4. Cashing in on good health
Suffolk Branch
(R) That this meeting of RCN Congress asks Council to lobby in favour of moves to offer financial incentives to be healthy
Result
The resolution was rejected.
For: 6.74% (30)
Against: 93.26% (415)
Abstain: 22
Debate report
Congress voted overwhelmingly against a resolution to campaign for the use of financial incentives to encourage people to be healthy.
Proposer Sandra Gover, RCN Suffolk Branch, said that financial incentives “help people achieve their goals” and that “health promotion should be at the root of everything we do."
Steve Fenner of the West Sussex branch said that financial incentives hold great promises for certain groups to modify particular behaviours.
But Linda Bailey, Public Health Forum, said there is currently no robust evidence that financial incentives work, and suggested we instead make it easier for people to live healthy lives – a minimum price for alcohol, for example.
David Shenfield, Inner London Central Branch, suggested incentives can work in certain cases and mentioned a successful incentive scheme in Brazil where child benefits are only received if children attend school.
“Vote against this,” said Jenny Aston, Advanced Nurse Practitioner Forum. “Education and empowerment of patients is much more effective. Money is not a simple answer.”
Stephen Walton of the Northern region also asked Congress to not think incentives are the right way forward. “Motivation comes from within,” he said.
Greg Usrey, Greater Glasgow Branch, said he has seen financial incentives yield great results among a group of pregnant smokers, while Gareth Philips, Gwynedd Branch, urged Congress to avoid incentives “like the plague."
Iain McGregor asked where the money would come from. “We need to look at ourselves before others,” he added.
Background
Healthy behaviours can be encouraged by providing education, information and professional support; improving the physical and social environment; regulatory action; and the use of financial levers.
These financial levers can act either as ‘disincentives’, for example raising tax on cigarettes to discourage smoking, or ‘incentives’ such as offering rewards for positive behaviours like losing weight, taking up exercise and smoking cessation.
However, a recent review of evidence on the use of incentives in smoking cessation concluded that while early and medium term quit rates were encouraging, early success tends to disappear when there is no more incentive. Similarly, an analysis of incentives in nine weight loss trials showed no greater long term success after 12 or 18 months.
Incentives may be more appropriate when they are targeted or time limited. The Best Fed Babies project in Scotland, for example, provided pregnant women with shopping vouchers to encourage better nutrition and 93 per cent of babies were born at or above normal birth weight.
However, the use of financial incentives raises ethical questions such as should people be paid to ‘help themselves’, and whether the practice sustainable in the longer term? The media frequently profiles stories about incentives and disincentives; for example, on whether it is right for governments to impose taxes on foods which are high in saturated fat or sugar.
In 2010 the National Institute for Clinical Excellence (NICE) held a Citizens Council seminar to discuss incentives (National Institute for Health and Clinical Excellence, 2010). When asked if there were any circumstances in which incentives are acceptable, 12 of the 32 members present voted “no” and 20 voted “yes - but with conditions”. Reasons for caution included lack of evidence, potential for abuse, whether incentives undermine long term behaviour change, and concerns about the negative effect on public opinion. Those in favour suggested incentives may be best used when targeted at particular groups and as part of a wider package of help.
The level of intervention considered appropriate differs in the four UK countries. In England, the coalition government has promoted behavioural economics. For example, the ‘nudge’ theory of behaviour change, which relies less on aggressive state intervention and regulation and more on subtle environmental changes which prompt individuals to make healthier choices.
In contrast, the recent Review of Health and Social Care in Northern Ireland considered encouraging health behaviours through taxing unhealthy food and minimum alcohol pricing. Meanwhile, Scotland is focusing on encouraging better health through the financial disincentive of a minimum unit price for alcohol.
The Welsh Assembly Government uses the principle of citizenship to promote healthy activity; for example funding free swimming for children aged under 16 and people aged 60 and over. The Welsh Assembly Government also promotes a national exercise referral programme which offers people access to a variety of fitness sessions and activities.
The RCN has supported the principle of using disincentives to change behaviour – for example, raising the cost of alcohol with a minimum price per unit.
References and further reading
Cahill K, Perera R. Competitions and incentives for smoking cessation. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD004307. DOI: 10.1002/14651858.CD004307.pub4.
Paul-Ebhohimhen V, Avenell A. Systematic review of the use of financial incentives in treatments for obesity and overweight. Obesity Reviews 2007;9:355–67.
National Institute for Health and Clinical Excellence (2010) The use of incentives to improve health: Citizens Council meeting 20th – 22nd May, 2010, (no place): NICE. Available at: http://www.nice.org.uk/media/9AF/56/CCReportIncentives.pdf
(accessed 5/3/12).
