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

6.1 GPs (General Practitioners)

GPs respond well to incentives, as proved through their response to the Quality and Outcomes Framework (QOF). QOF is designed to improve the level of care patients receive by rewarding practices for the quality of care they provide. It contains indicators on the levels of clinical treatment (coronary heart disease, mental illness, obesity), organisation (education and training, practice management), patient experience (length of consultations, patient surveys), additional services (cervical screening, maternity services) and holistic care36. As yet QOF has failed to re-orientate services towards prevention, as the contents are largely focused on short-term treatment.

Due to the links between unemployment and health, tackling long-term absence is a vital component in reducing the costs of public health issues. GPs with their responsibility for administering sick notes play a key role in facilitating the movement of people who have been off sick back into work. Their success in doing this has been questioned (e.g., by the Work and Pensions Select Committee in 2005)37. Evidence also suggests that employers are dissatisfied with the role of GPs in sickness absence — employers receive medical reports from GPs for only 50% of employees with long-term health problems and many believe that GPs do not give enough thought to the potential of a phased return to work38. GPs have expressed the difficultly of balancing their loyalty to their patients and an obligation to the benefit system and employers39.

Dame Carol Black in a recent review emphasised the role of the GP in getting individuals back to work and called for more to be done through GPs’ surgeries. This could include measures such as more employment advisors in surgeries and greater training for GPs with regards to occupational health. Practical measures such as the introduction of electronic sick notes could also be an essential part of making the process easier for GPs.

There may also be a role for occupational health professionals in assessing sickness (or for increasing occupational health training for GPs)40. A survey undertaken by revealed that two-thirds of respondent GPs were unaware of the evidence that work was good for health, although 90% indicated this information could help to change their behaviour.

By virtue of their close contact with employees, employers are also relatively well placed to spot the first signs of illness. In many cases, most notably in the example of mental health, businesses are taking over the functions of the NHS. Waiting times for psychological therapies of several months in some areas of the country mean it is in employers’ best interest to provide their own services as evidence suggests that the longer an individual is out of the workplace, the less likely he or she is to go back to work. Companies are innovative in terms of access, with organisations such as BT and GSK offering 24 hour phone counselling.

Another key area where business interventions occur is for musculoskeletal problems. A number of companies are providing opportunities to quick access to physiotherapy in order to prevent short-term conditions deteriorating into chronic ones. It is recommended by medical professionals that, in the case of patients with back problems, interventions should be offered as soon as possible for patients who have been off work for four weeks or more in order to best facilitate return to work41.

Government should move from exhortation to motivation. This means leading by example and following the practice of the best employers in regard to its own workforce. It means freeing up regulation to encourage companies and individuals to take on greater responsibility. Finally it means making sure individuals reap more of the benefits of good health to incentivise them to take greater responsibility — through co-payment and healthy living bonuses.

The NHS as a system is still largely focused on treating rather than preventing disease. It is a sickness service rather than a health service. While prevention has risen up the agenda in recent years, resources within the service are still tailored towards short term rather than long terms goals.

If the NHS could reorient itself towards prevention then the positive benefits experienced by business could also provide positive benefits for society. One of the key challenges for the health service is to get buy-in from providers, particularly GPs, on the prevention agenda. This is beginning to happen through mechanisms such as the quality and outcomes framework (QOF), but at present incentives still remain more aligned to current rather than future health service goals.

There is also a need for a focus on prevention of health costs within the wider public sector. As one in five workers are employed by the state, there is an opportunity for the public sector to take the lead in health promotion in the workplace42. Surveys suggest that absence levels per employee remain the highest in the public sector, with an average of 9.8 days in the public sector compared to 7.4 in manufacturing and production43.

However, some players in the public sector have made progress in improving the health of their workforces. Active Health Partners (AHP) work with a number of partners in Local Government to better understand and reduce the costs of absence, working to develop a comprehensive business case. As such, AHP have helped reduce absence rates in South Bedford District Council by 30% and Newham Council by 40%, with Newham Council realising savings of over £400,000.

