Money for health - moving to the root of the problem

There has been some debate recently about personal financial incentives to achieve healthy behaviour. The Harvard philosopher Michael Sandel has been brilliantly exploring the issue from many angles [ listen to radio 4 debate here: http://www.bbc.co.uk/podcasts/series/r4sandel ]

The argument against payment incentives is characterised as bribing people to be healthy and wasting money. Needless to say The Sun, The TaxPayers’ Alliance, and The Tories are not the biggest fans [ http://bit.ly/JLmcZB ]

However, the debate to-date largely misses a crucial link. Health and wellbeing are determined largely by behaviours / lifestyles (e.g. smoking, alcohol, diet, physical activity); and also directly by socioeconomic factors (e.g. income, education, occupation, housing, family, networks, culture). These behaviours / lifestyles are also determined by the same socioeconomic factors - "the causes of the causes” if you like. The pattern almost always follows that lower socioeconomic circumstances increases adverse behaviours and so impacts on health. There is plenty of evidence to support these pathways and also that shows that because of the adverse social and economic circumstances the "choice" of the adverse behaviour is not one necessarily freely taken (e.g. healthy foods are not so affordable or available; smoking and drinking often arise out of the chronic stress of poverty and unemployment).

We cannot, therefore, try to really improve lifestyles and behaviours without improving the underlying social and economic circumstances. To change this may be considered as "up stream" or requiring major political change and beyond the remit of health (or other) services. And obviously progressive taxation and / or better distribution of wages are the major solutions. However, incentivising with monetary / payment is an attempt in a relatively small, local, and direct way to address these socioeconomic causes of the causes.

A Dundee programme – called quit4u – offering payment of £12.50 a week (in supermarket food vouchers) to encourage people living in deprived circumstances to quit smoking has been shown to work. The two year evaluation, just published, demonstrates improved quit rates at 3 months and even 12 months [ full evaluation here www.healthscotland.com/documents/5827.aspx ]. At its launch the Dundee initiative was met with much the same aversion, which has dominated the debate on this area. But, at its heart has been an ethos of understanding this socioeconomic link and trying to do something, albeit in a small way, about it. So praise must go to NHS Tayside for taking this bold and groundbreaking action in the face of much hostility. We urge other health boards and Scottish Government to follow suit and take more positive action with the powers they have to make a difference to the lives of those most in need if we are going to tackle inequalities in health and wellbeing.