Is paying people to get fit the future of the NHS?

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Incentivisation is nothing new – but could it be used on a wider basis to point people in the right direction?

Research out last week showed that financial incentives were successful in helping people quit smoking. Now there’s talk of applying this to the national obesity crisis – but can the British public really be paid to lose weight?

Currently the NHS spends around £6 billion a year caring for overweight and obese people. The latest figures show the NHS pays out £1,800 more on overweight individuals over a lifetime compared to those at a healthy weight. And the problem is getting worse, with the World Health Organisation predicting 69 per cent of the population will be overweight by 2030.

Around two thirds of the adult population in the UK are either overweight or obese, says Helena Gibson-Moore, Nutrition Scientist at the British Nutrition Foundation. “Obesity can lead to a number of chronic diseases such as types 2 diabetes, heart disease and some cancers,” she explains. “Therefore finding successful, sustainable approaches to losing weight remains a public health priority.”

Faced with this extreme health crisis, the NHS could start taking radical steps to head it off at the pass. But is paying people to get fit and lose weight really the future for our public health service, and does it even work?

“We just don’t know,” says Amanda Daley, Professor of Behavioural Medicine at Loughborough University. “It might be that in the future the public could be given a physical activity tracker device (such as a Fitbit) paid for by the NHS, to help them monitor and increase their physical activity levels, but whether the NHS could afford this is another matter. We need more studies that focus on whether this would be cost effective – so looking at the costs of the incentives relative to the impact of the incentives on heath and some incentives might work better than others.”

Incentivisation is nothing new. The cycle to work scheme, which allows you to buy a bike using a pre-tax ‘salary sacrifice’ to save money, and subsidised gym memberships are common perks in the workplace to encourage health and fitness, while the sugar tax, introduced in April last year, financially penalises drinks that contain over 5g sugar per 100ml.

But Professor Daley urges caution when it comes to incentives, explaining that while short-term effects may look good, it is the longer term we should be paying attention to. “Incentives may be more likely to work for behaviours such as giving up smoking, which is a more defined behaviour,” she says. “For behaviours such as changing your diet, losing weight and increasing physical activity levels, they are less likely to work. These behaviours have to be done day in day out and that’s very hard for people to achieve and sustain, even with incentives.”

It seems the problem comes when the incentives become less important over time and people revert back to their old way of life. In that respect, a longer term solution would be to encourage people to be less reliant on external rewards and highlight all the personal benefits and internal rewards that come from doing more physical activity.

However, Neville Koopowitz, CEO of Vitality Healthcare, which has a strong programme of incentives for its members including weekly coffees and fortnightly cinema tickets, is adamant that incentives work. “We are firm believers that incentives will change people’s behaviour. We’ve seen from our programme that you have to keep people in the game with instant gratification,” he says. “Last year we conducted a study of 460,000 of our members across the UK, US and South Africa. We found that people were more active across the spectrum. With ‘at risk’ participants, whose BMI mass is greater than 30, we saw 160pc increase in activity level in the UK. We still have a way to go. Incentivisation is a very big part of that, but not the only part.”

The founders of Sweatcoin, a rewards-based app that calculates steps taken per day and swaps them for in-app rewards, also believe that the right incentives will be the answer to the problem of sustainability.

“The hardest thing to do is not just to change the behaviour, the problem is how do you sustain the behaviour change,” says Anton Derlyatka, co-founder and co-CEO of Sweatcoin. “Everybody knows about New Year’s resolutions – they only last two weeks. Our challenge is to create an experience that will create a sustainable change. That is why providing relevant, personalised incentives will work.”

Anton explains the problem lies in something called ‘present bias’, in which we only focus on what is going on right now, at the cost of the future. While exercise and healthy eating might result in us being slimmer or stronger in a few months, what we really want to do in the present is lie on the sofa eating takeaway because we’re tired and hungry.

However, Eugene Farrell, Mental Health Lead at AXA PPP healthcare, is cautious about a single-pronged approach to the obesity crisis and is concerned the focus on weight loss is addressing only part of the problem. Instead he advocates both mental and physical health are looked at as a whole, to give a more balanced approach to wellbeing.

“Rewarding people to reach single physical goals, such as walking 10,000 steps a day or running a certain distance throughout the week, may end up causing anxiety and stress as some people can become pre-occupied with attaining this,” says Farrell. “By treating both physical and mental health as one, whether that’s by practising mindfulness as well as going to a gym class or more simply walking to and from work, then you are looking after a greater number of aspects of a person’s health instead of just the physical part.”

Mike Burt, founder and MD of OnePerformance UK gym, is also concerned these incentives are short-term fixes to a more serious problem: “The main problem for me with all these apps and programmes is they are all quick fixes and they’re not looking at the long term, which is the only thing that’s going to make a difference”.

Burt concedes paying people to stop smoking can be effective as it is an addiction, but when it comes to exercise, change must be rooted in knowledge and childhood behaviours. “You don’t need expensive gym memberships to exercise, it’s just about being active every day, and it starts with the kids,” he says. “Ban social media, ban PlayStation. Stop producing all these things that are breeding kids who are used to sitting inside not doing anything. We need to create behaviours where we’re active and outside rather than sitting inside doing nothing from a young age.”

In an ideal world, we would all be eating healthy foods and exercising regularly, but as the rising obesity levels show, this is clearly not the case.

“Incentivisation may be a good way of kickstarting people to change their lifestyle, but other strategies will also be needed to help people maintain any changes they make over the long term,” says Professor Daley.  “We need a toolbox of strategies and incentives might be one of the tools. We also need to explore in more depth whether offering incentives for changing health behaviours is actually acceptable to the public, who would ultimately fund such an approach.”

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