Research by Deloitte has found that the major barriers to exercise are lack of motivation, and work and family commitments. A number of schemes have shown that individually targeted programmes that use incentives are a key element of changing behaviours. Some of these schemes have been particularly effective at targeting groups with the worst lifestyles. Examples can be drawn from a range of sectors (for example, insurance companies and city councils) and employing a range of different funding approaches (e.g., employer levies).

Insurance companies are incentivising individuals to engage in positive behaviours. Examples include the South African health programme Vitality and the United Kingdom programme PruHealth (made up of a partnership between Prudential UK and Discovery). A recent evaluation of the Vitality programme has found that highly engaged beneficiaries of the programme experienced lower costs per patient, shorter stays in hospital, and fewer admissions than all other comparative groups44. PruHealth has successfully led to some behavioural change, with 43% of UK members stating that being a member of the scheme has encouraged them to become healthier than they were before.

In Canada employers pay an experience-related insurance premium to cover long-term sickness and disability to workers’ compensation boards. The premiums can vary from less than 1% of turnover to 10%, depending upon industry and workplace practice, but there is an incentive on employers to encourage safe and healthy workplaces and to get sick employees back to work again. The Government of Nova Scotia has introduced a tax-back payment aimed at encouraging its population to undertake more exercise.

These examples highlight that addressing demand for public health services is not only the role of government. Indeed, as Alan Johnson, the British Health Secretary, said recently: “Tackling obesity requires a much broader partnership, not only with families, but with employers, retailers, the leisure industry, the media, local government and the voluntary sector. We need a national movement that will bring about a fundamental change in the way we live our lives.”45

In a speech to the House of Commons on 30 June 2008, the UK Health Minister highlighted the need to “develop better incentives for maintaining good health as well as providing good care”. Economic incentives play an important role in encouraging the development of positive habits, while the poor incentives lead to negative habits being developed46.

A tax on unhealthy activities (such as the consumption of unhealthy food ingredients) may be proposed to improve incentives (align the private and social costs of unhealthy activities) and provide sources of tax revenue that could be used to fund public health activities or reduce taxes elsewhere. This approach (of Pigovian taxation) is motivated by a desire to ensure that when people engage in unhealthy activities they consider the full costs (including those in the future) of their actions.

However, the practical and economic arguments for this increase in tax burdens are unclear. A tax on the consumption of certain food ingredients would, for example, be administratively difficult to introduce (given the range of ingredients contained in most foods) and would add significant additional administrative and compliance costs to the tax system. These complexities mean that it is unlikely that the base of activity over which the tax would apply would be clearly linked to the public health issue being addressed (in contrast to an area like smoking, where the link between consumption and damage is clearer)47.

36 NHS Information Centre (2008): National Quality and Outcomes Framework Statistics for England 2007-08.
37 House of Commons Work and Pensions select committee (April 2006): Incapacity Benefits and Pathways to Work, Third Report Session 2005-06, p 20
38 The Chartered Institute for Personnel Development and KPMG (November 2007): Labour Market Outlook Report.
39 Mowlam, A. and Lewis, J. (2005): Exploring how General Practitioners work with patients on sick leave, Department of Work and Pensions.
40 Mowlam, A. and Lewis, J. (2005): Exploring how General Practitioners work with patients on sick leave, Department of Work and Pensions.
41 Peninsula Medical School (2007): Avoiding long-term incapacity for work: Developing an early intervention in primary care.
42 The Oxford Health Alliance (2008): The OxHA workplace health programme.
43 Chartered Institute of Personnel and Development (2008): CIPD Absence Survey 2008.
44 Discovery Vitality Journal (2008): Reducing the cost of healthcare through lifestyle intervention.
45 Johnson, A. (2008): Speech to the Fabian Society on Obesity.
46 Morris, S. et al. (2004): “Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras”, The Lancet, Vol. 364 No. 9450. Volpp K.G. et al. (2008): ‘Financial Incentive-Based Approaches for Weight Loss’, JAMA, 300:22.
47 McLeod, R et al. (2001): Issues Paper, 2001 Ministerial Inquiry into the New Zealand Tax System, Treasury, Wellington, p. 71.

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