According to the latest national statistics, though life expectancy is steadily increasing, many in the UK will face major health problems across their lives due to a marked increase in ‘lifestyle diseases’ – illnesses and conditions related to the way we live our lives [Ref: Office for National Statistics]. ‘Lifestyle diseases’ include illnesses such as smoking-related cancers and lung and heart disease caused by obesity.  Aside from the impact on personal health, the cost to the public purse is significant; with the NHS paying out billions of pounds a year on treatments. When the Coalition government launched its white paper on health, many commentators noted a shift in emphasis in the discussion on lifestyle and health, with health minister Andrew Lansley distancing himself from the ‘lecturing’ tone of New Labour public health campaigns and instead making the case for a renewed sense of personal responsibility [Ref: BBC News]. One of the more controversial attempts to instil personal responsibility has been the suggestion that the government introduce economic incentives to encourage people to better health. Some argue that incentives amount to a form of bribery, that they mistakenly ‘reward bad behaviour’ or that they undermine our autonomy and capacity to make choices about the kind of lives we choose to lead.  The debate around incentives reflects a broader discussion about the changing face of public health, where some ask whether concerns about lifestyle have led to a ‘moralisation’ of health and an over-emphasis on individual behaviour whilst others argue it’s imperative to experiment with new measures to improve public health. Are economic incentives a positive step towards instilling a sense of ‘personal responsibility’ or are they bad news for moral autonomy?

Where have financial incentives been used and do they work?
The use of economic incentives and disincentives to encourage healthy behaviour has been trialled by a number of NHS trusts over the last few years [Ref: NICE] and been strongly endorsed by Health England [Ref: LSE]. In May 2010 the National Institute for Health and Clinical Excellence (NICE)  asked the public for its views on whether incentives have a role in encouraging people to live healthier lives, kick-starting a debate on their efficacy [Ref: NICE]. After receiving the broad support of its Citizens Council, NICE’s expert groups will take this view into account if asked to produce guidance which includes consideration of such schemes[Ref: NICE]. But do incentives actually work? Experts are divided. Although research by Health England suggests that incentives could be effective in encouraging healthy behaviour [Ref: LSE], others warn that there is no evidence to suggest that they work in the long term and that they will be unsatisfactory in tackling more complex behaviours such as smoking.

Coercion and autonomy
Even if incentives were proven to have a positive impact on health, some critics argue that their use can amount to coercion on the part of medical professionals and government [Ref: BMJ]. In assessing the value of incentives, argues one writer, we need to consider how their use is likely to impact on an individual’s sense of autonomy and agency in regards to their health [Ref: Guardian]. Some also predict that incentivising health will erode the trust between doctors and their patients, as doctors may be expected to take on the role of policeman in the running of such schemes. But proponents suggest that far from being coercive, incentives enable patients to make choices they find difficult to commit to in the short-term because of the lack of immediate reward [Ref: Health England]. Incentives, they argue, in fact promote autonomy by making it easier for people to act in line with their considered preferences about their long term health.

Health and inequality
The link between poor health and social inequality has been a concern of government for many years [Ref: Department of Health]. One of the reasons that health inequalities exist, say some, is that unhealthy behaviours are more prevalent amongst lower socio-economic groups. Despite ongoing health promotion messages under the previous Labour Government, most now agree that that such ‘information-providing’ measures are ineffective [Ref: Kings Fund]. In arguing for the use of economic incentives, supporters such as Richard Cookson draw attention to the success rates of schemes such as Oportunidades in Mexico [Ref: World Bank] and Opportunity New York City [Ref: Opportunitynyc] which he suggests have successfully used incentive schemes to improve health amongst the poorest sections of these countries. In making the case for the use of economic incentives, proponents such as Cookson suggest that the cost that disease caused by unhealthy behaviour places on the NHS justifies the degree of intrusion that such schemes imply [Ref: BMJ]. But others argue that the new enthusiasm for economic incentives is worrying. There are a variety of complex reasons why people continue to behave ‘unhealthily’ – not least that it is ‘enjoyable’. But importantly what the use of economic incentives also encourages is the marking out of individuals as ‘irresponsible’ and unwilling to behave in a socially acceptable way [Ref: BMJ]. Some argue that economic incentives are just another example of the growing trend towards ‘health paternalism’ and a political obsession with individual behaviour. This not only enforces a uniform idea of what the ‘good life’ should be, but also represents an attack on individual choice and ‘working class culture’ [Ref: Guardian].

Changing nature of public health– does it matter if we’re fat?
The debate around economic incentives and health takes place alongside a broader discussion about the changing nature of public health. The Nineteenth century focus on acute, infectious diseases caused by social factors like poor sanitation and housing has now been replaced by a concern for lifestyle diseases. Some suggest that this shift is the consequence of our improved health and a growing understanding of the behavioural factors that contribute to poor health. But others suggest that we need to be more wary of alarmist public health messages. In a striking example, Phil Collins points out that if the UK were to adopt the international measurement for obesity we would effectively halve the number of ‘obese’ children in one fell swoop [Ref: The Times]. But more than this, the reticent 21% who continue to smoke or the person who persistently exceeds the recommended daily intake of alcohol have to be free to make those choices. When choice is distorted by the use of incentives, critics argue, what we are left with is no choice at all.