How can we get people to make healthy choices?

Rather than relying on the NHS to make us better we could reduce our chances of getting ill by living healthier lives. That would save lives and reduce the strain on the NHS budget. Most of us already know the basic facts. These are that a combination of four health behaviours in adults is associated with a 14 year greater life expectancy. The four important behaviours are: not smoking, moderate intake of alcohol, physical activity, and consumption of more than 5 servings of fruit and vegetables daily(1).

We would be healthier and the NHS a lot better off if we behaved differently.

As a King’s Fund report in 2008 argued:

“Individual responsibility for health and self-care are key themes in recent health policy documents .... The Wanless review of health care funding (2002) showed that public engagement with health could help to reduce health care costs. Choosing Health (2004) looked at how information, services, retailers and marketers could make healthy lifestyles ‘an easier option’ for people. Our Health, Our Care, Our Say (2006) explored the future of health and social care based on an assumption of individuals managing their health and health care. These policies are based on a number of ideas:

• individuals should take greater responsibility for their health care
• individuals should adopt healthier behaviours to avoid ill-health in later life
• if individuals do change their behaviours, the hope is that better health will reduce future health costs.

For the NHS and health practitioners working within it the challenge is how to support people to adopt healthier behaviours and avoid risky ones. Much of the published material on models of individual behaviour and change is based on theory rather than practice, and there is little consensus on the elements of successful intervention. (2)

It seems that knowing the facts does not seem to make us behave according to them, so in its 2014 five year plan, NHS England prioritised a change of behaviour:

"The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. .... The NHS will .. back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors." (3 page 4)

One of the responsibilities of Public Health England, an agency of the Department of Health that applies research to public campaigns, is: "supporting the public so they can protect and improve their own health". (4)

Present and future trends

Work is already well advanced in this direction:

Change4Life (a government sponsored site to help people change eating, drinking and activity habits) has led the way across government in maximising the in-kind revenue from commercial and public sector partnerships. Over 200 national organisations have collectively provided £51.5 million of in-kind support to the programme. This level of investment is increasing year on year as the range of activity increases.

In addition local authorities, local supporters and the NHS have distributed about 30 million pieces of Change4Life material, thousands of Quit Tools and Kits. They have endorsed and supported ground breaking campaigns such as Be Clear on Cancer and FAST for local communities. (5)

We can expect to see locally based campaigns to try to change behaviour, often supported by web sites and social media. But is it enough just to provide information? Are we providing it in the right way? Should it be backed up with financial incentives like a ‘sugar tax’? What about coercion, like banning smoking or punishing unhealthy choices, for example removing benefits from those who don’t take exercise when they clearly need it?

Choosing Health; Making Healthy Choices Easier (2004) set out priorities including: smoking, obesity, diet and nutrition, exercise, drinking, sexual health and mental health (5a - para 12). It was understood at the time that people made choices on the basis of information received from many sources, including the advertising of unhealthy products, so government had to make sure there were effective and trusted sources of information and “the availability of those options so that people can take up the choices they want to make.” Actions at the time included “a new service – Health Direct – to provide easily accessible and confidential information on health choices with links to existing services... for example, information on diet and nutrition (provided by the Food Standards Agency) and support for parents (provided by Sure Start and other agencies).” (6 para 30)

By July 2008 a report was circulated on the Government Social Research Service (7) to provide “An overview of behaviour change models and their uses” (8) and it seemed we might be able to learn how to change public behaviour by understanding it better.

In the same year, the NHS Next Stage Review Final Report (9) repeated the same priorities and looked forward to voluntary partnerships through a Coalition for Better Health, with a set of new voluntary agreements between the Government, private and third sector organisations on actions to improve health outcomes. The Coalition was to be based on agreements to ensure healthier food, to get more people more physically active, and to encourage companies to invest more in the health of their workforce.

Yet, in 2015 we are still worrying about the cost of unhealthy choices and arguing about who is ultimately responsible for our health andhow best to affect the choices that prevent illness.

What have we learned? Funds and the time of NHS professionals are both limited. If we are to make real change, how can we prioritise our options to get the best results?

Sources and references