies to promote a healthy eating message.

There is evidence that publicity campaigns have limited success. Analysis by the National Social Marketing Centre has shown that campaigns are more effective when coupled with services and behavioural interventions, such as the provision of skills and the shift in desirability for health34. There is no evidence that previous campaigns, such as the Active for Life campaign in the 1990s, resulted in an increase of physical activity35. The Government may be successful in convincing the public that certain behaviours are undesirable, but it is more difficult to convince them to make a positive change. There is a need to consider and tackle the factors that lead to poor lifestyle choices, rather than simply warn the public of the possible outcomes of such choices.

5. Command and Control Approaches Are Suitable for Few Issues Only

The UK Government has also used command and control instruments to address the costs of unhealthy behaviours. Examples include the smoking ban and the prohibition of the display of tobacco products at the point of sale. Although changes in the rates of smoking can be attributed to many factors, following these interventions there has been a reduction in the numbers of individuals that smoke. The reduction in the rate of smoking has not been uniform across the population, with smoking rates remaining relatively high among some hard to reach groups of the population (such as people under 20 and people in routine and manual jobs).

Command and control approaches can effectively address some but not all public health issues. These approaches tend to provide a very clear signal about the level of damaging activity allowed, but provide few incentives for reducing activities in the way that costs the economy the least. In contrast, market-based approaches tend to provide stronger incentives for reducing harm at least economic cost, but may not provide as certain a reduction in harmful activity.

6. Personal Responsibility, Personal Incentives

The new health agenda turns on creating the right incentives for healthy behaviour. It puts the responsibility of individuals and employers first. Aspects of recent health policy (such as the successes of individual budgets) illustrate that there are real gains to be made from a public health policy that not only allows but encourages an individual to exercise more control over their health. There is, however, still some way to go in ensuring that the approach to public health realises the full potential of approaches based on increased personal responsibility.

32 HM Treasury (2007): 2007 Pre-Budget Report and Comprehensive Spending Review.
33 Johnson, A. (2009): Nanny State, Nudge State or no State?. Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 19 March.
34 National Social Marketing Centre (2006): It’s Our Health! Realising the potential of effective social marketing.
35 Health Development Agency (2004): The Effectiveness of Public Health Campaigns.

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